An Analysis on Mental Illness and Substance Use among Justice-Involved Individuals: Insights from the National Survey of Drug Use and Health
Abinaya Ramakrishnan
Honors Thesis
Department of Medicine, Health, and Society
April 2021
Thesis Advisor (s): Professor Gilbert Gonzales, PhD MHA Professor Carrie Fry, PhD MEd
Foreword:
The United States has one of the world’s highest incarceration rates where unprecedented incarceration rates began a dramatic increase in the 1980s. This was largely due to the fact that incarceration was the preferred punishment for drug crimes, nonviolent offenses, and minor infractions. However, due to the lack of community-based resources and mental health support, an increasing population of individuals with mental illness and substance use disorder got funneled into the criminal justice system. Today, more than half of all inmates have an addiction, mental illness, or both with an estimated 39-43% of all prisoners having at least one chronic condition. Further complicating matters, many carceral-involved individuals lack health insurance and access to preventative and/or primary care.
Like individuals with a history of mental illness or substance use disorder are more likely to be incarcerated, individuals who identify as LGBTQ are disproportionately likely to come into contact with the criminal justice system and have higher rates of mental illness and substance use disorder. A history of bias, abuse, and profiling toward LGBTQ people by law enforcement, along with high rates of poverty, homelessness, and discrimination has contributed to disproportionate contacts with the justice system, leading to higher rates of incarceration.
However, this population of justice-involved sexual minorities has been significantly
underrepresented in research because of lack of national databases that collect both incarceration history and sexual and gender identity. While past research has demonstrated the increased likelihood of mental illness and substance use in sexual minority and justice-involved
populations, no research, to our knowledge, has look at the intersection of these two populations.
The current research aims to better understand and quantify mental illness and substance use disorder and access to treatment services among justice-involved sexual minorities.
Another aim of the current project was to understand the impacts of the Affordable Care Act (ACA) for justice-involved individuals, with a specific emphasis on substance use and mental healthcare utilization. Prior research shows that jails have become the largest mental health provider in the nation where they support millions of under-or uninsured people with mental health issues and co-occurring substance use conditions. With the implementation of the ACA, it was hypothesized that Medicaid expansion offers benefits to many low-income adults with jail stays and other members to become eligible for coverage in the Marketplaces.
Moreover, it was thought that the ACA would improve coverage gaps for this population, which would likely translate to increased access and use of healthcare services. Our research seeks to answer whether the ACA was successful in improving healthcare coverage and utilization of mental health and substance use treatment services for this vulnerable population.
Both projects, connected through a common population and related outcomes, have results that lend itself to important policy recommendations. First, we recommend that more national databases offer questions asking about incarceration history and sexual and gender identity (SOGI questions) as this will help future researchers better understand health outcomes for these two vulnerable, at-risk populations. Second, we recommend targeted interventions to specifically address the unique issues that these populations face whether that be creating more inclusive LGBT+ training for physicians and prison staff, or providing more targeted support to justice-involved individuals through connections with local re-entry services and mental health and/or substance use counselors to have continuity of care. And finally, we recommend the decriminalization of mental illness and substance use, with a shift towards collaboration between the criminal justice system and public health systems through jail diversion programs and mental health courts and an increase in community-based programs.
Acknowledgements
I would like to first and foremost thank my mentors, Dr. Gilbert Gonzales and Dr. Carrie Fry, for their continuous support, dedication, and mentorship over the past year. Thank you for teaching me how to conduct a health policy project from start-to-end, for your technical
guidance, and for your constant encouragement and advice. I have learned so much from both of you, and for that I will forever be grateful. Second, I would like to thank my friends who have stood with me through endless discussions and frustrations about the state of our current
healthcare system in the United States – it aggravates and inspires me, and I thank you for being there with me through our long, late-night conversations. And finally, I would like to thank my family: Amma, Appa, and Aparna, for always being by my side through all my failures and successes.
TABLE OF CONTENTS
Title Page……….1
Foreword………..2
Acknowledgements………..…3
Section 1: Overview & Connection to MHS………...………5
Section 2: Sexual Orientation, Mental Illness, and Substance Use Disorder among Justice- Involved Individuals: Evidence from the National Survey of Drug Use and Health, 2015-2019 2.1 Abstract………..………7
2.2 Introduction………...……….8
2.3 Background………..10
2.4 Methods………..…..19
2.5 Results………..22
2.6 Limitations………...………25
2.7 Discussion………...…….27
Section 3: The Affordable Care Act and Healthcare Utilization among Justice-Involved Individuals: Insights from the National Survey of Drug Use and Health, 2010-2019 3.1 Abstract………29
3.2 Introduction………..……30
3.3 Background………..…32
3.4 Methods………...….34
3.5 Results………..…37
3.6 Limitations………...39
3.7 Discussion………40
Section 4: Conclusion & Policy Implications………41
Section 5: References……….46
Section 6: Tables and Figures………....65
SECTION 1: OVERVIEW & CONNECTION TO MHS
When someone shares that they have sprained their ankle or have been diagnosed with a bacterial infection, no one says “You should think more positive” or “Quit exaggerating”. But with mental illness, these are the types of phrases that people often hear – where physical illness is not treated the same as mental illness. Mental illness is a hidden illness and many communities do not consider it a real medical condition but rather a weakness of character. The course, Mental Illness Narratives (MHS 3450), is focused on uncovering these stories of individuals battling mental illness often alone or with little support where their families and support systems crumble in the face of adversity. This theme of hidden illness and bodies threads through other MHS courses such as Medicine and Literature (MHS 3050W) where the vulnerability of war-torn bodies is depicted alongside post-traumatic stress disorder or substance use, further showing how social factors like poverty, homelessness, and incarceration play intersect with these conditions.
Perhaps the most impactful course through my time in MHS was with Dr. Gilbert Gonzales understanding Healthcare Under the Trump Administration (or rather Healthcare Policy) where the course focused on the different aspects of the United States healthcare system from private vs public insurance, the roles of hospitals and different providers, and where the current
administration may re-direct previous healthcare efforts. This course has built on my
foundational knowledge of the current healthcare system, but also helped me identify large gaps that I hope this current thesis starts to address. MHS courses have always pushed me to look beyond the surface and understand the complexity that every issue has to offer – simply improving access to insurance coverage may not always lead to increased mental healthcare utilization, rather, each issue has its own layers of complexity that require effective strategies to target. A common theme through my MHS courses has been understanding the role that policies
and a person’s environment play in impacting the stories of these individuals and empowering their narratives. While the current healthcare system is far from perfect, and many policies still need to be created to support vulnerable individuals, an MHS lens offers the opportunity to understand medicine from more than a molecular biology perspective, and instead understand the foundational systems in place that propagate and/or hinder progress within the medical system.
