Medicaid work requirements are often presented as a way to reduce government spending and encourage employment. But when policies like this are implemented, the real-world consequences are often more complicated—and sometimes far more expensive than expected.

In July of 2025, the president signed legislation mandating that states implement work requirements for Medicaid recipients. In simple terms, most adults who want to remain on Medicaid will need to prove that they are working or volunteering for at least 80 hours per month.

Supporters of the policy argue that these requirements will reduce waste, save taxpayer money, and encourage employment.

But we already have a real-world example of how these policies play out.

The Arkansas Experiment

In 2018, Arkansas implemented work requirements in its Medicaid program. Several studies of the program found that the policy did not increase employment. Instead, it primarily reduced Medicaid enrollment.

Roughly 18,000 Arkansas residents lost their Medicaid coverage during the program’s implementation.

In practice, “work requirements” functioned less as an employment policy and more as a mechanism for removing people from the program.

A Population That Falls Through the Cracks

Many Medicaid recipients live with serious mental illnesses such as schizophrenia or bipolar disorder. With the right medication and support from family or community members, many of these individuals are able to function relatively well in everyday life.

But functioning with treatment does not necessarily mean someone is capable of maintaining regular employment.

When Medicaid work requirements go into effect, many of these individuals risk losing their health insurance.

Antipsychotic medications that might cost nothing—or perhaps a small copay—under Medicaid can easily exceed $1,000 per month without insurance coverage. Most people on Medicaid simply do not have the resources to absorb costs like that.

Once coverage disappears, medication adherence often disappears with it.

The Disability Exemption Problem

Supporters of work requirements often point out that exemptions exist for individuals who receive Social Security disability benefits.

This is true.

But the majority of people with serious mental illness are not receiving Social Security disability benefits. Obtaining approval for SSDI can be a lengthy and difficult process, even for individuals with severe conditions.

As a result, many people with serious mental illness remain in a gray area: too impaired to maintain steady employment, but not formally classified as disabled under federal standards.

These individuals are particularly vulnerable to losing Medicaid coverage under work requirement policies.

What Happens Next

When people with serious mental illness lose access to their medications, their symptoms often return.

Individuals who had been relatively stable in the community can quickly experience increases in psychotic or manic behavior. Unfortunately, situations like this frequently end with police involvement—and eventually, jail.

Once someone enters the jail system, the financial dynamics change dramatically.

Under the Constitution, incarcerated individuals have a right to healthcare. Jails must provide necessary medical and psychiatric treatment to the people they detain.

However, jails operate under very different purchasing conditions than Medicaid.

Medicaid programs negotiate drug prices on a large scale. Jails generally do not have that leverage. As a result, the same medication that might cost taxpayers roughly $100 per month through Medicaid can cost a jail $2,000 per month when purchased at retail rates.

Housing costs add another layer. Someone who may have been living with family members in the community—at essentially no cost to taxpayers—now becomes the responsibility of the local jail system. Housing an inmate often costs counties around $100 per day or more.

The Cost-Shifting Problem

Consider a simplified example.

A Medicaid work requirement removes someone from coverage, saving the state approximately $100 per month in medication costs.

But if that same individual decompensates, is arrested, and ends up in jail, the county may now be paying roughly $2,000 per month for the same medication, plus about $3,000 per month in incarceration costs.

What began as a $100 monthly savings at the state level can quickly become a $5,000 monthly expense at the county level.

For taxpayers, this distinction is largely meaningless. Whether the bill is paid through state taxes or local taxes, the same public ultimately bears the cost.

The question becomes simple: would we rather pay $100, or $5,000?

The Likely Outcome

When Medicaid work requirements take effect nationwide in January of 2027, the most likely outcome—based on available evidence—is not a surge in employment.

Instead, we are likely to see large numbers of people lose health insurance coverage. Among those affected will be individuals with serious mental illness who rely on Medicaid to maintain stability in the community.

For some portion of that population, untreated symptoms will eventually lead to police contact and incarceration.

The result will be increased pressure on local jail systems, higher medical costs for counties, and a significant transfer of financial and legal responsibility from state governments to local governments.

In other words, what appears to be a cost-saving policy at the state level will ultimately increase the total cost borne by taxpayers.

A Misallocation of Resources

Policies that shift costs rather than reduce them rarely represent real savings. More often, they simply move expenses from one part of government to another while making the underlying problems worse.

Medicaid work requirements appear poised to do exactly that.

Over time, policies that generate higher costs and worse outcomes tend to be reconsidered. The real question is how much money—and how much unnecessary instability—we will tolerate before that reconsideration occurs.

In a prior piece, I discussed the problematic incentive structure between many municipal governments and county governments. Here, I want to focus on a related issue: why city and town courts often do not evaluate defendants for competence to stand trial.

This is not an indictment of municipal governments. I have friends and colleagues who work in municipal systems. The point here is not to attack individuals, but to examine structures and incentives—and the downstream consequences they create.

What Is Competence to Stand Trial?

In the United States, a person cannot be legally tried for a crime, nor can he accept a plea agreement, if he is not competent to do so.

The legal definition of competence comes from the 1960 Supreme Court case, Dusky v. United States. The Court established what is commonly referred to as the “two-pronged test” for competence. To be considered competent, a defendant must:

1. Understand the nature of the charges against him, and

2. Be able to aid his attorney in his defense.

If a defendant cannot do either of those things, he is legally incompetent. This applies regardless of whether the alleged offense is a felony or a misdemeanor.

In a criminal case, any party—the prosecution, the defense, or the judge—can raise the issue of competence. If there is a reasonable question about a defendant’s competence, the court will typically order one or two independent forensic evaluations. The exact procedures vary by state, and some jurisdictions allow a single evaluation in misdemeanor cases.

If a defendant is found incompetent, the court generally orders competence restoration. Most often, that means a transfer to a state psychiatric hospital for a period of treatment, typically lasting a few months. If competence is restored, the defendant returns to court and the criminal case resumes where it left off.

If competence cannot be restored, things become more complicated. In many jurisdictions, including my own, the court must hold periodic review hearings—often every 90 or 180 days—to determine whether continued hospitalization is warranted. In practice, this can mean that some individuals remain in the state hospital system for years through repeated extensions. There is significant nuance here, but that is the basic framework.

It’s important to note that having a serious mental illness does not automatically make someone incompetent. Many individuals with diagnoses such as schizophrenia or bipolar disorder function well with appropriate treatment. Competence is a legal question, not a diagnostic one. The issue is whether the illness impairs the defendant’s understanding of the proceedings or ability to assist counsel—not whether a diagnosis exists.

County Courts vs. Municipal Courts

County-level courts are generally familiar with these procedures and budget for them. They typically allocate funds to pay outside clinicians to conduct competence evaluations when needed. If a defendant is found incompetent, court staff coordinate with the state hospital system and arrange transfer once a bed becomes available. Some jurisdictions experiment with jail-based restoration programs, but hospitalization remains the norm.

Municipal courts operate differently.

As I’ve discussed before, city and town courts often exist to retain local control and generate revenue. Competence evaluations are expensive. A relatively brief evaluation might cost $500 to $1,500. A more comprehensive evaluation can run $3,000 to $6,000. In larger jurisdictions, annual expenditures on competence evaluations can reach into the hundreds of thousands of dollars.

Most municipal courts do not maintain dedicated budgets for this.

Technically, a court cannot proceed if a defendant is incompetent. The constitutional options are clear:

• Pay for a competence evaluation,

• Transfer the case to a court capable of addressing the issue, or

• Dismiss the case if it cannot proceed.

There are circumstances where each of these solutions makes sense. But in practice, county courts are not always eager to accept transfers that come with the added financial burden of a competence evaluation and possible hospitalization.

As a result, some municipal courts rely on strategies that exist in a legal gray area.

Two Common Workarounds

The first strategy is simple: proceed without formally raising competence.

Unless someone goes on the record to question the defendant’s competence, no evaluation is required. If neither the defense, prosecution, nor judge formally flags the issue, the case can move forward.

There is an obvious risk that a conviction could later be overturned if it becomes clear that the defendant was incompetent. In reality, that risk is often low. Many defendants in these circumstances lack the resources, awareness, or legal assistance needed to file a meaningful appeal.

The second strategy involves delay.

Municipal courts may repeatedly reset court dates and continue cases for months. This may or may not be intentional. A defendant might fail to appear. A judge may not fully recognize the extent of a defendant’s mental illness. But the effect can be the same: the defendant sits in jail for three to six months while the case drags on.

Eventually, the court may offer a “time-served” plea agreement.

In many jurisdictions, defendants receive credit for time spent in jail—sometimes at a two-for-one rate. Six months in custody can translate into credit for a full year, which is the maximum sentence for a misdemeanor in nearly every state.

At that point, the case resolves without a formal competence determination.

The Downstream Costs

These practices create two serious problems.

First, they undermine the spirit of constitutional protections. The right at stake is the right to a fair trial—not the right to be processed through a legal system you do not understand, or to sit in jail for months because you are mentally ill and no one raised the issue.

Second, these strategies can create significant financial burdens—often shifted to the county taxpayer.

Consider a defendant who spends six months in county jail on a low-level charge. At $100 per day in housing costs alone, that is roughly $18,000. Add in psychiatric medications that may cost $2,000 per month, and the total can approach $30,000 for a case that began on a Trespassing charge.

The municipal court avoids the immediate expense of a competence evaluation. The county absorbs the jail costs. The constitutional issue is quietly bypassed.

Everyone technically followed procedure—at least on paper. But the incentives have produced an outcome that is both costly and troubling.

The Broader Issue

The right to a fair trial should not depend on the size of a town or the size of a court’s budget. It is a constitutional safeguard.

When competence determinations are quietly sidestepped because they are expensive, we do more than shift costs from one level of government to another. We weaken the integrity of the justice system itself.

If we care about fiscal responsibility and constitutional integrity, this is a gap we cannot afford to ignore.

I want to talk about city and town courts — and the way they interact with county jails in a way that creates a serious structural problem.

This is not an attack on municipal courts. I have friends and colleagues who work for town and city governments. Many of them are thoughtful, ethical public servants. The issue I’m describing is not about bad people. It’s about incentives.

We’ve discussed before how costs can cascade downward in government — federal decisions increase state costs, state decisions increase county costs, and so on. But the flow doesn’t always move in one direction. Sometimes decisions at the local level create financial burdens at higher levels of government.

Municipal courts are a good example.

When Towns Choose to Run Courts

Some states do not allow towns and cities to operate their own courts. Others mandate that they do. But in many states, municipalities have the option.

These local courts typically handle misdemeanor crimes, traffic infractions, and ordinance violations.

If you’re an elected official in a town, you might reasonably ask: why would we run our own court system when the county already operates one?

In most jurisdictions, counties must run courts. They don’t get to opt out. So from a purely financial perspective, a town could simply allow the county to handle its cases and avoid the overhead.

On the surface, towns appear to have a disincentive to operate their own courts. Yet many of them do.

Why?

Revenue.

How Municipal Courts Generate Revenue

Local courts generate revenue through fines, fees, and bail.

If someone is arrested and bail is set, the court requires payment for release. If the person fails to return to court, the money is forfeited. Even if they do return, courts often impose fines and administrative fees. Those funds go to the municipality.

There may be other motivations — local control, administrative efficiency — but revenue retention is powerful.

And here’s the key: to maximize revenue, overhead must stay low. One judge. One court day per week. Minimal staff.

By limiting expenses while collecting fines and fees, the court becomes a revenue center.

There’s also a political advantage. Property tax increases are highly visible and unpopular. Court fees are not. Most residents have no idea how much revenue their town generates through its court system.

In effect, municipal courts allow towns to bring in money without explicitly raising taxes.

You could argue that fines, fees, and cash bail function as a form of regressive taxation. That’s a conversation worth having. But even setting that aside, there’s a deeper structural issue.

The Cost of Jail

Municipalities may operate courts. But in most cases, they do not operate jails.

County governments do.

Counties pay for jail construction, maintenance, staffing, medical care, food, transportation — everything. Jails are expensive. In many jurisdictions, incarceration costs exceed $100 per inmate per day. In my jail, it’s closer to $120.

At $100 per day, per inmate, a 1,000-bed jail costs roughly $36.5 million per year.

County officials know this. In my county, I participate in our Justice Reinvestment Advisory Committee, where department heads regularly review jail costs and strategies to reduce them.

Counties have a clear incentive: keep people out of jail when possible, and minimize length of stay when incarceration is necessary.

Municipal courts have a different incentive: generate revenue.

That’s where the conflict emerges.

A $250 Bail, A $3,000 Bill

Imagine someone — let’s call him Homer — is arrested for trespassing in a town.

The town police bring him to the county jail. The town judge sets bail at $250 and schedules the next court date one month out.

The town is implicitly assuming Homer will pay the $250 to get out. If he fails to appear later, the court keeps the bail. If he does appear, the court may impose fines and fees. Either way, the municipality generates revenue.

But what if Homer cannot afford $250? He remains in the county jail for 30 days awaiting his court date. At $100 per day, that’s $3,000 in county expenses — in order to potentially collect $250.

This is not about accusing judges of malicious intent. It’s about recognizing that the incentive structure produces outcomes where bail forfeiture becomes revenue and detention costs are externalized.

And this isn’t only about money. When someone sits in jail for 30 days over $250, they can lose employment, housing stability, access to medication, and community supports. The people least able to afford bail are often already on the margins — homeless, mentally ill, or both.

When their court date arrives, they may fail to appear. That generates a bench warrant. The cycle begins again.

In more extreme cases, I have seen municipal courts hold individuals in county jail for six months pretrial on low-level, non-violent charges because they could not pay $250 in fees. Six months at $100 per day is $18,000.

County taxpayers spend $18,000 while the town attempts to collect $250 from someone who is already destitute.

It would be difficult to design a system that misallocates resources more dramatically.

The Incentive Mismatch

The problem is straightforward:

• Municipal courts generate revenue from fines and fees.

• Counties absorb the cost of incarceration.

• Municipalities are not financially responsible for the jail time their court decisions create.

This is a classic incentive misalignment. Towns pursue revenue while counties bear the expense.

A Simple Structural Fix

There are multiple ways to address this, but one reform stands out because it simply realigns incentives.

