report

January 2019

Mass Incarceration Threatens
Health Equity in America

J

University of California
San Francisco

Robert Wood Johnson
Foundation

Authors
Julia Acker, University of California, San Francisco
Paula Braveman, University of California, San Francisco
Elaine Arkin, Independent Consultant
Laura Leviton, Robert Wood Johnson Foundation
Jim Parsons, Vera Institute of Justice
George Hobor, Robert Wood Johnson Foundation
Acknowledgments
We thank the following individuals who provided insightful and substantive comments on drafts:
Dwayne Proctor, Robert Wood Johnson Foundation
Tracy Orleans, Robert Wood Johnson Foundation
Susan Egerter, University of California, San Francisco
Maisha Simmons, Robert Wood Johnson Foundation
Margaret diZerega, Vera Institute of Justice
Suggested Citation
Content from this publication may be reproduced without permission provided the following
citation is referenced:
Acker J, Braveman P, Arkin E, Leviton L, Parsons J, Hobor G. Mass Incarceration Threatens Health
Equity in America. Executive Summary. Princeton, NJ: Robert Wood Johnson Foundation, 2019.
The goal of this report is to raise awareness that mass incarceration is a major threat to
health equity in our nation. While awareness of detrimental effects of mass incarceration has
been growing, its impact on health and health disparities has not received much attention. This
report discusses how incarceration and health are related, not only for those who experience
incarceration, but also for their families, their communities, and the nation as a whole. This
report also reviews promising programs, policies, and justice reform proposals to help end mass
incarceration and its devastating health and social consequences in America.

Foreword
This report also offers an Executive Summary. Other reports on health
equity from the Robert Wood Johnson Foundation (RWJF) include What
Is Health Equity? And What Difference Does a Definition Make?, Early
Childhood Is Critical for Health Equity, and Wealth Matters for Health
Equity. The first report defines health equity (below) and takes a deeper
look at what it means and implications for action. These reports aim to
assist those working in public health, health care, and other sectors that
powerfully shape health—such as law enforcement, courts, education,
child development, employment, housing, and community development—
to build a world in which everyone has the opportunity to be as healthy as
possible.
Health equity means that everyone has a fair and just opportunity to be
as healthy as possible. This requires removing obstacles to health such as
poverty, discrimination, and their consequences, including powerlessness
and lack of access to good jobs with fair pay; quality education and
housing; safe environments; and health care. For the purposes of
measurement, health equity means reducing and ultimately eliminating
disparities in health and its determinants that adversely affect excluded or
marginalized groups.
According to this definition, health inequities are produced by inequities
in the resources and opportunities available to different groups of people
based on their racial/ethnic group; socioeconomic, disability, or LGBTQ
status; gender; and other characteristics closely tied to a history of being
marginalized or excluded.

Contents
Introduction

2

Mass Incarceration Harms
the Health of Inmates,
Families, Communities,
and the Nation

6

Marginalized Groups
are Disproportionately
Incarcerated

14

Inequitable Policies and
18
Practices Drive Dramatic
Disparities in Incarceration
What Can Be Done to
End the Vicious Cycle?

21

Mass Incarceration—
We Know Enough to Act

29

Resources

30

References

31

Mass Incarceration Threatens Health Equity in America

section 1

Introduction
An estimated 2.2 million American adults are currently serving time in prison
or jail,1,2 and more than 45,000 American youth are confined in juvenile
detention facilities, adult prisons, and jails.5 The number of people incarcerated
in the United States increased every year from 1980 to 2008. Despite
subsequent decreases to a two-decade low in 2016, both the number of
people incarcerated and the incarceration rate in the United States still exceed
those of every other nation in the world, including totalitarian regimes.3,4 This
unacceptable level of incarceration—often referred to as mass incarceration—
appears to be the result of policies enacted from the 1970s through the 1990s
that imposed tougher penalties for crimes, including more severe sentencing
and compulsory incarceration for minor repeat offenses.3 The First Step Act,
which was enacted on December 21, 2018, will affect those incarcerated in
federal prisons—nearly 181,000 people of the 2.2 million people in prison or
jail in America—but does not address the primary drivers of mass incarceration
in the United States. This punitive approach has been applied since the early
1970s, particularly in relation to the War on Drugs. The continuing War on
Drugs has targeted drug users who could benefit more from treatment than
punishment. It has been accompanied by the rise of aggressive over-policing
of communities of color, which has in turn contributed to dramatic racial
inequities in incarceration. The stated rationale behind these practices is
that harsher sentencing and tougher responses to crime will strongly deter
and, thus, reduce crime overall. During the nearly five decades of increasing
incarceration rates, however, rates of crime have fluctuated and are today
similar to those in the 1960s, when the incarcerated population was less than
one-seventh of its current size.6,7

2 | Copyright 2019 Robert Wood Johnson Foundation

At the same time, considerable evidence shows that mass incarceration
has produced enormous negative effects on society overall, particularly for
individuals in the most disadvantaged groups. The men and women behind
bars in this country have been largely among the poorest members of society,
with a pre-incarceration median income that is 41 percent lower than that of
currently non-incarcerated people of similar ages.8 While members of racial or
ethnic minority groups represent 39 percent of the population nationally,9 they
make up 60 percent of incarcerated persons.10 Black Americans are the most
affected, representing 33 and 34 percent of the prison and jail populations,1,2
respectively, but only 13 percent of the population overall.9 Black men bear
an especially high burden, with research indicating that 1 in 3 will experience
incarceration during his lifetime. 10

With approximately 2.2 million
American adults and youths
behind bars, the United States
incarcerates many more
persons—both in absolute
numbers and as a percentage of
the population—than any other
nation in the world.

Among individuals who are incarcerated, future prospects for employment,11
economic stability,12 affordable housing,13 and education3 are curtailed and in
many cases eliminated, with dire consequences for their families’ health and
well-being as well: An estimated 2.7 million children nationwide are growing up
with one or both parents behind bars,12 while “approximately 10 million children
have experienced parental incarceration at some point in their lives.”14 Within
communities, high rates of incarceration disrupt social and family networks,
reduce potential economic development, and generate distrust and resentment
toward law enforcement, which may ultimately increase neighborhood crime
rates.7 Each of these factors contributes to wider gaps in incarceration and
health between socially advantaged and disadvantaged groups. For the nation
as a whole, mass incarceration diminishes productivity and prosperity, wastes
immense levels of resources,15 and appears to have a negligible impact on
crime rates.7 It creates cycles of repeat offending and repeat incarceration and
contributes to the entrenchment of intergenerational poverty.16

Mass Incarceration Threatens Health Equity in America

Definitions of Terms Used in This Report
Health refers to health status or outcomes rather than
health care (which is only one of many important
influences on health).
Health equity means that everyone has a fair and
just opportunity to be as healthy as possible. This
requires removing obstacles to health such as poverty,
discrimination, and their consequences, including
powerlessness and lack of access to good jobs with fair
pay; quality education and housing; safe environments;
and health care. For the purposes of measurement,
health equity means reducing and ultimately eliminating
disparities in health and its determinants that adversely
affect excluded or marginalized groups.
Health disparities are differences in health that
adversely affect groups of people who historically have
been excluded or marginalized (for example, people of
color, people living in poverty, people with disabilities,
LGBTQ persons, and girls/women). Health disparities
are used to measure progress toward achieving health
equity.
Discrimination is a broad term that includes, but is
not limited to, racism. Prejudicial treatment has been
based on a wide range of characteristics, including
not only racial or ethnic group, but also low income,
disability, religion, LGBTQ status, gender, and other
characteristics that have been associated with social
exclusion or marginalization.
Racism refers to prejudicial treatment based on racial or
ethnic group and the societal institutions or structures
that perpetuate this unfair treatment. Racism can be
expressed on interpersonal, structural/institutional, or
internalized levels.
Excluded or marginalized groups are those who
have often suffered discrimination or been excluded or
marginalized from society and the health-promoting
resources it has to offer. They have been pushed
to society’s margins, with inadequate access to key

