Incarceration History and Continuity of Healthcare: Barriers to Care Access and Service Utilization Among Adults with Mental Illness

Abstract Background Individuals with incarceration histories experience multiple barriers to healthcare access and continuity of care. For adults with mental illness, a population facing structural inequities in healthcare, prior incarceration represents an additional risk factor for unmet healthcare needs and fragmented service utilization. Understanding how incarceration history shapes healthcare outcomes independent of traditional social determinants is essential for designing equitable reentry services and bridging care continuity gaps across criminal justice and healthcare systems. Methods Using the Andersen Behavioral Model of Health Services Use, we analyzed Wave V Add Health data (N = 3,764 adults with mental illness; 529 (14.1%) with prior incarceration). Using inverse probability weighting regression, we examined associations between incarceration history and two primary outcomes: (1) unmet healthcare need and (2) emergency department use as usual source of care. We tested ten moderators (race, insurance, health status, social status, functional limitations, chronic illness, family support, friend support, acute depression, depression score) to identify subpopulations at highest risk. Results Adults with incarceration histories had significantly higher odds of unmet healthcare need (adjusted OR = 1.45, 95% CI: 1.13–1.86) and emergency department as usual source of care (adjusted OR = 1.80, 95% CI: 1.25–2.58). Incarceration’s adverse effect persisted across demographic, economic, and clinical strata: nine of ten tested moderators did not significantly modify this association (all interaction p > 0.05), indicating a universal structural effect independent of measured risk factors. Notably, friend support paradoxically amplified rather than buffered incarceration’s effect on unmet need (interaction OR = 2.33, p=.004). Conclusions Incarceration history represents an independent and universal structural determinant of healthcare discontinuity for adults with mental illness that operates independent of poverty, insurance gaps, or illness severity. The paradoxical amplification among those with friend support suggests that emotional support increases awareness of unmet healthcare needs without corresponding access enablement. System-level rather than individual level interventions are needed to bridge justice healthcare continuity gaps.