key: cord-0749126-enqoixy1 authors: Gutierrez, Carmen; Patterson, Evelyn J. title: Risk and implications of COVID‐19 among the community supervised population date: 2021-10-28 journal: Criminol Public Policy DOI: 10.1111/1745-9133.12563 sha: 0eafd56f6df6466e016fc16515e3e1c70b2414e3 doc_id: 749126 cord_uid: enqoixy1 RESEARCH SUMMARY: Despite growing national awareness that COVID‐19 in jails and prisons constitutes a public health emergency in the United States, remarkably little attention has been paid to understanding how the virus affects people under community supervision. We used data from the National Survey on Drug Use and Health (NSDUH) to explore differences in the extent to which men under community supervision are vulnerable to COVID‐19 and have access to care during the pandemic, relative to men who are not involved with the U.S. criminal legal system. Results from this study highlight the greater levels of risk for serious illness or death from COVID‐19 and the disproportionate lack of health insurance among men under community supervision. POLICY IMPLICATIONS: Jurisdictions across the United States are currently relying on decarceration to contain the spread of COVID‐19 in jails and prisons. Decarceration efforts alone, however, are insufficient for addressing the spread of COVID‐19 among people involved with the U.S. criminal legal system. People released from jails and prisons or diverted from incarceration during the pandemic must be given the opportunity to receive the COVID‐19 vaccination upon their transitions. Likewise, individuals under community supervision must be prioritized for immediate vaccination against COVID‐19. People involved with the U.S. criminal legal system should also be eligible for emergency Medicaid during the COVID‐19 crisis, and their health insurance coverage should remain available beyond the pandemic. the COVID-19 crisis, and their health insurance coverage should remain available beyond the pandemic. Carceral institutions in the United States have unsurprisingly become the world's leading sites of COVID-19 outbreaks. Due to overcrowded and close living conditions, poor ventilation, and lack of protective equipment, jail and prison environments are particularly susceptible to the spread of infectious diseases Dolan et al., 2016; Gough et al., 2010; Maruschak et al., 2009) . To date, carceral settings have accounted for 40 of the top 50 largest known clustered outbreaks of COVID-19 in the United States (Smith et al., 2020) . Reflecting their disproportionately high prevalence of chronic medical conditions that contribute to the risk of severe illness from the virus, the COVID-19 death rate among incarcerated people is approximately three times higher in comparison to that in the overall population (Saloner et al., 2020) . Given the constant cycling of people in and out of jails and prisons, the threat of COVID-19 inside carceral institutions also extends to the general public (Dumont et al., 2012; Reinhart & Chen, 2021; Spaulding et al., 2009; Wang et al., 2021) , and there are important reasons to expect that the effects of the virus may be particularly devastating for people in the community on probation and parole. People under criminal legal supervision in the community through probation or parole are a group that overlaps significantly with the population in jails and prisons, who have been shown to have disproportionately high levels of serious illness and death caused by COVID-19 (Altibi et al., 2021; Saloner et al., 2020) . The chances of serious illness or death upon exposure to COVID-19 may, in fact, be greater for the community supervised population. Compared to those in jail and prison, people under community supervision have higher overall levels of mortality and generally worse access to health care (Mallik-Kane & Visher, 2008; Wildeman et al., 2019) . Without a doubt, the risk of COVID-19 transmission is lower in the community than inside carceral institutions (Franco-Paredes et al., 2020; Reinhart & Chen, 2021; Wang et al., 2021) . Nevertheless, people under community supervision likely face disproportionately high levels of exposure to the virus as a result of their interactions with jails and prisons as well as home and work environments that suffer heavy burdens of COVID-19 cases (Reinhart & Chen, 2020; Wang et al., 2021) . The community supervised population is also now partially composed of people who have been released from jail and prison during the pandemic. In response to the rapid number of COVID-19 outbreaks in jails and prisons, legal officials across the country began releasing individuals on an early basis and diverting people from incarceration in attempts to contain the spread of the virus (Brennan Center for Justice, 2020; Prison Policy Initiative, 2020; So et al., 2020) . While doing so likely lowered the transmission of cases in carceral institutions, these actions also significantly increased the size of the population under community supervision and relocated the risks associated with COVID-19 to their homes and communities. Prior to the pandemic, approximately 4.4 million people (1 in 58 adults, and roughly 69% of the total population supervised by the criminal legal system) were estimated to be under community supervision through probation or parole (Kaeble & Alper, 2020; Maruschak & Minton, 2020) . Recent reports suggest that nearly 200,000 individuals were added to this population between March and October 2020 through efforts to reduce the number of people in jail and prison during the pandemic (Franco-Paredes et al., 2020) . People released from incarceration to community supervision during the pandemic, and especially those with unanticipated releases, likely face particularly high risks for adverse COVID-19 outcomes due to the additional stress of the pandemic on top of the preexisting challenges associated with the transition from incarceration to the community (Desai et al., 2021; Mallik-Kane & Visher, 2008) . No study to date, however, has investigated the potential impacts of COVID-19 among people on probation and parole in the United States. In this article, we use data from the 2015-2019 National Survey on Drug Use and Health (NSDUH) to explore differences in the extent to which people under community supervision are vulnerable to COVID-19 and have access to care during the pandemic, relative to people not involved with the U.S. criminal legal system. Because data on actual COVID-19 cases and deaths among this population is not available, we rely on several years of data in the most recent pre-COVID period to make robust inferences about the current circumstances and vulnerabilities of people under community supervision. We infer disparities in vulnerability to COVID-19 in two ways. First, we examine differences in health risks that the Centers for Disease Control and Prevention (CDC) associates with severe COVID-19 illness. Second, we investigate differences in the factors identified by the CDC that put people in need of taking extra precautions during the pandemic (e.g., substance use disorder [SUD] , disability, rural residence, and asthma) as well as differences in the extent to which these factors overlap with the risk for severe COVID-19 illness. We infer access to care based on health insurance coverage and analyze disparities in uninsurance across COVID-19 health risks and extra precautions factors. For all outcomes, we compare results among men under community supervision to men without criminal legal system involvement. We hypothesize that men under community supervision would be more vulnerable to COVID-19 and have worse access to care during the pandemic. From a policy perspective, this research provides an important snapshot of the potential longterm effects of ongoing efforts to contain the spread of COVID-19 in U.S. jails and prisons. Public health experts, civil rights organizations, and advocacy groups have justly appealed for decarceration in response to the increasing number of COVID-19 outbreaks in jails and prisons. Jail and prison environments are particularly vulnerable to the transmission of COVID-19 due to overcrowded and close living conditions, poor ventilation, and lack of protective equipment Dolan et al., 2016; Gough et al., 2010; Maruschak et al., 2009) , and people who are incarcerated have a high prevalence of chronic diseases that contribute directly to higher rates of severe viral illness and death (Wilper et al. 2009 ). Efforts to reduce the size of the incarcerated population during the pandemic should therefore lower the transmission of COVID-19 in detention facilities and help protect the lives of the more than two million people living behind bars in the United States. However, people released from jail and prison have historically experienced worse health and higher odds of death during the transition back to their communities (Binswanger et al., 2007; Patterson, 2013) . Moreover, planning for the health and safety of reentering individuals during the pandemic remains uncertain. Because individuals under community supervision overlap significantly with the population of people released from jail and