By Jayne Price

This report forms part of PRT’s National Lottery Community Fund funded Building Futures Programme that, since 2020, has been exploring the experiences of people serving long-term prison sentences. The programme has defined its long-term cohort to include those men that will spend 10 or more years in prison and eight years or more for women. Based on consultation with 121 men and women aged 50 and over serving these sentences in 39 prisons in the UK, it provides insights into the age-specific experiences of this cohort. It aims to influence positive changes that would provide a more humane prison experience that recognises the distinct needs of this group. The prison population is ageing (around 17% of people inside are aged 50 and over). By July 2025 it is projected that the population aged 50 years and over will increase from 14,193 (November 2022) to 14,800. This shift is being driven by increased longevity amongst the general population as well as specific patterns of crime and sentencing. These trends are compounding pressures on a system that has been overcrowded every year since 1994 and where staff shortages continue to dog the system. These trends present significant challenges to the government, the prison system, those who live and work within it, and those responsible for providing services, including health and social care. These challenges include meeting human rights and equalities duties, such as the right to dignity and family life, and the right not to be discriminated against due to protected characteristics (including age and disability). These concerns have helped to drive an increase in research on the experience of older people in prison. For example, in 2020 the House of Commons Justice Committee published the findings of its inquiry into the ageing prison population. It found poor coordination between prisons, local authorities and social care providers; high levels of inconsistency in reasonable adjustments to meet the needs of those with disabilities; and a shortage of activities tailored for and accessible to older people in prison. The committee called for a national strategy for older prisoners, concluding that: “The greater needs of older prisoners and the challenges many prisons face in meeting these warrants a specific policy for the cohort.” PRT was one of many organisations to welcome the government’s commitment to produce such a strategy and its announcement in October 2020 that a steering group had begun to work on priorities that would include measures to ensure that older people in prison: • Are held in the most appropriate environments. • Can access a purposeful regime within prison. • Can access health and social care services equivalent to those within the community. • Are prepared for their release and resettled effectively. Findings The Older Offender Strategy is yet to be published. For this reason, our proposals are incorporated under our central recommendation that, as a matter of urgency, the government should publish a draft national strategy for rapid consultation and final publication before the end of the parliamentary year. These proposals are based on our consultation, and this report aims to ensure that the experiences, needs and ideas of older people with lived experience of prison can contribute to this positive change. Below we summarise key themes identified by participants. • Sentencing and adapting to prison life. For many participants, having already ‘lived a life’ minimised the feeling of ‘missing out’ and provided a sense of emotional maturity, which made adapting to the sentence easier than if it had happened at an earlier life-stage. However, this could also exacerbate people’s sense of loss. Having had independence, with the ability to make choices and have ‘normal’ responsibilities, the loss of autonomy was hard to accept. There were few opportunities to grieve this previous life, and respondents felt themselves becoming deskilled, disconnected, and institutionalised. • Relationships outside. Participants spoke about alternate lives continuing outside, with families and friends moving on without them. They talked about how having limited relationships with people on the outside impacted their motivation for leaving prison, and compounded feelings of loneliness and disconnection. Many had or expected to experience bereavements of loved ones whilst inside or have been/will be ‘deserted’ by family members unwilling to maintain their relationship. Some will leave prison with no friends or family to return to. Others are faced with the prospect of their own death in prison. • Purposeful activity. Many participants felt that education, behavioural programmes, and other activities were focused on the needs of younger people and/or were difficult to access. They reported few opportunities to engage with programmes aimed at the older prisoner cohort, and a high number of activities were based on employment, which was not always relevant to this group. Some wanted more opportunities to use the skills they had as a way of using their time purposefully, including peer mentoring or teaching roles that could benefit others. • Relationships inside. Despite the desire to provide support to younger prisoners, participants reported that the relationship between different age groups in prison could sometimes be strained. Older prisoners spoke of favouring a quieter, calmer environment, and being more compliant. The risk of elderly prisoners becoming vulnerable to intimidation and humiliation around their age-related health needs was also raised. • Health and wellbeing. Participants spoke about the importance of dignity around growing old in prison, particularly in relation to health and social care. For example, some shared instances of being unnecessarily cuffed when attending hospital visits. As participants age, the importance of these issues grows. From menopause to mobility-restricting conditions, participants faced a multitude of health concerns and faced barriers in getting the healthcare they required. They felt that their diet, physical space and day-to-day lifestyles (often sedentary and isolated) accelerated the onset of frailty and worsened health outcomes.

