COVID-19 wasn’t the first virus to devastate prisons and jails…and it won’t be the last. By learning from their past failures, state and local leaders can take steps now to prepare for the next inevitable viral threat.

by Emily Widra, April 21, 2023

On Monday, April 10th, President Biden signed a congressional resolution ending the national emergency declaration, and the separate national public health emergency declaration is set to expire on May 11th, thereby rolling back the last major federal policies designed to respond to the ongoing threat of COVID-19. As the nation enters this new period, we reviewed the experience of COVID-19 — and other pandemics and epidemics behind bars — to understand what correctional institutions and policymakers need to do to prepare for when the next viral outbreak occurs.

Defining endemic vs. epidemic vs. pandemic

  • Endemic: Diseases that present at a relatively consistent, predictable rate among a group of people.
  • Epidemic: A sudden increase in the number of people with a condition that spreads over a large geographic area.
  • Pandemic: Occurs when an epidemic spreads globally.


A pattern of pandemics and epidemics behind bars

COVID-19 wreaked havoc on the nation’s jails and prisons, with more than 3,000 deaths among incarcerated people, 300 deaths among correctional staff, 660,000 reported cases among incarcerated people, and 247,000 reported cases among correctional staff. The pandemic underscored what public health experts have long known: prisons and jails are not designed to provide adequate health care or prevent disease transmission, and in fact, they often are the sites of disease outbreaks.

It is important to recognize, though, the terrible consequences of the COVID-19 pandemic behind bars weren’t necessarily unique to this particular virus. Rather, COVID-19 is one more example of a historic pattern of just how vulnerable people in jails and prisons are to communicable illnesses and how — without any serious change to our reliance on mass incarceration — this population will continue to bear the disproportionate burden of public health crises, inevitably affecting the health of communities outside of correctional facilities as well.


The tuberculosis (TB) pandemic is primarily concentrated outside of the United States, but people in prisons and jails within the U.S. are disproportionately affected by TB when compared with the general U.S. population. TB cases and diagnoses have decreased steadily since 1992 in the U.S., but rates of TB in local jails, state prisons, and federal prisons actually increased from 2020 to 2021.


Hepatitis C — considered an epidemic — is also significantly more common among incarcerated populations than the general U.S. population: in 2012, 11% of people in state and federal prisons had ever been diagnosed with Hepatitis B or C, compared to only 1.1% of the general U.S. population.1 While the virus is generally considered treatable outside the walls of a prison, state and local leaders have consistently missed the opportunity to get control of the virus behind bars by their failure to implement screening and treatment protocols behind bars.


An estimated one in seven individuals living with HIV passes through the correctional system annually. Nationally, the overall prevalence rate of HIV in the U.S. in 2019 was 431 per 100,000 people and the number of new HIV infections declined 8% from 2015 to 2019. But HIV/AIDS is far more prevalent in prisons. The total U.S. prison population faces an prevalence rate that is more than 2.5 times higher: 1,144 per 100,000 people in prison have HIV/AIDS, highlighting how disproportionately affected incarcerated people are by HIV.


What these disease-specific disparities show is simple: for so many illnesses and diseases, incarcerated people face higher rates of infection and illness than their non-incarcerated counterparts.

The elevated rates of infection and disease are correlated with a number of other factors that overlap significantly in the incarcerated population, including poverty, lack of access to healthcare and insurance prior to incarceration, homelessness, history of drug use and other preexisting chronic health issues, inadequate correctional health care, congregate living settings of correctional facilities, and health care gaps upon release from prisons and jails. So, regardless of what the next pandemic brings, we know that people in prisons and jails are particularly vulnerable to communicable diseases and often face higher mortality rates than those outside of prison walls facing the same illness.


Lessons learned

To even begin to prevent catastrophic illness and death behind bars during the next inevitable outbreak, correctional institutions and policymakers need to reflect on the emergency (and preparatory) measures that COVID-19 showed were necessary.

