Community Supervision and Health

When thinking about health and the criminal justice system, many of us picture clinics made of cinder blocks and patients in blaze orange. Yet, there are more than twice as many people living in our communities and serving out sentences under community supervision than are incarcerated in jails and prisons combined, totaling nearly 4.5 million or roughly one in 58 Americans.1 In contrast to people detained in correctional facilities, more of these individuals retain their health insurance and access care in their regular community clinics and hospitals. We know that in general, people under correctional control have higher levels of chronic physical and mental health conditions, and that Black, Indigenous, and people of color (BIPOC) are disproportionately subjected to the criminal justice system.2 However, we are only beginning to understand the relationship specifically between community supervision and health. With the potential to impact health, health inequities, and healthcare access for millions of patients, it is crucial for physicians to understand community supervision and common health concerns for people on community supervision.

What is Community Supervision?

Community supervision is a category of sentencing that includes both probation and parole. Probation can take the place of a jail or prison stay with someone serving out a sentence in the community. This is different from parole, which is an early release from jail or prison contingent on a term of supervision. In both situations, there are often many requirements for regular meetings with probation or parole officers, frequent drug testing, and limitations on travel. Importantly, failing to abide by these requirements can lead to reincarceration.

Inequity in Community Supervision

Similar to the justice system as a whole, community supervision disproportionately impacts certain racial and ethnic groups. People placed on probation are more likely to be younger, male, and identify as BIPOC.3 When probation rates were at their peak in 2007, nearly one in 12 Black men in the United States were under probation.4 There are not only inequities in who is subjected to community supervision, but the very nature of probation and parole can also lead to a disparity in who is “successful” at meeting the specified requirements and who “fails’’ and goes to jail or prison. While numerous factors contribute to one’s ability to meet requirements, health can play an important role. For example, someone who receives dialysis three times a week or who develops a leg infection from poorly controlled diabetes may be physically unable to make a probation officer meeting. Considering that BIPOC individuals are already more likely to have many chronic health conditions, community supervision has the potential to exacerbate existing health inequities.

Community Supervision and Health

People on probation and parole have different health considerations than people incarcerated in jails or prisons. While individuals are not physically confined as in incarceration, the conditions of community supervision can be traumatizing and anxiety-provoking, especially for many who have previously been incarcerated. People on community supervision can maintain existing public health insurance enrollment, if available in their jurisdiction, and can potentially access care in the community. However, this subset of justice-involved individuals does not have the same constitutional guarantee to health care as do people under incarceration and access to care often remains limited for people on community supervision. Finally, people who do not meet strict requirements of their probation or parole are typically incarcerated, which has well-described negative health consequences.5 While there are few studies that look specifically at the health of people on probation and parole, we do know that people on community supervision have high health needs. People on probation

are more likely than the general population to have a wide array of chronic physical health conditions like asthma or diabetes, disabilities, communicable diseases such as HIV or hepatitis B or C, and mental health conditions including substance use disorders.6,7 Overall, people on probation have higher mortality rates than the general population.8 In addition to having complex health profiles, people on community supervision also access the health system in different ways. When compared to the general population, people on probation have higher rates of emergency department and inpatient care and lower rates of outpatient visits.7

Improving the Care of People on Community Supervision

We have a lot to learn about how to best care for our patients on community supervision, and we can design better policies and programs with more detailed information. In the Health, Homelessness, and Criminal Justice Laboratory (HHCJ Laboratory housed in the Hennepin County Research Institute), we are linking datasets from Medicaid claims and county administrative data to understand what specific health conditions affect people on probation, as well as how these differ by race and ethnicity. This level of detail is especially important when designing justice-oriented interventions that recognize and eliminate existing health inequities. For instance, specific types of substance use disorders affect racial and ethnic groups differently. An informed public health program might target multiple substance use disorders, rather than the single most prevalent, to avoid disproportionately benefiting one group while worsening overall health disparities.

Conclusion

Millions of people who receive care from physicians in the general healthcare system are also involved in the criminal justice system through community supervision. People on probation and parole have complex health needs and patterns of healthcare use that suggest limited access to care. Ideally, we would stop subjecting these individuals to the criminal justice system in the first place. Until then, the healthcare community can best meet their needs by understanding community supervision and common health conditions for patients on community supervision. Failure to adequately control chronic disease can result in poor health and interfere with the requirements of supervision. With better care and smarter policies, we can work toward ensuring that the health needs of people on probation and parole are met and do not result in reincarceration.

Marin Olson is a graduating medical student at the University of Minnesota Medical School. She has worked with the Health, Homelessness, and Criminal Justice Laboratory throughout medical school and recently participated in the TCMS Dr. Pete Dehnel Public Health Advocacy Fellowship. She will start her residency in emergency medicine at the University of California, San Francisco this summer. Contact: olso7943@umn.edu.

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United States, 2017-2018. Published online 2018. Accessed August 9, 2020. https://www. bjs.gov/content/pub/pdf/ppus1718.pdf. 2. Wilper AP, Woolhandler S, Boyd JW, et al.

The Health and Health Care of US Prisoners:

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AJPH.2008.144279. 3. Phelps MS. Mass Probation and Inequality. In: Ulmer JT, Bradley MS, eds. Handbook on Punishment Decisions: Locations of Disparity. 1st ed. Routledge; 2018:43-66. doi:10.4324/9781315410371-3. 4. Phelps MS. Mass probation: Toward a more robust theory of state variation in punishment. Punishment & Society. 2017;19(1):53-73. doi:10.1177/1462474516649174. 5. Wildeman C, Wang EA. Mass incarceration, public health, and widening inequality in the

USA. The Lancet. 2017;389(10077):1464-1474. doi:10.1016/S0140-6736(17)30259-3. 6. Winkelman TNA, Phelps MS, Mitchell KL,

Jennings L, Shlafer RJ. Physical Health and Disability Among U.S. Adults Recently on Community Supervision. J Correct Health Care. 2020;26(2):129-137. doi:10.1177/1078345820915920. 7. Hawks L, Wang EA, Howell B, et al. Health

Status and Health Care Utilization of US Adults

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Health. Published online July 16, 2020:e1-e7. doi:10.2105/AJPH.2020.305777. 8. Wildeman C, Goldman AW, Wang EA.

Age-Standardized Mortality of Persons on Probation, in Jail, or in State Prison and the General Population, 2001-2012.

Public Health Rep. 2019;134(6):660-666. doi:10.1177/0033354919879732.

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