London: Prison Reform Trust, 2024. 52p.

By Claudia Vince and Emily Evison

Progression refers to the processes through which people in prison move through the system towards release. This includes engaging in formal programmes and interventions to reduce their risk levels, as well as spending time in different prison spaces, including lower security conditions. Often, progression and risk as concepts are conflated and many prisoners report feeling confused by what is being asked of them. For those serving long sentences, their route to freedom is determined by sentence progression. Therefore, progression is a key concern for people serving long and indeterminate prison sentences. Our previous work has highlighted some challenges faced by long-sentenced prisoners in the male estate, including how prisoners often feel confused and uncertain about how they are meant to progress, and to make positive, productive use of their time. Many prisoners we consulted with noted they spent years – and sometimes decades – feeling stagnant and stuck in the system, unable to engage in meaningful personal development.1 For women serving long sentences, opportunities for meaningful progression are consistently reported as a major concern. A lack of specialist spaces for long-termers, issues surrounding what programmes are available in each prison, and a lack of tailored support from staff mean many women are at a loss in how to progress through their sentence. Our third Invisible Women briefing will focus on the lived reality of how it feels as a woman to serve a long prison sentence, paying attention to the ways the prison service does – and does not – equip women to progress through their sentence towards release. The briefing is the result of long-term consultation work with our Building Futures Working Groups in HMPs Send and Bronzefield, ad hoc groups in HMP New Hall, responses to consultation questions from women in our Building Futures Network, and consultation with a woman now living in the community

London: Prison Reform Trust, 2024. 20p.

By Prison Reform Trust

With the advent of the 21st century, there has been increased emphasis on the ‘movement for public and service user involvement in human service education and research’, which constitutes ‘the knowledge base of the services and practitioners we may all need to turn to at particular times in our lives for help and support’ (Beresford & McLaughlin 2020). Terminology such as ‘service users’, ‘experts by experience’, and ‘people with lived experience’ are somewhat broad and contested (see Livingstone & Cooper 2004; Repper & Breeze 2007; McLaughlin 2009), and seek to describe individuals and groups who have first-hand experience of or have been in contact with a range of services (typically but not exclusively provided by the public sector) and have amassed expertise related to the impact of these services. This includes sectors such as physical and mental health, social care, education, as well as criminal justice, in particular prisons and probation. Inclusion of the perspectives of service users in the fields related to social work, health and mental health services increasingly constitutes embedded practice. The following report: • Provides a rationale for engaging service users in prison officer training. • Summarises key literature on what makes a high performing prison officer, with emphasis on the areas where the perceptions of staff, prisoners, policy makers and experts without lived experienced overlap. • Explores examples of service user involvement with staff training from the literature.

Literature searches were conducted using GoogleScholar and idiscover. While there has been a marked increase in literature related to service user involvement in research and evaluation practices, there remains a distinct deficiency in literature related to their involvement in the recruitment and assessment of staff. This is especially acute in the field of criminal justice, in which service users continue to complain of paternalistic or distrusting attitudes and tokenistic attempts at inclusion outside of programmes related to peer mentoring (Buck et al. 2020). Academic literature analysing service user involvement tends to approach the topic from the perspective of the experience of service user participation in research. Methods employed tend to be qualitative in nature, focus on storytelling, focus groups and interviews, with small samples, or take an autobiographic or semi-biographic approach. Outside the academic literature, the focus tends to be on positioning statements, statements of purpose, and advice and toolkits. Considering the absence of pertinent literature, this review draws on grey literature, including publications, studies, and reports in the fields of mental health and social care to demonstrate that a) meaningful inclusion of service users in staff recruitment and evaluation is possible, and b) that there are several methods pertinent to this area of research that exist within the broader literature

London: Prison Reform Trust, 2024, 45p.

