Episode 41: Matthew Lindquist

 
Ep41_Lindquist_photo.jpg

Matthew Lindquist

Matthew Lindquist is a Professor of Economics at the Swedish Institute for Social Research at Stockholm University.

Date: November 24, 2020

Bonus segment on Professor Lindquist’s career path and life as a researcher.

A transcript of this episode is available here.

Episode Details:

In this episode, we discuss Prof. Lindquist's work on the health effects of prison:

"The Health Effects of Prison" by Randi Hjalmarsson and Matthew Lindquist.

 

Transcript of this episode:

 

Jennifer [00:00:08] Hello and welcome to Probable Causation, a show about law, economics, and crime. I'm your host, Jennifer Doleac of Texas A&M University, where I'm an Economics Professor and the Director of the Justice Tech Lab.

 

Jennifer [00:00:18] My guest this week is Matthew Lindquist. Matthew is a Professor of Economics at the Swedish Institute for Social Research at Stockholm University. Matthew, welcome to the show.

 

Matthew [00:00:29] Thank you. Thank you for having me.

 

Jennifer [00:00:31] So today we're going to talk about your research on how longer prison sentences affect health and mortality. But before we get into that, could you tell us about your research expertise and how you became interested in this topic?

 

Matthew [00:00:43] So I'm a Professor of Labor Economics at the Swedish Institute for Social Research, here at Stockholm University. And much of my work investigates the importance of family background as a determinant of adult outcomes—outcomes like income, education, entrepreneurship, but also crime. And what I've mainly been interested in is documenting the persistence of disadvantage across generations and also then trying to understand what are the mechanisms that drive this persistence. So, for example, why do poor children grow up to be poor adults? So my first papers on crime were together with Professor Randi Hjalmarsson and she's at the University of Gothenburg, which is also here in Sweden. And those were then on the topics of intergenerational crime. So I come with my intergenerational mobility background. She comes with her crime background and we team up and write those papers. And today, of course, we're going to be talking about the effects of prison.

 

Matthew [00:01:41] So this is the first paper in a larger project where we're interested in studying the effects of prison on recidivism, labor market outcomes, but most importantly, and where we wanted to start was health—health and mortality. And I think this kind of fits into my perspective of wanting to study and understand the problems faced by the most disadvantaged populations. And as we'll see, the prison population is both in Europe and the United States and other places in the world. But they really are a disadvantaged population and we're interested in health inequality and whether prison exacerbates or mitigates this inequality. And health inequality actually is one of the topics that's studied here by some of my colleagues at the Swedish Institute for Social Research. Then, of course, there's also this emerging literature coming out of the US about increased access to health care and the fact that it may actually have a causal influence on reducing crime. So I think there's a growing literature—a small but hopefully growing literature—that looks at the intersection between health, prison and crime. So that's the main reason we're looking for- interested in this topic.

 

Jennifer [00:03:03] Yeah. So when we think about prisons and incarceration, we often consider effects on outcomes like recidivism or employment, as you mentioned. So why health? What are the various ways in which being incarcerated might affect your health outcomes?

 

Matthew [00:03:15] Well, I think "So, why health?" is two parts, actually, to the question. I mean, one is why is it important? And I mentioned studying inequality, but it is actually a really large question in the public health literature, because these people also go back to their home communities and can have an impact on their home communities. And we don't know a lot about the causal effects of health. But if we think about how more time in prison—so prison in general or more time in prison—can affect health, we think about it in several different ways. So if you think about the contemporaneous effects, that is how is your health affected by prison while you're in prison. And you can imagine a whole host of negative channels or negative effects that prison might have: overcrowding, increased exposure to communicable diseases—so there's been a big literature on prison and HIV, TBC, Hepatitis, other forms of infectious diseases, and of course, all of the prison systems today have to solve the question of COVID-19. There can be poor hygiene and sanitation. Prison can be a very violent and stressful environment in some countries. Poor nutrition, potentially. And in some countries there's low or even no access to proper health care. So you can imagine all of these things working together to have negative health consequences while you're in prison.

 

Matthew [00:04:42] But on the other hand, imagine there's this positive health shock. Imagine that there are a whole number of potentially positive channels. You're keeping people sober and drug free for a longer period of time. We know for people with mental health issues, for example, having daily routines and regular meals is important, adhering to medication regimes, so in other words, someone's there to help you comply with your medication regime or your health care regime because we know noncompliance—in other words, not taking your medicines on a regular basis—is a huge problem. But then also there could be that some people are gaining access to health care treatment that they either didn't seek out or couldn't afford when they are outside of prison. So the prison system can offer health care treatment. They can also offer treatment for drug abuse, et cetera. And what we'll see, for example—and we'll get into this when we talk about the Swedish context—is that the treatment plan that you're given when you arrive in prison is actually a function of the time served because people serving very short sentences might not even have time to make it in to these treatment programs. So there are a lot of both negative and positive channels that prison could have on your health that are contemporaneous.

 

Matthew [00:06:03] And then in this study, we're going to be talking about the effects that prison might have post release. So once you leave prison, well, we think there could be these direct channels that if you're infected by HIV or COVID or something, that will of course affect you even when you leave prison—or the stressful environment, poor nutrition—these can have long run effects—or low access to health care—these things can affect you after you've left the prison system. But then there also might be indirect effects. This is something we- Randi and I tend to call the "healthy lifestyle hypothesis," that if prison makes you stop committing crime, then basically you're living a more healthy lifestyle once it's over. So these post release effects can be either direct through health care provided while you're in prison or they might actually be indirect by you living a healthier lifestyle once you leave prison, and in particular by not returning to a dangerous environment and by not returning to crime.

 

Jennifer [00:07:08] Your paper is titled "The Health Effects of Prison," and it's coauthored with Randi Hjalmarsson. So before the study, what did we know about the net effects of incarceration on health?