prison each year, results from this study can help inform our understanding of the current and future spillover effects that decarceration efforts have on local communities during the pandemic. Exploring the extent to which people under community supervision are vulnerable to COVID-19 and have access to care during the pandemic also adds to our understanding of the relationship between health and involvement with the U.S. criminal legal system, more broadly. Existing research on the relationship between health and the U.S. criminal legal system largely focuses on incarceration, while less focus has been given to probation and parole. Community supervision, however, likely has its own independent effects on health above and beyond spillover effects from incarceration. In the COVID-19 pandemic, the risk of death associated with the transition from incarceration to community supervision may be higher than ever before. Further, because decades of unjust policies and policing have disproportionately entangled Black and Latinx people in the U.S. criminal legal system (National Research Council, 2014) , the extent to which decarceration efforts contribute to the spread of COVID-19 among the community supervised population has significant implications for racial inequalities in COVID-19 outcomes. Understanding the potential impacts of COVID-19 among people on probation and parole in the U.S. can therefore deepen and advance our knowledge of population disparities in health, and, in the context of a global pandemic, provide significant theoretical and policy relevance. In the United States, more than six million people are under some type of surveillance by the criminal legal system on any given day (Maruschak & Minton, 2020) . More than 2 million people are incarcerated in jail or prison, including nearly 500,000 people in jail (75% of the total jail population) who have not been formally convicted of any crime but are living behind bars as a result of pretrial detention (Sawyer & Wagner, 2020) . Roughly 4.4 million people (approximately 69% of the total number of people under surveillance by the criminal legal system) are under community supervision through probation or parole. In a discrete sense, incarceration and community supervision represent distinct categories of involvement with the U.S. criminal legal system. However, they are inextricably linked. At least 95% of people in prison are eventually released to the general population, and approximately 80% are released to parole supervision (Travis, 2002) . All people on parole were therefore previously in prison, but not all people who leave prison are required to serve additional time on parole. Like parole, probation is also a court-ordered period of supervision in the community. People who spent time in jail may be conditionally released to probation following their formal conviction or pretrial detention. Not all people sentenced to a period of probation necessarily spend time in jail or prison, however, as probation is generally imposed as a lower form of punishment in lieu of incarceration. Although probation is defined as an "alternative" to incarceration, there are important reasons to expect that individuals who spend time on probation also cycle through jails and prisons. Several studies find that probation increases the chances of future incarceration due to imposed restrictions and monitoring of individuals (Aebi et al., 2015; Phelps, 2013 Phelps, , 2017 Tonry & Lynch, 1996) . In 2018, approximately 42% of individuals on probation failed to successfully complete their supervision. Among those who failed to complete their supervision, over one-third (38%) were sentenced to incarceration due to technical violations (Kaeble & Alper, 2020) . The number of people who eventually become incarcerated for violating conditions of their probation, however, is likely much higher than what is recorded by point-in-time estimates. An additional 9% of those who failed to complete their probation in 2018 were found to have absconded or to have been discharged to a warrant, and the outcomes of another 38% were unknown or unreported (Kaeble & Alper, 2020) . Moreover, many people on probation report having spent time behind bars prior to their current sentence of community supervision. According to data from the National Survey on Drug Use and Health, nearly 27% of people on probation reported having also spent time in prison at some earlier point in their lifetime (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics & Quality, 2020). Like those in jail and prison, the population under community supervision suffers disproportionately from health problems that may increase their risk of severe COVID-19 illness. Severe COVID-19 illness is defined as illness requiring hospitalization, admission to intensive care unit (ICU), intubation or mechanical ventilation, or resulting in death (CDC, 2021) . According to the CDC, adults of any age are at increased risk for severe COVID-19 illness if they have any one of the following health conditions: cancer, cerebrovascular disease, chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes (types 1 and 2), heart conditions (such as heart failure, coronary artery disease, and cardiomyopathies), obesity (body mass index [BMI] ≥30 kg/m 2 ), pregnancy (current and recent), and cigarette smoking (current and former). The risk of severe COVID-19 illness increases with the number of underlying medical conditions in an individual (Price-Haywood et al., 2020; Rosenthal et al., 2020) . Existing research finds that people under community supervision are significantly more likely to experience at least one chronic health condition in their lifetime, relative to people in the general population (Gutierrez & Pettit, 2020; Winkelman et al., 2020) , and comorbid conditions are considered to be common among individuals in jails and prisons (Skarupski et al., 2018) . People under community supervision may therefore be especially vulnerable to severe consequences associated with exposure to COVID-19. The extent to which chronic health issues among the community supervised population align with the conditions that the CDC associates with severe COVID-19 illness, however, remains unknown. More research is also needed on whether and how people under community supervision have multiple, co-occurring chronic health issues that would further exacerbate their risk for severe COVID-19 illness. In addition to having a higher prevalence of underlying medical conditions that may directly impact their outcomes associated with exposure to COVID-19, people under community supervision also experience other health issues that may indirectly add to their risk of illness or death from COVID-19. Health conditions such as disability and SUD, for example, are more common among people under community supervision and are linked to adverse COVID-19 outcomes (Allen et al., 2020; Baillargeon et al., 2020; Wang et al., 2020) . According to a recent study, nearly a quarter (23%) of people on community supervision report having at least one disability, compared to approximately 16% of people in the general population (Winkelman et al., 2020) . In line with the U.S. Department of Health and Human Services (2011) , these estimates of disability include six specific disability types: hearing, vision, cognitive, ambulatory, self-care, and independent living. With respect to SUD, one report finds that approximately 35%-41% of men aged 18-49 on community supervision meet the DSM-IV criteria for drug or alcohol dependence or abuse. Among similarly aged men in the general public, roughly 16% meet the DSM-IV criteria for alcohol or drug dependence or abuse (Feucht & Gfoerer, 2011) . While health factors such as disability and SUD may not directly contribute to the risk of severe illness or death from COVID-19, people with disabilities and SUD are more likely than people in the general population to develop severe COVID-19 illness in part because they have higher levels of underlying chronic medical conditions (CDC, 2020a (CDC, , 2020b Gleason et al., 2021; Makary, 2020; Turk & McDermott, 2020) . Because they are more likely to live in congregate settings, face greater barriers to practicing social distancing, and, in some cases, are less able to effectively use personal protective equipment (PPE), people with disabilities and SUD also face greater risks of contracting the COVID-19 virus (Dixon-Ibarra & Horner-Johnson, 2014; Landes et al., 2020; Okoro et al., 2018) . People with disabilities and SUDs may also experience unique stressors related to the pandemic that can further exacerbate negative health outcomes of COVID-19 Turk & McDermott, 2020) . Consequently, the CDC recognizes people with disabilities and SUD-as well as individuals in certain other health and social categories, including people who live in rural communities-as groups who should take extra precautions during the COVID-19 pandemic (CDC, 2020b) . According to the CDC, rural living status is associated with needing to take extra precautions during the pandemic due to inadequate health care capacity, health care workforce shortages, lower rates