Health Care Continuity in Jail, Prison and Community


Slide 1: Health Care Continuity in Jail, Prison and Community Hampden County Correctional Center Baystate Brightwood Health Center Springfield, MA 2006

Slide 2: Percent of Total Burden of Infectious Disease Found Among People Passing Through Correctional Facilities, 1996 Condition Estimated # of Total # in US Pop’n Releases as % releases w/ Cond’n w/ Cond’n of US Pop’n w/ Cond’n AIDS 39,000 229,000 17% HIV+ 98,000-145,000 750,000 13-19% HepBsAg+ 155,000 1-1.25 million 12-16% Hep C+ 1.3-1.4 million 4.5 million 29-32% TB disease 12,000 34,000 35% Hammett TM, Abt Associates, Nat’l HIV Prevention Conf. Aug 1999

Slide 3: Background • Health Needs – Infectious Diseases – Chronic Medical Disease – Mental Health Disease – Substance Addiction and Abuse • “33d state,” “But They All Come Back” (J Travis 2005) – Most return to core urban areas – ~ 650,000 releases from US prisons/yr – ~ 9 million releases from US jails/yr

Slide 4: Percentage of inmates reporting any physical, mental, alcohol and/or drug problem(s) and the percentage out of these inmates wanting help 100 Percentage of inmates 80 60 reporting problem 40 wanting help 20 0 Male Female Gender HCCC 1999 intake data in Conklin TJ et al. AJPH,

Slide 5: Chronic Medical Illness: Comorbidity 60% 50% 40% Psych 30% ETOH cage>2 >5 drinks 20% 10% 0% Psych ETOH cage>2 >5 drinks HCCC 2001

Slide 6: Viewed from whatever angle, whether social, economic, administrative, or moral, it is seen that adequate provision for health supervision of the inmates of penal institutions is an obligation which the state cannot overlook without serious consequences to both the inmates and the community at large.” National Society for Penal Information: Rector FL, editor. Health and Medical Service in American Prisons and Reformatories. New York: J. J. Little & Ives; 1929.

Slide 7: The Triad Corrections Public Health Public Safety Community Health

Slide 8: Model transitional programs: Searching for Common Ground Project • NCCHC, Dr. Lambert King, JEHT Foundation • 2 prison systems, 1 jail – Aftercare Planning Policy of North Carolina DOC – Accountability Model of Oregon DOC – Hampden County, MA Public Health Model

Slide 9: North Carolina DOC Aftercare Planning Program • 6 mo prior to release, inmate and social worker (along with institutional treatment team) complete an aftercare plan to coordinate the inmate’s mental health, medical care, and other social service needs post-release • Social worker completes form with referrals to relevant service agencies in the community • Host of community-based partners • Each person receives a copy of the aftercare planning form, medical record copy, packet includes information on other agencies, social security card, driver’s license, and records of programs completed

Slide 10: Oregon DOC Accountability Model • Six Components 1. Criminal Risk Factor Assessment and Case Planning 2. Staff-Inmate Interactions 3. Work and Programs 4. Children and Families 5. Reentry 6. Community Supervision and Programs

Slide 11: Oregon DOC Accountability Model: Reentry program features • Reentry Facilities: 7 prisons strategically located to encourage reach-in by the community. Transfer to facility closest to home 6 mo before release. • Criminal Risk Factors Identified and Mitigated through an enhanced assessment process leading to an automated corrections plan tracked through incarceration and supervision in the community. • Family Orientation through partnering with county community corrections agencies, Parole, and citizen Rehabilitation of Errants group (to Multnomah County– receives ~ 1/3 of all releases).

Slide 12: Oregon DOC Accountability Model: Reentry program features (2) • Information Network For Oregon (INFO): a resource directory used by a variety of other agencies providing info on resources and services available in each city and county in Oregon. Produced by inmates at Powder River Correctional Facility. • Oregon Trail/Offender Debit Card: built on the Oregon Trail Card for food stamps and other public assistance, inmates leaving receive “Offender Debit Cards” instead of checks for any monies in their trust accounts. • Smart Start: In partnership with Dept of Human Services, sexual health and family planning information delivered in last months before release. “Smart Start” packets on release: bag of over-the-counter birth control and personal hygiene items.

Slide 13: Community Integrated Correctional Health Care The Hampden County Community Health Model

Slide 14: Hampden Co. Community Integrated Model • 4 jail health teams integrated with 4 community (neighborhood) health centers • Patients assigned to health team by zip code or prior association with community health center • Dually based team members in 4 health centers and jail – Physician(s) and case manager in both community health center and jail – Nurse practitioner, primary nurse primarily jail based • Community corrections (probation/parole/DRC)

Slide 15: Drug-Related Arrests of Persons Residing in Specific Neighborhoods EForPk 40,000 16 Acres Median Family Income 35,000 Lib Pine Pt E Spf BosRd ForPk 30,000 Ind UppH McK 25,000 20,000 Bay Bri 6Cor 15,000 Met OldH S.End Mem 10,000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Annual Rates of Arrest (per 1,000) Springfield Community Partnership and Prevention Alliance, 1995

Slide 16: Outcomes • HIV patient show rate: 84-90% • Cost effectiveness: $9-10/inmate-day, 10% of $44 million budget. ACA avg cost prisons 10%. Mass 12%. • Community opinion, family opinion, patient’s opinion. • Promotes county-wide cooperation and coordination. • Evaluation and research. • Absolute decrease in emergency room visits and hospitalizations after vs. before jail. • Multivariate analysis shows increase primary care follow-up with increase health care. • Scheduling appointments increases follow-up.

Slide 17: Public Health Model for Corrections • Education • Prevention • Early detection • Reservoir of Illness • Treatment • Proactive v. Reactive • Continuity of care • Sentinel function • Data • Public Health Department • Community-integrated model

Slide 18: Challenges/Opportunities Numbers

Slide 19: Bureau of Justice Statistics: Adult correctional populations 1980-2002

Slide 20: Corrections Statistics- USA • 2 million+ incarcerated. “33rd state”. World ~ 8 million. • Including probation and parole, 6.7 million persons involved with corrections- over 3% of all U.S. Adults • 13% of African-American men cannot vote • “Invisible population” • 25% of some neighborhoods • Incarceration rate has more than tripled since 1980

Slide 21: Annual Releases of Adults Sentenced to Corrections: Massachusetts, 1989-2000 25,000 20,000 15,000 10,000 5,000 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Hampden All County HOC State/DOC TOTAL Mass DOC; Community Resources for Justice, Inc.

