United States correctional health systems are in crisis. Few have the funds needed to adequately care for a burgeoning number of prisoners. Some are accused of neglected prisoner health. In California, the prison health system failed its duties so completely that a federal judge took the system out of the state's hands and placed it into receivership.
How have things gotten to this point? A number of factors, including the ravages of methamphetamine and other substance abuse, an increased number of mentally ill inmates, a graying prison population and the continuing problems of HIV, tuberculosis and hepatitis C, have combined to create a "perfect storm" that threatens to swamp correctional health care. The situation is dire, and solutions must be found quickly.
1. The Growing Prison Population
The United States prison population just keeps growing. In 1995, the total U.S. inmate population was 1.59 million, according to the Bureau of Justice Statistics. By June 30, 2004, that figure had grown to 2.13 million, an average yearly increase of 3.5 percent. There are two factors that have contributed to the increase of inmates: the mass closures of state psychiatric hospitals and the current trend toward incarceration rather than rehabilitation.
PRISONER HEALTH COSTS HIT $3.3 BILLION
Medical care expenditures at U.S. state prisons
rose by one-third between 1996 and 2001 (the most recent year for which national statistics are available.) Despite the large increase, the portion of health care in prison operating costs remained steady at 12 percent.
Some of those inmates - as many as 16 percent, according to a 1999 Department of Justice report - are mentally ill. Up until the 1960s, as many as 470,000 seriously mentally ill patients received inpatient psychiatric treatment through state hospitals. Then came a push to deinstitutionalize the mentally ill. According to a report by the Treatment Advocacy Center, fewer than 60,000 mentally ill patients now receive treatment through state inpatient programs.
Tougher sentencing guidelines and laws such as California's "Three Strikes" program, which mandates life imprisonment for repeat felons, have also contributed to the growing inmate population, and the rate of incarceration is outpacing the rate of release, according to the Bureau of Justice Statistics. By 1998, 28 states and the District of Columbia enacted truth-in-sentencing laws that require criminals to serve at least 85 percent of their sentences.
Communities want to be tough on crime, but as more criminals are locked up for longer periods of time, states need more funds to pay for jails and prisons. According to a 2004 report by the Council of State Governments, state corrections budgets grew an average of 8 percent a year from 1998 to 2001, outpacing overall state budgets by 3.7 percent. Now, as many states are facing budget crunches, it is becoming more difficult for them to keep up with correctional funding needs.
2. The Incarcerated Elderly
Truth-in-sentencing guidelines have led, in part, to an older prison population. Fewer prisoners are being paroled because of mandatory minimum sentences, so they're spending more time behind bars. And the harsh prison lifestyle causes inmates to age more quickly than civilians. In prison, 55 is considered old, and older inmates are more expensive to care for. According to some estimates, it costs up to $70,000 to house an elderly inmate, about three times as much as it does for a young one. As of June 30, 2004, there were 71,900 inmates in custody who were 55 or older.
The older the inmate, the more likely he is to develop any of age's attendant diseases, such as diabetes, heart disease, certain cancers and Alzheimer's disease. And treatment for those ailments cannot be denied. Inmates have the right to adequate medical treatment, regardless of age or condition. Expensive treatments such as kidney dialysis and heart surgery are more likely to be necessary for elderly inmates.
Some states, such as Texas and Arizona, have dedicated correctional facilities for elderly inmates, with specially trained medical staff to deal with geriatric illnesses. Other states, however, lack such resources. Their medical staff, already, stretched thin, must also deal with the diseases common among elderly inmates, and doctors and nurses may even have to provide hospice or make arrangements for end-of-life care.
3. The Mentally Ill
Many inmates who are locked up, particularly in jails, are there because they have nowhere else to go, according to Mary Zdanowicz, executive director of the Treatment Advocacy Center. The state mental hospitals that previously provided care have all but shut down. They began shedding patients at a fast pace in the 1960s, partly because of the push for deinstitutionalization and partly because of the creation of Medicaid. Medicaid provides health insurance for the poor, but it does not cover inpatient psychiatric care. The hospitals exploited a loophole in the Medicaid law to provide care until the 1990s, when Congress caught on, according to Zdanowicz. Then came another round of closures.
Community mental health centers were supposed to pick up the slack. In 1963, President John F. Kennedy signed the Community Mental Health Centers Construction Act, which was supposed to create 2,000 community mental health centers by 1980. But by 1980, fewer than 500 centers had been constructed. With state hospitals closed and community centers few and far between, the mentally ill who did not have private insurance suddenly had few treatment options.
