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The Current State of Public and Private Prison Healthcare

February 24, 2017

The landmark Supreme Court case Estelle v. Gamble addressed the medical treatment of US prisoners, affirming their Constitutional protection to sufficient health care. Over 40 years later, the practical application of this decision is still in question, as correctional health care often fails to meet the needs of inmates when administered by state facilities. And because alternatives, such as privatized health care, come with its own set of social and economic concerns, the lack of political pressure on this subject represents a gap in contemporary policy.

The United States has the fastest growing prison population in the world, with 750 adults per 100,000 currently incarcerated [1]. Compared to similarly industrialized Western nations, the United States is an outlier, filling its cells with record numbers of nonviolent offenders. Since the declaration of the War on Drugs, inmates have increasingly been overrepresented by those who have committed drug offenses [2]. Due to mandatory minimum sentencing laws, judicial discretion is minimized in these cases, which further facilitates the systematic incarceration of Americans.

Moreover, the “Three-Strikes” sentencing law, which exacerbates sentences for those who have been previously convicted two or more times, ensures lengthier prison terms for those who have committed violent crimes. While social scientists are divided over the necessity of this law, one undeniable implication is the high costs of supporting the growing inmate population for prolonged periods, accounting for housing, food, and health care.

<p><em>Prison populations of comparable Western nations. (Source: </em><a href="http://www.prisonstudies.org/"><em>World Prison Brief</em></a><em>. Produced by Vernoique de Rugy, Mercatus Center at George Mason University)</em></p>

Prison populations of comparable Western nations. (Source: World Prison Brief. Produced by Vernoique de Rugy, Mercatus Center at George Mason University)

Understanding Prison Health Care

As the population affected by mass incarceration grows, so too does the impact of penal policy. One aforementioned aspect of this is prison health care, which, when sufficient, treats the emergencies and chronic illnesses of inmates, and when insufficient, becomes its own form of capital punishment [3]. In 1976, the Supreme Court ruled in Estelle v. Gamble that all prisoners are entitled to adequate medical care [4]. The case, brought about by an inmate who was injured during prison labor, invoked the Constitution’s Eighth Amendment against cruel and unusual punishment [5]. A significant advance for prisoners, Estelle v. Gamble ostensibly addressed the plight of inmates who were previously subjected to discretionary care. Despite this ruling, however, the 2.3 million incarcerated Americans who currently depend on their jailers for health care continue to face limited access to medical examinations and prescription medication [1]. In this regard, incarcerated individuals have little choice over their health care, as they are separated from the private workforce (foregoing benefits) and ineligible for Medicaid while incarcerated [6].

Out of options and seeking treatment, inmates also face extra fees. In 35 states, inmates have medical copayments, which go toward prison revenue [4]. Authorized by the Federal Bureau of Prisons, this money is taken from commissary accounts, which are made up of prison job wages and family contributions. The rational purpose of copays is to deter prisoners from abusing health care services but, as an adverse side-effect, copays are a financial strain on inmates whose income can be as low as 12 cents/hr [7]. A 2014 study found that incarcerated people aged 27-42 had a median annual income of $19,185 (41% less than the median income of non-incarcerated people of the same age group); consequently, many prisoners also cannot rely on their families to supplement their wages [8]. Thus, while even personal care items like deodorant ($1.93), toothpaste ($1.50), and sanitary pads ($2.63/pack) are worth multiple days of pay, these prices pale in comparison to $20-$100 copays [9].

<p><em>Incarcerated men are at the lowest ends of national income distribution. (Source: </em><a href="https://www.prisonpolicy.org/reports/income.html"><em>Prison Policy Initiative</em></a><em>)</em></p>

Incarcerated men are at the lowest ends of national income distribution. (Source: Prison Policy Initiative)

Moreover, studies show that inmates’ copays have little effect on health care budgets for state facilities [10]. In Virginia, for example, state facilities collect about $500,000 a year in copays but spend upwards of $160 million on health care. In 2014, Pennsylvania collected about $373,000 in copays, despite spending $248 million. In effect, inmate copays serve as a financial burden with only marginal benefit. While a necessary one-time doctor’s visit may seem worth the prisoner’s sacrifice, many facets of health care are ongoing.