Slide 22: Challenges to Continuity & Responses • Time (jails). – Community-based program. – In various locales sheriff’s dept agreed to only release participants in care program intervention between 8am-5pm Mon-Fri. • Distance (prisons). – Technology- telemedicine, EMR. – Transfer policy. – Use of jails for transitional programs

Slide 23: Models of Case Management release A B C D E

Slide 24: Challenges • Mindset • Costs • After release

Slide 25: HIV voluntary counseling and testing program: summary • Costs $6071 per new HIV infection identified • Should 0.46 cases and would save societal dollars • Savings (for the most part) do not accrue to corrections • Collaborations Varghese et al, HCCC, 2001

Slide 26: Barriers to Continuing Care In the Community after Release 1 month after release A Big Somewhat of Not a Not Problem a Problem Problem Applicable Not being able to pay for care 29 (23%) 18 (15%) 68 (55%) 9 (7%) or meds Not being able to get an 25 (20%) 20 (16%) 73 (59%) 6 (5%) appointment Not liking the care you get 11 (9%) 15 (12%) 88 (71%) 10 (8%) from providers Not having transportation 51 (41%) 21 (17%) 48 (39%) 4 (3%) Conflicts with work or other 18 (15%) 23 (19%) 78 (63%) 5 (4%) activities Chronic Illness Cohort, HCCC, 2001

Slide 27: Facilitators to Continuing Care In the Community after Release 1 month after release Very Somewhat Not Not Helpful Helpful Helpful Applicable Post-Release Medical 43 (35%) 5 (4%) 4 (3%) 72 (58%) Appointment Set Up in Advance 83% Dually-Based Providers 57 (46%) 29 (23%) 19 (15%) 19 (15%) 54% Health care in Jail 53 (43%) 55 (44%) 14 (11%) 2 (2%) 43% Health education in Jail 58 (47%) 43 (35%) 20 (16%) 3 (2%) 48% Drug/Alcohol Treatment in Jail 50 (40%) 30 (24%) 14 (11%) 30 (24%) 53% Chronic Illness Cohort, HCCC, 2001

Slide 28: Operational Elements for Promoting Continuity of Care • Discharge planning starts early • Case Management • Personally connect with health worker before reentry • Dually based health care workers • Schedule post-release appointments • Summary health record • Medical benefits • Medication • Holistic: mental health, addiction, family

Slide 29: Relationship of scheduling appointment and primary care follow-up, stratified by level of trust Trust of jail care n Risk Ratio (95%CI) Low 28 1.2 (0.6-2.6) Med 26 1.3 (0.7-2.6) High 47 1.9 (1.1-3.2) All 101 1.5 (1.1-2.2) • Correlation of appointment scheduled with going to doctor is most evident in group with higher trust of health care in jail • Trust in health care in community showed less modifying effect

Slide 30: Non-medical health needs 1. Food 2. Basic safety 3. Housing 4. Transportation 5. Income 6. Family role

Slide 31: Non-medical health needs 1. Food Other priorities: 2. Basic safety 2. Cigarettes 3. Housing 4. Transportation 5. Income 6. Family role

Slide 32: Invisible Punishments: “Collateral Sanctions” • Employment • Public assistance • Housing • Driver’s license • Voting • Education • Parental rights • Expunging criminal record

Slide 33: Contextual and Organizational Elements for Promoting Continuity of Care • Geography • “Bureaucratic simplicity” • Pre-existing collaborative relationships • Presence of a “champion” • Precipitating events • Public health worker in corrections • Information system

Slide 34: Geography: sites for reentry • Rhode Island • Oregon: DOC facility • Virginia: jails • Hampden County: jail, day-reporting, community corrections • Hawaii

Slide 35: Three Groups Benefit • Public • Individual patient – Reduction of disease – Unpopular to – Reduction of post- mention discharge medical costs • Less morbidity • Lower incidence • Jail – Enhanced public safety – Better environment • Decreased recidivism – Cost-effectiveness • Increased healthy behaviors

Slide 36: Some Key Points • Almost everyone returns. Temporarily displaced. • Triad of corrections, community and public health- collaboration needed for mission, expertise, expenses. Structure to maintain collaboration. • Jails and prisons differences • Geographic plan • Dually-based health care workers, personal connection • Schedule appointments

Slide 37: Community health care after release At 1 month: • 46% had appointment set up • 60% went to first appointment. Comparing 6 months before and after incarceration: Intake (%) 6m (%) Went to regular doctor 64* 56* Went to ER 46 34 Admitted to hospital 24 10 * median visits 2 3 Chronic illness cohort, HCCC 2001

Slide 38: Self-reported health Intake 6 months (n=131) % % General Health Fair/poor 55 34 Good 24 33 VG/excellent 21 33 Pain (mod/severe) 40 20 Emotional problem 66 43 (mod/severe) Chronic illness cohort, HCCC 2001

Slide 39: In Jail Services and Post-Release Health Care Use (Physical)- instrumental variable multivariate analysis Following Release In jail service Doctor ER Hospital Doctor Visits ↑ 0.02 ↓ NS ↓ NS Case Management ↑ 0.02 ↓ NS ↓ NS Discharge Planning ↑ NS ↓ NS ↓ NS Appointment Made ↑ 0.01 ↓ NS ↔ NS Chronic illness cohort, HCCC 2001

Slide 40: Percent of Smokers Involuntarily Ceasing Smoking While Incarcerated Who Remained Cigarette Abstinent, by Length of Time Post-Release Chronic illness cohort, HCCC 2001

Slide 41: Hepatitis Program • Education, from admission, peer ed, groups. • Hep B vaccinate all. (? Target those •Education with known negative serology, age •Prevention above vaccine below 45. ( 18y- VFC) •Early detection • Voluntary counseling and testing, •Treatment includes HIV and hepatitis serology profile (A?, B, C) •Continuity of • ALT on admission care • Link to community health centers •Data • Collaboration with Dept of Public Health • Vaccination and PPD info wallet card and/or electronic health record

Slide 42: The health care system realizes net savings even when there is no incidence in prison, or there is no cost of chronic liver disease, or when only one dose of vaccine is administered. Thus, while prisons might not have economic incentives to implement hepatitis B vaccination programs, the health care system would benefit from allocating resources to them.