Counties could charge municipalities a per diem fee for housing individuals in jail on behalf of municipal courts. If a town had to pay, for example, $30 per day for each person it keeps in the county jail, the financial calculus changes quickly.

Trying to collect a $250 fee while paying $30 per day means that after about a week, most of the potential revenue is gone. After that point, continued detention becomes a financial loss. Municipal courts would still exist. They could still enforce ordinances and impose fines. But they would be incentivized to resolve cases quickly and avoid unnecessary detention.

Nothing in this proposal prevents enforcement. It simply ensures that the level of government creating the jail bill shares responsibility for paying it. Some municipal courts already operate efficiently and collaborate productively with county officials. The issue arises when financial incentives are misaligned. When incentives align, systems stabilize. When they don’t, taxpayers pay more and vulnerable people sit in jail longer than necessary.

And that is not a good outcome for anyone.

Assisted Outpatient Treatment (AOT), also known as outpatient civil commitment, is one of the most misunderstood tools in modern mental health policy.

It sits at the intersection of psychiatry, law, and public safety. It’s gaining momentum across the country. And it addresses a very specific — and very costly — gap in our treatment system.

If you want a deep dive into the policy side, the Treatment Advocacy Center is the de facto authority on AOT and has extensive resources available. What follows is a practical explanation of how AOT works, why it exists, and what problems it does — and does not — solve.

The Gap in the Treatment Continuum

There is a giant gap in the mental health treatment continuum between outpatient care and the state psychiatric hospital.

Outpatient care is for people who have a mental health problem or two but are generally able to function day-to-day. They see a therapist. They take medication voluntarily. They live in the community.

State psychiatric hospitals are, at least on paper, designed to treat the sickest individuals — people who require intensive, long-term stabilization.

But what about the people in between?

What about someone whose symptoms are too severe for routine outpatient care, but not quite severe enough to justify a long-term stay at a state hospital?

Before AOT, the only real option was short-term emergency hospitalization at a community psychiatric facility.

Most people don’t realize how short-term those hospitalizations actually are. In the movies, someone checks into an inpatient psych hospital and emerges two months later, transformed.

That is not reality.

Most psychiatric hospitals discharge patients within three to seven days. That works if someone is normally stable and experiencing a temporary crisis.

It does not work for someone with a chronic and serious mental illness who does not believe they are sick.

Anosognosia and the Revolving Door

Roughly half of individuals with schizophrenia-spectrum disorders have impaired insight into their illness. This condition is called anosognosia.

If someone does not believe they are ill, they will not voluntarily take medication.

Without treatment, their symptoms escalate. They become too unstable for outpatient care. They are detained under emergency commitment statutes. They stabilize briefly in the hospital. They are discharged within days. They stop medication again.

And the cycle continues.

Community (often homelessness).
Hospital.
Jail.
Repeat.

This merry-go-round is extraordinarily expensive and destabilizing — for the patient and for the community.

Where AOT Comes In

Assisted Outpatient Treatment interrupts that cycle by leveraging the civil court system.

AOT wraps therapy, medication management, and case management around the patient — backed by a court order.

In plain terms, the judge says: You can participate in treatment in the community, or you can be hospitalized.

It is coercive. That’s not something to gloss over.

But in most states, to qualify for AOT, the petitioner must show that the individual has a serious mental illness and a history of deterioration or dangerousness without treatment. There must be a documented pattern. There must be evidence.

If those criteria are met, the ethical question shifts. Allowing someone to repeatedly decompensate, cycle through jail, and deteriorate further is not morally neutral.

If moral arguments don’t move you, consider the fiscal ones. It costs over $100 per day to house someone in jail. It can cost $2,000 per day to keep someone in a state psychiatric hospital. The financial burden of untreated serious mental illness is immense — and that’s before considering the human cost.

AOT is designed to prevent that downward spiral.

How the Process Works

Forty-seven states have outpatient civil commitment statutes, but procedures vary. Here’s how it works in my county.

There are two primary referral pathways: community referrals and jail referrals.

Community Referral

A therapist or prescriber submits a referral to the AOT liaison at the local community mental health center. The case is reviewed for three criteria:

1. Is there a serious mental illness?

2. Is the person dangerous or gravely disabled without treatment?

3. Is there a documented history of treatment refusal leading to deterioration?

If those criteria are met, the team considers practical factors like housing, transportation, and family involvement. These aren’t deal-breakers, but they affect planning.

An MD must sign the civil commitment petition in my state. Once signed, the petition is filed with the civil court.

Jail Referral

Inside the jail, referrals can come from therapists, attorneys, judges, or me. I review cases from both a clinical and legal perspective.

The legal piece matters. The goal is often to secure dismissal of criminal charges upon commitment to AOT. That means the prosecutor’s office, the court, and the community mental health center all need to align.

Judges are not going to release someone charged with serious violent felonies into AOT. The appropriate candidates are typically individuals facing misdemeanors or low-level felonies whose criminal behavior is clearly linked to untreated mental illness.

Notice how many systems have to coordinate for this to work.

The Court Hearing

Once filed, the court schedules a hearing. The petitioner presents evidence. The patient has representation and can contest the petition.

In my experience, most patients are cooperative by the time we reach this stage. Occasionally the hearing is adversarial.

If the court approves the commitment, treatment begins immediately. In my county, a case manager attends the hearing. When court adjourns, the patient can meet their case manager on the spot. Sometimes housing placement or treatment initiation happens the same day.

Every petition I’ve filed has been approved. That’s not a flex. It reflects careful screening and evidence-based filing. When you bring a well-documented case to court, judges tend to take it seriously.

Enforcement and Review

AOT orders are time-limited and reviewed regularly — often monthly.

If the patient participates, the system works as intended.

If the patient stops participating, the judge has options. Depending on state law, that may include ordering medication as part of the treatment plan or temporarily hospitalizing the patient for involuntary medication.

As a last resort, the court can order full inpatient commitment to a state hospital.

That is not the goal. It exists primarily as leverage. Given the choice between hospital confinement and community-based treatment, most individuals choose to remain in the community.

What AOT Is — and What It Isn’t

AOT is not a cure-all. It will not solve homelessness. It will not fix every case of serious mental illness. It will not eliminate incarceration entirely.

It is a targeted intervention for a narrow but high-impact population: individuals with serious mental illness who repeatedly deteriorate because they refuse treatment and lack insight into their condition.

It is not about controlling people.

It is about preventing the cycle of jail, hospital, street, repeat.

For the patients it works for, AOT provides stability, continuity of care, and a real chance to live safely in the community. It also saves substantial money for local and state governments.

If you’re interested in starting or improving an AOT program in your area, feel free to reach out. I’m happy to help you think it through.

On the surface, cutting taxes and smoking methamphetamine don’t seem to have much in common. One is a fiscal policy decision. The other is a powerful stimulant that ruins lives.

But when you look at the behavioral economics of tax cuts and the psychology of methamphetamine use, the parallels are uncomfortable—and surprisingly strong.

To make the case, we need to understand both.

Methamphetamine, Briefly

I’ll start with a disclaimer: I’ve never smoked meth. But I know many people who have.

Methamphetamine, like all amphetamines, is a stimulant. It increases energy, motivation, and cognitive speed. That last part is important: speed, not accuracy. If you’ve ever talked to someone who is high on meth, you’ve probably noticed that they speak very quickly, but what they’re saying often doesn’t reflect good judgment or coherent reasoning.

Meth also floods the brain with dopamine. It feels very good—temporarily. When the high wears off, you’re right back where you started, except now you’re poorer and often worse off than before.

That’s the basic pattern: intense short-term relief followed by longer-term harm.

Tax Cuts, Simplified

Now let’s talk about tax cuts.

There are many types of taxes and many ways to cut them. The U.S. tax code is roughly a thousand pages long. To keep this simple, imagine a hypothetical income tax set at 20% that gets cut in half to 10%.

What happens next?

There are two major effects.

First, taxpayers get more money in their pockets. If you earn $50,000 per year, a 10% cut means an extra $5,000 to spend.

Second, the government now has $5,000 less to spend on public goods and services—things like roads, schools, fire departments, and emergency services. These aren’t optional luxuries. They’re the infrastructure that makes modern society possible.

In short, tax cuts provide immediate liquid cash by diverting money away from shared investments and into individual hands.

Who Actually Benefits?

At first glance, tax cuts feel like a win. Cash in your pocket is cash in your pocket.

But tax cuts don’t affect everyone equally.

A person earning $50,000 a year gets $5,000. A person earning $2 million a year gets $200,000 from the same cut. The money flowing into private pockets would otherwise have funded public services, and the largest share of that diversion goes to the highest earners.

Two things matter here:

1. A tax cut isn’t free money—it’s money taken from public services.

2. Tax cuts disproportionately benefit wealthy individuals.

A Simple Town Example

Imagine a town with ten residents.

Nine earn $50,000 per year. One earns $2 million.

After the tax cut:

• The nine average earners each save $5,000.

• The high earner saves $200,000.

Total lost revenue: $245,000.

Now look at the town’s expenses:

• Road maintenance: $100,000

• Police department: $200,000

• Fire department: $100,000
  Total: $400,000

Before the tax cut, revenue covered these costs. Afterward, it doesn’t. The town has to cut services.

Let’s say road maintenance is eliminated entirely, and the fire department absorbs the remaining cuts.

At first, nothing dramatic happens. But over time, the roads deteriorate.

One morning, you hit a pothole on your way to work and destroy your suspension. Repairs cost $3,000. A few weeks later, a small brush fire spreads because the fire department can no longer staff full coverage. A public park that cost $25,000 to build is lost.

Between car repairs and public losses, you’re now down $500—even after your tax cut.

The pattern should feel familiar.

Borrowing From the Future

This is where the meth analogy starts to matter.

Smoking meth feels good immediately. The consequences arrive later. By the time they do, the relief is gone and the damage remains.

Tax cuts work the same way. They offer short-term relief while quietly degrading the systems that make daily life affordable and functional. Eventually, both your body (with meth) and your community (with tax cuts) end up worse off than before.

So why do people support tax cuts when the benefits are so uneven?

Most people aren’t irrational or stupid. They’re stressed. They’re operating with incomplete information and very short time horizons.

Hyperbolic Discounting and Social Disconnection

Two well-established behavioral patterns help explain this.

The first is hyperbolic discounting: when people are under stress, they prioritize immediate rewards and discount future consequences.

The second is social disconnection: people who feel disconnected from their communities are more likely to focus on short-term gains rather than long-term collective outcomes.

Most people who use meth are stressed, depressed, and lonely. Meth provides temporary relief. Long-term damage feels abstract when survival feels urgent.

Tax cuts appeal in the same way. People who are financially stable and socially connected tend to support long-term investments in public goods. People who are struggling and disconnected want immediate cash relief. In both cases, what’s happening is the same: borrowing happiness from tomorrow.

Why the Cycle Repeats

Meth becomes addictive because the brain adapts. The more dopamine you flood it with, the more it needs just to feel normal.

Tax cuts follow a similar cycle.

Joe gets a $5,000 tax cut. The roads deteriorate. He pays thousands in repairs. The services still aren’t fixed. He’s stressed, broke, and desperate.

So what does Joe support next?

Another tax cut.

The more public services erode, the more relief tax cuts seem to offer—even though they’re causing the problem. Like meth, tax cuts become more “necessary” the more damage they cause.

Withdrawal Is the Hardest Part

Eventually, both systems hit bottom.

Meth withdrawal is brutal. Recovery requires enduring short-term pain for long-term stability.

Tax withdrawal works the same way. By the time communities realize they need to restore funding to function, many residents are already financially exhausted. Convincing desperate people to accept higher taxes becomes extraordinarily difficult—even when it’s necessary.

Where the U.S. Is Now

This isn’t theoretical.

As of February 2026, U.S. national debt exceeds $38.5 trillion. Decades of overspending combined with repeated tax cuts have left public systems strained and households stressed. The financial benefits have flowed overwhelmingly to the wealthiest Americans. The social costs have landed on everyone else.

Is There a Treatment?

There is.

If you rule out higher taxes on working people and rule out endless borrowing, the remaining option is taxing accumulated wealth.

A wealth tax doesn’t touch paychecks. Income isn’t wealth. Wealth taxes redirect a portion of highly concentrated assets back into public systems—schools, healthcare, infrastructure, and the social supports that young adults now lack as depression rates hit historic highs.

Like addiction treatment, it isn’t painless. But it works.

What we know won’t work is continuing the behavior that created the problem in the first place.

If you want more context, episodes 1–5 of this series go deeper into these dynamics. As always, I’m open to questions, pushback, and suggestions for future topics.

This article is part of our introductory series on jail mental health. The goal here is to explain what mental health treatment in a jail actually looks like, how it differs from treatment in the community, what it would look like in an ideal system, and why it almost never works that way in practice. The discussion also highlights the single biggest structural problem in jail mental health care: care coordination.

Mental Health Treatment in the Community

In the community, mental health treatment is usually structured and voluntary. For many diagnoses, the standard treatment is three to six months of weekly therapy. That timeline is not universal. Some people may need therapy twice per week, while others may need treatment for a year or longer depending on symptom severity and treatment goals.

If therapy alone is not sufficient, or if someone experiences severe symptoms such as psychosis or mania, medication may be needed. All of this typically happens voluntarily and at the patient’s own pace. Compared to what happens in jails, community treatment is relatively organized and predictable.

Why This Model Does Not Work in Jails

This model breaks down almost immediately in a jail setting.

First, jails do not have enough therapists. The therapists who are available are responsible for many mandatory tasks beyond therapy, including mental health evaluations, suicide risk assessments, segregation assessments, sick call requests, and urgent clinical issues. At the same time, roughly one-third of most jail populations probably need therapy. In a jail with one thousand inmates, that translates to approximately three hundred people needing services.

Even if a jail somehow had one therapist for every one hundred inmates, which most do not, that would still mean each therapist would be responsible for thirty therapy patients in addition to a full workload of other required duties. Weekly therapy for everyone is simply not possible. In most jails, the best-case scenario is a brief monthly check-in for some patients. While there are exceptions in particularly well-funded or grant-supported facilities, this is how jail mental health operates in the vast majority of jails.