As an MHS student, I am pushed to think critically about complex issues and two issues that have interested me deeply are (1) healthcare disparities among vulnerable populations such as justice-involved, homeless, sexual minority, and foster-care individuals and (2) access to mental illness and substance use treatment. Seeking to combine my passion for both of these topics, my honors thesis takes a more in-depth look at this common theme of social determinants of mental health and substance use, understanding how social factors like sexual orientation, incarceration history, and insurance coverage impact access to healthcare in the United States. Today, I am honored and privileged to present my current findings, aided by the perspectives and knowledge that my MHS courses have offered me, and hours of research understanding the complexities of the United States healthcare system. To me, medicine goes beyond mitigating illness or trauma, it lies in also improving a patient’s health by promoting health equity through advocacy and research.
SECTION 2:
Sexual Orientation, Mental Illness, and Substance Use Disorder among Justice-Involved Individuals: Evidence from the National Survey of Drug Use and Health, 2015-2019
2.1 ABSTRACT:
Importance: Although prior research has documented higher rates of incarceration among sexual minorities, little research has examined the intersections of the justice-involved and sexual minority populations. Research is needed to better understand the health needs of justice- involved sexual minorities to make informed policy and public health measures.
Objective: To examine the prevalence of mental illness, substance use, and access to treatment among sexual minorities who have been involved with the criminal justice system.
Design, Setting, Participants: This retrospective analysis used data from the 2015-2019 National Survey on Drug Use and Health. We conducted multivariable logistic regression to assess the relationship between sexual minority status and criminal justice involvement with mental illness, substance use disorder (SUD), and access to treatment among US adults.
Main outcome and measures: Substance use (alcohol, inhalant, hallucinogen, sedative, pain relievers, heroin, cocaine, marijuana, and tranquilizer misuse), severity of mental illness, suicidality, mental health treatment (inpatient, outpatient, prescription), and SUD treatment for individuals based on sexual minority status and criminal justice involvement.
Results: Approximately 10% of justice-involved individuals identified as sexual minorities.
Among justice-involved individuals, sexual minorities were more likely to have a serious mental illness, suicidal ideation, depressive thoughts, and to use the following substances: inhalants, hallucinogens, alcohol, marijuana, and cocaine. Justice-involved sexual minorities were also
more likely to have access to mental health and SUD treatment than their heterosexual justice- involved peers. The increased probability of receiving treatment for mental illness and substance use was also observed when comparing heterosexual and sexual minorities who were not
involved with the criminal justice system.
Conclusions and relevance: This study provides new population-based research to a limited body of evidence on the health disparities and mental health needs of justice-involved sexual minority populations who may face additional stressors and discrimination. More research and programmatic interventions are needed to better support justice-involved sexual minorities in order to achieve mental health equity for this vulnerable population.
2.2 INTRODUCTION
Approximately 6.7 million individuals (2.8% of the adult population) are under
correctional supervision on any given day in the United States, which includes individuals under community supervision in jails or prisons, parole, and probation.1,2,3 Research approximates that 70% of inmates experience chronic physical, mental health, and substance use conditions with diabetes, tuberculosis, HIV/AIDS, and depression present at higher rates compared to the general population.4,108 However, poor access to health care is a pervasive problem in correctional
facilities where many justice-involved individuals do not receive proper access to healthcare due to numerous barriers which include difficulty navigating the healthcare system, disruption of medication during incarceration, and lack of access to behavioral health services.5,6,7 But with recent closures of mental health institutions, many jails and prisons have become the primary mental health system for many under-or uninsured people with mental health conditions and co- occurring mental health and substance use conditions.71
Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) adults represent approximately 4-5% of adults nationwide, according to population-based survey data.8 Research suggests that sexual minorities are more likely to have substance use and mental health disorders, as a result of exposure to structural and interpersonal discrimination.9-12 A study conducted in 2015 by the Substance Abuse and Mental Health Services Administration (SAMHSA) using data from the National Survey on Drug Use and Health (NSDUH) found that sexual minorities were more likely to be current cigarette smokers, currently drink alcohol, have SUDs (related to alcohol, marijuana, or misuse/dependence on pain relievers), and need substance use treatment compared to their heterosexual counterparts. They also found that sexual minorities were more likely to have serious mental illness and a major depressive episode, and thus, more likely to receive mental health services in the past 12 months compared to their sexual majority
counterparts. Yet, seeking treatment for their behavioral health conditions has also been shown to put LGBTQ+ individuals at risk of experiencing provider-based discrimination or stigma which can exacerbate existing conditions.13
Public health research at the intersections of justice involvement and LGBTQ status are scarce. Previous reports suggest that a higher percentage of adults that identify in the LGBT spectrum are incarcerated than their heterosexual and cisgender peers. Research from the National Inmate Survey (2011-2012) found that incarceration rates of self-identified LGB were 1882 to 100,000 which is more than three times that of the general US adult population.
Additionally, they found 33.3 percent and 26.4 percent of women in prisons and jails,
respectively, identified as lesbian or bisexual which is 8-10 times larger than the proportion of women who identify as lesbian or bisexual in the US adult population.14 Another study by the National Gay and Lesbian Taskforce and the National Center for Trans Equality found that 1 in 6
transgender people are sent to jail or prison in the US. Specifically, transgender people of color experience higher rates of justice-involvement and transgender women are incarcerated at twice the rate of transgender men (21 versus 10 percent).15 LGBT people of color are overrepresented in the criminal justice system due to pervasive stigma, discrimination, family instability, poverty, profiling, and other police tactics.16,17,18 To the best of our knowledge, there has been no
comprehensive study analyzing mental health and SUD issues among the criminal justice- involved, LGBT population. Our research fills important research gaps and uses nationally representative data to examine the prevalence of mental health conditions, access to care, social supports, and behavioral health treatment for justice-involved LGB adults. Knowing their health needs will better inform public health and clinical practice as well as health policy reforms to better support justice-involved LGBT people.
2.3 BACKGROUND
How prevalent is mental illness and substance use disorder in the United States, today? How common is treatment for individuals with these conditions?