4 | Copyright 2019 Robert Wood Johnson Foundation

opportunities. They are economically and/or socially
disadvantaged. Examples of historically excluded/
marginalized or disadvantaged groups include—but are
not limited to—people of color; people living in poverty,
particularly across generations; religious minorities;
people with physical or mental disabilities; LGBTQ
persons; and girls/women.
Incarceration means confinement in prison, jail, or a
detention center.
Mass incarceration refers to extremely high rates of
incarceration and the disproportionate incarceration of
specific groups of the population. In the United States,
the group most affected by mass incarceration is young
black men from large urban centers.17
Juvenile incarceration refers to court-mandated
placement of individuals under age 18 in out-of-home
correctional facilities including youth detention centers,
group homes, long-term secure facilities, and adult
prisons and jails.
The justice system is the set of government agencies,
policies, and practices responsible for prosecution
and punishment, including law enforcement, courts
and accompanying prosecution and defense lawyers,
correctional facilities, and community reentry and
post-release supervision. In this report, the term “justice
system” rather than “criminal justice system” is used
deliberately to avoid stigmatizing individuals involved
with the justice system, including offenders and those
who may not have committed crimes.
Prisons (also called “penitentiaries”) are state- or
federally-administered facilities that house inmates
convicted of felony offenses and are serving sentences
of (typically) one year or more. State and federal
prisons housed approximately 1.3 million and 189,000
individuals, respectively, in 2016.1

Private for-profit prisons (often referred to simply
as “private prisons”) are private for-profit, thirdparty-owned confinement facilities contracted by a
government agency. Private prisons currently operate
in 28 states and house 8 percent of the total state and
federal prison population.18
Jails are county- or city-run facilities that house
inmates convicted of misdemeanor offenses who
typically serve sentences of less than one year. Jails also
house people who have been arrested and are awaiting
trial or sentencing, as well as inmates who have been
sentenced to prison and are waiting to be transferred
to another facility. In 2016, approximately 741,000
individuals were incarcerated in U.S. jails.2
Probation refers to a period of supervision of an
offender who has been conditionally released from
prison on parole; probation is sometimes imposed
instead of incarceration. Approximately 3.8 million U.S.
persons were on probation at the end of 2015.19
Parole refers to the conditional release of prisoners
before completing their maximum sentence period.
At the end of 2015, an estimated 870,500 individuals
were on parole.19 Parolees may be re-incarcerated if
they violate the conditions of their parole. Examples
of conditions of parole include obeying the law,
keeping mandatory appointments with a parole officer,
abstaining from drug and alcohol use, obtaining
employment, and not voting in elections.
Recidivism is repeat offending.

Mass Incarceration Threatens Health Equity in America

section 2

Mass Incarceration Harms The Health
of Inmates, Families, Communities, and
the Nation
Substantial evidence links incarceration with poor health outcomes.
In the United States, incarceration not only punishes through confinement, but
is also associated with a range of adverse health effects that last far beyond
the period of confinement. Longitudinal studies have documented strong,
pervasive links between incarceration and multiple adverse health indicators
across the lifespan, even after considering health before incarceration.13,20,21
Compared with individuals who have never been incarcerated, current and
former inmates have significantly higher rates of communicable diseases
(including sexually transmitted infections, HIV, hepatitis C, and tuberculosis);
chronic health conditions (such as hypertension, diabetes, arthritis, and
asthma); and psychiatric and substance use disorders.20 Most adult inmates are
released from correctional facilities with more chronic medical problems than
they had before admission.13 According to the U.S. Department of Justice, onethird of illness-related deaths in state prisons from 2001 to 2004 (the latest
years for which this statistic was reported) resulted from conditions not present
at the time of admission.22 The five leading causes of death in state prisons
during these years were heart disease, cancer, liver disease, AIDS, and suicide.22
Juvenile incarceration also predicts a range of adverse health outcomes in
adulthood, including worse general health; suicidal thoughts, intentions, and
behavior; substance abuse; greater physical and psychological limitations; and
premature death.23-27
Examining mortality among New York state adult parolees over a 10-year
period, a 2015 study found that each year spent in prison corresponded with
a two-year reduction in life expectancy.28 In the two weeks following release
from prison, the mortality rate of former inmates is approximately 13 times
higher than that of the general population, primarily due to drug overdose.29
Rates of suicide among those who are incarcerated are 60 percent higher than
rates in the national population.30
Although incarceration has repeatedly been correlated with poor health
outcomes, researchers face the challenge of distinguishing the effects of
incarceration from the effects of cumulative health-damaging life experiences
before incarceration. Adult and juvenile offenders—who are largely from
marginalized communities that suffer high rates of disease and premature
death3—enter correctional facilities with multiple health problems.31,32 Few
studies, moreover, have examined the direct health effects of the experience
of incarceration itself and of conditions in different types of facilities (public
prison, private prison, jail, or juvenile facilities). Despite these limitations, current
scientific evidence documents profoundly harmful effects of both juvenile and
adult incarceration on the health of inmates throughout their lives.21,32
6 | Copyright 2019 Robert Wood Johnson Foundation

Longitudinal studies have
documented strong, pervasive
links between incarceration and
multiple adverse health indicators
across the lifespan, even after
considering health before
incarceration.13,20,21

Prison and jail conditions directly compromise inmate health in
many ways.
How can the links between incarceration and poor health be explained,
independent of the health damage that inmates are likely to have experienced
before being incarcerated? U.S. prisons, jails, and juvenile correctional facilities
are unhealthy environments, where inmates are exposed to a wide range
of conditions that are detrimental to physical and mental health.33,34 When
inmates are released, their health can be further compromised by societal
stigmatization and denial of opportunities for gainful employment, stable
housing, education, and other conditions that promote good health.23

A 2015 study found that
each year spent in prison
corresponded with a two-year
reduction in life expectancy.28

Because prisoners are more likely than never-incarcerated individuals to have
experienced unhealthful living conditions prior to confinement, incarceration
could, at least in theory, improve health for those confined. For example,
correctional facilities can provide respite from toxic home and neighborhood
environments, regular and healthy meals, reduced access to drugs and
alcohol, and increased access to medical care and treatment for substance
dependence.3,21 Correctional facilities are the only places in the United States
where health care is constitutionally mandated, thus presenting a unique
opportunity for individuals to receive medical care that they might not receive
otherwise. Quality of care varies considerably across facilities, however, and
often fails—sometimes dramatically—to meet community standards of care.33,35
The increase in the size of the incarcerated population has resulted in a scarcity
of medical staff and resources; substance abuse treatment in particular has
consistently failed to meet demand.33 In at least 35 states, inmates in state
or county correctional facilities must make copayments—some as high as
$10036—to access medical treatment. This can be a major deterrent to seeking
care for inmates who typically earn $0–$4.90 per hour if they are actually able
to secure employment while incarcerated.37 In a 2017 survey of inmates across
83 prisons in 21 states, 63 percent of prisoners reported being denied needed
health care and nearly 40 percent reported having to wait weeks or months to
receive needed care.38 For female prisoners, poor access to feminine hygiene
products and pregnancy-related care can be significant threats to health
equity, as can lack of staff who are trained to provide women-specific trauma
treatment.39
Correctional environments are often so inherently unhealthy that even the
most well-intended efforts to provide adequate health care are ineffective.33
Factors contributing to unhealthy conditions include substandard meals;
overcrowding; violence and sexual assault; and solitary confinement.
Within prisons, jails, and juvenile correctional facilities, living conditions
are often inhumane and degrading. Prison meals often are unsanitary and
nutritionally inadequate,33 putting inmates at greater risk of food-borne
illness,40 unhealthy weight gain, and chronic diseases such as hypertension

Mass Incarceration Threatens Health Equity in America

and heart disease.41 Many U.S. prisoners report having been denied meals or
given too little food, being served food in containers labeled “not for human
consumption,” and/or being served moldy, spoiled, or insect-infested foods.38
High incarceration rates make overcrowding a pervasive problem that can
affect every aspect of an inmate’s life, greatly amplifying the stresses of
confinement.33 In 2016, the Federal Bureau of Prisons reported operating
federal prisons at 114 percent of capacity overall.1 That same year, 14 state
prison systems and 17 percent of U.S. jails were operating at or over capacity.1,2
Twenty percent of juvenile facilities were operating at or over capacity
in 2014.42 Many inmates are double- or triple-bunked in cells originally
intended for one or in rooms designed to be common spaces. Overcrowding
jeopardizes cleanliness and standards of hygiene, often compromising
air quality and sanitation levels. The growing number of inmates has
corresponded with longer waiting lists for educational, vocational, and drug
abuse treatment programs and reduced recreational and work opportunities,
contributing to greater inmate idleness and subsequent tension and violence.43