of vaccination, as well as higher levels of chronic illness in the population. The extent to which people on community supervision live in rural communities, and whether and how levels of rural living status in the community supervised population overlap with their prevalence of chronic health conditions associated with severe COVID-19 illness, however, remains unclear. And while it is widely known that people under community supervision have high levels of chronic health conditions, disability, and SUD (Feucht & Gfoerer, 2011; Gutierrez & Pettit, 2020; Wang et al., 2020; Winkelman et al., 2020) , existing research has not yet estimated the extent to which chronic health conditions associated with severe COVID-19 illness overlap with factors such as disability and SUD among people on community supervision. More research on the community supervised population is therefore needed to identify the potential intersections between the chronic health conditions associated with severe COVID-19 illness and factors identified by the CDC that should require people to take extra precautions during the pandemic, such as disability, SUD, and rural living status. The COVID-19 pandemic has taken a devastating toll on the lives of people in jail and prison. According to the COVID Prison Project, nearly 20% of the U.S. jail and prison population has been infected with COVID-19 (over 417,000 cases in total) and more than 2,700 people in jail and prison have died from the virus as of July 29, 2021 (COVID Prison Project, 2020). Since April 2020, more than 40 of the 50 largest known clusters of COVID-19 cases in the United States have occurred in jails and prisons (Smith et al., 2020) . As of June 2020, rates of COVID-19 cases and deaths were, respectively, 5.5 and 3.0 times higher among people in prison, compared to the overall population (Saloner et al., 2020) . National levels of cases and deaths among people in jails are less clear. COVID-19 outcomes may be even worse in jails than in prisons due to the higher turnover of people in jails as well as the greater levels of underlying medical conditions among people in jail relative to people in prison (Maruschak et al., 2015) . There are also important reasons to expect that existing estimates of COVID-19 in jails and prisons represent lower bounds of actual cases and deaths, due to substantial undertesting and underreporting by detention facilities during the pandemic (Barnert et al., 2020; Franco-Paredes et al., 2020; Maxmen, 2020) . In response to the increasing number of COVID-19 outbreaks in jails and prisons, public health experts, civil rights organizations, and advocacy groups have made urgent calls for decarceration. Accordingly, jurisdictions across the country have been restricting new admissions to incarceration and accelerating the release of individuals already incarcerated. A recent study finds that these decarceration activities have reduced the overall incarcerated population in the United State by approximately 11% during the pandemic (Franco-Paredes et al., 2020) . Decreasing the size of the incarcerated population is expected to lower the transmission of COVID-19 in jails and prisons by lowering the density of people in confinement and improving the implementation of physical distancing interventions and infection prevention protocols (Franco-Paredes et al., 2020) . At the same time, this process of decarceration has also significantly increased the number of people under community supervision and has relocated the risks associated with the COVID-19 virus to the homes and communities of people released from jail and prison. Approximately 200,000 people were added to the community supervised population between March and October 2020, and more people have likely been added since then (Brennan Center for Justice, 2020; Franco-Paredes et al., 2020; Prison Policy Initiative, 2020; So et al., 2020) . The movement of people from carceral institutions to community supervision during the pandemic has significant implications for the spread of COVID-19 in areas where people return home from jail and prison. One recent study examined the consequences associated with the cycling of people in and out of the Cook County Jail in Illinois during March 2020, a period early in the pandemic when COVID tests were not generally available and quarantine procedures were not widely adopted. The results showed that admissions and releases were associated with nearly 16% of all COVID-19 cases in the state of Illinois as of April 2020 (Reinhart & Chen, 2020) . As people under community supervision overlap significantly with individuals who cycle through jails, these findings suggest that the spread of COVID-19 cases resulting from jail may be particularly concentrated among people on probation and parole. The prevalence of cases among people under community supervision, however, remains unknown. More research is therefore needed to understand the health of people leaving jails and prisons and those serving time on community supervision during the COVID-19 pandemic. People released from jail and prison face significant health challenges in the process of reentering their communities. As previously mentioned, people who spend time in jail and prison, and, likewise, those who spend time on probation and parole, are particularly disadvantaged with respect to their health. People in jail and prison have especially high levels of physical health conditions, mental illness, and SUD Maruschak et al., 2015) . With a constitutional right to health care behind bars, most individuals serving time in jail or prison receive attention from medical providers and the majority of those with health problems report receiving prescription medication or some other form of medical treatment during their incarceration (Mallik-Kane & Visher, 2008; Maruschak et al., 2015) . While the quality of such health care is likely deficient (Lindquist & Lindquist, 1999) , existing work suggests that the basic provision of care in jails and prisons provides at least some health benefits to people during incarceration (Patterson, 2010) . The health benefits associated with incarceration are fleeting, however, as most people lose access to care and face exacerbated health issues upon their release (Binswanger et al., 2007) . The general lack of access to health care among people involved with the U.S. criminal legal system is deeply concerning during the COVID-19 pandemic. Estimates vary but researchers approximate that 70-80% of adults leaving jail and prison have historically lacked health insurance coverage at the time of their release (Mallik-Kane & Visher, 2008) . However, since implementation of the Patient Protection and Affordable Care Act (ACA), and especially the provision of the Medicaid expansion, people involved with the criminal legal system, including those on probation and parole, have seen increasing levels of health insurance coverage after incarceration (Gutierrez & Pettit, 2020; Saloner et al., 2016; Winkelman et al., 2017) . Still, not all previously incarcerated and community supervised people live in states that adopted the Medicaid expansion, and people insured by Medicaid continue to have their coverage suspended during their incarceration due to the federal inmate exclusion policy. The COVID-19 crisis has also likely further complicated health insurance access among people involved with the criminal legal system. The extent to which people under community supervision have health insurance coverage during the pandemic and whether and how coverage varies across groups considered to be at the greatest risk of severe illness or death from COVID-19, however, remains unknown. We pooled data from the 2015-2019 years of the National Survey on Drug Use and Health (NSDUH) to construct our analytic data set. It is important to note that these data represent the most recently available years of the NSDUH and were collected in a pre-COVID period. Given challenges of data collection during the pandemic and potential year-to-year vagaries in single year estimates, our pooling of several years of data in the most recent pre-COVID period make our estimates about the current circumstances and vulnerabilities of people under community supervision the most robust as possible. Conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA), the NSDUH is a nationally representative, cross-sectional survey of the noninstitutionalized U.S. population aged 12 years and older. The sampling frame contains residents of households as well as individuals living in noninstitutionalized group quarters and temporary housing units, including halfway houses and homeless shelters (Center for Behavioral Health Statistics & Quality, 2019). Data from the NSDUH are particularly useful for our investigation because the survey collects comprehensive information about health as well as detailed information about respondents' involvement with the criminal legal system. We restricted our analytic sample to adult males aged 18-64 years. Limiting the sample to nonelderly men was important for several reasons. First, nonelderly men make up the vast majority of the population