• 1.

    Rockey N, et al. Challenging health inequities in incarceration: A call for equitable care for kidney disease and hypertension. Curr Hypertens Rep 2023; 25:437445. doi: 10.1007/s11906-023-01267-z

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Maruschak LM, et al. Medical problems of state and federal prisoners and jail inmates, 2011–12. Department U.S. of Justice, Office of Justice Programs. Bureau of Justice Statistics, February 2015; pp. 122. Revised October 4, 2016. Accessed December 4, 2021. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Widra E, Herring T. States of incarceration: The global context 2021. Prison Policy Initiative. September 2021. https://www.prisonpolicy.org/global/2021.html

  • 4.

    Curran J, et al. Estimated use of prescription medications among individuals incarcerated in jails and state prisons in the US. JAMA Health Forum 2023; 4:e230482. doi: 10.1001/jamahealthforum.2023.0482

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Panesar M, et al. Evaluation of a renal transplant program for incarcerated ESRD patients. J Correct Health Care 2014; 20:220227. doi: 10.1177/1078345814531726

  • 6.

    Shavit S, et al. Transitions Clinic Network: Challenges and lessons in primary care for people released from prison. Health Aff (Millwood) 2017; 36:10061015. doi: 10.1377/hlthaff.2017.0089

    • PubMed
    • Search Google Scholar
    • Export Citation

Incarceration Linked to Kidney Risk and Care Access Challenges

Bridget M. Kuehn
Search for other papers by Bridget M. Kuehn in
Current site
Google Scholar
PubMed
Close
Full access

Serving the Underserved

The following article is the third of a five-issue series focused on caring for patients in underserved populations. Inspired by several sessions at Kidney Week 2023, this series features unique patient and physician perspectives, explains legal protections and limitations, and seeks to identify opportunities to improve kidney care for these communities.

For 10 years, Laura Maursetter, DO, FASN, associate professor of medicine at the University of Wisconsin–Madison and section chief of nephrology at the William S. Middleton Memorial Veterans’ Hospital in Madison, has provided telehealth care to individuals with kidney diseases in 31 of the 36 correctional facilities in Wisconsin. A medical assistant works with Maursetter and coordinates six, 30-minute visits each week with patients in the facilities. The facilities run laboratory tests and fax her the results.

“It ends up being pretty seamless, and as you get to know the facilities a little bit better, it becomes a lot easier to communicate,” she said.

Maursetter's work has given her a window into the high rates of kidney diseases among people who are incarcerated and the challenges they face both in prison and as they transition to life after prison. She noted that patients who are incarcerated face unhealthy dietary options and may or may not have control over their medications or when they are administered. There are also only two facilities in the state that have dialysis services.

“Patients who need dialysis have to go to [those facilities] even if it doesn't align with the level of security they require,” said Maursetter, who shared her experience at the “Serving the Underserved: Improving Kidney Health in Underserved Populations” at Kidney Week 2023 in Philadelphia, PA.

These challenges are not unique to Wisconsin. A recent review of the literature in Current Hypertension Reports identified a lack of chronic disease care and access to specialists, limited control over lifestyle, and difficulties transitioning to care in the community after release as widespread challenges affecting individuals with kidney diseases who are incarcerated (1). Maursetter noted that a staggering 1.9 million people are incarcerated across the United States, and an estimated 5% or 96,000 of them may have kidney conditions (2).

“This is a uniquely vulnerable population,” said the recent review's senior author (1), Katherine Rizzolo, MD, a nephrologist and assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine, MA, in an interview with Kidney News. She explained that many individuals lack health care access before involvement with the criminal justice system, and there are limited data available about their experiences during incarceration and after to help guide efforts to improve their care. “We don't know what we are dealing with,” she said.

Magnified disparities

The United States has the highest incarceration rate in the world (3). Maursetter noted that this is the result of changes in sentencing policies that have accelerated incarcerations despite no increase in crime rates. There are also extreme disparities among those who are incarcerated in the United States, with many individuals who already face kidney disease-linked health disparities being disproportionately affected.

Men comprise the bulk of people who are incarcerated in the United States. Most are between the ages of 25 and 54 years, but the population 55 years and older who are incarcerated increased 300% between 1990 and 2009, Maursetter said. “We have an aging population in our prison system,” she said.

There are also marked racial, ethnic, and economic disparities among these populations. A White man has a 1 in 17 risk of incarceration compared with a 1 in 3 chance for a Black man in the United States, she noted. Poverty and educational levels also play a role. For example, a White man between the ages of 20 and 34 years without a high school degree has a 1 in 8 chance of incarceration compared with a 1 in 57 chance for peers with a high school degree. Maursetter said a boy whose family is in the bottom 10% of US incomes is 20 times more likely to be in prison by the age of 30 years than is a boy whose family is in the top 10% of incomes. She clarified that it is not that these groups are more likely to commit crimes but rather that these groups are more scrutinized.

Many of the same factors that are associated with increased incarceration risk—being a member of a minoritized racial or ethnic group, poverty, and lower educational level—are also linked with elevated kidney risks, she noted.