Mental health care, for example, is often inaccessible. As reported by American historian David Kaiser and human rights activist Lovisa Stannow in The Shame of Our Prisons: New Evidence, 2.2 million severely mentally ill people in the United States at large do not receive psychiatric treatment. Chronic mental illnesses such as schizophrenia and bipolar disorder are associated with a high probability of incarceration, but in prison, mentally ill inmates are not guaranteed sustained medication. The problem is particularly acute in jails, as a jail-stay is often temporary but can be prolonged for up to 23 months. In prisons too, being denied counseling and medication can have adverse effects, such as intensifying altercations between inmates and correctional officers, as well as among inmates themselves. 

<p><em>Percentages of mental health care. (Source: </em><a href="https://www.nimh.nih.gov/health/statistics/prevalence/inmate-mental-health.shtml"><em>National Institute of Mental Health</em></a><em>)</em></p>

Percentages of mental health care. (Source: National Institute of Mental Health)

This threat of being denied medication due to limited health care access extends beyond mental health. The case of Ashley Diamond, a 36-year old transgender woman, illustrates another issue with prison health services. After being sentenced to a men’s facility, Diamond was denied both her hormones and prescription medication at Baldwin State Prison [11]. Her lawsuit against Georgia’s Department of Corrections, which drew high volumes of press coverage, cited limited access to hormone therapy as a chief concern. The Justice Department declared formal support for Diamond, agreeing that the hormone therapy was necessary medical care. While Diamond has since been released from prison, no tangible change in her medication manifested during her sentence, which represents how stark deviations on the inside can be from federal standards.

Implications of Privatization

One caveat to the problem with prison health care is that increasingly more prison health care systems are privatized. Not only did existing health care companies see the profitability in providing a service for which the need is rapidly increasing, but also large, correctional health care providers have been established to cater specifically to this sector [12]. As of 2012, over 20 states have switched over to private health care operations in their prisons as a cost-cutting measure. In hiring companies over individual medical professionals, states do not have to provide benefits and pension costs to state workers. While economically defensible, the quality of services provided by these private companies is under investigation not only by human rights groups, but also by federal judges, who have presided over numerous cases centering on poor medical care.

Moreover, the health care spending for states is actually increasing – which is just the tip of the iceberg when it comes to this complex issue. Increased spending has vast implications, as expensive prisoner maintenance continues to burden states and private care, while often inadequate, represents a cheap option.

<p><em>Increase in prison health care spending in 2008 dollars. (Source: </em><a href="http://www.pewtrusts.org/en/research-and-analysis/reports/2014/05/15/managing-prison-health-care-spending"><em>The Pew Charitable Trusts</em></a><em>)</em></p>

Increase in prison health care spending in 2008 dollars. (Source: The Pew Charitable Trusts)

Private Companies at the Federal Level

If costs are still high, why privatize? The largest American correctional health care providers are Corizon Health and Wexford Health Sources [13] [14]. Established 35 and 23 years ago, respectively, Corizon and Wexford currently serve a combined total of 571 correctional facilities across the country. As outlined by Wexford’s president, Mark Hale, privatization succeeds as a model because “health care is required by the Constitution but is not a core competency of [state departments].” It is true that the state struggles to provide medical care, as evidenced by the federal court supervision of California correctional care [12]. Medical treatment in California facilities has been found to be inadequate for the past six years, necessitating federal oversight of the state-run system. Committed to cost control and integrated care, private prison companies outwardly represent the constructive future of correctional health care. In practice, however, these companies have run into trouble over their inhumane treatment of inmates.