Correctional officers and guards are also at risk
The health and well-being of correctional officers
and guards have been largely neglected in scientific
circles and policy debates about mass incarceration. A
new landmark report by researchers at the University
of California, Berkeley confirms that correctional
officers and guards are exposed frequently to
violence and trauma that increase their risks of
serious injury, post-traumatic stress disorder (PTSD),
depression, and suicide.55 Among a sample of over
8,000 guards and parole officers, half reported that

they often feel in danger at work. Such work-related
stress is accompanied by significant adverse health
consequences, including headaches, digestive issues,
high blood pressure, diabetes, and heart disease.55
State-sponsored programs exist that are intended to
improve the well-being of officers and guards, but
are seldom used. Many correctional facility staff are
concerned about negative repercussions from seeking
such assistance.55

Violence and sexual assault are pervasive features of incarceration. In 2011
and 2012, 4 percent of all prison inmates and 3.2 percent of all jail inmates
(totaling approximately 80,600 inmates nationwide) reported experiencing
sexual victimization by either another inmate, staff, or both during the prior
year.44 Nearly 10 percent of youth in state juvenile correctional facilities in
2012 reported being sexually assaulted in the facility.34 Female inmates and
inmates with mental disorders are at particularly high risk of sexual assault.45
Although there are no nationwide surveys measuring rates of physical violence
in correctional facilities, research suggests it is common.46 Examining the
prevalence of inmate-on-inmate and staff-on-inmate physical victimization
in 14 adult prisons over a six-month period, one study found that male and

8 | Copyright 2019 Robert Wood Johnson Foundation

Male and female prisoners are
18 and 27 times more likely to
experience physical assault than
males and females in the general
population.47

female prisoners are 18 and 27 times more likely to experience physical
assault than males and females in the general population.47 In a nationally
representative survey of incarcerated youth, 43 percent of children in juvenile
correctional facilities or camp programs “said they were somewhat or very
afraid of being physically attacked, while 45 percent reported that staff
use force when they don’t need to.”34 Both violence and sexual assault are
likely to be underreported. Fear of retaliation by other inmates and/or staff
often discourages inmates from reporting instances of sexual and physical
victimization to authorities.46 By one estimate, only 8 percent of all prisoners
who experience sexual assault report their victimization.48
Solitary confinement also presents a threat to inmate health. With
overcrowding, correctional facilities have become increasingly reliant on
solitary confinement as a form of inmate control and punishment. Solitary
confinement refers to imprisonment in an isolated cell, often for 23 hours a
day, with varying restrictions on exercise, showers, reading materials, food
and toiletry purchases, visitation, interpersonal contact, and participation in
educational and vocational activities offered to inmates.49 Sometimes, solitary
confinement is not a part of the sentencing of an offender sanctioned by a
judge, but is applied as an administrative measure by prison officials in response
to inmate infractions.50 In Illinois, 85 percent of inmates who had been held
in solitary confinement over a one-year period had been sent there for minor
infractions such as using abusive language.51 Inmates often are placed in
solitary confinement for months or even years, with many county jurisdictions
allowing prisoners to be confined in isolation indefinitely.50
Decades of research on solitary confinement have consistently documented
its adverse psychological effects, including anxiety, insomnia, paranoia,
hallucinations, cognitive dysfunction, aggression, loss of impulse and
emotional control, self-harm, and suicide.52 While no federal reporting system
tracks how many inmates are isolated at a given time, one study estimated
that, in the fall of 2014, between 80,000 and 100,000 prisoners were being
held in isolation, not including persons confined in jails, juvenile facilities, or
military and immigration detention centers.49 Reports on individual facilities
also reveal egregious overuse of juvenile solitary confinement, often without
constitutionally-mandated due process protections.34 In the Rikers Island
correctional facility in New York City, for example, three-fourths of the 140
adolescents held in solitary confinement in July 2013 were mentally ill.53 Along
with extremely high rates of incarceration, the overuse and lack of regulation
of solitary confinement makes the U.S. incarceration system particularly brutal
and inhumane by international standards.50 The United Nations Human Rights
Committee, the Committee Against Torture, and the United Nations Special
Rapporteur on Torture all have condemned solitary confinement practices
in the United States, stating that “they may amount to cruel, inhumane or
degrading treatment in violation of international human rights law.”54

Along with extremely high
rates of incarceration, the
overuse and lack of regulation
of solitary confinement makes
the U.S. incarceration system
particularly brutal and inhumane
by international standards.50

Mass Incarceration Threatens Health Equity in America

Discrimination and Incarceration Trigger a
Vicious Cycle that Threatens Health Equity

Racism and/or
lack of economic
opportunity

Discriminatory
policing, arrest,
and treatment
in court

Incarceration

Worse physical
and mental health

Desperate poverty;
powerlessness;
homelessness

The diagram above demonstrates how racism and/or lack of economic
opportunity can lead to prejudicial treatment in the justice system, which
can trigger a vicious cycle that increases a person’s risks of poor health
in many ways. Discriminatory treatment by both the police and courts
markedly heightens the likelihood of incarceration among people of color
and poor people in all racial groups. Incarceration then leads to worse
health through exposure to an array of unhealthy conditions both during
incarceration (including overcrowding, violence, and poor sanitation) and
after release (including social exclusion and marginalization, as reflected
in barriers to employment and therefore earnings). Social exclusion
and marginalization in turn lead to greater poverty, powerlessness, and
homelessness, further exacerbating the risks of poor health.
This diagram is a simplified representation of a complex process. For
example, racism, lack of economic opportunity, and prejudicial treatment
by police in themselves can each lead to ill health—independent of
whether incarceration occurs—such as when a person’s ability to afford
decent housing or healthy food is limited, or when use of excessive force
by the police results in injury.

10 | Copyright 2019 Robert Wood Johnson Foundation

Social exclusion
and marginalization;
inability to earn
income, obtain
housing, or vote

The health consequences of incarceration persist long after release.
The most serious health consequences of incarceration may not manifest
until after release. Individuals treated for chronic health conditions while
incarcerated often face obstacles to accessing care after leaving the justice
system. Many are released without medications or scheduled follow-up
appointments in the community, and many suffer from mental health or
substance abuse problems that can prevent them from keeping up with
treatment.13 Only 19 percent of correctional facilities provide HIV-infected
inmates with CDC-recommended discharge services, which include making
an appointment with a community health provider, assisting with enrollment
in Medicaid or the AIDS Drug Assistance Program, and providing a copy of
the medical record and a supply of HIV medications.56 During the first two
weeks after release, former prisoners experience exceptionally high mortality
rates, particularly from drug overdose, cardiovascular disease, homicide, and
suicide.57,58
The stigma associated with having a criminal record can permanently diminish
a person’s employment and housing opportunities. Only 55 percent of former
prisoners have any earnings during the first year after release, and those who
find employment often are relegated to low-wage jobs with poor benefits
and no health insurance.11 Precarious employment or low income hinders an
individual’s ability to afford rent, health insurance, medical care, healthy food,
and basic utilities such as heat and electricity—all of which can adversely affect
health. Individuals facing housing instability or outright homelessness are at
increased risk of adverse health consequences including illnesses due to, or
aggravated by, exposure to inclement weather and/or violence. Exposures
to health-harming conditions are further exacerbated in many states where
former inmates are denied educational loans, government-subsidized housing,
food stamps, and other social services.13,23
For juveniles, even short periods of incarceration can have severe long-term
consequences. Youths who have experienced confinement are less likely
to return to school in the future; many who do resume their schooling are
classified as having a disability due to a behavioral or social disorder, which
reduces the likelihood that they will graduate.59 Holding other variables
constant, being arrested between ages 13 and 15 lowers a person’s chances of
enrolling in college by 35 percent and increases his or her chances of being on
welfare at ages 18 to 20 by 14 percent.60
The limits and barriers faced by individuals following incarceration can create
cycles of offending and reoffending, in which former inmates too often
become career offenders with limited opportunities outside of crime. In three
national studies examining recidivism during the 1980s to 2000s, nearly twothirds of ex-prisoners were rearrested within three years after release.61 Among
youth who have been released from detention centers, approximately 70 to 80
percent are rearrested within two or three years.62

The limits and barriers faced
by individuals following
incarceration can create cycles
of offending and reoffending, in
which former inmates too often
become career offenders with
limited opportunities outside
of crime.