Slide 43: Multivariate model for predicting Hepatitis C % criteria % HCV detected % HCV+ Variables included 10.2 36.5 74.5 Shared needle 25.5 75.0 61.0 S. needle or ALT 29.2 81.3 57.7 S. needle, ALT or HxHep 35.6 90.1 52.7 S.needle/ALT/HxHep/HBc 19.4 57.3 68.7 ALT alone Definitions: Shared needles: Have you ever shared needles? ALT: above ULN. HxHep: Has a medical professional ever told you that you had hepatitis? HCCC 1999

Slide 44: Hepatitis B Seroprevalence- All Detainees by Age 50 40 1.9 Prevalence 30 4.8 40 20 37 0 27.9 10 4.2 16.7 7.3 7.9 0 <20 20-29 30-39 40-49 50+ Age anti-Bs only HCCC 1999

Slide 45: Vaccination needs of Hep C pts • Of inmates who tested positive for hepatitis C, 65% were negative for hepatitis A antibodies. • Likewise 39% of those positive for hepatitis C were negative for all hepatitis B serology. HCCC 1999

Slide 46: Medical Care Utilization and Coverage 200 patients with chronic health conditions • Hospitalized, past 6 months (24%) • ER Use, past 6 months (56%) • Medicaid coverage, past 6 months (68%) • No Coverage, (14%) • Sought care, but cost too much (19%) HCCC 2001

Slide 47: Economic Analysis in Public Health • Can aid in resource allocation process – determine program costs and benefits – determine cost-effectiveness of programs compared to alternatives • Can indicate important areas for research • Is increasingly required – for program evaluation – prior to program implementation

Slide 48: Economic Analysis in Correctional Health • Inmates often have comparatively high rates of health conditions • They are accessible • They can provide a link to non-incarcerated persons • Correctional health care programs often face severe budget constraints • Economic and cost-effectiveness analysis can quantify the cost and benefit (“production”) of correctional programs

Slide 49: Community Integrated Correctional Health Program •Health needs in their community Community •Community standard of care Health Centers : •CBO interactions •3% patients at HCCC

Black and White History in Prisons and Society – Social Stratification

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Slide 1: Black/White history • Jim Crow: Late 1800s to 1960s – System of formal Black-White segregation • After ‘Reconstruction’ in the South – Supreme Court: Plessy v. Ferguson (1896) • Plessy: ‘of seven-eighths Caucasian, and one- eighth African blood’ • Denied a seat on a first class coach in Louisiana • Court upheld ‘separate-but-equal’

Slide 2: Civil Rights era • Civil Rights era – Supreme Court: Brown v. Board of Ed (1954) • Court overturned Plessy • Rejected ‘separated-but-equal’ • School districts can’t segregate – Social movement mobilization – Challenge to segregation, 1950s-1960s

Slide 3: Civil Rights Act (1964) • Bans employer discrimination based on: – race – sex – religion – national origin • Allows current inequalities to persist – Past discrimination affects qualifications

Slide 4: 1884-1914: 3,600 lynchings Murder of James Allen and John Littlefield, Marion, Indiana, 1930

Slide 5: Executions for rape, 1930-1967 50 Not Black Black 405

Slide 6: Men in Prison, 2004 9,000 8,000 White Latino Black 7,000 Per 100,000 Men 6,000 5,000 4,000 3,000 2,000 1,000 0 18-19 20-24 25-29 30-34 35-39 40-44 45-54 55+ Source: BJS, “Prisoners in 2004.”

Slide 7: The Rich Get Richer and the Poor Get Prison

Slide 8: U.S. v. the world: Incarceration USA 724 Russia 564 South Africa 344 Israel 109 Mexico 191 England 145 Australia 120 China 118 Canada 116 Germany 97 France 88 Sweden 81 Japan 60 India 31 Rates per 100,000 population: US 2004, others most recent. Source:

Slide 9: People in prison and jail 2,250,000 2,000,000 1,750,000 1,500,000 1,250,000 1,000,000 750,000 500,000 250,000 0 1986 1988 1996 1998 1980 1982 1984 1994 1990 1992 2000 2002 2004 Source: Bureau of Justice Statistics Correctional Surveys. Update: prison clock

Slide 10: People without freedom 8,000,000 7,000,000 Probation 6,000,000 Parole 5,000,000 Jail 4,000,000 Prison 3,000,000 2,000,000 1,000,000 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Source: Bureau of Justice Statistics Correctional Surveys.

Slide 11: Chance of ever going to prison, men 35 Black Latino White 35 30 30 25 25 Percent 20 20 15 15 10 10 5 5 0 0 1977 1980 1974 1983 1986 1989 1992 1995 1998 2001 Source: Bureau of Justice Statistics, “Prevalence of Imprisonment in the U.S. Population, 1974-2001.”

Slide 12: What the justice system does • Maintain a visible ‘class’ of criminals • Project an image – Threat of crime = threat from the poor • A system designed to fail – Practices that lead to crime, not prevent it • Turns the middle class against the poor – ideological function

Slide 13: And how it maintains crime • Criminalizes victimless crimes – Crimes with no unwilling victim • Arbitrary power for enforcers – Increases alienation, mistrust of the system • Prisons are painful and demeaning – Overcomes any deterrent effect

Slide 14: And how it maintains crime (2) • Failure to provide job training or jobs • Life-long stigma – No voting rights for former felons – Registration laws and police records • No legitimate means of success – No opportunity for ‘legitimate’ means Update: Today’s NYT

Slide 15: Florida’s ex-felons in 2000 57,489 26,359 Bush’s margin in Florida: 537 votes Non-voters Republican If ex-felons could vote: Democrat Gore wins by 31,003 529,666 With 613,514 disenfranchised ex-felons: Assumes 14% would have voted, 69% of them for Gore.

