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incarceration
To Ensure Health Equity, Congress Should Renew the Affordable Connectivity Program
As a physician delivering telemedicine-based addiction care to rural and low-income communities, the program has been the essential linchpin for creating access to lifesaving medications for opioid use disorder.
Apr 03, 2024
In an ironic twist, people recovering from opioid addiction recently gained permanently expanded access to telemedicine services through a new federal policy—but many are likely to be among the 22 million low-income households losing access to affordable internet.
The Federal Communications Commission recently began to wind down the Affordable Connectivity Program, the country’s largest, most successful internet affordability program. This government-sponsored benefit program, introduced during the pandemic, provides low-income Americans with a one-time subsidy to purchase an internet-capable device and monthly subsidies for broadband services.
As a physician delivering telemedicine-based addiction care to rural and low-income communities, the Affordable Connectivity Program has been the essential linchpin for creating telemedicine access to lifesaving medications for opioid use disorder.
I urge Congress to renew funding for the Affordable Connectivity Program and pursue legislative pathways to permanently expand internet access to all.
Substance use disorders are life-threatening chronic conditions, but they’re treatable. More than 70% of people with substance use disorders transition into recovery. However, early recovery is fragile. When people are ready to engage in care, low-barrier, rapid access to care is vitally important to support treatment success, especially during reentry from incarceration when the overdose risk is up to 129 times greater than community-based populations. Nearly half of people using opioids in rural areas were recently incarcerated, emphasizing the need for expanded rural access to treatment.
Yet, in-person addiction care is disproportionately limited in rural communities, requiring long drive times to access care. This is simply not an option for most of my patients, particularly those in early recovery. Most are trying to rebuild their lives while confronting significant financial debts incurred during past periods of expensive, prolonged substance use and incarceration. Stigma locks them out of high-earning positions, effectively segregating them to low-wage positions with limited opportunities for advancement and usually no access to benefits like paid time off to engage in care.
Many of us can get a leg up during hard times from family or peers. However, most patients in early recovery are at the starting line of repairing social relationships weakened by trust lost during active substance use and prolonged absence during incarceration. Often, the social supports they can access are facing similar resource-limited circumstances, with minimal ability or bandwidth to help with transportation or finances.
Every day, my patients choose what they can afford from a menu of necessities.
What will you have today?
- Food
- Transportation to work
- Cellphone access
- Savings toward rent
- Fees to obtain a driver’s license
Rarely can they cover more than one or two at a time. How could expensive, time-intensive travel to distant healthcare ever compete?
It shouldn’t have to. And thanks to the relaxation of telemedicine rules and the Affordable Connectivity Program, it hasn’t had to.
While the Affordable Connectivity Program’s $30 monthly subsidy sounds inconsequential, the true value of costs saved is much higher, as the collateral costs (e.g., transportation, lost-wages) of in-person services are avoided. With reliable access to data plans, my patients attend their medical appointments from their worksites during their lunch breaks or easily negotiate alternative breaks with their bosses, who are more willing to be flexible because work can quickly resume when patients remain on-site. This has allowed patients to consistently receive addiction treatment without incurring lost wages and transportation costs during the two-to-four-hour long process of in-person care. With their financial distress tempered, my patients have more quickly transitioned from survival mode to future planning.
The Affordable Connectivity Program also enabled internet access to key social resources that promote health and stability. My patients have taken online classes, searched and prepared for jobs, and built healthy social connections with online recovery communities, the latter particularly key for rural patients with limited in-person social options.
Funding for the Affordable Connectivity Program is projected to run out in April unless Congress acts quickly to renew funding. Amidst the Affordable Connectivity Program’s wind down, my team has begun switching patients to the remaining alternative telecommunication benefits for low-income households, like the Lifeline program. However, this inferior program provides only $9.95 monthly toward internet service—insufficient to cover the entire cost of a plan—and limited options of qualifying service providers. For my patients battling homelessness living in tents, cars, and motel room rentals while working tireless hours to survive and endeavor toward stable thriving, a $20 increase in monthly expenses is insurmountable.
The communities with significantly limited internet access—rural, low-income, Black—are also disproportionately impacted by the opioid crisis and low access to in-person treatment. Their precarious internet access falsely positions the internet as a luxury, rather than an essential resource for healthcare, education, employment, transportation, and social belonging. Internet access is a health equity issue.
I urge Congress to renew funding for the Affordable Connectivity Program and pursue legislative pathways to permanently expand internet access to all. Without swift action, I fear that losing the Affordable Connectivity Program will lead to more lives lost to treatable substance use disorders.