By Eli Miller, Bryan D. Martin, and Chad M. Topaz

During the early stages of the COVID-19 pandemic in 2020, Mayor Bill de Blasio ordered the release of individuals incarcerated in New York City jails who were at high risk of contracting the disease and at low risk of committing criminal reoffense. Using public information, we construct and analyze a database of nearly 350,000 incarceration episodes in the city jail system from 2014—2020, paying special attention to what happened during the week of March 23—29, 2020, immediately following the mayor’s order. In concordance with de Blasio’s stated policy, we find that being discharged during this focus week is associated with a lower probability of readmission as compared to being discharged during the same calendar week in previous years. Furthermore, comparing the individuals discharged during the focus week of 2020 to those discharged during the same calendar week in previous years, we find that the former group was, on average, slightly older than the latter group, although the difference is not large. Additionally, the individuals in the former group had spent substantially longer in jail than those in the latter group. With the release of long-serving individuals demonstrated to be feasible, we also examine how the jail population would have looked over the past six years had caps in incarceration been in place. With a cap of one year, the system would experience a 15% decrease in incarceration. With a cap of 100 days, the reduction would be over 50%. Because our results are only as accurate as New York City’s public-facing jail data, we discuss numerous challenges with this data and suggest improvements related to the incarcerated individual’s age, gender, race, and more. Finally, we discuss the policy implications of our work, highlight some opportunities and challenges posed by incarceration caps, and suggest key areas for reform. One such reform might involve identifying and discharging low-risk individuals sooner in general, which might be feasible given the de Blasio administration’s actions during the early stages of COVID-19.

PLoS ONE 17(1): 2022, 20p.

By Bowen Cho

In this report, we invite readers to explore the historical, racialized, disablist, and political economic contexts of mass incarceration, including the ways that incarceration has expanded beyond prisons, jails, and correctional supervision in the 21st century. As well, publics often think of incarceration narrowly, such that they make invisible the containment of Disabled people in institutional and extra-carceral systems. This report is in part a corrective and counterpoint to policy papers on disability and criminal legal reform published by non-disability advocacy and mental health advocacy organizations in recent years. Because the ideologies of eugenics, ableism, and disablism are thriving in the 21st century, disability is often used as a rhetorical frame arguing for the restriction of carceralism for certain groups and its expansion for others. Mass incarceration in the 21st century includes physical confinement, but also accounts for the rapidly expanding, technocratic industries of e-carceration and psychotropic incarceration. Our conceptions of physical confinement must go beyond prisons and jails, and include detention centers, psychiatric hospitals, nursing homes, and residential treatment facilities. One cannot replace the other. Recognition of incarcerated people must similarly be expanded to include detained immigrants, people under electronic monitoring and surveillance, and people experiencing involuntary psychiatric commitment. Black people and Indigenous people continue to be disproportionately impacted by policing and carceralism, particularly in the increased criminalization of poverty, houselessness, and mental illness, and the ways that these statuses intersect with racism and disablism.

Berkeley, CA: Disability Rights Education and Defense Fund (DREDF) , 2024. 120p.