Mental illnesses are common in the United States with nearly 1 in 5 adults living with a mental illness.19 According to the National Survey on Drug Use and Health (NSDUH), any mental illness is defined as a mental, behavioral, or emotional disorder with serious mental illness defined as mental illness that results in serious functional impairment, which substantially interferes with one or more major life activities.20 Data from the 2019 NSDUH indicates that approximately 51.5 million adults over the age of 18 have a mental illness, with prevalence higher in females (24.5%) compared to males (16.3%). Younger adults have a higher prevalence of mental illness (29.4%) and it was reported at higher rates among individuals with two or more races (31.7%). In 2019, it was estimated that 31.1 million adults (5.2%) ages 18 and older had a
severe mental illness with the highest prevalence among adults ages 18-25 years (8.6%).21 While mental and behavioral disorders are among the leading causes of illness and disability in the US, over half of all mental health conditions go untreated or undetected with only 41 percent of people with a mental illness receiving professional health care services.22
According to the Surgeon General’s Report on Alcohol, Drugs, and Health, 1 in 7 people will develop a substance use disorder at some point in their lives, yet only 10% of them will receive treatment.23 Substance misuse is the use of any substance in a manner, situation, amount, or frequency that can cause harm to the users or to those around them. Prolonged, repeated misuse of a substance can lead to a substance use disorder, a medical illness that impairs health and function. Severe and chronic substance use disorders are commonly referred to as
addictions.24 Research suggests that nearly 48 million people (18%) said they used an illicit drug or misused prescription drugs in the past year.25 Drug overdose deaths have more than tripled since 1990 where more than 700,000 Americans have died between 1999-2017 due to
overdosing on a drug. Alcohol is the most widely-abused substance in the United States, yet alcoholism is often left untreated where research shows that about 6% of the US populations (15 million people) have an alcohol use disorder, but only 7% of those with a disorder are ever treated.26 Additionally, substance use disorders often occur simultaneously in individuals with mental illness as a way to cope with overwhelming symptoms. To that end, about 20% of
Americans with depression or anxiety also have a co-occurring substance use disorder.26 It is also important to note the economic burden of substance use disorder in the US where alcohol and drug addiction cost the US economy over $600 billion every year.24
What populations are especially affected by mental illness and substance use disorder? What are barriers to care and treatment for these populations that persist in society today?
Among persons with mental illness and SUD, disparities in quality and outcomes of care are more prominent for racial and ethnic minorities and those from lower socio-economic status groups. Although rates of depression are lower in adults who identify as Black (24.6%) and Hispanic (19.6%) than their white counterparts (34.7%), only 32% of Black and Hispanic people received mental health services compared to 48% of white people.26-28 However, the prevalence of substance use and SUD is equal across racial lines, though more common in gender and sexual minorities. Several barriers to care persist such as lack of insurance, mental illness stigma, lack of diversity among mental health providers, and distrust in the health care system.29 Despite these findings, racial and ethnic minority groups are prosecuted and incarcerated for substance- related offenses at higher rates than their racial and ethnic majority counterparts. These
disparities are exacerbated when considering gender and sexual minority status in addition to racial and ethnic minority status.
Barriers are especially pronounced among the LGBT (lesbian, gay, bisexual, transgender) population. Population surveys estimate that almost 9 million (3.8%) US adults identify as lesbian or gay (1.7%), bisexual (1.8%), or transgender (0.3%).30 People in the LGBT community experience mental illness at higher rates, due to stigma, discrimination, and violence directed at sexual or gender minorities. LGBT individuals are more than twice as likely as cisgender, heterosexual men and women to have a mental health disorder in their lifetime and 2.5 times more likely to experience depression, anxiety, and substance misuse.31 A recent study found that for LGBT individuals, 61 percent have depression, 45 percent have post-traumatic stress
disorder, and 36 percent have an anxiety disorder. Additionally, 40 percent of transgender
individuals have attempted suicide in their lifetime which is nearly 9 times the overall rate in the United States.32 A study by Gonzales and Henning-Smith using the Behavior Risk Factor
Surveillance System from 2014-2015 found that gay and bisexual men and lesbian and bisexual women reported higher odds of frequent mental distress compared to their heterosexual
counterparts.33 Additionally, a study conducted by the SAMHSA found that sexual minorities were more likely to have substance use disorders, particularly related to their use of alcohol and illicit drugs (marijuana; cocaine in any form, including crack; heroin; hallucinogens; inhalants;
methamphetamine; and the misuse of prescription pain relievers, tranquilizers, stimulants, and sedatives) compared to their sexual majority peers.34
Many LGBT people have reported experiencing stigma and discrimination when accessing health services, causing some to delay or forego necessary health care. A study by Willging, Salvador, and Kano conducted interviews with 20 providers in rural areas to document their perceptions of LGBT mental health care and found that the majority of rural providers claimed that there was no difference in working with LGBT patients versus non-LGBT ones.
The study found that despite the providers’ claims of acceptance, lack of education on LGBT mental health issues, and homophobia influenced services for rural LGBT people.35 In fact, many LGBT patients had been denied services, discouraged from broaching sexuality and gender issues, and secluded within residential treatment facilities.35-37
While many politicians and lobbying groups have claimed homosexuality to be a mental disorder, it is important to note that ALL major professional mental health organizations have affirmed that homosexuality is NOT a mental disorder; they have also claimed that being transgender or gender variant is NOT a mental illness and does not imply any impairment in judgement, stability, reliability, or general social or vocational capabilities.38 Yet, as a result of
social marginalization, LGBT individuals have less social support where bisexual people feel especially isolated and transgender individuals have higher rates of poverty and unemployment which are worsened by discrimination.39 Contrary to other minority groups, LGBT individuals have higher rates of mental health service use than their heterosexual counterparts.31, 34
Unsurprisingly, the US carceral system is the number one provider of mental health care in the US, with upwards of 65% of individuals with a mental illness being incarcerated at some point in their lives.40 Unfortunately, people in a mental health crisis are more likely to encounter police than get medical help resulting in almost 2 million people with mental illness getting booked into jails every year.41-43 Nearly 15% of men and 30% of women with a serious mental health condition end up in the carceral system.42 Recent estimates suggest that 44 out of 50 state prisons and jails hold more individuals with a serious mental illness than the largest state
hospital. Justice-involved groups are more likely to have bipolar disorder (63%), schizophrenia (37%), major depression (29%), and a co-occurring substance use disorder (65%). Numerous reports indicate that individuals with a severe mental illness (SMI) are over-represented in the criminal justice system, with prevalence estimates ranging from 15 to 25 percent.43 In its report on the U.S. prisons and offenders with mental illness, the Human Rights Watch indicated that up to 16 percent of adults in state prisons have significant psychiatric or functional disabilities.44
Jails and prisons are constitutionally obligated to provide treatment to inmates with serious medical and psychiatric conditions leading them to become de facto mental health
“systems” for millions of justice-involved people.45 The case of Ruiz v Estelle set the precedent for the minimum requirements for the provision of mental health services in the US correctional system.46 To receive accreditation by the American Correctional Association and the National Commission on Correctional Health Care, an adult correctional facility must provide all inmates
with standard mental health screening and crisis and suicide intervention.47,48 As a result, for many, contact with the criminal justice system may represent their first occasion for any mental health treatment.49 Research shows that jails provide opportunities to treat mental health
