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Skip Navigation LinksHome > January 2012 - Volume 112 - Issue 1 > Challenges to Health Care Delivery in U.S. Prisons
AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000410351.11158.85
AJN Reports

Challenges to Health Care Delivery in U.S. Prisons

Nelson, Roxanne

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Aging inmates, chronic diseases, and poor follow-up after release strain the system.

Health care is one of the major expenses in the corrections system, and costs are rising. In state prisons, they increased by 10% annually from 1998 to 2001, according to a report by the Pew Public Safety Performance Project, One in 100: Behind Bars in America 2008. The report also cites figures from the Council of State Governments, showing that $3.7 billion per year was being spent to cover medical costs, accounting for 10% of the budget for correctional spending. Rising costs stem partly from an overall escalating population of inmates who are aging in prison. Twenty years ago, only about 25% of the federal prison population was older than 50 years, but that number was forecast to reach 33% by 2010 (the new data haven't yet been released).

Inmate Brian Rochele...
Inmate Brian Rochele...
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Inmates have a constitutional right to health care, according to longstanding interpretations of the Eighth Amendment, which prohibits “cruel and unusual” punishment. Part of the rising cost of health care in prison can be attributed to attempts to fulfill that obligation, as well as to a 1976 ruling by the U.S. Supreme Court mandating that states provide medical care that “generally meets a community standard.” And statistics show that as an overall group, inmates are extremely vulnerable to illness—they have higher overall rates of serious and chronic illnesses and infectious diseases, such as HIV and hepatitis C, than the general population, according to a study by Wilper and colleagues in the April 2009 issue of the American Journal of Public Health. Hepatitis C is one of the biggest concerns and one of the most expensive conditions—the latest therapies may run as high as $30,000 per inmate annually, and the disease is widespread in the prison population. At one California prison, it was estimated that at least half of the 3,200 inmates were infected with the virus, although other state facilities place the prevalence at between 25% and 40%, according to the Pew report. Mental health disorders and substance use and dependence are also highly prevalent, and according to the Center for Prisoner Health and Human Rights (www.prisonerhealth.org), addiction and mental illness are often at the root of incarceration in the first place.

Despite the high prevalence of medical conditions and mandates to provide adequate care, inmates have traditionally received subpar medical care and have been marginalized by the U.S. health care system. Because of the huge variance among states and facilities in how prisons are run, it's difficult to ascertain trends in improvements or backslides in health care delivery over the past five or 10 years. In fact, “Some systems, surprisingly, are responding with more resources, in part as a response to community attention and even court mandates,” said Lorry Schoenly, PhD, RN, CCHP-RN, a correctional health care risk consultant. “On the other hand, especially in small, resource-strapped systems, I've seen a movement toward greater use of unlicensed staff. Depending on the situation, this can be troubling,” she added. “Systems are also seeking alternative sentencing options to allow individuals to remain in the community and, therefore, in the community health system.”

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The analysis by Wilper and colleagues examined data from the 2004 Survey of Inmates in State and Federal Correctional Facilities and the 2002 Survey of Inmates in Local Jails, which showed that large proportions of inmates with serious chronic physical illness didn't receive adequate care during their incarceration. For example, 13.9% of federal inmates, 20.1% of state inmates, and 68.4% of local-jail inmates with a persistent medical problem hadn't received a medical examination since beginning their prison term.

Continuation of prescription medication was also problematic. Before entering prison, approximately one in seven inmates was taking a prescription medication for an active medical problem. However, upon incarceration, 20.9% of federal, 24.3% of state, and 36.5% of local-jail inmates stopped their medication.

Lead author of the study, Andrew Wilper, MD, MPH, told AJN that “barriers to accessing care in different detention facilities are multifactorial: there is heightened security within the jail or prison, which can result in limited physical access to clinical services. Limited employee education regarding the signs and symptoms of illness and limited health care staffing also play a role in reducing inmate access to care.”

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Wilper, who is with the Boise Veterans Affairs Medical Center in Boise, Idaho, noted that after being released, inmates also face an amplification of the many barriers to care that the general population contends with. “First, former inmates may return to social circumstances in which seeking medical treatment is a low priority, relative to other concerns such as securing food and housing,” he said. “Next, recently released inmates are unlikely to carry health insurance. Consequently, many health facilities and physicians are unlikely to provide them with care.”

The result may be a reliance on EDs, where care is designed for acute conditions rather than the many chronic medical and mental health problems that this population faces.

Joan A. Flores, MSN, NP-C, WHNP-BC, agreed that access to adequate health care can be difficult for inmates once they're released from the prison system. In her own meta-analysis of 10 studies (published with Linda Honan Pellico in the July–August issue of the Journal of Obstetric, Gynecologic and Neonatal Nursing), which evaluated the experiences of women reentering the community after incarceration, she found that they face formidable challenges and myriad health issues.

“Many women lose their public health insurance once they're imprisoned, and upon leaving prison, it can take several months to reenroll in a state-funded health insurance program,” said Flores, who works in private practice in San Leandro, California. “Also, many women who end up in prison are struggling with drug addiction, and there aren't too many rehabilitation programs out there that focus on the unique needs of women dealing with substance abuse issues.”

Receiving proper care for other mental health issues is also difficult once women leave prison, and many within the prison system struggle with psychiatric diagnoses.

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Nurses working in the correctional system have an opportunity to improve outcomes and change lives, said Schoenly. “Many nurses aren't aware of the corrections specialty,” she said, noting that she wasn't aware of it until she responded to an advertisement to be a nurse educator in a state prison system.

There's a great need for professional nurses in this invisible field, and nurses can make a tremendous difference in the lives of this vulnerable and marginalized group, according to Schoenly. Safety is often a concern for those thinking about working in a jail or prison, but Schoenly pointed out that safety at work is important for all nurses. “Certainly patient violence is a potential in corrections,” she said. “The advantage in this setting is that there are more resources devoted to protecting staff members. Correctional officers are physically present and consider staff welfare a top priority. And in fact, many correctional nurses comment that they feel safer working in this setting than working in other specialties such as nursing homes or EDs.”

According to Flores and Pellico's study, women's health NPs and nurse midwives can help enormously in efforts to eliminate health disparities that former inmates face by participating in system-wide changes. Providers can push for public policy changes, the authors write, that address the effects of separating mothers from their children during incarceration, as well as “the disproportionate criminalization of low-income women and women of color… and the stigma that limits opportunities for economic sustainability among the formerly incarcerated.”—Roxanne Nelson

© 2012 Lippincott Williams & Wilkins, Inc.