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California Flooding Highlights the Risks of Extreme Weather on People Behind Bars
State and federal government entities are not equipped or prepared to protect the 1.9 million people in our nation’s jails, prisons, and detention facilities during more frequent and severe weather disasters.
Mar 24, 2024
In February, California faced a “monster storm.” This storm was the second atmospheric river storm to hit the state within a week, leaving nine confirmed dead in its wake. While this storm was record breaking, California saw similar weather patterns and severe flooding last year, and we can only expect these occurrences to continue and increase in intensity as climate change fuels a rise in extreme weather events.
In 2023, a series of storms created Tulare Lake in a previously dry basin near Corcoran, California. Protected only by a levee in need of repairs, the highest concentration of incarcerated people in the state were left at risk of flooding. Last spring, flooding caused by storms affected visitors’ access to the Substance Abuse Treatment Facility and State Prison at Corcoran and forced the California Department of Corrections and Rehabilitation to stop accepting transfers.
Despite no news yet on the effects of California’s most recent storm on people in carceral facilities, it is only a matter of time before these stories come to light. California’s disaster response plans fail to account for its incarcerated population. Over and over again across the country, weather-related disasters have threatened the lives and well-being of people behind bars. Still, this problem remains unmitigated—state and federal government entities are not equipped or prepared to protect the 1.9 million people in our nation’s jails, prisons, and detention facilities during these disasters.
As medical professionals, we implore lawmakers and prison administrators to take proactive measures to prevent the health risks of freezing winters and scorching summers from becoming recurring nightmares in the years ahead.
These extreme weather incidents extend beyond just flooding in California. During the 2023 summer of record-breaking heat, states and the federal government put hundreds of thousands of lives at risk by confining people to carceral facilities that lack universal air conditioning and air filtration equipment—we saw extreme heatwaves and raging wildfires in Canada cause widespread panic and lethal ramifications for people behind bars, including reports of at least 41 heat-related deaths in the Texas summer alone. Over 30% of California’s wildland firefighting crews are made up of incarcerated people, putting them directly in harm’s way. Increasing frigid winter temperatures have also caused suffering and death in facilities ill-equipped with adequate heating systems. During the brutal winter storm Uri of 2021, people incarcerated in Texas prisons faced freezing temperatures and power blackouts, described by one person as “being in a meat locker.”
Correctional facilities are often situated in geographically vulnerable areas, susceptible to a gamut of natural disasters, from floods and hurricanes to blizzards and wildfires. And incarcerated people, devoid of the agency to evacuate, are left unprotected. The impacts of the catastrophic Hurricane Katrina in 2005 serve as a stark reminder of these consequences. Major flooding left prisons under water and without food and water for days due to a lack of coordination to plan and evacuate facilities, highlighting the critical need for including prisons in emergency preparedness planning. Yet almost two decades later, states still rarely incorporate jails and prisons into their emergency disaster response plans, rendering incarcerated individuals an afterthought even under emergency evacuation orders. They are often left stranded in dire circumstances, used as free labor, and denied access to critical medical treatment for weeks, if not months, during these emergency events.
As medical professionals, we implore lawmakers and prison administrators to take proactive measures to prevent the health risks of freezing winters and scorching summers from becoming recurring nightmares in the years ahead. We call upon them to develop comprehensive strategies for the threat of extreme weather, such as creating evacuation plans and implementing temperature reporting and standards for indoor temperatures—planning ahead for the weather extremes that will certainly occur can save lives.
With predictions of increasingly frequent and severe temperatures and natural disasters on the horizon, safeguarding one of society’s most vulnerable and rapidly-aging populations must be a paramount concern.
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Trump Is Being Treated Unlike Other Criminal Defendants—Better
Those looking for fairness in the criminal justice system may wish to see Trump treated like an ordinary criminal defendant. But instead, what if everyone else accused of a crime were treated more like Trump?
Aug 09, 2023
Former President Donald Trump often complains that he is being treated unfairly by the prosecutors charging him with crimes.
Trump is now the subject of three federal and state criminal cases—and it is true that he is being treated unlike other criminal defendants.
The prosecutors are treating Trump a lot better than the average criminal defendant.
Most criminal defendants are just arrested and taken to jail, where they may sit for months or even years while they await trial, unless they plead guilty.
We are law scholars who have defended clients in criminal and civil cases, and we wish that our clients received the advantages that prosecutors are giving Trump.
Early Warnings
Trump’s unique treatment began before he was even charged with any crime. First, he had ample warning of the investigations because he got letters from the Justice Department saying he was a target of each investigation. These letters were sent to Trump a few weeks before his two federal indictments in June and July 2023.
Especially in white-collar cases, criminal defendants sometimes receive target letters that warn them of an impending indictment and sometimes give them the chance to testify.