In Idaho, Corizon was accused of negligence and poor medical care by a federal judge. In Illinois, numerous inmates have reportedly accused Wexford of insufficient care. While the list of cases and complaints goes on, the lack of competency in prison health care is cause for concern when neither private companies nor the state provides a viable option. The Center for Prisoner Health and Human Rights recognizes this problem, listing on their website a resource guide on medical care.[15]

Private Health Care in Private Prisons

More controversial than the installment of private correctional care companies in state facilities is the role of private health care in private prisons. In this arena, the two largest private prison companies are CoreCivic (formerly known as Corrections Corporation of America) and the GEO Group [16] [17]. Together, these private companies run over 170 federal correctional facilities under contracts. Traded publicly, these companies keep their operating costs low by using less dollars than allocated per head (about $34/day) on inmates [18].

Following the 2016 Presidential Election, stock in CoreCivic and the GEO Group has risen 50% and 21%, respectively, with stock for both group’s chief holder, The Vanguard Group, Inc. valued at over $447 million dollars [19] [20]. The responsibilities of private companies to their shareholders directly conflict with federal standards, as companies often spend as little as possible to maximize margins. In 2015, for example, CoreCivic (then, CCA) reported $1.9 billion in revenue, which is equivalent to over $3,300 per prisoner [20]. Health care is one area in which costs are kept particularly low to make this sort of revenue possible. Although CoreCivic does not disclose a number for its health care spending, long-term studies of American prisons suggest that health care is often the second-largest expense of all prisons after staff [20]. For example, in one California prison 31% of the budget is dedicated to health care, as treatments for rampant conditions such as diabetes, heart disease, asthma, and HIV/AIDS tend to be expensive. When they can, private prison companies like CoreCivic avoid taking inmates over 65 or with chronic illnesses [21]. When they can’t, they improvise; CoreCivic has a history of denying hospital stay to patients and punishing them when they make repeated requests [20]. For these reasons, access to health care in private prisons receives more scrutiny than public prisons who outsource treatment. While their records are not subject to public access laws, CoreCivic has faced very public law suits and deadly prison riots. One case occurred in Mississippi, where a correctional officer was beaten to death by inmates who cited inadequate access to medical care as a chief concern [20].

The Debate

Inhumane, expensive, and (in some cases) deadly, the private health care practices in prisons concern many analysts. Some argue, however, that the potential benefits of private prisons and outsourced health care outweigh the costs. Studies have shown that, in comparison to public facilities, private prisons are better at finding and seizing contraband that can also put inmates’ lives at risk [22]. Similarly, data shows that inmates in private prisons are less likely to use drugs in prison. As another statistic shows that fewer deaths occur among inmates in private prisons, one might also infer that insufficient medical care is not putting inmates’ lives at risk, and trained correctional officers are adept at reducing inmate-on-inmate violence and suicides.

Private prisons also create more jobs among non-state workers and help reduce the overflow in overpopulated state and federal prisons [23]. Proponents of private prisons thus argue that, while these benefits come at the expense of quality health care and daily needs, the results are crucial to maintaining a functioning penal system.

Within public facilities, correctional care companies similarly reduce the burden of state expenses. Moreover, outsourcing care is a risk-management strategy for states, as the private companies assume liability for negative medical outcomes, relieving the rightfully inexperienced state of the duties of medical care [24].

Policy Moving Forward

 In spite of the debate over the economic validity and necessity of private health care in prisons, it is undeniable that the quality of care suffers from privatization. One proposed strategy for reducing costs and improving care for inmates is telehealth, the use of electronic information and telecommunications to improve long-distance health care [25]. This would cut down on transportation costs and hospital stays, assuming the care provided drew upon qualified medical opinions.

Another option which has already been pursued by states is Medicaid financing for eligible prisoners. While Medicaid does not usually apply to those who are incarcerated, Medicaid can reimburse states up to a percentage for care delivered outside of prisons. With this solution, the responsibility of quality health care is again assumed by the federal government, and states are relieved of the pressure to cut corners on health care costs.