 

Matthew [00:07:19] So there's a difference between what we know, the effects of prison. So the causal effects of prison, we actually know very little. But there's a very large literature, I mean a very large literature. We know quite a lot about the health of current and former inmates. So this is a big question in the medical literature, in the public health literature, penology and criminology as well, and there's studies from all over the world. So we have documentation of the correlations. We have documentation of studies that measure health at intake, when you start at prison, they measure health during prison, and they also measure health after prison. And there's a universal consensus—so the reading is very bleak—so there's a universal consensus that mortality rates for former prisoners are much higher than those of the general population. And these are both from natural and unnatural causes. So suicide, for example, is one of the leading causes of death for former inmates. But then, of course, there's also overdoses and violent deaths.

 

Matthew [00:08:23] So there's a very large literature showing the correlations between prison and health. And a couple of examples- several examples- so one that I'd like a lot is written by Patterson. It's in the American Journal of Public Health. It's from 2013. And she looks at New York State parolees. And so everyone has been in prison. So her question is similar to ours, does more time in prison affect your health? And in her paper, she compares those with longer and shorter sentences. And she has nice data and has nice control variables. And basically what she finds is that an additional year in prison—so, for example, moving from three years in prison to four years in prison—actually reduces life span by two years, which is an incredible number. Right? I mean, this is really important. One additional year in prison is correlated with lifespan expectancy that's two years shorter.

 

Matthew [00:09:25] There are similar studies for Sweden that are talking about suicide, for example. The suicide rate among former inmates in Sweden is about 18 times larger than the general population. And in the data we're going to talk about today, you'll see these incredible numbers. So 10 years after release, 13 percent of our population, our prison population has died. Now, 12 percent of the prison population dies before the age of 50. And if you compare that with comparable demographic groups in the general population, that's about three percent. And if you were to compare it to academic professors, then the number would be around one percent. So the mortality rates from both natural and unnatural causes are very high among former prisoners and it's a very well studied population.

 

Matthew [00:10:17] Now, the question then, of course, is whether this is purely correlational or whether it's a causal effect. So these groups of people have poor health when they arrive at prison. They have poor health during prison. So it might not be so surprising that they have poor health after prison. So there's a large literature, but really it's a very small literature, if any. I mean, maybe I could go out on a limb and say that we're among the first to really try and get at the causal effect of spending more time in prison, the mortality of former inmates.

 

Jennifer [00:10:58] So why don't we know more than we do about the causal effects? Why is it so difficult to measure the effect of prison on someone's health?

 

Matthew [00:11:06] So as I was saying, I was- so typically we talk about, well, is it because it's hard to find data or is it hard to find a causal experiment? Right. So we're not running randomized trials. You know, we're not flipping a coin and sending some people to prison longer and some people to prison shorter. So it would be unethical to run experiments on this group of people. But as I said, what's difficult to disentangle, why it's hard to get at the causal effect, is the fact that those who go to prison have very poor pre prison health. Right. So it's a negatively selected group. Those that go to prison are less healthy than those who don't go to prison. And among those who go to prison typically, and in particular in the United States, those who are in prison for longer periods of time are more negatively selected than those who are in prison for shorter amounts of time. So it's difficult to disentangle. It's difficult to identify the causal effect due to this negative selection of the the the prison population, their their initial disadvantage. And we must also keep in mind that they even return to more unhealthy environments once they leave prison.

 

Jennifer [00:12:27] Yeah and so you mentioned the study before in New York where she had nice controls. But I guess the concern here is that there's always stuff you can't see in the data.

 

Matthew [00:12:36] Exactly. And what we're afraid of is this piece that we can't see is going to be related negatively to your health. So this piece that you and I can't measure is more likely also going to affect your health outcomes. And this is why we need to find some form of what we call exogenous variation. We don't want to flip a coin, but we're looking for something in the data that is similar to a coin toss. We want people to stay in prison for a longer amount of time, but we want that to be uncorrelated. Well, we don't want them to stay in prison for a longer amount of time. We want to see that the variation in the amount of time you spend in prison is uncorrelated with both your observable and unobservable characteristics. So identification of the causal effect really is the barrier. There are many people who collect a lot of data on this. Although I will, you know, I do think that we have exceptionally good data because, as you see, we'll be using Swedish registered data for the entire population and the entire prison population as well.

 

Jennifer [00:13:47] Yeah we'll get into the dream dataset you have in a moment. Yeah, so you find a policy experiment. So in the 1990s, there were two policy changes in Sweden that provided sudden shocks to the length of time someone with a particular sentence would spend in prison. So tell us about those policy changes.

 

Matthew [00:14:05] So prior to 1990, or actually prior to 1993, so in the 80s, if you were sentenced to four more months of prison in Sweden, you served half of that time. And this was a strict rule. So we don't have any "you're not released for good behavior" and you're rarely, if ever, kept longer for bad behavior. So if you're sentenced to one year in prison, then you serve six months and then you're put on probation. OK. Now, in July 1993, there was a new policy put into place. So if you were convicted before July 1993, let's say to one year, then you served six months. But after the reform, those who were sentenced between four and 23 months of prison actually now had to serve two thirds. So we call this the two thirds reform. Before the reform, you serve half of your sentence. After the reform, you served two thirds. And this is more or less of a strict rule that applies to to the entire prison population. So we see this increase in the amount of time, not that you're sentenced to—you're still sentenced to the same length of time—but you have to serve a larger share of that time.

 

Matthew [00:15:24] Now, in 1999, after examining and evaluating and thinking about this policy, they extended the same policy to the entire prison population. So even those serving two or more years in prison. So after 1999, everyone serving four or more months in prison- excuse me, once again we have to distinguish between being sentenced and the amount of time you actually serve. So the first reform affects those sentenced between four and 23 months. The second reform in 1999 affects those sentenced to 24 or more months. So now everyone sentenced to four more months has to serve two thirds of their time. Whereas before these reforms, you served half of your sentence. So what we're going to do in this paper is we're going to try and measure the effect of spending more time in prison. And we use this reform and we say that you're fully treated if you're in the new two thirds regime. Our control group then is going to be those who are in the old half time regime.

