Organizations working to reform parole systems in their states are encouraged to sign on to these 16 principles.

by Emmett Sanders, July 10, 2025

Parole systems in America are failing. They’re inaccessible, they’re hard to navigate, they grant parole for far too few people, and those who are paroled are often set up to fail.

It doesn’t have to be this way.

Prison Policy Initiative has partnered with the MacArthur Justice Center’s National Parole Transformation Project to produce Principles for Parole Reform. This document features 16 guiding principles for advocates to consider when pushing for parole reform in their jurisdictions. Drawing from our own extensive research and advocacy experience, and created with guidance from advocacy organizations across the country, this document reflects dozens of conversations with those most impacted by unjust parole policies: currently and formerly incarcerated people and their families.

The principles cover key areas of parole such as access and eligibility, preparation and process, criteria considerations, parole board composition, revocation hearings, and more. Each principle includes an explanation of why these reforms are necessary, as well as concrete examples of common-sense policies that advocates can draw from when working to implement change.

The problems with parole

Discretionary parole allows states to periodically review incarcerated people’s circumstances with the goal of releasing people who can safely return to their communities. Parole is a vital tool for decarceration, but in its current form, it usually does not achieve its goals.

At its core, discretionary parole is a recognition of the fundamental humanity of those in prison: a promise that, in our society, people are more than their worst moments. However, the distance between the promise of parole and its reality is vast. Parole processes are a minefield of racial disparities, opaque processes, over-politicization, and little representation or assistance for those hoping to make it to the other side of decades of incarceration. Access to parole is limited in some states and nonexistent in others. Where it exists, the process is so complicated and restrictive that only a fraction of those who apply are granted release. Others apply over and over again only to be denied, often for subjective reasons or for things they cannot change. The result of this flawed system is the same throughout the country: Broken promises and prisons bursting at the seams with people who could be safely released.

To learn more about the need for parole reform in the US, please read:

Making reform a reality

These 16 principles aim to make parole fairer, more accessible, and more transparent for everyone.

We know that varied political realities mean different reforms are possible in different states. Nevertheless, we hope that the principles we offer in this document will serve as a useful guide for advocates across the country looking to close the distance between the promise of discretionary parole and the reality. The 16 principles are listed below, and are explained in more detail on MacArthur Justice Center’s website.

16 guiding principles for parole reform

  1. Every incarcerated person should have access to parole release systems.
  2. When someone is eligible for parole, there should be an enforceable presumption of release, and parole boards should be required to use forward-looking, objective criteria to justify why release is inappropriate, rather than requiring incarcerated people to justify their fitness for parole.
  3. Parole boards should be required to adhere to consistent, clear guidelines about how to make parole release decisions. People denied parole should have the opportunity to challenge the basis on which their denial decision was made.
  4. Parole should be granted or denied based on forward-looking, objective factors within the control of the incarcerated person, and should focus exclusively on how a person has grown, changed, or been productive since being incarcerated, rather than the underlying crime of conviction.
  5. When a person is denied parole, they should be given specific, actionable changes that they can make to increase their chances of parole in a future hearing. Parole boards should then honor these efforts and grant parole when people have satisfied previously stated requirements.
  6. When a person is denied parole, they should be able to appear before the board again for reconsideration within a reasonable amount of time.
  7. People who are up for parole and their loved ones and supporters should have the ability to attend parole hearings and speak to the parole board on their behalf.
  8. People should have access to counsel at parole hearings and be provided competent, effective, and free counsel that adheres to best practices for indigent defense if they cannot afford it. People should be provided with resources and support to prepare for their parole hearings.
  9. Parole Boards should be diverse in their backgrounds, and should include community-based practitioners trained in psychology and rehabilitation, trauma experts, people who are formerly incarcerated, and other experts with the ability to fairly and objectively evaluate candidates for parole. People with backgrounds in law enforcement and corrections should not be the majority of parole board members.
  10. Parole Boards should be required to release information publicly about their decisions, including grant rates, the reasons for denial of parole, length of setbacks, and demographic and charge information of people who appear before the parole board.
  11. Imposition of conditions, including supervision fees, should be an individualized process that begins with the presumption of no conditions and allows for the removal of conditions that are no longer serving a purpose.
  12. People on supervision should have a variety of options for how to check in that allow for minimal disruptions to the re-entry process.
  13. Supervision should not be indefinite; no person should be on supervision for the rest of their life after parole release.
  14. Parole boards must ensure the due process rights of people facing revocation are protected, including the right to counsel and other safeguards to ensure fair hearings.
  15. People on supervision should not be returned to prison solely for non-criminal conduct.
  16. The amount of time that can be revoked should be capped and proportionate to the seriousness of the violation.

Join the effort

If your organization works on parole reform and would like to sign on to these principles, you can do so through MacArthur Justice Center’s National Parole Transformation Project’s website.


The Fourth Circuit has revived an incarcerated person’s lawsuit challenging a $15 fine taken from his account as punishment.

by Regan Huston, July 3, 2025

In August of 2020, Demmerick Brown, a man incarcerated in Virginia’s Red Onion State Prison, went to the prison barbershop to get a haircut and a shave. This was the height of the COVID-19 pandemic, and naturally the barber asked Mr. Brown to remove his protective mask so he could shave his face. The next day, Mr. Brown received a disciplinary ticket fining him $15 for failing to wear a mask.

After a perfunctory disciplinary hearing, Mr. Brown had the money deducted from his trust account. Then, he sued, alleging that he had not been afforded appropriate due process before having his money taken. But the District Court found that he wasn’t entitled to due process. The court said that this was because $15 was too small an amount of money to trigger constitutional protections.

What the court failed to understand is that $15, while just being the cost of a sandwich outside prison walls, represents dozens or hundreds of hours of labor inside, and people rely on the money they make behind bars to fill their basic needs and contact their families.

In 2024, the Prison Policy Initiative filed an Amicus Curae brief in a suit filed by Rights Behind Bars, who represent Demmerick Brown. In our brief, we drew on our years of work studying the economics of life behind bars to help the Fourth Circuit understand that $15 inside doesn’t mean the same thing as $15 does on the outside.

On Tuesday, the Fourth Circuit rightfully reaffirmed that incarcerated people deserve due process rights when their money is taken away from them. The opinion cites our brief, concluding that, “Fifteen dollars may be a sum of small consequence outside prison walls, but it is of great significance within them: the amount is more than a week’s worth of wages at Red Onion State Prison where Brown is incarcerated.”

This is one important step in recognizing the lived experiences of people behind bars, and their constitutional rights.

From providing testimony to completing custom research projects, the Prison Policy Initiative is available to help work on projects across all stages of the criminal legal system. Learn more about the work our advocacy department does here, and drop us a line if we can help.


Incarcerated people and their loved ones will continue to be exploited by sheriffs and telecom companies for two more years, while these same interests lobby the FCC to water down its rules.

by Wanda Bertram, July 2, 2025

On Monday, the Federal Communications Commission abruptly announced a two-year postponement of rules reducing prison and jail phone rates that it passed unanimously last year in accordance with the Martha Wright-Reed Fair and Just Communications Act. The FCC’s reversal defies the Act, a bipartisan law that gave the agency a deadline (which it is now blowing past) to implement these regulations.

In a statement, FCC Commissioner Anna M. Gomez blasted the decision, saying the Commission was “shielding a broken system that inflates costs and rewards kickbacks to correctional facilities at the expense of incarcerated individuals and their loved ones.”

Families should not have to face two more years of being squeezed by telecom companies and the prisons and jails they collude with. Unfortunately, this order means that they will do just that. By kicking implementation of its rules down the line, the FCC is capitulating to a system it has already acknowledged is full of bad incentives.

A gift to sheriffs and prison telecom companies

Why is the FCC changing course on an order that all of its members — including Trump-appointed Chairman Brendan Carr — voted for last year?

In large part, the move is a response to a small group of sheriffs who have lashed out in reaction to its 2024 order. Before the order, companies had been able to offer commissions and other kickbacks to agencies they partnered with (which drove up the prices of phone calls for consumers). The 2024 order barred companies from offering almost all kickbacks and commissions. In retaliation, a handful of sheriffs, most notably the sheriff of Baxter County, Arkansas, have said they will no longer offer phone calls at all.

Additionally, before the order, prison telecom companies provided call monitoring services to prisons and jails that were — inappropriately — paid for via the rates charged to consumers. The new rules triggered some companies and sheriffs to claim that they could not provide these services if families didn’t foot the bill. Piggybacking on these claims, several Republican state attorneys general filed a lawsuit against the FCC, arguing that the 2024 order has put police investigations in jeopardy. While the FCC’s 2024 order addressed these concerns, the order yesterday echoes the language in the lawsuit.

What this means for incarcerated people and their families

The 2024 order technically went into effect earlier this year, but it granted prisons and jails with active contracts an extension of up to one year (or to the end of their contracts, whichever came sooner) to implement new rates. That means that while many facilities have already changed their contracts, many have not.

The original rate caps and deadlines set by the FCC’s 2024 order
Facility type Old phone rate caps (per minute) New phone rate caps (per minute) New video rate caps (per minute) Effective date
Prisons $0.14 $0.06 $0.16 Jan. 1, 2025
Large jails (1,000+) $0.16 $0.06 $0.11 Jan. 1, 2025
Medium jails (350-999) $0.21 $0.07 $0.12 Apr. 1, 2025
Small jails (100-349) $0.21 $0.09 $0.14 Apr. 1, 2025
Very small jails (0-99) $0.21 $0.12 $0.25 Apr. 1, 2025

Incarcerated people in facilities that have not yet amended their rates (or that have amended them, but reverse the changes in light of this move by the FCC) will continue to be charged the old rates until April 2027. In the meantime, we expect that sheriffs and the prison telecom industry will lobby aggressively for rollbacks to the 2024 order, meaning that the new rules, when finally implemented, may look very different than what the FCC originally passed.

Justice delayed

The 2024 FCC order was projected to save the loved ones of incarcerated people many millions of dollars every year — cutting the maximum allowed phone rates by approximately half, thus sparing households from debt and from impossible choices between communication and other basic necessities. In postponing its own rules, the agency is delaying economic justice for millions of working-class and low-income families.

This backtracking is also defying Congress. As FCC member Gomez noted, the Martha Wright-Reed Act was “a bipartisan law that ensures prison communications are priced fairly and no longer exploit incarcerated people and their families.” Rather than fulfilling the mandate of this law — the product of decades of advocacy by consumers, advocates, and law enforcement officials — the FCC’s latest move concedes to profit and political interests.

The Prison Policy Initiative strongly opposes this decision. Together with our allies, we will fight to ensure the historic 2024 order is not watered down to protect profits, but implemented as written to protect families.


For some of the thousands of pregnant people entering jails each year, at what might be their moment of greatest need — going into labor — jails turn a blind eye, harming mothers, newborns, and their families. The latest project from our partners at Advocacy and Research on Reproductive Wellness of Incarcerated People, or ARRWIP, illuminates these haunting stories and the dire need for data and education about pregnancy in jails.

by Leah Wang and Bianca Schindeler, July 1, 2025

In the confines of an unsanitary jail cell, a woman delivers a baby alone: This is a typical news article about a jail birth. But when it comes to the 1.5 million women1 cycling through jails each year, what more do experts know about jail births on a larger scale? The answer: Nothing — there is no regular data collection on pregnant or postpartum people held in local jails.2 (As for those in prisons, there is some limited data collection.3)

Given the lack of transparency from jails about pregnancies, birth outcomes, and other facets of reproductive care, a team of student researchers is drawing attention to this data blind spot. The Birth in Jails Media Project, which draws entirely from local news coverage of jail births, provides a rich picture of how some pregnant people experience incarceration, labor, and childbirth, with more detail about jail conditions and staff responses than a national dataset can typically provide.4

infographic showing outcomes of 35 births occurring inside jails between 2013 and 2023

In this briefing, we present the first-ever published findings from the Birth in Jails Media Project, one of many indispensable efforts from Advocacy and Research on Reproductive Wellness of Incarcerated People (ARRWIP), a reproductive justice-oriented research group at John Hopkins University led by researcher and obstetrician-gynecologist Dr. Carolyn Sufrin. (We’ve previously lifted up ARRWIP’s important work on contraception, abortion, breastfeeding, and medication for opioid use disorder policies for pregnant women in custody.)

Cases surfaced by the Birth in Jails Media Project suggest pregnant people going into labor behind bars experience great distress and maltreatment, often facing no choice but to give birth without medical assistance, support, or basic safety protocols. While the 35 mothers and newborns included in these cases are likely a small and unrepresentative share of all jail births between 2013 and 2023,5 their stories are powerful calls to action: Pregnant people in jails are in dire need of proper and timely care, and their experiences cannot continue to go undocumented. Lawsuits filed by mothers and advocates, our Media Project partners note, can be credited for moving the needle in some states, but too many stories remain in the shadows.

Because cases involving grave negligence or abuse are more likely to receive news coverage, the Media Project dataset may be skewed toward worse outcomes for pregnant people in jails. But the stories truthfully surface what has happened — and what will likely continue to happen — at some women’s moment of greatest need. Although jails operate independently of one another, the stories reveal systemic ignorance, lacking or nonexistent policies, and patterns of violence that call attention to misconceptions about how and why pregnant people become and remain incarcerated at all.

[The jail’s staff and medical contractors] “engaged in a cycle of punishing and isolating Ms. (unnamed here), while allowing her mental and physical health, and that of her unborn baby, to dangerously deteriorate.” – from a lawsuit filed in Virginia, after a 2021 jail birth resulting in neonatal death

Methodology and project details

To begin, the researchers6 conducted a web search of news articles from 2003 onwards using the keywords “birth in jail.” Based on those web results, the team defined the project’s scope as in-jail births occurring between 2013 and 2023 – the ten full years before the project’s start. After reviewing hundreds of news articles, the research team established a dataset of 261 news articles covering 35 births occurring within jails across 21 states. Births were excluded if they occurred outside of a jail, like at a prison or a hospital. Some news articles referenced additional births happening in the same jails, but if those did not generate their own sufficient news coverage, they were excluded from the dataset.7

Where possible, the researchers noted the specific conditions of delivery: whether the birth was preterm (earlier than 37 weeks) or full term; any known health impacts on the newborn or mother; family separation outcomes; any information related to a lawsuit; any administrative or policy response from the jail; active or pending legislation resulting from the case; responses from community members and advocates; and relevant quotes from anyone involved.

