Healthcare Behind Bars, Part 1: Prisoners of the system

FIRST OF A SERIES

The already tenuous taxpayer-supported prison healthcare system is buckling under growing financial strains and delivery challenges. This story launches a three-part examination of the nation’s prison healthcare system, offering a broad overview of this patient population, the challenges in caring for incarcerated patients and legal issues unique to prison healthcare.

Part II, to run March 19, will explore the growing niche of outsourcing prison healthcare services, both to not-for-profit hospitals and health systems and to investor-owned companies specializing in that business.

Part III, to run April 16, will take a look inside prison healthcare programs, accompanying the physicians, nurses and other caregivers who provide care to some of the sickest and, at times, scariest patients around.

The multibillion-dollar business of caring for the nation’s 2.2 million prisoners and inmates continues to snare headlines, sap government resources and pose enormous financial and delivery challenges for the federal, state and local government agencies charged with providing those services and the taxpayers who fund them.

But in an era of shrinking government budgets for social services, the prison healthcare system—a “mini me” version of the $2 trillion overall U.S. healthcare system—presents a moral dilemma to America’s national conscience. How does the country fairly and adequately care for those convicted of crimes or awaiting trial without siphoning too much governmental funding from other vital and more popular services for the general population?

In response to prisoner complaints as well as lawsuits from inmates, advocacy organizations and government agencies, judges around the country are intervening on behalf of prisoners, ordering jails and prisons to boost staffing, increase pay and even hire new doctors and nurses. In other cases they have compelled institutions to offer broader ranges of healthcare services to the incarcerated.

Some examples:

Last year, a Michigan federal judge found the state’s Department of Corrections in contempt of court, threatened to fine the department $2 million for providing constitutionally inadequate healthcare to state prisoners, and ordered it to hire more physicians at three state prisons near Jackson. U.S. District Judge Richard Enslen ordered the department to hire more nurses, create a staffing plan and make other healthcare improvements.

A federal monitor has overseen healthcare at the Jackson facilities since a consent decree was signed to settle a 1980 class-action civil rights lawsuit. The decree set standards of care that Enslen contended the state has repeatedly failed to achieve.

In August 2006, a mentally ill Michigan prisoner, Timothy Souders, 21, died after being kept naked and shackled to a bed for as long as 17 hours a day. In his 61-page order released in November, Enslen ordered sweeping changes and banned the kinds of restraints used on Souders. He wrote that what a prisoner “does not deserve is a de facto and unauthorized death penalty at the hands of a callous and dysfunctional healthcare system that regularly fails to treat life-threatening illness.”

Earlier this month, a monitor appointed by a federal judge to oversee improvements in California’s correctional healthcare system met with state legislators, warning them that unless action is taken soon, he would seek court orders to mandate improvements. California’s projected $1.9 billion prison healthcare budget for 2008 does not include money to build new prison acute-care and mental health hospitals that are needed according to the federal monitor.

The U.S. Justice Department’s Civil Rights division concluded in a report last year that medical and mental healthcare as well as sanitary conditions at the Dallas County (Texas) Jail were inadequate and violated the constitutional rights of the inmates detained there. Among other deficiencies, the office found substandard acute- and chronic-care services; failures to appropriately manage communicable diseases and medication administration; and insufficient staffing, specialty care and training. For each deficiency Assistant Attorney General Wan Kim cited multiple failures of care resulting in harm or death to prisoners.

Hospitals increasingly are caught in the middle, picking up the tab for uninsured prisoners, such as in Oklahoma City where Oklahoma County rules prevent it from paying for treatment for pre-existing conditions in prisoners, leaving hospitals to provide care for which they’re unlikely to be reimbursed. Some hospitals and health systems, such as 806-bed Parkland Health & Hospital System, Dallas, have contracted to care for county prisoners to varying degrees of success. For-profit companies to which states and municipalities often outsource prison healthcare services also have come under fire for understaffing facilities and skimping on care.

Experts in prison healthcare say solutions to the systemic problems are complex and varied. After all, it’s not like government authorities have a choice in providing health benefits to prisoners. Some 30 years ago the U.S. Supreme Court created a right for prisoners denied to most other Americans: a constitutional right to healthcare.