Reduce incarcerated populations:

In prisons:

In jails:

  • State and local legislatures can expand the list of “non-jailable” offenses, which are not subject to arrest but can only be fined or cited.
  • Police and law enforcement departments can reduce the number of arrests — especially for “petty offenses” — and prosecutors can opt out of prosecuting people for certain offenses utilizing diversion services or other alternatives to incarceration.
  • Jails can refuse to rent space to other agencies. In some states, as much as 8% of jail capacity is dedicated to USMS, 10% to ICE, and 66% to state prisons.
  • Jails should refuse to admit people accused of violating technical rules of their state probation or parole. As we recently found, people detained for technical violations can make up a huge part of a jail’s population.
  • Nobody should be detained simply because they cannot afford money bail.

Improve health services during incarceration:

  • Eliminate medical co-pays. Unaffordable medical copays in prisons and jails can lead to increased spread of disease in and around correctional facilities and postpone access to medical treatment, often resulting in worsening ailments/illnesses. With a highly infectious virus posing an ongoing threat, this can have deadly consequences. Forty states still charge incarcerated people copays to seek medical treatment. While some states suspended these fees during the COVID-19 pandemic, many have already reinstated them.
  • Support access to existing vaccines and promote vaccine education. Vaccination efforts should include an educational component that allows incarcerated people to get the information necessary to feel comfortable taking the vaccines. Additionally, the relationship between people in prisons and the medical staff of that prison is often defined by mistrust. Information about the safety and efficacy of any vaccine is limited for people behind bars, and governments should bring in outside medical experts and community leaders who will have the trust of the people who are incarcerated and give them multiple opportunities to ask questions and voice their concerns.

Develop systems to identify and respond to viral outbreaks early:

  • Establish metrics to identify outbreaks and protocols to respond to them: Corrections officials must recognize that the threat posed by viral outbreaks could dramatically increase quickly. They should have established processes to monitor the threat the virus poses and, when appropriate, plans to impose more rigorous interventions — such as education, masking, increased testing, and enhanced hygiene practices — to stop its spread.
  • Create outbreak response plans. During the COVID-19 pandemic, rather than developing plans to mitigate the harm of an inevitable outbreak, most states were focused on restricting the movements of incarcerated people within facilities — in other words, they attempted to “contain” the virus, which is all but impossible with communicable diseases. While many facilities do have outbreak plans for specific illnesses (like influenza), these plans are often outdated. Such plans should be reviewed and updated frequently, and should always include up-to-date contacts in local public health departments.
  • Include incarcerated populations in the priority groups for testing, treatment, and vaccinations.



Our colleagues at the UCLA Law COVID Behind Bars Data Project found that the mortality rate in U.S. prisons increased by 61% during the first year of the pandemic. There is no doubt that the failure of officials across the country to quickly and adequately respond to the COVID-19 pandemic in correctional settings is to blame. Moving forward, prisons and jails need to remember the lessons learned during the past three years to avoid repeating the same mistakes that helped the virus spread within both prisons and the surrounding communities. The nation’s overreliance on incarceration has left too many vulnerable people behind bars in the face of public health crises.



  1. We use 2012 data here because the Bureau of Justice Statistics’ report, Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12, contains a general population estimate that is standardized to match the prison population by sex, age, race, and Hispanic origin for 2012. In 2016, 10% of people in state prisons and 4% of people in federal prisons reported ever having hepatitis, but there is no standardized general population comparison included in that report.  ↩

Unique survey data reveal that people under community supervision have high rates of substance use and mental health disorders and extremely limited access to healthcare, likely contributing to the high rates of mortality.

by Emily Widra and Alexi Jones, April 3, 2023

Research shows that people on probation and parole have high mortality rates: two and three times higher than the public at large.1 That certainly suggests that our community supervision systems are failing at their most important — and basic — function: ensuring people on probation and parole succeed in the community.

pie chart showing the majority of people under correctional control are under community supervision rather than in prison or jail

With a similar approach to our recent series regarding the needs of people incarcerated in state prisons, we did a deep dive into the extensive National Survey on Drug Use and Health (NSDUH). The results of this survey, administered by the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA), provide key insights into these specific — and often unmet — needs faced by people under community supervision. Because this survey asks respondents if they were on probation or parole in the past 12 months, this dataset comes closer than any other source 3 to offering a recent, descriptive, nationally representative picture of the population on probation and parole.2

The data that we uncovered — and the analyses of this same dataset by other researchers discussed throughout — reveal that people under community supervision have high rates of substance use4 and mental health disorders and extremely limited access to healthcare, likely contributing to the high rates of mortality. Moreover, the data show that people on probation and parole experience high rates of chronic health conditions and disability, are extremely economically marginalized, and have family obligations that can interfere with the burdensome — often unnecessary — conditions of probation and parole.