Read the entire methodology

Most births in jails happened inside jail cells, after repeated calls for medical assistance went ignored

Among the 35 jail births identified in the news between 2013 and 2023:

  • At least two-thirds of births (25) occurred inside jail cells, which often contain nothing more than a mattress, a toilet, and a floor as options for delivery. For context, only about 22% of jails nationwide reported having medical treatment or hospital functions in 2019 (the most recent year these data were collected). At least three births happened inside “isolation” or solitary confinement cells; one woman, about to give birth, was put in solitary “to muffle her screams” because of her agonizing labor pains.
  • In at least 24 cases, jail staff ignored repeated cries for help or medical assistance. In several instances, pregnant people called out for help or used their cell call buttons to no avail; in some cases, loved ones called the jail to ask that someone check on the mother. And in a few appalling instances, news coverage and lawsuits claim that staff laughed at or belittled the woman in labor, wrongfully assumed she was only experiencing withdrawal symptoms, told her to deal with the pain, or simply watched the delivery, providing no assistance whatsoever.8
  • One-fourth of babies (9 of 35) were stillborn or died within two weeks of being born. Five others suffered a documented injury or infection. It’s impossible to draw a straight line between these newborn babies’ health and the jails’ conditions, but in a few instances, delivery in a jail cell or into a toilet likely led to various infections of the eyes, blood, and placenta; in other newborns, inhaling water or fecal matter caused respiratory issues.
  • In at least one-third of births, the baby was born preterm (before 37 weeks of pregnancy). Preterm birth is a leading cause of infant mortality and health conditions that can negatively impact an individual throughout their life. There are many risk factors for preterm birth, including maternal stress, anxiety, substance use, chronic health problems, and certain pregnancy histories. Jails should provide health care that addresses risk factors; the most vulnerable pregnant people, unfortunately, are often forced to rely on jails for the chance to access medical care.9
  • More than half of jail births (19 of 35) led to a lawsuit, some of which were filed against private healthcare companies contracted to provide care inside jails. Many of the lawsuits remain unresolved; one lawsuit was dismissed, and eight ended in settlements reportedly ranging from $16,000 to $1.5 million.

“That pain [of labor] was indescribable. What hurt me more, though, was the fact that nobody cared.” – A mother who gave birth unassisted in a Colorado jail cell in 2018

Jail births led to only minimal changes in jail policy and practice

The Media Project research team found that when a jail’s administration formally responded to a mother’s complaint or lawsuit, they tended to deny wrongdoing, holding firm that correctional and medical staff followed protocol. Disturbingly, some jails admitted that their medical staff had no training on pregnancy or childbirth (thereby absolving them of misconduct). In a few cases, legal action and advocacy to address these horrifying incidents have led to some common-sense changes that should be on the books in every state.10

bar graph showing most pregnant people entering jail are still pregnant when released, fewer than 10 percent give birth during a jail stay, and fewer than 1 percent give birth inside the jail

For example, after one woman gave birth in a Colorado jail cell in 2018 with no medical support, the jail instituted mandatory trainings and updated its policies to ensure that pregnant people in their custody at any stage of labor are immediately taken to the hospital, as part of a settlement agreement. Years later, Colorado lawmakers passed HB23-1187, which allows courts to offer bonds or alternative sentences to pregnant defendants.

A 2020 Florida law, the Tammy Jackson Act, also contains promising care provisions for pregnant people in custody, but has failed to prevent at least two in-jail births — one of which resulted in a newborn’s death — since the law went into effect. Florida advocacy groups have been working for years to advance another bill, “Ava’s Law,” which would allow judges to delay someone’s incarceration by up to 12 weeks to allow for birth or bonding with a child, mandate pregnancy tests for women who are not released after 72 hours, and require relevant data collection, among other provisions.11

“I basically held my baby all night, until she died, until she turned blue” – a mother who gave birth three months early in a Florida jail, whose baby died hours later

The Birth in Jails Media Project highlights an urgent need for documentation and policies focused on jail pregnancy

Now that there are some national-level data from state and federal prisons (collected by the Bureau of Justice Statistics), it is time to ask jails to produce the same information. After all, the outsized growth of women’s incarceration compared to men’s incarceration in recent decades has disproportionately occurred in local jails. Indeed, the Bureau of Justice Statistics concluded in a recent “feasibility study” that it should be possible for jails to report this kind of data. Beyond counts of pregnant people entering jails (and prisons), these statistics should include:

  • Specific live birth outcomes, such as the location of delivery, preterm, early term, and full term births, instances of low birth weight, and neonatal deaths;
  • Other occurrences such as cesarean deliveries, miscarriages, abortions, stillbirths, ectopic pregnancies, and maternal deaths;12
  • The actual provision of maternal healthcare services to people while in jail, such as pregnancy tests, prenatal vitamins, special diets, routine and high-risk prenatal care, and postpartum depression screening;
  • Linkages to comprehensive demographic, health, and sentencing data.13

Data collection aside, some basic education on maternal health could support improving outcomes for pregnant women currently cycling through jails. In the instance where a pregnant person is incarcerated, correctional officers and frontline correctional health staff must be trained on how to recognize labor signs and other urgent maternal warning signs to facilitate appropriate and timely care. Along with training and education, jail staff must, importantly, believe, document, and respond to pregnant women’s reporting of their labor and other concerning pregnancy symptoms.

Ultimately, improved access to reproductive healthcare, expanded data, and fundamental training may help avoid distressing births behind jail walls, but our partners at ARRWIP insist that locking up pregnant people endangers maternal and newborn health and perpetuates structural inequities. Deeper reforms at the sentencing level, such as caregiver mitigation or diversion laws, combined with desperately-needed care standards and oversight,14 would be more effective in moving pregnant women and mothers out of jails to community-based supports and to their families.

Footnotes

  1. We acknowledge that people of many different gender identities can become pregnant. Unfortunately, the data published by many sources we use are only broken out by administrative, binary sex variables: male and female. The gender identities of pregnant people in the ARRWIP study of jail pregnancy are also based on surveys administered to jails. The inclusion of people outside the gender binary depends on the specific policies and practices of the jurisdiction.  ↩

  2. In 2020, the Advocacy and Research on Reproductive Wellness of Incarcerated People (ARRWIP), a research team led by Dr. Carolyn Sufrin, published the most recent estimate of pregnant people admitted to jails each year as part of the Pregnancy in Prison Statistics Project, or PIPS. From a survey of six jails, including five of the largest jails in the U.S., they estimated that there are 55,000 annual admissions of pregnant people to jails each year, which is about 3% of female jail admissions. This 3% figure is slightly more than the 2% of women who were pregnant entering state prison, but more importantly, represents tens of thousands more women compared to state prison admissions. To our knowledge, this study is also the only large-scale study of pregnancy outcomes in jails.  ↩

  3. In April 2025, the Bureau of Justice Statistics published Maternal Healthcare and Pregnancy Prevalence and Outcomes in Prisons, 2023, which is based on data collected for the first time in 2024. This dataset includes the prevalence of pregnancy among people in state and federal prisons, pregnancy outcomes, and some limited data on the types of services, medical care, and support offered to incarcerated pregnant people.  ↩

  4. Unlike most Prison Policy Initiative publications, which are centered around a dataset and analysis that we make available for further study, this briefing does not include a data appendix, nor will it link to news articles or directly identify those in the dataset. The Birth in Jails Media Project aims to draw attention to this matter while honoring individual stories and highlighting the urgency for aggregate, de-identified data. A dataset with links to the articles is available upon reasonable request by contacting arrwip@jhmi.edu.  ↩

  5. The total number is unknown; for some context, 35 jail births nationally over ten years — or just under 4 births per year — is a very small proportion of pregnancies which end during a jail stay. In their study of 6 jails, Dr. Carolyn Sufrin et al. found that 224 pregnancies out of 1,622 admissions of pregnant people ended in custody, whether in a live birth, miscarriage, stillbirth, induced abortion, or ectopic pregnancy. In their dataset, two births (of 144 live births) happened inside the jail.  ↩

  6. The Birth in Jails Media Project was conducted by members of ARRWIP’s student research team. It was led by doctoral student Bianca Schindeler with support from Dr. Carolyn Sufrin, ARRWIP’s research program manager Camille Kramer, Ava Chan, Devanshi Trivedi, and Sonia Hamilton, M.D.  ↩

  7. Two additional cases fell on the border of inclusion criteria and therefore were excluded from main results; however, case details were still fully reviewed and documented, with one referenced later in the report. These included one birth in a U.S territory, and one birth that occurred in transport from jail to hospital.  ↩

  8. One woman described informing the judge during her court hearing that she was experiencing painful contractions and needed to go to the emergency room, but the judge sent her back to jail where she did not receive medical care, was ignored by jail staff, and birthed alone in her cell several months before her due date. In another egregious case — which ultimately did not meet the research criteria — correctional officers were transporting a jailed pregnant woman to the hospital, but stopped for coffee en route. Both cases reportedly led to the newborns’ death.  ↩

  9. While most people may not dream of giving birth in a jail cell, the painful reality for some pregnant people is more complicated: When poverty, substance use, racial discrimination, and violence coalesce, jail may represent a safety net — a guarantee of at least some prenatal care, as Dr. Carolyn Sufrin notes in her 2017 book, Jailcare.  ↩

  10. In 2024, a legislative working group in Virginia published recommendations for the treatment of incarcerated pregnant women with substance use disorders; their report includes a list of states which have laws regarding screening, treatment, sentencing, diversion, and staff training, but the impacted population is limited to pregnant women with a known substance use disorder.  ↩

  11. In May 2025, SB 206 (or “Ava’s Law,” in memory of the baby who died hours after being born in a Florida jail cell) was withdrawn from consideration, after being introduced at least twice before in the Florida legislature.  ↩

  12. Surveys of jails and prisons led by Dr. Carolyn Sufrin and ARRWIP, as core works of the Pregnancy in Prison Statistics Project, use many of these metrics, suggesting the feasibility of collecting such data nationally. Unfortunately, their surveys were only conducted once, covering twelve months between 2016 and 2017.  ↩

  13. Hopefully, the Bureau of Justice Statistics’ upcoming and long-awaited Survey of Inmates in Local Jails includes at least as much pertinent information as it did during the last survey over 20 years ago, in 2002 (which asked people in jails about pregnancy, obstetric exams, and prenatal care).  ↩

  14. According to Dr. Carolyn Sufrin, the American College of Obstetricians and Gynecologists (ACOG) has published recommendations for pregnancy care in custody, and accreditation programs exist for correctional facilities to show some effort to provide such care. However, these programs are voluntary, and the lack of uniform standards leads to problematic variability from jail to jail.  ↩


The health burdens of jail expansion are heaviest in places that already lock a lot of people up. Those places also would see the largest benefits from decarceration, including fewer deaths each year.

by Jacob Kang-Brown, June 24, 2025

It is tough to get nationally-representative, individual-level data on incarceration’s health impacts. But researchers are increasingly providing evidence that the criminalization of poverty, addiction, and mental health issues has sharp harmful consequences. Jailing in general is associated with higher mortality (death) rates. At the community level, higher levels of jailing causes more communicable and noncommunicable disease, mortality, and harms maternal health. For individual people, jailing has major impacts on mental health and maternal-child health.

bar chart showing that the risk of death increases by 39 percent for people who were incarcerated, and the risk of overdose death increases by 208 percent,

A new cohort study by a group of scholars at the U.S. Census Bureau, the Hennepin Healthcare Research Institute, and the medical school at Mount Sinai published in the medical research journal, JAMA Network Open adds to the evidence and has important local policy implications. This study, led by Dr. Utsha Khatri, found that people incarcerated on a given day in 2008 had a 39% higher risk of death compared to similar people who were not incarcerated, and their risk of overdose death was 208% higher. Additionally, the paper suggests that expanding the use or size of local jails is associated with more deaths county-wide. These nationally-representative findings build upon previous research linking incarceration and mortality.

What makes this paper particularly useful for policymakers and advocates is its effort to measure the impacts of both individual experiences of incarceration and county jail incarceration rates. County jail rates measure how much a given county relies on jailing as a response to issues of health and safety.1 How counties use their jails varies widely across the United States; the jail incarceration rate in Nashville is over five times the rate in Minneapolis, to cite just one example.2 This new study drew county-level jail rates from the Vera Institute’s Incarceration Trends Project dataset and leveraged local variation to better understand how jails impact death rates, breaking out overdose deaths for special attention. One caveat worth noting on the individual-level impacts: because millions of people flow through local jails each year, the findings in the study may understate the harms of incarceration.3

Methodology

The paper pulls from the Mortality Disparities in American Communities study. This dataset linkage effort connects restricted records from the Census with data from the National Death Registry. Khatri et al.’s sample is 3.2 million people who responded to the American Community Survey in 2008, including 45,000 people who were incarcerated at the time they were surveyed. Everyone was tracked through the end of 2019 to see if they survived.

Read the entire methodology

The survival analysis research design compares people who were incarcerated with similar people who were not incarcerated, nesting everyone within similar counties. At the individual level, the authors adjusted for age, sex, race and ethnicity, employment, marital status, household income, and educational attainment. The county-level measures included jail incarceration rates, the percentage of the county who reported being Black or African American, average household size, population density, and poverty rate. Because this is not an experimental or quasi-experimental research design, the observed associations are not causal claims. In other words, the authors don’t attempt to show higher jail rates or the experience of incarceration as the cause of the increase in deaths they observed; they simply show the strength of the relationship between those variables.

Limitations

The United States does not track everyone who has been incarcerated in a centralized database that social or medical researchers can access. Lacking that, the single-day measurement of incarceration based on a single day in 2008 creates some issues: this leads to error that would likely cause the authors to under-estimate the harmful impact of incarceration on health. Some of the people that are in the “non-incarcerated” control group at the time of the survey would have been formerly incarcerated, and others would become incarcerated later, between the time of the survey and the end of the study period in 2019. Thus, these measures would probably underestimate the statistical association between incarceration and increased mortality. Because jail stays are typically quite short (often days or weeks, with an average stay of 32 days), we know a far larger number of people are impacted by incarceration each year than are counted on a single day. Nonetheless, this study provides evidence that is consistent with other research that more jailing causes health harms even to people who were not locked up.

Health harms of incarceration affect everyone, making jail expansion versus decarceration a matter of life and death

This study found that people incarcerated on a single day in 2008 had a 39% higher risk of death — and a 208% higher risk of death by overdose — compared to similar people who were not incarcerated. These results are from models that adjust for individual- and county-level factors, and it’s worth noting that having been incarcerated had a much stronger impact on risk of death than other measures linked to death rates like income, education, or indigeneity (that is, whether one identifies as American Indian or Alaska Native). Similarly, the estimated impact of incarceration on overdose mortality was higher than many other individual-level risk factors.