Second, therapy must fit within the jail’s operational schedule. Jails are busy environments with constant competition for time and space. On any given day, medical staff, mental health staff, correctional officers, attorneys, child services agencies, reentry services, and the courts may all need access to the same inmates. Jails also operate on rigid schedules with multiple daily lockdowns for meals and inmate counts.

In practice, this means that for a therapist to see a patient, several conditions must align: no other department can need that inmate at the same time, confidential meeting space must be available, officers must be available to move the inmate, and the inmate must be willing to participate. Many individuals who need mental health services in jail refuse them even when they are offered.

Between these logistical constraints and short lengths of stay, it is rare for a therapist to meet with the same patient for multiple sessions. In many cases, the patient is released before a second appointment can occur.

There is one narrow set of circumstances in which therapy can happen more consistently: when a patient is severely ill, housed long-term on a mental health unit, facing serious charges that prevent rapid release, and when the jail has interns available who are not overwhelmed with other responsibilities. Outside of these conditions, individual therapy in jails is uncommon.

Group Therapy in Jails

Group therapy is more feasible than individual therapy in jails, but it comes with its own limitations.

Traditional psychodynamic or process-oriented groups do not work in jail settings. These groups depend on trust and vulnerability among participants, neither of which is realistic in a custodial environment. As a result, jail-based groups tend to focus on surface-level skills such as anger management, emotional regulation, communication, or parenting.

Group therapy also requires that participants be housed in the same area of the jail. It is not operationally realistic to transport multiple inmates from different housing units to a group session each week. Additionally, groups must be appropriate for all participants. Some therapeutic group formats, such as moral reasoning exercises, require a level of cognitive and emotional stability that many patients on mental health units do not have.

This creates a persistent dilemma. Individuals are housed on mental health units because they are acutely ill or suicidal. Once they stabilize enough to meaningfully participate in groups, they are often moved back to general population to make room for sicker patients. As a result, the people most capable of benefiting from group therapy are often no longer housed where groups are offered.

Some jails and prisons have step-down units for recently stabilized patients who are not yet ready to return to general population. These units are where the most effective group therapy tends to occur, but they are not common in jails.

Overall, group therapy exists in some facilities, but individual therapy is rare. Therapists in jails primarily serve as assessors, diagnosticians, and gatekeepers for higher levels of care rather than traditional treatment providers.

Behavior Modification as Treatment

Another non-medication intervention commonly used in jails is behavior modification. This approach uses structured incentives and consequences to encourage adaptive behavior without coercion. For example, an inmate might earn extra recreation time for keeping their cell clean or participating in programming.

Behavior modification can be effective for many patients, particularly those without severe psychosis or mania. While it is not a solution for all mental health conditions, it can promote stability and cooperation when applied consistently.

Medications in Jail Mental Health

Psychotropic medications are the backbone of mental health treatment in jails. This is largely because they can be administered quickly and efficiently. A single medical assistant can distribute medications to multiple patients in minutes, whereas therapy requires extended one-on-one time.

Most jails administer medications two or three times per day and can provide urgent medications when needed. The majority of mental health patients receive antidepressants or low-level anxiolytics. A smaller but more complex subset requires antipsychotics or mood stabilizers.

Patients taking antidepressants typically comply with treatment. Patients requiring antipsychotics or mood stabilizers are more likely to refuse medication, which introduces significant legal and ethical complexity.

Involuntary Medication in Jails

Jails are not hospitals, but they house individuals who may be more dangerous or disabled than patients in psychiatric hospitals. At the same time, many jail inmates have not been convicted of a crime and retain strong civil rights protections. This tension becomes most apparent when clinicians believe a patient requires medication but refuses it.

Involuntary medication is avoided whenever possible due to ethical and safety concerns. Delusions or hallucinations alone are not sufficient justification. The patient must pose an imminent risk of harm to themselves or others, or be gravely disabled. For practical purposes, grave disability typically means the inability to care for basic needs or communicate meaningfully due to mental illness.

In emergencies, clinicians may administer a one-time dose of short-acting medication such as haloperidol and lorazepam without patient or court consent. These situations are considered medical emergencies.

Problems arise when emergencies recur daily. Repeated involuntary injections increase the risk of injury to patients, officers, and medical staff. In these cases, long-acting antipsychotic injections may be safer, but they require additional authorization because their effects persist for weeks.

The most common path to approval is a court petition requesting permission to medicate involuntarily. Courts may approve, deny, or hold a hearing. While hearings allow patients and attorneys to object, they often reinforce the clinician’s case when the patient is visibly unstable.

An alternative pathway exists under the Supreme Court case Washington v. Harper¹, which allows approval through an independent medical review committee. In practice, this approach is nearly impossible to implement in jails due to logistical and financial barriers. As a result, most facilities rely on court authorization.

Care Coordination and the Revolving Door

Care coordination is the most significant failure point in jail mental health systems. Individuals with serious mental illness are frequently released back into unstable environments with little support. Many are homeless, impoverished, socially isolated, and lack transportation.

Shelters often refuse individuals with severe mental illness due to safety and resource limitations. Hospitals are reluctant to admit homeless psychotic patients because of low reimbursement rates, behavioral challenges, and Medicaid’s lifetime cap of 190 inpatient psychiatric days. EMTALA requires hospitals to accept emergencies, which has led to a system where suicidal statements become the only reliable pathway to admission.

State psychiatric hospitals are largely unavailable due to systemic underfunding and capacity issues. We will get into this in a future article.

When a patient leaves jail, medication adherence often collapses. Without follow-up care, relapse is common, and rearrest frequently follows within days or weeks.

Ideally, jails would provide a short supply of medication at release, but cost barriers usually prevent this. The best alternative is early discharge planning and collaboration with community mental health providers. Some communities offer jail-based intake, mobile response teams, or field-based medication reinitiation, but these services are inconsistent.

Mental health courts and assisted outpatient treatment programs can help bridge these gaps, though they are not universally available.

Conclusion

Mental health treatment in jails is shaped far more by structural constraints than clinical best practices. While medications and limited programming can stabilize patients temporarily, the lack of continuity of care ensures that many individuals cycle repeatedly through the system. Understanding these limitations is essential for anyone interested in meaningful reform.

If you have questions or would like to see deeper coverage of any of these topics, let me know, and I can get into more detail in future articles and videos.

The Medicaid Inmate Exclusion Rule is often described as a way to save taxpayer money. In practice, it does the opposite. It shifts federal and state healthcare costs onto local governments, forces jails to purchase care at inflated prices, and ultimately redistributes public money upward to pharmacies and pharmaceutical companies.

To understand why, it helps to start with what Medicaid is and how it works.

Medicaid is a government health insurance program created to help low-income individuals access medical and mental health care. As of September 2025, approximately 77 million people in the United States were enrolled in Medicaid. For the purposes of this discussion, Medicaid does two important things.

First, it subsidizes the cost of care. Medical and mental health services are expensive, and these subsidies make treatment far more affordable for patients. Second, and more important here, Medicaid negotiates and sets rates for medical services and prescription medications. Those negotiated rates are substantially lower than what providers/manufacturers charge on the open market.

Some examples make this easier to see.

Consider a basic medical service, such as an X-ray for a suspected rib fracture. With Medicaid, a patient might pay around three dollars out of pocket, while Medicaid pays approximately twenty dollars to the provider. The total cost of the X-ray is roughly twenty-three dollars. Without insurance, the same X-ray could cost around two hundred dollars, nearly ten times as much, because the patient is charged the full retail rate rather than the negotiated Medicaid rate.

The same pattern applies to mental health medications. A thirty-day prescription for an ADHD medication might cost a Medicaid patient two dollars out of pocket, with Medicaid paying an additional five dollars, for a total of seven dollars. Without insurance, that same prescription could cost around forty dollars out of pocket.

In both cases, the total amount paid for care is dramatically lower when Medicaid is involved.

This brings us to the Medicaid Inmate Exclusion Rule.

The rule states that when a person who is enrolled in Medicaid is incarcerated in a jail or prison, their Medicaid benefits are suspended for the duration of their incarceration. Even though the individual was insured at the time of arrest, jail medical staff are prohibited from billing Medicaid for any services or medications provided. For billing purposes, the incarcerated person is treated as if they have no health insurance at all.

This rule has existed since Medicaid was created in 1965. The original rationale was that if a local government chose to arrest someone, that government should be responsible for providing medical care during incarceration.

That logic breaks down quickly under scrutiny. Local governments do not decide which behaviors are criminalized. They are responsible for enforcing laws passed by state legislatures and Congress. This creates a mismatch between who makes the laws and who bears the financial burden of enforcing them. States and the federal government define crimes, while counties and cities absorb the costs of incarceration and constitutionally required medical care. This is an unfunded mandate in practice, even if it is not labeled as such.

When this issue is raised, a common reaction is to frame it as a moral argument. Some people respond by suggesting that allowing Medicaid billing in jails means giving criminals free healthcare, or shifting costs unfairly from counties to state governments. Neither claim holds up.

First, many people in jail are not criminals. Most jail inmates are pre-adjudicated, meaning the court has not yet determined guilt or innocence. People can spend weeks or months in jail awaiting trial, and jails are constitutionally required to provide medical and mental health care during that time. Denying access to negotiated insurance rates before any finding of guilt raises serious fairness concerns.

Second, there is no such thing as free healthcare. Medicaid is funded by taxpayer dollars. Jail healthcare is also funded by taxpayer dollars. The question is not whether taxpayers pay, but how much they pay and who benefits from the system.

Because Medicaid negotiates lower prices, care provided through Medicaid is significantly cheaper than care purchased without insurance. The Inmate Exclusion Rule forces jails to buy medications at full retail prices, often five to ten times higher than Medicaid rates.

As a result, the rule does not reduce healthcare spending. It shifts costs onto local governments while dramatically increasing the price they must pay for the same care.

The beneficiaries of this arrangement are not taxpayers. Treatment providers benefit to some extent, but the largest winners are pharmaceutical companies and large pharmacy contractors. Because jails are barred from using Medicaid’s negotiated rates, they must pay monopoly retail prices for medications.

This becomes especially costly for certain populations. HIV medications and long-acting antipsychotics routinely cost jails thousands of dollars per month per patient. A single inmate prescribed a brand-name antipsychotic can add six thousand dollars to a jail’s monthly pharmacy bill. A brand-name HIV medication can add another five thousand dollars. Some inmates require multiple medications, and it is not uncommon for a single individual’s prescriptions to exceed ten thousand dollars per month.

If that same individual were in the community with Medicaid, their out-of-pocket cost might be ten dollars, and Medicaid itself might pay around one hundred dollars total. Exact figures are impossible to provide because privacy laws limit access to detailed Medicaid reimbursement data for specific medications.

The practical effect of the Inmate Exclusion Rule is that cities and counties pay far more for care than state or federal governments would pay for identical treatment in the community. The rule extracts money from local taxpayers and transfers it upward to drug manufacturers and large healthcare corporations. At the same time, these inflated costs strain county budgets, making it harder to raise employee wages, maintain facilities, or fund other essential public services.

The most straightforward solution would be to allow incarcerated individuals to retain Medicaid coverage during incarceration. That approach would immediately reduce costs and align jail healthcare spending with community healthcare spending. However, state budgets are already under pressure from numerous federal mandates, and many states would struggle to absorb these additional costs.

A more practical middle-ground solution is possible.

One option is to allow jails and prisons to bill Medicaid for services and medications, while requiring them to reimburse Medicaid for the full cost of those claims, plus a fixed surcharge, such as ten percent. This approach preserves local responsibility for paying for care while allowing jails to access Medicaid’s negotiated rates. It would dramatically reduce county healthcare expenditures while creating a modest new revenue stream for state Medicaid programs without raising taxes.

This model would not incentivize overbilling, since counties would still be responsible for the costs. Medicaid utilization review and existing oversight mechanisms could remain in place to prevent abuse.

The Medicaid Inmate Exclusion Rule does not save money. It wastes local tax dollars, inflates healthcare costs, and channels public funds to private corporations for no clear public benefit. Understanding how this system works is the first step toward fixing it.

For policymakers interested in addressing this issue, practical solutions exist. I am happy to discuss them further with anyone interested in reforming this policy.

Today’s article is about managing mental health crises in jails. This article will cover what constitutes a crisis, typical responses and solutions, and common problems that arise.

Before getting into the details, it is important to start with a disclaimer. What follows is a discussion of jails in general, and what constitutes a crisis relative to the other issues jails deal with every day. If a particular diagnosis or experience is described as “not a crisis,” that is not meant to minimize or invalidate anyone’s experience. The goal here is to explain how jails prioritize limited resources, not to comment on what symptoms do or do not deserve attention.

Defining a Mental Health Crisis in Jail

Mental health issues in jail exist on a spectrum. For practical purposes, inmate problems can be divided into three tiers.

Tier One: Situational Stressors and Low-Level Mental Health Issues

The lowest tier consists of what can best be described as situational stressors. These include anxiety, depression, irritability, and insomnia that did not exist prior to incarceration.

These reactions are normal and predictable consequences of jail. Incarceration involves a sudden loss of freedom and autonomy. Inmates lose access to family and friends, employment, income, housing stability, personal routines, privacy, and basic choices such as what to eat or when to sleep. At the same time, they are facing uncertainty about their legal case, potential sentences, plea negotiations, future employment, and relationships.

Feeling depressed, anxious, angry, or unable to sleep in this environment is not pathological. These emotions, by themselves, do not constitute a crisis.

In my jail, if someone is struggling to adjust and requests to speak with a counselor, a counselor will see them. What will not happen is removing the inmate from general population, housing them in the mental health unit, or prescribing medication simply to suppress a normal emotional response to incarceration.

Pre-Existing Mental Health Diagnoses

This same tier includes most inmates who had a diagnosed mental health condition prior to incarceration. When an inmate enters jail with a documented diagnosis, they are typically evaluated by a therapist and/or prescriber to assess current symptom severity and determine whether previously prescribed medications should be restarted.

Some medications are unlikely to be continued in jail. Prescription stimulants for ADHD are rarely provided because of their high trade value. Benzodiazepines and hypnotics for anxiety or sleep are also typically discontinued due to safety risks and diversion concerns. In some cases, non-stimulant or alternative medications may be considered, but these issues are generally low priority.