Slide 16: Failure to stop crime • Recent declines – Partly the result of anti-crime policies? • But still higher than 1960 rates – Same policies didn’t work for many years • Other explanations – Stabilization of the drug trade – Fewer teenagers – Economic improvement

Slide 17: California, thousands in prison 500 480 450 400 350 300 250 200 150 100 Imprisonment (left) 50 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 Sources: Bureau of Justice Statistics; Bureau of Labor Statistics.

Slide 18: California prison, murder rate 500 Murder (right) 14 450 12 400 350 10 300 8 250 200 6 150 4 100 Imprisonment (left) 2 50 0 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 Sources: Bureau of Justice Statistics; Bureau of Labor Statistics.

Slide 19: California prison, murder, jobs 500 Murder (right) 14 450 12 400 350 10 300 8 250 200 6 150 Unemployment (right) 4 100 Imprisonment (left) 2 50 0 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 Sources: Bureau of Justice Statistics; Bureau of Labor Statistics.

Slide 20: Reiman’s Pyrrhic defeat theory Pyrrhic victory: victory at such a high cost, it’s really defeat Pyrrhic defeat Failure to stop crime benefits the powerful so much it amounts to success.

Public Safety and Public Spending: Forecasting America’s Prison Population, 2007-2011

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Slide 1: Public Safety, Public Spending: Forecasting America’s Prison Population, 2007-2011 Adam Gelb, Project Director Public Safety Performance Project The Pew Charitable Trusts, Pew Center on the States October 2, 2007

Slide 2: Where We’ve Been

Slide 3: Where We’ve Been – Costs Growth in State Corrections Costs $50,000,000,000 $45,000,000,000 $40,000,000,000 $35,000,000,000 $30,000,000,000 $25,000,000,000 $20,000,000,000 $15,000,000,000 $10,000,000,000 $5,000,000,000 $0 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Source: Bureau of Justice Statistics

Slide 4: Where Are We Going? Report Objectives  To estimate the future size and cost of state and federal prison systems  To examine the reasons for projected growth  To highlight state efforts to control corrections spending  To outline the challenges ahead for state policy makers

Slide 5: Projection Formula 2011 State Prison Population = [2006 population x 0.453957294846] µ 2005 UCR ± 29384823 ÷ Census projection of 16-24 year-olds x .267 – .364SES¥ – [1/HS graduation rate x .8003] JUST KIDDING! – We called the states

Slide 6: What We Found – National

Slide 7: National

Slide 8: National

Slide 9: Estimating Future Prison Costs  Operating Costs: National average in 2005 dollars – $23,876 per inmate  Capital Costs: Midpoint estimate $65,000 per bed

Slide 10: What We Found – Costs New Prison Spending, 2007-2011 $16,000,000,000 $15,000,000,000 $14,000,000,000 $12,500,000,000 $12,000,000,000 $10,000,000,000 $8,000,000,000 $6,000,000,000 $4,000,000,000 $2,000,000,000 $0 Operating Costs Capital Costs

Slide 11: Regions

Slide 12: State Highlights

Slide 13: State Highlights 10 Lowest-Growth States  Delaware 0%  New York 0%  Connecticut 0%  Maryland 1%  Louisiana 4%  Wisconsin 5%  Tennessee 5%  Missouri 6%  Massachusetts 6%  Rhode Island 7%

Slide 14: Key Drivers and Trends  Population growth, esp. in West  Growing admissions (1980-1992)  Longer length of stay (1992- )  Probation and parole violators (60% of growth)  Women (57%) growing faster than men (34%)  Rising age (up from 31 to 34)  Methamphetamine cases  Mental health cases  Workforce recruitment and retention  Sex-offender laws will be felt in out-years

Slide 15: Tremendous State Variation

Slide 16: Tremendous State Variation Admissions x Length of Stay = Prison Population Admissions, Length of Stay Determined Largely by Policy Choices State Policy Choices = State Prison Population / Costs

Slide 17: CT –Targeted Reform  Problem  Identified technical violators as driver  Solution  Set goal of reducing TVs by 20%  Hired 96 new POs  Started 2 new supervision/service programs  Public awareness campaign  Result  Highest growth to flat  Crime drop parallel to national reduction

Slide 18: NC – Broad System Reform  Problem  Lack of truth, violent offenders serving short terms  Solution  Build prisons for violent/chronic offenders  Abolish discretionary parole release  Establish comprehensive guidelines  Create state/local partnership for low risk  Result  One of highest incarc. rates to middle of the pack  Crime fell in sync with national drop  Estimated $2 billion in savings over past 12 years

Slide 19: Exciting Time in Criminal Justice  Advances in science of behavior change  Cognitive-Behavioral Treatment  Motivational Interviewing  Contingency Management  Advances in supervision technology  Accurate, on site, rapid-result drug screens  GPS monitoring  Broad public support for alternatives  Trend toward Managing for Results  Budget pressure  Bipartisan reform efforts across the nation

Slide 20: Implications Central Question is Being Reframed OLD “How can we demonstrate that we’re tough on crime?” NEW “How can we deliver taxpayers the best return on their investment?”