 

  • bar chart showing that incarceration increases risk of death by 39 percent, more than poverty, not finishing high school, and identifying as American Indian or Alaska Native, which each raise the risk by about 10 percent
  • bar chart showing that incarceration increases risk of overdose death by 208 percent, more than divorce or separation, not finishing high school, and poverty

The elevated risk of death from overdose after incarceration is well documented: criminalization of addiction causes a lot of harm. But other research has shown that incarceration is associated with a wide range of health issues, which may help explain the increased risk of death from any cause. People are entering and exiting the toxic prison and jail environment all the time, either upon their arrest and release or as staff clock in and clock out. Other studies have found links between incarceration and health outcomes ranging from:

This study by Khatri et al. also found county-level jail incarceration was associated with an increase in deaths generally. The researchers estimate that a local jail incarceration rate 10% higher than the national county average leads to a 0.45% increased risk of death across the board. While this is much smaller than the 39% higher risk for people that were incarcerated, it applies to all people. The authors do the math and it works out to an additional 4.6 people dying for every 100,000 people in the population a year. This relationship is linear: for each 10% increment over the average, a county experiences another 4.6 additional deaths per 100,000 people, so a county with a jail rate 20% higher than average could expect 9.2 additional deaths per 100,000 and so on. Because large increases in jailing are common after new jail construction, and many counties have sustained lower jail rates after COVID-related changes in 2020, it’s worth applying this finding to larger numbers and the associated annual numbers of deaths.

bar chart showing that while a 50 percent increase in Baldwin County's jail rate could lead to 57 more deaths per year, a sustained 25 percent decrease in Contra Costa County's jail rate could reduce deaths by about 52 per year

Comparing two suburbs can illuminate the relationship between jail rates and county deaths: Contra Costa County, in the San Francisco Bay Area, reduced its jail population by 25% between 2019 and 2024. In contrast, Baldwin County, Ala. (between Mobile and Pensacola) is opening a new jail this summer that will expand capacity by 50%. The study from Khatri et al. suggests Contra Costa’s 25% jail population reduction (on top of an already relatively low incarceration rate) could translate to an average of 52 fewer county residents dying each year as a result of the harms from the jail. For perspective, Contra Costa averaged 47 homicides a year over the last decade, so this would be a meaningful change. Conversely, if the number of people in the Baldwin County jail increases by 50% to fill up the new facility, this study suggests an additional 57 deaths in the county each year. Given there were only 20 murders in the county in 2023, this would be quite a concerning increase.

For people who live in counties considering steps to reduce criminalization, pretrial detention, and overall jail capacity, this research provides clear evidence of the harms of incarceration. Jail construction is expensive and tends to crowd out public investment in other needs like community-based healthcare. Criminalization of addiction doesn’t address problematic substance use, and better community-based treatment options are needed. Moreover, some studies suggest jail construction leads to even more criminalization rather than deterring crime. Decarceration is one of the best tools to combat early deaths caused by this dynamic between criminalization, incarceration, and austerity — what geographer Ruth Wilson Gilmore terms “organized state abandonment.” By comparing the number of deaths due to the harms of incarceration to the numbers of murders reported, we can get a sense of the scale of this abandonment. Communities across the United States don’t have to tolerate these burdens of incarceration. Instead, as this new paper suggests, working to reduce jailing could help improve community health.

Footnotes

  1. In addition, some counties also use their local jails like private prisons, providing space to incarcerate people on contracts with the state prisons, federal agencies like ICE, or other counties in exchange for payments to cover their operating costs.
     ↩

  2. Nashville, Tennessee’s surrounding county, Davidson, had 299 people in jail per 100,000 in spring 2024. Minneapolis, Minnesota’s county, Hennepin, had 58 people in jail per 100,000 residents in spring 2024. The 2024 data is sourced from Vera’s Incarceration Trends Project, an older version of which was used by Khatri et al. in their study.
     ↩

  3. For more on this, see the discussion of limitations in the methodology below.  ↩


The Trump Administration has made a lot of claims about how it will change the criminal legal system. We explain where the president and federal government have full control over the system, where they have some influence, and where their power ends.

by Mike Wessler, June 11, 2025

Sections
By the numbers
Independence of state & local authorities
Federal influence
The president & executive branch
Control over federal spending
Federal policing and prosecutions
Enforcement of civil rights laws
Pardons and commutations
Appointments
The bully pulpit
Congress
Federal courts
These are not normal times
Impacts on state and local governments

There is little question that the President of the United States is the most powerful person on the planet. They can launch military strikes, shake the foundation of the economy, and dramatically alter our international alliances, all with a stroke of their pen. And if you have heard President Trump speak about the criminal legal system lately, you’d likely think the office also has the power to control who is arrested and incarcerated, and what the conditions are like when they get there. The truth, though, is much more complicated.

It is important to remember that the United States doesn’t really have a single, unified criminal legal system. It has thousands of smaller systems, and state and local governments have direct authority over the vast majority of them. However, while the president and the federal government don’t have direct control over most of these systems, they have many tools at their disposal to indirectly impact how they are operated.

In this briefing, we explain the federal government’s traditional role in the United States’ criminal legal system, highlighting where it has direct control, ways it can exert indirect influence, and the relative size and scope of its power. It is important to note that, in this piece, we rely on how our government normally works, when limits on federal power are honored and where the president obeys court orders. We don’t explore every nuance of federal law or possible tools that the federal government could hypothetically deploy.1 Instead, we aim to help you understand the avenues of influence it has traditionally exercised.

Actions and statements from the Trump administration raise serious doubts about whether these limits will be respected. Understanding the contours of power and authority outlined in this briefing can provide clues about what to expect in the future and serve as a helpful barometer of how far actions by the administration have deviated from the standards of recent decades.

The federal criminal legal system: By the numbers

While the president and members of Congress may talk a lot about crime, prisons, and incarceration, the truth is they directly control only a small sliver of the overall carceral system.

Pie chart showing the federal government has direct authority over only about 13% of the incarcerated population.

As we explain in the latest edition of our flagship report, Mass Incarceration: The Whole Pie, there are roughly 2 million people incarcerated in the U.S. on any given day.2 Of those, only a relatively small portion are under the direct control of the federal government:

  • Approximately 204,200 are in federal prisons or jails;
  • Roughly 48,000 are in immigration detention facilities.34

In total, about 13% of incarcerated people — approximately 252,200 people — are under the direct control of the federal government. For context, the federal incarcerated population is only a little larger than the number of people in prisons in jails in the single states of Texas, which has 11% of the national incarcerated population, and California, which has 10%. Those numbers show that, rather than being a massive monolith, the federal carceral system is roughly the same size as the criminal legal systems in some of the larger states in the country.

Make no mistake, 252,200 people under direct federal control is a lot, but it represents only a relatively small portion of the total number of people behind bars on any given day in this country.

So, who has direct authority over the other 87% of people incarcerated in this country? State and local governments.

Independence of state and local authorities

State prisons and local jails hold the vast majority of people who are incarcerated in this country. Those facilities and systems are operated and overseen by state and local governments and are largely independent of the federal government. You should think of state prisons and local jails as systems that operate in parallel (and occasionally overlap) with the federal system, rather than as subsidiaries of it.

State legislators write laws that dictate what actions are considered crimes and the possible punishments for those actions. Police and prosecutors — operated by both state and local governments — enforce those laws by carrying out arrests and prosecutions. County sheriffs operate local jails. And the state government runs the prison system that confines people sentenced to incarceration by state courts.5

Generally speaking, state and local governments hold the vast majority of the control in the criminal legal system, and the federal government plays a relatively small role.

Examining recent progress towards decriminalizing marijuana offers a helpful — albeit unique — example of how state and local governments operate in parallel with the federal government when it comes to law enforcement. Currently, 24 states have made the recreational use and possession of marijuana legal. That means that state and local law enforcement cannot arrest or prosecute someone for simply possessing or using marijuana.6

However, the possession of marijuana remains illegal under federal law. Even if you are in a state that has made recreational use of marijuana legal, the federal government could, in theory, still arrest and prosecute you for it. Usually, though not always, the federal government has respected states’ ability to write their own criminal laws, and in doing so, has avoided prosecutions that are contrary to state law.

Importantly, if someone is sentenced to incarceration, the entity that prosecuted them usually determines where they serve their sentence. If they’re prosecuted under state law, as most people are, they’ll usually serve their sentence in a state prison. If they’re prosecuted under federal law, they’ll likely serve their sentence in federal prison.7

Federal influence over state and local policy

While the federal government has direct control over a relatively small portion of the nation’s criminal legal systems, the president, Congress, and the federal courts have many ways to exert indirect influence over how states and local governments address public safety, prosecute crimes, operate their prisons, and more.

It is essential to recognize that the federal government’s influence and power to shape state and local criminal legal system policy is not inherently good or bad. This power has been used to both shrink and grow the carceral footprint in America. Understanding the contours of these powers can help you see how they’re being used.

The president and the executive branch of the federal government

The president and the executive branch of the federal government likely have the most tools at their disposal to influence how state and local governments operate their criminal legal systems. Some of these mechanisms are direct actions that essentially force the hands of state and local governments by using the promise of providing or eliminating funding or threatening legal action, while others rely on the prominence and prestige of the presidency to exert pressure and encourage specific actions.

Control over federal spending

While Congress controls the amount of money budgeted for various federal government programs,8 the president has immense discretion over how that money is spent and how laws are implemented. From the money allocated by Congress, presidents can often direct money to their own priority programs, while offering fewer resources to programs that are less important to them. These choices can dramatically impact state and local criminal legal systems.

A prime example of this is the Department of Justice’s Office of Justice Programs. This office provides millions of dollars in grants to state and local governments, as well as other organizations that provide services related to the criminal legal system. How this money is spent and what programs receive money have huge impacts on state prison populations and local police activities.

Under President Biden, many of these grants were awarded to organizations and programs designed to keep people out of the criminal legal system, reduce violence, and support victims of crime. However, shortly after taking office, the Trump administration cancelled roughly $820 million in Biden-era grants, indicating that they didn’t align with the administration’s priorities. The administration has said this money will instead be allocated toward programs that align with its focus areas, which many people assume means it will result in more money for policing and prison construction.

Additionally, the Department of Justice provides funding to state and local law enforcement through a series of grants and other programs. Many of these programs require state and local officials to comply with federal policing standards and collaborate with federal authorities on certain criminal investigations and prosecutions. This funding allows federal authorities to expand their reach and exert new pressure on local elected and law enforcement officials.

Another example of how executive branch agencies use money to shape state criminal justice policy is the Justice Reinvestment Initiative, which is partially funded by the U.S. Department of Justice. This program connects state leaders with experts to help them develop strategies to reduce crime, improve services for people with substance use disorder and mental health issues, and reduce spending on prisons and jails. Through this model, the federal government helps to lay the groundwork for state policy reforms. This framework allows the federal government, despite not having a direct voice in the decision-making for states, to influence state policies.

While the president cannot directly instruct states on how to operate their criminal legal systems, making funds available for specific uses can push them to take actions that the president wants. The money can motivate officials to follow the federal government’s lead, and conversely, when money dries up, force them to abandon strategies that aren’t in line with the president’s priorities.

Federal policing and prosecutorial power

The president appoints the attorney general of the United States to head the Department of Justice. Over the last fifty years, presidents have generally respected the independence of their attorneys general, based on the recognition that law enforcement should not be influenced by politics or personal grievance. The Trump administration has made clear it will no longer respect that independence.

While the attorney general is generally considered the top law enforcement official in the nation, they only have direct policing and prosecutorial power over allegations that federal crimes have been committed. As we explained above, this has traditionally been a relatively small portion of the total criminal cases around the country, with state and local governments maintaining jurisdiction over the vast majority.

It is important to note that the attorney general has incredibly wide discretion over which cases the Department of Justice pursues. There are a lot of actions that are criminalized by both the state and federal governments. However, in the vast majority of these cases, state and local authorities take the lead on arrests and prosecutions.

In theory, however, an attorney general could direct federal law enforcement to take primary authority over far more cases than it has traditionally pursued. This would swell the federal prison population and the federal government’s role in the criminal legal system. The fear of federal intervention in the criminal legal system can be used to coerce states to more aggressively pursue prosecutions that the president and federal government have prioritized.

Enforcement of civil rights laws

One of the most powerful ways that the federal government has positively impacted state and local law enforcement and prisons is through the enforcement of civil rights laws.

Even when state or local officials are responsible for policing or incarceration, they must still abide by civil rights protections in the U.S. Constitution. If they don’t, the U.S. Department of Justice can bring a federal lawsuit against the prison, police department, or other government body. These lawsuits often focus on things like racist policing practices, inhumane prison or jail conditions, and police brutality.

Often, these cases are resolved by consent decrees, in which the state or local government entity agrees to take specific actions to resolve the practices that violated federal law. In a break with the past, the Trump administration has announced that it is abandoning many of these efforts to rein in abuse in prisons and jails and by law enforcement.

Pardons and commutations

Presidents have the power to pardon or commute the sentences of people convicted of federal offenses. A pardon absolves a person of their criminal conviction, ending any remaining time in prison or on probation and wiping the conviction from their record, like it never happened. A commutation, on the other hand, reduces a person’s sentence, but doesn’t remove the conviction from their criminal record.

It is important to note that a president can only grant pardons and commutations to people convicted of federal crimes. They have no power to change the criminal sentences of people convicted of state crimes, which means most criminal convictions in the country are outside of their reach.

Appointments to courts, agencies, commissions, and more

The people who run the day-to-day operations of the federal government matter, and the president appoints a significant number of judges, agency heads, and members of regulatory boards that shape criminal legal system policy in this country.

The president nominates people to fill vacancies in federal courts,9 including the United States Supreme Court. By nominating people who share their worldview on public safety, prison conditions, crime, and other issues, the president indirectly shapes how federal courts rule on these issues for decades to come. Importantly, these courts will also regularly be asked to weigh in on whether state or local policies violate the U.S. Constitution, giving them considerable influence on what and how criminal legal system policies are implemented.

Presidents also appoint the heads of most federal departments and most agencies in the executive branch. The people appointed to these positions are the ones managing the day-to-day operations of the federal government, making the specific choices about how money is spent, where staffing resources are focused, and how the administration implements federal laws.