Mass Incarceration Threatens Health Equity in America

section 3

Mass incarceration harms the health of families, communities, and
the nation.
A household member’s incarceration can have drastic consequences for a
family’s health and well-being. The majority of incarcerated parents were their
households’ primary earners prior to sentencing but are unable to provide
economic support to their children and partners while serving time in prison or
jail.12 Incarceration of a family member thus reduces a household’s economic
resources while at the same time increasing household expenses due, for
example, to legal fees and the costs of phone calls and visits to correctional
facilities.63 As a result, families with an incarcerated family member are
significantly more likely to live in poverty64 and experience homelessness65
than other families, diminishing their chances for economic mobility and
good health. Additionally, among women the stress of having an incarcerated
partner is associated with a higher risk of mental disorders and physical
health problems.63,66 The high incarceration-related likelihood of relationship
dissolution or divorce can further increase the risks of family instability and
child neglect.63,66
The relationship between a parent and child can suffer significantly as a result
of parental incarceration. The loss of care, companionship, nurturance, and
stability can create chronic stress for the child.i A rich body of longitudinal
and other studies has documented numerous adverse effects of parental
incarceration on children, independent of many other factors known to
influence outcomes. For example, paternal incarceration is associated with
significant increases in aggressive behaviors and attention deficits in early
childhood.67 Having an incarcerated father predicts poorer educational
outcomes and lower likelihood of college enrollment, while research on
the effect of maternal incarceration on children’s educational outcomes is
inconclusive.12,68 When mothers are incarcerated, children often are placed
in the foster-care system,69 creating significant disruption that may adversely
affect children’s development and lifelong health.70 Parental incarceration in
childhood increases children’s risk of drug abuse, criminality, and delinquency
as they mature68 and predicts a wide range of health problems—including poor
self-rated health, HIV/AIDS, asthma, high cholesterol, migraines, depression,
PTSD, and anxiety—during young adulthood.71 Children of incarcerated parents
are also far more likely than other children to be incarcerated themselves as
juveniles and later in life.72
Not only are families affected, but whole communities can suffer when rates
of incarceration are high. For example, the perpetual cycling of people with
high rates of communicable diseases between correctional facilities and the
community poses significant public health risks. The justice system’s failure to

The effects of chronic stress in childhood on lifelong health are discussed in another RWJF report,
Early Childhood is Critical for Health Equity.
1

12 | Copyright 2019 Robert Wood Johnson Foundation

A rich body of longitudinal and
other studies has documented
numerous adverse effects
of parental incarceration on
children, independent of many
other factors known to influence
outcomes.

ensure continuity of medical care for released inmates encourages the spread
of HIV, hepatitis C, tuberculosis, and other infectious diseases.13 The removal of
high numbers of men in their 20s, 30s, and 40s can cripple economic mobility
in neighborhoods already fraught with concentrated poverty.73 Taking into
account individual- and other neighborhood-level risk factors, neighborhoods
with high incarceration rates have been shown to have higher than predicted
rates of psychiatric disorders; the association between neighborhood levels of
incarceration and mental illness have been observed both for individuals who
have been incarcerated and for those who have not.74
Incarceration rates in a neighborhood can have significant political implications.
Inmates from urban neighborhoods who are incarcerated in rural areas are
classified as residents of the county in which they are incarcerated75—a system
that can significantly reduce the census in inner-city neighborhoods. By
reallocating public investment and political representation from inner-city
communities of color to small rural towns, this shift in population numbers
can have the effect of depriving impoverished urban communities of federal
subsidies and the ability to elect politicians that serve their best interests.
Mass incarceration consumes large portions of government budgets, with
local, state, and federal governments spending approximately $180 billion
each year on corrections, policing, and criminal court systems.15 As discussed
earlier, current and formerly incarcerated individuals, their families, and their
communities generally are sicker and financially worse off than the rest of the
population. This situation strains our nation’s health care resources, diverting
social and financial capital from investments in education and economic
development to issues that could be prevented with a justice system focused
less on excessive punishment and more on rehabilitation and providing
healthful conditions. The massive growth in the number of incarcerated
persons has significantly reduced the number of Americans who can actively
participate in civic life by voting and serving on juries; approximately 1
in 40 adults currently is politically disenfranchised because of a criminal
conviction—a statistic that includes individuals who have completed their
sentences and those on probation or parole.3 Furthermore, people under
correctional supervision of any kind are excluded from most major population
surveys of key social indicators—such as unemployment, educational
attainment, income inequality, morbidity, and mortality—that governments
routinely use to identify unmet need, allocate resources, and frame social
policy. This means that population surveys for 2016 excluded more than 2.2
million individuals who were incarcerated1,2 and approximately 4.7 million
individuals who were on probation or parole.19 Reported indicators therefore
underestimate the true extent of racial and social inequality in this country.76

Local, state, and federal
governments spend
approximately $180 billion each
year on corrections, policing, and
criminal court systems.15

Mass Incarceration Threatens Health Equity in America

section 3

Marginalized Groups Are
Disproportionately Incarcerated
Incarceration is strongly linked to social disadvantage.
Findings from a wide array of sources document the strong links between
incarceration and many measures of social disadvantage. Research shows that
before becoming incarcerated, incarcerated men and women, respectively,
were 2.5 and 1.5 times as likely as non-incarcerated men and women of similar
ages to have lived in poverty.8 From 1999 to 2014, during the three years
before becoming incarcerated, only 49 percent of male inmates ages 18 to
64 were employed and only 13 percent had incomes above $15,000.11 In 2003,
a Department of Justice report revealed the vast majority of prisoners had
not completed high school.77 There have been no nationwide studies on the
educational backgrounds of prisoners since then, but recent state-level data
show most prisoners in Georgia and Minnesota state-run facilities do not have
a high school diploma.78,79
People of color make up the majority of the incarcerated population. Black and
Latino adults, respectively, are 5.9 and 3.1 times more likely to be imprisoned
than their white counterparts;1 in some states, the black-white disparity is more
than 10 to 1.80 Young black men, especially those with little education, are the
most affected: Among black men born between 1965 and 1969 who did not
complete high school, 57 percent experienced incarceration by their 30s.81
In 2015, 10 percent of black children, 3.6 percent of Latino children, and 1.7
percent of white children had a parent behind bars.82
American Indian persons also are strikingly overrepresented in the justice
system, especially in states with large American Indian populations. In
2010, American Indians represented 22 and 29 percent of the incarcerated
populations in Montana and North Dakota, respectively, though they only
accounted for 6 and 5 percent of the overall populations in those states
that year.83,84
While rates of juvenile incarceration have declined in the United States (by
54% overall from 2001 to 2015),5 greater declines in incarceration rates among
white youths relative to youths of color have led to racial and ethnic disparities
that are wider today than two decades ago. Black, American Indian, and Latino
youth, respectively, are approximately 5,85 3,86 and 1.6587 times as likely as white
youth to be incarcerated.
The dramatic increase in the incarcerated population from 1980 to 2008
was accompanied by an upward shift in the age composition of incarcerated
persons. From 1974 to 2013, the percentage of state prison inmates age 40 or
older increased from 16 to 40 percent, while the median age of state prisoners

14 | Copyright 2019 Robert Wood Johnson Foundation

Among black men born between
1965 and 1969 who did not
complete high school, 57 percent
experienced incarceration by
their 30s.81

rose from 27 to 36 years old.88,89 This shift largely reflects the proportion of
incarcerated individuals who are aging while in prison. Admissions to prison,
however, are highly concentrated among people under age 30.90

Men are more likely than women to be incarcerated, but rates of
incarceration among women are increasing.
At the end of 2016, 93 and 85 percent of the U.S. prison and jail populations,
respectively, were men.1,2 Research shows that when men and women are
arrested for the same federal crime, men are significantly more likely to be
charged and convicted. On average, men receive 63 percent longer sentences
than women convicted for the same crime.91 At the same time, the number
of incarcerated women has increased while the number of men behind bars
has decreased; nearly 110,000 women were in jail during 2014 compared with
fewer than 8,000 in 1970.92

Incarceration rates are also higher among persons with existing health
problems and disabilities.
As mentioned earlier, incarcerated adults and juveniles are predominantly
from poor, medically-underserved communities3 where residents are more
likely to be exposed both to harmful environmental toxins in their homes
and neighborhoods and to greater levels of drug use and trafficking. At the
same time, residents of these communities are far less likely to have access
to needed health care and/or rehabilitation services. Poor health and minimal,
low-quality, or nonexistent medical care all increase a person’s likelihood
of arrest and incarceration.31,32 Given the starkly inadequate medical and
substance abuse treatment available in most prisons and jails, inmates’ health
problems are likely to worsen during incarceration and after release.3
Persons with disabilities also represent a large proportion of incarcerated
individuals; people with disabilities are 3 and 4 times as likely as non-disabled
people to end up in prison and jail, respectively.93 The Center for American
Progress calls the incarceration of persons with disabilities “unjust, unethical,
and cruel” as well as economically foolish, given that providing communitybased prevention and treatment is far less costly than holding an individual in
confinement.93

