Lentis/Healthcare in U.S. Prisons

As of 1976, prisoners are the only people in the United States to have a constitutionally protected right to healthcare under the Eighth Amendment. Prior to then, prison healthcare was inadequate. Nonprofessionals, sometimes even prisoners themselves, were often responsible for providing health care. Care was negligent at best. Reform came in the 1970s when legal decisions were made ensuring prisoners received healthcare comparable to that offered to the general public.

However, multiple unique challenges associated with the provision of healthcare in prisons remain. For instance, the war on drugs resulted in a massive increase in prison population with a high proportion of prisoners at risk for HIV and other infectious diseases, which can be expensive to treat. Moreover, the implementation of mandatory minimum sentences has increased the proportion of older prisoners, who require a majority of healthcare resources. Finally, the push to deinstitutionalize the mentally ill has led to an influx of such individuals to prisons. Consequently, prisons have become the primary locations caring for mentally ill.

These complications are pulling prison healthcare in opposite directions. Fear of lawsuits and commitment to adequate care motivates prisons to expand healthcare access. However, concerns regarding rapidly rising costs motivates prisons to limit access and services. For example, in the 1990s managed care practices, like co-pays, were adopted into prisons. This issue offers insight into the impact of trust, guidelines, and privatization on system operation.

Prisons
Prisons do not seem keen to discuss the topic of healthcare. Public prisons provide specific information about the care they offer, with no prominent public statements mentioning healthcare. Private prisons do mention healthcare in public statements, but generally only so far as claiming to offer "comprehensive [services]" without “interfer[ing] with anyone’s access to health care.”

Correctional healthcare researchers have collected data from public prisons that suggests healthcare available to prisoners is inadequate. The study found that over 10% of inmates with a persistent medical problem had not received a medical examination since incarceration, and over 20% of inmates with an active prescription medication at the time of incarceration no longer received the medication in prison. The percentages may not seem high, but prisoners receiving a single medical examination and their prescribed medication is not a high standard.

Prison Workers
Prison workers show a general sense of distrust of prisoners. Kelly Brumley, a Memphis prison worker, witnessed a coworker shred unheeded medical requests. Susan Lawrence, a physician and attorney who has worked in prisons, states that “the default attitude among guards and other staff is that inmates are lying about being sick.” These statements indicate a level of distrust that has contributed to a poor correctional healthcare system.

Prisoners
Prisoners are most affected by this issue so their perception is essential. Young (2000) interviewed 15 women prisoners in a northwestern state prison about their experience with health care. They were asked to rate their care as adequate or inadequate and their treatment as empathetic or non-empathetic. Of the women interviewed, 14 reported an instance of inadequate care and 68.3% of all accounts were characterized as such. The women in Young (2000) reported doctors ignoring their complaints for "about a month and a half" and responding to treatment failures saying "Oh well, we tried...". These instances reveal serious neglect by healthcare providers. All women interviewed offered an instance of non-empathetic care and 48.9% of all accounts were characterized as such.

While the study follows a single prison, the sentiment is reflected by prisoners nationwide as evidenced by the multitude of lawsuits filed on account of problems with prison healthcare. Lawsuits are commonly filed for deliberate indifference. To win the case, prisoners must prove the prison knew about the problem and intentionally ignored or worsened it. For instance, in Jett v. Penner (2006) the court ruled in favor of the inmate who presented sufficient evidence proving the prison doctor deliberately ignored his need for a permanent thumb cast. Also, many lawsuits are filed on grounds of delayed treatment. This requires proof that treatment was necessary. For example, in Boyd v. Robeson County (2005) the court ruled in favor of the prisoner who presented clear evidence the prison guard ignored his symptoms of appendicitis ultimately leading to a ruptured appendix. Many of the lawsuits filed by prisoners contesting inadequacies of healthcare are not ruled in favor of the prisoner. However, the fact that so many are filed proves that there is a negative perception of healthcare amongst the prisoners. This will inevitably affect their treatment seeking behavior and interactions within the system. Moreover, it seems to indicate that although prisoners are legally entitled to healthcare, the definition of adequate healthcare is blurred by the prison healthcare providers.