Jails are more concerned about conditions such as major depressive disorder, PTSD, bipolar disorder, and psychotic disorders like schizophrenia or schizoaffective disorder. As long as inmates with these diagnoses are stable and medication compliant, they are typically housed in general population regardless of diagnosis.

Panic Attacks

Another common low-level issue involves panic attacks. Officers frequently report that an inmate is “losing it” or “flipping out,” only for mental health staff to find someone having a panic attack. Panic attacks are extremely uncomfortable, but not dangerous. People often fear they will pass out, which is essentially impossible during a panic attack due to elevated adrenaline levels.

Panic attacks are common in jail because jail is a stressful environment. They are also highly treatable with education and reassurance. Medication is generally not recommended, as it tends to worsen the problem over time.

In the event of a panic attack, a counselor should respond and help the inmate calm down. A panic attack is not a crisis and does not warrant removal from general population.

Tier Two: Issues That Require Intervention but Are Not Always Crises

None of the issues discussed so far constitute a crisis in a jail setting. The second tier includes situations that may or may not represent a crisis but usually still require intervention.

Suicidal Statements and Malingering

The most common mental health call in jail involves inmates stating that they are suicidal. If you watched/read previous articles, you know that jail’s do everything they can to avoid suicides, and that suicides are one of the biggest sources of liability. Inmates are well aware that saying they are suicidal is the fastest way to get attention. As a result, jails constantly deal with suicidal claims.

In my experience, the majority of these claims are not associated with genuine suicidal intent. They are often motivated by secondary gain, such as changing housing, escaping lockdown, resolving conflicts, or accessing privileges. Clinically, this behavior is referred to as malingering.

A major role of jail mental health staff is distinguishing genuine risk from malingering. If suicide risk is anything other than low, the inmate should be placed on suicide watch. If malingering is suspected, the counselor will attempt to address the underlying issue. Sometimes this can be resolved by changing housing assignments, moving the inmate to protective custody, or providing case-related information (e.g. who is the inmate’s attorney, when is his next court date, and other basics). If the behavior continues, the inmate is usually placed on suicide watch anyway.

This is not done for clinical reasons. It is done for behavior management and liability reduction.

An inmate who is malingering may escalate behavior if ignored, including flooding cells, starting fires, or constructing ligatures to “prove” seriousness. There is also the risk of accidental death during a staged suicide attempt. In the aftermath, investigators will see only a suicide, not an accident, and mental health staff will be scrutinized.

Therapists cannot predict suicide. Risk assessment does not work that way. Nevertheless, liability considerations dictate conservative responses.

Hallucinations

Hallucinations may or may not represent a crisis. People with genuine hallucinations often do not voluntarily report them, so self-report raises red flags for possible malingering. That said, some individuals do recognize their hallucinations.

Mental health must assess the quality of the hallucinations for severity and functional impairment. If hallucinations do not interfere with functioning and the inmate is willing to remain housed in general population, relocation is usually unnecessary.

When it comes to hallucinations, content matters. Hearing comforting voices is not a crisis. Hearing voices commanding violence or self-harm, suggesting the jail food is poisoned, or other paranoid content is usually a crisis, and requires removal from general population, assuming malingering has been ruled out.

Kites and Bizarre Behavior

Mental health is sometimes called when inmates are “kited out” of a housing unit. A kite is an anonymous note passed to staff warning that an inmate is behaving bizarrely and/or is at risk of being harmed.

Mental health must determine whether the behavior is genuinely psychiatric or whether other dynamics are at play. The response may involve moving the inmate to a mental health section, protective custody, or another general population unit.

Other Non-Crisis Situations Requiring Special Housing

Some inmates are not in crisis but may still require alternative housing, including individuals with intellectual disabilities, autism, blindness, deafness, or transgender inmates. These situations typically involve classification decisions, sometimes with mental health input.

Tier Three: Acute Mental Health Crises

The highest tier of mental health crises includes situations requiring movement to the mental health unit, involuntary medication, restraints, seclusion, or hospitalization.

These situations involve inmates who are suicidal, violent, or gravely disabled due to mental illness.

Examples include:

• Suicide attempts or active self-harm

• Command hallucinations to harm others

• Refusal to eat due to delusional beliefs

• Severe paranoia preventing basic functioning

• Inability to maintain hygiene or coherent communication

Immediate Response and Housing

The first step is relocation to the mental health unit or medical unit. Extremely small jails without such units may need to transport inmates to hospitals.

Suicidal inmates are placed on suicide watch. Homicidal inmates require separation from peers, and are often treated as suicide watch for the purpose of observation and monitoring. Psychotic or gravely disabled inmates should be housed in the mental health unit with appropriate supervision.

Involuntary Medication

Each state has its own legal standards and each jail has their own policies for involuntary medication. Mental health or medical staff must determine whether criteria are met.

Correctional staff should not override these decisions. Interfering with emergency treatment transfers liability to the officer involved. Once authorized, supervisors determine whether special operations teams are required. All interventions must be recorded with handheld and body cameras. Cameras do not add liability; they protect jail staff.

Attempts should be made to obtain voluntary compliance before forced administration. If unsuccessful, officers secure the inmate, and medical administers the injection. With experience, this process takes only a few minutes.

For repeated episodes, long-acting antipsychotic injections may be petitioned through the court. (Some jails may be large enough to establish a Harper Committee [See Washington v. Harper] for the purpose of authorizing involuntary medication, but for most jails this burden is impractical).

Clinical Restraints

Clinical restraints may be necessary when inmates are actively attempting to harm themselves or others. The two most common methods for restraint are restraint chairs and four-point restraints.

Restraints are unpleasant but not inherently uncomfortable when applied correctly. Many inmates calm down or fall asleep in restraints once their adrenaline subsides. However, restraint use still carries some risks and requires proper training and policy adherence.

Not all restrained inmates require medication. Some inmates (most notable those with substance use disorders) will deliberately act-out in order to obtain benzodiazepines. Automatic medication can reinforce this behavior, leading to more clinical restraints (and wasting resources).

During restraints, continuous monitoring, vital checks, circulation checks, and regular reassessment are required. In my experience restraints rarely exceed one hour. Longer durations require continued one-on-one monitoring. Following restraint use, inmates are typically placed on suicide watch.

Clinical Seclusion

Some inmates pose a risk to others but not themselves. Padded seclusion rooms (if your jail has them) provide a safe space for brief containment. These rooms are designed to prevent injury and are used for short durations only.

That pretty much wraps it up for this one. Come back next week for a discussion on the Federal Medicaid Inmate Exclusion Rule and how it ostensibly saves taxpayers money, while in practice it does the opposite.

The Scope of the Staffing Crisis

Let’s start with the data. According to the U.S. Census Bureau, local jails lost approximately 17,000 correctional officers between 2013 and 2023. The Bureau of Labor Statistics expects this trend to continue, projecting a 7% reduction in correctional officers by 2034.²

Some jails are operating at truly alarming levels of understaffing.
One jail in Atlanta is currently short 59% of its authorized staffing.
A jail in Virginia has been operating at roughly 50% staffing for five years.

These are extreme examples, but nationally it’s common for jails to operate 20–30% short-staffed.

Why Understaffing Is So Dangerous

Running short-staffed in a correctional facility is not just inconvenient — it’s dangerous.

Short staffing leads to:

• Longer shifts

• Mandatory overtime

• Increased officer burnout

• Reduced safety

• More frequent lockdowns

Lockdowns increase inmate frustration, which leads to more mental health crises, more violence, and more disciplinary issues. From the officer’s perspective, you’re working long hours in a dangerous environment, often alone, supervising inmates who are stressed, mentally ill, and angry.

In an Associated Press article on the Fulton County Jail, officers reported situations where one officer was responsible for monitoring up to 200 inmates at once. This is an objectively terrible working condition.

Turnover and Overtime

Unsurprisingly, correctional facilities experience 20–30% annual staff turnover.
That means your entire workforce turns over every 3–5 years.

Because jails can’t close, governments are forced to rely heavily on overtime to keep facilities operational. In some states, overtime costs reach hundreds of millions of dollars annually. Nationally, overtime spending almost certainly reaches into the billions.

Some Facilities Have Fixed This — How?

Here’s the key question: if staffing is such a problem, why aren’t all jails understaffed? Some facilities maintain staffing levels of 95% or higher. Let’s look at what they’re doing differently.

Case Study #1: Utah Department of Corrections

In February 2024, Utah was short about 400 officers. Within a little over a year, they hired approximately 350 new officers and now report having more applicants than openings.

What changed?

• Officer pay increased by 40%

• Improved recruitment advertising

• Streamlined hiring process

Case Study #2: Wisconsin Department of Corrections

In early 2024, Wisconsin had a 56% vacancy rate. Within a year, they reduced that vacancy rate to 17%.

Their strategy?

• Officer pay increased by 65%

That’s it.

Case Study #3: Arapahoe County Jail (Colorado)

Arapahoe County regularly operates at 95% staffing capacity. I reached out to them directly, and a big thank-you to Jon at the Arapahoe County Sheriff’s Office for taking the time to speak with me.

According to Jon, their success comes from:

• Starting salaries near $80,000 per year

• Predictable schedules (primarily four 10-hour shifts)

• Strong workplace reputation

• Streamlined hiring with frequent applicant communication

• Using the jail as a pipeline into police positions (they generally only hire police who have worked in their jail)

The Common Thread

Every successful example has the same core solution:

They pay officers enough to make the job competitive. Advertising and hiring efficiency help — but compensation is the foundation.

“Pay Doesn’t Matter” — Does It?

Some organizations argue that higher pay doesn’t improve staffing. The Prison Policy Institute has made this claim, noting that inflation-adjusted wages rose between 2013 and 2023 while staffing declined. They argue the solution is reducing jail populations rather than increasing staffing.

Here’s my rebuttal — in three parts.

Rebuttal #1: Wage Growth Was Minimal

Between 2013 and 2023:

• CPI inflation was 31%

• Nominal correctional officer wages rose 35%

That’s a real wage increase of about 3% over ten years — effectively nothing.

Rebuttal #2: CPI Misses the Real Cost of Living

CPI measures consumer goods — not housing.

Between 2013 and 2023:

• Median rent increased by 50%

If your wages increase 35%, consumer prices increase 31%, and rent increases 50%, your standard of living has declined. Officers are worse off today than they were a decade ago.

Rebuttal #3: Jail Populations Are Already Reduced

Jails have been reducing populations for years — especially since COVID. At this point, many facilities have already released their lowest-risk individuals. What remains is a population that is more violent, unstable, and resource-intensive.

You can want fewer people in jail and want safe staffing for the people who remain. These positions are not mutually exclusive.

Opportunity Cost and the Labor Market

This brings us to a key economic concept: opportunity cost.

People don’t buy jobs with money — they buy jobs with time. Taking a corrections job means giving up every other job you could do with that same time. So how does corrections pay compare?

According to the Bureau of Labor Statistics:

• Median correctional officer salary: ~$53,000

• Comparable to truck drivers and bus drivers

• $5,000–$10,000 less than police officers

Now compare corrections to other non-degree careers:

• Crane operators: ~$65k

• Railroad workers: ~$75k

• Electricians: ~$62k

• Plumbers: ~$63k

• HVAC techs: ~$60k

Corrections pays 15–20% less than many alternatives — and with worse working conditions.

Pay Growth and Job Quality

Corrections also lacks meaningful wage growth. Officers with 20 years of experience often make only marginally more than those with five. Promotions add responsibility without proportional compensation.

Combine that with:

• Dangerous environments

• Trauma exposure

• Poor lighting and infrastructure

• Mandatory overtime

• Public stigma

Low pay + hard job = predictable staffing crisis.

Adam Smith explained this centuries ago. Dangerous, unpleasant, stressful jobs require a wage premium. Corrections does not offer one.

Why Can’t Local Governments Fix This?

If low pay is the problem, why not just raise wages? Because local governments are broke. They must fund jails, police, schools, fire departments, EMS, roads, and more — with limited revenue. Raising wages means either cutting other services or raising taxes.

And here’s the problem: states often prohibit local governments from raising taxes.

How We Got Here: Block Grants and Unfunded Mandates

Since the late 1970s, the federal government shifted from fully funding programs to issuing block grants — fixed sums that don’t adjust for inflation or demand.

Programs like:

• TANF

• Mental health services

• Substance use treatment

Many of these block grants are worth 40% less in real terms than when they were created. Yet the mandates remain. When governments are required to provide services without adequate funding, that’s called an unfunded mandate. States then pass these costs down to counties and cities — while simultaneously limiting their ability to raise revenue.

Cost Shifting and Liability Dumping

States cut expensive services — like psychiatric hospitals — which pushes people with severe mental illness into jails. Local governments absorb the cost. Then, when something goes wrong, lawsuits target:

• Jail administrators

• Mental health staff

• County governments

This is called liability dumping.

The Bottom Line

Your jail is understaffed because officers are underpaid. Officers are underpaid because local governments are poor. Local governments are poor because costs are pushed downward while revenue is capped.

Ending on a Hopeful Note

None of this can be fixed quickly — and it certainly can’t be fixed at the jail level alone. This is the result of decades of federal and state policy decisions. But it can be fixed. If we address the economic distortions discussed earlier in this series and begin stabilizing public finances, this problem is solvable — albeit slowly, over decades. The longer we wait, the harder it becomes.

Suicide prevention is one of the most important responsibilities of jail mental health systems. In this article, the focus is on why suicide is such a significant risk in jails, how to build a layered suicide prevention system, and what suicide watch should look like in practice.

This discussion approaches suicide prevention from an operational perspective. It is not a tutorial on how to conduct a clinical suicide risk assessment. That topic will be addressed in a separate article.

The First Three Rules of Jail Mental Health

Jail mental health has a few core rules.

The first rule is that no one dies in the jail.
The second rule is that no one dies in the jail.
The third rule is to remember that suicide is statistically the most likely way someone will die in a jail.

With those rules in mind, suicide prevention must be approached as a system with multiple overlapping layers of protection.

Intake Screening and Early Warning Signs

The first layer of suicide prevention begins at intake. Medical staff should ask arresting officers whether the individual made any suicidal statements or engaged in concerning behavior during the arrest.

The inmate should then be asked directly about suicidal thoughts during the nursing intake assessment. At the same time, medical staff should remain alert to behavioral and physical indicators of self-harm risk, even if the inmate denies suicidal intent.