Many people are incarcerated because they cannot afford bail or
court fees.
Nationally, 65 percent of jail inmates have not yet been convicted of a crime2
but are detained as they await trial—often because they cannot afford cash
bail; in 2015, the median cash bail set nationwide was $10,000.94 Additionally,
many people are incarcerated because they cannot afford court-imposed
fees, fines, or restitution that often are mandatory regardless of a defendant’s
economic status. In felony cases, legal financial obligations average $2,540,
and this amount can increase rapidly due to high statutorily-mandated interest

Mass Incarceration Threatens Health Equity in America

rates when defendants cannot pay their fees at once.95 Many states also charge
additional late fees and payment plan fees when defendants do not pay their
debts in a lump sum.96 Although debtors’ prisons have been illegal in the United
States since 1833, thousands of Americans continue to be arrested and jailed
each year because they owe consumer debts—such as utility bills, medical bills,
and student loans—that may be as low as a couple of dollars.97

Most incarcerations are for non-violent crimes.
Approximately 60 percent of incarcerated individuals are jailed or imprisoned
for a non-violent offense such as theft, drug possession, drug trafficking, or
driving under the influence.98 Drug offenses account for 20 percent of total
jail and prison sentences98 and over 25 percent of sentences served by
parents.12 In 2016, over 74 percent of convicted drug trafficking offenders
were black or Latino,99 although, on average, individuals in these groups use,
buy, and sell drugs at similar rates as whites.3 Nearly 23 percent of confined
youth are incarcerated for a technical violation or status offense such as
violating curfew, not reporting to their probation officer, or failing to follow
through with referrals.98

16 | Copyright 2019 Robert Wood Johnson Foundation

People with disabilities are 3 and
4 times as likely as non-disabled
people to end up in prison and
jail, respectively.93

Detention of Immigrants and their Children is a Threat to Health Equity
The United States maintains the largest immigration
detention system worldwide, with approximately
400,000 immigrants incarcerated each year.100 The
annual U.S. Immigration and Customs Enforcement
(ICE) budget has increased steadily almost every year
since 2005 and currently totals $7.6 billion.101 Over the
years, ICE has increased its reliance on private forprofit prisons to manage immigrant detention; the
detention of migrant children alone has produced $1
billion annually in profit for firms that have contracts
to incarcerate immigrants.102 ICE is the only U.S. law
enforcement agency with a minimum statutory
quota—currently set to 34,000 daily—on the number of
individuals to incarcerate.103
In an effort to deter undocumented individuals from
crossing the southern border, President Trump’s
administration recently separated over 2,000 immigrant
parents and children and deported hundreds of
parents without their children. The vast majority (88%)
of detained immigrant families from Central America

“have demonstrated to a Department of Homeland
Security asylum officer that they have a credible fear
of persecution if deported.”104 These families have not
violated any laws.105 In fact, international laws—to which
the United States is a signatory—stipulate that people
seeking asylum from persecution must be given the
opportunity to make their case. They should not be
treated as criminals when seeking refuge from one of
the world’s most dangerous regions where children
and adults are often physically abused, raped, and
murdered; perpetrators are not prosecuted; and no
place is safe.104 Family separation has not proven to
substantially reduce immigration at the southern border
or make America safer.105 It has, however, caused
thousands of innocent children and their parents to
suffer extreme psychological trauma that will likely
dramatically damage their health for many years
to come.106

Mass Incarceration Threatens Health Equity in America

section 4

Inequitable Policies and Practices Drive
Dramatic Disparities in Incarceration
The unprecedented growth in the U.S. incarcerated population since the
1980s primarily reflects the emergence of policies from the 1970s to the
1990s mandating more severe sentencing for lesser crimes, longer minimum
sentences for violent crimes and minor repeat offenses, and harsher policing
of drug crimes, particularly street trafficking in urban areas. Even while crime
rates remained stable or declined from the 1970s to the early 2000s, many new
prisons and jails were built and anti-crime policies became increasingly severe.3
Such policies have contributed to high rates of incarceration among black
Americans in particular, and have both created and perpetuated significant
public health problems in our nation’s most vulnerable communities.
Beginning in the 1960s, the federal government began closing in-patient
mental health facilities and releasing patients to the community without
adequate supports in place. Funding was inadequate for providing
comprehensive treatment programs, including for severely mentally ill persons
who required 24-hour in-patient care. The lack of adequate treatment,
rehabilitative services, and supportive housing arrangements for mental health
patients led to significant increases in homelessness and the shunting of people
with psychiatric illnesses into the justice system.107,108
The baby boom from the end of World War II to 1960 and resulting increase in
the youth population during the 1960s corresponded with a sharp rise in crime
that was consistent with population growth.109,110 Another key development
during this period was the passage of the Civil Rights Act of 1964, which
marked the end of the era of Jim Crow laws that systematically and explicitly
supported racial segregation and discrimination. Civil rights protests and public
disorder were linked together by some politicians,111,112 as reflected in the “law
and order” emphasis of President Nixon’s 1969 presidential campaign. The
media popularized the term “War on Drugs” shortly after a press conference
given by Nixon on June 18, 1971—the day after he declared drug abuse to be
“public enemy number one” in a special message to Congress. Increasing racial
tensions and intolerance of drug crime contributed to expanded enforcement
within impoverished black communities, where crack cocaine use was more
common than in white communities.113 In 1982, President Reagan announced
his own administration’s War on Drugs, which led to markedly increased
funding of federal law enforcement agencies. At the same time, the Reagan
administration gave lower priority to public health initiatives, including drug
treatment, rehabilitation, prevention, and education.114 The Anti-Drug Abuse Act
of 1986 imposed mandatory minimum sentences for the trafficking of cocaine,
with far harsher punishment for crack (used more often by blacks) than powder
cocaine (used more often by whites).113

18 | Copyright 2019 Robert Wood Johnson Foundation

Even while crime rates remained
stable or declined from the
1970s to the early 2000s, many
new prisons and jails were built
and anti-crime policies became
increasingly severe.3

The explosive growth of the incarcerated population in the 1980s led to
other changes as well, notably the advent and dramatic expansion of private
for-profit prisons.115 This allowed accommodation of substantially greater
numbers of prisoners and introduced monetary incentives for these for-profit
companies to incarcerate large numbers of prisoners while spending as little
as possible.115 Flawed program evaluations led to the conclusion that withinprison rehabilitation efforts were ineffective.116 In fact, the Supreme Court once
ruled to end rehabilitation programs completely. In the 1989 case Mistretta
v. United States, judges decided: “Defendants will henceforth be sentenced
strictly for the crime, with no recognition given to such factors as amenability
to treatment, personal and family history, previous efforts to rehabilitate oneself,
or possible alternatives to prison.”117 This belief was shared widely by both
Democratic and Republican leaders at the time.116
By 1991, the U.S. incarcerated population reached numbers that were
unprecedented in world history, and 1 in 4 young black men was incarcerated
or otherwise involved in the justice system (for example, was arrested or
on trial).118 In 1994, President Clinton signed a law that included a federal
three-strikes provision that mandated life sentences for offenders convicted
of a violent crime after two or more prior convictions, one of which could
be a non-violent crime such as a drug offense. Growing support for more
aggressive policing of lower-level crimes also proliferated during this time.
For example, in the 1990s under Mayor Giuliani, the New York City Police
Department (NYPD) adopted an aggressive strategy known as “stop and frisk”
in which police stop, detain, question, and search civilians on the streets for
weapons, drugs, and other contraband, often without any evidence of criminal
activity. From 2002 to 2014, the NYPD stopped and frisked five million New
Yorkers; 88 to 91 percent of the people stopped were people of color, and
82 to 90 percent of the people stopped had committed no offense.119 While
intended to reduce major crime by targeting minor offenses, in practice “stop
and frisk” has operated as a racial profiling practice that increases the likelihood
of incarceration for African Americans and Latinos.120

From 2002 to 2014, the NYPD
stopped and frisked five million
New Yorkers; 88 to 91 percent of
the people stopped were people
of color, and 82 to 90 percent
of the people stopped had
committed no offense.119

Policies that may not have
been consciously race-driven
in their intent have in practice
resulted in the disproportionate
incarceration of people of color.