Finally, the most overlooked appointments that presidents make are to the various rule- and regulation-making boards and commissions scattered throughout the government. These bodies are tasked with filling in the details of how specific legislation is implemented, giving them immense power to shape both the federal and state criminal legal systems. Recent examples include:

  • The Federal Communications Commission: In 2022, Congress passed the Martha Wright-Reed Just and Reasonable Communications Act, which tasked the Federal Communications Commission with issuing new regulations reducing the cost of phone calls from prisons and jails. The Commissioners took sweeping action to do just that. This impacted nearly every prison or jail in the country, regardless of whether it was run by the federal, state, or local government.
  • The Federal Trade Commission: Under President Biden, the commission took action to address junk fees that private companies charge to incarcerated people — even those not in federal custody. While the final proposed rules didn’t go nearly far enough to protect people in prison and jail, they demonstrate the far-reaching impacts of actions by this body.
  • The Postal Regulatory Commission: Postal mail remains a critical way that incarcerated people stay in touch with their loved ones on the outside. This commission sets the cost of postage and other rules around this service.

The bully pulpit

When all else fails, the president can also use their prominence in government, ability to garner media coverage, and public platform to influence how the public views and thinks about issues, even if they have no direct power over those issues. This is sometimes referred to as “the bully pulpit.”

There are few people more famous than the person sitting in the Oval Office. They have hundreds of media outlets clamoring for interviews. They can give speeches and statements that directly reach the public. And they usually have social media followings that reach hundreds of millions of people in the U.S. and worldwide.

While they don’t directly dictate policy, these are powerful tools, and when the president wants to, they can use them to raise awareness of issues they care about, pressure officials to take specific actions, or shift public sentiment and thinking broadly.

President Obama and President Trump have both used their bully pulpits — in far different ways — to discuss policing and influence the actions of local law enforcement:

  • In a 2014 speech, after a grand jury failed to indict a police officer who killed Michael Brown, President Obama gave a speech encouraging calm in the wake of that decision, giving voice to the frustration that communities of color feel with police, and encouraging local law enforcement to work to build public trust by improving their practices. President Obama had no direct say over the practices of local police departments, but by using the bully pulpit, he helped to draw public attention to the need for improvement in policing.
  • Meanwhile, during his first term, President Trump was speaking before a group of police officers in New York when he appeared to encourage more violence by law enforcement and urged them not to “be too nice” to people who are arrested. Again, President Trump had no authority over the specific policing practices of local departments, but his words provided a permission slip to officers to be more violent towards people in their custody.

Presidents have little direct authority over how local police officers do their jobs, but by using their bully pulpits in drastically different ways, one called on police to be part of a solution that improves trust in law enforcement, and the other encouraged more police violence. Both remarks helped to sway public opinion and police actions.

Congress

The president isn’t the only one with the power to influence the broader criminal legal system. Congress, through its control of federal spending, can pressure state and local governments to adopt its preferred policies on crime, policing, and incarceration. While it generally doesn’t have the power to tell state and local governments exactly what to do, it regularly uses federal funding to both incentivize actions it wants and punish actions it doesn’t.

The most infamous example of this is the 1994 Crime Bill.10 While this measure took many steps to expand the federal criminal legal system, arguably its most notorious impact was how it incentivized states to lock up more people for longer periods of time. The bill included financial payments for states that adopted so-called “tough-on-crime” policies. States that adopted these misguided policies were given billions of dollars to fund the construction of new prisons.

This is far from the only time Congress has flexed its financial power to get state governments to make their criminal legal systems harsher. Other examples include:

  • A 1991 law that threatened to withhold billions of dollars of federal highway funding for states that didn’t automatically revoke the drivers’ licenses of people convicted of drug offenses.11
  • A 1996 law that permitted the federal government to enter into agreements with local law enforcement agencies to enforce federal immigration law, with a pot of money available to entice government officials to join this effort.

Congress has also used this power for good by incentivizing or otherwise encouraging state and local governments to take meaningful steps to promote alternatives to incarceration, improve their criminal legal systems, and make their prisons and jails safer and less deadly:

  • The Prison Rape Elimination Act is a bipartisan law that sought to end sexual assaults against incarcerated people. It not only established standards for the elimination of sexual assault behind bars, but it also offered financial incentives for prisons and jails to comply with those standards and to report data on their progress to the federal government. Finally, and unrelated to money, the law mandates that it be publicly announced which states are complying with the law and which are not, which serves as an additional motivation for states.
  • The Deaths in Custody Reporting Act sought to bring transparency to the deaths of incarcerated people by threatening to reduce federal funding to states that did not report certain information to the federal government when someone dies in one of their facilities.
  • The Juvenile Justice and Delinquency Prevention Act offered financial incentives to stop states from incarcerating young people for “status offenses” such as curfew violations, stop states from incarcerating young people with adults, and address racial disparities in the incarceration of young people. States that comply with the law receive additional federal funding.

While Congress’s power to directly change state and local policy is limited, it understands that many cities, states, and counties rely on federal money to function. This provides Congress with a powerful tool to exert its influence far beyond Capitol Hill.

Federal courts

Federal courts — including the U.S. Supreme Court — have jurisdiction over a relatively small number of criminal cases, and they only directly adjudicate the guilt or innocence of people accused of federal crimes. Despite this, their rulings can have reverberations throughout state and local criminal legal systems.

That’s because federal courts have the authority to rule on whether state laws violate the U.S. Constitution or other federal laws.

During the latter half of the 20th century, federal courts regularly used their authority to make the criminal legal system fairer and less harsh, telling states they cannot:

These rulings have been particularly impactful because federal court decisions are binding on all levels of government, including presidents, governors, and all lower courts. Presidents and other government officials are constitutionally bound to follow these orders.

In recent years, however, the Supreme Court in particular has become increasingly reluctant to exercise this authority and has become more likely to defer to the executive branch to answer questions in this realm, rather than acting as a true check on its power.

These are not normal times

It is important to remember that everything written in this piece reflects how things normally operate. Anyone who has been paying attention since the start of the second Trump administration knows that we are living in decidedly not-normal times.

For example:

These unprecedented times make it hard to predict what is going to happen in the criminal legal system and in the numerous gray areas where the authority of different parts of the government overlaps. In normal times, it’s possible to guess how some of these conflicts would play out, but at a time when one branch of government is seeking to the trample the powers of the other branches and of the individual states — and those other branches and the states are largely letting it happen — all the normal bets are off.

What does this mean for the criminal legal system at the state and local level?

While the federal government has many tools at its disposal to influence policies related to crime, policing, and incarceration, the truth is that most of the power over these issues is in the hands of state and local officials.

As the Trump administration works to expand its reach in the criminal legal system, it is easy to feel that we’re helpless. That couldn’t be further from the truth.

By recognizing that state and local leaders make most of the decisions in this area, advocates can push them to stand up to the pressures of the federal government. They can urge them not to cooperate with unconstitutional and immoral actions by federal law enforcement. They can ask them to forgo funding that federal officials might use as leverage to coerce them into implementing harsh and misguided policies. And they can take action to work to make the criminal legal system fairer, smaller, and less punitive, even if the federal government has abandoned that cause.

State and local leaders are not powerless in these situations. It may be up to us to remind them of this fact.

Footnotes

  1. One area we do not cover that is of particular concern to many is the use of the Insurrection Act of 1807. This is an intentional choice because of rare use of this law, and its complexities and vagueness. To learn more about this measure, we encourage you to review this explainer from the Brennan Center for Justice.  ↩

  2. For consistency, in this explainer, we’re referencing numbers from the most recent edition of our report, Mass Incarceration: The Whole Pie 2025. This is important because, since that report was released there has likely been significant changes in the number of people in custody of the federal government for immigration-related reasons. Because of this, the numbers in this report related to immigration are almost certainly an under-count.  ↩

  3. In this briefing, we don’t discuss the immigration system in detail. This is intentional. We at the Prison Policy Initiative are quite familiar with the criminal legal system, but are not experts on immigration policy. If you want to understand how the immigration system has changed under the Trump administration, we have put together a guide of organizations and resources to jumpstart your research.  ↩

  4. It is worth noting that some of these people, while under the jurisdictional control of the federal government, are physically held in local jails that have rented space to Immigration and Customs Enforcement (ICE) or other federal law enforcement agencies.  ↩

  5. Some people sentenced to incarceration for shorter times are held in local jails, instead of prisons.  ↩

  6. It is worth noting that most states have rules around the possession and use of marijuana, and violating those rules could still get a person in trouble with the law. Most commonly, these rules ban the use of marijuana in public places. For example, in most states, smoking pot in a public park could still result in criminal arrest or citation.  ↩

  7. If you’re not sure whether a prison is run by the state or federal government, it can be helpful to look at the facility’s name. If the name contains the letters FCI (Federal Correctional Institution) or USP (United States Penitentiary) it is a federal prison. While the vast majority of federal facilities start with these acronyms, there are some federal facilities whose names don’t include these letters.  ↩

  8. We dive deeper into this later in this piece.  ↩

  9. We discuss the role and influence of federal courts in the criminal legal system later in this piece.  ↩

  10. It is worth noting there is considerable debate about the impact this law had on state prison construction. The subsidies for prison expansion weren’t massive, and academics dispute whether states would have made their sentencing laws harsher anyway (and some states claim that the subsidies had no effect). And the 1991 highway bill, which is mentioned below, both threatened to withhold a significant amount of money from states and made it incredibly simple for them to opt out of the requirement without losing their funds. But in both cases, Congress clearly expressed an opinion as an attempt to exert some influence on state governments.  ↩

  11. In one of our earliest campaigns, Prison Policy Initiative worked to end this practice. Learn more about this practice and our efforts on our driver’s license suspension campaign page.  ↩


Moving people between prisons can improve their access to treatment, programs, and visitation — but transfers can also be deeply traumatizing, disruptive, and destabilizing. In this briefing, we use transfer records and interviews with dozens of formerly incarcerated New Yorkers to examine how often people are moved, why they’re moved, and how this little-discussed aspect of prison life impacts them.

by Iolanthe Brooks, June 5, 2025

Most people imagine incarceration as confinement in one place. Yet few incarcerated people serve their sentence in just one facility. Many are transferred repeatedly — sometimes dozens of times — before release.

Transfers require incarcerated people to pack their belongings, undergo invasive strip searches, and take long trips while restrictively shackled — what one person described as “the worst experience of my life.” When a transfer bus arrives, its passengers might find themselves closer to loved ones or at a prison hundreds of miles from them. Each move upends nearly every aspect of an incarcerated person’s life, including peer networks, familiarity with officers, institutional culture, rules, housing configurations (e.g., cells vs. dorms), and program and job opportunities.

In some cases, transfers are beneficial. They can move someone to a prison with a lower security classification, more programs, or a safer culture, as well as one closer to home. Such transfers can boost program access and visitation, both of which research has shown to contribute to well-being and reentry preparedness. In other cases, transfers can have the opposite effect, severing program participation and introducing a person to a stressful new environment. Regardless, transfers always bring changes. As one person told me, “Once you become acclimated to a prison… you know how to exist in that prison… But once you transfer, that no longer holds any thread to your daily living. You’ve got to start from scratch all over again. People hate that — it’s nerve-wracking.”

An animation showing all prison transfers in New York State between 2021 and 2022, animated by week. Over the course of a sentence, many incarcerated people are made to zig-zag between prisons across their state due to prison transfer practices. The above animation shows all transfers in New York State between 2021 and 2022, animated by week.

Despite their importance, transfers are a fact of prison life that few non-incarcerated people think about and that have received limited attention from policymakers and researchers. How often do transfers happen? Why do prisons transfer people? Most importantly, what impacts do transfers have for incarcerated people?

To answer these questions, I interviewed 52 New Yorkers who left prison in the last few years1 and created a novel quantitative dataset, generated by linking together administrative transfer records obtained by public records requests. Although I focus on New York, reporting suggests that transfers are similarly common and consequential in other state prison systems and in the Federal Bureau of Prisons.2

Recent legislative efforts in New York and a handful of other states encourage transfers closer to home for parents with young children. These policy reforms show how prison transfer systems could be reoriented to support success upon release. However, my research reveals that, for most people, transfers remain a harmful and all-too-frequent disruption.

Transfers are common, even during public health emergencies

The chart below shows New York’s total monthly transfers from 2020 to 2022. Before the pandemic, the New York state prison system made over 3,000 transfers a month. At the onset of COVID-19, transfer rates dropped precipitously amid concerns — later actualized in New York and other states — that transfers would spread the virus. By June 2020, however, transfers had resumed at close to pre-pandemic levels.3 After a year of starts and stops, an internal staff email in July 2021 reported that transfers had returned to full capacity, despite ongoing COVID-19 surges.4

By 2022, New York was making an average of 3,167 transfers a month, with a total of just under 38,000 transfers in 2022. As I explore more below, only a small number of these transfers were to move incarcerated parents to prisons closer to their children under the new law implemented in late 2021.

A chart showing how New York prison transfers rose and fell in response to COVID-19 policies and proximity laws. Public records obtained from the New York Department of Corrections and Community Supervision show the ebb and flow of transfers between December 2019 and December 2022, as the department responded to the COVID-19 pandemic and new proximity laws.5

While some incarcerated people move often, others spend decades in a single prison

Over the course of their sentence, an incarcerated person can move multiple — even dozens — of times. In 2022 alone, two New Yorkers were transferred ten times each. Of everyone transferred that year, about half moved more than once.

Of course, not everyone transfers this often. Interviews with formerly incarcerated New Yorkers showed varied transfer histories. As Felix summarized, “People’s incarcerations take different trajectories… You can land in a spot [and] stay there for a long time.” Or, as he experienced, you can get “transferred all over the place.”

Felix’s 22 transfers were largely for disciplinary reasons, especially early in the two decades he spent incarcerated. He described seeing the same people transferred from one maximum security prison to another. “Every time I’d go to the box, it’s all of us going to the box… It was like, ‘oh, you back? Oh, you here?’… Like, 10 years of just sitting on buses… Not staying in any one place — unless it’s solitary confinement — for any longer than a year.”

A map of New York State with lines showing how Felix was transferred to prisons around the state. The above graphic illustrates Felix’s 22 transfers over the 21 years he spent incarcerated. After criss-crossing the state, Felix was eventually released and returned to his family in the Hudson Valley.