 

Jennifer [00:16:41] Yeah, so walk us through the what you actually do with the data in this natural experiment a little bit more. So you've got people who are convicted right before the policy change and people convicted right after. So you're going to compare those two groups?

 

Matthew [00:16:55] Exactly. So- and we're going to kind of even do more than just those. So we're going to do this even finer than that. What we do in the paper is that- imagine that both you and I steal a car and are convicted and sentenced to 12 months in prison. You're convicted before the reform and I'm convicted after the reform. You and I are identical. We committed the same crime. We were sentenced to the exact same number of months, 12. But you were convicted and sentenced before the reform. And I was convicted and sentenced after the reform. So now we're kind of like in our coin toss, right? We have two identical people and we flip a coin. You're convicted before, I'm convicted after. You serve half of your time, you serve six months in prison. I serve two thirds, I serve eight months in prison. So now all of a sudden, I serve two more months in prison than you do. And this has nothing to do with who I am or my observable or most importantly, this has nothing to do with my unobservable characteristics. Remember, we were worried about these negative unobservable characteristics that would drive both the fact that you spent more time in prison and the fact that you had worse health. Now we take two identical people and it's just by chance that the one serves two more months in prison than the other. And now, as I said before, we are going to look within sentence month bins. So we're only going to compare people sentenced to four months with other people sentenced to four months. People sentenced to 12 months are compared to other people sentenced to 12 months. And even within these bins, we compare people who commit the exact same crimes and have similar criminal histories.

 

Jennifer [00:18:45] So how big a change was this in practice? How much longer did individuals spend in prison on average as a result of these policy changes?

 

Matthew [00:18:52] So on average, it's just shy of two months. So we're going to restrict our study today to those sentenced to four to 48 months. So the typical treatment here is two months longer in prison, but some people serve up to eight months longer in prison. Now, there's also one other important thing to note here is that the probation system in Sweden is actually quite different. Right. So there are two things that are quite different. One, we have no kind of early parole system. So these are strict rules, half time and two thirds. So that helps our study. The second is that the probation system is also different. So everyone is on one year of active probation, regardless of how much time you had left to serve before you were released. And then we have this residual passive probation that people with longer sentences can still be exposed to. So neither the sentencing rules help us, but also the probation rules help us because probation are basically not changing after the reform.

 

Jennifer [00:20:01] And what was the what was the motivation for this policy change? Is this sort of a tough on crime move or what was going on there?

 

Matthew [00:20:08] Yeah, so that's quite interesting and this has been studied a lot by criminologists and political scientists, so it's actually very well documented and we can follow when different decisions were being made. So actually, you have to go back to 1983. So before 1983, everyone was serving under the two thirds rule. So really the half time rule was the experiment and the experiment ran for ten years and then was removed in two steps. Right. For the shorter sentences in 1993 and then the longer sentences in 1999. Yes in part it was a tough on crime, but it was more that the half time reform was this lenient on crime reform that politicians were maybe somewhat skeptical to. And the police and the general population. But as in many countries, there are kind of policy cycles that go up and down. So the 80s was a time where the social workers and prison workers really thought that shorter sentences and the provision of more treatment was the way to solve crime. There was a lot of discussion around this, but there was a good consensus. So this reform didn't catch people by surprise. And it doesn't surprise me now that I've read the kind of the underlying history behind the reforms. So basically, it was a return to the status quo that was before 1983 is the short answer.

 

Jennifer [00:21:42] That's really interesting. OK, so tell us a bit more about the context you're studying. You're focused on the effects of spending more time in prison in Sweden. So what are prisons in Sweden like?

 

Matthew [00:21:52] Yeah, so and it's also very interesting that- so what I'm going to describe, we have to kind of separate between two things, but they're quite related. I want to talk about the prison system that existed in the 90s because that's the time of the experiment. And it is in many ways quite similar to the prison system that we have today. But today and I mean, literally just today, the director general of the prison system was in the news and he had a debate article in Sweden's largest newspaper about just today, September 22nd 2020, they've hit the ceiling. So they're at full capacity for the first time in a long time. And it's interesting that the Swedish population is interested in this question and that they want to talk about it and that it's getting so much media play right now. And what he's worried about is he's worried that overcrowding is going to lead to the fact that they might not be able to give prisoners the treatment that they need in order to help them reintegrate into society. So that's what's happening literally today as we speak.

 

Matthew [00:22:56] But if we back up, I'll talk about what prisons looked like then. And prisons today look quite similar to that. So the prison population is much smaller in Sweden. That's where we should start. So it's 25 percent smaller than the European average. Sweden is a country of 10 million people, about the size of Michigan or Ohio. So 25 percent smaller than the European average, and it's 10 times smaller than the US, which, of course, the US is the outlier here. So we have roughly 10,000 people churning through the system each year, but we only have about four or five thousand places. So their sentences are much shorter in Sweden. So that's important to keep in mind as well. Sentences are based primarily on your current offense, not on your past offenses. So in our data during the 90s and early 2000s, the average sentence length is about five months. And 85 percent of the prison population has a sentence of less than one year.

 

Matthew [00:23:59] Prisons are also smaller, so on average, prisons only hold 85 people. So we have a lot of prisons that are smaller. The largest prison holds about 422 people and or 420 people. And really some of those places are used in reserve to keep people temporarily. So you can imagine it's not quite what we're used to in the US context. These are smaller. Everyone has a private cell where you can close your door. The cells are on a corridor, and the corridors then connect to kitchens and recreation facilities. When you arrive at prison, you have—and this is quite important to our story, now, the things that I'm going to say here is that—when you arrive to prison, you get a personal treatment plan. So you sit down the first week in prison with the health care officials but- and with the rehabilitation staff. And you make a plan. OK, so do I have any health issues? If so, what do I need help with? Do I take any medications? You have a health exam where they look for any problems. Then you make a plan for education, for work in the prison, for staying in touch with your family, for staying in touch with your children, what about visiting hours, etc.-, education. And also there's a clear end date which they find is very important. People want to know what's the end date? So everyone gets an individual treatment and action plan that they're supposed to follow while they're in prison. You're placed close to home, if it's deemed suitable. Some people are moved far away from home on purpose. We have the highest cost per prisoner in the world, but similar to some of the other Nordic countries. And we have the lowest- one of the lowest inmate to staff ratios in the world.

