Courtney Boen, PhD, MPH

Even when policies have seemingly nothing to do with health, they can affect health outcomes. For example, education, housing, and environment policies influence the conditions in which people live and the choices they make.

Now, a new study reveals how incarceration policies can affect health outcomes too. While less recognized, incarceration plays a meaningful role in population health and birth outcomes, according to the study from LDI Senior Fellows Courtney Boen and Atheendar Venkataramani, Penn HEDAP Analyst Elizabeth Bair, and Duke Professor of Sociology Hedwig Lee.

Atheendar Venkataramani
Atheendar Venkataramani, MD, PhD

In the past six decades, incarceration rates skyrocketed in the U.S. Researchers pointed to  “tough-on-crime” policies – many of which were implemented in the 1980s and 1990s – as a driving force. Research and policy discourse frequently lump all tough-on-crime policies together, but these policies had different goals, were subject to different levels of public discussion, and were implemented differently based on social, economic, cultural, institutional, and political variation amongst states.

The researchers focused on two of the most well known of these types of state-level incarceration policies, both adopted during the 1990s: three strikes and truth-in-sentencing. 

Three strikes policies aimed to increase sentences for individuals convicted of committing three or more serious felonies or violent crimes. While its effects on crime and incarceration remain unclear, these laws generated intense public and political discourse rooted in racism and fueled by a catchy baseball-themed moniker. 

Truth-in-sentencing policies aimed to ensure that individuals served the full length of prison sentences imposed by judges and sentencing guidelines. Some evidence has indicated that adoption of truth-in-sentencing reduced crime rates, but these laws have received generally less attention from the public.

To learn about the potential impact of these two incarceration policies on health outcomes, the researchers examined birth weights in states that did and did not adopt them. They used a difference-in-difference research design that allowed them to examine how the implementation of the policies affected Black and White birth outcomes over time. While Black infants were more likely than White infants to be low birth weight or very low birth weight and born preterm, there were different patterns of birth outcomes linked to state adoption of either incarceration policy.

States that adopted three-strike laws saw immediate worsening of birth outcomes amongst Black infants, especially those from lower socioeconomic status backgrounds. These effects, which were seen immediately after policy implementation, were not experienced by White infants. 

However, the three-strikes policies were not linked to significant increases in incarceration rates, and any changes in crime rates occurring as a result of the policy materialized after birth outcomes had already worsened, according to the study findings. The findings indicated that highly-racialized public discourse may have played a role in adverse birth outcomes among Black infants, primarily by driving stigmatization and discrimination that increased Black birthing parent stress. The authors cite immediate harmful effects of the policy on birthweight – even in advance of actual implementation of the policy – as well as the extensive news coverage of three strikes as evidence in favor of this explanation.

In contrast, the researchers found that truth-in-sentencing policies, which were less publicly discussed, were linked to gradual improvements in birth outcomes for both Black and White infants. These improvements coincided with a reduction in crime rates. 

The researchers suggest that  incarceration policies can impact  birth outcomes through three countervailing pathways:

The study’s findings demonstrated the profound impacts that incarceration policies can have on health outcomes and particularly highlighted how political and public discourse can further stigmatize, marginalize, and criminalize groups, regardless of how the policy is designed or implemented. Further research is needed to understand the different pathways through which policies impact health, and how they intersect with one another. 

Policy choices can profoundly shape population health in ways that are not always visible or easy to record, and these findings contribute to the growing literature on the differing mechanisms through which policy can influence population health and the broader understanding of symbolism in driving health outcomes. That policies can exert health impacts by changing both material circumstances or by people’s affect – even among those not directly affected – can provide a roadmap for scholars and policymakers interested in understanding links between a range of social policies and health.  

The study, “Heterogeneous and Racialized Impacts of State Incarceration Policies on Birth Outcomes in the U.S.,” was published November 2023 in the National Bureau of Economic Research. Authors are Courtney Boen, Elizabeth Bair, Hedwig Lee, and Atheendar Venkataramani.


Kaday Kamara

Kaday Kamara

Policy Coordinator

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