1. The Health Consequences of Incarceration Michael Massoglia Penn State University

2. 2 Basic Questions Does incarceration affect later physical health? Does incarceration affect later physical health? Does incarceration explain some of the racial disparity in health between whites and nonwhites? Does incarceration explain some of the racial disparity in health between whites and nonwhites?

3. Mechanisms and Processes The correlates of health and crime are similar. The correlates of health and crime are similar. Macro structures: Inequality, poverty, residential conditions. Macro structures: Inequality, poverty, residential conditions. Shaw and Mckay (1934) Shaw and Mckay (1934) Life course markers: Marriage, educational attainment, income Life course markers: Marriage, educational attainment, income Individual factors: Substance use, risk taking behavior Individual factors: Substance use, risk taking behavior

4. Spurious Associations Lifestyle theories: Lifestyle theories: Suggests an association may be evident, but a function of lifestyle choices (i.e. drug use) and therefore spurious Suggests an association may be evident, but a function of lifestyle choices (i.e. drug use) and therefore spurious Personality theories: Personality theories: Suggests an association may be evident, but a function of underlying individual characteristic (i.e. risk taking behavior) and therefore spurious Suggests an association may be evident, but a function of underlying individual characteristic (i.e. risk taking behavior) and therefore spurious

5. Linking Health to Incarceration Status Social Bonds and the Life Course Social Bonds and the Life Course Fractured bonds Fractured bonds Living Conditions Living Conditions Exposure to disease and stress Exposure to disease and stress Social Hierarchy Social Hierarchy Societal participation and control over life Societal participation and control over life

6. Racial Differences In Health One of the most persistent findings in the literature indicates racial inequalities in health One of the most persistent findings in the literature indicates racial inequalities in health Whites have better health than minorities across almost all indicators of health Whites have better health than minorities across almost all indicators of health Williams and Collins (1995) conclude that black health functioning has worsened over the last 25 years Williams and Collins (1995) conclude that black health functioning has worsened over the last 25 years Blacks can expect to live fewer years while at the same time living more of their life with chronic disease (Hayward 1999) Blacks can expect to live fewer years while at the same time living more of their life with chronic disease (Hayward 1999) Large scale systems of inequality are often used to explain these persistent health differences Large scale systems of inequality are often used to explain these persistent health differences

7. Incarceration in the United States Significant increase in rates of incarceration over the last 25-30 years Significant increase in rates of incarceration over the last 25-30 years Incarceration a “phase in the life course” for some individuals, particularly poor minorities (Pettit and Western 2004) Incarceration a “phase in the life course” for some individuals, particularly poor minorities (Pettit and Western 2004) Risk of imprisonment: Changes from 1979-1999 Risk of imprisonment: Changes from 1979-1999 Whites (1.4------2.9) Less than HS (4.1----11.2) Whites (1.4------2.9) Less than HS (4.1----11.2) Blacks (10.5----20.5) Less than HS (17.1---58.9) Blacks (10.5----20.5) Less than HS (17.1---58.9)

8. Incarceration in the United States Correctional policies and the emergence of a new “felon class” in society. Estimates indicate this new “class” comprises … Correctional policies and the emergence of a new “felon class” in society. Estimates indicate this new “class” comprises … 7.5 percent of the adult population 7.5 percent of the adult population 22.3 percent of the black adult population 22.3 percent of the black adult population 33.4 percent of the black adult male population 33.4 percent of the black adult male population (Uggen et al 2006) (Uggen et al 2006)

9. Prisons and Inequality System of inequality? System of inequality? Prisons and stratification in the labor market and earnings (Western and Beckett 1999; Western 2002; Pager 2003) Prisons and stratification in the labor market and earnings (Western and Beckett 1999; Western 2002; Pager 2003) In the labor market, Pager concluded the “mark” of a criminal record is more detrimental to blacks In the labor market, Pager concluded the “mark” of a criminal record is more detrimental to blacks Disruption of the marriage market more severe for blacks (Staples 1987; Wilson) Disruption of the marriage market more severe for blacks (Staples 1987; Wilson) Irwin (1985) “underclass of society” Irwin (1985) “underclass of society”