 

Matthew [00:25:54] And if we want to talk a little bit more about the health care that's provided, each prison has a clinic that is open every day and there are always nurses on call. Medical doctors visit a minimum twice a week, depending on how large the facility is. And the larger facilities, which I mean, 2- to 400 people will have full time psychologists working Monday through Friday. They also have trained staff that help administer medication. So you're not allowed to keep medication in your cell. So someone comes to you and gives you what you need on a daily basis. And there are a lot of different treatment programs available. You'll probably recognize the names of some of these treatment programs because Sweden borrows programs from the US, they borrow them from the UK, and they borrow them from Canada. So, for example, there are several versions of the Addicts and Alcoholics Anonymous 12 step program, although it doesn't really have the religious flavor in Swedish prisons. We still have this 12 step program that's provided in different amounts. Motivational discussions, but then also the Correctional Service of Canada's program. They have a program for offender substance abuse called the OSAP. So that's another one. So we have programs that are quite similar to those in the UK, Canada, and to some extent to the United States.

 

Matthew [00:27:18] To sum it up, we have very good prisons when you look at it in international perspective. So one of the questions I typically get then is, well, if prisons are so good in Sweden and in the Nordic countries, typically better than the US or in other countries, then what can we learn from studying Swedish prisons? And I think actually we can learn quite a lot. I think it's quite interesting. If you use that kind of as a proof of concept- so imagine we ask the following question. But first, let's go back. All of the correlation literature, without exception, shows that former inmates have really high rates of mortality higher than the other rest of the population. Then the question is, does prison harm health and increase mortality? Then let's refine the question and say, must prison harm your health? Does it have to harm your health? How would we even study that? Well, you'd go to a country that has good prison conditions and then you'd ask whether good prison conditions harm your health. And if they do, then you know that prison in general must be harmful. So that's one of the ways I want to think about it. And maybe towards the end of the talk today or the end of our discussion, we can talk about some of the lessons for the US and compare it to some of the other studies in the US to see if we can come up with what can we learn from Sweden and how can we apply this maybe to other countries.

 

Jennifer [00:28:50] Yeah. And so just within the Swedish context, you're going to be looking at what's the effect of staying in prison longer versus being released earlier. So, again, let's talk about the context here. If someone's not in prison in Sweden, if they get out earlier, what types of health care services are likely available to them in their communities?

 

Matthew [00:29:09] Yeah, so this is interesting and important, too. So not only is the treatment different, but the lack of treatment, you know, as we typically call the counterfactual, what happens outside of prison. So, of course, Sweden has a tax financed health care system that is easily accessible and open to all. Right. We have to pay a small fee when we go visit the doctor or nurse. It's about 15 dollars, which is small for you and I. It could be a hindrance to some people, especially this group of people. But it's also- there's a cap so that you never have to pay more than 150 dollars a year in total to visit doctors and nurses in Sweden. We do have to pay for prescription drugs. And again, there's a cap at 250 dollars a year, so never more than 250 dollars, which is not a large sum for everyone, but it might matter for others. There is one oddity in the Swedish system, in my opinion. We do have to pay for dental and eyeglasses. Those are only covered for children. So adults have to pay that out of pocket. There are voluntary rehab programs outside of prison. There are even forced rehab programs, but they're not used very often. Imagine someone is- becomes a ward of the state for mental health issues or for serious drug abuse issues. But it's not used very often.

 

Matthew [00:30:27] I would, however, say that there are good mental health care services in Sweden, but I would argue that they're rationed to a larger extent than the regular health care services. This is another oddity. Well, maybe not an oddity. Maybe this is in other countries as well. But it seems that the waiting times to get into the mental health care service are longer than what you might think. But, of course, as in other countries, we have health care available. But then the question is about take-up rates. And this is something, again, we want to look at more closely in the future. Just because services are available, some populations might not take up these services. And even those who do take up these services, imagine if you have problems with drug addiction and you're also a diabetic. How easy is it if you're couch surfing or maybe even living on the street or you're having problems in general, how easy is it to comply with your medical treatment plan if your life in general is not so stable? So this is another thing we'd like to look at is- about this population. How much health care do they use when they're outside of the prison system?

 

Jennifer [00:31:49] So one advantage of doing a study like this in Sweden is that you have all the data you could ever dream of, or at least close to it.

 

Matthew [00:31:55] Almost, almost.

 

Jennifer [00:31:58] So tell us about the data that you're using for this study.

 

Matthew [00:32:01] Yeah, so we've spent a lot of time. So we're using data for this study, but the data we've collected is for a larger project. So we spent several years getting seven different government authorities to cooperate with us and supply us with registered data for the full population. And in today's paper, we are going to be using the full population of inmates from the Swedish prison and probation service. And we have everyone who's ever entered the prison system since 1992. We also at '92 have a snapshot of those who were in prison in '92, so those who'd entered earlier. So we have the entire population. And then also we can do comparisons of our prison population with the general population because we have a sample of the general population as well. So we know the start date of prison and we know the end date so we can count the number of days that someone has been in prison. But then remember, the key to our identification strategy was we need to know the conviction date because it's the conviction date where you're convicted and sentenced before the reform or after the reform. So we go to the convictions register from a different authority, and from there we can get the conviction date that led to you being put in prison. But there's also- that also lets us measure and control for criminal history. And it will also allow us to study recidivism, future criminal acts once you've left prison.

 

Matthew [00:33:35] Then we match this data set- so now we're only going to be looking at prisoners in this paper. And then we match this with both inpatient and outpatient hospital records. And what we can do with that is that what we'll do is we'll look at the nights that you spend in the hospital. And we divide that up by looking at people who've spent nights in a psychiatric ward, an alcohol ward, a narcotics ward, or a general ward—and general is just everything else—but we take out maternity wards because we don't want to get that confused in here. We know their hospital history and even post release hospital stays, we know that as well.

