Large Minnesota study underscores disproportionate rates of health problems among recently incarcerated and unhoused people

In a study of more than 4.3 million people in Minnesota, researchers found widespread disparities in health conditions between the general population and people who were recently unhoused, jailed, or imprisoned.

by Emily Widra

The U.S. disproportionately locks up people who are unhoused and in poor health despite the fact that these populations are often better served by social and public health supports outside of jail and prison. A new study from researchers at the Minnesota Electronic Health Record Consortium underscores the desperate need for these additional supports and better, targeted interventions for accessing medical care and housing during reentry.

The Minnesota researchers use data compiled directly from a statewide electronic health record system to analyze the prevalence of various health conditions across more than 4.3 million adults in Minnesota who were seen by healthcare providers between 2021 and 2023. In their comparison of recently incarcerated people, recently unhoused people, and the total statewide population, the researchers find significant disparities: recently incarcerated people face higher rates of many health conditions than the statewide population, and unhoused people face the highest rates of nearly every condition included in the study. By including race and ethnicity in their analysis, the researchers also show how existing racial disparities in health are magnified among these populations. Ultimately, their findings add to mounting evidence that unhoused and recently incarcerated people are overwhelmingly sicker than the general population.

In this briefing, we unpack some of the most important findings from this new research, focusing primarily on recently incarcerated populations, though we look at the unhoused population at the end as well. We also note that the dataset the researchers used — the Minnesota Electronic Health Record Consortium (MNEHRC) — is a unique collaboration between healthcare systems and public health agencies in Minnesota, offering publicly available and regularly updated population-level health data for millions of people. By linking the health records with data about homelessness and incarceration (as well as other factors, like Medicaid enrollment), this dataset not only serves as a public health monitoring tool, but also allows researchers to conduct large-scale studies like this one.

Rates of all common mental health conditions are higher among recently incarcerated people

Across the board, the researchers find that compared to the total Minnesota population, mental health conditions — depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder, psychotic disorders, and suicide attempts — are far more prevalent among people who have been recently jailed or imprisoned. Some mental health diagnoses among formerly incarcerated people may have been brought on or exacerbated by incarceration, which is itself a traumatizing experience. Other data tell us that, even well before entering a prison, people who are arrested have much greater odds of serious mental illness or psychological distress than those who are not arrested, reflecting the practice of sweeping people experiencing mental health crises into the criminal legal system instead of redirecting them to community-based services.

Anxiety and mood disorders. In Minnesota, depression and anxiety are more prevalent among recently jailed and imprisoned populations, across almost all racial and ethnic groups, than in the statewide population. This is consistent with other data indicating a vast overrepresentation of people with mood disorders behind bars. Rates of bipolar disorder, too, are higher among recently incarcerated people — at five times the statewide rate.

PTSD. Recently incarcerated people in Minnesota are diagnosed with post-traumatic stress disorder (PTSD) at more than four times the statewide rate. Within racial and ethnic categories, the most dramatic disparities in PTSD are concentrated in two groups: recently jailed white people, whose rate is more than four times that of the white population statewide, and recently imprisoned Hispanic people, for whom PTSD is more than five times as prevalent as the statewide Hispanic population.

Suicide. For decades, the rate of suicide deaths has been far higher in prisons and jails than in the national population. In the Minnesota study, recently incarcerated people were also far more likely to have a suicide attempt documented in their medical record than the statewide population. Nearly 9% of recently jailed people and 7% of recently imprisoned people had considered or attempted suicide, compared to less than 2% of the total population. And while Asian and Pacific Islander people generally report some of the lowest rates of diagnosed mental illnesses in the state, the prevalence of serious mental health concerns skyrockets for those recently incarcerated. A history of suicide attempts is almost twelve times as common among Asian and Pacific Islander people who were recently imprisoned, indicated in 12% of their medical records, compared to Asian and Pacific Islander Minnesotans as a whole.

These numbers reflect the nation’s shameful practice of responding to mental illness and mental health crises with criminalization: 40% of people in state and federal prisons in 2016 and more than 44% of people in local jails in 2012 had been diagnosed with a mental illness at some point. A number of behaviors associated with mental illness — including loitering, disorderly conduct, and trespassing — can result in arrest, conviction, and incarceration, even while posing little-to-no threat to public safety. However, access to any sort of mental health treatment is extremely limited for incarcerated people: in state prisons, more than half of people had an indication of a mental health problem in 2016, but only a quarter (26%) received professional help since entering prison. In local jails, suicide is the leading cause of death: someone in jail is more than three times as likely to die from suicide as someone in the general U.S. population.

While we cannot say from the data presented whether these mental health concerns were a contributing factor to — or result of — their contact with the criminal legal system, it’s clear that some of the state’s most vulnerable people are disproportionately incarcerated and returning to their communities with mental health needs. These findings underscore the urgent need to bolster mental health treatment in the community.