Jail or prison conditions may exacerbate those risks. Life in correctional facilities is stressful, with limited opportunities for exercise. Dietary options often feature high-fat and high-sodium foods. Individuals who are incarcerated may work for 14 to 60 cents per hour, earning money that they may use for co-pays or purchasing supplementary food, including few healthy options, Maursetter said. For example, a patient of Maursetter's was repeatedly hospitalized for fluid overload. When she reviewed the list of supplemental foods that he was purchasing, she discovered that ramen noodles (which can contain 1600 mg of salt per package) were a staple in the facility.

People who are incarcerated were granted the right to health care in 1976. But Maursetter noted that there is little incentive for private or public prisons or jails to screen for, diagnose, and treat individuals in custody. “Standards can be quite different among groups providing care,” she said. Routine appointments are often limited or may require a co-pay of as much as $100 per year. A physician or advanced practice practitioner may staff the facility, but patients or their guards may control medications. “You are not necessarily sure whether people are getting the medicines they are using,” Maursetter said. A 2023 study found that people who are incarcerated are 3 times less likely to be treated with diabetes medications and 2.4 times less likely to receive anti-hypertensives (4).

Lead author of the review (1), Nathan Rockey, MD, a resident at the University of Colorado, Aurora, and Denver Health, said in an interview that prison and jail health care systems often focus on providing acute emergency care or transitioning patients who require hospital care. In that setting, he noted, it may be difficult to establish initiatives to recognize and treat chronic diseases.

Rizzolo, who treats patients with kidney diseases through a federally qualified health center that has a partnership with a prison and local jails, said there are limitations to the care she can provide. Often, routine testing and screenings are not available. “Sometimes, as a [practitioner], I feel helpless,” she said. “We’ll do the best, but we can't screen or treat patients like we normally would.”

Hemodialysis is often the default option for patients with kidney failure, the review found (1), although some programs have successfully tried home peritoneal dialysis. Few people with kidney diseases who are incarcerated are considered for transplant despite evidence that it can be both efficacious and cost-effective among this population (5). Rizzolo noted that concern about whether the individual will have access to insurance or adequate finances after release is often a barrier. She, however, argued that nephrologists should consider transplants because the law requires a community standard of care for people who are incarcerated, and transplant is the gold standard.

Tenuous transitions

Circumstances can become tenuous for individuals after release. Although health care is an individual's right while in prison, they may face barriers to access after release. Some states provide coverage through Medicaid, but navigating the enrollment process can be a challenge, Rockey said.

Individuals who have been newly released often have poorly controlled diseases and face elevated rates of mortality during the post-release period, Maursetter noted. They may receive 30 days of medications upon release but have limited time to access insurance, find a physician, and make appointments to get refills, Maursetter continued. Discrimination in accessing care or employment, high rates of homelessness, and other psychosocial challenges after leaving prison may create additional challenges, Rockey said. “Upon release from prison, there is so much going on socially, and seeking a [practitioner] for chronic diseases can take a back burner by necessity,” Rockey explained. “You are trying to find a job, restart a life, and reintegrate.”

However, there are ways to create more seamless access to care. Some institutions have created transition clinics that work with individuals nearing release (6), Rockey said. These clinics rely on multidisciplinary teams, including physicians, social workers, case managers, and others, who work with patients to help them transition into community care more smoothly and address social determinants of health, such as employment, housing, and transportation. “There are a lot of opportunities to intervene to make it more logistically seamless and to improve disparities,” Rockey said.

According to Rizzolo, there is a huge need for more research on this vulnerable population, including qualitative research that captures individuals with lived experience with chronic diseases while incarcerated and after release and the barriers to care that they experienced. Advocacy is also needed to promote system-wide change in the care received by people during incarceration and as they leave the system and to reduce US incarceration rates, she said.

Maursetter recommended routine screening for kidney diseases among individuals who are incarcerated and the implementation of standardized care. She also encouraged nephrologists to provide care for this population and to collaborate with social workers and others to address the unique needs of the population. “How can we help facilitate care a little better, open up our offices, and take care of patients in a way that is a little bit more holistic?” Maursetter asked.

References

  • 1.

    Rockey N, et al. Challenging health inequities in incarceration: A call for equitable care for kidney disease and hypertension. Curr Hypertens Rep 2023; 25:437445. doi: 10.1007/s11906-023-01267-z

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Maruschak LM, et al. Medical problems of state and federal prisoners and jail inmates, 2011–12. Department U.S. of Justice, Office of Justice Programs. Bureau of Justice Statistics, February 2015; pp. 122. Revised October 4, 2016. Accessed December 4, 2021. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Widra E, Herring T. States of incarceration: The global context 2021. Prison Policy Initiative. September 2021. https://www.prisonpolicy.org/global/2021.html

  • 4.

    Curran J, et al. Estimated use of prescription medications among individuals incarcerated in jails and state prisons in the US. JAMA Health Forum 2023; 4:e230482. doi: 10.1001/jamahealthforum.2023.0482

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Panesar M, et al. Evaluation of a renal transplant program for incarcerated ESRD patients. J Correct Health Care 2014; 20:220227. doi: 10.1177/1078345814531726

  • 6.

    Shavit S, et al. Transitions Clinic Network: Challenges and lessons in primary care for people released from prison. Health Aff (Millwood) 2017; 36:10061015. doi: 10.1377/hlthaff.2017.0089

    • PubMed
    • Search Google Scholar
    • Export Citation
Save