 

Matthew [00:34:16] But then our main outcome then is going to be mortality. So we are going to follow people every year, up to 10 years after being released from prison. And we have an all-cause mortality variable. So did you die, yes or no? But then, of course, we also have the ICD codes, the ICD 10 codes, and we have these codes and we're mainly looking at the primary reason for death. Sometimes someone has more than one ICD code. And we're looking at the ICD 10 codes for suicide, intentional violence. And these are extremely- I mean, this population has a large number of suicides and intentional violence, murder. So those are the two leading causes. And then overdoses, I guess, if you put in overdoses as well. Those are the three leading causes of death. But then we also have ICD codes for circulatory cancer and digestive. And basically that covers like 80 percent of the deaths in the entire population of prisoners. We also have a coroner's note. So you get this ICD code, but the coroner also makes a note whether she or he thinks that the death was alcohol or narcotics related. So those can overlap, these the corner notes can overlap with the ICD codes. Whereas the ICD codes are mutually exclusive.

 

Matthew [00:35:40] Then we match on the usual suspects. We have their birth dates, their immigration status, income, employment, whether they have children or not, whether they're married, etc. And in part, the immigration data is important because we also want to be able to make sure that they don't emigrate from Sweden. So we look at people who are released from prison and are alive and living in Sweden that they haven't emigrated because, of course, if they emigrate from Sweden, then we can't see when they die.

 

Jennifer [00:36:13] OK, well, let's talk about the results. What do you find is the effect of spending more time in prison on mortality?

 

Matthew [00:36:19] OK, so contrary to previous correlational evidence, we find that more prison exposure reduces the overall risk of death. But when we look at the entire sample, we always find that mortality goes down, but they're not always significant defects. Right. So there's an amount of imprecision in these estimates. So it's really only at the two year mark that we can see a marginally significant reduction in deaths. So two years after release. So the estimates are always negative and negative means that death rates go down. So mortality is always lower in our estimates. But what's interesting is despite the fact that they're imprecise, is that we can clearly rule out midsize effects or large size effects. So the kind of correlations that you see in the descriptive studies that are out there, we can rule out those. Our data are not consistent with that, despite that we have a precision problem- or, not a precision problem, the data is what it is. So we see that our estimates are negative. Death rates go down, but they're not always significant.

 

Jennifer [00:37:35] And then the picture becomes much more interesting when you look at the different causes of death. So what do you find there?

 

Matthew [00:37:41] Yeah, so again, I think if we want to talk about interesting, I still want to argue the following. And the same thing is in a more in a more recent- an American study, the fact that we can get zeros when all of the previous literature says that prison should be very, very detrimental to your health, it should raise the risk of death. The fact that we get zeros that actually look more like decreases than anything else, I think that is the first main takeaway- that we can rule out large causal effects of prison on death for the population as a whole. But of course, it's much more exciting with like significant effects and so on. So first I'll talk about, you know, if we look at subsamples of the data, what we see is that for any cause of death—again, just death, yes or no, our all-cause death measure—we see that for subsamples of the population, we actually get significant decreases in the death rate. And it's interesting that this- these subpopulations are actually more positively selected. So it's those who are less serious criminals or who had prior employment, they were not far away from society. Right. They were closer to society than the others. And we do see that spending more time in prison reduces the risk of death for this particular group of people.

 

Matthew [00:39:07] But I think almost more interesting to me, because I guess we haven't really talked about the descriptives of this population. I mentioned that the population we're looking at has these really high death rates. Within 10 years of being released to prison, 13 percent of our sample dies within 10 years. So there's this huge number. But what I didn't say before is that there is a huge issue of mental health in this population. So 20 percent of our sample has spent at least one night in a psychological ward in the five years preceding going to prison. And it's not just that they showed up to like get some kind of treatment or some kind of care. They actually spent the night in a psychological ward. So one in five of our prison sample has spent the night in a psychological ward. And what we know from the previous literature is that suicide is one of the major one of the major causes of death. Here is where prisoners really stand out. And what we also know is that there's this mental health issue in the prison population. So then what we do is we go on and look at death by cause of death. OK. So we look at suicide and there we find across the board significant reductions. So we find them in the short, medium, and long run. So spending more time in prison—that is being fully treated by the reforms, you spend more time in prison—lowers the probability of committing suicide by about 38 percent 10 years out. OK.

 

Matthew [00:40:48] We also then look at violent deaths, which is another thing that's very specific. And there we find reductions in violent deaths, but only in the short run. So only in the first year after release. And the last kind of interesting cause-specific finding that we have, not in the short run but in the long run—so 10 years later—we find that death from circulatory causes is reduced as well. So we find that- we find the zero effect for overall mortality rates, but then it's- mortality goes down for some populations. And then when we look at cause-specific rates—and we chose these causes because these are the ones that are important for the prison population—and we see that indeed spending more time in prison, and what we're going to claim is that it's getting more treatment focused on mental health issues while in prison, lowers the suicide rate among this population. There are fewer violent deaths and in the long run, they survive and die less often from circulatory death.

 

Jennifer [00:41:57] So people who are incarcerated tend to be an extremely diverse group and we might expect different subpopulations to be affected in different ways. You already talked about this a little bit, but say more about what you find when you look at the heterogeneity among this population.

 

Matthew [00:42:13] Right. So so what I've said so far is that we see significant reductions in the risk for suicide in both the short and the long run, very large effects. And then we also see in the short run effects for violent death and then also in the long run for circulatory death. So what we wanted to do then is we wanted to look at each of these causes of death to see if the effect size was driven by particular populations. So you can imagine, for example, is- are our results concerning suicide driven by those with previous mental health issues? And this is exactly what we find. So if we break up our sample into those who have experienced and have spent time in psychiatric wards before versus those who have not, then we see that it really is the population of individuals with previously documented mental health issues that go to prison, spend more time in prison, and have a lower rate of suicide.