"What happens is that very often, when people become symptomatic, they will act in such a way that they draw attention from law enforcement. When law enforcement finds that there is no place to bring them for treatment, the only resource that they have is to bring them to jail," Zdanowicz says. She says that in her community in Arlington, Va., she is aware of cases where police officers have been taken off the street to hold people for up to 30 hours, waiting for a psychiatric bed, which is admittedly impractical.
For the mentally ill, problems may escalate in jail. For instance, they may refuse to take their medications, and corrections officers can't force them to, whereas if the inmates were patients at a state hospital, caseworkers could get a court order requiring them to take the medication. When the mentally ill do not take their medication, their symptoms escalate and they may become violent. "It's a huge management problem, because to have someone psychotic under the best of circumstances is dangerous, but in a confined facility, it's a recipe for disaster," Zdanowicz says.
The unmedicated mentally ill may be a risk to themselves or others in a prison or jail setting, but they can also be at risk, according to Dr. George Pramstaller, chief medical officer of the Michigan Department of Corrections. "We're placing them in a milieu where they are at risk, because they are preyed upon by non-mentally-ill inmates," he says. "We have several levels - not all mentally ill inmates are in general population. Only those that can function in general population are there, but still, those that are in general population are at somewhat of an increased risk because of their mental illness."
And there are other drawbacks to incarcerating the mentally ill. Correctional officers and health service providers may not have the special training they need to deal with mentally ill inmates. Also, providing mental health services in a prison setting is costly. "Since the closure of most of the state mental hospitals, quite a percentage of those people have ended up in prison, and now we're caring for them in a setting that actually costs more than the state mental hospitals did," Pramstaller says.
Although figures for the exact cost of treating the mentally ill in prison are not readily available, Nanette Schroeder, director of health services for the Minnesota Department of Corrections, says that for fiscal year 2004, the department's health per diem for inmates is $10.63, and inmates who needed mental health care received an extra $1.74 per day allotment. That means the department spent an average of about $3,880 per year on care for non-mentally-ill inmates, versus about $4,515 for the mentally ill - a difference of $635 per inmate.
4. Meth and Other Substance-Abuse Problems
As methamphetamine addiction continues to spread across America, meth-related arrests are climbing. The National Association of Counties reports in a survey of 500 law enforcement agencies, 87 percent experienced an increase of meth-related arrests over the past three years. For 58 percent of counties, meth is the biggest drug problem, and 50 percent of counties estimate that 1 in 5 of their jail inmates are held because of meth-related crimes. And the problem is no longer confined to meth "hot spots" in the Midwest and along the West Coast. According to Dr. James H. Clare, dental practitioner for the North Carolina Department of Corrections, "In the calendar year 2000, there were 14 meth lab busts in North Carolina. In the year 2004, that had gone up to 317. So that's a pretty big jump." Clare says that North Carolina's border states, particularly Tennessee, have experienced similar rises in meth busts.
Methamphetamine addicts can greatly increase a correctional facility's health care costs. One county in Indiana reports an overall budget increase from $800,000 in 1999 to $3.4 million in 2004, largely due to the medical expenses rung up by meth-addicted prisoners. At a state jail in Arizona, dental costs rose from $565,000 in 2002 to nearly $700,000 in 2004. And in Minnesota, the dental budget jumped from $1.2 million in fiscal year 2002 to just over $2 million in fiscal year 2004, although director of health services Schroeder says that much of the increase is attributable to a new facility in the corrections department. But some of the funds are being spent to combat inmates' "meth mouth," extensive decay and gum disease that often includes the front teeth. Jails are particularly affected by meth mouth, says Clare, because they don't have the resources in place to correct dental problems, while prisons usually do. In addition to meth mouth, chronic meth abusers may develop other health issues that demand treatment, such as a psychosis similar to schizophrenia, and liver, kidney and lung damage.
Meth addicts aren't the only ones who drive up prison health care costs. All addicts may have additional health needs. Those addicted to heroin, for instance, may have contracted hepatitis C or HIV from sharing needles. Drug treatment programs also add to the budget, but in the long run, they may save money by reducing recidivism.