One in ten recently incarcerated Minnesotans has a diagnosed substance use disorder

In the Minnesota study, people with a recent experience with incarceration are more likely to have a diagnosed substance use disorder than the statewide population: more than one in ten have an opioid use disorder or an alcohol use disorder. Among recently incarcerated people, the rates of all substance use disorders measured — for alcohol, opioids, hallucinogens, methamphetamine, cocaine, and cannabis — are between 4 and 22 times the rates of those disorders among the total state population.

Alcohol. More than one in five (21%) recently jailed people in Minnesota have a documented alcohol use disorder. And while the prevalence is lower among recently imprisoned people (14%) than recently jailed people, it is still almost four times the statewide rate (4%). Across almost all racial and ethnic groups, the prevalence of alcohol use disorder is higher among those recently incarcerated. Statewide, Native people have the highest rate of alcohol use disorder (12%), which nearly doubles for those recently incarcerated: 23% of recently jailed and 19% of recently imprisoned Native people have a documented alcohol use disorder. Similarly, while only 3% of Minnesota’s Hispanic population has an alcohol use disorder, that rate jumps dramatically to 18% among recently jailed Hispanic people and 11% among those recently imprisoned. These results indicate a clear need for alcohol use treatment for people leaving jails and prisons across all racial and ethnic groups.

Opioids. The criminal legal system is frequently the default response to the opioid epidemic: people who use opioids are disproportionately arrested, jailed, and imprisoned, but behind bars, they rarely receive necessary treatment. In the Minnesota study, opioid use disorder is ten times as prevalent among recently imprisoned people than the total population (among recently jailed people, it is seven times the statewide rate). Across all racial and ethnic categories, opioid use disorder is far more prevalent among people recently released from jail and prison — and this has lethal consequences. Previous research out of Minnesota found that the rate of overdose death for people released from jail was nearly 16 times that of the Minnesota general population, and the rate for people released from prison was a shocking 28 times the general population rate.

Methamphetamine. Rates of methamphetamine (meth) use disorder are much higher among recently jailed (12%) and recently imprisoned people (17%) compared to the statewide population (0.8%). This is consistent with national trends in meth use and criminalization: nationally, there has been a surge in methamphetamine use, arrests, and overdose deaths in recent years. From 2015 to 2019, methamphetamine use disorder prevalence increased 37%, while overdose deaths climbed 170%. Among more than 32,000 people arrested for the first time in 2023 that tested positive for drugs, more than a quarter (26%) tested positive for methamphetamine alone. In the Minnesota study, methamphetamine use disorder is most prevalent among Native people, both statewide (6%) and among those recently jailed (18%) and recently imprisoned (22%). However, the largest within-race disparities between the statewide population and the recently incarcerated population are among white, Hispanic, and Asian or Pacific Islander people.

Despite the deep unpopularity of the War on Drugs, the U.S. still responds to substance use (and related crime) as an individual failure requiring punishment, rather than as a public health problem — and it’s not working. Nationally, around 8% of people met the criteria for substance use disorders in 2019, but such disorders are far more common among people who are arrested and jailed (41%) and people incarcerated in federal (32%) or state prisons (49%). Establishing healthcare support for people during reentry — and ensuring seamless access to medications for opioid use disorder during incarceration and reentry — is a crucial part of reversing these trends.

Serious health conditions are more common among recently incarcerated people

The Minnesota study also shows that recently incarcerated people are more likely than the statewide population to suffer from most of the physical health conditions measured, including respiratory conditions like asthma and chronic obstructive pulmonary disease (COPD) and cardiovascular conditions like high blood pressure, heart disease, and stroke.

While health issues may begin before arrest, incarceration often exacerbates problems or creates new ones: being locked up in and of itself causes lasting damage, and mortality (death) rates inside prisons and jails are disturbingly high. Of course, we know that people often do not get adequate medical care while behind bars: more than 20% of incarcerated people in state prisons and 68% in local jails with a persistent medical condition go without treatment. This has serious consequences: the number of people who died annually in jails and prisons increased by about 33% from 2001 to 2019, and prior research shows that each year in prison corresponds to a two-year decline in life expectancy. In the Minnesota study, the elevated rates of respiratory and heart conditions among recently incarcerated people, relative to statewide rates, are especially concerning.