Who is under community supervision?

A brief demographic overview of the community supervision population

At the start of 2020, an estimated 4.1 million people were under community supervision, with the vast majority (80%) on probation. Most people on probation (75%) and parole (88%) were men and were serving a probation sentence for a felony offense (69%). Among people on probation, the “most serious offense” they were most often convicted of was drug related (26%). Among people on parole, most had a maximum prison sentence of a year or more (93%), and most commonly had been convicted of a violent offense (36%).5 Black people were overrepresented in both parole and probation populations: Accounting for 14% of the total U.S. population, Black people made up 30% of the probation population and 37% of the parole population. While most people involved in the criminal legal system — and under community supervision — are men, women serving criminal sentences of any kind are actually more likely than men to be under community supervision: in 2020, 86% were on probation or parole, compared to 67% of men serving sentences. In addition, people on probation (9%) and parole (10%) are twice as likely to identify as lesbian, gay, or bisexual when compared to the total population (5%).


Substance use and mental health

Three in 10 people under community supervision have substance use disorders, four times the rate of substance use disorders in the general population. Similarly, 1 in 5 people under community supervision has a mental health disorder, twice the rate of the general population.

  • bar chart showing a larger portion of community supervision populations experience mental health and substance use disorders than the general population
  • bar chart showing that two thirds of people with substance used isorders and one third of people with mental health disorders on community supervision are not receiving the treatment they need
bar chart showign one third of people under community supervision who have opioid use disorder receive medication-assisted treatment

In addition, NSDUH data illustrate that most people on probation and parole do not have adequate access to healthcare, implying that probation and parole offices are failing to match people with the services they need to succeed in the community. Nearly one-third of people on probation and parole with a mental health disorder report an unmet need for mental health treatment. Over two-thirds of people with substance use disorders report needing treatment, but not receiving it. Similarly, only about one-third of people on community supervision with opioid use disorder report receiving medication-assisted treatment (MAT), the “gold standard” of care.

Finally, many people on probation and parole have no health insurance, even though many people on probation and parole have incomes low enough to qualify them for Medicaid.6 25% of people on probation and 27% of people on parole were uninsured at the time of this survey. This lack of treatment access reported by people under community supervision represents a massive failure of probation and parole offices.


Physical health and well-being

Criminal legal system involvement is concentrated among people who are socioeconomically disadvantaged and these same populations are at an elevated risk for a number of negative health outcomes. Public health researchers Winkelman, Phelps, Mitchell, Jennings, & Shlafer (2020) analyzed the same NSDUH data (but from 2015-2016) and found that people under community supervision are more likely to report fair or poor health, more chronic conditions, a diagnosis of COPD, hepatitis B or C, or kidney disease than people in the general population.

The community supervision population also has higher rates of disabilities, with particularly high rates of cognitive disabilities.7 Such disabilities can interfere with individuals’ ability to keep track of the 18 to 20 requirements a day people on probation must typically comply with. The particularly high rates of all types of disabilities among people on probation and parole also reflects the larger pattern of criminalizing people with disabilities.

bar chart showing larger percentages of community supervision population with numerous chronic conditions and disabilities than the general U.S. population


Economic disadvantage, education, and children

The NSDUH data also indicate that people on probation and parole are extremely economically marginalized, which can interfere with probation and parole conditions. 3 out of 5 people on probation have incomes below $20,000 per year, with women and Black people having among the lowest incomes. More than half have a high school education or less. And people on probation and parole are three times more likely to be unemployed than the general population. Yet, as we have discussed before, people on probation and parole are required to pay unaffordable fees and costs associated with their supervision conditions (such as drug testing or ignition interlock devices), even though many are living well below the poverty line.

bar chart showing larger percentages of community supervision report income under $20,000 than in the general population

Finally, the data reveal that many people — and more than half of women — on probation and parole have children. Yet, probation and parole requirements almost never consider childcare or eldercare responsibilities when setting supervision conditions, even as some states require courts to consider a defendant’s caretaker status when considering a sentence to incarceration.