5. HIV, Hepatitis C and Tuberculosis
Prisons and jails represent a fertile breeding ground for the spread of diseases like HIV, AIDS, hepatitis C and tuberculosis. According to a 2003 report by the RAND Corporation, inmates have a rate of active tuberculosis that is four times greater than the rest of the population, a rate of hepatitis C that is nine to 10 times greater, a rate of HIV infection that is eight to nine times greater, and a rate of AIDS that is five times greater.
Cramped quarters can lead to the rapid spread of tuberculosis, which requires treatment with a lengthy dose of expensive antibiotics. Although it can be treated, tuberculosis is particularly problematic because it is spread through the air. Also, there are increasing reports of antibiotic-resistant tuberculosis.
INMATES HAVE SERIOUS HEALTH ISSUES
The prisoner population suffers from a variety of serious illnesses. The latest national statistics from the mid-1990s show that inmates are eight to 10 times more likely to have HIV infection, and 17 times more likely tohave TB disease than the U.S. population overall.
Hepatitis C represents one of the biggest problems facing correctional health care systems today, because it is easily spread and expensive to treat. Inmates may have contracted the disease before being imprisoned, but by engaging in a variety of behaviors in prison, including unprotected sex and the sharing of needles for drug use and tattoos, they can rapidly spread the disease throughout the prison population. Hepatitis C is extremely expensive to treat, costing between $24,000 and $30,000 per inmate infected. There are no known cures, and the virus usually leads to chronic liver disease.
According to Pramstaller, the chief medical officer of the Michigan Department of Corrections, hepatitis C has been a real drain on resources: "I would say that up to a few years ago, our level of funding I think was adequate to take care of the needs of both the mentally ill and the chronically ill patients in the Department of Corrections. But then what happened is that hepatitis C came on the playing field, and then the state budget problem came on the playing field, and given those two new developments, we now find ourselves in a situation where we're having a real hard time meeting the needs of all inmates."
HIV can also spread easily in prison, through unprotected sex and shared needles. Drug therapies exist to slow the progress of the virus and keep it from developing into full-blown AIDS, but those therapies are costly and may require the hiring of additional medical personnel, such as a medical consultant or a full-time nurse to track the inmates being treated and monitor the disease's progress. Although cases of HIV and AIDS in prison are beginning to decline, according to figures from the Bureau of Justice Statistics, there were still 23,864 HIV-positive prisoners as of 2002, and there were 5,643 with confirmed cases of AIDS. It can cost $14,000 a year to treat each HIV-positive inmate, and as much as $34,000 for each AIDS patient.
Clearly, correctional health care systems must find a way to stop rapidly increasing cost of inmate care. Savings can be achieved in two ways: by decreasing the overall prison population and by more effectively using resources. Below are some programs that might work.
Elderly Inmates - Inmates who are seriously ill, who have served the bulk of their sentences and who no longer pose a risk to society could be made eligible for "compassionate release" programs. Medicare, Social Security or VA funds could then pay for their medical needs. However, many governors and legislators are reluctant to release any prisoners, even those who doctors say are likely to die within six months, for fear of seeming soft on crime. In California, for instance, only 30 percent of inmates who applied for compassionate release between 2000 and 2002 were approved.
In addition to compassionate release programs, states and counties should take the time to assess the number of older inmates they have now and try to predict their need for geriatric care in the future, says Dr. Cynthia Massie Mara, associate professor of health care administration and policy at Pennsylvania State University. In some cases, it may make sense to create a separate elder care facility, although then the general population would lose the "stabilizing effect" that she says older inmates bring to a correctional setting.
Why Correctional Health Care is Important to the Community
Another possible solution, Mara says, is giving judges more latitude in sentencing guidelines. "In those cases where in the current sentencing policy it says there must be a sentence of life without the possibility of parole, the judges could have another category. It would be a life sentence, but with the possibility of parole - no guarantee - after serving 25 years or maybe longer, and reaching a certain age." The inmate would also have to be judged a minimal risk to society.
Mentally Ill - According to Zdanowicz at the Treatment Advocacy Center, more money should be spent on psychiatric beds instead of sending the mentally ill to jail. There is also evidence that, in the absence of inpatient facilities, court-ordered outpatient treatment can be used to monitor the mentally ill. One of the biggest problems, Zdanowicz says, is that some of the mentally ill do not take their medications consistently, but court-ordered treatment can make sure that they do so. "You can save a lot of money by ensuring that people stay in treatment because you're not calling the police out and you're not risking the tragedies that can occur," when the mentally ill go untreated, she says.
