1. Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
Proposition 47 was passed in California in 2014 to reduce prison sentences for non-violent drug offenses from felonies to misdemeanors. This prop affects both future sentences and the ability to petition for resentencing for currently incarcerated individuals. While this proposition was developed largely in an effort to reduce overcrowding in California prisons, it may have significant potential health implications as well. We know that incarceration is linked with negative health outcomes, particularly related to substance use and mental health. We also know that there are significant racial differences in incarceration, with African Americans being imprisons at significantly higher rates than whites both nationally and in California.
2. Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)
An evaluation of Prop 47 is informative because, while it was not proposed as a health initiative, it may have significant health implications. It is important to understand if this proposition could reduce negative health consequences like substance use disorder, mental health diagnoses, infectious disease transmission, overdose etc. This would help us understand if reducing penalties for drug possession can have an effect on health outcomes. (Reduced sentencing may reduce other mediators that could impact health outcomes like associations with gang activity, loss of social networks, loss of job, gap in school etc).
3. Specify the outcomes and populations you think most affected or least affected by the policy.
The population most affected by prop 47 are non-violent drug offenders who would have otherwise received felony charges for their offense, but now will receive only misdemeanors. This will reduce the rate and/or duration of incarceration for these offenses and will also afford certain inmates the opportunity to petition for resentencing. Individuals with violence offenses or non-drug offenses will not be affected by the policy. The outcomes I would study are health outcomes including substance use disorder, mental health diagnoses, HIV/HCV, and overdose.
4. Propose a study design to evaluate the policy. Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
This is challenging because we cannot randomize prison sentences. I can think of two different study designs. (1) We could compare California after prop 47 with another state that has not implemented the prop. Ideally our “control” state would otherwise closely resemble California’s prison rates, laws and population. We could then compare health outcomes among this population of low-level drug offenders in both states. (2) Another option would be to evaluate health outcomes among drug offenders in California before and after Prop 47. Our “cases” would consist of individuals who were charged with a misdemeanor instead of a felony drug offense because of Prop 47. The “controls” would be individuals who matched the offenses as the cases but were charged with felonies because their sentence was prior to 2014. We would then be able to compare health outcomes for the two different populations. Either of these study designs are challenging for a number of reasons: we don’t have an ideal comparison – if we compare CA to a state without prop 47, we can approximate a comparison, but we must assume there are other differences in criminal justice policies that may affect our outcome – it may be difficult to control for all the variation. Also it could be difficult to ascribe causation to prop 47 not other policy reform efforts that have taken place between 2014-present since this was a time of significant reform. Finally, on an individual level, it may be difficult to track outcomes if individuals are not receiving medical care.