conditions and receive medication where rates of medication use among jail inmates rode from 38.5 percent at the time of admission to 45.5 percent after admission.71 However, numerous studies have document seriously substandard care in incarceration settings which have
highlighted the absence of coordinated discharge planning between jails and community health care.109,110
Mental health services provided in jails typically focus on identifying mental illness, crisis management, and short-term treatment. Steadman and Veysey found that mental health services widely varied depending on the size of the facility, such that small jails offer more minimal screening and suicide prevention, whereas larger jails offer comprehensive services.48 In fact, the Cook County Jail in Chicago, IL is the largest provider of mental health services in the entire nation. Incarceration in a prison can last for years and typically provides a greater range of mental health services than shorter term jails where a recent survey found that 77 percent of US prisons provide access to inpatient care and 36 percent have specialized housing.47,50 The primary barrier to improving mental health treatment in adult correctional facilities is inadequate state funding.49
Many studies highlight that while justice-involved individuals may receive mental health services and treatment during their time in prisons and jails, they face serious barriers during reentry and community integration. In general, recidivism among offenders with mental illness is especially high, where one study reported 64 percent of offenders with a mental illness were rearrested within 18 months of release.51 This pattern of relapse is highly associated with poor
coordination of services and treatment upon release into the community which can be
exacerbated by unstable housing, unemployment, poverty, and lack of community ties.49,53 Since the 1965 enactment of Medicaid, individuals are excluded from coverage during incarcerated, however, most offenders are eligible for Medicaid or Medicare through Supplemental Security Income or Social Security Disability Insurance (during periods when they are not
institutionalized) after their release. However, varying state policies lead to the termination of these benefits during the period of incarceration, with some states requiring individuals to wait up to 90 days for benefits to be reinstated upon release while other states incorrectly terminate eligibility and inmates must reenroll before their care is restored52. To reduce disruption in care, some states such as Ohio and Oregon, have been changing policies to auto-enroll offenders 90 days before their release to allow for benefits to be immediately re-instated upon release.52,53 Intersectionality of mental illness with stigma
The theory of intersectionality was initially developed to describe the meaning and consequences of membership in multiple stigmatized social groups.111 People with mental illness are often members of multiple stigmatized social groups and therefore may experience stigma and discrimination not determined solely by their mental illness but other factors as well, such as sexual minority status and prior justice-involvement. Research suggests that to be effective, interventions need to be flexible and targeted rather than universal in order to address the implications of intersectionality.112
Black, Latino, and multiracial lesbian, gay, bisexual, transgender, queer (LGBTQ) people have been disproportionately affected by hate crimes and violence towards LGBTQ
communities.113 Research has utilized the minority stress theory to examine stigma as a form of violence and source of inequities in psychological health and substance use for the LGBTQ
community.114,115 Specifically, minority stress theory states that several stress processes occur as a result of minority status (sexual orientation), including distal minority stressors in the form of discrimination and violence as well as proximal stressors such as expectations of rejection.116 A substantial body of research has provided evidence for this framework, demonstrating that sexual minority stigma is associated with depressive and anxiety symptoms117, substance use118, post- traumatic stress119, suicidality120, and lower self-esteem121. In additional, emerging literature suggests that racial and sexual minority stigma may interact to lead to negative psychological and behavioral health outcomes. A study by English, Rendina, and Parsons, found that racial discrimination and its interaction with jay rejection sensitivity were significantly related with higher levels of depression and anxiety symptoms at 6 months which led to higher levels of heavy drinking at 12 months.122 Another study by Bogart et al. found that in an intersectional quantitative study of 181 Black gay and bisexual men, racial, sexual orientation, and HIV discrimination interacted to predict higher levels of depressive symptoms, though none of the main effects of these forms of discrimination were association with depressive symptoms.123 Together, these studies show that Black, Latino, and multiracial LGBTQ individuals are at a unique risk of experiencing minority stress because they face sexual minority discrimination within their racial group and racial discrimination within their sexual minority group.
Additionally, research suggests that mental illness discrimination persists in correctional facilities as well where inmates are denied earn-time reductions in sentences, parole
opportunities, placement in less restrictive facilities, and opportunity to participate in sentence- reducing programs because of their status as psychiatric patients of their need for psychotropic medications.124 But this stigma persist even after inmates leave correctional settings where research shows that Caucasians and other majority groups may be more negatively impacted by
stigma than minority groups, impeding their motivation or self-efficacy for obtaining
employment.125 In criminology literature, the impact of stigma has been discussed in labeling theory, but little empirical research has explored the role of stigma among offenders.126 One of the studies, Winnick and Bodkin, examined how 450 male offenders thought people in society would react to the label of “ex-con”. They found that offenders perceived a great amount of stigma especially in employment and childcare where increased public stigma has been linked to poor psychological health and social functioning.127 Literature has also suggested that this
structural and public stigma results in offenders feeling like outsiders, causing them to withdraw from the community and engage in higher rates of criminal actions.126 Moore, Stuewig, and Tangney found that inmates who perceived more public stigma were more likely to commit violent offenses in the year after their release where labeling theory posits that these offenders might perceive more stigma towards criminals to more closely fit the stereotype of a typical
“criminal”.128 In sum, among inmates nearing community re-entry, perceived and anticipated stigma are important considerations as they may lead to worsened psychological and behavioral conditions.
What policies and institutions help support individuals to receive treatment and healthcare services for mental illness and substance use?
The federal government creates large-scale changes and provides oversight across states to help implement federal laws. Some influential pieces of legislation include the Americans with Disabilities Act (ADA), the Rehabilitation Act, the Mental Health Parity and Addiction Equity Act (MPHAEA), and more recently, the Affordable Care Act (ACA) which have all played major roles in providing constituents with mental health and SUD support and access to treatment.54 The federal government is a major funding stream for mental health services. In
addition to funding mental health services that are under Medicare and the Department of Veterans Affairs, the federal government also matches states’ Medicaid programs and Children’s Health Insurance Program (CHIP). While these programs do not exclusively focus on mental health, Medicaid is the single largest funder of mental health services in the country. The federal government also provides Mental Health Block Grants (MHBG) that support states in building community mental health resources.55
Regulations can also be issued by state agencies that can address a variety of issues ranging from treatment facilities, medical records, and standards for involuntary treatment.
While states receive federal support via Mental Health Block Grants and partial funding through match programs for services provided through Medicaid and CHIP, each state has a lot of freedom in designing and funding its own mental health system.56 As a result, the state’s role in funding mental health services varies greatly across different states. Moreover, depending on the state’s political and economic climate, states will either allocate more or less funding towards comprehensive mental health services.