These indicators may include:

• Cuts or scars on the wrists, arms, or legs

• Flat affect, vacant expression, or marked withdrawal

• Statements suggesting hopelessness or a lack of desire to live

Examples of passive suicidal statements include phrases such as “I just want to go to sleep forever” or “I will never leave this place.”

Any of these signs or statements should result in the inmate being held in a location where they can be observed until mental health staff complete a more thorough evaluation.

Placing an Inmate on Suicide Watch

If mental health staff determine that an inmate is at risk for suicide or self-harm, the inmate should be placed on suicide watch. Some facilities refer to this as Close Observation, which is a more flexible term that allows observation for reasons beyond suicide risk.

At this point, the inmate should be housed in a mental health unit if one exists. If not, the inmate may be placed in a medical unit or another designated observation area. Whenever possible, the inmate should be housed in a suicide-resistant cell.

Suicide-Resistant Cell Design

A suicide-resistant cell is designed to minimize ligature opportunities. Ligature-based hanging is the most common method of suicide in jails, making ligature points the primary environmental hazard.

Key features of a suicide-resistant cell include:

• Minimal or no ligature points

• A single bunk made of composite material without sharp metal edges

• No desks, chairs, or tables

• No electrical outlets

• Bright lighting controlled from outside the cell

• A secure door with no gaps that could be used to anchor fabric

• A metal mirror rather than glass

The cell should contain only a bed and a toilet.

Fire suppression systems also deserve attention. Tamper-resistant sprinkler heads are not tamper-proof. If an inmate damages a sprinkler head, the exposed fixture can become a ligature point. In such cases, the inmate should be moved or the cell repaired immediately.

The Role of Cameras

Cameras in suicide-resistant cells serve two purposes. First, they provide secondary observation. Cell feeds can be displayed in officer booths or counseling offices, increasing the likelihood that concerning behavior will be noticed quickly.

Second, cameras act as a deterrent. Inmates who know they may be observed are less likely to attempt self-harm. This mirrors the logic behind the Panopticon design (watch the video to learn more), where uncertainty about observation discourages dangerous behavior.

Although cameras reduce privacy, courts have consistently held that inmate safety outweighs privacy concerns in these contexts.

When Suicide-Resistant Cells Are Not Available

Facilities without suicide-resistant cells may need to house inmates on suicide watch in traditional cells. In those situations, housing suicidal inmates together can provide an additional layer of protection.

It is difficult for an inmate to attempt suicide without interruption when another person is present. Cellmates are likely to alert staff if they observe dangerous behavior.

Observation Checks and Timing

The primary method of monitoring inmates on suicide watch is direct visual checks, often referred to as checks or clocks. Staff physically observe the inmate at random intervals ranging from every 7 to 15 minutes.

This timing is intentional. Approximately 90 percent of jail suicides occur through hanging or self-asphyxiation. Irreversible brain injury can begin after approximately five minutes without oxygen, with death or severe injury likely after ten minutes.

Randomized checks prevent inmates from timing suicide attempts between observations. Some facilities layer additional officer rounds on top of mental health checks, increasing observation frequency even further.

Clothing and Property Restrictions

Inmates on suicide watch are issued suicide-resistant smocks, typically made of durable canvas material that is difficult to tear or fashion into a ligature. Footwear is limited to soft shoes or sandals.

Initially, inmates may have only a mattress and no additional property. As risk decreases, privileges can be gradually reintroduced. Suicide watch is inherently restrictive and uncomfortable. While these conditions reduce risk, prolonged exposure can worsen mood, so restrictions should be eased as soon as it is clinically safe to do so.

Daily Clinical Contact and Treatment

If staffing allows, an advanced-level mental health provider should meet with inmates on suicide watch daily. These visits are often brief but provide continuity and monitoring.

Medication management may be part of treatment, though medications are not typically forced. Antidepressants are commonly prescribed when appropriate, while recognizing that medication alone is not a complete solution to suicide risk.

Authority to Place and Remove Suicide Watch

Any staff member should be able to initiate suicide watch temporarily if there is concern for safety. The inmate should remain under observation until mental health staff complete an evaluation.

Decisions to discontinue suicide watch should, at a minimum require approval from both a licensed prescriber. In my jail, I instituted a policy which requires both a licensed prescriber and a behavioral health supervisor to agree to rescind suicide watch. Requiring two clinical approvals provides both safety and accountability.

Step-Down and Follow-Up

After removal from suicide watch, inmates should transition to a step-down housing unit if available. If not, temporary placement in mental health or medical housing may be appropriate.

Follow-up appointments are essential. A common model includes check-ins after one day, three days, and one week to monitor for recurrence of suicidal thoughts.

Movement and Release Considerations

Any movement of an inmate on suicide watch should require approval from a licensed mental health staff member. This includes court appearances, transfers, hospital visits, and release.

Release presents particular risk. Individuals released from jail experience suicide rates significantly higher than the general population during the first year after release.

If an inmate is released while on suicide watch, a mental health evaluation should occur immediately. Depending on findings, this may include safety planning, family involvement, or emergency psychiatric detention if necessary.

Summary: A Layered System

Effective suicide prevention relies on multiple overlapping protections:

• Intake screening

• Staff awareness and reporting

• Mental health evaluation

• Suicide-resistant housing

• Frequent observation checks (or clocks)

• Video monitoring

• Clinical follow-up

• Controlled movement and discharge planning

No single measure is sufficient. Each layer reduces risk incrementally, making suicide less likely and more difficult to carry out.

This layered approach is how jails reduce the most common cause of death in custody and uphold the most important rule of jail mental health: no one dies in the jail.

In this episode of the Jail Mental Health introduction series, we focus on the medical intake process and why it is often the most important ten minutes a person will spend in jail.

The Booking and Intake Process

When someone is brought to jail, several steps must be completed before they are admitted. These include fingerprinting, photographing, inventorying personal property, and completing a medical evaluation.

The medical evaluation serves a critical function: the jail must decide whether it can safely accept custody of the arrested person. If medical staff identify a serious issue—such as a suspected fracture, internal bleeding, or other acute medical instability—the jail may refuse to accept the individual until they receive hospital care and medical clearance.

Although it may seem counterintuitive, jails are legally permitted to refuse admission when a person is medically unstable. In these cases, the arresting officer must transport the individual to a hospital before the jail will accept them.

Prescreen vs. Full Medical Evaluation

Jails typically use one of two approaches to intake medical screening.

The first is a brief prescreen, often lasting one to two minutes. Its purpose is to determine whether the individual can safely remain in the jail. Once the prescreen is completed, the arresting officer may leave, and the inmate waits in a holding area until a full evaluation can be conducted later. The second approach is a full medical evaluation conducted immediately upon arrival.

The prescreen model prioritizes efficiency for law enforcement, while the full evaluation model prioritizes efficiency for medical staff. Neither approach is inherently wrong. The decision reflects whether the facility prioritizes returning officers to duty quickly or reducing duplication of medical work.

Who Conducts the Evaluation

In many jails, intake evaluations are conducted by registered nurses. Other facilities may use medical assistants, EMTs, nurse practitioners, or similar professionals. Using physicians for routine intake evaluations is rare simply because they’re expensive and in short-supply.

Core Components of the Medical Intake

A proper intake evaluation should cover several areas:

• Current medical conditions

• Prescribed medications

• Allergies

• Recent injuries

• Mental health diagnoses and treatment history

If the individual reports taking psychiatric medication, staff should determine whether they are actively engaged in treatment and identify the pharmacy used to fill prescriptions.

When contacting a pharmacy, staff should document:

• The name of the pharmacy employee

• Medication names and dosages

• Administration instructions

• Most importantly, the last refill date

It is common for inmates to report medications they have not taken recently or were never prescribed. Verification ensures that prescribers can make informed decisions about whether to restart or temporarily bridge medications during incarceration.

Substance Use Screening

Substance use screening is a critical component of intake. At least half of all jail admissions involve individuals with a diagnosable substance use disorder. Substances such as alcohol, benzodiazepines, and stimulants interact with many prescription medications and can cause serious withdrawal syndromes.

Underreporting and Risk Management

Inmates frequently minimize or deny substance use due to fear of self-incrimination or stigma. As a result, clinicians should assume underreporting. For example, someone reporting two to three drinks per day is likely consuming significantly more. In correctional settings, caution is essential. Alcohol withdrawal is especially dangerous, and failure to identify it during intake can have fatal consequences.

Why Not Drug Test Everyone?

Routine drug testing at booking seems reasonable, but it has limitations. First, inmates cannot generally be compelled to provide urine samples, and blood testing typically requires strong justification and often a court order.

Second, standard urine drug screens are limited. Many do not reliably detect:

• Synthetic cannabinoids

• Kratom

• Certain benzodiazepines

• Gabapentin

• Xylazine

• Ketamine

• Some hallucinogens

• Fentanyl and other synthetic opioids

A negative drug screen does not rule out intoxication, withdrawal, or substance-induced psychosis.

Editorial Aside: Ethics and Economics of Drug Testing

Some jails avoid routine drug testing due to cost, time constraints, or concerns about triggering additional detox protocols. This raises ethical concerns. If half of all admissions involve substance use disorders, and we know underreporting is common, there is a strong argument that facilities should at least attempt drug screening for every inmate.

From a financial perspective, the cost is modest. At roughly $30 per test, screening 10,000 admissions would cost about $300,000 annually.

This must be weighed against the cost of a death in custody. Even when no wrongdoing occurs, litigation defense alone can exceed $100,000. Many jurisdictions settle lawsuits simply because it is cheaper than trial, even when liability is unclear. Viewed this way, drug testing is often a cost-containment strategy rather than an expense.

Mental Health and Suicide Screening

Intake evaluations also include mental health and suicide screening. The primary goal is to determine whether mental health staff need to be involved immediately.

At a minimum, inmates should be asked whether they are currently thinking about harming themselves or others and whether they have a history of suicide attempts. Positive responses require referral for a more comprehensive mental health assessment.

It is important to acknowledge limitations. Some suicides are impulsive. Others involve individuals who deliberately conceal suicidal thoughts. I am aware of multiple jail suicides in which individuals denied suicidal ideation during intake and had no overt warning signs.

Suicide occurs approximately four times more often in jails than in the community. Staff should be cautious and risk-averse, but it is also important to recognize that not all suicides are preventable.

Social History and Discharge Planning

Whenever possible, intake evaluations should gather information about housing status and emergency contacts. This information supports both data analysis and discharge planning. If someone is homeless at intake, that fact is immediately relevant. Shelter availability is limited in many communities, and early involvement of reentry services improves outcomes.

Extreme weather makes this especially important. Releasing someone without housing in winter can place them in immediate danger and contribute to a cycle of re-arrest. Jails increasingly function not only as psychiatric facilities, but also as de facto homeless shelters.

When Intake Cannot Be Completed

Sometimes an inmate is too intoxicated, psychotic, or disruptive to complete intake. In these cases, coordination between medical, mental health, and custody staff is essential. Consider an inmate who is actively psychotic, refusing medical procedures, and threatening staff. Medical may want observation, mental health may want specialized housing, and custody may push for segregation.

Psychotic inmates should not be placed in segregation. The decision between medical or mental health housing must be made on a case-by-case basis, with safety as the priority.

Managing Intake Volume

Finally, facilities should attempt to manage the flow of admissions whenever possible.

Warrant sweeps can result in large numbers of inmates arriving simultaneously. If intake evaluations take thirty minutes and only one nurse is available, even a small surge in bookings can create delays lasting many hours.

Extended holding times are dangerous. Inmates awaiting intake may develop withdrawal symptoms, experience medical complications, or suffer unnoticed injuries. These situations create risks for inmates and liability for facilities. Adequate staffing and coordination with law enforcement can reduce these bottlenecks.

Closing Thoughts

The medical intake process is brief, but its consequences are enormous. Decisions made during these first minutes determine safety, treatment, and outcomes for the rest of an inmate’s stay.

In the next episode, we will focus on suicide prevention in more detail.

In the previous article, we covered the basic mechanics of how jails operate. This article does the same thing for the mental health side. The goal here is to explain what mental illness is, how treatment normally works, and why treatment inside a jail looks very different from treatment in the community.

What We Mean by “Mental Illness”

Mental illness is a broad term. In clinical settings, it usually refers to a diagnosable condition that affects emotions, thought processes, or behavior in a way that interferes with a person’s ability to function.

It is important to distinguish clinical disorders from normal human experiences. Feeling sad, anxious, angry, or overwhelmed is not the same thing as having a mental illness. Those emotions are part of being human. They become a clinical disorder only when they are persistent, severe, and significantly impair functioning over time. Diagnosis is more nuanced than this simplified definition, but this is generally what clinicians are looking for.

This distinction matters because incarceration itself causes distress. Being in jail can make people sad, anxious, angry, or hopeless. In fact, it would be surprising if it did not. As a result, jail can make mentally healthy people appear mentally ill, and it can significantly worsen symptoms for people who already have a diagnosed condition.

Mental Illness vs. Serious Mental Illness

Mental illness and Serious Mental Illness (SMI) are not the same thing.

SMI is a technical term commonly used in research and clinical settings to indicate severity. People with mental illness have symptoms that interfere with their lives. People with serious mental illness have symptoms that, if untreated, make independent functioning impossible. Individuals with SMI often pose a risk of harm to themselves or others if left untreated in the community.

One important feature of serious mental illness is anosognosia. Approximately 50% of people with SMI lack awareness that they are ill. This is not denial in a psychological sense; it is a neurological symptom. Anosognosia becomes critically important when discussing involuntary medication and civil commitment, which are topics we will return to later.

Conditions That Are Not Mental Illness, but Still Matter

Some conditions are not mental illnesses but still require special consideration in jails. These include:

• Autism spectrum disorders

• Intellectual disabilities

• Traumatic brain injuries (TBIs)

People with these conditions may not need psychiatric treatment, but they often do not function well in general population. A major concern is exploitation. I have seen inmates with these conditions have food stolen, phone accounts drained, or otherwise be taken advantage of by more savvy inmates.

In these cases, mental health staff may become involved not because treatment is needed, but because housing and classification decisions require clinical input.