involved with the criminal legal system, including those under community supervision (Kaeble & Alper, 2020; Wildeman et al., 2019) . Thus, results from our analysis can be considered widely generalizable to the majority experience of community supervision and can be used to make comparisons to the overall incarcerated population. Second, because age itself is a significant determinant of health and everyone aged 65 and older is considered high risk for severe COVID-19 illness (CDC, 2021), our exclusion of elderly people allows us to better understand disparities in COVID risk between people under community supervision and those in the general population that arise from factors that may be addressed through interventions. Third, as part of our analysis focuses on health insurance coverage, it was important for us to focus sharply on nonelderly men because this group, specifically, has historically been excluded from low-income health insurance options like Medicaid that have recently become more available since adoption of the ACA (Gutierrez, 2018) . Results from our study therefore help reveal the effectiveness of the ACA among the community supervised population, comprised of mostly low-income nonelderly men, during the pandemic. We further restricted the sample to those who had complete data on their prior-year involvement with the criminal legal system. Prior-year involvement with the criminal legal system was determined through questions in the NSDUH that ask respondents to report whether during the previous 12 months they had been: arrested and booked for breaking the law (not counting minor traffic violations); on probation; and/or on parole, supervised released, or other conditional release from prison. Men were identified as being under community supervision if they reported being on probation or parole in the previous 12 months. Men were identified as having no involvement with the criminal legal system if they reported no arrest, probation, or parole in the previous 12 months. Men who reported a past-year arrest, and not probation or parole, were excluded from the analysis. Our analysis followed the CDC's guidance regarding health factors placing people at high risk for severe COVID-19 illness, updated on December 29, 2020 (CDC, 2020a). The CDC health risks we included were: cancer, coronary heart conditions, obesity (body mass index [BMI] of 30 kg/m 2 or higher), current cigarette smoker, kidney disease, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). Survey question information and other technical details on these variables is available in the Supporting Information Appendix. Additional health risks currently identified by the CDC as conditions associated with increased risk for severe illness from COVID-19 are immunocompromised state (weakened immune system) from solid organ transplant, pregnancy, and sickle cell disease. We did not include measures for immunocompromised state or sickle cell disease because the NSDUH lacks information on these conditions. We did not include pregnancy because our sample was restricted to people who reported their sex as male. Due to the skip logic of the survey, self-identified males in the NSDUH do not have the opportunity to report pregnancy status at the time of the interview. In addition to classifying health conditions that put people at increased risk for severe illness from COVID-19, the CDC also identifies factors that should require people to take extra precautions during the COVID-19 pandemic, updated on December 22, 2020 (CDC, 2020b). The CDC "extra precautions factors" we included were: SUD, disability, rural residence, and asthma. Survey question information and other technical details on these variables is available in the Supporting Information Appendix. The CDC identified the following additional factors that put people in need of extra precautions during the COVID-19 pandemic: developmental and behavioral disorders, homelessness, and pregnancy and breastfeeding. We did not include these measures due to lack of information in the NSDUH or lack of relevance in our sample. Unlike the CDC health risks that are directly associated with the risk of severe COVID-19 illness, the CDC "extra precautions factors" are indirectly linked to severe COVID-19. As previously mentioned (see Section 3, Community Supervision and COVID-19 Health Risks), groups in this category are more likely to have chronic medical conditions, live in congregate settings, and face greater barriers to health care, making them more likely to contract the virus and develop severe COVID-19 illness (CDC, 2020a (CDC, , 2020b Makary, 2020; Dixon-Ibarra & Horner-Johnson, 2014; Landes et al., 2020; Okoro et al., 2018; Gleason et al., 2021; Turk & McDermott, 2020 ). We considered health insurance coverage to approximate access to care. Prior to the COVID-19 pandemic, men involved with the criminal legal system, including those on probation and parole, saw increasing levels of health insurance coverage through the Patient Protection and Affordable Care Act (ACA) (Gutierrez & Pettit, 2020; Saloner et al., 2016; Winkelman et al., 2017) . Whether and how health insurance coverage among men under community supervision varies by the CDC health risks and extra precautions factors associated with COVID-19, and the extent to which current levels of coverage among men under community supervision differ from those among men without criminal legal involvement, however, remains unknown. Addressing these gaps in knowledge, we evaluated the relationships between high risk for severe COVID-19 illness, extra precautions factors, and health insurance coverage. This allowed us to establish a better understanding of access to care among people under community supervision during the COVID-19 pandemic. Our measure of health insurance coverage focused on uninsured status. Respondents were identified as uninsured if they reported being without health insurance at the time of the interview. We conducted a multistep analysis. First, we evaluated the CDC health risks associated with severe COVID-19 illness. We began by estimating the unadjusted prevalence of each CDC health risk associated with severe illness from COVID-19 as well as an overall indicator for being at high risk for severe COVID-19 illness by criminal legal status and age. Because the population under community supervision was significantly younger than the population of men without criminal legal involvement (see Supporting Information Appendix Table 1 ), we then used demographic standardization techniques to generate age-adjusted estimates for those in the community supervision group, based on the age distribution of the general adult male population in our sample. Then, we estimated the average number of CDC health risk factors and the distribution of these risk factors by criminal legal status and age group, among the sample of men at high risk for severe COVID-19 illness. Second, we turned our attention to the CDC extra precautions factors. Similar to how we calculated the CDC health risks, we first estimated the unadjusted prevalence of each extra precautions factor and then used demographic standardization techniques to generate age-adjusted estimates for men in the community supervision group. Next, we assessed the prevalence of high risk for severe COVID-19 illness across each of the CDC extra precautions factors by criminal legal status and age, and then used demographic standardization techniques to generate age-adjusted estimates for men in the community supervision group. Third, we considered the relationships between high risk for severe COVID-19 illness, extra precautions factors, and health insurance coverage. We estimated the prevalence of men without health insurance among the sample at high risk for severe COVID-19 illness and across each of the extra precautions factors by criminal legal status and age. For men under community supervision, we used demographic standardization techniques to generate age-adjusted estimates. For all analyses, we compared outcomes among men under community supervision to men without criminal legal involvement. Significance testing was performed using z-statistics. We applied survey weights created by NSDUH analysts to make estimates nationally representative for the noninstitutionalized population, and we adjusted standard errors for the survey's complex sampling design. Within each age group, NSDUH results reflect a growing body of literature on health disparities, with adult men under community supervision being more likely than men without criminal legal involvement to suffer from conditions that the CDC associates with higher risk for severe COVID-19 illness (for results by age group, see Supporting Information Table A2 ) (Binswanger et al., 2009; Massoglia & Pridemore, 2015; Wilper et al., 2009) . For both groups of men without criminal legal involvement and under community supervision, the overall risk of severe COVID-19 illness increased with age. However, the disparity in risk decreased with age as men under community supervision had disproportionately higher levels of risk for severe COVID-19 at younger ages. For