Slide 21: Public Safety, Public Spending: Forecasting America’s Prison Population, 2007-2011 Adam Gelb, Project Director Public Safety Performance Project The Pew Charitable Trusts, Pew Center on the States October 2, 2007

What is the Price of Failure? A Comparative Analysis of Prevention and Delinquency in US Prisons

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Slide 1: What is the Price of Failure? A Comparative Analysis of Prevention and Delinquency Mary Magee Quinn and Jeffrey Poirier, American Institutes for Research National Center on Education, Disability, and Juvenile Justice (EDJJ)

Slide 2: Overview s The role of school-based prevention in meeting the needs of at-risk youth s The importance of ensuring at-risk youth are educated s The financial and social costs of not preventing juvenile/adult crime s The impact of the justice system on juvenile offenders and their families s The long-term benefits and savings of reduced delinquency

Slide 3: Why Prevention? s An 18 year old is five times more likely to be arrested for a property crime than a 35 year old s In 1997, 15-19 year olds comprised 7% of the overall population but 1 out 5 arrests for violent offenses and 1 out of 3 property crime arrests s Overall, teenagers are responsible for 20- 30% of all crime Source: National Bureau of Economic Research, 1999

Slide 4: Levels of Prevention Tertiary Secondary Primary

Slide 5: Primary Prevention s Strategies applied to intact groups or populations, such as a school-wide discipline plan used to help all students in a school meet behavioral and academic expectations s Focuses on avoiding the initial occurrence of a problem

Slide 6: Reading Programs s Youth in Correctional Facilities x Median age 15.5 years x 9th grade (placement) x 4th grade reading level (mean) x More than 1/3 read below 4th grade

Slide 7: Adult Literacy 40 35 30 25 Completely 20 Illiterate Functionally 15 Illiterate 10 5 0 General Incarcerated Population Adults

Slide 8: Reading Programs s Prison-based literacy programs are significantly more effective than boot camps or shock incarceration s The more education prisoners receives, the less likely they are to be re-arrested or re-imprisoned

Slide 9: Literacy s Quality reading programs can reduce recidivism by 20%. s Probationers had significantly lower re-arrest rates (35% vs. 46%) s Recipients of GED had significantly lower re-arrest rates (24% vs. 46%) s Inmates with 2 years of college (10% vs. 60%)

Slide 10: Education Level Findings from Texas study, 1994 60% 50% 40% Without degrees All Degrees 30% AA 20% BA 10% MA 0% Recidivism Rates (1990-1991)

Slide 11: Levels of Prevention Tertiary Secondary Primary

Slide 12: Secondary Prevention s Focus on preventing repeated occurrences of problem behavior through more targeted interventions s Efforts provide additional support when universal preventative efforts are not sufficient

Slide 13: Secondary Prevention s Example: students who have more than one disciplinary referral in a given month for fighting may be provided with special instruction in conflict resolution or social skills

Slide 14: High/Scope Preschool Programs s Benefits x fewer acts of misconduct x higher grade point averages x higher rates of employment x lower rates of welfare dependence

Slide 15: High/Scope Preschool Programs s Costs x $39,278 per child x $964 increased need for funds for secondary education programs s Savings x reduced need for special education x reduced crime rate x $6,495 lifetime tax payments

Slide 16: Tertiary Prevention s Most intensive level of support and intervention s Attempts to reduce the impact of a condition or problem on the individual’s ability to function in the least restrictive setting

Slide 17: Tertiary Prevention s Example: the needs of students identified as having an emotional/behavioral disability are addressed through special education services and behavior intervention plans so that they may benefit from the educational program s Includes outside agency support

Slide 18: Home Visit Programs s Costs x $2700/year from third trimester through age 2 x $6000/year for day care and early childhood education s Benefits x 11 serious crimes prevented per million dollars spent Source: RAND, 1996

Slide 19: Parent Training s Costs x $500/year per family for instruction and supplies x $2500/year per family for program management s Benefits x 157 serious crimes prevented per million dollars spent Source: RAND, 1996

Slide 20: High School Graduation s Adult Inmates in State Facilities x 70% have not completed high school x 46% have had some high school x 16.4 % have had no high school at all Source: U.S. Department of Justice, 1996

Slide 21: Graduation Incentives s Costs x $3130/year for 4 years for each youth s Benefits x 258 serious crimes prevented per million dollars spent on incentives Source: RAND, 1996

Slide 22: Delinquent Programs s Costs x $10,000/year per youth (conservative estimate) s Benefits x 72 serious crimes prevented per million dollars spent

Slide 23: Comparison of Number of Prevented Serious Crimes per Million Dollars 300 258 250 200 157 150 100 72 50 11 0 Home Visits Parent Training H.S. Graduation Incentives Delinquency Programs

Slide 24: Students with Disabilities  The arrest rate among high school dropouts with disabilities was 56%, compared with 16% among graduates, and 10% among those who “aged out” of school.  Among dropouts with serious emotional disturbances, the arrest rate was 73% three to five years after secondary school Source: SRI International, 1992

Slide 25: The Costs of Crime for Communities and Victims s Lost property and wages s Medical and psychological expenses s Decreased productivity s Pain and suffering s Decreased quality of life/societal well- being (e.g., fear of crime, changing lifestyle due to risk of victimization)

Slide 26: The Costs of Crime for Communities and Victims s Incarceration (prisons/correctional facilities) s Increased demand for criminal/civil justice services s Opportunity costs: since greater percentage of government expenditures must be dedicated to crime-related costs, fewer resources are available for education/other government services

Slide 27: Who incurs these costs? s Crime victims s Government agencies s Taxpayers s Society

Slide 28: Cost of Victimization s 23% of all U.S. households victimized s Crime victims lost $17.6 billion in direct costs in 1992 (includes losses from property theft/damage, cash losses, medical expenses, and amount of pay lost because of injury/activities related to the crime) s Crimes included: attempts and completed offenses of rape, robbery, assault, personal and household theft, burglary, and motor vehicle theft Source: U.S. Department of Justice, National Crime Victimization Survey, 1994

Slide 29: Expenditures for the Criminal and Civil Justice System s Total: $147 billion in 1999 (police protection, corrections, and judicial/legal activities) s 309% increase from 1982-1999 s Local government funded half of these expenses (note: local government funded 44% of education costs in 1999) Source: U.S. Department of Justice, 1999

Slide 30: Expenditures for the Criminal and Civil Justice System s States contributed another 39% s Criminal and civil justice expenditures comprised 7.7% of all state and local expenditures Source: U.S. Department of Justice, 1999

Slide 31: Costs of Juvenile Crime s A life of crime costs society $1.5-$1.8 million s Cost of juvenile crime: x Victim costs: $62,000-$250,000 x Criminal justice: $21,000-$84,000 3 Total: $83,000-$335,000 x For every 10 crimes committed, only one is caught x Chronic juvenile offenders are very likely to become involved in the adult system Source: Cohen, Journal of Quantitative Criminology, 1998

