The United States has the highest incarceration rate of any country, with more than half of those individuals serving in state prisons. Heart disease is the leading cause of death for Americans. In a recent study, researchers from the Leonard Davis Institute of Health Economics (LDI) examined records from state prison systems to understand how incarceration impacts cardiovascular outcomes. They found increasing rates of cardiac death among prisoners, along with low treatment rates. In 2019, over 30% of those who died from cardiovascular disease had not received diagnostic testing, and more than 25% were not given medications for the condition that caused death.

The study, by Penn LDI Senior Fellows Lauren Eberly, Sameed Khatana, and Ashwin Nathan, and colleagues analyzed more than 18,000 cardiac deaths from all 50 states over 19 years and found that nearly one-quarter of cardiovascular deaths resulted from a condition that developed after admission to prison and that most deaths occurred after 10 years served.

Eberly discusses the study and the need for changes in policy and practice below.

What motivated you to do this work on heart care for individuals in prison?

Eberly: This work was inspired by my experience treating justice-involved individuals in my cardiology clinic. I have had many patients who developed cardiovascular disease while incarcerated and who were not receiving their needed cardiovascular medications. This research was driven by a desire to advocate for quality cardiovascular care for this population and to inform future equity efforts by examining how the racialization of mass incarceration may contribute to cardiovascular health inequities nationwide.

What is your most important finding about incarceration and cardiac deaths?

Eberly: Nearly one-third of deaths among incarcerated individuals were due to cardiovascular disease, and age-adjusted cardiovascular mortality rates have increased since 2012 among those incarcerated in U.S. state prisons. Perhaps most importantly, a large proportion of individuals who died from cardiovascular disease while incarcerated did not receive a medical evaluation (19%), diagnostic testing (31%), or medical treatment (27%) for the condition at any point during their incarceration. Black incarcerated individuals were more likely to die from a cardiovascular cause than white individuals and were less likely to receive medical care and treatment for the condition determined to be the cause of death. This provides further evidence that mass incarceration is a sociopolitical driver of health inequities.

How does cardiovascular mortality among incarcerated people compare to the rates in community-dwelling individuals?

Eberly: We did not compare the mortality of incarcerated individuals to that of community-dwelling individuals. However, we found that age-adjusted cardiovascular mortality rates have been increasing among incarcerated individuals since 2012, in contrast to a decline in cardiovascular disease mortality in the overall population from 1999 to 2023.

What limitations about studying cardiac deaths during incarceration should readers be aware of?

Eberly: The majority of people who are incarcerated eventually return to the community. This study evaluated only deaths that occurred while incarcerated and, therefore, does not fully capture the broader health impact of incarceration. Additionally, this database from the Bureau of Justice Statistics reports rates of medical evaluation, diagnostic testing, and medical treatment as binary variables. As a result, we lack further details about the type or quality of care provided  (i.e., which medications were given, which testing performed), or the timing of care relative to the death (other than excluding emergency care). This points to the need for improved transparency and public reporting of quality care metrics across all prison systems.

What recommendations do you have for policymakers about cardiac care behind bars?

Eberly: In addition to broader efforts to address mass incarceration, I think we need targeted initiatives to ensure quality and equitable cardiovascular care for this population. While prisons are legally obligated to provide adequate medical care to those incarcerated, this study and my experience treating my patients have demonstrated that the system is falling short. Currently, there are no federal regulations governing health care standards in prison systems. Comprehensive standardized guidelines for cardiovascular screening, evaluation, and management tailored to carceral settings are needed. Additionally, Medicaid and Medicare cannot pay for health care services for individuals while they are incarcerated. Enacting policies to allow for coverage continuation could increase oversight and support more standardized, quality care. Lastly, incarceration produces and exacerbates risk factors for cardiovascular disease. Carceral policies should guarantee the human right to nutritious food and dignified health care.

Where are you going next with the research on heart care in prisons?

Eberly: We hope to perform a qualitative study that centers patient voices to better understand their experiences receiving care while incarcerated. We aim to continue using this work to advocate for strategies that ensure high-quality, equitable cardiovascular care for this population, while also addressing mass incarceration as a public health issue.

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The article “Cardiovascular Mortality and Access to Healthcare Among Individuals Incarcerated in U.S State Prisons from 2001-2019” appeared in the The Journal of the American Heart Association. Authors include: Lauren Eberly, Kaitlyn Shultz, Sanjay Kishore, Margaret Hayden, Sarah Turecamo, Howard M. Julien, Emily Niklaus Davis,  Ashwin Nathan, and Sameed Ahmed M. Khatana.

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