Correctional Health Care, Ignore at Your Own Risk

In todays society where a tough on crime stance can get you elected, health care for inmates is often ignored.   This happens because people don’t understand that improving inmate health care can lower the amount of money THEY will have to spend on it.  I have presented my points of view on this topic here before, but here is a great article by Niko Karvounis  that I found today on Health Beat Blog that goes into greater detail on the subject.

Keep Criminals Healthy—Or Else

One of the most infamous records the U.S. holds is that of the world’s incarcerator. As of 2006, 2.2 million Americans were incarcerated, more than even China—which has over four times the population of the U.S.

California is the most cell-happy state in the union, with its prison population in midyear 2006 at over 175,000, or 11.3 percent of the total prisoners in the country. The Golden State’s 175,000 inmates are held in 33 prisons—meaning there’s roughly 5,307 inmates per prison.

Put differently, every prison health care system has 5,307 potential patients, day in and day out. That’s quite a caseload, and it’s made much worse by the fact that prisoners are in much poorer health than the general population. Indeed, the California prison system is in the throes of a health care crisis—one that highlights why we should all care about the quality of medical services for inmates.

As you might guess, prison is an unhealthy place. Prisoners are more than eight times as likely to be infected by HIV, four times as likely to have active tuberculosis, and more than nine times as likely to have hepatitis C. According to the National Commission on Correctional Health Care, about 3 percent of the U.S. population spends time in prison or jail—but between 12 and 35 percent of the total number of people in the nation with some communicable diseases (like AIDS and Hepatitis B) pass through a correctional facility.

Commission data shows similar trends occur for mental illnesses (see the table below). Prison inmates have rates of schizophrenia and other psychotic disorders that are three to five times greater than the general population. Their incidence of bipolar disorder is up to three times greater than people outside prisons. And prisoner rates of drug and alcohol abuse are also higher.

The Commission’s report is a little dated (from 2002), but there’s no indication that the problem has gotten any better. Thus for all intents and purposes, California has 33 facilities dealing with large populations of individuals far more likely to need serious and regular medical care. The problem is, of course, these facilities aren’t hospitals—they’re prisons. They’re meant to quarantine and punish, not to treat. And in California especially, they traditionally have done little good for patients.

Just how bad is the California prison health care system? Unconstitutionally bad—and that’s not just me talking. In 2001, a class action law suit against the state was brought to a U.S. District Court judge who found that the system’s quality of medical care was so abysmal that it violated the U.S. Constitution’s Eighth Amendment, which forbids cruel and unusual punishment.

The state settled the suit in 2002, agreeing to institute reforms—except it never made any real headway. In 2005 the judge got fed up and established a federal receivership. The receivership is an arrangement that literally strips all state officials, from the Governor to the Department of Corrections, of their authority to manage medical care operations in the prison system. The state government is no longer responsible for prison health care; the reins were handed over to Robert Sillen, a long time health care expert, who began his tenure in September 2006.

He has his work cut out for him. On the receivership program’s home page you can read Sillen’s memos, which point out some of the more startling problems. In 2006, the California prison system saw 426 deaths—15 percent of which were preventable or possibly preventable. Among the remaining unpreventable deaths (315) “more than half reflected lapses in care that may have contributed to earlier death or more suffering among terminal patients.”

Part of the problem has been poor staffing. Before the receivership, prison health care workers were grossly underpaid and there was a high level of turnover and vacancies. Correctional officers doubled as nurses, blurring the line between enforcement and care. In 2005, at least 40 health care staff—about half of which were physicians—were found to have spent weeks, months, and even years at home with full pay because of insufficient oversight.

Sillen has taken various measures to bring in honest, medically accredited staff and offer them better compensation. He’s also had to push for an increased equipment budget, because for years California prisons have lacked things as basic as gauze, whiteboards, and training texts.