2.4 METHODS Data Source
This study uses data from the 2015-2019 National Survey on Drug Use and Health (NSDUH), a cross-sectional and nationally representative survey of the civilian, non-
institutionalized population. The survey is conducted annually and sponsored by the Substance Abuse and Mental Health Service Administration (SAMHSA) with a response rate above 70%
each year that measures the prevalence of drug use and mental health disorders in the United States. We restricted our sample to individuals at or above the age of 18 years, because this age
group was asked specific questions about criminal justice history, sexual orientation, and behavioral health outcomes.57
Study Sample
Starting in 2015, the NSDUH questionnaire added questions gathering data about sexual orientation, and thus we pooled data from 2015-2019 to create our analytic data set. In the sexual orientation module, respondents were asked which of the following categories best represents how they identify themselves: heterosexual, lesbian or gay, or bisexual.57 Sexual minorities were defined as those who reported identifying as gay, lesbian, or bisexual. Although the NSDUH does ask further information about sexual attraction, we chose to focus this analysis on
differences by sexual orientation identity among justice-involved individuals. Justice-involved individuals were defined as those who reported being arrested or booked, paroled, or on probation in the past 12 months preceding the survey interview date. Consistent with previous research, we did not take into account whether a person had an interaction with the criminal justice system prior to this in order to keep a standard reference time-frame for all outcomes.58,59 Our analysis excluded individuals who did not answer questions related to criminal-justice involvement (n=2,080) and individuals who did not answer questions related to sexual identity because they didn’t know (n=1,364), they refused to answer (n=2,060), and for other reasons (n=119).
Mental Illness, Substance Use, and Treatment Outcomes
We examined outcomes that represent the wide spectrum of mental illness and substance use. All variables and outcomes are based on self-report. Substance use/dependence is a
composite score of any abuse or dependence on cocaine, heroin, non-medical prescription opioids, or stimulants in the past 12 months. Alcohol use disorder, cocaine use disorder,
hallucinogen use disorder, inhalant use disorder, pain reliever use disorder, heroin use disorder, sedative use disorder, marijuana use disorder, and tranquilizer use disorder were defined by the NSDUH based on whether the participant met the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria within the past year. Suicide ideation was defined as seriously thinking about killing oneself in the past 12 months, suicidal plan was defined as making plans to kill oneself in the past 12 months, and suicide attempt was defined as trying to kill oneself in the past 12 months. For suicidality, all adult respondents were first asked: “At any time during the past 12 months, did you seriously think about trying to kill yourself?” and those who said “yes”
were then asked “Did you make any plans to kill yourself during the past 12 months?” and those who said “yes” were asked “Did you try to kill yourself during the past 12 months?”. Major depression was defined as having a major depressive episode in the past year as defined by the assessments and diagnostic criteria of DSM IV.60 Mental illness severity is based on a prediction model developed by SAMHSA to measure severe mental illness (SMI) prevalence that utilized Kessler’s six-item (K6) instrument to measure psychological distress in the previous 30 days and the World Health Organization Disability Assessment Schedule (WHO-DAS).57 Drug use and mental illness treatment included any outpatient, inpatient, residential, or medication-based treatment in the past 12 months.
Statistical Analysis
We used descriptive statistics to characterize the study sample and estimate the prevalence of each outcome of interest by sexual minority status and criminal-justice
involvement status. Next, we estimated multivariable logistic regression models to compare the odds of each outcome between individuals who identified as sexual minorities and their
heterosexual peers by justice-involvement status while controlling for demographic and
socioeconomic characteristics. Then we repeated logistic regression analyses to compare each outcome between criminal-justice and non-criminal justice involved individuals by sexual minority status. All logistic regression models controlled for age in years (18-25, 26-34, 35-49, 50 and older), race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and other/multiple races), relationship status (married, divorced or separated or widowed, never married), the presence of children in the household, educational attainment (less than high school, high school graduate, some college, college graduate), employment status (employed full-time, employed part-time, unemployed, other), household income (less than $20,000;
$20,000-$49,999; $50,000-$74,999; $75,000 or more), health status (excellent/very good/good, fair/poor), and insurance status. Results from the logistic regression models are presented as adjusted odds ratios (ORs) with standard errors. We conducted all analyses using Stata version 16.1 using survey weights and the svy command to adjust standard errors for the complex survey design of the NSDUH. This study was deemed exempt from review by the Vanderbilt University Institutional Review Board (IRB) because data were obtained from de-identified, publicly available, and secondary sources.
2.5 RESULTS
Sociodemographic Characteristics of the Study Sample for Justice-Involved Sexual Minorities
After applying survey weights, approximately 2.8% of heterosexual and 0.3% of sexual minority individuals were justice-involved in the NSDUH from years 2015-2019. Approximately 9% of criminal-justice involved individuals in the NSUDH 2015-2019 considered themselves lesbian or bisexual; 91.03% considered themselves heterosexual. Table 1 presents the
sociodemographic characteristics by criminal justice involvement and sexual minority status.
Most justice-involved sexual minorities were bisexual (68.5%), and fewer were lesbian or gay
(31.5%). Compared with justice-involved heterosexual individuals, justice-involved sexual minorities tended to be younger (38.5% were 26-34 years), racial/ethnic minorities (22.6% were non-Hispanic Black, 19.9% were Hispanic), never married (67.4%), better educated (10.8%
graduated college), less likely to have a child in the household (44.5%), unemployed (17.5%), earning less than $20,000 a year (41.1%), uninsured (78.2%), and have worse overall health (21.5% reported fair or poor health status).
Non-criminal justice involved sexual minorities and heterosexuals shared similar patterns with some notable exceptions. Most non-criminal justice involved sexual minorities were bisexual (61.5%) and more than one-third (38.5%) were lesbian. Compared with non-criminal justice involved heterosexual individuals, sexual minorities were younger (30.64% were 18-25 years), racial/ethnic minorities (13.04% were non-Hispanic Black, 18.14% were Hispanic), never married (62.28%), less likely to have a child (32.51%), better educational attainment (34.97%
had some college), unemployed (7.14%), earn less than $20,000 a year (22.16%), and report fair/poor health status (15.18%). However, non-criminal justice involved sexual minorities were less likely to be insured (88.4%) compared to their heterosexual peers (90.9%).
Mental Health and Substance Use Outcomes by Criminal Justice Involvement and Sexual Minority Status
Table 2 presents prevalence estimates and multivariable logistic regression results for mental illness and SUDs by criminal justice involvement and sexual minority status.