Meanwhile, Alexander found himself stuck in one maximum security prison for over 15 years. In his words, “You get used to people leaving — being transferred… and you sitting there. It was troubling, because some of the people that’s leaving helped you get through your stress, and y’all was there for each other… Now, I’m alone… like, damn, everybody who was here with me before is gone. [And] the officers don’t know me now, so I’m being mistreated.”

A map of New York State with lines showing how Alexander was transferred across the state. Alexander was transferred just 5 times in 28 years, eventually returning home to Brooklyn, NY.

Felix and Alexander represent two trajectories through a prison sentence, marked by different levels of movement.

On the one hand, Alexander felt stuck in place. Even without moving, his relationships with other incarcerated people and staff were uprooted as others transferred around him and staff moved on to new jobs or different prisons. People who spent long stretches in a prison like Alexander often wished they could access programs and opportunities elsewhere, move closer to loved ones, or follow mentors who had transferred out. Yet many reported being reluctant to submit transfer requests, since they could not control where the prison system would choose to move them, including to a worse, less safe, or more distant facility.6 Others were grateful to stay put, having no interest in transferring.

On the other hand, Felix moved constantly and chaotically — what one person called “ping-ponging” from prison to prison, and another called the “I Love New York State tour.” Moving frequently meant he could rarely complete programs or build long-lasting relationships. As incarcerated writers often report, friendships not only afford a sense of safety and stability in a prison’s unpredictable environment but can also provide transformative mentorship and deep emotional support. Constant transfers stymied Felix’s access to such relationships, while exacerbating the turbulence and stress of incarceration.

Transfer requests account for only a small portion of movement between prisons

Even though people incarcerated in New York can request transfers, the data show that transfers are not predominantly driven by requests from incarcerated people. For the most part, moves are involuntary.

In New York, incarcerated people can request a transfer provided they have been in their facility for a sufficient amount of time and do not have recent disciplinary tickets.7 In December 2021, the state joined several others in passing legislation mandating the department to allow parents of children under 18 years old the opportunity to transfer closer to home. Between June 2021 and May 2022, almost 6,000 people submitted requests under this program alone.

Although the data show an increase in transfers by request in 2021-2022, these moves were overshadowed by transfers for other causes. Indeed, 92% of transfers in 2022 were for reasons other than incarcerated people’s requests. Mainly, transfers were recorded as happening for programming, “general confinement,” and disciplinary reasons. For instance, individuals might be moved to a facility that offers a certain treatment program — or they might be transferred to solitary confinement or restricted (disciplinary) housing units for breaking prison rules, or even as a retaliatory punishment for speaking out about conditions.

Three bar charts for years 2020, 2021, and 2022 showing that prison transfers for administrative, disciplinary, and other reasons overshadowed those done at the request of incarcerated people. The percentage of transfers recorded as happening by the request of the incarcerated individual increased between 2020 and 2022, but was greatly overshadowed by the percentage of transfers for all other reasons.

Research shows that visitation — especially with one’s children — reduces misconduct, bolsters mental health, and is an important part of successful reentry. When transfers are done to achieve these ends, they play an important role in reducing the harm of incarceration. Conversely, when done for punitive or arbitrary reasons, transfers can exacerbate those problems. Recent legislative efforts to allow parents to transfer closer to their children are important first steps toward expanding incarcerated people’s voice in housing determinations. The data show, however, that more work is needed to shift the balance of coercion and agency in prison placement.

Transfers to different security levels are relatively rare

Another reason prisons might transfer people is to respond to security classification changes. Prisons are typically assigned a security level, while incarcerated people’s classifications shift over time. As a result, transfer rates could be driven by changes in security classification. Transfer records from 2021 and 2022, however, show that only one-third of transfers moved people to different security levels. Most transfers shuffle people laterally between prisons of the same security level. Of transfers between security levels, the majority moved people from maximum security prisons down to medium ones.

Two stacked bar charts showing how most prison transfers are between the same security classification levels, and those between different levels are primarily for people stepping down from maximum security. Most prison transfers happen within security classification levels (for example, between medium-security facilities) or to step down from the maximum security level. Otherwise, transfers to different security levels are relatively rare.

Overall, these findings suggest that prison administrators use transfers for a variety of reasons other than changes to security classifications.

Transfer-driven population turnover creates mass instability

Transfers substantially affect prison populations. Some facilities transfer people in and out more often, but — as my recent article shows – all are implicated in prison-to-prison moves and the turnover it brings. Over the course of 2022, over 70% of New York’s prisons transferred the equivalent of 50% or more of their January populations to other facilities. Of those, nine prisons (18%) had turnover of over 100% of their start-of-year population size.

A bar chart showing that half of New York prisons transferred out 60 percent or more of their populations each year, with another 9 prisons averaging more than one transfer per person. Half of New York’s prisons transferred the equivalent of 59% or more of their January populations to other facilities. While the other half transferred smaller proportions of people, most still had turnover rates between roughly 20-60% of their January populations.

Constant population turnover from transfers combines with that of prison releases and new entries, making everyday life in prisons unstable and uncertain. Interview participants, for example, described realizing a friend had transferred when they didn’t show up to breakfast or a standing basketball game. Meanwhile, they recounted fearing who might arrive on daily transfer buses.8 As one person put it, “You never knew, that bus coming in could be from hell.”

Transfers do not do enough to bring incarcerated New Yorkers closer to home

When a person is incarcerated far from home, they are less likely to receive visits, which have been linked to everything from mental health benefits to reduced recidivism. On average, transfers in 2021 and 2022 originated about 175 miles from the transferee’s county of conviction, which I use as a proxy of their home area.9

While requested transfers brought incarcerated New Yorkers an average of 147 miles closer to home, most transfers have little impact on distance from home. People transferred by request started farther from home than for other transfers, an average distance of 225 miles compared to 169 miles. Their transfers brought them much closer to home — 78 miles away on average, compared to 199 miles for all other transfers. Aside from transfers by request, all other transfers brought incarcerated people an average of 29 miles farther away from their conviction county, an increase of 17% from their average starting distance.

Transfers and Distance from Home

All transfers Transfers by request Transfers not by request
Sending prison’s average distance from conviction county (median) 175 miles
(159 miles)
225 miles
(229 miles)
169 miles
(147 miles)
Receiving prison’s average distance from conviction county (median) 187 miles
(191 miles)
78 miles
(65 miles)
199 miles
(207 miles)
Average change in distance from conviction county (median). Positive values indicate moving farther from conviction county, and negative values indicate moving closer. 12 miles
(9 miles)
-147 miles
(-162 miles)
29 miles
(20 miles)

People transferred by request started farther from home than those transferred for other reasons, and typically ended up closer to home. All other transfers brought incarcerated people an average of 29 miles farther away from their conviction county.

Harrowing journeys, with long-term impacts

For incarcerated people, transfers can be harrowing. As documented by journalists and academics alike,10 they often involve long trips with circuitous routes, including stops at multiple prisons and breaks for corrections staff. During transfer trips, incarcerated people have little access to food or bathrooms, and recount uncomfortable seats and painfully restrictive shackling. As Hugo put it, “By the time you get off the bus, you either got a cut or your leg is swollen [with] black and blues.”

For Linda, who is in her mid-sixties, transferring was “the worst experience of my life,” adding that, “You’re on this bus, you’re shackled to somebody else.” To avoid needing to use the bus bathroom while shackled to a stranger, Linda decided not to drink anything and to skip eating the bagged bologna sandwich she was given for lunch. Her bus left “early in the morning” but didn’t arrive at the next prison “until late evening,” despite it being about a six-hour drive away. Overall, she felt that “[the officers] don’t care about you. They don’t care if you use the bathroom. They don’t care if you’re going to eat. They just want to make sure they get you from one location to another.”

Because transfers upend nearly every aspect of incarcerated life, the first few weeks in a new prison can be especially difficult — and even dangerous. Recently transferred people need to restock possessions lost during transfers, requiring them to spend their often limited funds on exorbitantly expensive commissary goods. They also have to learn the rules of their new facility, including formal policy differences and informal “politics.” Without this know-how, recently transferred individuals are prone to disciplinary tickets and victimization.11

Overall, the destabilization of a transfer often proves challenging. As two participants commented:

It was hard. Don’t get me wrong, I was furious because my whole life was planned out and everything was just taken away. And that’s kind of what these transfers do: they disrupt your life. What little life that we had in there, they just broke it up. So, when you have a plan, and you want to get these programs… they take it all away and you got to start all over.

— David, incarcerated 25 years and transferred 6 times.

It’s designed to break you…They move you from plantation to plantation. You lose people, you lose property. You lose so much through a transfer… In prison because of all the violence, who’d want to get moved? You want to be in the hell you already know, the hell that you already got comfortable in. Now they’re sending you to another man-made hell that you got to start all over [in]… No one wants that.

— Wyatt, incarcerated 29 years and transferred 9 times.

In the long term, transfers disrupt relationships that are essential to prison safety and stability. These relationships can not only provide mentorship and care but also a helping hand during reentry, and are the crucial building blocks of incarcerated organizing.

While transfers create disruption and loss, they can also have enormous positive potential. They can bring incarcerated people closer to their loved ones, move them to prisons with the specific programs they are interested in, remove them from dangerous situations, and add variety to the monotony of a long sentence. Policymakers have the opportunity to balance the positive potential of transfers against their negative impacts.

Expanding incarcerated people’s agency in transfer decisions

Transfers are a common part of prison life with dramatic effects on incarcerated people’s well-being. From suddenly-severed friendships and arduous bus rides to the constant turnover they produce, transfers are often stressful and destabilizing experiences. As they upend incarcerated people’s lives, they have the opportunity — and risk — of bettering or worsening their access to loved ones, programs, jobs, and safety.

Rather than continuously shuffling incarcerated people, transfers should be used to prioritize stability and autonomy. Policymakers can mitigate the punishing aspects of transfers without undermining their positive potential, following in the footsteps of recent legislative reforms.12 For instance, existing legislation is tailored to parents of minor children but could be expanded to people with aging family members, adult children, or indigent loved ones who cannot afford long journeys to visit. Likewise, giving incarcerated New Yorkers the opportunity to “veto” the prison that the state determines for them following a request might diminish fearfulness around submitting them. Above all, incarcerated people should have the opportunity to stay in place if they prefer, particularly if they have no disciplinary issues and are succeeding in their programs, jobs, and relationships.

Methodology

Data Sources

This research uses two quantitative data sources, both shared by the New York Department of Corrections and Community Supervision (DOCCS) through Freedom of Information Law requests. The first is a summary of every transfer record in 2020-2022, with the sending and receiving facilities and its cause. I used text parsing tools to digitize these records into a spreadsheet. Using this data, I calculated detailed statistics about transfers, including how many happened, their causes, and per-person transfer counts by year. Reflecting this data source, I operationalize “a transfer” based on how DOCCS defines them; for example, the data does not include transfers between prisons and jails, temporary transfers for court visits, or temporary medical transfers to outside hospitals.

The second data source is 24 files, one for each month of 2021-2022. Each file provides the population under custody for the first of that month, with information including each person’s unique identification number and county of conviction. I linked these records by unique ID to generate a list of the conviction counties of every person incarcerated in the 2021-2022 period. Finally, I merged this conviction county information into the transfer records described above, so that each transfer record included the conviction county of the person transferred. With this information, I was able to calculate distance changes from home.

Data Cleaning

Working with the above administrative datasets required significant data cleaning. I constructed several variables, including:

  • Transfer cause: I consolidated two of the codes for transfer cause into the category of “transfers by request”: “Area Of Preference” and “Area Of Children.”
  • Distance variables: I used United States Census data to geocode the centroid of New York’s counties and Google Maps’ coordinates to geocode each of New York’s prisons. Then, I used ArcGIS Pro to calculate the highway mileage of the quickest route for 1) the distance between the sending prison and the conviction county centroid and 2) the distance between the receiving prison and the conviction county centroid. I use an individual’s conviction county as an imperfect proxy of their “home” region. In doing so, I join other researchers who use the same proxy.
  • Facility security levels: The security level of each prison is based on the DOCCS website.
  • Facility population size: Each facility’s starting population size is based on DOCCS’s publicly reported data for the facility population on December 31, 2021 (see page 10 in the linked report). I calculated the proportion of the population transferred by dividing the total number of transfers “out” (i.e., where the given prison was the “sending” facility) by the starting population size.

Qualitative Data

The quotes included here come from interviews with 52 formerly incarcerated New Yorkers about their transfer experiences. Interviews were conducted in June 2023-August 2024 and participants were recruited through reentry nonprofits based in New York City. As part of the interview, participants recalled their transfer histories; Felix’s and Alexander’s transfer history maps are based on this self-reported data. All names used in the above are pseudonyms. This study was approved by the Northwestern University Institutional Review Board.