Slide 32: Costs of Dropping Out s In 1991, annual cost of providing for youth who fail to complete high school and their families: $76 billion s Lost wage productivity: $300,000 Source: Joint Economic Committee, 1991

Slide 33: Cost of Effective Prevention and Intervention Source: Washington State Institute for Public Policy, 2001 Program Net Cost Taxpayer Taxpayer Benefit-to- per Savings Savings Cost Ratio Participant and Victim Benefits Early Childhood $8,936 -$4,754 $6,972 $1.78 Education for Disadvantaged Youth Quantum $18,964 -$8,855 $16,428 $1.87 Opportunities Program Multidimensional $2,052 $21,836 $87,622 $43.70 Treatment Foster Care

Slide 34: The Costs of Crime for Juvenile Offenders s Separation and isolation s In correctional settings: x Negative behaviors are often reinforced x Higher rates of sexual victimization and suicide x For youth with cognitive disabilities, it is difficult to un-learn the prison experience x Lack of special education services and an absence of skill-based programming

Slide 35: The Costs of Crime for Juvenile Offenders s For youth who are sent to adult facilities, there are higher rates of re-offending and the number of serious crimes committed s More youth today are being referred to correctional settings for behaviors that are mental health related s Competing missions within the juvenile justice system (protection v. rehabilitation) s The juvenile court is not familiar with the impact of mental health/cognitive disabilities on behaviors

Slide 36: The Cost of Ignoring Families s Family involvement (surrogates, extended family, etc.) and stability are critical to the success of prevention and corrections programs s The family will be a part of the youth’s life long after the professionals leave s When parents do not have the skills/knowledge to advocate for their child’s learning/mental health needs, their children are more likely to drop out of school and become involved in the justice system

Slide 37: The Cost of Ignoring Families s Families are seen as the problem and not part of the solution, leading to increased reliance on foster care and costly, ineffective multiple placements s Families become distrustful of the systems that have failed their children often for many years s The rate of recidivism is impacted by the degree to which youthful offenders have a stable adult in their lives

Slide 38: Conclusion s Prevention/intervention programs for at-risk youth will not eliminate juvenile crime, but can reduce it and will bring net benefits to both society and the juvenile s Have a long-term vision when considering the costs of prevention programs s Consider the impact of incarceration on juvenile offenders and the role of families


The High Cost of Imprisonment in America

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U.S. Department of Justice
Office of Justice Programs
Bureau of Justice Statistics
Special Report

State Prison Expenditures, 2001[Download Full Report in PDF]

June 2004, NCJ 202949

This file is text only without graphics and many of the tables.
A Zip archive of the tables in this report in spreadsheet format
(.wk1) and the full report including table and graphics in
.pdf format are available from:

This report is one in a series. More recent editions may
be available. To view a list of all in the series go to

By James J. Stephan
BJS Statistician


States spent $29.5 billion for prisons in 2001,
about a $5½ billion increase from 1996, after
adjusting for inflation

* Prison operations consumed about 77% of State correctional
costs in FY 2001. The remaining 23% was spent on juvenile
justice, probation and parole, community-based corrections,
and central office administration.

* State correctional expenditures increased 145% in 2001
constant dollars from $15.6 billion in FY 1986 to $38.2
billion in FY 2001; prison expenditures increased 150% from
$11.7 billion to $29.5 billion.

* Excluding capital spending, the average cost of operating
State prisons in FY 2001 was $100 per U.S. resident, up from
$90 in FY 1996.

* Outlays for new prison construction, renovations, equipment,
and other capital account activities amounted to less than 4%
of total prison expenditures in most States.

* Spending on medical care for State prisoners totaled $3.3
billion, or 12% of operating expenditures in 2001.

Correctional authorities spent $38.2 billion to maintain the Nation’s
State correctional systems in fiscal year 2001, including $29.5
billion specifically for adult correctional facilities. Day-to-day
operating expenses totaled $28.4 billion, and capital outlays for
land, new building, and renovations, 1.1 billion.

The average annual operating cost per State inmate in 2001 was
$22,650, or $62.05 per day. Among facilities operated by the
Federal Bureau of Prisons, it was $22,632 per inmate, or $62.01
per day.
In a followup to a study based on FY 1996 data, this report
presents unique statistics on the cost of operating State
prisons in FY 2001. Information was obtained by extracting
corrections data from each State’s responses to the U.S.
Census Bureau’s annual Survey of Government Finances. Item
categories were standardized across jurisdictions, and
reported figures were verified with State budget officials.

Expenditures are the total amounts paid for prison operations,
including interest on indebtedness. Figures are net of amounts
derived from revenue-generating activities such as farm and
industrial production and services.

The increase in cost of corrections outpaced
the cost of health, education, or natural

State spending for corrections increased from $65 per resident
in 1986 to $134 in 2001. Per capita expenditures for State
prison operations alone rose from $49 in 1986 to $104 in 2001.

At an average annual increase of 6.2% for total State correctional
spending and 6.4% specifically for prisons, increases in the cost
of adult incarceration outpaced those of health care (5.8%),
education (4.2%), and natural resources (3.3%).

Although correctional spending grew at a faster rate than many
other State payments between 1986 and 2001, it remained one of
the smaller cost items. For example, the outlay for education,
at $374.5 billion, was nearly 10 times larger, and that for
welfare, at $260.3 billion, was nearly 7 times larger.

State correctional expenditures include the cost of operating
prisons and related institutions. Such institutions are
reformatories; prison farms; centers for the reception,
evaluation, and classification of inmates; and correctional
facilities exclusively for the criminally insane or for the
treatment of drug and alcohol addiction. State correctional
expenditures are primarily for operating adult facilities.
Other spending pays for juvenile correctional activities,
adult parole boards and programs (including court programs),
and correctional administration not associated with specific
penal institutions.

