Health Disparities of People Living in the Community on Probation: A Call to Action for Community and Public Health Systems

The criminal justice system in the United States reaches far beyond the people behind bars. In fact, the majority of those with criminal justice involvement are in the community on probation or parole. Black and Brown people and those who are socioeconomically disenfranchised are disproportionately affected by the criminal justice system as a result of decades of unjust policies. With 2.2 million people incarcerated in the United States and 11 million jail admissions yearly, mass incarceration is an urgent public health issue. There is robust evidence that incarceration has adverse effects on the health of individuals, families, and communities. People who have been incarcerated have a higher prevalence of chronic health conditions,¹ such as heart disease, asthma, and certain cancers such as cervical and lung cancer; high rates of adverse substance use outcomes²; and a very high risk of death after release from incarceration.² Nearly half of Americans have had a family member incarcerated, and this experience has been associated with increased cardiovascular health disparities, increased poverty, and worse health for children with incarcerated parents.³ Mass incarceration also leads to persistent health and social inequalities and systematically disengages communities from civic involvement.⁴

What is less understood is the health impacts of other forms of the criminal justice system such as probation. Despite the reality that 3.6 million people are on probation annually and that probation has been touted as an alternative to incarceration, relatively little research has been conducted on the intersection of probation and health. One recent study found that people on probation died at a rate more than three times higher than that of people incarcerated in jail and twice as high as those in the general public.⁵ The causes of death and associated chronic health conditions in that study were not measured.

In this issue of AJPH, Hawks et al. (p. 1411) characterize the chronic physical and mental health conditions and health care utilization patterns of US adults on probation. They used data from a nationally representative survey, the National Survey of Drug Use and Health, which has been used previously to study chronic health conditions and insurance access in people with criminal justice involvement. They found that, compared with the general population, for those on probation there was a higher odds of having one or more chronic health condition (e.g., chronic obstructive pulmonary disease, hepatitis, HIV/AIDS, heart disease, kidney disease, a recent sexually transmitted infection), having a behavioral health condition, and reporting poor health. Those on probation had lower ambulatory care and higher acute care utilization. They found that those on probation had a 20% lower odds of using outpatient medical services and higher odds of receiving care in emergency departments (80%) or through hospitalizations (70%) than the general public, regardless of insurance status.

Their findings demonstrate that enrollment in Medicaid may provide insurance coverage but does not ensure access to or engagement with health care services. This is likely attributable to additional barriers to care that people with criminal justice involvement face, such as discrimination in health systems, low trust of health care providers, and the need to navigate complex health systems. People have competing needs that they must prioritize while also contending with the stress of being under probation surveillance, such as employment, housing, and substance use recovery, with health care often falling last on the list.

COMMUNITY HEALTH SYSTEM IMPLICATIONS

The findings of Hawks et al. underscore that criminal justice involvement in all forms is a social and structural determinant of health. High rates of chronic conditions and utilization of acute care services signals systemic inequities in health systems for people on probation. Given that all probationers are living in the community, there is a clear call to action for community and public health systems to implement interventions that are specifically focused on addressing the unique health needs of people on probation. Yet, from our experience working with community and public health systems across the United States to improve health care for people with criminal justice involvement, few have the capacity to do that.

Most health systems do not routinely screen patients for histories of recent incarceration, let alone other criminal justice involvement such as probation. Similarly, most health plans, including Medicaid-managed care plans, do not query members about criminal justice involvement and therefore fail to identify opportunities to provide case management and social service supports to this population. Community clinics often lack services that meet the needs of people with criminal justice involvement, such as integrated behavioral health services, trauma-informed care, and legal services. Health systems either have few relationships with criminal justice entities or lack experience in creating effective partnerships. Partnerships that are overly coordinated with the criminal justice system (e.g., having clinics set up in probation offices) run the risk of replicating systems of control and further eroding the low trust patients with criminal justice involvement have in the health system.

The vast majority of community health systems have been historically underfunded to adopt evidenced-based programs that may help. Culturally relevant health care services that include embedding staff with lived experience into primary care teams have been shown to improve engagement in primary care, reduce acute care utilization, and reduce probation violations among people with histories of criminal justice involvement.⁶ These types of primary care transformations could improve health outcomes for people on probation, but few sustainable funding mechanisms through Medicaid exist to support hiring community health workers, who are at the core of these programs. Also, most health systems infrequently hire previously incarcerated people to work on health teams, despite evidence that people with criminal records can thrive in health system workplaces.

PUBLIC HEALTH IMPLICATIONS

The findings presented by Hawks et al. give rise to serious questions about the health and health care disparities of people on probation. To be sure, more research is required to understand the effect on people experiencing probation of the complex intersection of the criminal justice and health systems. Yet, these effects cannot be ignored and should give us pause in accelerating probation as a benign alternative to incarceration.

Public health systems need to examine their role in perpetuating health and social disparities created by policies of the criminal justice system. Community health systems too must acknowledge the inherent bias against people who have criminal justice system involvement⁷ and the inherent systemic racism in health system practices. Funding needs to be dedicated to building more robust systems that address the specific needs of all community members affected by the criminal justice system and that are focused on promoting a broader vision of health and wellness. Additionally, successful system transformation requires that people affected by the criminal justice system are both leading and at the core of the work. This requires investment in educational and career development pipelines for people affected by the criminal justice system (e.g., prison and postincarceration higher education initiatives) and health systems’ commitment to valuing and supporting the lived experience of people affected by the criminal justice system. In this time of parallel and deeply related movements of bipartisan support to end mass incarceration and a national reckoning with structural racism in US institutions, there is an opportunity for public health leaders to demand and advance a new vision of justice that no longer causes or perpetuates health and social disparities in communities that have been affected by the criminal justice system.