Read the entire methodology

Footnotes

  1. Interviews were conducted between June 2023 and August 2024, and participants were recruited through reentry nonprofits. As part of the interview, participants recalled their transfer histories; the transfer history maps included here are based on this self-reported data. All participant names are pseudonyms. This study was approved by the Northwestern University Institutional Review Board.  ↩

  2. The limited multi-state research that does exist, summarized on pages 3-5 of this 2016 Comment letter from the Prison Policy Initiative to the Census Bureau, finds that (1) “Nearly 75% of incarcerated people are moved between facilities before they go back home,” (2) “30% of people in federal and state prisons have been at the current facility for less than six months,” and (3) median length of stay at a given facility ranges from less than 6 months to just under a year across Georgia, New York, and Massachusetts, with similar findings in Washington, Oregon, and Nebraska. Elsewhere, the Prison Policy Initiative reports that “12% of people serve time in at least five facilities before returning home.”  ↩

  3. These included transfers of at-risk elderly New Yorkers to a prison in far-upstate New York, in an effort by the state to protect them from the virus. A class-action lawsuit filed on behalf of the men transferred argues that the moves instead exposed them to COVID-19.  ↩

  4. June-August 2021 was the height of the surge of the Delta variant of COVID-19.  ↩

  5. At the onset of the COVID-19 pandemic in late March 2020, the New York Department of Corrections and Community Supervision briefly paused transfers (per an internal email, obtained by public records request). In June 2020, they announced that transfers will “slowly resume.” Later, an internal email obtained by public records request shows that in early/mid-July 2021, the department informed superintendents that transfers had resumed at 100% capacity and that everyone transferred was being screened for COVID-19 symptoms and must wear a mask. Beginning in December 2021, the department implemented a law requiring them to allow parents of children under 18 to request a transfer closer to home.  ↩

  6. In New York, incarcerated people can submit a transfer request for a specific “hub” and list the facility they would like to transfer to, but they are not guaranteed placement there. Interview participants described fearing transfers farther from home (concerns a “hub” request can mitigate) and to more dangerous prisons.  ↩

  7. Based on their understanding of prison rules, interview participants reported varied lengths of time they had to be in a prison prior to submitting a request. In an email in April 2025, New York corrections department staff confirmed that, as of April 2025, in order for an incarcerated person to request a transfer, “a maximum-security incarcerated individual must be in the Department for at least one year and in their current facility for six months with an acceptable disciplinary record. Medium security incarcerated individuals must be within a hub and positively programming for a period of two years and must demonstrate favorable disciplinary adjustment. Cases are reviewed semiannually to determine transfer eligibility. Should they meet transfer eligibility requirements, their assigned Offender Rehabilitation Coordinator will advise them at their first semiannual review.”  ↩

  8. Participants explained that New York aims to account for this, transferring people only to prisons where they do not have a “no contact” or listed “enemy.”  ↩

  9. Although research suggests that the majority of arrests occur in the arrestee’s county of residence and, on average, take place close to their home address, conviction county is an imperfect proxy for home region.  ↩

  10. See: Brooks, Iolanthe, and Asha Best. “Prison fixes and flows: Carceral mobilities and their critical logistics.” Environment and Planning D: Society and Space 39.3 (2021): 459-476; Turnbull, Sarah, and Dawn Moore. “Understanding carceral mobilities in and through lived experiences of incarceration.” Punishment & Society 26.5 (2024): 948-966; and journalism including, I Got the Prison Transfer I Fought For. My Feelings Were Surprisingly Mixed and For a Prison Transfer 45 Minutes Away, I Spent 12 Days in Hell.  ↩

  11. In an extreme example, Robert Brooks, a Black man, was beaten to death by Marcy Correctional Facility officers in December 2024, just 30 minutes after a transfer from nearby Mohawk Correctional Facility. The New York Times, summarizing the Onondaga County district attorney, described the attack as appearing “to have been a sort of violent initiation into life at Marcy Correctional Facility. He called the attack a ‘welcome to Marcy,’ and said it was ‘emblematic of the problems here and throughout the system.’” While recounting much less severe stories, participants in my research described guards making bombastic and threatening speeches to new arrivals, “letting you know,” as Elijah put it, “that this is not your house, this is our house, and we [correctional officers] do what we want to do,” including “roughing up” incarcerated people.  ↩

  12. Emma Kaufman makes a similar argument about the need for oversight and consent in her writing about interstate transfers, advocating for “[trying] to build prisoners’ views into the assessment of whether or not a transfer is going to be legal” and to “bring prisoners’ experiences and their family members’ preferences into this legal regime.”
     ↩


Please welcome our new Senior Researcher, Jacob Kang-Brown!

by Danielle Squillante, May 27, 2025

Jacob Kang-Brown

We’re excited to announce that Jacob Kang-Brown has joined our team as a Senior Researcher. In this role, he’ll research and write briefings and reports, help develop new projects, and provide additional support for the research team’s use of large datasets and quantitative analysis.

Before joining Prison Policy Initiative, Jacob was a Senior Researcher at the Vera Institute of Justice where he specialized in analyzing incarceration trends. His work has appeared in The Lancet Public Health, The New York Review of Books, Contexts, SSM-Population Health, The Atlantic, Dissent, USA Today, and American Jail Magazine, in addition to the Vera Institute of Justice. He holds a PhD in Criminology, Law & Society from the University of California, Irvine and bachelor’s degree from Wheaton College (Ill). Jacob has also worked for Physicians for Social Responsibility-Los Angeles and the L.A. County Commission on Human Relations.

Welcome to the team, Jacob!


Our review of copay policies show that exemptions are so limited, ill-defined, and inconsistent that they fail to make the copay system less harmful for incarcerated people.

by Emily Widra and Dr. Emily Lupez, May 15, 2025

In most states, people incarcerated in prisons must pay medical “copays,”1 which are essentially fees to access health care including physician visits, medications, dental treatment, and other health services. While these fees may seem reasonable at two or five dollars, research shows they actually act as barriers to health care for incarcerated people who typically earn less than a dollar an hour, if they are paid at all. Prison administrators claim these fees deter the “overuse and abuse” of limited health care resources,2 and have countered critiques by including waivers and exceptions in their copay policies and insisting that no one is denied care because they can’t afford to pay. However, our review of these policies and evidence from a recent study show that these exemptions are so limited, ill-defined, and inconsistent that they fail to make the copay system fairer and less harmful for incarcerated people. Instead, these exemptions lend a veneer of rationality to prison medical fee policies — which are known to limit access to care — ultimately helping to perpetuate them.

We reviewed each state’s prison copay policy, including any waivers or exemptions, to build upon the initial findings of Dr. Lupez and her colleagues, which indicated that copay waivers are likely not working as intended. They found that, despite two-thirds of states that charge copays having chronic condition waivers, people with chronic conditions in states charging copays were substantially more likely to have never seen a doctor since admission compared to those in states without copays.3 If copay waivers were being applied routinely and consistently, we would expect people without a chronic condition (i.e., people ineligible for a chronic condition waiver) to be more likely to have never seen a doctor since incarceration, but this was not the case, implying that these waivers are not promoting healthcare access for some of the most vulnerable people in prison.

bar chart showing the percentage of pregnant people not receiving an obstetrical exam and the percentage of people with chronic medical conditions who have not seen a medical provider in state prison by relative expense of medical copays compared to average prison wages In research published in 2024, Dr. Lupez and her colleagues found that among people incarcerated in state prisons for any amount of time, more unaffordable copays were associated with worse access to the necessary healthcare, like obstetrical examinations for pregnant people and seeing a medical provider for people with chronic medical conditions. For more details, see New research links medical copays to reduced healthcare access in prisons.

To better evaluate how copays and copay exemptions function in prison systems, we analyzed policies from all states charging medical copays and the federal Bureau of Prisons. While we cannot estimate the frequency with which care is actually exempt from copays, our analysis of the various policies reveals that copay waivers are inevitably inconsistently4 or retroactively applied,5 unclear to incarcerated people,6 and frequently left up to the discretion of a single healthcare provider, administrator, or other correctional staff.7 This helps explain why incarcerated people may expect to be charged a burdensome fee every time they seek medical care, regardless of potential exemptions, and in turn, how that fee functions as a significant barrier to healthcare access.

Key findings from our study of prison copay policies

Almost all state prison systems charging copays have policies outlining exemptions for some healthcare services for some incarcerated people. Among the 40 prison systems still charging these fees, the exemptions can be based on any number of factors including how the care was requested,8 the specific health condition,9 the type of medical care required,10 and the circumstances leading to treatment.11 Ultimately, we find that copay waiver policies frequently rely on the discretion of individual healthcare providers or correctional staff and are far too limited and have far too many caveats to meaningfully counteract the harmful deterrent effect of copays on healthcare access.

map of the united states showing which prison systems charge medical copays greater than one week's wages, those that charge copays less than one week's wages, and those with no copays

Below, we highlight the most striking examples from our analysis that illustrate why waivers or exemptions still fail to ensure appropriate and equitable access to the care people need.

Staff-initiated versus patient-requested care. In most states (33), incarcerated people are expected to pay a fee if they request their own medical care, but medical care requested or initiated by healthcare staff, correctional staff, or facility administrators is exempt from fees.12 In some cases, this reflects standardized or systems-based visits like mandatory tuberculosis testing, which is more aligned with the priorities of the carceral system (i.e., infection control) than patient needs. Staff-initiated visits force incarcerated people to rely on the prison medical system to monitor when preventative care or chronic health condition follow-ups are due, a process likely hindered by staffing shortages and the absence of sufficient medical record systems.13 Exemptions for care initiated by correctional staff — such as a request for a mental health evaluation — require incarcerated people to depend on correctional staff to access healthcare services, compromising patient privacy — when medical information has to be shared with non-medical staff — and establishing a system where staff exert control over who gets seen by medical providers, undermining patient autonomy.

Medical emergencies. Only 27 prison systems include an explicit exemption for emergency treatment, and in most of those states, the emergency is defined by either healthcare providers14 or departmental staff,15 not the person actually experiencing the medical emergency.16 In seven states with medical fees, incarcerated people are required to pay the fee for emergency medical care if the injury or illness is determined — by medical staff, correctional staff, or in a disciplinary hearing17 — to be self-inflicted.18 An additional two states specify that care provided for self-inflicted injuries are subject to copays (although do not specifically mention emergency medical care). At least one state (Michigan) requires the incarcerated person to pay all costs associated with the treatment of injuries and illnesses determined to be self-inflicted, which is inevitably above and beyond the initial fee for health services; essentially, such policies use medical fees as additional punishment for accidents, self-harm, and mental illness.19 In our survey of state policies, we only found two states with policies specifying that people with serious mental illness could be exempt from the fees associated with medical care for self-harm20 and only one other state (Texas) that exempts medical treatment for all self-inflicted injuries from medical fees. Policies charging fees for medical care needed for self-inflicted injuries are particularly cruel given the mental health harms caused by incarceration itself. In states that punish self-harm this way, incarcerated people not only have to suffer these injuries — they must also financially pay for them.

Work-related injuries. Almost half of prison systems that charge copays (17) have some exemption for medical care associated with work-related injuries. In some prison systems, only the initial medical treatment for a work-related injury is exempt,21 and in others, the treatment for work-related injuries is exempt from the medical fee only if it is a medical emergency.22 In some prison systems, the treatment for work-related injuries is only exempt if it was reported at the time of the injury and is verified by an incident report (filed by correctional staff).23 Like the exemption for emergency care, this exemption relies entirely on the accuracy and timeliness of staff reporting workplace incidents. It’s also worth noting that incarcerated workers generally do not have the workplace health and safety protections that people do outside of prisons (such as those enforced by the Occupational Safety and Health Administration or similar state programs). They are also often exposed to dangerous work conditions. So it’s remarkable that when incarcerated people are injured under work conditions controlled by the prison system itself, they are often still assessed medical fees and experience lost wages, given the lack of standard labor protections like sick leave.

Chronic health conditions. While most states (26) have exemptions related to care for chronic health conditions like cardiovascular disease, diabetes, HIV, or mental illness, many (17) of these exemptions only apply if the appointment is scheduled by a health care provider or as a part of a recurring “clinic,” not if the individual seeks additional care outside of previously scheduled appointments.24 Someone who meets the exemption criteria may also need to pay copays for the initial two or three nursing sick call visits before clinicians identify them as someone who should be exempt from copays.25 In Alaska, for example, people with chronic conditions are charged a $5.00 fee for their initial provider visit and $5.00 every year “for ongoing treatment of the chronic condition.” At least three states (Georgia, Indiana, and Oklahoma) mention an exemption for fees associated with prescriptions for chronic conditions, but do not exempt chronic condition-related provider visits or other treatments from the fee.26 People in state prisons suffer disproportionately from chronic health conditions when compared to the total U.S. population, and financial barriers to treatment will only exacerbate the poor health outcomes of incarceration.27

bar chart showing how many prison systems have exemptions for menstruation-related healthcare, treatment for substance use, vaccinations, hospitalization, and pregnancy-related healthcare

Pregnancy-related care. In 18 prison systems, some or all of the care related to pregnancy is exempt from copays. In some states, like Arizona and New Hampshire, they are only exempt from copays for pregnancy-related medical care (i.e., they would not be exempt from copays for treatment for a non-pregnancy-related illness or injury).28 Five states and the federal Bureau of Prisons only exempt prenatal care (care while pregnant) with no mention of delivery-related care or postpartum medical care.29 At least three states explicitly exempt postpartum medical care from copays.30 About 4% of people (or 3,500) in women’s prisons in 2016 — disproportionately women of color — were pregnant at admission, and many of them did not received the basic prenatal care you would expect, like an obstetric exam, medication, special diets, testing, or pregnancy education. Given that many prison systems seem to have limited or no policies exempting pregnant people from medical copays, many may not seek care during their pregnancy. Combined with a lack of robust healthcare resources in prison to identify people in need of care, it’s no wonder many pregnant people are not receiving necessary medical care.

Menstrual health. Only one state’s copay exemption policy makes any mention of menstrual health: in Arizona, people “who require additional feminine hygiene products due to medical issues” can complete a form and submit it to Health Services, and the copay is waived for the subsequent medical appointment. Only half of state prison systems (25) are required by law to provide menstrual products, and only 18 of those systems are obligated to provide those products for free.31 Not only do many women have to pay for their menstrual products, but they also must pay for any healthcare related to problems caused by inadequate access to menstrual products. For the more than 85,000 women in prison in 2023, inadequate access to period products and reproductive healthcare can have serious health consequences, and almost every single prison copay policy fails to even address menstrual health.

Substance use. Only eight states and the federal Bureau of Prisons explicitly exempt substance use related healthcare from medical copays. Even when healthcare providers refer people to substance use treatment, incarcerated patients are frequently charged for their initial request for an appointment with the provider, and many incarcerated people may not know how to access treatment without being charged copays and fees. Any perceived barrier to accessing substance use treatment behind bars has serious consequences for the more than half-million people in prison who reported a substance use disorder in the year before their admission.32

Vaccinations. About one-quarter of prison systems with copays (13) waive them for vaccinations explicitly. Even when vaccinations are exempt from copays, there are often additional caveats: in West Virginia, the waiver only applies to vaccinations and preventative care “provided or made available to all inmates.” While these exemptions may clearly apply to the distribution of the COVID-19 vaccine in 2021, it is unclear how this may play out when an incarcerated person requests a specific vaccine that may not be offered to the entire facility population, like the HPV vaccine,33 the pneumococcal vaccine,34 or Hepatitis B vaccine.35

In addition to these highlighted findings, we have categorized the state copay policies we found according to the conditions or types of medical care that are exempt (and under what circumstances) and compiled this information in our appendix table.

Conclusion

“Copay” fees for medical care in prison are unaffordable at prison wages. They deter necessary care for an incarcerated population that faces many medical conditions — often at higher rates than national averages — and that routinely receives inadequate health services behind bars. The copay waiver policies ostensibly meant to “fix” this problem of copays deterring necessary care are, in many states, extremely limited with only a handful of care types or medical conditions exempted. Oftentimes, the exemptions are so ill-defined and inconsistent that it is hard to imagine any fair, consistent implementation of these policies. Many incarcerated people may be unaware that such waivers exist at all; even if they are aware, the complexity of the waiver criteria makes it nearly impossible for them to determine whether, when, or how a waiver might apply to their care.