By Pasangi S. Perera, Vanessa E. Miller,; Kate Vinita Fitch, et al

Since 2014, Medicaid expansion has been implemented in many states across the US, increasing health care access among vulnerable populations, including formerly incarcerated people who experience higher mortality rates than the general population. OBJECTIVE To examine population-level association of Medicaid expansion with postrelease mortality from all causes, unintentional drug overdoses, opioid overdoses, polydrug overdoses, suicides, and homicides among formerly incarcerated people in Rhode Island (RI), which expanded Medicaid, compared with North Carolina (NC), which did not expand Medicaid during the study period. DESIGN, SETTING, AND PARTICIPANTS A cohort study was conducted using incarceration release data from January 1, 2009, to December 31, 2018, linked to death records from January 1, 2009, to December 31, 2019, on individuals released from incarceration in RI and NC. Data analysis was performed from August 20, 2022, to February 15, 2024. Participants included those aged 18 years or older who were released from incarceration. Individuals who were temporarily held during ongoing judicial proceedings, died during incarceration, or not released from incarceration during the study period were excluded. EXPOSURE Full Medicaid expansion in RI effective January 1, 2014. MAIN OUTCOMES AND MEASURES Mortality from all causes, unintentional drug overdoses, unintentional opioid and polydrug overdoses, suicides, and homicides. RESULTS Between 2009 and 2018, 17 824 individuals were released from RI prisons (mean [SD] age, 38.39 [10.85] years; 31 512 [89.1%] male) and 160 861 were released from NC prisons (mean [SD] age, 38.28 [10.84] years; 209 021 [87.5%] male). Compared with NC, people who were formerly incarcerated in RI experienced a sustained decrease of 72 per 100 000 person-years (95% CI, −108 to −36 per 100 000 person-years) in all-cause mortality per quarter after Medicaid expansion. Similar decreases were observed in RI in drug overdose deaths (−172 per 100 000 person-years per 6 months; 95% CI, −226 to −117 per 100 000 person-years), including opioid and polydrug overdoses, and homicide deaths (−23 per 100 000 person-years per year; 95% CI, −50 to 4 per 100 000 person-years) after Medicaid expansion. Suicide mortality did not change after Medicaid expansion. After Medicaid expansion in RI, non-Hispanic White individuals experienced 3 times greater sustained decreases in all-cause mortality than all racially minoritized individuals combined, while non-Hispanic Black individuals did not experience any substantial benefits. There was no modification by sex. Individuals aged 30 years or older experienced greater all-cause mortality reduction after Medicaid expansion than those younger than 30 years.

JAMA Netw Open. 2024, 12 p.

By Carmen Johnson et al and the UCLA BioCritical Studies Lab

The BioCritical Studies Lab analyzed a sample of 180 deaths in 10 city and county detention centers in Maryland between 2008 and 2019. These detention centers are distinct from state correctional facilities in that they primarily confine persons who are awaiting trial or arraignment. Our study sample reflects only deaths self-reported by these 10 city and county detention centers to the Bureau of Justice Statistics (BJS) during this time period. Our sample represents only a portion of all in-custody deaths known to have taken place throughout Maryland during the study period. Our analysis produced five key findings: - First, the detention centers with the most instances of in-custody death in our study sample are situated in jurisdictions with both high rates of poverty and large numbers of Black residents. The confluence of these two factors is strongly correlated to in-custody death. - Second, the average age of in-custody deaths officially designated as “natural” is substantially lower than life expectancy among the non-jailed population, possibly indicating the widespread misclassification of deaths attributable to violence and/or negligence as “natural” by the Maryland Office of the Chief Medical Examiner. - Third, over 80% of the deaths in our sample took place while the decedent was awaiting trial, meaning they had not been convicted of any crime at the time of death. - Fourth, about half of the decedents included in our sample died within 10 days of their admission to the detention center, and more than one sixth died less than two days after their admission, suggesting that even short stays in detention present a significant risk of premature death. - And fifth, there currently exist high barriers preventing public access to key information regarding deaths in Maryland detention centers that place comprehensive study of this social problem out of reach. We conclude by making several recommendations as to how policymakers might address the problems described in this report, including systematically reducing jail populations through the elimination of pretrial detention, establishing an explicit mandate for the Office of the Chief Medical Examiner to investigate all instances of in-custody death, and codifying new standards for publicly reporting information about in-custody deaths when they occur.  