 

Matthew [00:43:16] Now, we also then looked at for violent deaths, well who's driving these effects? And it is those who are more prone to violent crime, so it's those who have committed violent crimes, who then later do not die a violent death, at least in the short run, in our in our sample. And then circulatory death, I think this is kind of interesting because it's also a question of when we think of circulatory disease, we think of this being a long term lifestyle effect. And we find two things here. The first thing we find is that it's the older prisoners who are the ones where we can see these effects. Right. They're- the ones who are over the age of 45—well, actually in the paper we cut the age at 33 so above age 33—but it's the older prisoners, and what we'll show shortly is that it's the older prisoners who've been in prison for a long time, this is the group that has- we lower the chance of dying from circulatory diseases in the very long run. So you can see that there are different populations. Right. Our results for suicide are being driven by one population, whereas our results for circulatory death are being driven by another population. But these results seem to make sense because they're driven by the populations where these causes of death are more acute.

 

Jennifer [00:44:43] You also consider whether the effects vary with the length of the sentence. So what do you find there?

 

Matthew [00:44:48] Yeah, so before we talk about the length of the sentence or the questions like why we're interested in the sentence the sentence length, so the question is whether the effects I guess one of the questions is whether the effects are linear or not. So in other words, does making shorter sentences somewhat longer have the same effect as making longer sentences much longer? Right. So so it's not clear that they will- and I actually think- so, this is one of the things where I think the economics of crime literature, this is one of the big questions I think we should be looking at. And there's this really nice paper by Evan Rose and Yotam Shem-Tov, "Does Incarceration Increase Crime?" where they're trying to see whether they're making sentences longer affect recidivism or not. So I think that's a very interesting topic to study.

 

Matthew [00:45:38] So in our context, we want to know whether it's making long- short sentences somewhat longer or is it making longer sentences even longer that drives our results? But at the same time, we've already shown that there are heterogeneous effects. And we also know that there are compositional differences. For example, those in the four to 12 month bins have more mental health issues and they're less serious criminals, whereas those in the 48 month bins are more serious criminals, more violent criminals. So it's going to be difficult for us to distinguish between are there non-linear effects or are effects at different sentence lengths, are they simply driven by the fact that there are different people at different sentence lengths? So what do we do? We take our data and we run the same regression, but we first run it on those only serving four to 12 months. Then we run it on those 13 to 23 months and then we run it on those 24 to 48 months. We run these regression separately where each new regression is for a group of people who's spending a longer time in prison than the one before. And then basically we say, well, are the effects, do they differ by sentence length? And we don't actually see a lot here. The estimates become somewhat less precise. There are not a lot of differences between these different groups. Remember, also, we're looking at those from four to 48 months. So we're not really sure what would happen if we looked at people at five years sentences or 10 year sentences or 20 year sentences. And those kind of sentences exist in other countries.

 

Matthew [00:47:26] So- but we do find one interesting result, or at least one that I think is particularly interesting. And this actually relates back to what I said before about circulatory death, is that older inmates who are serving longer sentences, they're the ones who are driving this effect on circulatory death. And to me, that seems to make sense because to have an effect on circulatory disease, you would think that you have to spend a longer time in prison before you could actually get effects from spending more time in prison. And then we only see it in the older population because that's when circulatory diseases start popping up in the population. They just don't pop up in the young population. They pop up when you're older.

 

Jennifer [00:48:10] OK, and so you then consider the potential mechanisms underlying these effects that you just talked about. First, you consider whether the policy changes affected the prison experience in ways other than simply increasing the time spent behind bars. So what are you worried about here and what do you find?

 

Matthew [00:48:29] Yeah so it's not so much a worry as it is a question of what are the mechanisms. So basically, the entire time I've been talking, I've been saying the reform has increased the number of days that you spent in prison. So I'm saying it's spending more days in prison. That's what we're studying. And that's the mechanism. Right. But the reform could also be viewed as a package. So what we want to know is what is it about this package that is driving these effects that we see? Is it, as we claim, more days in prison or could there be other things happening? Because you can imagine more days in prison, all else equal, will mean that the stock of prisoners is growing. Right. So what if this leads to overcrowding and if overcrowding has a negative effect on health? So that works against us finding beneficial effects. But at the same time, that might mean we're underestimating the beneficial effects. If there's overcrowding due to the reform, we want to know because that would be one of the channels that we're studying. It would be part of the package. Or whether because people have to spend a longer amount of time, they're being put in different types of facilities. So then it would be- the question would be, well, being in a different facility, does that affect your health? Or it could be changes in peer composition, et cetera. So we try and think about, well, if this reform is a package with a number of ingredients, do we see any changes in these other ingredients? And the short answer is no. We don't see overcrowding, people don't get put into different kinds of facilities, and the average characteristics of your peers don't tend to change between those who are spending time in prison before and after the reform. So our short answer to this is no. And the main effect of the reform really is spending more time in prison. That just helps us understand what's going on here more and allows us to get back to the question at hand of increasing the number of days in prison.

 

Jennifer [00:50:30] So another possible reason that this policy change could be affecting health outcomes is that inmates are receiving more and or better health care while they're behind bars. And that's sort of the case they've been making all along. So you were able to obtain detailed data on prison health services, which help you shed light on this. What did those data tell you?

 

Matthew [00:50:50] So just so that the listeners are clear on this, those who haven't looked at the paper yet, for inmates serving time during the 1990s and early 2000s, we weren't able to get their health care usage while they were in prison. But starting in about 2001, 2002, we can get very detailed health care data. So we know exactly what medicines you're taking, what treatment programs you're taking, how many, etc.. And what we see is that inmates are offered tremendous amounts of health care services: nurses, doctors, necessary medications, visit with the psychologists. But what's also interesting is that all of these things are kind of lumpy. So spending more time in prison actually gets you more treatment and more intense treatment than spending less time in treatment. In fact, the people who are not included in our sample—those serving one to three months—they actually don't get enrolled in treatment programs at all, which really surprised me. Right. But the prison authorities say, well, but they're in for such a short time. By the time they get settled in prison, we can't offer them- the programs we could offer them would be so short that they wouldn't be very meaningful.