example, the overall risk for severe COVID-19 illness among men under community supervision in the 18-25 age group was higher than that of men without criminal legal involvement in the 26-34 age group (44.8% vs. 41.5%, respectively). Among men under community supervision in the 26-34 age group, the level of risk was almost equal to that among men without criminal legal involvement in the oldest, 50-64 age group (57.5% vs. 58.3%, respectively). To account for these stark age differences in risk and to adjust for the younger age distribution among men under community supervision (see Supporting Information Appendix Table 1 ), Figure 1 presents the population average estimates for men without criminal legal involvement alongside age-standardized estimates for men under community supervision. The age-adjusted estimates confirm higher levels of risk for severe COVID-19 illness among men under community supervision relative to men without criminal legal involvement, and show a higher prevalence of risk for severe COVID-19 illness among men under community supervision than what is otherwise shown in average estimates not adjusted for age (for unadjusted estimates see Supporting Information Appendix Table 2 ). According to these results, nearly two-thirds (64.3%) of men under community supervision face a higher risk for severe COVID-19 illness compared to less than half (47.9%) of men with no criminal legal involvement, based on having at least one CDC risk factor. Important to note is that the CDC guidelines identify patients as high risk for severe COVID-19 illness based on any of the listed conditions, and patients with multiple conditions are likely to be at even greater risk. Recognizing the potential for compounding risk, Table 1 presents evidence on the average number of risk factors and the distribution of these risk factors by age group. Overall, the share of men under community supervision who had at least three conditions was 3.8% versus 4.4% for men without criminal legal involvement (difference not statistically different). The average number of risk factors increased with age for all men, and men under community supervision had a greater number of average risk factors than men without criminal legal involvement across each age group. To further reveal the unequal burden of risk for severe COVID-19 illness among men involved with the criminal legal system, we explored the factors identified by the CDC that put people in need of taking extra precautions during the pandemic. Supporting Information Appendix Table 4 presents the distribution of the CDC extra precautions factors by criminal legal status and age group. Supporting Information Figure A1 shows these results with age adjustment for the population of men under community supervision. Consistent with existing research, levels of SUD and disability were significantly higher among men under community supervision than among men with no criminal legal involvement (Fearn et al., 2016; Feucht & Gfroerer, 2011; Winkelman et al., 2020) . A more novel finding shown in these results is that men under community supervision were significantly more likely than men with no criminal legal involvement to live in rural communities. According to Supporting Information Appendix Figure 1 , the share of people living in rural communities is approximately 18.6%among men under community supervision compared to 13.3% among men with no criminal legal involvement. In contrast to some existing evidence on the health conditions of formerly incarcerated populations (Wang & Green, Note: Health risks shown in exhibit are cancer, based on self-reported diagnosis from a medical provider in the past year; heart condition or heart disease, based on self-reported diagnosis from a medical provider in the past year; body mass index (BMI) higher than 30 kg/m 2 , based on self-reported height and weight; current smoker, based on self-reported daily cigarette smoking during the past month; kidney disease, based on self-reported diagnosis from a medical provider at any time before the interview; type 2 diabetes, based on self-reported diagnosis from a medical provider at any time before the interview; and COPD (chronic obstructive pulmonary disease), based on self-reported diagnosis from a medical provider at any time before the interview. The CDC high risk indicator is based on having at least one of these factors. Estimates among men under community supervision are age-standardized to the overall population of U.S. men aged 18-64. Asterisks indicate that the estimate is statistically significantly different from the estimate among men with no criminal legal involvement at the indicated levels. *p < 0.10 **p < 0.05 ***p < 0.01 Source: Authors' calculations using data from the National Survey on Drug Use and Health (NSDUH), 2015-2019 2010), the prevalence of asthma among men in the NSDUH data was not statistically significantly different between men without criminal legal involvement and men under community supervision. Figure 2 shows the prevalence of high risk for severe COVID-19 illness among those groups that the CDC recommends take extra precautions during the pandemic. Across all extra precautions groups, the prevalence of being high risk for severe COVID-19 illness was significantly greater among men under community supervision relative to men without criminal legal involvement. Disparities in high-risk prevalence were largest between men with SUD and asthma. Among those with SUD, the share at higher risk was 48.5% for men with no criminal legal involvement versus 63.8% for men under community supervision. Among those with asthma, the share at higher risk was 53.0% for men with no criminal legal involvement versus 71.7% for men under community supervision. Figure 1 . Asterisks indicate that the estimate is significantly different from the estimate among men with no criminal legal involvement at the indicated levels: *p < 0.10, **p < 0.05, ***p < 0.01. We evaluated the relationships between high risk for severe COVID-19 illness, extra precautions factors, and health insurance coverage to better understand how criminal legal involvement affects access to care during the COVID-19 pandemic. Figure 3 shows the percent uninsured among men at high risk for severe COVID-19 illness, overall, and across extra precautions factors by criminal legal status. In general, men under community supervision had significantly higher levels of uninsurance than men without criminal legal involvement. Among the overall group at high risk for severe COVID-19 illness, men under community supervision were about twice as likely to be uninsured as men with no criminal legal involvement (25.8% versus 13.7%). Levels of uninsurance varied among high-risk men across groups in need of extra precautions. For high-risk men under community supervision, the share uninsured was highest among those living in rural communities (30.7%). Uninsurance disparities by criminal legal status were largest among high-risk men living in rural communities and with asthma. Compared to their high-risk counterparts without past-year criminal legal involvement, the percent uninsured among men on community supervision was 2.2-times higher for those in rural communities and 2.6-times higher for those with asthma. The spread of COVID-19 among people under community supervision in the United States warrants immediate research and public health attention. In the best of times, people under community supervision face significant risks to their health and safety and struggle with meeting the demands of their supervision and transitioning back into society after spending time in jail or prison. They face discrimination in the housing and job markets (Pager, 2003; Mallik-Kane & Visher, 2008) , and experience significant challenges with accessing needed medical care (Mallik-Kane & Visher, 2008) . Rates of SUD and mental illness are elevated among formerly incarcerated people (Winkelman et al., 2020) , and in the first two weeks following their release from prison, formerly incarcerated people face a risk of death from overdose that is 12-times higher than what is observed in the general population (Binswanger et al., 2007) . In the context of the COVID-19 crisis, these preexisting difficulties of community reentry have likely only become much worse. Since the pandemic erupted in March 2020, health care and social services have become overwhelmed with new demand, and mass unemployment and housing shortages have added to the hardship of finding a job and a place to live. COVID-19 has also introduced new stressors, such as social isolation, loss of control, and unstructured time, which exacerbate the existing risks of mental illness, substance misuse, and drug overdose (Binswanger et al., 2007; Desai et al., 2021; Johnson et al., 2018; Melemis, 2015) . The lives of people under community supervision are also uniquely affected by pandemic responses in the criminal legal system. As COVID-19 cases continue to rise rapidly in jails and prisons, legal officials are releasing and diverting people from incarceration in an effort to contain the virus. From March to October 2020, these