States spent $29.5 billion on prisons
in fiscal 2001

State prison expenditures totaled $29.5 billion in fiscal year
2001. Adjusted for inflation, this was approximately $5.5
billion more than was spent in FY 1996.

California reported the largest prison expenditure, $4.2
billion, and North Dakota the smallest, $26.8 million.

As a non-State activity, correctional spending by the Federal
Bureau of Prisons (BOP) was outside the scope of this report.
However, outlays for its operations in FY 2001 amounted to
$3.8 billion, or about 11% of the Nation’s prison expenditure.

Operating costs averaged $22,650
per inmate in fiscal year 2001

State prison operating expenditures totaled $28.4 billion in
fiscal year 2001. This total, divided by the number of
prisoners, produced a nationwide average annual operating
cost per inmate of $22,650. Adjusted for inflation, the
equivalent figure in 1996 was $22,515.

The average operating cost to incarcerate one inmate in the
Federal Bureau of Prisons system during FY 2001 was $22,632.

The $28.4 billion State operating cost, divided by the U.S.
resident population, resulted in a nationwide average
operating expenditure of $100 per person. The highest costs
per resident were recorded in the District of Columbia
($251), Alaska ($243), and Delaware ($204). The lowest costs
per resident were in West Virginia ($34), North Dakota ($38),
and New Hampshire and Minnesota ($48 each).

State correctional systems with integrated jail-prison facilities
may have higher operating costs than other jurisdictions because
the costs of housing jail inmates are included as State
expenditures. Of the six States with integrated jail-prison
systems in 2001, four had average annual operating costs per
resident above the average for States not operating integrated

Compared to 1996, prison spending in 2001 revealed a greater emphasis
on facility operation

Over three-fourths of the States spent 96% or more of prison funds
on current operations such as salaries, wages, benefits, supplies,
maintenance, and contractual services. In 1996 State spending on
current operations accounted for 94% of total expenditures.

The District of Columbia, Hawaii, Alaska, Tennessee, and Utah
allocated all or nearly all prison expenditures to current
operating activities. By contrast, Nebraska spent the lowest
proportion (79%), followed by Missouri (83%), Wisconsin (84%),
and Wyoming (86%).

Salaries, wages, and benefits made up about two-thirds of State
prison operating expenditures, nationwide, in 2001. Other
operating costs comprised about a third. Other operating costs
covered a wide variety of outlays, such as inmate health care,
food, utilities, supplies, fees, commissions, and contractual

A majority of States spent 4% or less of prison expenditures on capital projects

Thirty-seven jurisdictions used 4% or less of all prison dollars
to finance new construction, renovations, major repairs,
equipment, land, buildings, and other nonrecurring outlays during
FY 2001. Among this group, the District of Columbia, Alaska, Hawaii,
and Utah spent less than 1%. Four other States allocated significant
proportions of prison funds to capital projects: Nebraska (21%),
Missouri (17%), Wisconsin (16%), and Wyoming (14%).

Spending on State prison capital projects decreased 25% from 1996 to 2001

Total capital expenditures of State prisons, adjusted for
inflation, declined 25% from $1.5 billion in FY 1996 to
$1.1 billion in FY 2001.

Many factors associated with variation in prison costs

Much of the variation between States in the cost of operating
prisons was outside the influence of correctional officials:
differences in the cost of living, variation in prevailing
wage rates, climate, and other factors. Although important,
they were beyond the scope of this study.

However, certain corrections-related factors were possible to
analyze. For example, employee salaries, wages, and benefits
consumed more than half of prison operating expenditures.
Their influence was measurable by comparing inmate-to-staff
ratios with operating costs per inmate. High inmate-to-staff
ratios were most common in States reporting low average costs
per inmate, and low inmate-to-staff ratios predominated in
States with high average annual costs per inmate.

Cost savings may also have been made from the operation of
larger capacity prisons. Eight of the 10 States with average
annual operating expenditures per inmate over $30,000 had an
average number of inmates per facility under 800. By contrast,
3 of the 7 States with average annual operating expenditures
per inmate under $15,000 had an average number of inmates per
facility over 800.

Transfer payments, which included intergovernmental monies
from one government to another as well as intra-governmental
payments from one department or agency to another, varied
significantly by State. In the 1996 State prison expenditure
study, when these payments were last identified separately,
departments of corrections in the South received about 8% of
their total expenditures from transfer payments, compared to
about 4% in other regions.

More than three-fourths of State prison capital expenditures were
for new construction, renovations, and major repairs, including
fees and services of architects, engineers, appraisers, and
attorneys. In FY 2001 these components consumed nearly the
entire capital account in Missouri (99%) and Washington (97%).

The second-largest capital expenditure was for equipment purchases
and installations, including furnishings, office equipment, motor
vehicles, and other devices having a useful life of more than 5
years. The average outlay was approximately 23% of total capital
spending. In Alaska, Delaware, Nevada, and Utah, however, equipment
accounted for the entire capital spending category in FY 2001.

The purchase of land, rights-of-way, existing structures, title
searches, and related costs (not shown in table 4)included less
than half of 1% of State prison capital expenditures, nationwide.
Four States reported outlays in this category that exceeded 2%:
Oregon (4.6%), New Mexico (3.9%), Florida (3.4%), and Arkansas

Over a quarter of prison operating costs for basic living expenses

Prisoner medical care, food service, utilities, and contract
housing totaled $7.3 billion, or about 26% of State prison
current operating expenses.

Inmate medical care totaled $3.3 billion, or about 12% of
operating expenditures. Supplies and services of government
staff and full-time and part-time managed care and fee-for-
service providers averaged $2,625 per inmate, or $7.19 per
day. By comparison, the average annual health care
expenditure of U.S. residents, including all sources in FY
2001, was $4,370, or $11.97 per day.***Footnote: U.S.
Department of Health and Human Services, National Center for
health Statistics, citing Centers for Medicare and Medicaid
Services in Health, United States, 2003, table 116.***

Five States reported annual medical costs per inmate above
$4,000: Maine ($5,601), New Mexico ($4,665), California
($4,394), Massachusetts ($4,049), and Alaska ($4,047).
Three States spent less than $1,000 per inmate: Louisiana
($860), Montana ($922), and Kentucky ($960).