 

Matthew [00:52:06] So what we can see is both in terms of health care, but then also even in treatment programs. So the probability of entering a treatment program rises rapidly as you move from four months to eight months to 12 months. It doesn't peak until about 32 months. So there's a rapid rise in being offered treatment programs as you spend more time in prison. And then also the intensity of these programs depends on the number of months that you are going to be spending in prison. And some people spending longer sentences are actually enrolled in more than one program. So without getting into too many details, the simple punchline is there's a lot of service available to inmates, both health services and treatment programs, and the quantity and intensity or the being enrolled, the extensive margin—are you enrolled in a program, yes or no—and the intensity with which you're treated increases rapidly as we lengthen the prison sentence. And we really do believe that this is the main mechanism. We think it's a direct mechanism, that getting more health care in prison improves your outcomes once you leave prison.

 

Jennifer [00:53:28] And finally, you consider whether spending more time in prison reduces recidivism or increases employment upon release. If so, those might be the reasons, or at least part of the reason, that we see long run effects on health. You're able to test this directly using your data. So what do you find? Is it possible that this explains your results?

 

Matthew [00:53:46] Yeah, so as I said, we like to call this like the the "healthy lifestyle mechanism." And basically the idea that we have is that if you- if prison helps you to- it rehabilitates you so that you don't commit crime, and we actually do see that recidivism goes down. So reform exposure decreases the two year risk of returning to prison or the risk of returning to prison within two years by about four percent. We also see that short term employment rates go up for the people who have spent more time in prison. So we find these other outcomes that are also benefiting these people. So the question is whether- because we, you know, as labor economists, we think that, you know, income and employment and so on, that could have- having good income and employment outcomes could actually benefit your health and well-being. So what we see is that there are beneficial effects in terms of not committing crime and higher employment rates and higher earnings for these people. So we're wondering if the health effects that we see could be driven by these kind of changes in healthy lifestyles that are not related to the health care that you received when you were in prison.

 

Matthew [00:54:55] So basically then what we found is that we think there are two potential mechanisms. We have this direct mechanism of health care treatment improving health outcomes, and we have this indirect mechanism, where lifestyle changes might improve health outcomes. But at the same time what we find is that the population driving one set of results is different from the population driving the other set of results. For example, remember we said that those with the overall mortality decreases was driven by the more positively selected inmates, those who were closer to the labor market and less criminal. Well, here we see these beneficial labor market effects and reduction in recidivism, we see it among the more negatively selected population. There are some exceptions to this where the two do overlap. But in general, this indirect mechanism is driven mainly by other populations. And therefore we think that the health effects that we find are more likely driven by the direct effect of health care treatment when in prison.

 

Jennifer [00:56:05] OK, so that is your paper. Have any other papers related to the health effects of prison come out since you and Randi first started working on the study?

 

Matthew [00:56:13] Yeah, so there's a really cool study and of course, everyone says, well, Sweden, what about the United States? Well, now we can turn to urban Ohio and we can turn to a new working paper released this last summer. And I know you can get this. It's on their home page of Samuel Norris and Matthew Pecenco and Jeffrey Weaver and their paper's entitled, "The Effect of Incarceration on Mortality." So they're looking at urban Ohio, which I would say Ohio, you know, 10 million, 11 million people, industrial structures, not too dissimilar from Sweden. But of course, with different prison system and with a different health care system outside of prison. And what they do is they don't quite have this coin toss so like the reform that that we have. But what they look at is, you know, you and I go before the judge and we're both convicted of the same crime—again, stealing a car—but I'm sent to prison and you're sent home. So basically they're looking at the extensive margin—did you go to prison, yes or no—where remember, we were looking at everyone goes to prison, but we were looking at spending more time in prison. So the questions are tiny bit different. But still, they're looking at does going to prison affect mortality? And they use both an event study and also kind of a diff-in-diff analysis to see whether any are being sent to prison, yes or no, has effect on mortality in Ohio. And I think what they find is really interesting. And I would encourage people to look at both papers at the same time.

 

Matthew [00:57:41] So basically another difference is that they look at people who- the mortality risk while you're in prison. OK. So we looked at post prison. They look at when you're in prison. And what they find is that prison reduces- it actually, the mortality risk halves while people are in prison. So basically being in prison is safer than being on the streets. OK. And there's this huge effect and it saves thousands of lives every year. But what's interesting there is now I'm kind of going off script here in the sense that you know, now I'm going to interpret their paper, so it would be interesting to see if they agree with me. But here in this case, they don't spend a lot of time talking about health care or that that prison is so good, which is what I've been saying. Basically what it looks like is being on the streets is really dangerous. Right. So is- remember we're talking again about the counterfactuals, so people dying of suicide, overdoses, and murders, and other causes of death. So being in prison reduces those risks, not necessarily because prison is great for your health, it's because being on the street is so dangerous for you.

 

Matthew [00:58:54] Now, another thing they do is then they do look at post release mortality and they find zeros in the sense that they—again, let's remind what we're talking about is that the correlation literature says that former inmates have a high risk of death. They do something that's more causal and they're allowed to push those down to zero. So they don't find the beneficial effects that we find. But at least we're agreed on the fact that we don't see these negative detrimental effects of prison on the mortality of former inmates. So I think that's really fascinating. And I think for us, it's really good that there's a US study in the sense that we need more studies on the topic to get a better picture of what's going on.

 

Jennifer [00:59:42] Yeah. So what are the most important policy implications here? What should policymakers who are listening take away from your study and the other work in this area?

 

Matthew [00:59:51] Yeah, so so our main message is that health care provision in prisons can improve post release health outcomes of this disadvantaged population. But I want to be really clear about this. So what we're not advocating is locking up more people for longer periods of time. I mean, what we're saying and what our study says is that making these rather short sentences somewhat longer, it enabled the Swedish prison and probation service to provide more effective services to Swedish inmates. And this has to do with the practical way these programs are provided for people and the lumpiness of the treatments and programs. So, again, you know, making these shorter sentences somewhat longer allowed the prison officials to provide better and more effective treatment.