decarceration activities added up to 200,000 people to the population under community supervision and more people have potentially been added since then (Brennan Center for Justice, 2020; Franco-Paredes et al., 2020; Prison Policy Initiative, 2020; So et al., 2020) . Planning for the health and safety of these individuals during the pandemic, however, remains uncertain, and COVID-19′s impact among people on probation and parole has not been previously investigated. Motivated by the timely need for research and lack of knowledge in this area, our study provides the first nationwide picture of the risk for severe COVID-19 illness among men under community supervision in the United States. First, we investigated levels of risk for severe COVID-19 illness among men under community supervision. Consistent with existing research, our results showed that men under community supervision were more likely to suffer from conditions that the CDC associates with higher risk for severe COVID-19 illness (Binswanger et al., 2009; Wilper et al., 2009; Winkelman et al., 2020) . On average, nearly two-thirds (64.3%) of men under community supervision were at risk for severe COVID-19 illness compared with less than half (47.9%) of men without criminal legal involvement. Our results also showed striking age differences in the risk for severe COVID-19 illness among men under community supervision. Men under community supervision in the 26-34 age group, for example, shared a similar prevalence of risk for severe COVID-19 illness as men without criminal legal involvement in the oldest, 50-64 age group (57.5% vs. 58.3%, respectively). Second, we explored the extent to which criminal legal status intersects with the factors identified by the CDC that put people in need of extra precautions during the pandemic. Our results revealed that men under community supervision were more likely than men in the general population to be in groups that the CDC identifies as needing to take extra precautions against COVID-19. Further, among groups in need of extra precautions, risk levels for severe COVID-19 illness were greater for men under community supervision. For men under community supervision, we found high-risk levels to be greatest among those with a disability, those living in rural areas, and those with asthma. With over 70% of men in these groups at high risk for severe COVID-19 illness, our results highlight the ways that criminal legal status intersects with multiple social and health factors to compound the risk of illness and potential premature death for men under community supervision. Lastly, we evaluated levels of health insurance coverage to better understand the extent to which men under community supervision have access to care during the COVID-19 pandemic. Consistent with existing research (Gutierrez & Pettit, 2020; Saloner et al., 2016; Winkelman et al., 2017) , we observed large overall differences in health insurance coverage by criminal legal status, with men under community supervision being about twice as likely to be uninsured as men without criminal legal involvement. Fully one-quarter (25.9%) of the overall group of high-risk men under community supervision were uninsured. Uninsured rates were similar or lower for high-risk men under community supervision in the extra precautions groups with SUD, disability, and asthma. High-risk men under community supervision who lived in rural communities, by contrast, saw significantly higher rates of uninsurance (with an average level of 30.7%). These findings add to existing literature on health insurance among people involved with the U.S. criminal legal system by uncovering the extent to which men under community supervision lack coverage during the current COVID-19 pandemic, and provide new evidence on how men under community supervision with certain health and social characteristics are especially vulnerable to being uninsured at this time. The findings revealed in this study have numerous policy implications. Overall, they indicate that decarceration efforts alone are insufficient for addressing the COVID-19 crisis among people involved with the U.S. criminal legal system. People under community supervision, like those in jail and prison, are highly vulnerable to serious illness or death upon exposure to COVID-19much more so than the average person in the general population (Raifman & Raifman, 2020; Selden & Berdahl, 2020) . Many of those at risk for severe COVID-19 illness lack health insurance coverage, potentially causing them to go without needed medical care during the pandemic. If exposed to the virus, people under community supervision during the pandemic will be more likely to end require hospitalization and to die prematurely due to complications from COVID-19. People released from incarceration to community supervision during the pandemic, and especially those with unanticipated releases, may be particularly at risk for adverse COVID-19 outcomes, due to the additional stressors of the pandemic on top of the preexisting challenges associated with the transition from incarceration to the community. Reentry programs and servicessuch as jail and prison discharge planners, community-based reentry support organizations, and health care providers who serve formerly incarcerated patients-must adapt to assess and address the pandemic-specific needs of every individual returning to the community. First and foremost, people released from detention must be tested for COVID-19 and be given safe places where they can self-quarantine for a minimum of two weeks in order to protect their health and limit community transmission. One possible way to facilitate this process is to provide temporary housing for people upon their release from incarceration, potentially in places like empty hotel and motel rooms, like what has already been done in states like New York and California (Vansickle, 2020) . Discharge planners, probation and parole supervisors, reentry support organizations, and local health departments should work together to identify the living situation where the returning individual will be relocating to after their quarantine and recommend that all members of the household self-quarantine or receive negative COVID-19 test results before the returning individual's relocation. This process should also ensure that the returning individual has personal protective equipment and the information and tools necessary to assess their potential symptoms of and exposure to the virus upon their relocation. Discharge planners, probation and parole supervisors, reentry support organizations, and local health departments should also work together to provide additional support for individuals who meet the criteria for being high risk for severe COVID-19 illness, based on the CDC health risks and extra precautions factors. In addition to their immediate pandemic-specific needs, discharge planners, probation and parole supervisors, reentry support organizations, and local health departments must also work together to assess and address other health and basic needs of the returning individual that have always been important and are further complicated by COVID-19. Along with the CDC health risks and extra precautions factors, this network of reentry services and health providers should screen for the presence of all chronic physical and mental health conditions, and must work to connect returning individuals with appropriate medical care and treatment plans. Especially during the pandemic, it is critical that reentry support organizations and probation and parole officers assist clients with securing health insurance and identifying appropriate health care providers, including those who accept patients regardless of insurance status or offer low-cost services (Desai et al., 2021) . Reentry support organizations and probation and parole officers should also be sure to connect clients to medical providers who have the experience and competency to work with people involved with the criminal legal system, as well as people who are marginalized along other lines, such as race/ethnicity and disability status (Nelson, 2002) . Further attention and consideration should also be given to clients in rural areas, who likely experience heightened difficulties with accessing medical care and social services (Douthit et al., 2015) . In states with the Medicaid expansion, most men under community supervision are likely eligible for Medicaid coverage (Cuellar & Cheema, 2012) . Discharge planners, reentry support organizations, and probation and parole officers in these states should enroll their clients in Medicaid and ensure those who were enrolled prior to incarceration are reenrolled given that the Medicaid inmate exclusion policy that interrupts Medicaid coverage during incarceration. Expansion states should also allocate time and resources to managing the suspension and reactivation of Medicaid benefits for people released from incarceration to help prevent patients' Medicaid enrollment from terminating completely in response to the federal inmate exclusion. To provide more support to people involved with the criminal legal system