The skyrocketing costs of correctional health care received new attention earlier this year with the release of a state prison health care spending report from The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation. UMass Medical School’s Warren Ferguson, MD, a national leader in the field of correctional health, served as an external reviewer of the highly anticipated report. Ferguson is director of academic programs for the Health and Criminal Justice Program within the medical school’s Commonwealth Medicine division, and is a professor and vice chair of Family Medicine & Community Health. Here, Ferguson sheds some light on the reasons why it’s expensive to care for inmates.
1. Why is the cost of providing health care to inmates soaring in the United States?
The inmate population has a disproportionate share of certain illnesses that are expensive to treat, including mental illnesses, substance abuse and chronic infections such as HIV and hepatitis C that are brought on by injection drug use. Aging in prison also accounts for a large proportion of the cost increase. The Pew Charitable Trusts report found the majority of states with the highest increases in cost also experienced the highest rise in inmates age 55 and older. With increasing age comes higher prevalence of such chronic conditions as cardiovascular disease and cancer, along with the costs associated with their treatment. In addition, aging brings deterioration in function with higher rates of dementia, frailty leading to falls, and vision and hearing loss. Lastly, large, rural states that place prisons at great distance from hospitals are more expensive because of the high costs of transportation and wages.
2. What changes are necessary to get the cost of correctional health under control? Will state and federal correctional departments need to institute policy reform, or will it require changes in the way health care is delivered to those behind bars?
The majority of states witnessed their health care costs peak a few years ago. In part, this is because of mounting pressures on hospitals and providers to reduce their costs. Beyond the costs of care associated with the medical system, there are a variety of potential strategies to reduce costs, some related to criminal justice policies and some related to health care delivery.
Alternative sentencing for individuals with nonviolent offenses that include court-ordered community treatment for substance abuse and mental health illnesses is gaining momentum across the country. It is too expensive to house these individuals in prisons and it sets up the likelihood for a cycle of recidivism. While controversial for victim advocacy groups, medical parole or compassionate release for those no longer a threat to society will return inmates to community settings, where care is less expensive. Mandatory sentencing laws that emerged from the war on drugs need to be reconsidered. For example, should a low-level dealer of marijuana really be sentenced to life in prison after a third offense? Likewise, our policies toward juvenile offenders set up a very high risk for repeated incarceration as an adult.
With respect to medical policies, states bear the brunt of the costs of expensive therapies for HIV, hepatitis C and mental illnesses. Why should the federal prison system receive discounted drugs while states pay full price? Why is inmate care paid for without any federal match while other publicly funded health and human service programs are subsidized by the federal government? More research is needed to determine if proven care transformation strategies in the community can be adapted for prison health care systems. Improving care for chronic illnesses can reduce the costs of complications with better outcomes. Technologies to mitigate the cost of transportation, such as telehealth consulting from distant specialty hospitals, can reduce the transportation and security costs of off-site care.
3. Are there chronic conditions that plaque the incarcerated more than the general public? If so, why, and how are those diseases being treated?
Clearly, chronic infections from injection drug use have a much higher prevalence than in the general public, as does serious mental illness. Following the deinstitutionalization of individuals with mental illnesses that began 50 years ago, inmates with violent tendencies or insufficient resources to remain in community-based care systems have been at high risk of committing crimes and becoming incarcerated. Traumatic brain injury also has a higher prevalence because of trauma experienced by inmates before, during and after incarceration. Veterans are at higher risk because those suffering from post-traumatic stress disorder can turn to alcohol or drugs to cope, leading to incarceration. Chronic illnesses such as diabetes and hypertension are not significantly higher than in the general community.
4. How does a history of being in prison or jail influence an individual’s future health?
When you consider the negative impact of incarceration on future success, and in turn how success predicts health, the consequences are substantial. It is a myth that your sentence ends when you finish your time. Most employers now complete CORI checks and will not hire individuals with felony convictions in their past. Many states have restrictions on public housing or getting a driver’s license back after release from prison. Without a job to pay for housing or food on the table, or the ability to get to work if you land a job, how can you even think about your behaviors that contribute to health, such as a healthy diet or exercise? Without health insurance (not an issue here in Massachusetts), how can you afford medications for chronic conditions? Health is heavily influenced by social determinants. Providing access to medical care is less predictive of good health than serving basic life needs.