In that 1976 decision, Estelle v. Gamble, a Texas inmate claimed he was subjected to cruel and unusual punishment in violation of the Eighth Amendment to the U.S. Constitution for inadequate treatment received for a back injury he suffered while performing prison work. The high court concluded that inmates must rely on prison authorities to treat medical needs, which would otherwise go unmet and could result in pain and suffering or even a lingering death. “The infliction of such unnecessary suffering is inconsistent with contemporary standards of decency,” the U.S. Supreme Court concluded in its 8-1 decision.

The decision sparked dramatic changes in the way healthcare is delivered in prisons and jails around the nation, launching a multibillion-dollar industry. The American Medical Association and the American Bar Association worked to establish a commission to study correctional health services in 1972. They set the first jail standards in 1976 and the first standards for juvenile facilities and prisons in 1979. In 1983, the National Commission on Correctional Health Care was incorporated to accredit correctional healthcare facilities.

The Gamble case also triggered waves of litigation by prisoners and prisoner advocacy groups, including the American Civil Liberties Union, which compelled correctional institutions to provide a community standard of healthcare services rivaling and, in some cases, exceeding the coverage that insured Americans enjoy.

B. Jaye Anno, a co-founder of the National Commission and now a Santa Fe, N.M., correctional healthcare consultant, says that at the time of the Supreme Court decision, healthcare in correctional settings was considered a privilege, not a right.

“Before that if you were a sick prisoner you had to convince a correctional officer of your illness, and if he liked you, he’d take you to the nearest emergency room,” Anno recalls. “There were no on-site healthcare delivery systems in prisons. You were often treated by unlicensed ‘inmate nurses.’ In those days there were many impaired physicians or doctors with significant restrictions on their licenses who couldn’t see patients or get hired elsewhere (other than treating prisoners). The Gamble case changed all that.”

Anno and her late husband, Chicago attorney Bernard Harrison, another co-founder of the commission, who had been a vice president of the AMA, worked with the association’s Jail Project in the early 1970s to study the institutional problems and recommend improvements.

She says by the early to mid-’90s most jails and prisons boasted respectable healthcare delivery systems. Physicians now operate under clinical protocols and guidelines comparable to those outside of prisons and are tightly credentialed. Jail and prison health systems and hospitals are accredited by three national bodies: the National Commission, the American Correctional Association and the Joint Commission.

Joseph Paris, a physician, former medical director for the Georgia Department of Corrections and prison health consultant, says the Gamble case shook up the national correctional establishment.

“It became quickly apparent that most systems operated well below standards set by the Supreme Court. Litigation became a wave around the country,” he says. “The courts maintained oversight of those programs for years after (lawsuits were filed and settlements signed). Standards improved, and correctional healthcare began to resemble the care someone on the outside would receive if that person happened to be well-insured. This provoked a massive improvement in (prison) healthcare.”

Paris says the litigation forced cities, counties and states to spend large amounts to improve the healthcare offered to prisoners. He says the cost of providing a “community standard of care” to prisoners comparable with that received by most insured Americans averages about $4,000 per inmate annually. He says that improving quality usually reduces litigation, but doesn’t necessarily lower costs. And as government budgets are stretched and the number of uninsured approaches 47 million, he sees little popular support for continued improvements for increasingly costly prison health services.

State prison healthcare spending can vary widely. In 1998, California spent $483 million on prison healthcare for its roughly 157,000 prisoners, just over $3,000 per prisoner annually, or about 13% of its corrections budget. North Dakota spent about $826,000 on its roughly 800 prisoners, or a little more than $1,000 per prisoner, less than 5% of its total corrections budget. That year states spent an average of 12% of their total corrections budgets on prison healthcare, according to a 2001 book by Anno sponsored by the federal National Institute of Corrections, titled Correctional Health Care: Guidelines for the Management of an Adequate Delivery System.

Meanwhile, changes in judicial sentencing rules, an epidemic of drug use and decades of “tough on crime” laws have packed prisons and jails, contributing to overcrowding conditions and quality-of-care problems.

“We are on an incarceration frenzy,” says Joel Dvoskin, a psychologist and mental health consultant who teaches at the University of Arizona College of Medicine and is president of the American Psychology-Law Society. “In 1970, there were fewer than 400,000 prisoners and inmates in prisons and jails. Now we’re on track to have 2.5 million people behind bars.”