 

Matthew [01:00:39] And in general, if we kind of look kind of big picture, we think that the social returns to these health investments may be quite large. And the question, which we need more research on, is well, if the United States could provide this kind of treatment, the potential beneficial effects might even be larger in countries where the health care system outside, right, so the health care system outside of prison, if it is not as good and doesn't provide as much care for people for this population. There could be even bigger benefits, potentially. But also one of the ideas that I've been thinking about—and again, I really would like to hear what these American authors say about their paper or about their American study—is that the fact that going on probation and going home instead of going to prison is very risky for you. Maybe we could provide these health care and treatment programs in the probation system. And this is something I'm interested in looking at for Sweden as well. Do we have to provide them in prison or could we provide them to all these people who went on probation and could have saved them that way instead? So those are several of the points. But then also, I guess, remember when we talked about previous literature, I'd also like to point out back to this new literature that's mainly coming out of the United States showing that access to health care services outside of prison can reduce crime. And I think in general, investments in public health care programs, it's a potential avenue for improving well-being and reduce crime.

 

Matthew [01:02:21] And then the final point I'd like to make is not so much a policy lesson, but it's to remind people, remind our listeners about the large overlap between the population with serious mental illness and the prison population. So practitioners know this, the practitioners already know this, that the prison population and the population with mental health issues overlap. So last summer and the August 10th, 2019 issue of The Economist—and it might have just been in the European version, maybe it's in the American version as well—but The Economist interviewed the Cook County sheriff. So for those of you don't know, Cook County is the county in the United States for- that services the city of Chicago. So Chicago is in Cook County. And basically the sheriff there had a very long interview about exactly this topic, about wanting to view the Cook County jails more as part of the mental health institution or mental health system and the need for mental health services to be provided through the jail system, as opposed to only seeing it as some form of the criminal justice or the punishment system. So practitioners already know this, but I guess we really need to remind citizens and you and I and other people and politicians about this specific overlap in these two populations.

 

Jennifer [01:03:47] Yeah, they need resources to able to provide these services.

 

Matthew [01:03:51] Absolutely.

 

Jennifer [01:03:52] And I think politically, it just it's one of the things I hear from practitioners in the US is that it's difficult to make the case to provide a lot more services in prisons when we're not providing them to the general public. And so there is- it's an interesting political economy question about how we how we go about expanding access to the types of services and programs that would make us all safer and making sure everyone feels like it's fair also.

 

Matthew [01:04:19] Absolutely. I mean, I totally understand that. So we're- it's a difficult question, but Sweden is an interesting case, I think. And then we need cases from different countries with different systems, both prison systems and health care systems in order to kind of map out. Right. Because we can't like we can't know the truth by just one study. We kind of have to map out the territory by ringing it in with more than one study from- or looking at the same question, but from different angles to get a better view of the topic.

 

Jennifer [01:04:53] Yeah. So speaking of which, what's the research frontier here? What are the next big questions in this area that you and others will be thinking about in the years ahead?

 

Matthew [01:05:00] Yeah, so it's not a new topic, but what about going back to the "what works in prison" topic, so the economics of crime crowd, you know, we're getting into this. But imagine that it's an old topic. So it's not new. But at the same time, we're getting more skilled at providing better answers to these type of questions. So I can imagine labor economists evaluating the effects of various policies that are being given treatment programs within prisons and using the same kind of tools that we've used historically to study active labor market policies. Are some treatment programs better than others? For example, the Swedish prison system has dropped short programs saying that they don't work. Is that correct or not? And that's something that we will be helping them with in the future. Also, can we screen for mental health issues and/or conditions like ADHD and then provide long lasting treatment that could lower recidivism? We're also interested in looking at can these kind of services be provided in a probation setting? This summer, Sweden was supposed to change its probation system to a more strict active probation system, but it didn't happen because of COVID. And we're wondering with within this system, we can provide care so that we don't have to provide all of the care when people are sitting behind bars. We could maybe move some of that care to the probation system or even to the electronic monitoring system.

 

Matthew [01:06:29] So imagine also the following, you know, for young students: I don't think Randi and I will do this right now, but imagine if you're a young student and the big issue that we I mean, we're talking about it every day is how prisons are dealing with this pandemic. Right. So this is a very big public health issue. And you can imagine comparing how different prison systems are dealing with the issue and how that not only affects inmates, but also affects the people working in the prison system and also affects the populations like the home populations. So some countries are releasing people- inmates early to send them home and how that affects the spread.

 

Matthew [01:07:10] I think the next thing Randi and I will probably be doing is using this same kind of identification strategy to go back to what we first started doing, the intergenerational effects of crime. Right. This is where she and I started writing together, because you can imagine also that spending more time in prison might have effects on the spouses or the children, especially the children of these inmates. We'd also like to do a bit more descriptive work, as I was saying before. What is the take up rate and the medication programs for prisoners before they go into prison, during prison, and once they get out of prison? So we can see just continuing doing- collecting more data and continuing working on these kind of health care issues for the prison population and their families.

 

Jennifer [01:08:06] So many important open questions. My guest today has been Matthew Lindquist from Stockholm University. Matthew, thanks so much for talking with me.

 

Matthew [01:08:14] Thank you very much for having me.

 

Jennifer [01:08:21] You can find links to all the research we discussed today on our website, probablecausation.com. You can also subscribe to the show there or wherever you get your podcasts to make sure you don't miss a single episode. Big thanks to Emergent Ventures for supporting the show. And thanks also to our Patreon subscribers. This show is listener supported, so if you enjoy the podcast, then please consider contributing via Patreon. You can find a link on our website. Our sound engineer is John Keur with production assistance from Haley Grieshaber. Our music is by Werner and our logo was designed by Carrie Throckmorton. Thanks for listening, and I'll talk to you in two weeks.

Jennifer DoleacDifference-in-Differences, Incarceration, Health