Does time in prison make people healthier, or less healthy? On the one hand, prisons are a challenging environment. They are stressful, and the risks of harm through violence are high. As we've discovered recently, they are also an excellent super-spreading environment for infectious diseases. And prisoners may suffer from reduced nutrition, or reduced access to health care. On the other hand, perhaps prisoners' nutrition and/or access to health care may be improved by being incarcerated. Many prisoners have untreated (or undiagnosed) mental health problems, or substance abuse problems, that can be more effectively treated in an institutional setting.
So, which is it? No doubt, it depends on the particular prison context, and the health of the prison population at the time they go into prison. Let's take a particular prison context: Sweden, which has an excellent reputation for rehabilitation (see here and here), and a relatively low prison population (74 per 100,000 population, compared with 155 in New Zealand, and 505 in the US). This recent article by Randi Hjalmarsson (University of Gothenburg) and Matthew Lindquist (Stockholm University), published in the American Economic Journal: Applied Economics (ungated earlier version here), looks at the impact of time in Swedish prisons on health outcomes.
Hjalmarsson and Lindquist make use of a neat natural experiment, being:
...Sweden’s 1993 and 1999 early release reforms, which held sentences constant but increased the share of time inmates were required to serve from 50 percent to 67 percent. Exposure to the two- thirds reform depended on the date of conviction and sentence length. Shorter sentences (4–12 months) were fully treated by the first reform and longer sentences (≥ 24 months) by the latter; intermediate sentences were partially treated by both.
Because time in prison changed, but prison sentences did not, Hjalmarsson and Lindquist look at how the increase in the number of days in prison affects health, while holding sentence length (and therefore, the severity of crime the prisoner is being sentenced for) constant. Their final sample consists of nearly 47,000 sentences of between 4 and 48 months, which commenced between 1992 and 2001. Because Swedes have an effective population register, Hjalmarsson and Lindquist are able to link prisoner records with hospital and mortality data. Looking at the impacts up to ten years after release from prison, they find a variety of impacts, including that:
...exposure to the two-thirds reform does not harm post-release health and actually improves it. Though the reduction in mortality risk is not quite significant when looking at the entire sample, these aggregate results mask important heterogeneity in two dimensions. First, significant reductions in the overall chance of death (especially in the first two years post release) are seen for positively selected subsamples, including those with no past prison exposure, property offenders, relatively young offenders, and those with some past employment. Second, significant effects are seen for the whole sample when zooming in on causes of death particularly relevant for this population. There is a large, significant, and immediate reduction in the chance of suicide; the chance of suicide is still reduced by 38 percent ten years after release. These suicide results are driven by individuals with previously identified mental health issues and by violent offenders.
Taken all together, these are positive results for the Swedish prison system. Why does it do so well? Hjalmarsson and Lindquist can't definitively tell, but note that:
First, health care in Swedish prisons is of high quality. Second, more time in prison is positively related to visits with medical professionals (doctors, nurses, and psychologists), medication, and starting and completing treatment programs. High-quality health care and treatment that increases with time served is consistent with our findings of the health-improving effects of the reform.
So, if we want to improve the health of prisoners, should we be keeping them in prison longer? That would probably be extending these results too far. Remember that context matters. As Hjalmarsson and Lindquist note, the health care available in the Swedish prisons is high quality, and prisoners access it readily. That is not the case in all prison settings. So, we shouldn't use these results to conclude that prisons improve health, but rather that Swedish prisons improve health, and that moving towards the Swedish model may have positive impacts. Of course, then we run into other problems, because Hjalmarsson and Lindquist also note that:
...Sweden spends more money per inmate than any other country...
If we want better health incomes for prisoners, this comes with an increase in cost. We'd need to weigh up those costs and benefits to make a sensible decision about what is best to do. As the saying goes, there is no such thing as a free lunch (as my ECONS101 students will learn when teaching starts next week! [*]).
[HT: Marginal Revolution, last year]
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[*] Not literally though. I'm not offering them free food. Instead, we will cover the concept of opportunity cost in the second lecture.
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