Decades of tough-on-minor-crime policing and sentencing produced
the cumulative effect of massively increasing the rates of incarceration
among residents of poor communities of color.7 Whether these policies
were motivated by any deliberate racial targeting remains debated, but it is
undisputed that they created enormous disruptions within communities and
further exacerbated the negative effects of mass incarceration for often-minor
crimes.119-121
Black Americans continue to be unfairly targeted and racially profiled, especially
for minor crimes. On average, black and Latino suspects are 30 percent more
likely to be arrested than white suspects, regardless of other factors known
to influence police officers’ decisions to arrest.122 Taking into account both

Mass Incarceration Threatens Health Equity in America

criminal history and the nature of the arrest charges, black people also are
significantly more likely than white people to receive a prison sentence rather
than a drug treatment referral for drug-related crimes.123
Over the last two decades, “zero tolerance” policies for misbehavior in public
schools have resulted in an alarming number of suspensions, expulsions, and
youth arrests for non-violent disruptive behavior that schools previously
considered routine and managed internally.124 Lacking resources and teachers
with specific training to maintain discipline, many schools—primarily those that
serve children of color—have become increasingly reliant on metal detectors,
surveillance cameras, and police officers to patrol school hallways. This shift
has effectively turned many schools into prison-like security environments that
can further promote problematic behavior and disengagement from school.125
Black children are significantly more likely to be disciplined than other children,
despite the lack of conclusive evidence that they misbehave at higher rates.126
Nationwide between 2011 and 2012, black students accounted for 31 percent
of all in-school arrests but only 16 percent of school enrollment.127 The phrase
“school-to-prison pipeline” was coined to reflect this phenomenon, which
condemns many children of color to years, or even their entire lives, behind
bars for behavioral issues—often arising from traumatic experiences—that
could be better addressed through supportive social and mental health services
rather than punishment.

20 | Copyright 2019 Robert Wood Johnson Foundation

section 5

What Can Be Done to End
the Vicious Cycle?
The Eighth Amendment to the United States Constitution prohibits the federal
government from imposing excessive bail, excessive fines, or cruel and
unusual punishments. Americans deserve an equitable justice system that
deters crime, protects public safety, rehabilitates offenders, and treats people
fairly. The evidence shows that our current system of mass incarceration
generates questionable benefits for public safety7 while wasting immense
levels of government resources15 and producing serious negative health effects
for incarcerated persons, their families and communities, and the nation as
a whole.3,13,21 There are, however, reasons to be optimistic that our current
justice system can be reformed, with corresponding reductions in health
inequities, given an emerging consensus across the political spectrum that the
justice system should be fundamentally altered.128 Numerous bipartisan efforts
(described below) are underway to reduce our nation’s incarceration rates.
Not surprisingly, however, the issues are complex and multifactorial, requiring
multiple strategies at the local, state, and federal levels.129 Some reforms have
already reduced incarceration and crime rates simultaneously, but further
steps are needed. The following section provides an overview of some key
approaches that have been pursued or suggested to end mass incarceration
and thereby achieve a more equitable and healthier society.

To advance equity, many states are reducing their incarceration rates
while improving public safety and minimizing costs.
Since 2007, at least 33 states have passed laws—often unanimously—intended
to simultaneously reduce incarceration, control justice system costs, and
improve public safety. Such reforms have included “reducing lengthy prison
sentences, eliminating mandatory minimum sentences, expanding parole
eligibility, establishing and strengthening diversion programs, and investing
the savings in evidence-based prison alternatives that can help break the
cycle of recidivism.”130 Some states and local jurisdictions have developed
promising alternatives to incarceration for non-violent offenders who do not
pose a threat to community safety. Most alternative programs include mental
health and/or substance abuse treatment services and require counseling,
community supervision, and community service.131 Many of these programs,
particularly those designed for mentally ill offenders, have been shown to
produce long-term cost savings and improvements in recidivism.132 As of 2015,
eleven states enacted broad juvenile justice reforms intended to divert low-risk
youth offenders from the system and increase investment in evidence-based
alternatives.133 Most states that have decreased their incarcerated populations
have experienced concurrent declines in crime. On average, from 2010 to
2015, crime rates decreased more in the 10 states with the greatest declines in
incarceration rates than in the 10 states with the largest increases. 134

Strategies to End
Mass Incarceration
and its Harmful
Effects on Health
ll

Reduce excessively long
sentences and eliminate
mandatory minimum
sentences.

ll

Invest in alternatives to
incarceration, including
diversion programs for adults
and youths.

ll

Stop incarcerating people for
inability to pay cash bail and
court-imposed fines and fees.

ll

Address discriminatory
policing through training and
monitoring.

ll

Eliminate private prisons.

ll

Invest in inmate rehabilitation
and community reintegration
programs.

ll

Ensure access to high-quality
healthcare, drug treatment,
and education, including
while confined.

ll

Address the overuse of
solitary confinement.

ll

Implement policies that
show promise for reducing
poverty and eliminating racial
discrimination.

ll

Invest in programs and
services for children with
incarcerated parents.

Mass Incarceration Threatens Health Equity in America

Since 2007, More Than 30 States Have Reduced Both Incarceration and Crime

WA
MT

VT

ND

ME

MN

OR
ID

SD

WI

WY
NV

PA

UT

IL
TX

CA

AZ

NM

TX

IA

NE

KS

OK

IN

OH
WV

MO

CT
NJ
DE
MD
DC

NC

TN
AR

SC
AL

GA

LA

AK

---

VA

KY

MS
TX

NH
MA
RI

NY

FL

State imprisonment and crime rates, 2007–2016135
Imprisonment down, crime down
Imprisonment up, crime down
Imprisonment up, crime up
Imprisonment unchanged, crime up
Imprisonment unchanged, crime down
Imprisonment down, crime up

Data source: Gelb A, Denney J. National Prison Rate
Continues to Decline Amid Sentencing, Re-Entry Reforms.
Philadelphia, PA: Pew Charitable Trusts; 2018.

States, counties, and nongovernmental organizations are leading
efforts to eliminate inequitable fees, fines, and bail.
The American Bar Association (ABA) recently adopted a set of guidelines for
legislative, judicial, and other government entities at the federal, state, local,
territorial, and tribal levels to avoid incarcerating people for inability to pay
court-imposed fines and fees.136 The guidelines urge jurisdictions to limit fees
to what an individual is able to pay and waive fines completely when payment
would cause a significant hardship. They also state that courts should hold
“ability-to-pay” hearings before imposing sanctions for nonpayment, and that
incarceration, deprivation of fundamental rights (such as revoking the right
to vote), or other disproportionate sanctions (such as suspending a driver’s

22 | Copyright 2019 Robert Wood Johnson Foundation

Most states that have decreased
their incarcerated populations
have experienced concurrent
declines in crime. On average,
from 2010 to 2015, crime rates
decreased more in the 10 states
with the greatest declines in
incarceration rates than in the
10 states with the largest
increases. 134

license) should never result from inability to pay a fine, fee, or restitution.
The ABA also calls for making fine and fee information publicly available and
monitoring collection agencies’ compliance with ABA guidelines.ii
The Vera Institute of Justice called 2017 a “breakthrough year for bail reform.”94
The Bronx Freedom Fund and other nonprofits have established over thirty
charitable bail funds that, in 2017 alone, paid bail for 2,000 individuals who
could not afford it.94 Several bail funds employ the Revolving Bail Fund Model,
which recycles refunded bail money to cover other people’s bail. This makes
it possible for offenders and innocent persons to avoid pleading guilty simply
because they cannot afford bail.137 New Jersey implemented a new bail system
that requires judges to conduct risk assessments and consider nonfinancial
conditions of release before permitting the use of cash bail as a last resort.
Since its implementation, New Jersey’s pretrial jail population has dropped
over 16 percent. Risk assessments, however, may be based on criteria such
as income, education, and employment, which would tend to discriminate
against low-income people, especially low-income people of color.138 Many
other states and local jurisdictions have passed similar legislation limiting cash
bail amounts and eliminating bail for some nonviolent and misdemeanorlevel offenses (an approach that has been criticized, however, when pretrial
detention is mandatory for those who do not qualify for exemption
from bail).139

Jurisdictions across the United
States are implementing
approaches to build more
trusting police-community
relationships and minimize
use of force in police-civilian
interactions.