Los Angeles; BioCritical Studies Lab, Institute for Society and Genetics, University of California – Los Angeles.  2023. 26p.

By David Olson, Don Stemen, & Patrick Griffin 

Loyola University Chicago’s Center for Criminal Justice, through the support of the John D. and Catherine T. MacArthur Foundation, collaborated with the Illinois Department of Corrections’ Planning and Research Unit to examine the number, characteristics, and circumstances of individuals on Mandatory Supervised Release (MSR, or “parole”) who violated conditions of their release and were returned to prison (i.e., “technical violators”). Over the past two decades, between 20% and 30% of all admissions to the Illinois Department of Corrections (IDOC) have been individuals returned to prison as MSR technical violators. Given the substantial impact of these technical violations on overall prison admissions in Illinois, this report examines the characteristics and circumstances that led to those returns to prison during state fiscal year (SFY) 2020 (July 2019 through June 2020). Specifically, the Loyola team analyzed detailed information for all those returned to prison due to technical MSR violations during SFY 2020 (N=5,052), and compared it to findings from similar research that was conducted with a one-month sample of technical MSR violator admissions in 2010 (see https://spac.illinois.gov/publications/researchreports/msr-violators). What Did We Find? 1) The rate of technical violation admissions to IDOC has been relatively stable over the past decade, whether measured as a percent of admissions or as a percent of IDOC exits returned to prison within 3 years of release. Over the past two decades, technical violators have accounted for somewhere between 20% and 30% of all admissions to prison; similarly, between 20% and 30% of all of those returned to prison within 3 years of their release during this period have been returned as technical violators. 2) Although technical violators account for 20% to 30% of all admissions to IDOC, they tend to stay in prison for a shorter period of time than court-sentenced individuals. Over the past two decades they have accounted for a smaller proportion - between 7% and 12% - of the IDOC population. 3) Although the proportion of admissions accounted for by technical violators has remained relatively consistent over the past decade, the number of admissions for technical violations has decreased, consistent with the overall decrease in admissions to prison. During the 10-year period from 2010 to 2019 (pre-COVID), total admissions to prison fell 39%, with a 38% decrease seen in admissions for technical violations and a 40% decrease in court sentences. 4) Although previous research found wide fluctuations from month to month in the number of technical violators returned to prison during the 2001 to 2011 period, often due to politically-driven crackdowns, the only substantial change in admissions during the past decade occurred when COVID-19 dramatically reduced arrests and admissions to prison in Illinois. 5) Of those individuals returned to prison due to technical violations in SFY 2020, most (58%) were returned, at least in part, because of an arrest while on MSR, often for a violent crime or firearm possession offense. 6) One out of every 5 people (20%) “returned” to prison for technical violations in SFY 2020 did not have an approved place to live, and so were not in fact released at all (referred to as “gate violators” by IDOC). Most (84%) of those returned as gate violators had been serving prison sentences for sex offenses, a population that historically has challenges finding approved housing upon release from prison. 7) COVID-19 dramatically reduced the number of admissions to IDOC for technical violations and resulted in a shift in the nature of technical violations that resulted in admission to prison. While the percent of prison admissions accounted for by technical violations did not change between SFY 2011 and the portion of SFY 2020 that preceded the beginning of the COVID-19 pandemic, a smaller portion of those admitted in the pre-COVID part of SFY 2020 were for non-arrest violations and a larger share of admissions involved new arrest charge(s), particularly for violent and firearm possession offenses. 

Loyola Chicago Center for Criminal Justice, 2023. 11p.

