Incarcerated people are the only people who are constitutionally guaranteed primary healthcare (1). It was determined that a failure to provide proper medical care to inmates violates the eight amendment. Yet, incarcerated and non-incarcerated population have among the most stark health disparities.
According to a 2017 Bureau of Justice statistics, more than half of state prisoners and two thirds of jail inmates met the criteria for drug dependence from 2007 to 2009 (2). Mental illness prevalence in prisons is “roughly 50% compared to approximately 10% in the community, and 28% to 52% if Americans with serious mental illness have been arrested at least once.” From 2011 to 2012, 40 percent of prisoners and jail inmates reported having a chronic medical condition. Additionally, 21 percent of prisoners and 14 percent of jail inmates reported ever having tuberculosis, hepatitis, or STDs excluding HIV or AIDS. Compared to the general population, the incarcerated population are disproportionately affected by severe conditions and illnesses that result in poor health.
The U.S. has the highest incarceration rate in the developed world at 655 per 100,000 as of 2019 (5). With the “tough on crime” rhetoric during the Reagan Administration, incarceration rates peaked during the 90s, resulting in millions of people in jails and prisons. According to 2018 Bureau of Justice statistics, nearly 2.2 million people were incarcerated in U.S. prisons and jails by the end of 2016 (6). With longer sentences, the average age of the incarcerated population rose. From 1993 to 2013 the number of inmates aged over 55 increased 400 percent. The increase in mass incarceration over the last 40 years, propelled by the War on Drugs and harsher sentences for criminals, has led to overcrowded facilities and a burden on state correctional budgets.
Prisons are inherently unfit to manage chronic disease cases because they require a high level of extra care and accommodation that many correctional settings do not have the financial resources to provide. This fact becomes especially important because longer sentences increase the portion of older inmates. Correctional facilities should account for the increase in age of the population in order to deliver proper health care that supports older inmates and prisoners. However, the issue is rooted in having a lack of funding for structural changes that allows for better access to care for chronically ill inmates.
One of the most concerning issues that arises with the rapid influx of inmates in the prison system is the massive consequence on the health of prisoners. Correctional facilities have seen an increase in cases involving chronic conditions, such as cancer and high blood pressure, and therefore an increase in healthcare costs (4). The crowded conditions and lack of proper resources and education make prisoners much more susceptible to communicable diseases like tuberculosis, HIV, and Hepatitis C (8). Furthermore, according to an assessment done by the Justice Department, the institutions with the highest percentages of aging inmates “spent five times more per inmate on medicare—14 times more per inmate on medication” than those with lower percentages. The growing population of older prisoners does require more money to be spent on treating their illnesses.
Privatization of prison health care systems as a cost cutting measure compromises quality of medical care. By hiring private companies over individual medical practitioners, states are not required to pay benefits and pension costs to state workers (10). While privatization is a cheaper option to minimize costs and maximize profits for shareholders, these companies are not subject to government standard accountability. For example, in 2012, “a court-ordered investigation of Corizon in Idaho revealed ‘inhumane’ conditions… where terminally ill inmates were left for periods of time without food or water and slept in soiled linens.” Ultimately, corporate executives and shareholders profit as prisoners become victims of malpractice and wrongful death or injury. Nevertheless, society has to pay the price for the shortcomings of “both private health care providers—who often fail to deliver adequate care—and of public health care for released inmates receiving treatment and for their families and friends who become infected and cannot afford private care.”
The fundamental question is what is the purpose of prisons and jails? Is it public safety and reduction in recidivism? The core purpose of criminal justice should be rehabilitation. With this goal in mind, outcomes for prisoner health could be drastically improved. Rehabilitation programs that provide prisoners with education and resources for employment opportunities can reduce recidivism rates. For example, in Ohio, inmates who enrolled in college courses had a re-offending rate of 18 percent, while inmates who did not take any courses had a re-offending rate of 40 percent (12). In Minnesota, prisoners who had participated in work-release programs, which gave prisoners opportunities to work in the community as they reached their release dates, were twice as likely to find work within the first couple years of release than inmates who were not enrolled in the program (13). From 2007 to 2011, the state of Minnesota was able to save $1.25 million due to the decrease in recidivism rate. Unfortunately, the state of most of our correctional systems and its healthcare system conflicts with the idea of optimal medical care and rehabilitation for correctional populations.