during the pandemic and beyond, states that have not yet adopted the Medicaid expansion should urgently change their policy to do so. These potential state actions would align with the Medicaid Reentry Act, a federal policy recently introduced to the U.S. House of Representatives as part of a COVID relief package, which would improve health care transitions for people returning home from incarceration by allowing Medicaid to cover their medical services in the 30-day period prior to their release (H.R. 1329, 116th Congress, 2019). For both newly returning individuals and all others under community supervision during the pandemic, it is also critical that reentry support organizations and probation and parole officers providers give their clients information and resources about the virus and the COVID-19 vaccinations. COVID-19 protective measures, policies, and norms have evolved over the course of the pandemic, and misinformation about the virus has been widespread (Mian & Khan, 2020) . Reentry and community supervision services should deliver clear, sufficient, and relevant information to their clients that updates them on our growing knowledge of COVID-19 symptoms, protective measures, and the vaccine. As this population may be particularly disadvantaged with respect to their access to COVID-19 vaccines, reentry and community supervision services should assist clients with making appointments to receive their vaccines and provide necessary follow-up for those who require two doses of the vaccination. Service providers should also give tailored support to clients who may face particularly high barriers to the vaccine and who may have more reasons to be distrustful of the health care system, such as those who are Black or Latinx, have some type of SUD, have some type of disability, or live in a rural area (Douthit et al., 2015; Nelson, 2002) . The drastic changes to society in response to COVID-19 also make it important for reentry programs and probation and parole departments to make structural changes to their operations that would improve their clients' overall wellbeing and decrease their risk of incarceration during the pandemic. The elimination of probation and parole fees during the pandemic, for example, would allow the community supervised population to better manage their daily lives in the context of the pandemic that has brought on unprecedented levels of unemployment, unstable housing, and food insecurity (Galea & Abdalla 2020; Millet et al., 2020) . Limiting arrests and incarceration for technical violations during the pandemic is another policy change that would further protect the lives of people under community supervision and lower the overall spread of COVID-19 that occurs through the transfer of people in and out of jails and prisons. According to the Prison Policy Initiative, probation and parole departments in California, Colorado, and Wisconsin have already implemented these kinds of policy changes (Prison Policy Initiative, 2020). Other jurisdictions therefore have models to follow in activating their own policy changes as the pandemic continues. As reentry programs and community supervision departments adapt to the pandemic, the health and safety of service providers themselves should also be considered. People under community supervision likely face high levels of exposure to the virus due to their interactions with jails and prisons as well as home and work environments that suffer heavy burdens of COVID-19 cases (Reinhart & Chen, 2020; Wang et al. 2021 ). This makes service providers similarly vulnerable to being exposed to COVID-19 given their ongoing contact with people under community supervision. Like people working directly in jail and prison facilities, service providers who work with people under community supervision should be considered frontline workers during the pandemic, and their jobs should come with the provision of personal protective equipment, regular COVID-19 screenings, and prioritization for COVID-19 vaccinations. Reentry programs as well as probation and parole departments should also consider reducing or suspending in-person check-ins during the pandemic to help protect staff and the supervised population. Some service providers have already implemented these policy changes, including probation and parole departments in New York, Rhode Island, and California (Prison Policy Initiative, 2020). In these departments, in-person check-ins have been replaced with telephone calls, text messages, and video call check-ins. Like service providers, the broader communities that interact with the community supervised population should also be considered an important population that policymakers can help protect during the pandemic. The communities where formerly incarcerated and community supervised individuals reside are disproportionately made up of low-income, Black and Latinx populations that are also disproportionately burdened by the COVID-19 virus and targeted by formal social control (Harding et al., 2019; National Research Council, 2014; Raphael, 2011; Reinhart & Chen, 2020; Wang et al. 2021) . Reflecting historical and contemporary patterns of racism and inequality, these communities generally face high levels of risk for severe COVID-19 illness, poor access to COVID-19 vaccinations, and substantial reasons to distrust the U.S. health care system (CDC 2021; Nelson 2002; Seldon & Berdahl, 2020) . Accordingly, reentry, probation, and parole providers should work with local organizations to connect families and neighbors of the returning and community supervised populations to COVID-19 testing and screening, needed health care services, and COVID-19 vaccinations. Local governments, public health officials, and social workers should also work together to ensure that individuals living in communities with higher concentrations of people on probation and parole have health insurance coverage by enrolling eligible people in Medicaid and finding alternative and affordable plans for people in nonexpansion states. Combined, these community-level efforts can help mitigate the public health risks associated with COVID-19 as well as the racial inequalities that exist and continue to widen during the pandemic. Our study had several limitations. First, we measured health risks using self-reported data on conditions diagnosed by a health care provider. Thus, if people under community supervision were less likely to visit a health care provider and to be diagnosed with a health issue, then actual disparities in condition prevalence might have been even larger than we observed (Frank et al., 2013; Mallik-Kane & Visher, 2008; Nelson, 2002; Wang et al., 2013) . Second, data in the National Survey on Drug Use and Health do not include all risk criteria. Our estimates therefore represent lower bounds of men at high risk for severe COVID-19 illness. The inclusion of all risk criteria might provide further evidence of disparities because the prevalence of risk factors not included in the NSDUH, such as immunocompromised state from solid organ transplant and sickle cell disease, is likely unequal across groups according to their involvement with the U.S. criminal legal system (Binswanger et al., 2009; Massoglia & Pridemore, 2015; Wilper et al., 2009) . Third, our sample reflects an imperfect representation of people under community supervision. People under community supervision who experience homelessness or residential instability are generally excluded from our analysis because the NSDUH sampling design focuses on noninstitutionalized, community-residing individuals. Further, because we limited our sample to men aged 18-64 years, our study wholly excluded women, nonbinary people, and elderly individuals aged 65 and older. These groups have distinct health profiles and health needs that should be investigated in future research. The data may also undercount people under community supervision due to the possibility that respondents in the NSDUH may intentionally or unintentionally fail to report being on probation or parole at the time of the interview (Lattimore et al., 2016) . Fourth, our measure of health insurance coverage does not fully estimate access to health care. Individuals with health insurance may still encounter significant barriers to accessing care, including lack of a nearby provider, limited hours of medical clinics, difficulty finding available physicians, inability to get a referral for a provider, and lack of translation services (Betancourt et al., 2016; DeVoe et al. 2007 ). In consideration of the continuing spread of COVID-19 in jails and prisons and the increasing number of people on probation and parole as a result of pandemic responses, we examined the risk of severe COVID-19 illness and additional compounding health risks including lack of health insurance among adult men under community supervision in the United States. To our knowledge, this is the first study to provide national estimates on the extent to which people under community supervision are vulnerable to COVID-19 and have access to care during the pandemic. Our analysis highlights the higher levels of risk for serious