Ultimately, we conclude that these copay exemption policies fail to make the copay system any less harmful for incarcerated people, especially the large number of incarcerated people with chronic medical needs. Instead, these exemptions simply give cover to prison systems that limit access to care and prioritize their bottom lines by imposing medical fees on a largely poor, medically vulnerable population with no other options.36 Rather than tinkering with the edges of these policies through waivers and exemptions, prison systems should drop copays altogether.

Appendix Table

Jurisdiction Copay amount Intake or transfer Routine Vaccinations Communicable diseases Chronic conditions Diagnostics Pregnancy-related Sexual-assault related treatment Mental health treatment Substance use Emergency Staff-initiated Prescription medications Medical or mobility devices Infirmary, hospitalization, and/or inpatient care Work-assignment related Other notable exemptions Relevant legislation Sources
Alabama $4.00 Intake only (includes mental health and dental) Yes (includes dental) Yes (includes sexually transmitted infections) Yes, in chronic care clinic if staff-initiated If on-site Pregnancy-related or postpartum care If on-site If on-site If “non-self-inflicted” (includes dental) Yes Some (chronic condition refills) Infirmary Yes (if not subject to workers compensation or job insurance) Missed appointments (for some reasons) DOC Admin. Reg. 703 (2023)
Alaska37 $5.00 Intake only Yes Yes, but initial visit subject to copay and must pay $5.00/year for ongoing treatment of chronic condition after first year Pregnancy-related care Assessments and screenings Some (communicable diseases, psychiatric) Medication line visits DOC Policy 807.07 (2016)
Arizona $5.00 (maximum) At reception centers or when returned to custody Only Hepatitis C-related (in ADCRR) or HIV/AIDS related (in ADCRR and contracted beds) Yes Pregnancy-related care If serious mental illness is present (in ADCRR and contracted beds); if ASPC-Phoenix psychiatric hospital or mental health center Yes (includes people requiring administrative examinations like “response to suicide prevention/watch”) People with developmental disabilities; people “who require additional feminine hygiene products due to medical issues;” minors DOC Dept. Order 1101 (2018) and Glossary of Terms
Arkansas $5.00 (maximum) Intake only (includes dental) Yes (includes dental) Only if related to testing/prevention Yes, in chronic care clinic Yes Yes Yes (includes dental) DOC Policy AR 0893 (2005)
Colorado $3.00 Intake only Yes If instituted by department for public health reasons or related to a state/national emergency Yes (includes initial sick call requested later determined to be due to chronic condition) Yes, unless “no-show” Pregnancy-related care Yes (includes mental health) Intake screenings, emergencies, in residential treatment program, or if serious mental illness is present If related to chronic care condition Yes (includes dental) Infirmary Comfort and/or end-of-life care; disability status screenings; medical care related to a “vision, hearing, or lower extremity mobility disability”; “A $5.00 co-pay fee will be charge dfor self-declared emergencies that may or may not require transport outside of the facility” Proposed legislation to end medical copays in prison (Colo. H.B. 25-1026 (2025)) DOC Admin. Reg. 700-30 (2024)
Connecticut $3.00 If scheduled Yes If necessary per staff Yes (includes dental) If court commitment conflicts with specialty appointment DOC Administrative Directive 3.12 (2020)
Delaware $4.00 Intake only Yes Yes, in chronic care clinic (includes mental health) Yes Yes Yes Yes Some (psychiatric) Glasses (first pair) Infirmary Health assessments required by policy; “Co-pays will not be charged when seen by one or more providers for the same problem three times in a seven-day period.” DOC Policy E-01.1 (2021)
Federal $2.00 Yes For chronic infectious diseases If staff-approved Prenatal care Yes Yes Yes Yes BOP Program Statement 6031.02 (2005)
Florida $5.00 Intake only If follow-up routine care If instituted by department for public health reasons, requires medical action to protect others from a communicable disease, or is a voluntary HIV test request If staff-initiated Yes Yes Care that is “provided in connection with an extraordinary event that could not reasonably be foreseen, such as a disturbance or a natural disaster” 2024 Fla. Stat. S 945.6037
Georgia $5.00 Intake only Yes (excludes “minor infections such as a cold or influenza”) Prenatal and obstetrical care Yes Yes38 Yes Some (communicable diseases, chronic conditions, antibiotics) If “deemed necessary” by staff Examination following use of force DOC Policy 507.04.05 (2022)
Hawaii $3.00 Yes (includes mental health and dental) Yes (includes sexually transmitted infections) Yes Pre- and post-natal care Yes (includes patient-initiated) Infirmary Yes “Special needs incarcerated individuals with mental health disabilities or disorders that interfere with the ability to carry our normal activities are exempt from the copayment plan. This includes, but is not limited to, instances of self-mutilation, suicide attempts or incarcerated individuals in special holding or therapeutic housing units.” DOC Policy COR.10.A.11 (2024)
Idaho $2.00 Yes (includes dental) Only tuberculosis prophylaxis Yes, in chronic care clinic Yes Yes Yes Yes Yes Glasses (once every two years with prescription) Infirmary for chronic condition Yes DOC Procedure Control Number 411.06.03.001 (2018)
Indiana $5.00 Yes Yes (annual) Yes If instituted by department for public health reasons Yes Yes Yes Yes Yes Some (psychiatric, chronic, neuroleptic) Glasses, dentures, ostomy supplies, stockings, braces Yes “The service is provided as a result of an injury received while in the custody of the department” 210 Ind. Admin. Code Article 7 (2025)
Iowa $3.00 Yes (includes mental health and dental) Yes (includes eye exams) Sexually transmitted infections testing and prophylaxis If staff-initiated (includes mental health) or if civilly committed For emergency care, forensic medical examinations, and STI prophylaxis Intake screenings or if staff-initiated If determined by staff Yes Some (see policy) If not associated with patient negligence Skilled care; exposure to chemical agents “not associated with patient negligence” DOC Policy HSP-505 (2020)
Kansas $2.00 Intake only Yes If staff-initiated or for group sessions Yes Yes Infirmary Evaluations requested by the Prisoner Review Board Kan. Admin. Regs. S 44-5-115c (2024)
Kentucky $3.00 Yes Yes, in chronic care clinic Yes DOC Policy 13.2 (2025)
Louisiana $2.00 Yes Yes (annual) Yes If instituted by department for public health reasons or patient-initiated requests related to “pandemic threat” Yes (includes DNA testing) Prenatal care PREA assessments If provided by mental health staff If provided by mental health staff Yes Some (communicable diseases, psychiatric) Glasses, prosthetics, dentures, Durable Medical Equipment (DME) Yes (as determined by the warden) “Any other instance the Secretary deems appropriate, expressed in writing.” DPSC Dept. Regulation No. HCP14 (2024) via email
Maine $5.00 All care while pregnant Only if serious mental illness or developmental disability is present39 or if inpatient at a state-funded mental health facility If necessary per staff (includes dental) Yes Proposed legislation to raise the copay maximum to $25.00 (L.D. 18 (132nd Legis. 2025)) 34-A ME Rev Stat S 3031 (2024)
Maryland $2.00 Yes Yes Yes Yes PREA assessments Yes Yes Yes DOC Executive Directive OPS.130.0001 (2015) and Md. Code, CS S 2-118 (2024)
Massachusetts $3.00 Intake only (includes mental health and dental) Yes (includes pre- and post-test HIV counseling) Yes Yes Prenatal and delivery care Yes Yes Yes (includes dental) Yes Yes Yes Care for terminally ill patients; care for patients hospitalized more than thirty (30) days successively during their incarceration; care for minor; “non-compliance counseling including counseling regarding medication compliance” Proposed legislation to end medical copays in prison (Mass. H.2372 (2023)) 103 DOC 763 (2024)
Michigan $5.00 Testing only (includes sexually transmitted infections) Yes If medical care is received or referred “within one hour” and is not “an intentional self-inflicted injury” Yes (with incident report) DOC Policy Directive 03.04.101 (2022)
Minnesota $5.00 Yes Yes If staff-initiated Yes Yes40 Yes Some (chronic conditions) Yes (with incident report) Initial evaluation and treatment of injuries from an assault DOC Policy 500.100 (2018)
Mississippi $6.00 Yes Yes If instituted by department for public health reasons Yes, in chronic care clinic or if “felt non-chargeable by the medical staff” Yes Prenatal care Yes (includes patient-initiated) Yes Yes Missed appointments (for some reasons) Inmate Handbook (2023)
New Hampshire $3.00 At reception centers or in first 14 days of incarceration If staff-initiated Pregnancy-related care If emergency, secure psychiatric unit or if serious mental illness or developmental disability is present If staff-verified (includes dental) Yes Sick-call visit for medication refills Initial prosthetics or functional aid devices determined to be medically necessary Inpatient Care for minors; people in maximum security and “punitive segregation” unless they request medical care NH DOC Policy Dir. Health Services 6.16 (2009) via email and NH Rev Stat S 622:31-a (2024)
New Jersey $5.00 Yes Yes If instituted by department for public health reasons Yes (includes patient-requested HIV testing) Yes Yes If requiring emergency transport to hospital Yes (includes dental) Some (psychiatric) Infirmary Medication provided immediately during a medical visit N.J.A.C. 10A:16-1.5 (2025)
North Carolina $5.00 Intake only Yes Yes Yes Yes, in chronic care clinic if staff-initiated If staff-verified If occurring within 14 days of initial visit Yes and residential facilities (including for mental health) Yes (with incident report) Medical examinations or treatment required following use of force, automobile accidents, fire and smoke incidences, and extraordinary events such as a riot or natural disaster; people in private substance abuse treatment centers, county jails, “safekeepers”41, out-of-state facilities, community transition center, or assigned to residential mental health, inpatient mental health, medical infirmary, or medical inpatient. DAC Policy S.1300 (2023)
North Dakota $3.00 Yes “Pre-existing conditions must have been diagnosed within the past 60 days to quality for exemption from the co-pay, unless the 60-day time frame is waived by DOCR medical or by appeal;” “Pre-existing conditions are subject to co-pay at least every 60 days” DOC Handbook (2021)
Ohio $2.00 Yes Yes If “an actual emergency exists” Yes (includes services following staff reports of sexual assaults and use of force) Medication refills (even if through sick-call) Yes Yes, for accidents Dental services DRC Policy 68-MED-15 (2022)
Oklahoma $4.00 Intake only Yes Yes If prescribed for public health reasons Yes Prenatal, perinatal, and postpartum care Yes Yes Yes (includes dental) Some (chronic conditions) Yes, initial acute treatment DOC Policy OP-140117 (2024)
Pennsylvania $5.00 Yes (includes mental health and dental) If requested by department (includes dental and mental health) Yes If prescribed for public health reasons If staff-initiated Yes Prenatal care Yes Yes Unless “self-inflicted” (as determined by staff) Yes Some (chronic conditions, psychiatric) Glasses, dentures, prosthetics (excludes customized items and orthotics) Yes42 Yes “Long-term care for an inmate who is not in need of hospitalization, but whose needs are such that they can only be met on a long-term basis or through personal or skilled care, and who needs the care because of age, illness, disease, injury, convalescence or physical or mental infirmary.” DOC Policy DC-ADM 820 (2021)
Rhode Island $3.00 Yes Yes, for people 40+ years of age (annual) Yes If instituted by department for public health reasons If staff-initiated (includes mental health) If on-site Prenatal care If on-site Yes If provided in an emergency room/urgent care center (includes emergency transportation) Yes Some (chronic conditions) Initial prosthetic limbs, “essential” mechanical aids as determined by department Annual dental cleaning; people who have applied for Medical Parole, but were denied for non-medical reasons; missed appointments (for some reasons) DOC Policy No. 2.28-3 (2007)
South Carolina $5.00 Yes Yes If instituted by department for public health reasons or during a known public health disease outbreak Yes, in chronic care or infectious disease clinic Yes Yes Some (psychiatric)43 Infirmary Yes (with incident report or if sent by supervisor) Hospice care DOC Policy HS-18.17 (2023)
South Dakota $3.00 Intake only If instituted by department for public health reasons Yes, in chronic care clinic Yes Pregnancy-related care Yes (includes mental health) Yes If resulting in hospital admission (includes dental) Yes (includes referrals to external specialty health care services) Medical housing unit Hospice or end-of-life care; disability status screenings DOC Policy 700-30 (2024)
Tennessee $3.00 Yes (includes mental health and dental) Yes Only tuberculosis testing/screening Yes, in chronic care clinic if staff-initiated Yes Yes, excludes initial visit for pregnancy test Yes (includes mental health) Yes Yes Yes (includes dental) Infirmary Yes DOC Policy 113.15 (2020)
Texas $13.5544 Yes (includes mental health and dental) Yes (annual) Yes Yes, in chronic care clinic (includes mental health) As part of intake process Prenatal care (includes counseling) Yes Yes (includes mental health and dental) Yes (includes dental) Yes Infirmary Physical evaluations following use of force incidents; procedures or testing ordered by a court or pursuant to state law; testing on behalf of third parties (paternity tests, compatibility for donation tests); medical treatment of self-inflicted injuries; no copay charged for “no-shows” because a visit did not occur Tex. Gov’t Code S 501.063 (2023) and DOC Admin. Dir. AD-06.08 (rev. 7) (2019) via public records request
Utah $5.0045 Utah Code S 64-13-30 (2024) and UT Division of Correctional Health Services FAQ
Washington $4.00 Intake only Yes (includes mental health) In residential treatment units or if staff-initiated If staff initiated and not for “self-induced injury” Yes (includes dental) Yes (with incident report) Medication distribution; court ordered evaluations DOC Policy 600.025 (2023)
West Virginia $3.00 If provided or made available to total custody population Yes Yes Treatment for severe mental illness Unless “self-induced” Yes Some (chronic conditions) Care required by state law DOC Policy Dir. 424.01 (2023)
Wisconsin $7.50 Intake only (includes dental) If determined by staff (includes dental) Yes (includes dental) Yes Medical, dental, or nursing care for people in juvenile correctional facilities who do not have “the opportunity to earn wages” Wis. Admin. Code DOC 316.04 (2024)

A handful of states have ended their use of copays and are therefore not included in this appendix table: California, Illinois, Missouri,46 Montana,47 Nebraska, Nevada, New Mexico, New York, Oregon, Vermont, Virginia,48 and Wyoming.

