Access to Primary Care for Persons Recently Released From Prison

In this response to Fahmy and colleagues' manuscript, I will speculate as to the magnitude of the problem of unmet primary care needs among those released from prisons in the United States. I will also offer suggestions for future inquiry in this line of research.

In this study, Fahmy and colleagues used an innovative methodology to examine whether discrimination exists in primary care seeking for people who were recently incarcerated in Canada. Given the universal availability of healthcare, the authors posited that no discrimination would occur. As my own research shows, access to health care is a major problem inside and outside of the prison system in the United States (Reingle Gonzalez & Connell, 2014). Specifically, my research showed that offenders in United States correctional facilities were unlikely to receive health care and needed medications for chronic physical and mental health problems during incarceration. The study by Fahmy and colleagues suggests that this unmet medical need may continue after release.

Incarceration rates per capita are much lower in Canada than they are in the United States. Further, formerly incarcerated persons in the United States may be covered by Medicaid (characterized by low reimbursement rates, and many providers do not accept Medicaid patients) or lack insurance coverage entirely. Therefore, it warrants consideration that the problem of discrimination in primary care access is even more prevalent in the United States compared to other countries, such as Canada.

The authors suggest that many recently released prisoners in Canada will disclose their status as a former offender to potential providers when requesting an appointment for primary care services. The implications of this practice are such that, if former prisoners do not disclose their criminal histories, discrimination will be less likely to occur. Therefore, it may be reasonable for prison pre-release counselors to discuss situations when it is (and when it is not) necessary to disclose one's criminal history. Future studies should examine the differential impact of self-identifying one's criminal history when seeking an appointment as a new patient, when seeking an appointment as an established patient, and when presenting medication history documents bearing the prison's name, on discrimination compared to controls with no criminal history.

In summary, this is an important area of research that has clear implications in terms of pre-release counseling for prisoners. These findings add to the considerable body of research that suggests that those with a criminal history experience discrimination when attempting to find employment and housing. I would encourage the authors to continue exploring the magnitude of the problem depending upon variable circumstances discussed above, and to identify opportunities to reduce barriers to primary care access among those with criminal histories.

Reingle Gonzalez, J. M., & Connell, N. M. (2014). Mental health of prisoners: Identifying barriers to mental health treatment and medication continuity. American journal of public health, 104(12), 2328- 2333.

Competing interests: None declared