illness or death from COVID-19 among men under community supervision and draws attention to the disproportionate lack of health insurance among those at higher risk for severe COVID-19 illness. Identifying those at greater risk for severe COVID-19 illness, especially among people in groups needing to take extra precautions during the pandemic, may help to attenuate the potential harmful effects of exposure to the virus. Our study provides a foundation of new knowledge on the impact of COVID-19 among the population of people involved with the U.S. criminal legal system. More research is needed to fully understand COVID-19 infections and outcomes among people involved with the U.S. criminal legal system, as well as among their families and communities. Future studies should also consider how the risk for severe COVID-19 illness among men under community supervision may change as the number of releases and diversions from incarceration continues to increase the size of the community-supervised population. As people involved with the U.S. criminal legal system are disproportionately Black and Latino men who face additional stigma due to their criminal records (e.g., Pager, 2003) , it is also important for future research to consider the unique psychological stressors, discrimination, and racism that may influence this population's physiological responses to COVID-19 infection and treatment. Building on our findings regarding the high levels of uninsurance among men under community supervision, another line of future inquiry should consider the role of the criminal record in shaping access to quality of care received for COVID-19 treatment. Such research would be especially important considering existing literature on health care providers' general lack of competency in working with people involved with the criminal legal system (Short et al., 2009; Wilmott, 1997) . The authors declare they have no known conflict of interest to disclose. Gutierrez https://orcid.org/0000-0001-9256-4468 Evelyn J. Patterson https://orcid.org/0000-0002-8701-9665 Have community sanctions and measures widened the net of the European criminal justice systems? Association of substance use disorders and drug overdose with adverse COVID-19 outcomes Characteristics and comparative clinical outcomes of prisoner versus non-prisoner populations hospitalized with COVID-19 The perfect storm: Incarceration and the highrisk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia The impact of substance use disorder on COVID-19 outcomes Prisons: Amplifiers of the COVID-19 pandemic hiding in plain sight Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population Release from prison-A high risk of death for former inmates Reducing jail and prison populations during the Covid-19 pandemic Indicators of mental health problems reported by prisoners and jail inmates Coronavirus disease 2019 (COVID-19): Other people who need extra precautions Evidence for conditions that increase risk of severe illness As roughly 700,000 prisoners are released annually, about half will gain health coverage and care under federal laws Releasing individuals from incarceration during COVID-19: Pandemic-related challenges and recommendations for promoting successful reentry Insurance + access not equal to health care: Typology of barriers to health care access for low-income families Peer reviewed: Disability status as an antecedent to chronic conditions: National health interview survey Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees Exposing some important barriers to health care access in the rural USA Public health and the epidemic of incarceration Trends and correlates of substance use disorders among probationers and parolees in the United States Mental and substance use disorders among adult men on probation or parole: Some success against a persistent challenge Decarceration and community re-entry in the COVID-19 era. The Lancet Infectious Diseases Emergency department utilization among recently released prisoners: A retrospective cohort study COVID-19 pandemic, unemployment, and civil unrest: Underlying deep racial and socioeconomic divides The devastating impact of Covid-19 on individuals with intellectual disabilities in the United States. NEJM Catalyst Innovations in Care Delivery HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis The institutional determinants of health insurance: Moving away from labor market, marriage, and family attachments under the ACA Employment and health among recently incarcerated men before and after the Affordable Care Act On the outside: Prisoner reentry and reintegration Alone on the inside: The impact of social isolation and helping others on AOD use and criminal activity Probation and parole in the United States COVID-19 outcomes among people with intellectual and developmental disability living in residential group homes Arrestee substance use: Comparison of estimates from the national survey on drug use and health and the arrestee drug abuse monitoring program Health behind bars: Utilization and evaluation of medical care among jail inmates Risk factors for COVID-19 mortality among privately insured patients. FAIR Health White Paper Health and prisoner reentry: How physical, mental, and substance abuse conditions shape the process of reintegration Pandemic influenza and jail facilities and populations Correctional populations in the United States Medical problems of state and federal prisons and jail inmates Incarceration and health California's San Quentin prison declined free coronavirus tests and urgent advice-now it has a massive outbreak Focus: Addiction: Relapse prevention and the five rules of recovery Coronavirus: The spread of misinformation Assessing differential impacts of COVID-19 on Black communities The growth of incarceration in the United States: Exploring causes and consequences Unequal treatment: confronting racial and ethnic disparities in health care Prevalence of disabilities and health care access by disability status and type among adults-United States The mark of a criminal record Incarcerating death: Mortality in US state correctional facilities The dose-response of time served in prison on mortality The paradox of probation: Community supervision in the age of mass incarceration Mass probation: Toward a more robust theory of state variation in punishment Hospitalization and mortality among black patients and white patients with COVID-19 Responses to the COVID-19 pandemic. Prison Policy Initiative Disparities in the population at risk of severe illness from COVID-19 by race/ethnicity and income Incarceration and prisoner reentry in the United States Incarceration and its disseminations: COVID-19 pandemic lessons from Chicago's Cook County Jail Carceral-community epidemiology, structural racism, and COVID-19 disparities Risk factors associated with in-hospital mortality in a US national sample of patients with COVID-19 Justice-involved adults with substance use disorders: coverage increased but rates of treatment did not in 2014 COVID-19 cases and deaths in federal and state prisons Mass incarceration: The whole pie 2020. Prison Policy Initiative COVID-19 and racial/ethnic disparities in health risk, employment, and household composition Custody vs care: Attitudes of prison staff to self-harm in women prisoners-a qualitative study The health of America's aging prison population Coronavirus in the US: Latest map and case count. The New York Times HIV/AIDS among inmates of and releasees from US correctional facilities, 2006: declining share of epidemic but persistent public health opportunity America's inmate population fell by 170,000 amid COVID. Some see a chance to undo mass incarceration Intermediate sanctions. Crime and Justice Beyond the prison gates: The state of parole in America Intellectual and developmental disability and COVID-19 case-fatality trends: TriNetX analysis The COVID-19 pandemic and people with disability ementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-and-disability-status U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration A new tactic to fight Coronavirus: Send the homeless from jails to hotels. The Marshall Project Incarceration as a key variable in racial disparities of asthma prevalence Decarcerating correctional facilities during COVID-19: Advancing health, equity, and safety A high risk of hospitalization following release from correctional facilities in Medicare beneficiaries: A retrospective matched cohort study COVID-19 risk and outcomes in patients with substance use disorders: Analyses from electronic health records in the United States Age-standardized mortality of persons on probation, in jail, or in state prison and the general population Prison nursing: The tension between custody and care The health and health care of US prisoners: Results of a nationwide survey The Affordable Care Act, insurance coverage, and health care utilization of previously incarcerated young men Physical health and disability among US adults recently on community supervision Additional supporting information may be found in the online version of the article at the publisher's website.