The growth of mass incarceration in the United States was accompanied by an unraveling of the social safety net. Federal income support effectively ended with welfare reform, funding for social programs was cut, and affordable housing development didn’t keep pace with a burgeoning real estate market. It is no coincidence that the communities most affected by these changes – low-income, Black and Latino – also experience higher rates of preventable injury, disease, and death. Health inequalities are preserved and reinforced by punitive social policies under inequitable conditions: this is structural violence. The combination of hyper-incarceration and vanishing public resources has contained and perpetuated these conditions in affected communities for the last four decades.

Enter the Patient Protection and Affordable Care Act (ACA) of 2010, a piece of legislation more than two thousand pages long and a signature accomplishment of the Obama presidency. Although it isn’t stated anywhere in the law, the ACA offers a public health approach that could accomplish significant criminal justice reform. The law represents a massive public investment, not just in healthcare, but more expansively, in the health and well-being of communities.

Aside from its immediate population health benefits, the ACA introduces the capacity and potential for preventing and reducing incarceration rates, and ameliorating many of the worst consequences of prison in these same communities. As state and local governments choose to adopt and implement the resources and mechanisms provided under the law, they will be directing investments into those same communities suffering the dominance of the criminal justice paradigm. From a systems perspective, the ACA offers a transformative conceptual and practical framework for improving health and social equity in the US. It is an enormous structural shift in the US policy landscape.

Two of the law’s core features related to healthcare coverage can serve as tools for decarceration: Medicaid expansion, and coverage for mental illness and substance use disorders. Access to healthcare will improve measurably for justice-involved individuals in states electing to expand Medicaid, because single adults are now eligible for coverage with the ACA. And Medicaid will pay for more than just medical care. It can cover case management services to help resolve issues that make being and staying healthy more complicated, such as unstable housing, food insecurity, unemployment, and transportation access. It can cover peer support services, and even housing assistance. Many of these services could also interrupt, reduce, and prevent hyper-incarceration; they seek to remedy the same issues. The ACA allows state governments and healthcare providers to re-envision health as a cross-systems, community-wide endeavor, and to institute policies and practices for financing a broad range of health-related services with Medicaid dollars.

The ACA is also designed to expand access to behavioral healthcare, especially important for the justice-involved population, where rates of mental illness and substance use disorders are disproportionately high. This pattern is also a consequence of history: as state psychiatric hospitals closed and the US declared a war on drugs, the criminal justice system began its exponential growth. Due to pervasive stigmatization and an under-developed healthcare response, behaviors related to mental illness and substance use disorders were frequently criminalized instead, precluding the development of an effective behavioral healthcare system to scale. Now, the ACA has firmly established parity in healthcare coverage for these conditions, alongside medical care, and includes behavioral health among the ten essential health benefits required of all plans. This arrangement will demand, and hopefully result in, greater availability and improved quality from the behavioral healthcare system. It should also invite the diversion of these problems away from the criminal justice system, because coverage for their care and treatment in the healthcare system is now better financed, and mandatory.

By adopting a public health approach to leverage the opportunities of the ACA, policymakers, advocates, scholars, and others can produce imaginative ideas for decarcerating individuals and communities. From this perspective, US healthcare reform is a vehicle for decarceration.

About the author

Daliah Heller

Daliah Heller views public health as a framework for designing and measuring social policy. She is currently a Clinical Professor at CUNY School of Public Health, where she oversees fieldwork training and promotes faculty‐student partnerships with local and global institutions. Previously, she served as Assistant Commissioner for Alcohol and Drug Use at the New York City Health Department, and Executive Director for a nationally-recognized harm reduction organization. She holds a doctorate in Social Welfare from CUNY, a graduate degree in Public Health from the Mailman School, and an undergraduate degree in Political Science from McGill University.