The perception of care is no better in private prisons than state owned facilities. In fact, prisoners in private prisons often indicate that they would rather be in public prisons with regard to medical care. During a transition from the U.S. Immigration and Customs Enforcement (ICE) handling the healthcare for a facility to CoreCivic, prisoners experience “chaos”. The prisoners had hoped the medical care might improve under CoreCivic, but found it to be worse, with inmate Alvarez Mendoza stating he would “rather be back in state [prisons].” Attorney Ty Clevenger corroborates this statement, saying that most of the inmates he has interviewed would “rather be in a state-run facility than a CoreCivic facility."

Private Healthcare Providers
A Pew Study found that 33 states use some level of private contracting for their prison healthcare needs, with 20 using only private contractors. Prisons save money by using contractors instead of building the infrastructure themselves and handling the logistics that come with providing daily healthcare to thousands of inmates. They are also able to focus resources on the day-to-day operations and shift liability onto the healthcare companies. There are 3 main players in the industry: Corizon Health, Centurion Managed Care, and Wexford Health Sources.

One problem with this system is that free market forces do not regulate these healthcare companies. Healthcare providers for private citizens are forced to provide market standard goods and services or they will lose customers. Prison health contractors are only regulated by the prisons themselves. The legal definition of adequate care is vague and leads to low regulation. Another form of regulation mentioned above is lawsuits leveled by unsatisfied prisoners. Unfortunately these cases have minimal effect on the companies, and this has led to speculation that these companies decided the profits from low standards of care are worth paying the settlements. Private healthcare contractors are for-profit companies, and as such they seek to lower costs. Many contracts between prisons and healthcare companies are on a per-prisoner rate, incentivizing them to cut costs in the care that they provide.

A study by Reuters on more than 500 jails found that those using leading healthcare contractors had higher death rates than jails with government run medical services. Reuters assed deaths from illness and medical conditions, suicide, and the effects of drugs and alcohol. The analysis revealed that using major private healthcare contractors led to death rates 18% to 58% higher than jails with government run healthcare, depending upon the company used.

Prison Industrial Complex
The term "prison industrial complex" refers to relationship between prison and industry. The industries motivation for profit has lead to prisons increasing numbers of incarcerated persons to support this objective. Large companies in the U.S. and around the world rely on discount labor provided by inmates to fuel their business. These include McDonald's, Wendy's, and Wal-Mart. The participants in this group are categorized by taking advantage of incarcerated people as a discounted resource. Private Healthcare contractors fit into this group as well. Research has shown that Corizon, one of the largest private healthcare providers, cut the amount they spent sending inmates to the ER by 58% in 2012. Over the next three years, their profit margin on prison care rose from 14% to 24%. Corizon denied all claims that they refused outside care to patients in need, citing the construction of a new jail infirmaries to explain the fall in ER numbers.

Healthcare Workers
Correctional Nurses are responsible for administering the care that prisoners receive. These nurses suffer burnout and job fatigue at a high rate because of the system they work in, resulting in a much higher turnover rate compared to other nurses. Prison systems have become the primary care providers for recovering addicts and the mentally ill. Nurses also may have to treat dangerous inmates, especially in high security facilities, adding a level of risk to the nurses' jobs. As mentioned above, inmates also have a much higher rate of infectious diseases like HIV. But many nurses also see these issues as the reason to work for correctional institutions. They see it as a moral calling to help people that in many cases have been failed by the system.

Conclusions
While more research into the specific role of prisons and prison healthcare workers is needed, the research thus far has yielded many lessons applicable to other issues. For one, this case study indicates that the perception of a system matters as much as the state of the system itself. Prisoners’ perception of the care they receive affects their actions inside the system. It is also important to clearly define standards in regulations. While more research into the prison's healthcare objectives is needed, it seems that prisons are able to take advantage of loosely defined terms to the potential detriment of the prisoners. Private entities in a free market need to be held accountable to the forces of that market. Without this pressure they are free to lower standards without repercussions. Those researching this case further may consider contrasting the U.S. system with foreign prison healthcare systems to gain additional insight.