In New York, "Kendra's Law," a court-ordered assisted outpatient treatment program has been in existence since 1999. In a March 2005 evaluation report, the New York Office of Mental Health found that in the three years prior to beginning the treatment program, 23 percent of 2,745 recipients had been incarcerated, 30 percent had been arrested, 97 percent had experienced psychiatric hospitalization and 19 percent had experienced homelessness. During the treatment program, those percentages dropped dramatically. Just 3 percent were incarcerated, 5 percent were arrested, 22 percent experienced psychiatric hospitalization and 5 percent experienced homelessness. Also, 88 percent received medication management, as opposed to 60 percent before beginning the treatment program, and 40 percent got substance abuse treatment, up from 24 percent.
There are now 42 states that have implemented similar assisted outpatient treatment programs. Those programs, combined with other community mental health services, may help keep many of the mentally ill as functioning, law-abiding members of society.
Substance Abuse - Sentencing nonviolent drug offenders to drug courts instead of traditional correctional institutions can reduce recidivism and save cities, counties and states millions of dollars. As of January 2005, there were 1,262 operational drug courts in the United States and another 575 in the planning stages, according to the National Criminal Justice Reference Program, part of the U.S. Department of Justice.
The benefits of drug courts have been shown at the national, state and local levels.
The National Institute on Drug Abuse has found that it costs about $4,700 per patient for a full year of methadone treatment, as opposed to an average of $18,400 for a full year of incarceration.
According to a 2003 study by the National Institute of Justice of 17,000 drug court graduates, just 16.4 percent were rearrested and charged with a felony within a year of completing the drug court program.
In New York, a 2003 study by the Center for Court Innovation found that among 2,135 offenders who participated in drug court, the re-conviction rate was 29 percent lower than offenders who did not take part in drug court.
In California, a 2005 report by the Department of Alcohol and Drug Programs found that from Jan. 1, 2001 to June 30, 2004, the state saved $42 million in prison costs by diverting offenders to drug courts.
A 2003 Washington State Institute for Public Policy report found a 13 percent reduction in recidivism and benefits of $1.74 for every dollar spent on drug courts.
In Dallas, a 2002 study by the Department of Economics at Southern Methodist University found that over a 40-month period, every dollar spent on drug court generated $9.43 in tax savings.
HIV, Hepatitis C and Tuberculosis - Peer education on how to prevent the spread of HIV and hepatitis C while incarcerated works, says Barry Zack, executive director of Centerforce, a community program for the incarcerated and their families. Inmates should also be offered tests for HIV, because treatment is less costly for HIV-positive inmates than it is for those with AIDS. Also, according to an editorial in The New York Times, the United States should take a cue from the World Health Organization when it comes to slowing the spread of HIV and hepatitis C in prisons. Inmates should have access to condoms and clean needles, the editorial says, because sex and drug use is occurring in prisons even though it is not supposed to. Tuberculosis patients must receive regular monitoring and those with active cases must be isolated from the rest of the prison population.
In addition, inmates with HIV, AIDS and hepatitis C must receive follow-up care once they are released back into the community, says Zack. If inmates are released without follow-up procedures in place, they run the risk of not receiving their medications in a timely manner and could develop resistance to treatment drugs.
General Resource Management - Often, correctional health care systems are plagued by outdated technology and infrastructure. Many practitioners have reported their frustration at trying to treat inmates who arrived for an appointment without a medical chart. But electronic medical records can help manage resources and streamline the charting process. Many facilities have not yet implemented EMRs because they are costly to put in place. In Michigan, however, Chief Medical Officer Pramstaller says that the Department of Corrections is currently transitioning to an EMR system, and he sees "hope on the horizon" because of it.
"Once we're 100 percent operational with [EMRs], we will be able to use the information in various reports that we can generate for not only quality assurance, but also for managing our resources, which will give us a whole new opportunity," Pramstaller says. "We'll be able to look at the utilization of pharmaceuticals and the utilization of a lot of things in much more creative ways than before. And in doing such, hopefully we'll decrease some of the duplication and some of the unnecessary stuff that's done, and in doing so, we'll free up some resources so that budgets won't be so tight."
For more on electronic medical records, visit www.correctionalnews.com and read the July/Aug 2005 Q&A with Todd Wilcox.