Substance Use Disorders

Substance use disorders are extremely common in jails. National estimates suggest that 40–60% of jail detainees meet criteria for a substance use disorder. Based on my own data, this estimate is accurate.

All jails have protocols for acute intoxication and withdrawal. Medical staff identify the issue at booking and place the inmate on a detox protocol when needed. This usually involves monitoring and, in some cases, medication to manage withdrawal symptoms.

There are three important things to understand about substance use disorders in jails.

Diagnostic Complications

Intoxication and long-term substance use can mimic psychiatric disorders. Depression, anxiety, psychosis, and mania can all be caused or worsened by substances. For this reason, clinicians often delay making a psychiatric diagnosis until the person has been in custody for a week or more.

Inmates Lie About Substance Use

People frequently minimize or deny substance use during intake. They often believe the information will be used against them, especially if their arrest involved drugs or alcohol. In practice, complete denial is usually inaccurate, and reported use is typically an underestimate. This matters most for alcohol, which presents unique risks. Severe alcohol withdrawal can appear days after booking and can be fatal. If someone who was recently booked becomes confused, hallucinates, or has seizures, medical staff should be alerted immediately to the possibility of alcohol withdrawal.

Treatment Is Difficult in Jail

Substance use disorders are very difficult to treat in jails due to:

• High inmate turnover

• Frequent housing changes

• Limited treatment staff

• Limited inmate motivation for treatment

Some jails have dedicated treatment units, but they are uncommon. Most jails focus on post-release treatment linkage, because the period immediately after release is especially dangerous. People are stressed, fully detoxed, and may return to prior levels of use without their previous level of tolerance, increasing overdose risk.

Personality Disorders

Personality disorders involve rigid, pervasive patterns of thinking and behavior that are highly resistant to change. Common examples include Antisocial, Narcissistic, and Borderline Personality Disorders. These occupy a clinical gray area. They are not typically disabling in the same way as mood or psychotic disorders, but they severely impair relationships.

They are not classified as mental illnesses largely because they are difficult to treat. Insight is limited, motivation is low, therapy is often sabotaged by the patient, and medication does not treat the underlying disorder.

Despite this, personality disorders matter in jails because these inmates often consume a disproportionate amount of mental health resources. They may exaggerate symptoms, act out, or repeatedly generate crises.

A former professor once suggested using one’s own frustration as a diagnostic indicator: the angrier a patient makes you feel, the more likely a personality disorder is involved. This heuristic is imperfect, but often accurate. We will revisit this topic when discussing malingering.

Levels of Mental Health Care

Mental health treatment should match symptom severity:

• Outpatient treatment for mild to moderate conditions

• Intensive outpatient or partial hospitalization for more severe cases

• Inpatient psychiatric hospitalization for acute danger (typically 3–10 days)

• State psychiatric hospitals for chronic or treatment-resistant illness (30–90 days or longer)

Jails contain people who fall into every one of these categories. In my jail, roughly one-third of inmates likely need outpatient treatment for a diagnosed mental illness, excluding substance use disorders. Approximately 4% have a serious mental illness that would be more appropriately treated in a psychiatric hospital. That rate is two to four times higher than in the community.

Jails also receive patients who are too disruptive or dangerous for psychiatric hospitals, including individuals who assault hospital staff or other patients.

In short, jails house some of the most difficult psychiatric cases in the system.

Who Provides Mental Health Care in Jails

Most jails contract with large correctional healthcare companies. Others partner with hospitals, universities, or counseling centers. Some run in-house programs staffed by county or city employees. My jail uses the in-house model, which I recommend, though each approach has tradeoffs.

Providers generally fall into two groups: therapy-focused and medication-focused staff.

Therapy-Focused Providers

• Mental health technicians or specialists handle crisis intervention, groups, and suicide watch monitoring.

• Counselors and clinical social workers conduct evaluations, suicide risk assessments, and segregation reviews. Therapy is a smaller part of their role.

• Psychologists typically serve supervisory and administrative roles. They oversee staff, review cases, manage policies, audits, and program development. They do not usually conduct competency evaluations for inmates in their own jail due to conflicts of interest.

Medication-Focused Providers

• Medical assistants pass medications, administer injections, and check vitals.

• Nurses conduct intake assessments and can administer as-needed medications under standing orders.

• Nurse practitioners and physician assistants diagnose mental illness and prescribe medication. They are the backbone of jail psychiatric treatment.

• Psychiatrists focus on medication management and supervision. While they sometimes serve as program managers, their time is usually more efficiently spent treating patients directly.

Common Medication Classes in Jails

Medications are typically grouped into four categories:

• Antidepressants – widely prescribed

• Anxiolytics – long-acting agents are preferred; benzodiazepines are usually avoided

• Mood stabilizers – primarily for bipolar disorder

• Antipsychotics – essential for serious mental illness

Benzodiazepines are rarely used outside of detox, due to abuse potential (and high trade value) and overdose risk.

Mood stabilizers reduce extreme mood swings but are often disliked by patients because they blunt positive emotions. They have little trade value in jail.

Antipsychotics are the most effective short-term treatment for psychosis. Long-acting injectable antipsychotics are especially important because many psychotic patients have anosognosia and refuse medication. Injections are safer and require fewer physical interventions. These medications are not without their trade-offs. We will do another article sometime in the future on dopamine-supersensitivity and why antipsychotics sometimes make the problem worse in the long-run.

The cost of these medications is a serious problem and deserves its own discussion. I’ll do an article on this in the future, and we can discuss why the federal medicaid exclusion rule is needlessly extracting money from local governments.

Divided Loyalties in Jail Mental Health

Unlike community clinicians, jail mental health providers have dual responsibilities: patient care and institutional safety. Confidentiality may be breached when safety or security is at risk. Treatment decisions are often driven by risk management rather than ideal clinical practice. This is not ideal, but it is the reality of correctional mental health.

Closing Thoughts

Jail mental health is complex and imperfect. Jails were never designed to serve as psychiatric treatment facilities, yet they have become the primary providers for people with serious mental illness.

Now that we have the basics covered, future articles can focus on more specific issues within this system.

In the previous series, we examined how economic forces have driven rising rates of mental illness—especially among young people. Now we can start digging into the role of jail in all of this. My plan is to explain the nuts and bolts of jails and jail mental health, and after we’ve been through the basics, we can get into some of the more complicated, convoluted, and backwards issues that prevent the mental health system from working.

First, we need to understand what jail actually is. This episode is part one of a two-part crash course on jails and mental health. Here, we will focus on the basics of jails. In the next episode, we will shift to the clinical side and discuss mental illness inside these facilities.

Jail Is Not What Movies Show You

In movies and television, someone is arrested for a serious crime and appears in court almost immediately for a jury trial. In reality, this is wildly inaccurate. In the United States, it often takes a year or more for a felony case—especially something like murder—to go to trial. I have personally seen cases take five years to resolve. During that entire time, the person may be sitting in jail.

Crimes and Sentencing: Three Tiers

• Felonies are the most serious offenses and can carry sentences of one year or more in jail or prison.

• Misdemeanors are less serious and typically carry sentences ranging from 30 days to one year in jail.

• Ordinance violations rarely involve jail time and usually result in a fine.

One important point is that the severity of a charge does not always reflect how dangerous a behavior is. Driving under the influence is extremely dangerous and often classified as a misdemeanor, while possession of marijuana is charged as a felony in some states.

Another important point is that people do not always serve the amount of time suggested by sentencing guidelines. I have seen individuals plead guilty to felonies and receive no jail time, and I have seen people with mental illness fight misdemeanor charges and remain detained—between jail and the state hospital system—for over a year. Technically, no judge sentenced them beyond the statutory limit, but functionally, they were incarcerated longer than the maximum sentence.

Jail vs. Prison

Jails and prisons are often conflated, but they serve very different purposes.

• Jails are short-term facilities. They primarily hold people who have been charged with a crime and are presumed innocent until their case is resolved.

• Prisons are long-term facilities for people who have been convicted of felonies.

The defining feature of jails is rapid turnover. In the jail where I work, the average length of stay is about 48 hours. In a single day, we may book and release 100 people. This rapid turnover is partly due to constitutional requirements. After an arrest, prosecutors must establish probable cause—basic evidence justifying the arrest—within roughly 48 hours. If they fail to do so, the person must be released. This becomes critically important later when we discuss people with severe mental illness who cycle in and out of jail every two days.

From a mental health standpoint, the jail environment is extraordinarily difficult. Jails are noisy, chaotic, confusing, stressful, and sometimes dangerous. Diagnosing and treating mental illness under these conditions is a major challenge, both for patients and for staff.

How Bail Works

Bail functions much like collateral at a pawn shop. A judge assesses how dangerous someone is and how likely they are to return to court. Based on that assessment, the court sets a dollar amount. If the person—or someone on their behalf—pays that amount, they are released. If they fail to appear in court, the money is forfeited. Judges can also deny bail entirely if they believe someone is a serious danger or flight risk.

The implication is: it is easier to get out of jail if you have money.

Many people in jail are indigent or homeless, and even a $500 bail is out of reach. This disproportionately affects people with mental illness, who are far more likely to be poor or unhoused. As a result, they remain incarcerated far longer than others charged with similar offenses.

Why Almost No One Goes to Trial

Television gives the impression that trials are the norm. In reality, they are exceedingly rare. Nationally, only about 2% of criminal cases go to trial. In my jurisdiction, that number is closer to 0.5%. Almost all cases are resolved through plea deals. There are two main reasons for this.

Trials Are Expensive

Trials cost taxpayers tens of thousands of dollars. Judges must clear their schedules, prosecutors and defense attorneys must prepare extensively, and jury trials consume enormous resources—sometimes over minor charges.

From the state’s perspective, trials are risky. Spending large sums only to lose the case is politically damaging for prosecutors.

Jail Is Too Costly for Ordinary People

Most people cannot afford to sit in jail for weeks or months while fighting a charge. Employers will not tolerate extended absences. Rent, car payments, childcare, and caregiving responsibilities do not pause because someone is incarcerated.

Roughly 60% of Americans cannot afford $500 in emergency expenses, which means many people are functionally coerced into plea deals. For some, pleading guilty to a crime they did not commit is the rational choice for survival. This pressure is even greater for people with mental illness.

Probation, Parole, and Holds

• Probation allows someone to remain in the community under supervision instead of serving a jail sentence.

• Parole allows someone to leave prison early under supervision.

• Holds occur when a person is arrested in one jurisdiction for charges pending in another.

If a person has an out-of-state warrant, the jail may detain them while the originating jurisdiction decides whether to extradite. These holds typically last up to 30 days. For minor offenses, extradition is often deemed too expensive, and the person is released. Again, the system runs on money.

Why Jails Have a Mental Health Crisis

Jails were never designed to be mental health treatment facilities. Yet there are ten times more people with serious mental illness in jails and prisons than in all long-term psychiatric hospitals combined.

This happened because mental health services are chronically underfunded at every level. The United States has eliminated approximately 96% of its state psychiatric hospital beds. Community mental health centers are overstretched, and insurance reimbursement rates are so low that many clinicians refuse to take insurance (insisting on cash payments only).

As a result, jails—never intended for this role—have become the largest mental health providers in the country. Police officers and correctional staff are now the most common first responders to psychiatric crises.

In a 50-mile radius of where I work, only two facilities house more mental health patients than my jail. One is a prison. The other is another jail.

Treating Mental Illness in a Jail Environment

Consider the conditions:

• High noise and constant disruption

• Extremely high patient turnover

• More psychiatric patients than a hospital

• Fewer mental health staff than a hospital

• Little to no medical history available for many very sick patients

• Patients often restrained during evaluations

• Housing environments filled with people who are nefarious or psychotic

It is difficult to imagine meaningful recovery under these circumstances. In the next episode, I will explain how jails attempt to provide care despite these constraints.

Two Concepts That Will Matter Later

Recidivism

Recidivism refers to being convicted of a crime, serving a sentence, and later being convicted again. High recidivism rates signal a mismatch between people’s problems and the system’s responses.

Competence to Stand Trial

In the U.S., a person cannot be tried or accept a plea if they are legally incompetent—that is, if they cannot understand their charges, the consequences, or assist in their defense.

Determining competence requires evaluations by independent clinicians. If a person is found incompetent, they must undergo competence restoration, usually at a state psychiatric hospital. This process is slow. From identification to evaluation, hospital waitlists, restoration, and return to jail, the timeline often exceeds seven months, even when everything goes smoothly. In some cases, it takes far longer.

Simply being mentally ill can result in longer incarceration than the sentence for the underlying offense.

What Comes Next

In the next episode, we will shift to discussing basic mental health care. We will examine what mental illness looks like inside a jail, who provides care, and what treatment is realistically possible under the conditions we have discussed.

In the previous episode, we examined how extreme wealth concentration took hold in the United States—and how the same mechanisms that concentrated wealth also eroded living standards and damaged mental health for ordinary people.

In this final episode, I want to focus on solutions. Specifically, how we can correct the policy mistakes of the past 45 years and move toward an economy that works for people across the income spectrum. Because when wealth pools at the top, the bottom loses stability, opportunity, and dignity—three things that are essential for mental health.

The good news is: fixing these problems does not require dismantling capitalism or reinventing our entire economic system. Capitalism can work. It has worked before. We simply need to put the guardrails back on.

Capitalism was never meant to be unregulated. Adam Smith, the father of capitalism, wrote in The Wealth of Nations:

“People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices.”

What Smith understood—centuries before modern economics—is that markets left entirely to themselves do not stay competitive. They consolidate. They exploit. And they harm the public.

In other words, capitalism only works when governments actively prevent monopoly and exploitation. The last episode explained what happens when those protections are removed, contradicting the ideology popularized by Milton Friedman and the Chicago School in the 1980s.

We need to be honest about where we are now. For millions of Americans, the economic foundation has already collapsed. History shows that people tolerate this only for so long before demanding change. If conditions continue to deteriorate, the consequences will affect everyone—regardless of political beliefs or personal wealth.

So let’s talk about what fixing this actually looks like.

1. Restore Real Antitrust Enforcement

The first issue we must address is the near-total collapse of antitrust enforcement in the United States. Monopolies and oligopolies suppress wages, raise prices, and accelerate wealth concentration. Laws designed to prevent this—the Sherman Act, Clayton Act, and Federal Trade Commission Act—still exist. But beginning in the 1980s, enforcement largely stopped. Courts started interpreting antitrust law narrowly, focusing almost exclusively on whether consolidation raised consumer prices. Even then, many companies were allowed to merge despite clear harm.

