Research Article: Psychological Distress and Health Insurance Coverage among Formerly Incarcerated Young Adults in the United States

Date Published: June 24, 2015

Publisher: AIMS Press

Author(s): Larrell L. Wilkinson, Saundra H. Glover, Janice C. Probst, Bo Cai, Lisa T. Wigfall.


The United States incarcerates more people per capita than any other nation. Studies have consistently demonstrated higher prevalence of serious mental illness among the incarcerated. Although health care may be available to individuals while incarcerated, research is needed to understand the context of health care coverage and mental health after incarceration. The purpose of this study is to estimate the point prevalence of psychological distress (PD) among young adults with incarceration experience, while comparing the prevalence to that of young adults in the general population. Additionally, this study characterizes the relationship between incarceration experience and PD, while also examining this association given an individual’s health insurance coverage status among young adults. Lastly, we examine if other individual, contextual, and behavioral factors influences the relationship between incarceration experience and PD, in addition to their health insurance coverage status. This study utilizes data from the 2008 panel of the National Longitudinal Survey of Youth 97, a population based survey dataset from the U.S. Department of Labor. Andersen’s Behavioral Model of Health Services Use provided the conceptual framework for the study. The Mental Health Index 5 (MHI-5) was used to determine PD or normal mental health. Chi-square testing and multivariate logistic regression were performed to examine incarceration experience in association to PD. The sample with incarceration experience reported almost double the proportion of PD (21%) compared to those without an incarceration experience (11%). Young adults who have been incarcerated reported greater odds of PD than those with no incarceration experience (COR 2.18; 95% CI, 1.68–2.83) and the association was diminished in the presence of health insurance status and model covariates. Future health prevention and health management efforts should consider the impact of health insurance coverage status, health behaviors, and life satisfaction on mental health status among young adults with incarceration experience.

Partial Text

The United States (U.S.) incarcerates more people per capita than any other nation and the prison population has increased fourfold during the past 25 years [1]. As of 2009, nearly 1% of U.S. adults received their healthcare from their jailers (nearly 2.3 million inmates). Each year, almost 700,000 mentally ill people are placed in U.S. jails [2]. Studies in Chicago, IL, have suggested that 9% of male inmates had a severe mental disorder and 6% had an episode prior to arrest [2]. Freudenberg highlights a 1998 Bureau of Justice report suggesting 16% of state prison inmates, 7% of federal inmates, and 16% of probationers reported either a mental condition or overnight stay in the mental hospital [2]. Historically, the Epidemiological Catchment Area Study (ECA) was one of the first studies to estimate the point prevalence of mental illness among this segment of the U.S. population. The study found that prevalence rates of current and lifetime major depression, mania, schizophrenia, and other severe disorders were significantly higher among the jailed sample than within the entire five-city non-institutionalized sample of the ECA, even when controlling for race [3]. Other studies that followed affirmed the high rates of mental illness and distress among adjudicated females in the United States [4]–[6] and men internationally [7],[8].

In the 2008 panel of the NLSY97, 498 persons were formerly incarcerated. Those with incarceration experience were comprised of 405 (79.85%) males and 93 (20.15%) females. The participants surveyed with incarceration experience were 61.01% (205) Non-black/non-Hispanic (White), 22.88% (173) Black, 14.67% (115) Hispanic, and 1.44% (5) mixed. Over half of participants surveyed with incarceration experience had less than a high school degree. Almost 76% of those with incarceration experience had never been married (Table 1). Also of interest, approximately 57% of the formerly incarcerated were completely uninsured, when compared to slightly over 20% of those with no incarceration experience (Table 1). Additionally, greater proportions of those with incarceration experience reported PD (20.73%), compared to those with no incarceration experience (10.72%). Significant differences were also observed within self-reported life satisfaction, whereas 29.84% of those with incarceration experience reported life satisfaction at the lowest levels, versus those with no incarceration experience (12.32%) (Table 1).

A nationally representative data set of young adults in the United States was used to demonstrate the association of reporting PD when having experienced incarceration. Furthermore, an exploration of how one’s health insurance status alone may confound the relationship of incarceration experience and PD was conducted. This relationship was also examined in the presence of demographic and other covariates. In this study, health insurance status is extended beyond having reported coverage (yes or no) during the past year, but also examines what type of health insurance individuals might have, and if they had coverage for the entire year. Findings from this study are in accord with earlier research showing that different types of health insurance are associated with poorer mental health [16]–[18]. Similarly, this study demonstrates the prevalence of PD is significantly greater in the formerly prisoned population versus the general population when examining young American adults [3]–[10]. Among young adults with incarceration experience, roughly 21% reported PD, greater proportions reported being uninsured for the full year and lower proportions reported having had a medical check-up during the past year. Additionally, roughly 67% of formerly incarcerated young adults reported not seeking medical treatment when injured or ill during the past year.

European studies and publications from the World Health Organization have well documented the prevalence rates of PD. Recent publications in the Journal of International Health and other government documents have reported SPD and PD in the United States. To date, few if any studies have focused on the young adult population of the United States, and less focusing on the impact of health insurance coverage status, especially in a population with incarceration experience. The proportion of Americans who have experienced incarceration has grown over the years. Still, little is known about the ability of young adults within this group to access health care given insurance status and their psychological well-being. This study offered a unique opportunity to estimate the rate of PD within this vulnerable sub-group and compare it to that of the general young adult population. Given the ongoing implementation of the ACA since 2010 and the age group in this study, implications for young adult enrollment may contribute to increasing health equity within this segment of the population [38]. Interventions directly targeting this group may have a significant impact on improving health outcomes for those with incarceration experience and their families, thus impacting the community.