One way to save lives in jails

A 1976 Supreme Court decision said that while the Constitution requires that incarcerated people receive healthcare, the quality of the care doesn’t need to be top-notch, only “reasonably adequate.”

Too often, it’s not adequate, according to Marcella Alsan and Crystal Yang, who study healthcare in U.S. correctional facilities.

In a first-of-its-kind study, the researchers found that jails that undergo accreditation, like most hospitals, saw a marked improvement in healthcare delivery and standards, a substantial decrease in deaths, and millions in cost savings.

To identify accreditation’s potential effects, the researchers conducted a randomized trial of 44 jails over a four-year period. Half (described as treatment facilities) were given generous subsidies toward accreditation costs, while the other half (control facilities) were offered a more modest subsidy at the end of the study. Jails hold people awaiting adjudication on a short-term basis and are usually run by local law enforcement. The population experiences higher-than-normal rates of hepatitis and sexually transmitted infections and faces a range of mental health challenges.

In this edited conversation with the Gazette, Alsan, Angelopoulos Professor of Public Policy at Harvard Kennedy School, and Yang, Bennett Boskey Professor of Law at Harvard Law School, discuss their findings.

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What prompted this study and how would you characterize the quality of healthcare provided to people in jail?

ALSAN: We had been looking at the intersection of health and corrections and we realized that there were some key differences between the healthcare you and I might receive as civilians and the healthcare people who are incarcerated receive. People who are incarcerated have a constitutional right to healthcare; they’re the only group that does. Over 90 percent of hospitals are accredited, but there’s nothing like that for corrections.

YANG: The quality of healthcare is generally quite low and varies to a great degree. Our study focused on county jails; you might see more uniformity and a little more oversight at state prisons or federal prisons. In July, President Biden signed a Federal Prison Oversight Act that sets up an inspector general to perform independent audits of all federal Bureau of Prisons facilities. That type of framework doesn’t exist for our nation’s 3,000-plus county jails. It’s estimated that only about 17 percent of all correctional facilities have voluntarily sought accreditation.

There are unique problems specific to the correctional setting. One is that there are major staffing retention and recruitment concerns. That means there might be difficulties with getting high-quality personnel and with training. That’s where accreditation might help, because there are standards that govern personnel and training.

What are some of the study’s most significant findings?

YANG: Collaboration between custody staff and medical staff is crucial to the delivery of healthcare in correctional facilities. We administered confidential staff surveys at the beginning of the study, as well as the end. One of the things that significantly improves is collaboration and coordination between medical and custody staff. That suggests accreditation is helping people work together better.

There were two major categories of quality standards where we saw increased compliance at treatment facilities versus control facilities. One is personnel and training. We also see substantial improvements in patient care and treatment — improvements in timeliness of early stage screenings for everyone who’s admitted. If county jails are analogous to an ER, it’s really important to get individuals in front of a qualified healthcare professional immediately after admission to figure out the best course of treatment.

Maybe the biggest finding is a 90 percent reduction in mortality in the treatment versus control facilities. That comes out to an estimate of almost 20 lives saved during the study. That’s huge, and makes accreditation also highly cost-effective. We also find suggestive reductions in six-month recidivism among individuals booked into the treatment facilities. This points to potential improvements in community safety. If you do a rough cost-benefit analysis, the net benefit of accreditation can be upward of $60 million in terms of saved lives and suggestive reductions in recidivism per jail per year.

Why does accreditation appear to have a positive effect?

ALSAN: What we learned from this experience is that there are very few instances where people are intending to produce harm. Oftentimes people don’t have the information they need as to how they should be conducting their training procedures, delivering their healthcare services. Sheriffs will say they did not volunteer to be the mental health providers for the U.S. But because of the upsurge in mental health challenges — the opioid epidemic and so on — they have become the default mental health care providers. So, there’s obviously a role for decarceration and improving mental health in the community.

But there’s also a role for providing support to sheriffs. The accreditation process is like a game plan: This is what you should be doing; this is what good care looks like. And this is how you translate those inputs into outputs. We subsidized the accreditation process for these facilities. We didn’t think the subsidy would be that crucial for obtaining accreditation. It’s about $5,000 to $10,000 for these small and medium-sized jails, which is the majority of jails in the United States. But just that amount of money is quite challenging to reallocate and budget for. We’re talking about county budgets, which are not always very fungible. So, this subsidy was really a facilitator for them becoming accredited.

What should policymakers and law enforcement learn from this research?

YANG: The main takeaway is that obtaining accreditation from the National Commission on Correctional Health Care is highly cost effective. It saves lives and might also have benefits for community safety given that we find suggestive reductions in recidivism. These findings might be important for a sheriff or local county official who hasn’t heard about accreditation but wants to minimize deaths, which will, in turn, minimize their litigation and liability risk, something sheriffs care a lot about. Sheriffs also care about community safety, and so, if recidivism is lower as a result of obtaining accreditation, that can be another attractive benefit.

ALSAN: Coming from a public policy standpoint, the federal government can affect the budget constraints of the states. It can provide subsidies; it can provide incentives for jails to take certain actions. Staffing is an issue — some jails don’t even have the staff to fill out the forms to get accredited.

So many systems have failed the people who find themselves arrested and in jail. Many of the men arrested have never seen a dentist. And so, there’s a level of frustration. Ninety to 95 percent of these people are going back into their communities. Why are we not using this as an opportunity for rehabilitation, for treatment, for screening? And that’s not even in our cost-benefit estimate; we’re just talking about the value of a statistical life. We’re not even including the potential prevention of community-based spread of different types of habits, different types of diseases, or just of despair. These are human beings. Not only that, they’re your neighbors.