General population Probation population Parole population
High school
education or less
33% 52% 57%
Unemployed 3-4% 11% 15%
Have children 41-42% 46% 43%
Men 40% 43% 41%
Women 43% 54% 50%



Probation and parole systems are failing to link people to the healthcare they need, despite all the evidence showing disproportionate rates of serious illness and death within supervised populations. These “alternatives” to incarceration, ostensibly created to help people address the problems that led to their conviction in a community setting, also set people up to fail with burdensome, often unnecessary requirements that show little regard for people’s individual circumstances, including low incomes and childcare obligations. The clearest example of these counterproductive conditions is the requirement to abstain from drugs or alcohol; given that so many supervised people with substance use disorders do not receive treatment, what hope do they have of staying out of jail when a positive drug test may constitute a “violation”? Probation and parole systems can’t be seen as true “alternatives” until they are overhauled to support people’s medical and personal needs instead of simply monitoring and punishing their mistakes. Until then, state and local governments should double down on their investments in diversion programs that are proven to connect people with care — and, to that same end, keep people out of courts and jail as much as possible.



  1. People on probation are also 3 times more likely to die than people in jails and state prisons over a given time period, adjusted for age (the study this was based on used data from 2001-2012).  ↩

  2. The Bureau of Justice Statistics conducts the Annual Probation Survey and Annual Parole Survey, which also provides a recent, descriptive, and nationally representative picture of the community supervision population. The demographic details available from the NSDUH are richer, however, going far beyond race, sex, age, and offense type. Moreover, the NSDUH presents self-reported data, while the BJS surveys present administrative data reported by probation and parole agencies.  ↩

  3. For the purposes of this analysis, we chose to use data collected in the 2019 NSDUH rather than the more recent 2020 survey results. In the 2020 NSDUH report, the authors cautioned that “care must be taken when attempting to disentangle the effects on estimates due to real changes in the population (e.g., the coronavirus disease 2019 [COVID-19] pandemic and other events) from the effects of these methodological changes.” Because of this warning, we elected to use 2019 NSDUH so that our results could be better compared over time. Researchers updating our work in the future, however, should note one important methodological change occurred in 2020: “2020 marked the first year in which substance use disorders (SUDs) were evaluated using criteria defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), as opposed to criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).”  ↩

  4. “Substance use disorders” in this analysis were evaluated by the using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). See footnote 3 for more information.  ↩

  5. The data on offense type for people on probation and parole used here from the Bureau of Justice Statistics, defines “violent” offenses as domestic violence offenses, sex offenses, or other violent offenses. However, generally, the distinction between “violent” and other crime types is a dubious one; what constitutes a “violent crime” varies from state to state, and acts that are considered “violent crimes” do not always involve physical harm. The Justice Policy Institute explains many of these inconsistencies, and why they matter, in its comprehensive and relevant report, Defining Violence.  ↩

  6. In all states, Medicaid provides health coverage for low-income people who qualify based on income, household size, disability status, and a handful of other factors. Most people in contact with the criminal legal system are likely eligible for Medicaid: People in prisons and jails are among the poorest in the country and have high rates of disabilities, making them likely eligible for Medicaid in almost every state. People in contact with the criminal legal system have drastically lower pre-incarceration incomes than people who are never incarcerated. In fact, 32% of people in state prisons in 2016 who had insurance at the time of their arrest were covered by Medicaid (compared to about 19% of insured people nationwide). As an additional indicator of need among this population, 50% of people in state prisons were uninsured at the time of their arrest.  ↩

  7. In this dataset, “cognitive disabilities” are defined as “serious difficulty concentrating, remembering, or making decisions.”  ↩

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