Approximately 40% of criminal-justice involved sexual minorities had a SUD in the past year with alcohol use disorder being the most prevalent (25.6%) followed by marijuana use disorder (10.7%). Compared to their criminal-justice involved heterosexual peers, justice-involved sexual minorities had a higher prevalence of all substance use disorders portrayed in Table 2. After
controlling for sociodemographic characteristics, there were no differences between heterosexual and sexual minorities who were justice-involved for sedative use disorder, pain reliever use disorder, heroin use disorder, and tranquilizer use disorder. However, justice-involved sexual minorities were more likely to report inhalant use disorder (OR, 5.50, p=0.002), hallucinogen use disorder (OR, 2.49, p=0.028), cocaine use disorder (OR, 1.93, p=0.015), alcohol (OR, 1.30, p=0.051), and marijuana use disorder (OR, 1.37, p=0.052) compared with their justice-involved heterosexual peers. Meanwhile, non-criminal justice involved sexual minorities were more likely to be dependent on all substances, except for heroin, compared with the non-criminal justice involved heterosexual counterparts.
Table 2 also presents comparisons of mental illness by justice-involvement and sexual minority status. More than 50% of criminal-justice involved sexual minorities from the NSDUH between years 2015-2019 had a mental illness. The prevalence of suicidal ideation (21.1%;
9.2%), planning to commit suicide (11.2%; 3.8%), and suicide attempts (6.0%; 1.9%) in the justice-involved sexual minority population were higher than in the justice-involved heterosexual population. Also, of note, more than one-fifth (22.0%) of justice-involved sexual minorities had a serious mental illness, and nearly one-quarter (25.2%) indicated having depressive thoughts in the past year. After controlling for sociodemographic factors, justice-involved sexual minorities were more likely to have mental illness (OR, 1.63; p<0.001), specifically serious mental illness (OR, 1.95; p<0.001) and moderate mental illness (OR, 1.44; p=0.007) and depressive thoughts (OR, 1.95; p<0.001), but not mild mental illness compared with justice-involved heterosexual individuals. Justice-involved sexual minorities were more likely to report suicidal ideations (OR, 1.94; p<0.001), plannings (OR, 2.48; p<0.001), and attempts (OR, 2.31; p=0.003) than their justice-involved heterosexual peers. Meanwhile, non-criminal justice involved sexual minorities
shared similar patterns with one notable exception: non-criminal justice involved sexual
minorities were more likely to have mild mental illness (OR, 1.39; p<0.001), compared with the non-criminal justice involved heterosexual counterparts.
Mental Illness and Substance Use Treatment by Criminal Justice Involvement and Sexual Minority Status
Table 3 presents prevalence estimates and ORs comparing access to mental illness and SUD treatment between justice and non-justice involved individuals by sexual minority status.
Interestingly, the prevalence of treatment for justice-involved sexual minorities for SUD treatment (22.7%), inpatient mental health treatment (8.6%), outpatient mental health treatment (19.6%), and prescription mental health treatment (29.8%) were higher than for their justice- involved heterosexual counterparts. Table 3 shows that almost half (45%) of justice-involved sexual minorities received treatment for SUD or mental illness in the past year. After controlling for sociodemographic characteristics, justice-involved sexual minorities were marginally more likely to receive treatment for SUD (OR, 1.29, p=0.03), any mental health treatment (OR, 1.58, p<0.001), inpatient mental health treatment (OR, 1.67, p=0.01), outpatient mental health treatment (OR, 1.43, p=0.03), prescription mental health treatment (OR, 1.64, p<0.001), and overall treatment for SUD or for mental illness (OR, 1.40, p=0.005). Non-criminal justice involved sexual minorities shared similar patterns, but they had a lower prevalence of treatment SUD and mental illness than their criminal-justice involved counterparts.
2.6 LIMITATIONS
There were several limitations to using the NSDUH from years 2015-2019. First, most responses to the NSDUH, especially in relation to substance use, suicidal behaviors, depressive
thoughts, and questions regarding mental illness were self-reported which can lead to response bias and social desirability bias. Moreover, reporting sexual orientation may suffer from selection bias. Our sample of sexual minority adults only includes those who were comfortable disclosing their sexual orientation in the NSDUH questionnaire. It is important to also note that the survey excludes homeless persons who do not use shelters, military personnel on active duty, and residents of institutional group quarters such as jails and hospitals, which have been
previously shown to have a high proportion of individuals who are sexual minorities and/or have a past history for criminal justice involvement.57
This study also does not consider sexual attraction, and only focuses on sexual identity, and thus does not consider individuals who are sexually active with or attracted to people of the same sex but do not identify as lesbian, gay, or bisexual. Furthermore, the sample size of justice- involved sexual minorities was relatively small (n=929). Thus, although there may be important differences between various subgroups (lesbians vs bisexual individuals), we did not have a sufficient sample size to analyze these distinctions. Moreover, because we only analyzed data about mental illness, substance use, and criminal justice involvement in the past year, we are unable to analyze longitudinal mental illness and substance use outcomes.
Finally, the NSDUH is a cross-sectional survey and cannot definitively establish the causal pathways for the observed associations between sexual orientation and mental illness and SUD outcomes because cross-sectional studies are prone to omitted variable bias.15 Missing unmeasured variables such as exposure to discrimination or nondisclosure of sexual orientation to family, friends, and providers may provide an alternative explanation for the relationship between sexual orientation to mental illness and/or SUDs. Further research should continue to explore the underlying causes of mental illness and SUDs among justice-involved individuals
and sexual minorities. Moreover, other nationwide questionnaires should seek to incorporate sexual orientation and justice-involvement data collection into ongoing assessment to facilitate a broader and more thorough research into this vulnerable population.
2.7 DISCUSSION
Health issues for criminal-justice involved individuals and for sexual minorities have been vastly understudied largely due to the lack of justice-involvement and sexual orientation and gender identity (SOGI) questions in nationwide surveys.61-63 This analysis is one of the first to examine the prevalence of SUD, mental illness, and access to treatment by sexual minority and criminal-justice involvement status among a representative sample of adults across the United States. We found that individuals who identified as sexual minorities had a higher prevalence of substance use and mental illness compared to their heterosexual counterparts, and this increased prevalence was especially prominent among those with prior justice-involvement.
Higher rates of mental illness and substance use translated to increased receipt of mental illness and SUD treatment for sexual minorities and justice-involved sexual minorities compared to their heterosexual peers. The large proportion of individuals who identify as sexual minorities and have had contact with the criminal justice system suggest that public health interventions are needed to target mental illness and substance use among this population through increased coordination between the carceral and healthcare systems.
