Recent events have exposed long-standing institutional and structural inequities in the United States, underscoring the urgent need for systemic policy changes that address these disparities.
Case in point: When addiction and incarceration intersect, the health risks skyrocket. Sadly, incarceration is all too often related to an untreated mental illness or addiction, and it disproportionately affects people of color.
The United States criminal legal system holds almost 2.3 million people in state and federal prisons, local jails, and other detention or correctional facilities. Estimates suggest nearly two-thirds of incarcerated persons have a history of substance use disorder (SUD), with up to 20% meeting criteria for opioid use disorder (OUD).
Releasing individuals who are incarcerated without connections to healthcare providers, medical coverage, safe and stable housing, or a support system can greatly increase their risk of relapse, overdose, and death—it has been estimated that individuals returning to the community after incarceration are 129 times more likely to die from an overdose than the general population.
Incarceration also affects racial minorities at significantly higher rates than whites. In 2018, Black Americans made up 12% of the total U.S. population but accounted for 33% of the sentenced prison population. More than one in four people arrested for drug law violations in 2015 was Black, although drug use rates do not differ substantially by race.
The COVID-19 pandemic has amplified these inequities and intensified health disparities. Individuals who are incarcerated are at increased risk of severe viral infection both due to their physical environments and higher rates of co-occurring health conditions.
This is a crisis that must be addressed.
To stem the spread of COVID-19 and prevent a further escalation of drug overdose deaths, Congress must pass bipartisan legislation to ensure that Americans who are incarcerated and at high risk for infection and poor outcomes can access the medical services they need.
Crowded conditions in jails and prisons accelerate viral spread. Being in such close quarters with dozens, if not hundreds, of other people (many with significant chronic conditions) is akin to adding high winds to a COVID-19 wildfire. According to the Centers for Disease Control and Prevention (CDC), prisons—like cruise ships, aircraft carriers, and nursing homes—are hot spots for transmission with at least 420 institutions reporting coronavirus cases among prisoners and staff.
As America’s prisons and jails begin to release thousands of individuals who are incarcerated during the pandemic, those without a place to go often end up on the street or in homeless shelters, where COVID-19 can spread at alarming rates. According to one recent analysis of COVID-19 exposure in Boston, the infection rate at homeless shelters was nearly 25 times higher (46.3 cases per 1,000) than the general population (1.9 cases per 1,000).
When it comes to addiction and overdose, the situation is just as grave. The extreme financial stress caused by the COVID-19 pandemic and economic fallout are now additional challenges in accessing evidence-based addiction treatment. Additionally, the isolation resulting from physical distancing measures is also a known risk factor for relapse and death amongst people with addiction.
Unfortunately, we are now seeing overdose rates surge in many states and cities. In parts of Ohio, for instance, drug overdose deaths are up more than 50 percent compared to the same time last year, a trend echoed in New York, Florida, and Pennsylvania, among other locales. And, recent research suggests that COVID-19 will lead to as many as 75,000 additional “deaths of despair,” including drug overdose.
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One critical part of the solution gaining traction among leaders of both parties in Congress—and that should be part of the next COVID-19 legislative package—is the Medicaid Reentry Act (H.R. 1329), which would allow states to restart Medicaid coverage for eligible individuals who are incarcerated for the 30 days prior to their release.
This bipartisan legislation would help states ensure continuity of care for these at-risk individuals and prevent dangerous outcomes such as relapse and overdose that could overburden hospitals already stretched to the limit. Ultimately, the Medicaid Reentry Act would help save lives by providing effective medical services, including mental health and addiction treatment services, before individuals reenter the community.
Before the pandemic began, federal and state action helped reduce the number of overdose deaths across the United States for the first time in nearly three decades, while increasing the number of patients with addiction receiving treatment. But much of that progress threatens to be undone unless bold action is taken soon.
We need Congress to allow Medicaid coverage for eligible individuals who are incarcerated to resume prior to their release so that this country can help stop overdose, stem the spread of COVID-19, and extend access to a population that for too long has been marginalized. Many lives are at stake.
Elizabeth Salisbury-Afshar, M.D., is a member of the American Society of Addiction Medicine. Kelly King is an associate member of the American Society of Addiction Medicine.