“Nobody ever got elected promising to raise taxes,” Dvoskin says, noting that courts have pushed state and municipal governments to improve medical and mental health services for prisoners. “We’ve seen an astonishing difference in the quality of mental health services in prisons since 1976. Litigation is a very bad way to improve things. But the threat of (litigation) is a very good way. Jails are public health outposts. Folks who would be running around infecting people sometimes get treatment in jails they wouldn’t or couldn’t get in the free world.”

The incarcerated include a healthy-size portion of unhealthy patients, a captive population that averages 2.2 million daily.

Between 9 million and 11 million prisoners will be released within a given year, often transmitting infectious diseases they acquired behind bars to the general public and back to prison if they return. But it isn’t just the fast-growing number of prisoners causing breakdowns in the prison healthcare system.

Though recent, accurate figures are not available, in 1996 between 12% to 35% of those in the U.S. with communicable diseases passed through jails or prisons, according to the National Commission. In 1997 there were 137,000 cases of sexually transmitted diseases among prisoners and three times that number—about 465,000—among released prisoners. More than one-quarter of inmates have some form of hepatitis, 12,000 have active tuberculosis and 135,000 have tested positive for TB.

While the number of both HIV-infected state and federal prisoners and AIDS-related prisoner deaths dropped for the fifth year in a row in 2004, the percentage of HIV-positive and AIDS patients in prison remains disproportionately high compared with the general population, according to the U.S. Justice Department’s Bureau of Justice Statistics.

The number of HIV-positive inmates decreased 2.6% to 23,046 in 2004 from 23,663 in 2003, and down 10.7% from a high of about 25,800 in 1999. AIDS-related deaths dropped 28% to 203 in 2004 from 282 in 2003 and the death rate from AIDS dropped as well. But the number of confirmed AIDS cases increased 1.4% to 6,027 in 2004 from 5,944 in 2003.

And the rate of AIDS cases among inmates (50 per 10,000 prisoners) remained more than three times higher than the general population (15 per 10,000 persons). Justice Department statisticians attributed the decrease in AIDS deaths and HIV infection to the introduction of protease inhibitors and antiretroviral therapies.

Government studies also indicate that more than 60% of prison and jail patients have mild or serious mental illnesses or substance-abuse problems. Those addictions aggravate complex respiratory conditions, infectious diseases and chronic conditions, such as diabetes and heart disease, prison health experts say. And the bulk of the cost of caring for them, estimated at between $7 billion and $8 billion annually for all prisons, is footed by taxpayers whose elected officials never want to be viewed as soft on crime or generous with benefits for criminals.

Prisoners typically don’t have high-powered lobbyists pleading their cases, as do seniors, people with disabilities and patients with cancer and heart disease. Prisoners are disproportionately black and Hispanic, mostly poor and frequently uneducated, according to federal prison studies and the American Correctional Association.

“We serve the most disenfranchised people in this country,” says physician Sergio Rodriguez, until recently the medical director of Cermak Health Services of Cook County (Ill.), the largest single-site correctional health facility in the country, which annually provides healthcare services to about 100,000 prisoners at the Cook County Jail.

“They never integrate into the healthcare system outside. We are their primary-care provider. They don’t see us as jailers, but as advocates. We are their doctors, sometimes the only ones they ever see.”

Rodriguez won’t be seeing his prison patients anytime soon. Shortly after Modern Healthcare interviewed him for this story, the interim chief of the Cook County Bureau of Health Services fired Rodriguez and four other prison health executives, alleging that they would resist budget-driven changes at Cermak Health Services.

R. Scott Chavez, vice president of the National Commission, says the prison healthcare industry lags behind its “free world” counterpart in a variety of ways, but also suffers from many of the same problems. He says the prison health system is highly fragmented between federal, state, county and city prisons and jails, with little or no communication, little outcomes data or access to information technology and no reliable, current national statistics about the healthcare conditions and status of prisoners.

“We don’t have good epidemiological information,” Chavez says. “We need, and have recommended to Congress a unified clearinghouse of centralized surveillance. We need better data. One of the major changes we’ve seen is a great push to apply evidence-based medicine to (correctional) settings. But the public doesn’t want to hear about the higher costs of accomplishing that, and institutions are doing more with less.”

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