The Milbank Quarterly
A Multidisciplinary Journal of Population Health and Health Policy
September 2015 Volume 93, Issue 3 Pages 447–649
http://onlinelibrary.wiley.com/doi/10.1111/milq.2015.93.issue-3/issuetoc

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Op-Ed
The Future of the World Health Organization: Lessons Learned From Ebola
LAWRENCE O. GOSTIN*
Article first published online: 8 SEP 2015
DOI: 10.1111/1468-0009.12134

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Original Investigation
The Institutional Effects of Incarceration: Spillovers From Criminal Justice to Health Care
JASON SCHNITTKER1,*, CHRISTOPHER UGGEN2, SARAH K.S. SHANNON3 and SUZY MAVES MCELRATH2
Article first published online: 8 SEP 2015
DOI: 10.1111/1468-0009.12136
Abstract
Context
This study examines the spillover effects of growth in state-level incarceration rates on the functioning and quality of the US health care system.
Methods
Our multilevel approach first explored cross-sectional individual-level data on health care behavior merged to aggregate state-level data regarding incarceration. We then conducted an entirely aggregate-level analysis to address between-state heterogeneity and trends over time in health care access and utilization.
Findings
We found that individuals residing in states with a larger number of former prison inmates have diminished access to care, less access to specialists, less trust in physicians, and less satisfaction with the care they receive. These spillover effects are deep in that they affect even those least likely to be personally affected by incarceration, including the insured, those over 50, women, non-Hispanic whites, and those with incomes far exceeding the federal poverty threshold. These patterns likely reflect the burden of uncompensated care among former inmates, who have both a greater than average need for care and higher than average levels of uninsurance. State-level analyses solidify these claims. Increases in the number of former inmates are associated simultaneously with increases in the percentage of uninsured within a state and increases in emergency room use per capita, both net of controls for between-state heterogeneity.
Conclusions
Our analyses establish an intersection between systems of care and corrections, linked by inadequate financial and administrative mechanisms for delivering services to former inmates.