By Diane Cheng, Arthur Rizer and Nila Bala

Marcus Bullock was 15 years old when he was sentenced to prison. He struggled with his time behind bars—missing his family, feeling disconnected from the outside world and losing hope. After he became depressed, his mother Sylvia promised to keep in touch daily. Her detailed letters and photos curbed Bullock’s loneliness and helped him envision life after prison. In Bullock’s words: “Little did I know, it would be my mom’s letters that saved my life.” Sylvia’s frequent communications gave him the strength to survive his incarceration, start a successful contracting business and launch Flikshop, a company that uses technology to help inmates stay connected with their families and loved ones. Bullock’s story demonstrates the importance of family connections for people who are incarcerated. In 2018, more than two million individuals were incarcerated in jails and prisons across the United States. However, the impact of incarceration is felt by millions more through the children, spouses, siblings, parents and other relatives connected to incarcerated individuals. Recent research suggests that nearly half of adults in the United States have had an immediate family member incarcerated for at least one night in jail or prison. Almost half of the inmates in federal prisons have minor children. Additionally, about one in 25 children (nearly 2.6 million) have a parent in jail or prison. Incarceration separates parents from their children, strains interpersonal relationships, harms mental and physical health and exacts deep financial costs to families. Further, incarceration has a disproportionate effect on communities of color and low income families. For example, Black adults are three times as likely as white adults to have a close family member incarcerated for more than one year. As Bullock’s story shows, positive family connections during incarceration are critical for an inmate’s wellbeing, their likelihood of successful re-entry after time served and the overall strength of their family. Technology can help families stay connected, but the cost, accessibility and quality of current options often pose barriers to meaningful interaction. The COVID-19 pandemic presents further challenges for family connection within correctional facilities, but also an opportunity to improve existing infrastructure via technology. If done right, improvements to both technological and non-technological options for family connection would ultimately benefit incarcerated individuals, their families and their communities at large

R STREET POLICY STUDY NO. 203 September 2020, 13p.

By Kristin Turney, Naomi F. Sugie, Estéfani Marín, Daniela E. Kaiser

Anticipatory stress—or worries about the future that produce emotional distress—may explain some of the deleterious repercussions of incarceration for health. We use nearly 500 interviews with incarcerated men and their family members to describe anticipatory stress stemming from the stressor of jail incarceration, a commonly experienced but understudied type of confinement distinct from prison incarceration. We identify and explain how jail incarceration involves a powerful confluence of factors that give rise to anticipatory stress about adjudication, family relationships, the well-being of loved ones, and reintegration. We describe three types of anticipatory stress proliferation between incarcerated men and their families. First, anticipatory stress commonly proliferates from incarcerated men to their children's mothers and their own mothers, with anticipatory stress being particularly salient when it involves the possibility of major changes, system irrationality, and powerlessness. Second, family members can experience anticipatory stress regardless of whether their incarcerated loved one reports anticipatory stress, shaped in part by men's extensive criminal legal contact. Third, family members with weak relationships with incarcerated men generally do not experience anticipatory stress despite the anticipatory stress endured by their incarcerated loved ones. This study provides a framework for understanding how other stages of criminal legal contact contribute to health inequalities among incarcerated people and their families.

Criminology, Volume 62, Issue 4, 2024, pages 830-858

By Justin D. Strong, Keramet Reiter, Gabriela Gonzalez, Rebecca Tublitz, Dallas Augustine, Melissa Barragan, Kelsie ChesnutI, Pasha Dashtgard, Natalie Pifer, Thomas R. Blair

