One serious problem with being an advocate of correctional mental health services is that you run the risk of coming across as an apologist, a Pollyanna, or a defender of the status quo. This is true even though every week I meet someone with an addiction problem so severe that he’d be unable to voluntarily seek or stay in treatment in the community. For someone like that, an arrest can be lifesaving. But to point this out will lead people to believe that I must oppose ready access to community care, pretrial diversion, alternative sentencing, mental health courts, or anything related to alternatives to incarceration.
That isn’t the case. Many problems require more than one solution. What I oppose is the idea that the solution has to be a simple dichotomous choice between arrest and incarceration versus community care. I’ve found discussions about criminalization of people with mental illnesses to be polarizing and unproductive. There will always be people with mental illnesses in jail and prison, because – like people with diabetes, heart disease, or AIDS – they sometimes commit very serious crimes. As a care provider, my view is that a patient’s need for treatment is independent of criminal culpability. An ill person deserves appropriate and skilled health care, regardless of the treatment setting. Moving someone from an understaffed, overcrowded correctional facility to an understaffed, overcrowded state hospital hardly solves the problem.
People make the argument that money spent on corrections would be better spent elsewhere, on services for at-risk youth, or on community substance abuse and mental health programs. I agree that all these programs are needed, but what rarely gets mentioned is that when money is diverted from jails and prisons, part of that money also includes funding for inmate health care. Taking away this money is like stealing a coat from a blind beggar in the winter time. If you want to make a serious problem worse, by all means, take away what little we have.
How much money are we talking here, anyway?
By some estimates , the money spent on health care for all American prisons is about $7.7 billion per year. That includes physician and related health care professional costs, laboratory and diagnostic testing, hospitalization costs, as well as medications. Fourteen percent of that, or about $1 billion, goes to mental health care. Those costs are expected to rise as the prison population continues to age. Meanwhile, federal spending on mandatory health care programs in 2013 was about $1 trillion. When the prison health care budget represents less than 1% of health care spending nationally, this doesn’t seem to be enough to be quibbling about and certainly not enough to be cutting or diverting elsewhere.
But of course, the correctional nihilists will respond, “You get what you pay for.” Inevitably, low-cost care becomes equivalent to low-quality care in the eyes of many Americans. But if you compare American medical outcomes globally, it’s been well established that we have fallen behind many countries in life expectancy and infant mortality, despite heavy investment in a broad spectrum of services and interventions.
Let’s compare that to prison. Because of data gathered through the 2000 Federal Death in Custody Reporting Act , as well as other studies, prisons have been able to demonstrate reduced mortality, compared with age-matched men in free society, particularly for minorities. That mortality rate doubles after release. Clearly, prisons appear to be keeping people alive more efficiently and at a fraction of the cost of our community services.
This is not to imply that incarceration should be the answer to every social problem. This is my response to the naysayers and nihilists who believe that jails and prisons are so far gone they are not worth investing in. The lives of many prisoners depend on that investment.
Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.