Respiratory conditions. Chronic obstructive pulmonary disease (COPD) is almost twice as common among recently imprisoned people than it is across the total Minnesota population. Rates of COPD for white people who were recently jailed (6%) or imprisoned (7%) are more than double that of the statewide white population (3%). Similarly, 6% of recently jailed Black people have COPD, compared to just 4% of Black people statewide. In general, Black and Native people in Minnesota have the highest rates of asthma (10%). But for Black people who were recently incarcerated, the rates climb even higher: 13% of recently jailed and 17% of recently imprisoned Black people have asthma. The high rates of asthma and COPD among recently incarcerated people indicate an urgent problem, especially since over the past two decades, more people have died in state prisons from respiratory disease than from drug/alcohol overdose, accidents, and homicides combined.

Heart conditions. Compared to the total Minnesota population, recently incarcerated people generally face higher rates of most cardiovascular conditions, including high blood pressure, coronary artery disease, heart failure, stroke, and heart attacks. High blood pressure (hypertension) is more prevalent among recently jailed people (38%) than the statewide population (33%) or recently imprisoned people (26%), but this appears to be primarily driven by the increase among jailed Hispanic people (38%, compared to 31% statewide). For all other racial and ethnic categories, hypertension rates were actually lower among those recently incarcerated.

Among recently incarcerated people, the Minnesota study shows racial disparities in the prevalence of various cardiac conditions. For example, recently jailed Black people are more likely than recently jailed white, Native, Hispanic, or Asian or Pacific Islander people to have coronary artery disease, heart failure, or a heart attack. Recently jailed Native people have the highest rates of stroke and peripheral vascular disease among all recently jailed groups. Among people who were recently in prison, Black people are the most likely to have heart failure or stroke and white people are most likely to have had a heart attack.

Nationally, data show that heart conditions are deadly behind bars: more than one in four deaths in jails and prisons is attributed to heart disease nationally. For Black people, heart disease is the leading cause of death in prison, with an average annual mortality rate between 2000-2019 (71 per 100,000), almost double the rate for Black people in local jails (39 per 100,000). Access to lifesaving cardiac treatment is limited behind bars: 30% of people who died in state prisons from cardiovascular disease in 2019 did not receive any diagnostic testing and more than 25% did not receive medications for their heart condition; Black people were even less likely to have received any treatment or evaluation.

Criminalization of homelessness puts disproportionately ill unhoused people in the crosshairs

Across the more than twenty mental health, physical health, and substance use conditions measured in the Minnesota study, the prevalence rates were highest among recently unhoused people for all but three conditions (hypertension, hyperlipidemia, and methamphetamine use disorder) — higher than the statewide population and even the recently-incarcerated populations.

Among recently unhoused people, the researchers found that rates of health problems varied by race similarly to the statewide population, only at much higher levels. For example, the prevalence of asthma, hypertension, and stroke are highest among Black people in the statewide population and among Black people in the recently unhoused population. But while 10% of all Black people in Minnesota have asthma, that rate goes up to 18% for unhoused Black people. Similarly, Native people in Minnesota have the highest rates of opioid and alcohol use disorders both statewide and among the recently unhoused population, but the prevalence of both disorders among unhoused Native people is more than double that of the statewide Native population.

The inclusion of those experiencing homelessness is relevant to people focused on criminal legal system reform because, of course, this is an increasingly criminalized population. Even before the current legislative and legal efforts to criminalize homelessness, almost 5% of people in state prisons in 2016 experienced homelessness in the days prior to their arrest, compared to just 0.2% of the total U.S. population experiencing homelessness on a given night in 2016. In a recent analysis, we estimated that at least 205,000 unhoused people are booked into jails each year. Further, research shows that the unhoused population is aging and that, like incarceration, homelessness contributes to “accelerated aging” with early onset of many chronic medical conditions, functional and cognitive impairments, and high rates of age-adjusted mortality.

The large-scale Minnesota study’s analysis of the recently unhoused population is an important contribution: the findings largely confirm problems that advocates have consistently raised alarms about. Unhoused people are particularly vulnerable to poor health outcomes (inevitably tied to limited healthcare access and poverty) and to criminal legal system involvement. While we chose to focus on the comparisons between the recently incarcerated population and the statewide population in this briefing, the data on the health conditions faced by recently unhoused people represents a new, invaluable source of information about just how vulnerable unhoused people are.

Conclusion

There’s a significant existing body of evidence pointing to the exceptional healthcare needs of unhoused and recently incarcerated people. This recent study out of Minnesota is potentially useful for researchers and advocates because it draws from a large novel dataset to contribute recent data on two populations that often face multiple barriers to accessing adequate healthcare. It drives home the longstanding arguments that these populations are in desperate need of additional support during reentry around accessing medical care. Ultimately, the publicly available dataset from the Minnesota study is a valuable resource for those seeking to better understand and meet the health needs of people returning home from prison and jail, including comprehensive reentry services, substance use disorder treatment, Medicaid and Medicare coverage, housing support, and access to healthcare providers.

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For additional visualizations, detailed data tables, and footnotes, see the full version of this briefing on our website.