Local governments are taking steps to prevent unnecessary arrests.
Another potential strategy to reduce the incarceration rate is to combat our
country’s legacy of discriminatory and excessively aggressive policing practices
in communities of color. In an effort to improve public safety, decrease
unnecessary arrests, and end police brutality, jurisdictions across the United
States are implementing approaches to build more trusting police-community
relationships and minimize use of force in police-civilian interactions. Such
programs train officers on relationship-based policing, procedural justice,
appropriate use of force, and crisis intervention for the mentally ill; provide
cultural competency and language instruction to officers working in immigrant
communities; and promote constructive dialogue between community
members and law enforcement in multiple ways.140 Many police departments
now also require use of body-worn cameras that record encounters with
civilians; regularly report use-of-force incidents; and follow strict investigation,
discipline, and accountability procedures.141 Such policies—which typically
resulted from community pressure following several high-profile incidents
in which excessive force by police caused fatalities or serious injuries in
communities of color—have not been used long enough or implemented
widely enough to gather sufficient evidence of effectiveness.

ii The ABA’s full set of guidelines on court fines and fees is available here.

Mass Incarceration Threatens Health Equity in America

Some reforms are achieving more humane, rehabilitative conditions
of confinement.
For the estimated 2.2 million adults1,2 and more than 45,000 youths5
currently behind bars, the conditions of incarceration should be humane
and rehabilitative and must not pose significant health risks to inmates.
Unfortunately, the reality of mass incarceration is that efforts for rehabilitation
often are neutralized by the unhealthy conditions of U.S. correctional facilities
discussed earlier.33 A systematic review of randomized studies across the globe
identified 59 interventions in prisons, jails, juvenile facilities, forensic psychiatry
hospitals, and/or communities associated with improvement in one or more
health outcomes during incarceration and the year after release.142 Successful
interventions took place across several states and countries, and varied by the
population served (for example, persons with chronic medical conditions or
substance use disorders). The review stated that the number of randomized
studies focused on current and former inmates is small relative to their high
rates of disease.142
State legal services organizations such as California’s Legal Services for
Prisoners with Children and the Texas Civil Rights Project can help people
receive appropriate medical and psychiatric care while incarcerated. In 1995,
the World Health Organization began its Health in Prisons Programme, which
works to ensure prisons “operate within the widely recognized international
codes of human rights and medical ethics in providing services for prisoners.”143
The program is known for its focus on the integration of public health and
prison health care, rehabilitation, and infectious disease prevention.
A landmark Supreme Court decision in 2011 ruled that overcrowding in
California’s prison system violated inmates’ Eighth Amendment rights and
ordered the state to reduce its prison population from the previous level of
nearly 200 percent of capacity to 137.5 percent of capacity within two years.144
Washington state has piloted the Prison Violence Intervention, which
engages prison staff, former inmates, current inmates, and inmates’ families
in activities designed to enhance safety and create optimal conditions for
treatment, rehabilitation, and successful reentry.145
The National Research Council recommends that use of solitary confinement
be minimized (and prohibited for certain vulnerable populations, including
inmates with mental illnesses); that criteria for solitary confinement be more
strict; and that solitary confinement be reviewed regularly to ensure that
those confined are returned promptly to regular cells.146 The American Public
Health Association has urged correctional facilities to “eliminate solitary
confinement for security purposes unless no other less restrictive option is
available to manage a current, serious, and ongoing threat to the safety of
others,” and has recommended eliminating the use of solitary confinement as a

24 | Copyright 2019 Robert Wood Johnson Foundation

The pension boards of New
York City and Philadelphia
voted in 2017 to divest from
private prisons, and New York
has become the first state to
withdraw its stocks completely.149

punitive measure.147 Solitary confinement of youth in the federal prison system
was banned in 2016, and ten states have enacted legislation to limit or prohibit
the use of solitary confinement in juvenile detention centers.148

Local governments are reducing reliance on private for-profit prisons.
Growing recognition of the high costs, substandard conditions, and safety and
security problems of private prisons has led to efforts to reduce reliance on
private for-profit prisons. President Obama’s administration began phasing out
the use of private contractors to run federal prisons in 2016, but U.S. Attorney
General Sessions reversed the order the following year. Local governments,
however, have continued to withdraw their investments in the private prison
industry. The pension boards of New York City and Philadelphia voted in 2017
to divest from private prisons, and New York has become the first state to
withdraw its stocks completely.149

The United States can learn from
other countries that use far less
punitive and dehumanizing
approaches to incarceration with
far better outcomes.

Correctional facilities are replicating model efforts to reshape
incarceration.
The United States can learn from other countries that use far less punitive
and dehumanizing approaches to incarceration with far better outcomes. In
Germany and the Netherlands, for example, retribution and incapacitation
are not the primary goal of incarceration; rather, the incarceration systems in
those countries are “organized around the central tenets of resocialization and
rehabilitation.”150 In the United States, incarceration is a deeply dehumanizing
and traumatizing experience, and too many offenders return to being
confined.61 We need to fundamentally redesign the system by considering why
we lock people up and how their experiences while incarcerated will affect
them after they are released. Connecticut’s Cheshire Correctional Institute is
piloting “T.R.U.E.”—an innovative program for male inmates ages 18 to 25 that
uses mentorship, conflict resolution and personal development training, and
therapeutic conditions to promote success after release.151 Missouri’s approach
to juvenile incarceration, which has moved away from prison-like facilities
in favor of smaller facilities offering comprehensive individualized treatment
regimens, has long been considered an excellent model but has not been
widely replicated.152

Policies and programs are helping inmates transition successfully back
into society.
An equitable justice system would make it possible for released inmates to
become productive members of society with meaningful employment, family
involvement, community ties, and good overall health. Relapsing into repeat
offending often happens because a released prisoner cannot meet life’s basic
requirements—such as employment, a livable income, and stable housing.
Addressing this requires high-quality transition programs, effective social
policies to enhance access to services, and coordination across programs
and services.

Mass Incarceration Threatens Health Equity in America

Maryland’s Montgomery County Pre-Release Center is a good example of
a comprehensive, government-run transitional facility that has reduced both
recidivism and justice system costs.61 The center provides eligible soon-to-be
released inmates with “structured, community-based, residential and nonresidential alternatives to secure confinement, in which they engage in work,
treatment, education, family involvement and other supportive programming
and services to prepare them for release.”153 There are several high-quality
government- and nonprofit-run reentry programs in operation throughout the
country; programs that have been evaluated for effectiveness are featured on
the website What Works in Reentry Clearinghouse maintained by the Council of
State Governments.
Recognizing the limits and barriers posed by a past criminal conviction, several
public housing authorities across the country have implemented policy
changes and reentry programs to promote housing stability for former inmates
and their families. In 2016, for example, the Housing Authority of New
Orleans (HANO) revised their criminal background screening policy to assess
applicants and their crimes more holistically.154 Public Housing Authority
Reentry Programs partner with corrections, social services, and other
community agencies. For example, Burlington’s Offender Re-Entry Housing
Program, funded by the Vermont Department of Corrections, provides
housing and referrals to behavioral counseling, substance abuse treatment,
and Social Security representatives, and works closely with vocational service
organizations and community justice centers to offer former inmates job
search assistance and supplemental case management services.155
To ensure that inmates are equipped with the skills they need to obtain
employment upon release, it is important that they receive adequate
educational and vocational training while incarcerated. A 2013 RAND
Corporation study concluded that receiving education while incarcerated
(including adult basic education, GED, postsecondary, and vocational
programs) reduces the odds of recidivism and increases the odds of obtaining
a job after release by 43 and 13 percent, respectively, and that every dollar
invested in correctional education saves $4–$5 in re-incarceration costs.156
While most states offer inmates adult basic education, GED, and vocational
programs, college is available to inmates in only 32 states. In 28 of these
states, inmates and/or their families must pay to participate in post-secondary
education classes.157 Pell grants—federal subsidies that cover the costs of higher
education for low-income students—were available to prisoners until Congress
banned inmates from the program in 1994. In 2015, the Obama administration
initiated the Second Chance Pell Pilot Program for state and federal prisoners.
There are approximately 4,000 inmates currently enrolled in Pell-funded
programs, but the future of the program, which must be renewed every year,
is uncertain under the Trump administration.158 A critical first step would be to
overturn the ban on Pell grants for inmates.