We also provide a detailed characterization of demographics for individuals who identify as LGB with prior justice-involvement. To our knowledge, this is the first study to show that justice-involved sexual minorities are more likely to be younger, be in poverty, and have poorer health status than their heterosexual justice-involved peers and their sexual minority non-justice- involved peers. We hypothesize that this may be due to the combination of prior incarceration
and sexual minority statuses as previous research has shown that each status independently has led to a higher prevalence of lower socioeconomic status and chronic healthcare conditions.59,61,62
Previous studies have shown that justice-involved individuals and sexual minority status independently lead to higher rates of mental illness and SUD.7,33,39,64. Our results support these previous findings and add that individuals who identify as sexual minorities and have been involved with the criminal justice system in the past year are more likely to experience more severe forms of mental illness and significantly higher rates of substance use disorder, especially for alcohol use disorder, marijuana use disorder, inhalant use disorder and hallucinogen use disorder. Given the large body of research that has documented barriers to care in sexual minorities, we hypothesize that these differences between sexual minorities and heterosexual justice-involved individuals may be due to discrimination, stigma, and minority stress that LGB individuals may face at higher rates. 32,33,34,35,39
The overlap we found between involvement in the criminal justice system, sexual minority identity, and mental illness and SUD suggests that access to treatment within the criminal justice system and community-based resources are critical public health issues. Prior studies show that sexual minorities have higher rates of mental health service utilization and are more likely to enter SUD treatment with more severe conditions.33,34,61 On the other hand, numerous studies emphasize that individuals in the criminal justice system have lower rates of mental health service utilization and SUD treatment, even though they have higher rates of severe mental illnesses and SUD than the general population.7,58,59 Our analyses found that sexual minorities, regardless of justice-involvement, were more likely to receive outpatient, inpatient, prescription, and general mental health treatment than their heterosexual peers. Our research also highlights that sexual minorities with prior justice involvement are more likely to have insurance
than their heterosexual peers which may translate to increased receipt of treatment for mental illness or SUD, which is contrary to prior research that has shown that increased access to insurance does not translate to increased healthcare utilization.3 We hypothesize that the higher prevalence of severe conditions of mental illness and SUDs may contribute to the higher levels of treatment among this population where a subset of this population may be forced to participate in mandatory treatment ordered by the criminal justice system due to the severity of their
condition.
SECTION 3:
The Affordable Care Act and Healthcare Utilization among Justice-Involved Individuals:
Insights from the National Survey of Drug Use and Health, 2010-2019 3.1 ABSTRACT
Objectives: To examine the impact of the Affordable Care Act (ACA) on healthcare utilization among justice-involved individuals in the United States
Methods: Data from the National Survey on Drug Use and Health from 2010-2019 was used to perform repeated and pooled cross-sectional analyses with a nationally representative sample of adults age 18-64 with a history of mental illness or substance abuse, with and without justice involvement (n=103,818). A difference-in-differences model was used to obtain differential changes in insurance coverage, mental health and substance use treatment based on justice- involvement before and after implementation of the ACA’s major coverage provisions in 2014.
Results: The implementation of the ACA was associated with a 3.31 percentage point
differential increase in rates of insurance coverage for justice-involved individuals compared to their non-justice-involved peers. However, following the ACA, the justice-involved population saw a differential decrease in receipt of prescription medication for mental health treatment,
(-3.96pp, 95% CI -6.50,1.42). Although there was a significant difference in access to substance use disorder treatment between justice and non-justice-involved populations in the pre-ACA period, there was no differential change as a result of the ACA.
Discussion: Health insurance coverage increased by a larger amount among formerly
incarcerated adults compared to those not recently involved in the carceral system following the implementation of the ACA. Despite a differential gain in insurance coverage, formerly
incarcerated individuals continue to face barriers to accessing behavioral health treatment. Better coordination between the carceral and health care systems and improved re-entry programs and conditions may facilitate access to health insurance coverage for formerly incarcerated adults.
3.2 INTRODUCTION
As of 2020, approximately 2.3 million individuals were under the supervision of the US correctional systems, with 1.3 million in prison, and more than 900,000 in jails.65 Around two- thirds all carceral-involved people have a substance use disorder, serious mental illness, or both, which is considerably higher than the general population.66,67,68,69 Additionally, the carceral- involved population has higher rates of chronic health conditions (such as diabetes, hypertension, and asthma) and communicable diseases (such as HIV and hepatitis) compared to the general population.69-71 While individuals previously involved in the criminal justice system have a higher prevalence of many health conditions, historical barriers such as lack of insurance and inadequate capacity in the health care system make it difficult to access health care
services.3,7,58,72 To this end, research has found that one-third of inmates using prescription drugs prior to incarceration did not receive medication in jail and more than half of individuals who needed blood tests or medical examinations failed to receive them during incarceration.67
Additionally, formerly incarcerated adults have less access to health care services upon re-entry to the community, reducing the likelihood of treatment for chronic conditions.
Approximately 80 percent of the justice-involved population lacked insurance upon re-entry into their community,73 and formerly incarcerated adults accounted for more than a third of the remaining uninsured population two years after the Affordable Care Act’s (ACA) coverage provisions were implemented.3,7,58 These high rates of uninsurance create barriers to accessing primary care and mental health services, which in turn lead to more acute or chronic
conditions.74,75
The implementation of the ACA’s key provisions provided new opportunities to address low rates of insurance coverage among people returning to the community after being
incarcerated. Approximately half of all carceral-involved people were expected to be newly eligible for health insurance, and roughly one quarter were expected to be newly eligible for Medicaid in ACA expansion states.67 While recent studies have suggested that the ACA improved health insurance coverage for formerly-incarcerated people, rates of treatment for substance use disorder and mental illness remain low in this population.3,7,58
Evidence on the ACA’s impact on healthcare utilization for the formerly incarcerated is mixed. One study found that increased health insurance coverage was associated with increased rates of outpatient, inpatient, and emergency department care among formerly-incarcerated people.7 Another study, however, found that increases in insurance coverage may not translate to an increase in treatment receipt. Indeed, previously-incarcerated men were less likely to have a source of primary care and more likely to report emergency department use than their never- incarcerated counterparts.3 Finally, increased access to treatment for mental illness or substance use disorders may improve re-entry outcomes for formerly-incarcerated adults.76
While previous studies have demonstrated a short-run increase in insurance and healthcare utilization after the ACA, no study, to our knowledge, has examined longer-term implications of increased coverage and financial access to care. In this study, we analyze the longer-term impacts (up to 2019) of the ACA’s coverage provisions on insurance coverage and healthcare use for carceral-involved adults using a national survey and quasi-experimental methods. Specifically, we estimated differential changes in coverage and utilization outcomes for those previously incarcerated compared to those without recent incarceration before and after the ACA’s coverage provisions in 2014 through 2019, hypothesizing that formerly incarcerated adults have lower rates of insurance coverage and behavioral healthcare utilization than their un- incarcerated counterparts and that these inequities continue to persist five years later.