10. Prisons and Exposure National Commission on Correctional Health Care report (2002) National Commission on Correctional Health Care report (2002) Total HIV/AIDS: 151,000-197,000 (20- 26%) Total HIV/AIDS: 151,000-197,000 (20- 26%) Hepatitis B: 155,000 (12-16%) Hepatitis B: 155,000 (12-16%) Hepatitis C: 1.3-1.4 million (38%) Hepatitis C: 1.3-1.4 million (38%) Tuberculosis outbreaks linked to correctional institutions Tuberculosis outbreaks linked to correctional institutions

11. Data National Longitudinal Survey of Youth (NLSY79) National Longitudinal Survey of Youth (NLSY79) A comprehensive health module in the NLSY, given to respondents at the age of 40 (N=5556) A comprehensive health module in the NLSY, given to respondents at the age of 40 (N=5556) Dependent Variable: Measure of physical health functioning at age 40. Dependent Variable: Measure of physical health functioning at age 40. A composite indicator capturing a range of health functioning taken from a widely used health questionnaire (SF-12) A composite indicator capturing a range of health functioning taken from a widely used health questionnaire (SF-12)

12. NLSY Equally divided between men and women, ages 40-44, 66% married. Equally divided between men and women, ages 40-44, 66% married. 20% at or below 125% of poverty level. 20% at or below 125% of poverty level. Approximately 75% white, average 13.7 years of schooling, 81% in the labor force. Approximately 75% white, average 13.7 years of schooling, 81% in the labor force. About 23% report binge drinking (5 drinks at one time, 2-3 times a month) or cigarette use. Slightly less than half the sample reports weekly exercise. About 23% report binge drinking (5 drinks at one time, 2-3 times a month) or cigarette use. Slightly less than half the sample reports weekly exercise. Slightly more than 5% of the sample was incarcerated, disproportionately minority. Average time of incarceration about 34 months. Slightly more than 5% of the sample was incarcerated, disproportionately minority. Average time of incarceration about 34 months.

13. Basic Associations in Health

14. Health Values-Racial Differences

15. Two types of analysis Regression analysis with covariate adjustment Regression analysis with covariate adjustment Controls for prior health, life course markers, and lifestyle indicators Controls for prior health, life course markers, and lifestyle indicators Propensity models Propensity models Account for differences across persons or groups in the likelihood of experiencing a treatment Account for differences across persons or groups in the likelihood of experiencing a treatment Rationale: Non-random likelihood of experiencing incarceration may bias the results generated from OLS Rationale: Non-random likelihood of experiencing incarceration may bias the results generated from OLS

16. Propensity Score Models Account for differences across persons or groups in the likelihood of experiencing a treatment. Account for differences across persons or groups in the likelihood of experiencing a treatment. Rationale: Non-random likelihood of experiencing incarceration may bias the results generated from OLS. Rationale: Non-random likelihood of experiencing incarceration may bias the results generated from OLS. Average effects and standard estimator (Rosenbaum and Rubin 1983: Winship and Morgan 1998). Average effects and standard estimator (Rosenbaum and Rubin 1983: Winship and Morgan 1998). The way individuals are assigned, or assign themselves, to the treatment determines how effectively the standard estimator estimates the true effect. The way individuals are assigned, or assign themselves, to the treatment determines how effectively the standard estimator estimates the true effect. Key assumption: Assignment into treatment is uncorrelated with outcome. Key assumption: Assignment into treatment is uncorrelated with outcome. Tables.pdf Tables.pdf Tables.pdf

17. Discussion Incarceration is a powerful predictor of health Incarceration is a powerful predictor of health Suggest incarceration impacts health multiple ways Suggest incarceration impacts health multiple ways Disease and stress exposure Disease and stress exposure Fractured social bonds Fractured social bonds Social hierarchy and social status Social hierarchy and social status Contributes to racial inequalities in physical health Contributes to racial inequalities in physical health

18. Implications for Policy Prison as part of the health care system. Prison as part of the health care system. Much attention toward health care while in prison. Yet little attention toward the long term health implications. Much attention toward health care while in prison. Yet little attention toward the long term health implications. Consequences of releasing 600,000 people a year from prisons. Consequences of releasing 600,000 people a year from prisons. Prison programs that promote maintaining social bonds. Prison programs that promote maintaining social bonds. Social policies that promote societal reintegration Social policies that promote societal reintegration Education and workplace skills programs. Education and workplace skills programs. Restoring the rights of inmates. Restoring the rights of inmates.

19. Directions for Future Work Short term vs long terms effects of incarceration Short term vs long terms effects of incarceration Gender differences Gender differences Regional or institutional variation Regional or institutional variation Variation in mental health Variation in mental health