Sentenced to a life of poor health

The United States currently ranks first in the world for incarcerated populations with about 2.1 million people detained; the next closest country is China with a prison population of 1.7 million. A major factor that creates the carceral state in the U.S. is the industry of the prison systems involving both the public and private sectors.

Despite the high rate of imprisonment within the U.S., the nation’s prison systems have a history of subpar care. This is evidenced by the National Institute of Corrections stating, “Health problems that plague our society plague the corrections industry at an even greater rate.”

The importance of this issue lies in the sheer number of incarcerated people. A population of 2.1 million people lacking or receiving improper medical care would be unacceptable in any other context, yet it is overlooked regarding the imprisoned population.

To further put the situation into perspective, according to the United States Census Bureau, currently a population of 2.1 million residents would be larger than the city of Phoenix (1,743,469) and a little smaller than the city of Houston (2,378,146), making the U.S. prison population the fifth largest city in the nation. The mistreatment of a population of this scale is absurd considering the fact that several cases of communicable diseases such as polio or monkeypox have the potential to put a city into a state of emergency. Yet, the increasing prison population is statistically proven to be plagued at a greater risk of these pathologies.

In 2015, a special report was published by the U.S. Department of Justice Office of Justice Programs regarding incarceration data collected in 2011- 2012:

Forty-four percent of prisoners reported ever having a chronic condition, compared to 31 percent of persons in the general population. Prisoners were about 1.5 times more likely than persons in the standardized general population to report ever having high blood pressure, diabetes, or asthma. About 45 percent of jail inmates reported ever having a chronic condition, compared to 27 percent of the standardized general population. Jail inmates were nearly two times more likely than persons in the general population to report ever having high blood pressure, diabetes, or asthma. An estimated 21 percent of prisoners and 14 percent of jail inmates reported ever having tuberculosis, hepatitis, or other STDs excluding HIV or AIDS, compared to 5 percent of the general population.

The inadequacy of existing reforms

There are multiple interventions proposed to address this issue, but they all have major gaps. An example of such a proposal is the Federal Bureau of Prisons (BOP) Health Management Resources. The BOP Health Management Resources are sets of clinical guidelines that are in line with the objectives of the Correctional Officers Health and Safety Act of 1998 for “infectious disease prevention, detection, and treatment of inmates and correctional employees.” This list of resources includes protocols for issues ranging from the management of hypertension, bipolar disorder, lice, and the Zika virus, along with COVID-19 vaccine guidance. Yet, these are only clinical guidelines when they should be recommendations. The actual implementation of these protocols likely varies widely by each facility according to its resources. For example, the BOP will recommend that an inmate be put in isolation if they present with a positive tuberculin skin test, yet a correctional institution might be limited by lack of space.

Another key piece of legislation that is failing to support carceral health standards is the Affordable Care Act (ACA). After the ACA was upheld (apart from the mandate for states to expand Medicaid) in 2012, each state still had the option for further Medicaid expansion. Medicaid prior to the expansion option included a population covered, pregnant women, children, and people over the age of 65. In states that expanded Medicaid programs, residents qualify for government service based on a resident income of 133 percent below the poverty level (U.S Centers for Medicare & Medicaid Services, 2022). The expansion thus encompasses “childless adults, which includes a sizable subset with criminal justice involvement.” This led to the Medicaid option being falsely deemed to be exclusively for “felons” because it prevented people from losing healthcare coverage once incarcerated, thus protecting the incarcerated population’s right to healthcare. This was not suitable in the public eye so the legislation was met with pushback and subsequent denial of coverage. This loss of coverage is also known as the “inmate exception.”

The Community Oriented Correctional Health Services (COCHS) is one nonprofit organization with a stake in the ACA expansion option. This is because the Act aligns with their mission to “integrate community healthcare with correctional healthcare.” Since 2010, COCHS has been a proponent of the ACA, arguing that the Act could potentially provide healthcare to incarcerated populations. They provide evidence for their support by using research from Washington state to suggest that treating substance abuse disorders, a disorder largely found within the inmate population, “showed a decrease in arrests and costs following treatment” that can be provided through the Medicaid Expansion option.

Imprisonment, for most, is not a permanent condition, and prisoners are released at the end of their sentences or upon parole and probation. Upon reintegration into society, there should be a continuity of care to help patients transition from (lack of) healthcare in prison to healthcare in society. Each environment carries health concerns that must be addressed. While incarcerated patients have a higher prevalence of chronic diseases such as hypertension, diabetes mellitus, and asthma, when released, these chronic illnesses still require the same level of attentive care. To manage these health concerns, prison healthcare should not be managed by vague clinical practice guidelines or privatized healthcare services.

The prison industrial complex, like any other business, aims to make revenue as well as limit spending as displayed by the employment of private services such as prison healthcare professionals. In several cases such as Walter Balla, et al. v. Idaho State Board of Correction (IDOC), these cutbacks were shown to be problematic for the prison because “serious problems with the delivery of medical and mental health care” happened within their use of a private Corizon Health care system. As reported in The New York Times, suicide is the leading cause of death among the prison population.

Evidence suggests that “many of these problems either have resulted or risk resulting in serious harm to inmates” within the Idaho State Correctional Institution. The private practitioners are not subject to the government’s standard accountability which creates more risks within prisons and jails. Similarly, regarding the inmate exception, health care organizations are typically required to participate in Medicaid and Medicare programs as evidenced by President Lyndon B. Johnson’s 1965 signing of these social programs into law.

These social programs were meant to protect “the health and well-being of millions of American families, saving lives, and improving the economic security of [the] nation,” yet this did not seemingly include the prison population. This is because, in this same legislation, correctional health care would be “exempt from this requirement, resulting in poor health care oversight.” The lack of oversight, again, leaves the care of the inmate population to the discretion of prisons and jails which, historically, has led to maltreatment.

Conclusion and a call to action

The U.S. prison population is massive and is still growing at a staggering rate, thus there must be radical interventions made to treat those incarcerated. Prison populations are historically at a greater risk of contracting communicable pathologies, yet proposals set forth are subpar in addressing this issue. This is both due to the government not directly intervening in correctional health standards, as seen in the Health Management Resources, and public stigma denying healthcare coverage for inmates (Medicaid expansion).

Lobbying cannot get to the root of the antiblack machine of the prison industrial complex or address the war on drugs. So, then what should we do as radicals?

Should we push for new legislation, take to the streets through picketing, advocate for the abolition of the carceral structures, or simply burn the state to the ground? Each of the solutions, in some capacity, has been implemented or attempted in the U.S. Thus, when we look through the annals of prison activism, we must critically analyze how past reformist solutions have both assuaged and shaped the current carceral state. As seen in the failure of the BOP Health Management Resources and the ACA expansion, working within the governmental structure through lobbying has failed time and time again. This is not a new issue at all because there have been pushes for prison reforms since 1787, yet the carceral population is continually climbing. There has been a five hundred percent increase in the last forty years; so, in the case of prison reform are we really slowly chipping away at injustice? I don’t think we are.

Rather than wait on the government to provide care to prisoners, I believe that as Joy James explained, we need to address the crisis of prison health care in a broader abolitionist program that seeks to deconstruct the current carceral system.

Featured image credit: Robert Crow; modified by Tempest.

Opinions expressed in signed articles do not necessarily represent the views of the editors or the Tempest Collective. For more information, see “About Tempest Collective.”