After 45 years of legal precedent, simply “enforcing the law again” is no longer enough. Congress must step in with statutory clarification. Antitrust law must explicitly recognize that harm includes loss of small businesses, weakened labor markets through monopsony, reduced innovation, and concentration of economic and political power.

2. Stop Wage Suppression and Restore Worker Leverage

Next, we must address wage suppression. Companies have developed a wide range of tools to weaken worker bargaining power, including non-compete clauses, mandatory arbitration, wage-fixing through benchmarking software, and misclassification of employees as independent contractors. These practices prevent workers from negotiating fair pay—even in competitive labor markets.

Passing laws is not enough. These laws must be enforced by regulators with the political will to challenge powerful corporations.

3. Fix Regressive Tax Policy and Tax Wealth

The United States has one of the most regressive tax systems among advanced economies. Lower-income Americans pay a higher proportion of their income in taxes than the wealthiest households. To correct this imbalance, we need to raise top marginal income tax rates, remove the income cap on Social Security taxes, and introduce a real wealth tax. Currently, the only meaningful wealth tax in the U.S. is the estate tax—and even that is largely optional due to strategies like “buy, borrow, die,” which allow the ultra-wealthy to avoid paying it altogether. (I will explain how this strategy works in a future article.)

Taxing wealth is the single most effective way to reduce wealth concentration. And reducing wealth concentration doesn’t just improve economic statistics—it reduces chronic stress, instability, and hopelessness, which are major drivers of mental illness. Economist Thomas Piketty has proposed a modest annual wealth tax ranging from 2% to 10% on very large fortunes. Even implementing only this single reform would significantly reduce wealth concentration and stabilize living standards.

About two-thirds of Americans support a wealth tax. But even if you oppose it ideologically, the math is unavoidable: without reducing wealth concentration, living standards will continue to fall and mental illness will continue to rise.

4. The Myth That Wealthy People Will “Flee”

A common objection to wealth taxes is that wealthy individuals will leave the country. This concern has been studied extensively. Nobel laureate Peter Diamond and economist Emmanuel Saez developed models examining how sensitive high earners are to taxation. Their findings are clear: they are not very sensitive at all. The top marginal tax rate that maximizes revenue without triggering mass tax avoidance is estimated to be between 70–80% on the highest incomes. In other words, wealthy people are not going to pack up and leave simply because taxes increase.

5. Fix Housing

Housing insecurity is one of the strongest predictors of chronic anxiety. Today, the top 10% of Americans own about 45% of the housing stock. This speculative ownership increases competition and drives prices up. There are many ways to address this. These include banning corporate ownership of single-family homes, taxing vacant housing units, restricting interest-only loans, and discouraging speculative hoarding. If we implemented a wealth tax, many investors would be forced to liquidate housing assets, naturally reducing prices and increasing supply.

The exact policy matters less than the goal: housing should be a place to live, not a vehicle for infinite asset appreciation.

6. Restore the Minimum Wage to Its Historical Role

The minimum wage once stood at about 45% of the median full-time income. Today, it is far below that. Research shows that restoring the minimum wage to this level has minimal impact on employment while significantly improving living standards for low-wage workers. In 2025 dollars, that would mean a minimum wage of about $13 per hour—not a radical idea, just a return to historical norms.

7. Reform or Ban Stock Buybacks

Stock buybacks function as a wealth transfer from workers to wealthy shareholders. They don’t improve productivity or innovation—only stock prices. Some things we could do to fix this would be to re-classify stock buybacks as a form of illegal market manipulation, or increase the buyback tax from 1% to 5% (or higher). This would push companies to invest in workers, wages, and productive capacity rather than financial engineering.

8. Invest in Public Goods

Once wealth concentration is reduced at the top, the next step is to rebuild opportunity at the bottom. Key investments include:

Family Stability

Universal or subsidized childcare improves child outcomes and allows parents to stay in the workforce. With current annual childcare costs around $12,000 (per child), this alone would dramatically improve family finances.

Housing Stability

Publicly built, mixed-income housing—done well—can increase supply without undermining private construction. Countries like Finland have proven this works.

Education

Free or subsidized community college and state universities improve lifetime earnings while eliminating one of the biggest financial stressors facing young adults.

Healthcare

Healthcare costs are one of the largest drivers of financial stress. While single-payer reform is complex (but still worth doing), expanding subsidies would immediately reduce financial harm.

Infrastructure

Upgrading aging infrastructure and expanding broadband internet creates good jobs and improves long-term productivity—a modern version of New Deal–style investment.

Why All This Matters for Mental Health

Taken together, these policies would significantly reduce wealth concentration, stabilize living standards, and reduce the social conditions that drive depression and anxiety. This series has focused on economics because mental health cannot be separated from material conditions.

Therapy matters. Medication matters. Access to care matters. But focusing only on treatment while ignoring economic policy is like bailing water out of a boat with a hole in the bottom. You can keep people afloat for a while—but unless you fix the hole, the boat keeps filling.

What Now?

The good news is that we live in a democracy. We can choose to fix this. The challenge is that democracy only works when people understand what’s happening—and most people don’t. If you care about mental health, justice, or the future of young people, your role is to educate others. Talk to your friends. Engage locally. Ask questions. Invite discussion instead of argument.

We all want the same things: meaningful work, stable housing, food to eat, and a reason to be optimistic about the future. That foundation is what young adults—maybe your children—need to build mentally healthy lives.

In the previous article, I explained how the United States experienced high living standards between 1945 and 1970, how external economic shocks led people to misinterpret why those living standards began to fall, and how, between 1980 and 2025, the country embraced policies that reduced living standards for the average American while dramatically increasing income for CEOs and wealthy families.

This article introduces the central concept of this series: wealth concentration.

Many people discuss this issue using the term “wealth inequality,” but wealth concentration is more precise and less misleading. The core problem is not inequality in the abstract, but the extreme concentration of wealth at the top. If the top 10 percent owned 30 percent of all wealth, the distribution would be unequal, but not extreme. If the top 10 percent owns 70 percent of the wealth (as it does in the United States), the concentration is extreme.

That level of concentration has real consequences. It does not merely rearrange numbers on a spreadsheet. It reshapes the material and emotional realities of ordinary families.

To understand how wealth became so concentrated, it helps to revisit the policy changes discussed previously. Beginning in the 1980s, wages for average workers stagnated while compensation for executives rose dramatically. Between 1980 and 2025, real wages increased by about 12 percent when adjusted for inflation. Over the same period, real CEO compensation increased by roughly 1,200 percent. CEO pay grew approximately twelve times faster than worker wages.

More striking than executive compensation, however, was the growth in asset values. Assuming dividends were reinvested, the real value of the S&P 500 increased by roughly 3,000 percent over that same period. Asset values grew about twenty-eight times faster than wages.

Several structural changes explain this divergence.

One of the most important was deregulation. Prior to 1980, the United States maintained a regulatory framework designed to preserve competition. Competitive markets benefit consumers and workers by pushing companies to lower prices, improve quality, and offer better compensation to attract skilled employees.

After 1980, many of these regulations were rolled back. Large corporations began merging with or acquiring smaller competitors. The airline industry illustrates this shift clearly. Where there were once a dozen or more major airlines, four companies now control approximately 80 percent of U.S. air travel.

This kind of market structure is known as an oligopoly, in which a small number of firms dominate an industry. Oligopolies reduce competition and raise prices because consumers have limited alternatives. When all major firms keep prices high, customers must either pay more or forgo the service.

Corporate consolidation also creates monopsony power. A monopsony occurs when a small number of firms control most employment opportunities in a sector. For example, a commercial airline pilot in the United States has very few employment options outside the major carriers. In monopsonistic labor markets, workers compete for jobs, which suppresses wages.

Deregulation in industries like airlines, telecommunications, banking, and media produced both oligopolies and monopsonies. Prices rose for consumers, wages fell for workers, and profits increased for owners. These dynamics contributed directly to the extreme levels of wealth concentration in the US today.

Alongside consolidation, companies increasingly adopted anticompetitive labor practices. One common example is the non-compete clause. These contracts restrict employees from working for competitors after leaving a job. Non-competes severely weaken workers’ bargaining power. If an employee cannot credibly threaten to leave for higher pay elsewhere, employers have little incentive to offer raises.

Another common practice in the 1980’s involved “no-poaching” agreements, in which companies secretly agreed not to hire each other’s workers. This further reduced labor mobility and suppressed wages by eliminating competition for employees.

At the same time, firms sought to reduce labor costs by shifting away from full-time employment. Many replaced full-time jobs with part-time, contract, or gig work to avoid paying for benefits such as healthcare, pensions, and payroll taxes. This transferred costs and risks from employers to workers, increasing wealth concentration while lowering living standards.

Financial deregulation also played a critical role, particularly through the rise of stock buybacks. Before the 1980s, stock buybacks were largely illegal. As financial regulations were relaxed, buybacks became a routine corporate practice.

When companies earn profits, they have several options. They can reinvest in the business by expanding operations, upgrading equipment, or increasing wages. They can distribute profits as dividends. Or they can buy back their own shares from the market. Historically, companies primarily reinvested profits. After 1980, corporate strategy shifted toward maximizing shareholder value, which meant a focus on stock buybacks.

Stock buybacks raise share prices by reducing stock supply and increasing demand (I explain this better in the video). This benefits existing shareholders by increasing the value of their holdings. In the United States, the top 10 percent of households own roughly 93 percent of all stocks. Buybacks therefore function as a mechanism for transferring corporate profits to wealthy asset holders.

Because these gains appear as asset appreciation rather than income, they are significantly tax-advantaged. Companies can even finance buybacks with borrowed money through leveraged recapitalizations. While this boosts share prices in the short term, it weakens company balance sheets, reduces resilience during economic downturns, and undermines workers’ ability to negotiate raises. Job security declines as firms become more financially fragile.

Another factor amplifying wealth concentration is the erosion of the minimum wage. Since the 1980s, the federal minimum wage has lost about 40 percent of its purchasing power. Beyond affecting low-wage workers directly, the minimum wage sets the wage floor for much of the labor market. When the floor is low, wages just above it remain suppressed.

Raising the minimum wage lifts compensation across the lower tier of earners without increasing executive pay or asset prices. As a result, minimum wage increases reduce wealth concentration while improving living standards.

Altogether, these changes created diverging paths of wealth accumulation. Wealthy households held assets that appreciated rapidly, while most working households relied on wages and, at most, home equity. Economists describe this as a K-shaped economy: asset values rise sharply while wage purchasing power stagnates or declines.

Because economic resources are finite at any given time, greater concentration at the top necessarily means less for everyone else. As asset prices grow faster than wages, the share of total wealth controlled by the top 10 percent increases each year.

Spending behavior further reinforces this dynamic. Ordinary households spend most of their income on goods and services. A person earning $60,000 per year might spend nearly all of it on necessities, with perhaps 10 percent available for savings or investment.

Wealthy households operate under entirely different constraints. A billionaire whose assets grow by just 5 percent annually gains $50 million in a year. After living expenses, the vast majority of that income is reinvested in additional assets. As a result, ordinary households primarily purchase goods and services, while wealthy households primarily purchase assets. The more wealth one has, the easier it becomes to accumulate even more.

Relative purchasing power matters more than nominal wages. A 5 percent raise does not improve living standards if asset prices rise by 10 percent. A household earning $50,000 that receives a raise to $52,500 may still fall behind if housing prices rise from $300,000 to $330,000 over the same period.

Housing illustrates this problem clearly. The wealthiest 10 percent of Americans own approximately 45 percent of all housing. As housing is increasingly treated as an investment asset, prices rise faster than wages, reducing affordability for everyone else.

By 1989, the top 10 percent of U.S. households controlled about 44 percent of total wealth. By 2023, that figure had risen to roughly 67 percent. As wealth concentrates at the top, fewer resources remain available to the rest of the population. Young adults face persistent financial strain, and these conditions triple the risk of depression.

Wealth concentration explains why living standards have declined, why anxiety and depression have increased, and why economic stress now dominates the mental health landscape. These outcomes are not inevitable. They are the result of policy choices, and policy choices can be changed.

The next article will focus on how this system can be repaired and what steps are necessary to improve living standards so future generations do not inherit an economy that systematically undermines their mental health.

In the previous article, I explained why depression is not the result of a chemical imbalance, but rather an economic one. The next question, then, is how this imbalance developed. The answer is that it did not happen by accident. It was the result of deliberate policy decisions made over decades.

To understand this, it helps to go back to 1945.

At the end of World War II, the United States was in an unprecedented economic position. Most industrialized nations had been devastated by the war. Their factories, infrastructure, and labor forces were severely damaged. By contrast, the U.S. mainland was untouched, and the country had already built a massive manufacturing base to support the war effort.

All the United States needed to do was shift from producing weapons to producing consumer goods. This allowed the country to dominate global manufacturing for roughly the next twenty years.

At the same time, the domestic policy environment strongly favored working-class Americans. Union membership was high, giving workers real bargaining power. The tax system was progressive, meaning higher earners paid higher rates, while working families paid relatively less. Wages rose alongside productivity, and a single income could often support an entire family. Strong social safety nets existed to support people during periods of unemployment or hardship.

This combination of industrial dominance and worker-friendly policy produced high levels of financial security. Living standards rose rapidly, and optimism about the future was widespread. This period represented the high-water mark for living standards in the United States. Notably, it was also a period of sustained GDP growth, demonstrating that high taxes on top incomes and corporations can coexist with strong economic growth and broadly shared prosperity.

That stability began to unravel in the 1970s.

A series of political crises in the Middle East led to sharp increases in global oil prices. At the time, the United States was heavily dependent on foreign oil. Nearly every sector of the economy relied on transportation powered by gasoline, so higher oil prices translated into widespread inflation across the entire economy.

At the same time, the global landscape had changed. By the 1970s, most industrialized nations had rebuilt their manufacturing sectors. The United States no longer held a monopoly on production and now faced international competition. Increased global supply drove prices down and placed pressure on companies to limit wage growth to preserve profits.

The combination of high inflation and stagnant wages is what economists refer to as stagflation.