We examine how solitary confinement correlates with self-reported adverse physical health outcomes, and how such outcomes extend the understanding of the health disparities associated with incarceration. Using a mixed methods approach, we find that solitary confinement is associated not just with mental, but also with physical health problems. Given the disproportionate use of solitary among incarcerated people of color, these symptoms are most likely to affect those populations. Drawing from a random sample of prisoners (n = 106) in long-term solitary confinement in the Washington State Department of Corrections in 2017, we conducted semi-structured, in-depth interviews; Brief Psychiatric Rating Scale (BPRS) assessments; and systematic reviews of medical and disciplinary files for these subjects. We also conducted a paper survey of the entire long-term solitary confinement population (n = 225 respondents) and analyzed administrative data for the entire population of prisoners in the state in 2017 (n = 17,943). Results reflect qualitative content and descriptive statistical analysis. BPRS scores reflect clinically significant somatic concerns in 15% of sample. Objective specification of medical conditions is generally elusive, but that, itself, is a highly informative finding. Using subjective reports, we specify and analyze a range of physical symptoms experienced in solitary confinement: (1) skin irritations and weight fluctuation associated with the restrictive conditions of solitary confinement; (2) un-treated and mis-treated chronic conditions associated with the restrictive policies of solitary confinement; (3) musculoskeletal pain exacerbated by both restrictive conditions and policies. Administrative data analyses reveal disproportionate rates of racial/ethnic minorities in solitary confinement. This analysis raises the stakes for future studies to evaluate comparative prevalence of objective medical diagnoses and potential causal mechanisms for the physical symptoms specified here, and for understanding differential use of solitary confinement and its medically harmful sequelae.

PLoS ONE, 2020, 20 p.

By Laurin Bixby, Stacey Bevan, and Courtney Boen

Disabled people are disproportionately incarcerated and segregated from society through a variety of institutions. Still, the links between disability and incarceration are underexplored, limiting understanding of how carceral institutions punish and contribute to the social exclusion of disabled people. Using data from the 2016 Survey of Prison Inmates, we estimated disability prevalence in state and federal prisons, assessing disparities by race, ethnicity, and sex, and we examined inequities in previous residence in other “punitive” and “therapeutic” institutions. Sixty-six percent of incarcerated people self-reported a disability, with Black, Hispanic, and multiracial disabled men especially overrepresented in prisons. Compared with nondisabled incarcerated people, disabled incarcerated people were more likely to have previously resided in other institutions, such as juvenile detention facilities and psychiatric hospitals. Together, our findings advance the understanding of disability in carceral institutions, highlighting the need for policy interventions redressing the mechanisms contributing to the high incarceration risks of disabled people and the disabling nature of prisons and other carceral institutions.

Health Affairs Vol. 41, NO. 10, 2022, 28 p.

By James René Jolin, Benjamin A. Barsky, Carrie G. Wade

By expanding health insurance to millions of people in the US, the Patient Protection and Affordable Care Act (ACA) may have important health, economic, and social welfare implications for people with criminal legal involvement—a population with disproportionately high morbidity and mortality rates. OBJECTIVE To scope the literature for studies assessing the association of any provision of the ACA with 5 types of outcomes, including insurance coverage rates, access to care, health outcomes, costs of care, and social welfare outcomes among people with criminal legal involvement. EVIDENCE REVIEW - The literature search included results from PubMed, CINAHL Complete, APA Psycinfo, Embase, Social Science Database, and Web of Science and was conducted to include articles from January 1, 2014, through December 31, 2023. Only original empirical studies were included, but there were no restrictions on study design. FINDINGS Of the 3538 studies initially identified for potential inclusion, the final sample included 19 studies. These 19 studies differed substantially in their definition of criminal legal involvement and units of analysis. The studies also varied with respect to study design, but difference-in-differences methods were used in 10 of the included studies. With respect to outcomes, 100 unique outcomes were identified across the 19 studies, with at least 1 in all 5 outcome categories determined prior to the literature search. Health insurance coverage and access to care were the most frequently studied outcomes. Results for the other 3 outcome categories were mixed, potentially due to heterogeneous definitions of populations, interventions, and outcomes and to limitations in the availability of individual-level datasets that link incarceration data with health-related data. CONCLUSIONS AND RELEVANCE- In this scoping review, the ACA was associated with an increase in insurance coverage and a decrease in recidivism rates among people with criminal legal involvement. Future research and data collection are needed to understand more fully health and nonhealth outcomes among people with criminal legal involvement related to the ACA and other health insurance policies—as well as the mechanisms underlying these relationships.

JAMA Health Forum, 2024, 10 p.