But target letters generally lack detail and are far from the norm across all criminal cases. Target letters are not legally required. The Justice Department spells out various reasons why its prosecutors do not need to send them, including risks of a defendant destroying evidence or endangering witnesses.
The Difference Freedom Makes
After Trump was charged with crimes in each of his three pending cases, his lawyers negotiated dates when he could submit to authorities for processing.
And after Trump’s brief arraignments in court, judges found he was not a flight risk and released him.
Most criminal defendants are just arrested and taken to jail, where they may sit for months or even years while they await trial, unless they plead guilty. Three-quarters of federal criminal defendants are locked up to await trial.
Defendants in courts across the country plead guilty to crimes even if they are innocent, in part because pleading guilty gets them home sooner.
It is hard for detained defendants to recover lost wages and from the humiliation they experience while in jail, even if they defy the odds and later win their case.
Pretrial detention has also been shown to result in a higher chance of being convicted and receiving longer sentences.
Indeed, defendants in courts across the country plead guilty to crimes even if they are innocent, in part because pleading guilty gets them home sooner. For some defendants, the pretrial detention is longer than their actual punishment will be, so pleading guilty resolves the case with credit for time served. But the stain of a conviction stays on their record forever.
Benefits of Time and Freedom
Because Trump is not sitting in jail, he is well positioned to ask that his trials be postponed far longer than would an ordinary criminal case. Federal law generally requires “speedy” trials, which are considered a right to protect defendants.
Trump got a lengthy delay, though it’s not as long as his legal team requested. Trump asked that his classified documents trial be held after the November 2024 election, but his trial is scheduled to begin in May 2024. Federal prosecutors pushed for a December 2023 start date. These kinds of compromise decisions are common in legal decisions like deciding court dates.
This timing gives Trump’s lawyers nearly a year to prepare arguments in his favor. They can easily meet with their client to do so, something that would be difficult if Trump were incarcerated.
Most criminal defendants face a very different experience.
For example, after federal prosecutors charged Air Force reservist Jack Teixeira in June 2023 for revealing classified information, he asked for provisions similar to those that judges made for Trump.
He argued that he, too, should be released to await trial. Teixeira did not have Trump’s wealth and easy ability to flee.
Nonetheless, the court determined that Teixeira poses a national security threat and must remain in jail. The case is still pending.
Other criminal defendants spend years in jail before pleading guilty or perhaps going to trial.
A Treasure-Trove of Information
The differences do not stop there.
Prosecutors in all three of Trump’s cases have explained, in great detail, the allegations against him.
The classified documents indictment recounted several text message conversations between Trump aides and transcribed a conversation in which Trump disclosed the contents of classified documents and acknowledged their classified status.
Prosecutors often withhold documents until the eve of trial or wait until after key witnesses have testified, all of which is legal.
The indictment regarding Trump’s alleged plot to overturn the 2020 election results was 45 pages long and included a play-by-play description of his plan.
Early in the documents case, federal prosecutors publicly disclosed key information about their investigation that could have helped Trump’s legal defense.
In contrast, criminal defendants typically do not know the precise allegations facing them this early in a case.
Prosecutors often withhold documents until the eve of trial or wait until after key witnesses have testified, all of which is legal. In some cases, they fail to disclose the information.
The Other Side of the Coin
Prosecutors’ decision to treat Trump differently from other criminal defendants could serve a few purposes.
The Justice Department is prosecuting a former president. That puts the department in a delicate, high-profile position, where it has the “Herculean task of putting an ethical rope through a needle,” as one former federal prosecutor has said.
So, prosecutors’ detailed indictments help inform the public about the breadth and depth of the allegations made against Trump.
Their approach could add legitimacy to the prosecution’s and the Justice Department’s goal of maintaining accountability and independence while countering Trump’s perception that the cases are “a witch hunt” and rooted only in politics.
What Would Fairness Look Like?
Those looking for fairness in the criminal justice system may wish to see Trump treated like an ordinary criminal defendant. But instead, what if everyone else accused of a crime were treated more like Trump?
In that world, perhaps most importantly, pretrial detention would be used quite sparingly and would not provide leverage to coerce guilty pleas. People who are charged with a crime have not been proven guilty, and pretrial detention inflicts serious harm on defendants, their cases and their loved ones.
Prosecutors would tell defendants from the earliest stage of the case the detailed allegations against them so that defendants can prepare a meaningful defense.
The U.S. legal system aims at the truth, and robust procedures serve that goal.
In our view, the more thorough the judicial process is, the more confident people can be that it reaches the right outcome—whether the case regards Trump or not. Looking at Trump’s special treatment offers a good place to start in thinking about how the criminal legal system should treat all people accused of a crime.
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