“This is a third or fourth call for help. I haven’t been able to keep food, liquids, meds down in days […] I feel like I am very close to death. Can’t hear, seeing lights, hearing voices. Please help me,” wrote Madaline Pitkin on April 23, 2014.
Pitkin, suffering from heroin withdrawal in Washington County Jail in Oregon, pleaded for help multiple times in her Health Care Request Forms while medical staff failed to properly address her worsening condition. The next morning, she was found on the ground of her cell, leaking brown fluid from her mouth and nose, and couldn’t be revived by Emergency Medical Services.
Pitkin died from dehydration, and a simple IV would have saved her life. Corizon Health, the private healthcare contractor for the jail, settled with the family for $10 million. Pitkin’s case isn’t a one-off, but an issue core to the poor conditions experienced by America’s incarcerated population.
The Problem with Private Prison Healthcare Contractors
County jails and state prisons outsource healthcare for inmates to private companies as a cost-saving measure. Especially for smaller counties with limited budgets, outsourcing is an easy way to save money and manpower. Additionally, outsourcing to private providers shields governments from liability if a lawsuit arises. In other words, contracts between correctional departments and private providers include clauses absolving governments from financial consequences when things go south.
In 2018, 62% of U.S. jails surveyed chose to outsource healthcare services to private providers. Arizona, Florida, New Mexico, Maryland, and Alabama, among other states, sign contracts with and cycle through the same three big players in this space: Centurion, Wexford Health, and Corizon Health. Corizon Health is now called YesCare, after filing for Chapter 11 bankruptcy and moving its assets to dodge hundreds of lawsuits.
Both public and private prison healthcare have poor track records. The Marshall Project, a nonprofit and nonpartisan news organization focused on criminal justice reporting, has identified at least 47 states that have been sued for deficient care. However, the largest difference between public and private healthcare providers lies in the profit structure.
Most correctional departments negotiate a capitation with private providers, a “fixed per-person, per-month payment” that allows providers to pocket the extra if they minimize spending on care. This leads to cost-cutting measures that materialize in delayed appointments and denied patient requests. At Chatham County Detention Center in Georgia, Corizon nurses who questioned practices were fired, and prescriptions were signed off by a psychiatrist who didn’t even see inmates, an illegal practice in Georgia.
A Reuters analysis of over 500 jails found that facilities run by the five largest private providers between 2016 and 2018 had death rates 18% to 58% higher than government-run medical facilities.
Why Should Healthcare be Provided to Prisoners?
In 1976, the Supreme Court decided in Estelle v. Gamble that only a “deliberate indifference” to a prisoner’s condition constitutes a violation of a prisoner’s Eighth Amendment protection against cruel and unusual punishment. This established the right for prisoners to receive healthcare nationwide, as a lack of medical care crosses this threshold.
In the following decades, after more lawsuits, a clearer standard of minimum care was established. An adequate medical system includes legitimate medical judgment made by competent medical staff, no serious delays to care, and a process to handle emergencies. These standards extend to dental care and mental health care as well.
It may be difficult to wrap one’s head around giving healthcare to prisoners when millions of law-abiding Americans don’t have access to healthcare themselves. After all, healing seems to contradict the very purpose of prison — to punish. But there is also a delicate balance with the second purpose of prison: to rehabilitate. Beyond the law itself, there are other reasons why it’s socially and morally proper to give healthcare to prisoners.
Eventually, inmates will re-enter society, and being healthy is essential for a smooth transition to contributing to society. Compared to the general U.S. population’s 31% prevalence of a chronic condition, 43.9% of state or federal prisoners and 44.7% of jail inmates have a chronic medical condition. Providing care to incarcerated individuals can prevent and manage their chronic conditions and save money on treatments for other illnesses that may arise. Vaccinations are also an essential public health measure to prevent the spread of disease and save costs. For example, for every dollar spent on vaccinating prisoners for Hepatitis B, $2.13 is saved in later treatments.
Additionally, prisoners are in the custody of the state, which means they lose autonomy over managing their health, making it the obligation of the state to fill that gap. Taking into account ethical considerations, prisoners don’t have a choice for who their provider is — they are completely beholden to the level of care the provider gives them. With no alternatives, it is perverse that the only avenue of treatment available to them is one that makes them sicker.
How Can Better Care Be Provided?
In the short-term, it is essential to increase oversight of private providers and funding to state and county correctional agencies. Jails that received accreditation with the National Commission on Correctional Health Care, a non-profit organization aiming to improve correctional healthcare, reduced mortality rates by nearly 70% and saved between $2.5 to $56.6 million yearly due to improved compliance and patient care. Efforts are being made in states across the country to allow Medicaid funding to be spent on correctional care, which could encourage states to use public-run facilities.
However, broader long-term solutions are essential to solving deficient healthcare, which begins with tackling prison overcrowding. Overcrowding leads to higher chances of disease transmission, longer backlogs to accessing care, shorter and lower quality appointments, and increased rates of prisoner stress and in-fighting.
At the root of overcrowding is the high rate of recidivism in the U.S. Within three years of being released, an estimated 68% percent of prisoners were arrested again. By six years, 79% were re-arrested, and by nine years, 83% were re-arrested. Recidivism puts pressure on the limited resources prisons have, in turn, making it even harder to rehabilitate prisoners to effectively re-enter society. By emphasizing rehabilitative measures, recidivism and, thus, poor prison healthcare can be tackled.
Measures including educating prisoners, helping them develop job skills, providing mental health and substance abuse treatment, maintaining family relationships while incarcerated, and utilizing halfway houses have all shown promise while time is being served. However, many barriers still stand in the way once they leave prison. States have policies in place that prevent ex-prisoners from obtaining SNAP benefits, TANF benefits, housing vouchers, and jobs and occupational licenses with a criminal record.
The U.S.’s incarceration rate is greater than any other democracy, with nearly 2 million people imprisoned, costing $182 billion of public resources yearly. Prison healthcare is a small but integral piece of the larger conversation about reforming our carceral state. Focusing on rehabilitation, especially for nonviolent offenders and juveniles, creates a smoother transition for re-entering society. Empathy isn’t a natural reaction in circumstances like these, but it certainly is essential to preserving humanity’s belief in the power of second chances.
