Disease and death rates for people who are incarcerated in our nation’s jails are underreported and not transparent. In correctional facilities, there are often few resources for physical and mental health care, despite the constitutional right of incarcerated people to receive such services.
One potential solution is to institute a health care accreditation process in jails. However, not many facilities have tried it, and both advocates and correctional experts are divided on whether it would help.
To test the effects of accreditation of health services in jails, a research team at Harvard University, with support from Arnold Ventures (AV), conducted a four-year randomized controlled trial (RCT) – believed to be one of the first RCTs of jails in the United States, and the first RCT of accreditation.
Marcella Alsan, the Angelopoulos professor of public policy at the Harvard Kennedy School of Government and the Harvard School of Public Health, and Crystal Yang, the Bennett Boskey professor of law at the Harvard Law School, randomized the timing that interested jails underwent the accreditation process (and also provided financial subsidies to cover the accreditation fees).
The resulting paper, “The Hidden Health Care Crisis Behind Bars: A Randomized Trial to Accredit U.S. Jails,” finds strong causal evidence that accreditation of health services in jails improves health processes, staff collaboration, and, importantly, health outcomes for incarcerated people. It also finds that accreditation can reduce recidivism, thus improving public safety.
“There is substantial and growing evidence that improving access to health care for those at high risk of criminal justice involvement puts people on a better path and reduces crime,” said Jennifer Doleac, Executive Vice President of Criminal Justice at AV. ”A key question going forward is how to do this in practice, particularly for those who are currently incarcerated. This ambitious study tests the effect of accreditation – something that might sound like bureaucratic red tape but turns out to have a big impact.”
We spoke with Alsan and Yang about how health care accreditation in jails can improve outcomes for incarcerated people and their communities.
This conversation has been edited for clarity.
Arnold Ventures
What is health accreditation as it relates to jails?
Crystal Yang
Accreditation happens when either a third party or a government agency inspects services and ensures that quality meets an industry-based standard. Accreditation is widespread for health care services in the United States. Almost all hospitals are accredited, and they have incentives to undergo that process. In correctional facilities, accreditation is fully voluntary and only 17% have undergone the process.
We studied whether health care accreditation in jails can improve processes and outcomes for incarcerated people. We partnered with the National Commission on Correctional Health Care (NCCHC), the gold-standard correctional accrediting body. They do a multiple-day audit of facilities’ health care services, interview staff, and speak with incarcerated people to determine whether the facility meets standards. Some facilities immediately get accredited, but many have deficiencies to correct.
Arnold Ventures
What problem is health care accreditation in jails trying to address?
Marcella Alsan
In jails, there are numerous challenges that make providing quality health care difficult, and we found that death rates are substantially higher than what is reported in the media and official statistics.
Crystal Yang
That discrepancy is what motivated the paper’s title: “the hidden health care crisis.” We also see a huge spike in deaths in the summer months, which is consistent with other work on lack of air conditioning and crowding that can occur during summer. Altogether, the data shows an alarming picture of conditions in our nation’s jails.
Arnold Ventures
How did you each become personally invested in this issue?
Marcella Alsan
For many years, I worked as a practicing physician in infectious disease, and I saw a lot of patients who have substance use issues, HIV, and other vulnerabilities. You get to know them, you hear about their experiences with jail facilities, and you really get to see the costs of the correctional system.
Crystal Yang
I worked as a federal prosecutor, and I’m interested in vulnerable populations in the criminal justice system. If you think about the jail population, it is the logical place to intervene if you can. Jails see more than 7 million admissions every year and represent one of the earliest stages of interaction between people and the criminal justice system. Going into this project, we wanted to intervene at an earlier stage so that people can obtain required medical care and stay healthier, which is good for them and the community.
Arnold Ventures
How did you design this study?
Crystal Yang
We designed an RCT, which gives us the ability to isolate the causal effect of receiving accreditation. We recruited 44 jails, with 22 in the control group and 22 in the treatment group. All 44 received a financial incentive, which is where our funders, including Arnold Ventures, played a major role. The treatment group began the accreditation process immediately, and they received up to 100% subsidy for their accreditation fee. The control group received a lower subsidy to undergo the accreditation process at the end of the study. That allowed us to compare the two groups. We were lucky to find jails that were willing to undergo this intensive study.
Arnold Ventures
What did your study find?
Crystal Yang
Our staff survey finds that measures of coordination and collaboration between the custody and health staff improve significantly at the accredited facilities. That is important, because in a jail, unlike in the civilian health care system, you depend on both the custody staff and the medical staff to provide health care. We also find significant increases in personnel credentials and training in the accredited facilities.
Additionally, we see improvements in timely medical and mental health screenings. This is important, because a lot of facilities were not doing that before undergoing the accreditation process, which means they could be missing urgent health crises. These screenings help better triage incarcerated people.
At the end of the paper, we do a rough cost-benefit analysis, and the net benefits of accreditation, under very conservative assumptions, are anywhere from $9 million to more than $90 million per facility per year. So, this is also a hugely cost-effective intervention.
Arnold Ventures
Did you see a change in mortality for incarcerated people?
Crystal Yang
We find a stunning nearly 90% reduction in mortality among the treatment facilities that received accreditation versus control facilities. The back-of-the-envelope calculation is that during the course of our study, receiving accreditation saved nearly 20 lives. It is a highly robust finding. It suggests that staff coordination and other improved processes are leading to measurable improvements in health care outcomes.
Arnold Ventures
Does accreditation have positive impacts on community safety?
Crystal Yang
We find that accreditation leads to a substantial decline in six-month recidivism. The recidivism findings are somewhat secondary, because we could only scrape or obtain booking records for 32 facilities. Still, it is a 50% to 60% decrease. We think that is really heartening. There is often a belief amongst the public, policymakers, and some academics that bad or punitive conditions in correctional facilities could deter people from committing additional crimes. Our findings counter that view. They suggest that by improving health care conditions, you can reduce recidivism. In other words, better conditions can lead to less additional crime. That generates improvements not only for those individuals but also for community safety.
Arnold Ventures
Why is it important to do rigorous research on public policy?
Marcella Alsan
Health in jails is a really important subject. These are human beings. Their lives are at stake. RCTs are the Cadillac, gold standard, and you want to generate the best evidence you possibly can and then translate it in a way that policymakers can comprehend. Unfortunately, there is no shortcut.