26 | Copyright 2019 Robert Wood Johnson Foundation

Receiving education while
incarcerated reduces the odds of
recidivism and increases the odds
of obtaining a job after release by
43 and 13 percent, respectively,
and every dollar invested in
correctional education saves
$4–$5 in re-incarceration costs.156

Better Futures Minnesota is a non-profit organization dedicated to helping
formerly incarcerated men reach self-sufficiency and create better futures for
themselves and their communities. The program provides job preparation and
aims to improve men’s confidence in their ability to achieve career success. At
this point, less than 15 percent of Better Futures participants have returned to
prison within a year after release.159
For people living with HIV, there are several models designed to improve
linkage to care after release from prison or jail. Unfortunately, however,
most models have not been widely replicated despite producing positive
results in research studies. One example is the Corrections Demonstration
Project, implemented by the Health Resources and Services Administration
and the Centers for Disease Control and Prevention from 1999 to 2004. The
project funded seven state health departments to connect correctional and
community health efforts—such as HIV screening, health education, counseling,
and primary care—to social services.160

By limiting incentives to relapse
into offending and by creating
alternatives, policies to reduce
barriers to employment for
former inmates may help to end
cycles of recidivism and thus
enhance public safety.161

By limiting incentives to relapse into offending and by creating alternatives,
policies to reduce barriers to employment for former inmates may help to
end cycles of recidivism and thus enhance public safety.161 As of 2018, 32
states and over 150 local jurisdictions have embraced “ban the box” and/
or “fair chance” policies that remove conviction history questions from job
applications and delay background checks until later in the recruitment process.
The Work Opportunity Tax Credit (WOTC), created in 1996, is a federal tax
credit for employers who hire people from groups facing significant barriers
to employment—including ex-offenders within one year of their conviction or
release. Unfortunately, however, ex-offenders account for a small percentage
of employees for whom employers obtain WOTC benefits.162 Some states
such as California, Illinois, Iowa, and Louisiana utilize their own employer tax
credits or deductions to promote ex-offender employment. Based on a study
of employer preferences for policy options intended to incentivize employment
of ex-offenders, the RAND Cooperation makes several recommendations to
improve such efforts. These include a guarantee to employers to replace an
ex-offender employee if the initial assignment is not a good fit; ensuring that
employees have reliable transportation to job sites; and reducing the amount of
paperwork required of employers.163

Policies to increase access to economic opportunity and eliminate
racial discrimination can help break the cycle of incarceration.
Reducing the severity of punishment in the justice system will not, by itself,
alleviate the underlying problems of racism and lack of opportunity that drive
high rates of incarceration and recidivism in America’s most disadvantaged
communities.3,164-166 Efforts must also focus attention on breaking the cycles of
economic disadvantage and racial discrimination that underlie and perpetuate
enormous disparities in who ends up behind bars. A range of policy changes

Mass Incarceration Threatens Health Equity in America

and programs is needed across many sectors. For example, research shows
that expanding the Earned Income Tax Credit (EITC) for childless workers
and raising the federal minimum wage would simultaneously reduce crime
and incarceration, improve public safety, and save the United States billions
of dollars each year.167,168 Increased investment in community development
programs also is critical for improving conditions in neighborhoods and
regions that have historically been excluded from opportunities for upward
economic mobility.iii

Several programs could protect the health of children with
incarcerated parents.
Given the enormous adversity confronting children with parents who are
currently or have been incarcerated, scaling up interventions that support
the developmental, health, and social needs of these vulnerable children is
critical. As noted earlier, these children experience disproportionate rates of
parental absence, foster care placement, and educational disadvantage, as
well as incarceration and poor health later in life—even after considering
their well-being before their parents’ incarceration. Programs and policies—
such as the Community-Centered Responsible Fatherhood Ex-Prisoner
Reentry Pilot Projects169—that can reduce financial strain, promote family
stability, and improve parent-child relationships before, during, and after
incarceration show promise for reducing the social and health disadvantages
these children experience.170 For children placed in foster care as a result of
parental incarceration, efforts should focus on enhancing the quality and
stability of placements, improving access to and quality of mental health and
substance abuse treatment, and strengthening support for young adults exiting
foster care by providing increased access to health care, housing, employment,
educational opportunities, and legal services.171 Notable models that have
been tried and evaluated in small-scale studies include the Multidimensional
Treatment Foster Care Program and kin-based care.171

iii Another RWJF report, Wealth Matters for Health Equity, describes a range of promising
initiatives to reduce economic inequality in the United States and improve the social and
economic conditions of individuals, families, and communities who have historically been denied
opportunities.

28 | Copyright 2019 Robert Wood Johnson Foundation

Efforts must also focus attention
on breaking the cycles of
economic disadvantage and
racial discrimination that
underlie and perpetuate
enormous disparities in who ends
up behind bars.

section 6

Mass Incarceration—We Know Enough
to Act
Mass incarceration and confinement under inhumane conditions represent
major threats to health equity in the United States. The health damage that
results from mass incarceration takes a disproportionate toll on people of color,
poor people, and people with disabilities. The profound damage is inflicted
not only on the individuals who are incarcerated, but also on their families
and entire communities. The U.S. incarceration rate by far exceeds those in
other nations and are driven by economic and racial inequities. Our inequitable
justice system exacerbates ongoing disparities in multiple domains—including
health. Few would dispute that eliminating mass incarceration and inhumane
treatment of the incarcerated is a critical moral and human rights imperative for
our nation.

Eliminating mass incarceration
and inhumane treatment of the
incarcerated is a critical moral
and human rights imperative for
our nation.

There is clear evidence that ending mass incarceration and inhumane prison
conditions also represents an economic necessity for our nation. Cities, states,
and the federal government currently spend billions of taxpayer dollars to
incarcerate vast numbers of people, most of whom have not committed a
violent or otherwise serious crime. Many people—including those who have
not yet been tried—are behind bars simply because they are poor. At the same
time, financial investments in mass incarceration have not been found to be
associated with reductions in crime rates or other societal benefits. In fact,
most cities and states that have recently lowered their incarceration rates have
experienced corresponding decreases in crime and improvements in public
safety, with significant financial savings.
With high rates of recidivism, many jails, prisons, and juvenile correctional
facilities are largely revolving doors. This underscores the importance of
prioritizing rehabilitation and post-release economic self-sufficiency, using
evidence-based approaches with demonstrated potential for success. Although
the issues are complex and challenging, bipartisan reform efforts are now
underway in many states and county jurisdictions. These actions should be
rigorously evaluated, and those strategies found to be most effective should be
replicated at multiple levels, including federally. We have a choice as a society:
We can continue to approach crime and punishment in ways that violate some
of our most fundamental and deeply-held values and that drain immense
levels of government resources, or we can redirect our efforts away from mass
incarceration—choosing instead to focus on treatment, rehabilitation, and
providing equitable opportunities for every American to live a dignified and
healthy life free of unjust, inhumane, and unnecessary incarceration.

Mass Incarceration Threatens Health Equity in America

Resources
The following organizations provide a range of information about efforts to end
mass incarceration and its harmful effects on health and well-being.

ll

American Civil Liberties Union, www.aclu.org

ll

American Friends Service Committee, www.afsc.org

ll

Center for Court Innovation, www.courtinnovation.org

ll

Center on Juvenile and Criminal Justice, www.cjcj.org

ll

Equal Justice Initiative, www.eji.org

ll

Fines and Fees Justice Center, www.finesandfeesjusticecenter.org

ll

John Jay College of Criminal Justice, www.jjay.cuny.edu/research

ll

MacArthur Foundation, www.macfound.org

ll

The Marshall Project, www.themarshallproject.org

ll

National Institute of Justice, www.nij.gov

ll

National Police Foundation, www.policefoundation.org

ll

Office of Juvenile Justice and Delinquency Prevention, www.ojjdp.gov

ll

PolicyLink, www.policylink.org

ll

Prison Policy Initiative, www.prisonpolicy.org

ll

Stanford Center on Poverty and Inequality, www.inequality.stanford.edu

ll

The Sentencing Project, www.sentencingproject.org

ll

Urban Institute, www.urban.org

ll

Vera Institute of Justice, www.vera.org

ll

What Works in Reentry Clearinghouse, whatworks.csgjusticecenter.org

30 | Copyright 2019 Robert Wood Johnson Foundation

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