Before Sillen the prison pharmacy system was a mess, wasting California taxpayers anywhere from $46 to $80 million. Sillen has brought a company called Maxor on board to vet the pharmacy framework and restructure it. Maxor started its work with a thorough overview of the system as it stands, and the findings were ugly. There were little to no drug tracking systems in place—in other words, there was no way of knowing what drugs or how many of them were being given to prisoners, circulated around, etc. In 2005, there were variations of more than 30 percent between the amount of drugs prisons purchased and what was dispensed to patients. The biggest gap—where more than 95 percent of the amount purchased was never dispensed to prisoners—was for narcotic controlled substances with a very high potential for abuse, Roxicodone and Oxycotin. You can imagine where most of it went. Oversight was non-existent.

This held true for pharmaceutical contracts as well. There was no system to keep track of contracts or keep tabs on whether or not they were being fulfilled, meaning the prison system never really knew it was being ripped off by suppliers. Medication was dosed out by medication aids—again, without the oversight of a pharmacist—in big bulk bottles, with almost no system to distinguish or separate medications.

Prison health care was so abysmal that it resembled “One Flew Over A Cuckoo’s Nest”—complete with a slew of Nurse Ratchets. In 2004 the California Department of Corrections report found that a whopping 19 percent of its on-staff physicians had been forced to make some sort of malpractice payment or had actions taken against their licenses by the state Medical Board.

As unsettling as all of this is, my point isn’t that California stinks; just that health care in prisons is a very precarious affair. Prisons are where we throw the unwanted and the offensive—they’re usually hidden from the public eye, which means they’re incubators for shady dealings and mismanagement. That may seem okay—after all, why should we care about the environment in which the dregs of society live? But it’s not.

There’s obviously a moral issue here—the fact that prison health care became so bad in California that it was actually unconstitutional makes it clear that there is some minimum level of health care that we think every human being, criminal or not, has a right to have. What makes this worse is the fact that about 20 percent of inmates in state prisons are for drug offenses—which means people caught for possessing marijuana are getting the same shoddy care as murderers. Does that seem fair? Do these people deserve to die from asthma—of all things—as six California prisoners did in 2006?

There are practical issues as well. Prisoners are more likely to acquire communicable disease and suffer from chronic conditions than the rest of us; the fact that the quality health care they receive is sub-standard only exacerbates these complications. And guess what? They’re getting out, and mixing with the general population.

According to the Justice Department, 95 percent of all state prisoners will be released from prison at some point, with the average age of released prisoners increasing from year to year, along with the proportion of released inmates who are drug offenders. A graying population of drug users who go for long periods of time with poor health care in an environment that incubates disease—this is really the last thing our straining health care system needs. And how many newly released inmates do you think have health insurance?

Our options are three-fold: leave things as is and let wasteful, ineffective prison health care burden public coffers and churn out public health risks that drive up the cost of health care nationwide; release fewer prisoners without improving prison health care (the “let ‘em rot” approach), which will drive up corrections costs and push our already critical mass of prisoners over the edge; or follow California’s lead and take a long, hard look at prison health care around the nation. The last option clearly makes the most sense, and has the added bonus of being the most compassionate strategy. We need to strive for accountability so that we can push for improvement.

In 2005 the New York Times did just this by taking a hard look at Prison Health Services, a for-profit firm that contracts with 28 states and provides health care for about ten percent of the 2.2 million persons incarcerated in the U.S. The Times’ series, called “Harsh Medicine,” is required reading for anyone interested in the issue (see part one here, two here, and three here). The series’ recounting of disturbing deaths and inadequate care is proof that what happened in California was no isolated instance—and importantly, not a failure somehow applicable to the backwardness of the public sector.

Indeed, there’s something far more fundamental than just bureaucratic failure at work. The fact is that in prison you can get away with murder. And that’s just unacceptable—from both a moral and practical perspective. It’s time to get serious about reforming health care in U.S. prisons.

Posted by Niko Karvounis on January 4, 2008