Factors beyond the scope of this report contributed to the
variation in spending levels for prisoner medical care.
Lacking economies of scale, some States had significantly
higher than average medical costs for everyone, and some
had higher proportions of inmates whose abuse of drugs or
alcohol had led to disease. Also influencing variations in
expenditures were staffing and funding of prisoner health
care and distribution of specialized medical equipment for
prisoner treatment.

Food service in FY 2001 cost $1.2 billion, or approximately 4%
of State prison operating expenditures.

As a percentage of total prison operating costs, South Dakota
and Hawaii allocated the largest proportions to food services,
11.3% and 8.2%, respectively, and North Carolina and Oregon
allocated the smallest proportions, 0.7% and 1.8%.

On average nationwide, State departments of correction spent
$2.62 to feed inmates each day. Pennsylvania ($5.69) and
Washington ($5.68) reported the largest amounts, followed by
Maine ($5.03), Hawaii ($4.87), and Iowa ($4.81). North
Carolina indicated the lowest cost ($0.52), followed by
Alabama ($0.72), Mississippi ($0.81), and Louisiana ($0.96).

Reports of low food costs often reflected prisoner-operated farm
and food processing operations. or example, Mississippi State
Penitentiary, Parchman, and South Mississippi State Penitentiary,
Leakesville, grew a wide variety of fruits, vegetables and grains,
and raised livestock for other Mississippi prisons. Prison
enterprises in North Carolina operated a cannery, a meat
processing plant, warehouses, and trucks to deliver food and
equipment to correctional facilities statewide.

Utility services for electricity, natural gas, heating oil, water,
sewerage, trash removal, and telephone in State prisons totaled
$996 million in FY 2001.

Utilities accounted for about 3.5% of State prison operating
expenditure. Among individual States, they consumed the most
in Alabama (5.7%), New Hampshire and Virginia (5.6%), and the
least in Rhode Island (0.5%), and Montana (1.5%).

Daily utility costs ranged from a high of $5.43 per inmate in
Massachusetts, $4.52 in Alaska, and $4.50 in Maine to a low of
$0.55 in Rhode Island, $0.89 in Louisiana, and $0.92 in

40 State correctional systems paid others to house some prisoners

All but 11 States had expenses relating to the contract housing
of prison inmates in private facilities, local jails, other
States’ facilities, or Federal facilities. The 11 States not
reporting con- tract housing costs for inmates in FY 2001 were
Alabama, Iowa, Kansas, Illinois, Maine, Massachusetts, Missouri,
New Hampshire, North Carolina, Washington, and West Virginia.

Contract housing averaged 6% of operating expenses, nationwide.
However, seven States spent more than 3 times this proportion:

Montana spent $26.1 million, all of it to house inmates in
private facilities. Louisiana paid $171.1 million, 81% of
it to house inmates in local jails; and Tennessee spent
$150.7 million, about a third of it to hold inmates in
private facilities and two-thirds in local jails.


Following a procedure similar to that used to produce State
Prison Expenditures, 1996, BJS asked government finance
specialists at the U.S. Census Bureau to identify each
State’s corrections function codes, as reported in the FY
2001 Survey of Government Finances. Census staff entered this
information into a data base, using a standardized format
provided by BJS.

The data to produce the graph in the Highlights on page 1 are
available with other tables of the report on the BJS
website < bjs>. These data include inflation-
adjusted costs for total State corrections and prisons as well
as costs per U.S. Resident.

This data extraction procedure included both inter- and
intragovernmental transfer payments, and clarified missing,
repetitious, and out-of-range data items.

Both department of corrections and State central office budget
specialists were asked to review the originally submitted numbers.
These officials worked with the Census Bureau to eliminate
duplicate reports, interpret expenditure codes, and understand
organizational functions and accounting procedures.

Budget officials sharpened the scope of the study by including
expenditures for central office personnel who performed prison
activities and deleting outlays that pertained to probation and
parole services, juvenile corrections, and nonresidential
community corrections — areas outside the prison function.

Upon final approval by each State’s designated financial
reviewer, Census staff completed the data adjustment
phase of the project with a 100% response rate for total
and operating expenditures.


Correctional expenditures shown in the Highlights figure may be
underreported. As the result of discussions between State budget
officials and U.S. Census Bureau specialists in government
finance who collected the data for this report, the total cost
to operate State prisons in FY 2001 was 1.1% higher than
originally reported to the Census Bureau in the 2001 Survey of
Government Finances.

Factors which contributed to the revised FY 2001 State prison
spending figure included adjustments for central office staff
assigned to prison, probation, parole, and juvenile activities;
elimination of duplicate fund reporting; and access to final
numbers following State submissions of preliminary numbers in
the Survey of Government Finances.

Data limitations

Expenditure data published in State Prison Expenditures, 2001
and State Prison Expenditures, 1996 were reported by State
budget officials, based on categories established by the
Census Bureau’s annual Survey of Government Finances. Previous
State prison cost data published by BJS were reported by
correctional facility operators.

Adjusting for inflation

State government expenditures for fiscal years 1996 and 2001
were inflation-adjusted in 2001 constant dollars, as
appropriate for State and local government spending. The
following annual chain-type price indexes for gross domestic
product were employed as divisors and unadjusted
expenditures as dividends to produce inflation-adjusted
expenditures in 2001 constant dollars:

The Bureau of Justice Statistics is the statistical
agency of the U.S. Department of Justice. Lawrence A.
Greenfeld is director.

James J. Stephan wrote this report and coordinated
data collection, under the supervision of Allen J.
Beck. Tracy L. Snell provided statistical
verification. Tina Dorsey and Tom Hester produced
and edited the report. Jayne Robinson prepared the
report for final printing.

Howard Trott, Shelley Blake, and James Batton of the
U.S. Census Bureau, Governments Division, Finance
Branch coordinated the data extraction process and
verified the information reported by State officials,
under the direction of Steven Owens. Pamela Butler
prepared the data for review by State contacts, under
the direction of Charlene Sebold.

June 2004, NCJ 202949 C