How can we improve the standard of care of prisoners and promote rehabilitation among incarcerated populations? There are multiple layers to addressing the unethical issues that pervades correctional facilities, but the most long-lasting and effective change happens at the policy level.
Often, the role of doctors who work in prisons is complicated by having multiple and possibly conflicting duties. According to a review of prison-specific ethical and clinical problems by Jean-Pierre Restellini and Romeo Restillini, doctors have a duty to “protect and promote the health of prisoners and to ensure they receive the best care possible,” while also having to follow the responsibilities of prison management. That means doctors may be required to disclose medical information regarding the patient to courts and officials.
A physician’s primary obligation should be to the wellbeing of their patients. Medical staff working in corrections facilities should have the ability to fully practice clinical independence, which is the “assurance that individual physicians have the freedom to exercise their professional judgement in the care and treatment of their parties without undue influence by outside parties or individuals.” It has been historically difficult to obtain clinical independence for doctors in the prison setting because correctional health care professionals were obliged to participate in custodial measures, such as matters of discipline or “performance of body cavity searches or the retrieval of body fluids for testing for illicit drugs, even when there are no medical indications for such actions.”
In order to amend these issues, the state should instigate structural reforms such as the separation of “health care provision from medical activities commissioned for forensic purposes by third parties” to reduce dual loyalty conflicts for doctors. Third parties that can commission medical activities include the correctional facilities administration, prosecutors, and government authorities (15). Ensuring clinical independence for medical professionals can support the overarching goal of providing medical care that protects the welfare and autonomy of the patients. By establishing strict guidelines for physicians’ duties, correctional facilities can prevent maltreatment of prisoners.
With the creation of Medicare and Medicaid in 1965, the “inmate exception” excluded Medicare and Medicaid from paying for healthcare in jails and prisons in the nation. This has adversely affected the under-resourced correctional health system that is “isolated from mainstream medicine and shielded from critical accreditation and external quality oversight mandates.” Repealing the inmate exception could improve both correctional health and community health as well as reduce wasteful public spending. Alleviating problems in correctional healthcare directly relates to community health once inmates are released back into free society. If chronic problems as well as infectious diseases, such as tuberculosis, HIV, and Hepatitis C, are not adequately addressed and treated by the correctional health care system, it can put a strain on community hospitals (16). By repealing the inmate exception, the federal government would take up the responsibility of providing quality medical care for prisoners and states would be relieved of the pressure to lower costs or privatize health care services.
Opioid addiction treatment tends to heavily rely on correctional health care systems that often do not consider long term treatment options and rehabilitation. Yet, evidence-based substance abuse treatment can be a cost-effective solution to the high percentage of prisoners with substance abuse and mental illness. Punishment is an ineffective method for treating prisoners whose substance abuse is directly related to their criminal behavior. In order to promote rehabilitation for prisoners, correctional health care systems should provide evidence-based treatment to alleviate withdrawal symptoms for prisoners and aid them in reducing their usage to a safe level. According to the National Institute on Drug Abuse, “the large economic benefit of treatment is seen in avoided costs of crime.”
Furthermore, many prisons generally lack a design that can accomodate proper geriatric care. Many older prisoners face environmental challenges such as poor lightning and dimly lit hallways, high bunk beds, steep staircases and low toilets (18). Structural designs of prisons are not the only issue for geriatric care in prison. Lack of access to resources and social limitations exacerbates physical and mental ailments older prisoners have. For example, “limited visitors policies, restricted opioid-prescribing practices, and mistrust between patients and clinicians” are barriers to the needed palliative care for this growing portion of the prison population. Corrections facilities should reconstruct their design to tend to the needs of elderly inmates and remove barriers that prevent them from obtaining proper medication and treatment.
We must promote rehabilitation as the foundation of prison rather than isolation and punishment. Part of rehabilitation is providing the necessary health services for addiction and other conditions as well as fostering education. What we need is an evidence-based approach that puts the needs and interests of patients in quality care and policy that improves public health after release from prison.
The U.S. has developed a system in which people who live in poverty and illness are punished and that punishment in turn generates more poverty and illness. In order to address the root of the problem, the solution has to come from the community. There needs to be better community health care so that people don’t have to get incarcerated in the first place. There needs to be a policy that instigates a positive-feedback system in which better healthcare for the incarcerated populations results in better community health and better community healthcare results in less incarcerations. We cannot forget that the prison population is part of the general population.
Edited by: Julia Bulova
Illustrated by: Helen Xiu