3.3 BACKGROUND
How has the Affordable Care Act impacted access to mental health services?
A decade after the passage of the Affordable Care Act (ACA) there is ample evidence that it has increased insurance coverage in the United States and enhanced access to affordable health services, including mental health. Research indicates that before the ACA, mental health care was particularly inaccessible for patients in individual and small-group health plans, and especially for the uninsured population.77 Before the implementation of the ACA, there were more than 48 million Americans who were uninsured, and prior research indicates that people with mental illness are more likely to be low income and uninsured.78 Leading up to the ACA, the Mental Health Parity Act of 1996 and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) required all large-group employer insurance plans to cover mental health services at the same level as medical and surgical services, meaning plans cannot impose stricter limits on or greater cost-sharing for mental health services relative to other medical or surgical
benefits.79,80 However, MHPAEA only applied to large employer-sponsored, federally-regulated plans that already offered these benefits. In fact, prior to the ACA, small group and individual plan insurers could screen patients for mental health history and use that information to deny coverage, exclude or cap mental health services and prescription drugs, and increase premiums and cost-sharing.77,80
The implementation of the ACA addressed these problems by increasing insurance eligibility and requiring all plans to offer mental health and substance use disorder treatment services at parity with medical and surgical benefits. Coverage expansion provisions occurred via the dependent coverage mandate, which allowed young people to stay on their parents’ plans until age 26, the removal of categorical eligibility and the increase in income limits for Medicaid coverage, and private insurance market reforms (including guaranteed issue and renewal, no medical underwriting, and premium and cost-sharing subsidies). Together, these expansions led to a drop in the number of uninsured to 30.4 million by 2018.78,81 The ACA also required
coverage of substance use disorder and mental health services at parity for individual and small- group plans, Medicaid expansion adults, and everyone enrolled in a Medicaid managed care organization.82
Research has shown that people with mental health conditions were more likely to have insurance as a result of the ACA. A study by Fry and Sommers comparing rates of mental health services and insurance access in expansion and non-expansion states found that Medicaid
expansion was associated with a significant increase (23 percentage points) in the proportion of adults with depression who gained health insurance.83,84 As a result of insurance coverage, studies have shown that access has improved for mental health patients with an increase in treatment and a decrease in unmet mental health needs because of cost.83,85 Numerous studies have highlighted
the improvement in overall access to mental health services, especially for lower-income adult populations in Medicaid expansion states.85-87 However, other research has found that the increase in mental health care and insurance coverage was universal, and these effects were experienced in both Medicaid expansion and non-expansion states.86 While some studies have found that Medicaid expansion has been associated with reduced severe psychological stress, others have found no difference in the mental health of adult populations.87,88
While mental health outcomes as a result of the ACA are slowly emerging and mostly preliminary, many studies have found that living in a Medicaid expansion state is associated with overall better mental health for lower-income individuals.77,83,86 Also, the dependent coverage provision has been associated with greater mental health coverage and access for young adults.89 Interestingly, while coverage and access have improved for many young adults as a result of the dependent coverage mandate, many studies have shown only a moderate relative improvement in the self-reported mental health for young adults, compared to an older control group, even though they have lower out-of-pocket spending for mental health and substance use conditions.91,92
3.4 METHODS Study Sample
The study uses data from the 2010-2019 National Survey on Drug Use and Health (NSDUH), a cross-sectional and nationally representative survey of the civilian, non-
institutionalized population. The survey is sponsored by the Substance Abuse and Mental Health Service Administration with a response rate above 70%. The NSDUH asks respondents about recent and historic substance use and mental illnesses, access to and receipt of treatment services, and demographic characteristics, including previous incarceration. We restricted our sample to respondents between 18 and 64 years old, as this population was the target of the ACA’s
coverage provisions. We also restricted our sample to only respondents with a diagnosed mental illness or substance use disorder in the past 12 months to ensure that respondents in the treated and comparison groups represented similar diagnostic profiles.57
Key Variables and Outcome Measures
Previously incarcerated respondents are defined as those who reported being arrested and booked, paroled, or on probation in the 12 months preceding the survey interview date.
Diagnosis of a substance use disorder and mental illness were based on DSM IV criteria.60 Our outcomes of interest were changes in health insurance coverage and treatment receipt. A
respondent was determined to be uninsured if they were not enrolled in a private or public health insurance plan at the time of the interview. Treatment receipt was also self-reported – drug use and mental illness treatment included any outpatient, inpatient, residential, or medication-based treatment in the past 12 months.
Study design and analysis
First, we compared survey-weighted, sociodemographic characteristics of the carceral and non-carceral groups, in the pre-period (2010-2014). We also estimated rates of health insurance coverage and any mental health or substance use treatment in both groups prior to the ACA. Then, we conducted a difference-in-differences (DID) analysis to quantify whether previous incarceration facilitated or hindered access to health insurance coverage or behavioral healthcare relative to those without a recent incarceration.
We used a linear probability model to estimate survey-weighted, differential changes in outcomes of interest across treatment groups (those previously incarcerated vs. those not previously incarcerated) before and after the ACA’s coverage provisions.92 Regressions were
adjusted for respondent’s age, ethnicity, sex, educational attainment, and employment status.93 We also adjusted for racial group membership, since institutional racism results in higher rates of incarceration, lower rates of health insurance coverage, and reduced access to healthcare services for racialized communities.
We estimated treatment effects over the whole post-period and for each year in the post- period to estimate time-varying treatment effects. This decision was made a priori, as more states implemented the ACA’s Medicaid expansion over the post-period. Additionally, we hypothesized that implementing re-entry services to connect previously incarcerated respondents to coverage and treatment may have resulted in lower rates of coverage enrollment and treatment receipt in the treated group in the years immediately following the ACA. These earlier
differential declines may be offset by later differential increases, resulting in no average differential change and masking these time-varying effects.
We also estimated regression models where we modeled a linear trend difference between the two groups in the pre-period to address the validity of the ‘parallel trends’ of DID designs. This results in a slightly different counterfactual assumption that the usual DID
assumption – that any changes from the linear extrapolation of the trend differential seen in the comparison group is a good proxy for what would have happened in the treated group without the ACA’s coverage provisions.93 This model also requires a fully saturated model that estimates time-varying treatment effects at each post-period time point.94,95
All analyses were conducted in Stata (version 16.1). This study does not qualify as human subjects research because data were de-identified and publicly available.
3.5 RESULTS