A similar solution, medical parole, addresses the high cost of taking care of older and chronically ill patients by granting parole to certain prisoners. While the state would have financial responsibility for these individuals, this option would yield considerable savings not only in health care but also in housing and food. On the outside, the parolees would ostensibly have more freedom to access care from non-corporate medical providers or from those who may know their history. Although some possibilities exist, reconstructing the health care system in prisons remains a multifaceted issue for which past policy proposals have left a lot to be desired. Chiefly, changing the way inmates receive medical care is not a popular political issue due to expense and lack of general public concern. Even in cases where some action is taken, lawmakers have little incentive to highlight this issue. One example of this is the Surgeon General’s Call to Action on Corrections in Community Health, which was blocked before release by the Bush administration over concerns of increased federal spending [1]. When there is little room in the budget, correctional care is not among the nation’s priorities.

And yet, Estelle v. Gamble made clear the federal government’s position that insufficient medical care “may result in pain and suffering which no one suggests would serve any penological purpose.” The injustice alone of poor health care as a side-effect of a broken system needs to be examined. At the same time, the rapidly increasing prison population coupled with the rising expense of care per inmate makes the problem immediate. Shedding light on the privatization of healthcare in prisons, albeit unpopular, is a necessary step towards comprehensive policy around one of America’s most costly concerns.

References

  [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661478/

  [2] https://www.theatlantic.com/health/archive/2012/03/the-war-on-drugs-how-president-nixon-tied-addiction-to-crime/254319/

  [3] https://www.aclu.org/issues/prisoners-rights/medical-and-mental-health-care

  [4] http://www.npr.org/sections/health-shots/2015/09/30/444451967/even-in-prison-health-care-often-comes-with-a-copay

  [5] https://www.law.cornell.edu/supremecourt/text/429/97

  [6] https://www.healthcare.gov/incarcerated-people/

  [7] https://www.publicintegrity.org/2014/09/30/15761/prison-bankers-cash-captive-customers

  [8] https://www.prisonpolicy.org/reports/income.html

  [9] http://nymag.com/thecut/2015/06/menstruation-can-become-humiliation-in-prisons.html

  [10] http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/07/22/no-escaping-medical-copayments-even-in-prison

  [11] https://www.nytimes.com/2015/04/06/us/ashley-diamond-transgender-inmate-cites-attacks-and-abuse-in-mens-prison.html?_r=0

  [12] https://www.washingtonpost.com/national/health-science/privatized-prison-health-care-scrutinized/2012/07/21/gJQAgsp70W_story.html?utm_term=.ce341fae1bfc

  [13] http://www.corizonhealth.com/About-Corizon/Locations

  [14] http://www.wexfordhealth.com/About-Us/History

  [15] http://www.prisonerhealth.org/resources-for-prisoners-families-and-advocates/prisoners-and-families/

  [16] http://www.corecivic.com/

  [17] http://www.geogroup.com/

  [18] http://www.npr.org/2016/07/17/486359433/reporter-found-lack-of-medical-care-as-undercover-prison-guard-at-for-profit-fac

  [19] http://fortune.com/2016/11/15/trump-prison-stocks-cca-elliott-paul-singer/

  [20] http://www.motherjones.com/politics/2016/06/cca-corrections-corperation-america-private-prisons-company-profile

  [21] http://www.newyorker.com/magazine/2016/12/05/trump-sets-private-prisons-free

  [22] https://www.nytimes.com/2016/09/13/opinion/benefits-of-private-prisons.html

  [23] http://futureofworking.com/6-advantages-and-disadvantages-of-private-prisons/

  [24] http://www.modernhealthcare.com/article/20130831/MAGAZINE/308319891

  [25] http://www.pewtrusts.org/~/media/assets/2014/07/stateprisonhealthcarespendingreport.pdf?la=en

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