Health and the justice system

As an intern on an emergency department rotation at the University of California, San Francisco, in 2003, Emily Wang, M.D., was shocked to learn that many of her patients had recently left prison, some within the past few days. Equally shocking, she realized, was that for many of these patients, prison offered them their first access to health care.

The U.S. Supreme Court has ruled that health care for inmates is required by the Eighth Amendment to the U.S. Constitution. Upon an inmate’s release, however, the mandate disappears and significant barriers to care arise. Most newly released inmates have no primary care providers and no insurance, and do not know how to navigate the health care system. For the 85 percent of inmates who received regular care in prison for such chronic conditions as diabetes and hypertension, one of their first stops upon release is the emergency department.

”To me,” said Wang, an associate professor of medicine, ”that was an incredibly inefficient way to run a health care system. It was frustrating. It was inhumane.”

In 2005, during her last year of residency, she began the Transitions Clinic Network (TCN) to help recently released inmates adjust to life outside prison by providing access to health care. What began as one clinic in San Francisco has grown into 15 clinics in seven states and Puerto Rico, with plans to expand. TCN has two clinics in New Haven, at the Yale Primary Care Center and the Cornell Scott-Hill Health Center.

This is how it works: TCN community health workers, all of them former inmates, meet former prisoners on their release. They help patients get insurance, see a primary care physician, and connect with services to help with housing and employment.

Kathleen F. Maurer, M.D., M.P.H. ’85, director of Health and Addiction Services and medical director of the Connecticut Department of Correction, views the peer advocate aspect of TCN as crucial. ”These patients relate to their peers in a way they couldn’t relate to a physician,” she said. In Connecticut, inmate patients are released with a four-week supply of medication and get help connecting to Medicaid, often their only source of insurance. Maurer said that the Department of Correction relies on TCN to help them stay connected to health care.

The criminal justice system has an enormous scope: 63 million Americans have criminal records, and 13 million move in and out of correctional facilities each year. It’s clear from medical literature, Wang said, that poor health can prevent former inmates from getting a job, and employment is one of the most important factors in helping them stay out of prison. Data from TCN show that former inmates who saw a primary care physician within a month of release had fewer emergency department visits and hospitalizations than those who did not. ”It seems like a place where the smallest sorts of adjustments can make the biggest gains,” Wang said.

With funding from the Yale Center for Clinical Investigation and the Patient-Centered Outcomes Research Institute, Wang and her colleagues are developing a Web-based platform that will disseminate to TCN clinics, patients, and community stakeholders the data she has collected through nationwide studies of TCN patients. TCN has also formed a partnership with Yale Law School to help TCN patients in New Haven address legal needs related to housing, employment, and other social issues related to the health of former inmates. ”There won’t be a singular solution,” Wang said, to addressing the criminal justice system’s impact on health equity, ”but a collective one.”