This period of stagflation coincided with strong union membership, which is critical to understanding what happened next. Many union contracts included cost-of-living adjustments. When companies raised prices to offset higher oil costs, inflation increased. Because wages were tied to inflation through union contracts, employers were then required to raise wages as well. This back-and-forth between prices and wages created what economists call a wage-price spiral.

Around 1979, this conflux of factors reached an inflection point. A new narrative emerged that blamed unions for inflation. This narrative ignored the fact that inflation had already surged due to external shocks, particularly oil prices. Workers were not demanding higher wages arbitrarily. They were attempting to preserve their existing living standards in the face of rising costs.

Beginning in the early 1980s, the United States underwent a dramatic policy shift. Taxes on high incomes were cut. Industries were deregulated. Companies began aggressively offshoring jobs. At the same time, labor unions were systematically weakened, reducing workers’ ability to negotiate for higher wages.

Productivity continued to increase, but the benefits of that productivity no longer flowed to workers. Instead, the gains were captured almost entirely by corporate executives and shareholders.

For working Americans, the consequences were profound. Over the next 45 years, the cost of living rose steadily while real wages stagnated.

Consider the federal minimum wage. In 1980, it was $3.10 per hour. Adjusted for inflation, that is equivalent to roughly $12 per hour in 2025 dollars. Despite rising living costs, the current federal minimum wage remains $7.25 per hour. In real terms, the minimum wage today is just over half of what it was in 1980. Low-wage workers are objectively worse off than they were four and a half decades ago.

What about the median household? In 1981, median household income was $21,020, which is approximately $76,000 in 2025 dollars. The current median household income is around $85,000. On paper, that suggests a real increase of about 12 percent.

Yet this improvement does not feel real to most households, and there is a reason for that.

Standard measures of inflation rely on the Consumer Price Index (CPI), which tracks everyday goods such as food, household supplies, and gasoline. Between 1980 and 2025, CPI inflation was roughly 293 percent. Groceries now cost about three times what they did then.

However, CPI fails to capture some of the largest expenses households face. Over the same period, housing costs increased by more than 300 percent. Childcare costs rose by approximately 600 percent. Health insurance costs increased by over 650 percent. The cost of a college degree rose by more than 1,200 percent.

These increases occurred gradually, which made them easy to overlook. Living standards did not collapse overnight. The American dream did not die suddenly. It bled out slowly over the course of decades.

For young adults, the consequences are especially severe. Many enter the workforce only to find that entry-level jobs do not pay enough to live independently. Most must live with roommates or family members. Even then, they face high healthcare premiums, significant student loan debt, and an economy that increasingly favors part-time, contract, and gig work to minimize labor costs. Those who do not attend college often face even worse financial prospects.

These conditions are fertile ground for anxiety and depression. Therapy can help people cope with these pressures, but it cannot repair the underlying economic conditions that created them.

At this point, it should be clear how policy changes produced widespread financial instability. The remaining question is where all that money went. In the next article, the focus will shift to wealth concentration and how gains at the top have translated into despair at the bottom.

The care that patients receive in state psychiatric hospitals is better than what they receive in most jails. However, the cost difference is enormous. For instance, the average cost of keeping someone in jail might be $100-$300 per day, depending on the jail. Meanwhile, the cost of keeping someone in a state psychiatric hospital is more than $1,000 per day. In my state (which publishes these costs on their website), the cost of a state psychiatric stay is $2,000 per day (ten to twenty times more than the cost of a jail stay). This is all at taxpayer expense.

What do you get for this additional cost? The main difference is that you have group and (sometimes) individual therapy. These are services that are often not provided in jails because they lack the budget to pay for them. Jails primarily treat mental illness with medication, because it’s cheaper and can be administered quickly (as opposed to therapy which takes 45-60 minutes and requires the inmates to leave their cells). State hospitals also tend to have nicer facilities, better quality food, and extracurricular activities (e.g. gardening, art classes, etc).

In the context of our current series on the relationship between wealth concentration (and economics in general) and mental health, this is highly relevant. What we’ll see as the series unfolds is that a lot of these people are mentally ill because of high levels of wealth concentration (and associated sequelae). Our society fails to tax wealth, leading to wealth concentration and mental illness. This also means that the government is broke, and can’t afford to pay for mental health treatment. Since it can’t afford treatment when people need it, patients become increasingly psychotic and violent, resulting in incarceration, and the necessary treatment (provided much too late at this point) becomes astronomically expensive. A typical stay in a state hospital is 90 days…at $2,000 per day, a routine stay costs $180,000 per patient.

We can take this a step farther. Note in the NPR article that the state psychiatric hospital did not respond to a request for a comment.

Eric Wandersleben, director of media relations and outreach for the department, declined to respond to detailed questions submitted before publication and, instead, noted that responses could be publicly found in a governor’s working group report released in late 2024.

It’s obvious why Mr. Wanderslenben does not want to comment. What is he supposed to say? “We don’t have enough state hospital beds because politicians keep cutting funding for mental health.” He’s not going to throw his own boss under the bus.

What would his boss say if he were asked for comment? Probably nothing. But what he’s probably thinking is, “there is no room in the budget to increase the number of state hospital beds, expand treatment options in jails, or to improve community mental health treatment.” That’s what I would be thinking if I were in his position. And why is there no room in the budget? I think you know where I’m going with this. Because we don’t tax wealth, state budgets (which rely in-part on the Federal budget) are tighter and tighter every year.

The results of this are fewer social safety nets, more depression, more psychosis, and more suicide. If we do not do something about the economic problems, this situation will only continue to get worse. Stay tuned to weekly videos for a deeper explanation and suggestions for how we fix these problems.

In the previous article, I discussed the relationship between tax policy, economic conditions, and mental health. That connection will remain a central focus going forward, as it is the primary reason I began this series. Before going deeper into economics, however, it is important to address a widespread misconception about depression.

For roughly the past forty years, most people—both inside and outside the mental health field—have been told that depression is caused by a chemical imbalance in the brain. Surveys suggest that more than 80 percent of people in the United States believe this to be true. The problem is that it is not true. On closer inspection, it is not even a plausible hypothesis.

Rates of depression have tripled over the past 25 years. That kind of change does not resemble a biological or genetic phenomenon. Human genetics do not shift on that timescale. The idea that a sudden chemical malfunction has emerged across an entire population simply does not hold up.

There are two primary reasons this belief persists.

The first is pharmaceutical marketing. Drug companies have spent billions of dollars over decades promoting the idea that depression is caused by a chemical imbalance. If depression can be framed as a biological defect, it can be treated as a pharmaceutical problem. This messaging has been extremely effective. Prozac, the most well-known antidepressant, generates more than two billion dollars in annual profit.

What is far less effective, according to large meta-analyses, are antidepressants themselves. For approximately 85 percent of people who take them, antidepressants do not perform better than a placebo. In addition, roughly 70 percent of users experience side effects such as emotional blunting, sexual dysfunction, and, paradoxically, suicidal thoughts. For many individuals, the costs outweigh the benefits. Despite this, antidepressants continue to be widely prescribed and aggressively marketed.

The second reason the chemical imbalance myth persists is motivated reasoning. People are more likely to accept explanations that are comforting or that offer a sense of control. A chemical or genetic explanation allows depression to be seen as something impersonal and unavoidable. If depression is caused by brain chemistry, then no deeper questions need to be asked.

The alternative is much more uncomfortable. It suggests that depression may be a response to the way people are living, the choices they are constrained to make, or the environments they inhabit. Accepting that explanation implies that meaningful change is required, not just at an individual level, but at a collective one.

There are two related misconceptions worth briefly addressing. One is the idea that serotonin plays a central role in depression. It does not. The other is the belief that depression is a genetic disorder. It is not. Research suggests that genetics account for roughly 10 percent of depression risk.

If depression is not caused by chemical imbalances and is only minimally influenced by genetics, then approximately 90 percent of depression must be attributable to individual circumstances and environmental conditions. Once again, consider the fact that depression rates have tripled in just 25 years. Either human brain function has changed at a rate never before seen in evolutionary history, or the environment has changed. The latter explanation is the only reasonable one.

In the previous article, I argued that collapsing living standards are the primary driver of rising depression rates. I also examined the financial realities facing young adults in the United States to illustrate how unsustainable those conditions have become.

The data support this conclusion. A 2021 study from the Substance Abuse and Mental Health Services Administration tracked rates of mental illness by age group over time. Among adults aged 50 and older, rates remained essentially unchanged between 2008 and 2021, hovering around 15 percent. For adults in their late twenties through forties, rates increased from roughly 21 percent to about 28 percent over the same period. Among the youngest group, ages 18 to 25, rates rose from approximately 18 percent in 2008 to 34 percent in 2021.

In other words, rates of mental illness among older adults have remained stable, while rates among younger adults have nearly doubled.

This pattern is not random. It indicates that the forces driving the mental health crisis are disproportionately affecting younger generations. The reason is economic. Adults over 50 are largely insulated from many of the pressures reshaping the economy. Many have already purchased homes, raised families, and accumulated retirement savings. They benefit from Social Security, have access to Medicare, and often hold pensions, investments, or other assets built during a more stable economic era.

Younger adults do not share those advantages. They face housing markets they cannot afford, student debt that delays or prevents financial stability, and shrinking access to healthcare and social programs. They are told that Social Security may not exist when they retire, despite being required to continue paying into it. They are increasingly aware that their standard of living will likely be lower than that of their parents.

These are not personal failures or psychological defects. They are rational responses to deteriorating conditions.

The rise in depression is not genetic. It is not chemical. It is economic.

With that foundation established, we can move on to connect tax policy, wealth concentration, and the modern depression epidemic. We will pick up here next time.

References:

1 - https://journals.sagepub.com/doi/abs/10.1177/0022146512471197

2 - https://www.bmj.com/content/bmj/378/bmj-2021-067606.full.pdf

3 - https://www.nature.com/articles/s41380-022-01661-0

4 - https://pmc.ncbi.nlm.nih.gov/articles/PMC5934326/pdf/nihms943355.pdf

I have been concerned for quite some time about rising levels of depression and suicide in the United States, especially among young people. According to Gallup’s 2025 data, approximately 18 percent of Americans report having depression. That figure was about 10 percent a decade ago and just 5 percent in 2005. In the span of 25 years, rates have tripled. Something is clearly wrong.

I am very familiar with depression and how it is typically treated. When people learn about depression treatment, they are often introduced to different schools of thought: behavioral, cognitive, psychodynamic, humanist, existential, and others. These schools are less like competing skill sets and more like different languages. They largely describe the same underlying phenomena, using different terminology and emphasizing different aspects of the human experience.

What these schools have in common is an underlying assumption about the person being treated. The assumption is that something is wrong with the patient.

But what if that assumption is incorrect? What if depression is not a disorder located within the individual, but a normal reaction to a hostile environment? In that case, there is nothing for the therapist to fix. There is no missing insight to uncover and no new coping skill that will solve the problem. What is needed is a better environment.

This raises an obvious question: what has changed? Why is the environment so much more distressing now than it was in 2005, when depression rates hovered around 5 percent?

I have been thinking about this question for nearly a decade, and the conclusion is difficult to avoid. The economic environment has become too hostile. For many young Americans, the math simply no longer works. Even with full-time employment, basic expenses exceed typical take-home pay.

To illustrate this, consider the financial situation of the average young adult in the United States in 2025. The data used here are publicly available and can be verified independently.

The median annual salary for young adults with a high school diploma is approximately $38,000. After taxes, this amounts to about $2,615 per month in take-home pay. Now compare that income to unavoidable expenses: housing, transportation, food, healthcare, insurance, utilities, and other basic necessities. When these liabilities are totaled, they come to slightly over $3,600 per month. Without saving any money or spending anything on recreation, the average person is already short by roughly $1,000 every month.

A similar calculation can be made for young adults with a college degree. Median income rises to about $63,000 per year, but student loan payments add roughly $1,000 per month in additional liabilities. Even with the higher salary, expenses still exceed income by approximately $500 per month.

This, I would argue, is the primary driver behind rising rates of depression in the United States. Life is objectively harder for young people today than it was 25 years ago. It was harder 25 years ago than it was 50 years ago. If current trends continue, it will keep getting harder. Living standards will continue to fall, and depression rates will continue to rise.

What I do not want—for my children, or for yours, for those fortunate enough to afford having children—is a society where the deck is stacked against them from birth. The United States is rapidly becoming a country with little social mobility, where the so-called American Dream is only attainable by those born into wealth.

This leads to another question: how did things get this bad?

There is no simple explanation, and it is not something that can be addressed quickly. The approach I plan to take is to explain the outcome first, and then, in future discussions, work backward to show how each policy choice contributed to collapsing living standards and a growing mental health crisis.

The explanation itself is not glamorous. The core issue is U.S. tax policy. Since the 1980s, the United States has increasingly adopted regressive tax structures that extract resources from the poor and working class and redistribute them upward to the wealthy. If this continues, the pressures driving despair will only intensify.

There are many ways to design a fair tax system, but any sustainable solution must move resources back into circulation for the bottom half of the economy. This is not an ideological claim. It is a mathematical one. Importantly, variations of these ideas already enjoy broad bipartisan support.

If you care about the growing mental health crisis, this series will continue to break down how we arrived at this point and what can realistically be done to change course.

For anyone struggling with depression driven by economic strain, it is important to understand that you are not alone. You are one of roughly 150 million adults in the United States for whom the financial math no longer works. Depression is not just a mental health crisis. It is a warning signal from the economy itself, indicating that something in the system is broken.

Addressing it will require collective action. The implications of coordinated change are profound, and worth taking seriously.

Welcome to Jail Psychologist! This is a website that compliments a YouTube channel about mental health, criminal justice, and public policy. It may seem strange to start with a series on economics. The reason for this is that our economic landscape lays the foundation for our mental health. In this initial series, I will explain how the US economy relates to living standards, how living standards relate to depression and mental illness, and what we can do to fix these issues and improve mental health outcomes. The concepts explained in this initial series are fundamental to understanding mental health in the US, and arguably more important than anything else that I will cover on this site.

Once this initial series is complete, we will go in-depth on correctional mental health. If you have any topics you would like to hear more about, please let me know in the chat or send me an email at jailpsychologist@gmail.com.