Definitions

Intake or transfer
Assessments and/or screenings that occur on admission, during the intake process, or when transferring between units or facilities.
Routine
Assessments or screenings that occur annually or on another routine basis.
Communicable diseases
Testing and treatment of communicable diseases (also known as infectious or transmissible diseases).
Chronic conditions
Treatment of chronic conditions including heart disease, cancer, diabetes, hypertension, osteoporosis, and asthma.
Diagnostics
Includes lab testing and provider-ordered x-rays.
Pregnancy-related
Healthcare related to pregnancy, including pregnancy testing, prenatal care, delivery and perinatal care, and postpartum care.
Sexual-assault related treatment
Healthcare for people after experiencing sexual-assault.
Mental health treatment
Assessments, screenings, and treatment of mental health conditions and disorders.
Substance use
Assessments, screenings, and treatment of substance use disorders.
Staff-initiated
Healthcare initiated by medical, correctional, or administrative staff including follow-up visits and referrals.
Medical or mobility devices
Devices and prosthetics to assist with disabilities, injruies, or chronic health conditions, as well as assistive devices like glasses, dentures, hearing aids.
Infirmary, hospitalization, and/or inpatient care
Treatment provided in an infirmary unit in a hospital, infirmary unit, or inpatient unit.
Work-assignment related
Injuries or illnesses related to a work-assignment.
Relevant legislation
Legislation pending regarding copays in prisons, as of publication in May 2025.

Footnotes

  1. Unlike non-incarcerated people, people in prison do not have a choice about their medical coverage, nor how “cost sharing” applies to them. There is no “insurance” system that covers them, so the term “copay” is a misnomer for the fee they are charged to request a medical appointment or to obtain a prescription. As the organization Voice of the Experienced argues, the use of this term legitimizes these unaffordable fees, which deter people from seeking needed medical care. They suggest more descriptive terms such as “medical request fees” or “sick call fees.”  ↩

  2. Of note, the National Commission on Correctional Health Care (NCCHC) argues that abuses of sick call can be managed with “a good triage system,” without imposing fees that also deter necessary medical services. And although providers must treat people regardless of their ability to pay, incarcerated people with “low health literacy” may not understand this right. The NCCHC warns that co-pays may actually jeopardize the health of incarcerated populations, staff, and the public.  ↩

  3. See eAppendix: Additional Material on Copayment Policies and Waivers.  ↩

  4. A 2010 qualitative study found that formerly incarcerated women frequently reported that copays hindered access to timely, quality healthcare when they were incarcerated. Participants reported inequitable administration of copays, including being charged copays that, based on policy, should have been waived for care related to contagious conditions, mental health, and follow-up visits. The participants also described the significant financial burden of copays and many ultimately decided to forego necessary medical care because of the expense.  ↩

  5. For example, in Delaware, copays are not charged when an individual is seen by healthcare providers for “the same problem three times in a seven-day period.” However, at the time of the initial sick call request, an incarcerated patient must expect to be charged a copay, because they cannot possibly predict that they will be seen three times in a seven-day period for the same problem and the copay will therefore be retroactively applied after those subsequent visits.  ↩

  6. For example, Oklahoma, incarcerated people must complete a form requesting health services that requires them to agree to a statement that “I will be charged $4.00 for each medical service I request and a charge of $4.00 for each medication(s) dispensed to me, with the exceptions noted in the above-reference operations memorandum. There is no charge to the offender for mental health services and/or mental health medications.” There is no mention of other types of care which are exempt — according to the waiver policy — from copays, like medications for asthma, pregnancy-related care, vaccinations, tuberculosis testing, or x-rays. It is easy to see how an incarcerated person might expect the $4.00 copay to apply to those services — regardless of the exemption policy — based on the mandatory request form. In addition, prisons do not consistently provide information to incarcerated people about what medical care is exempt from copays. A 2008 audit of the Nevada Department of Corrections found that five Nevada institutions provided no clear instructions on what types of visits were exempt from copays, and orientation manuals from West Virginia and Georgia informed incarcerated people that copays may apply to visits, but did not include information regarding which visits would or would not qualify for a waiver.  ↩

  7. For example, in Massachusetts, the Health Service Administrator or designee completes a “Weekly Self-Initiated Sick Call Log” indicating the total billable services provided, with no guidance or details about what services are “billable” or subject to a copay included on that log.  ↩

  8. For example, in Massachusetts, incarcerated people “shall be charged for a self-initiated sick call,” but any medical treatment initiated by health staff, correctional staff, the Department of Corrections, statute, or courts is exempt from the $3.00 fee.  ↩

  9. For example, in North Carolina, chronic care clinic visits for cardiovascular disease are exempt from the $5.00 fee.  ↩

  10. For example, in Mississippi, the $6.00 fee is waived for any lab work and x-rays ordered by a medical provider.  ↩

  11. For example, in Wisconsin, any medical, dental, or nursing services that are provided because of an injury sustained at an institution work assignment are exempt from the $7.50 fee.  ↩

  12. For example, in Connecticut, incarcerated people are charged $3.00 for “each inmate-initiated visit to the Health Services Unit,” but appointments initiated by health services staff or any Department of Corrections personnel are exempt from the fee  ↩

  13. Some prisons are still using paper medical charts and the electronic medical records for those systems not on paper can vary in sophistication. Processes for preventative care reminders or flags for patients being overdue for follow-up care for chronic conditions (which are fairly standard in non-carceral electronic medical records) are not always present in prison systems, requiring manual tracking by medical teams that are often understaffed. Even when appropriate follow up intervals are well tracked, the chronic shortage of staff faced by prisons often results in delayed, canceled, or never-scheduled follow-up appointments. This reliance on staff- and system-initiated healthcare for copay exemptions is not an appropriate way to facilitate access to necessary care.  ↩

  14. For example, in Maine, “emergency treatment as determined by the facility’s medical or dental staff” is exempt from the $5.00 fee.  ↩

  15. For example, in New Hampshire, copays are waived for “incidents of staff verified emergency visits.”  ↩

  16. For example, in South Dakota, the health care fee is charged for medical care related to “self-declared emergencies that do not require transport outside the facility.”  ↩

  17. For example, in New Hampshire, patients “will be charged the actual costs for all willfully or accidentally caused injuries to themselves or others, if they are found guilty of a rule infraction after a disciplinary hearing,” and in Alabama, any health care rendered to a patient “found responsible (through the Disciplinary Hearing process) for injuries to self or another individual” will incur a copay charge.  ↩

  18. For example, in South Dakota, people will be charged $3.00 for “care provided for self-harm/self-inflicted injury.” In Hawaii, “incarcerated individuals are required to pay the co-payment fee when treated for self-induced injury. This includes, but is not limited to: a. Instigated fights with other incarcerated individuals or staff, or deliberately punching, kicking, hitting, banging, etc., movable or immovable objects; b. Recreational injuries. c. Accidental injuries.”  ↩

  19. For example, in Michigan, incarcerated people receiving medical care related to an “intentional self-inflicted injury” are responsible for the “full cost of the medical care provided, including transportation costs.”  ↩

  20. In Georgia, fees associated with medical care for self-inflicted injuries are the default, but are “subject to review for appropriateness by mental health staff.” In Michigan, if a mental health professional’s determination that an individual “was mentally ill at the time of the self-injury, and either lacked substantial capacity to know right from wrong or was incapable of conforming their conduct to Department rules,” the fee and costs of medical care may be waived.  ↩

  21. For example, in Oklahoma, the “initial acute care treatment rendered for an on-the-job injury” is exempt from the copay, with no mention of subsequent follow-up care.  ↩

  22. For example, in Georgia, treatment for “injuries sustained on a work detail” are exempt only if they “meet the definition of an emergency.”  ↩

  23. For example, in Minnesota, treatment “for work related injuries verified by an incident report and reported at the time of the injury” is exempt from the copay.  ↩

  24. For example, in South Carolina, only chronic clinic visits “initiated by the [Department of Corrections] to monitor the applicable disease process on a routine basis” are exempt from the $5.00 fee, excluding from the exemption any ad hoc requests for medical care made by the patient.  ↩

  25. As correctional health expert Dr. Homer Venters explains: “many chronic care problems aren’t detected when a person arrives [at the jail or prison], so to get treatment… requires the sick call process… Many [correctional] systems have a practice of requiring two or three nursing sick call encounters before a person sees a doctor.”  ↩

  26. Notably, Georgia is one of several states that charge medical copays but do not pay incarcerated people for their labor.  ↩

  27. Research has found that incarceration is a catalyst for worsening health, is associated with limited access to adequate and routine healthcare even after release, and is associated with a number of poor health outcomes including higher rates of morbidity and mortality.  ↩

  28. In Arizona, copays are waived for “pregnant inmates (for pregnancy related issues).” In New Hampshire, “pregnant inmates whose illness relates to the pregnancy” are exempt from copays. In Maine, copay waivers apply when “the client: is pregnant.”  ↩

  29. In Louisiana, Mississippi, Pennsylvania, Rhode Island, Texas, and the federal prison system, “prenatal care” is listed as the only pregnancy-related copay exemption.  ↩

  30. For example, in Oklahoma, “prenatal, perinatal, and clinically indicated postpartum care” are exempt from the $4.00 copay.  ↩

  31. Importantly, laws regarding access to menstrual products do not automatically result in sufficient access to products for all incarcerated people. For more information on state laws around menstrual products in prisons, see the regularly updated The Prison Flow Project and the ACLU’s 2019 report, The Unequal Price of Periods.  ↩

  32. Medication-assisted treatment — often referred to as the gold standard of substance use treatment — in prison is associated with significant reductions in post-release overdose deaths.  ↩

  33. Incarcerated women face increased prevalence of cervical cancer compared to the general population. The vaccine is recommended for women under 26 and at least 6% of women in state prison in 2021 were under 24 years old.  ↩

  34. The U.S. Centers for Disease Control and Prevention recommends the pneumococcal vaccine for adults 50 years and older (at least 16% of people in state prisons in 2021 were over the age of 55) and in at least one study of people released from prison in Washington state, the most frequent infectious disease-related cause of death after release from prison was pneumonia.  ↩

  35. The Hepatitis B vaccine is recommended for all adults aged 19-59, meaning that the bulk of the prison population is eligible for this vaccine if they’ve not already received it. Some estimates suggest that between 12% and 39% of people with Hepatitis B or Hepatitis C (which does not have a vaccine, but can be prevented and treated) were released from jail or prison in the prior year.  ↩

  36. Some people may suggest increased funding for correctional healthcare, but because the carceral system was never designed to provide medical treatment (and already spends billions of dollars on medical treatment annually), we recommend decarceration and investment in community-based healthcare.  ↩

  37. “Prisoners are responsible to cooperate with the Department in seeking funding for medical procedures and hospitalizations that may be paid for from other sources, e.g. Medicaid.”  ↩

  38. “Self-inflicted injuries will be charged subject to review”  ↩

  39. “For the purposes of this paragraph, “a person with a serious mental illness or developmental disability” means a client who, as a result of a mental disorder or developmental disability, exhibits emotional or behavioral functioning that is so impaired as to interfere substantially with the client’s capacity to remain in the general prison population without supportive treatment or services of a long-term or indefinite duration, as determined by the facility’s psychiatrist or psychologist. The exemption under this paragraph applies only to supportive treatment or services being provided to improve the client’s emotional or behavioral functioning.”  ↩

  40. “Co-payments are not assessed in the following instances: Report of an alleged sexual assault, abuse, or harassment.”  ↩

  41. Medical services “resulting in non-charge” includes “infirmary care in a Department facility (with the exception of an inmate determined to be on a behavioral/volitional hunger strike, as opposed to refusing to drink/eat due to medical/mental health diagnosis. He/she will be charged a co-pay for every medical encounter)”  ↩

  42. In North Carolina, “safekeeper” refers to an individual in county jail custody who is housed in a prison.  ↩

  43. “No co-payment will be charged for certain medications. A list of these medications…will include: medications used exclusively for the treatment of mental disorders unless the inmate fills the prescription and then refuses to take the medication.”  ↩

  44. “An inmate confined in a facility operated by or under contract with the department, other than a halfway house, who initiates a visit to a health care provider shall pay a health care services fee to the department in the amount of $13.55 per visit, except that an inmate may not be required to pay more than $100 during a state fiscal year.”  ↩

  45. “For services provided outside of a prison facility while in the custody of the department, the offender is responsible for 10% of the costs associated with hospital care with a cap on an inmate’s share of hospital care expenses not to exceed $2,000 per fiscal year.”
    “There is a cap on the inmate’s share of expenses of $2,000 per fiscal year. An inmate with assets exceeding $200,000 upon entry into the Department’s custody is responsible to pay costs of all medical and dental care up to 20 percent of the inmate’s total asset value. After receiving medical and dental care equal to 20 percent of the inmate’s total asset value, the inmate will be subject to the normal co-payments.”  ↩

  46. In 2017, a bill was introduced in the Missouri state legislature to establish a 50 cent fee for correctional medical services, but it appears this legislation was not enacted.  ↩

  47. According to the Montana Department of Corrections, they do not charge copays, although the Department is authorized in statute to charge copays: “The department may, consistent with administrative rules adopted by the department, use a portion of the funds in an inmate’s account to: pay for the inmate’s medical and dental expenses and costs of incarceration” (MT Code S 53-1-107, 2024).  ↩

  48. According to a memo sent by the Virginia Department of Corrections dated March 1, 2023, the state ended their use of healthcare copays in prisons completely, after temporarily suspending copays in 2020.  ↩

See the appendix table and footnotes


Learn how advocates are responding to shifting arguments for new jail construction.

by Emmett Sanders, May 14, 2025

For decades, calls for new jail construction were largely accompanied by “Tough on Crime” rhetoric that ignored the fact that jails often house the most precariously situated members of our society. While these dehumanizing narratives persist, in many places jail construction has taken a carceral humanist turn that depicts cages as places of care and compassion and the jail as a service provider for those with mental health or substance use support needs.

This is just one of the ways in which arguments for new jail construction have evolved over time, leading communities to spend millions and sometimes even billions of dollars on new jail construction, even as public safety initiatives are being viciously defunded. Fortunately, those on the frontlines who oppose new jail construction have evolved their own arguments and have developed new strategies to push back.

On June 11, 2025, Prison Policy Initiative brought together a panel of activists who have pushed back against jail expansion in communities from Atlanta, Georgia, to Sacramento, California, all the way to Oahu, Hawai’i. We discussed how arguments for new jail construction have shifted over time, went over some useful strategies and tools for responding to these arguments, and talked about how our advocacy department can help support efforts to challenge new jail construction in your area.

Panelists included:

Watch the full webinar:

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