Medical and Mental Health Services

While incarcerated, people need access to medical care, dental care, eye care, and behavioral and mental health services. Prisons are required by law to provide adequate health care to people in prison and, like everyone, prisoners’ medical problems ranging from the flu to AIDS, hepatitis C, and cancer.

The main companies involved in this sector are:
Centene Corporation, of St. Louis, MO (NYSE: CNC)
MHM Services, of Vienna, Virginia (OTC: MHMI)
Correct Care Solutions LLC., (formerly GEO Care) of Nashville, TN (Private)
Corizon Health Inc., owned by Valitas Health Services, Inc., of St. Louis, MO (Private)
Armor Correctional Health Services, Inc., of Miami, FL (Private)
Emerald Healthcare Systems LLC, a subsidiary of Emerald Companies, of Lafayette, LA (Private)
Wexford Health Sources, Inc., of Pittsburgh, PA (Private)
Naphcare, of Vestavia Hills, AL (Private)
California Forensic Medical Group Incorporated, of Monterey, CA (Private)

History of Medical and Health Services in Prison
Although all prisons are required to provide adequate health care, this was not always the case. In 1972, a study of American jails by the American Medical Association found that 25 percent had no medical facilities whatsoever and 65 percent had first aid as the only medical care available. Prisoners in many states filed lawsuits to demand that jails and prisons provide adequate medical care. In 1976, the landmark Supreme Court decision Estelle v. Gamble established a standard of “deliberate indifference to serious medical needs” to apply the Eighth Amendment prohibition against cruel and unusual punishment to government obligations to provide health services to people in prison.

The Privatization of the Sector
By 1995, at least 40 states, the District of Columbia, Puerto Rico, and the Virgin Islands were under court order or consent decree regarding conditions, including health services, in either the entire prison system or in major facilities. In an effort to resolve these lawsuits and obey court orders, state and local governments needed to improve healthcare with severe budget constraints and overcrowding. More and more facilities contracted with private companies to provide prison and jail health services. Basic health care costs rose from an average of $880 per prisoner in 1982 to $2,308 in 1995 to $4,708 in 2010. The cost ranges between states. In California, the average cost per prisoner in 2015 was $11,793.

In 2011, states spent a combined $7.7 billion on correctional health, about 16 percent of all correctional spending for that year. In thirty-six states, the correctional system contracts out at least a portion of their correctional health services to outside vendors. Within the thirty-six states, twenty-four contract out all correctional health services to private companies. Types of services performed by private vendors including comprehensive care such as medical and mental health care, dental care, and specialized services such as dialysis, pharmaceutical services, or other medical specialties. Private prisons run by corporations such as CoreCivic, Inc. or The GEO Group, Inc. generally have in-house medical departments.

Controversies
In order to win a contract, companies respond to Request for Proposals (RFP) from government entities with the lowest bid. The first priority of these companies will be cost-cutting, to ensure they win the initial contract and maximize profits. Cost-cutting does not lead to quality medical care, and the methods used to cut costs are antithetical to improvement. These cost-cutting measures include:

  1. Expand the use of telemedicine – Long-distance medicine by video cuts costs because transporting prisoners to specialists and outside hospitals is enormously expensive -- guards and security must accompany the person at all times, including for hospital stays. In a jail or prison setting, telemedicine means that prisoners aren’t seen or physically examined by a doctor so examination results are often woefully inadequate and inaccurate. Telemedicine is used to provide some health care services to prisoners in 26 of 44 states according to a recent report.
  2. Require co-payments for medical visits – Requiring prisoners to pay for medical care was instituted to deter people from seeking medical care, discouraging so-called  “frivolous” sick call visits. Because prisoners’ income is extremely limited, requiring co-payments means that sick people will go untreated, “minor” medical problems will worsen, infectious diseases may spread, and serious diseases like cancer may not be diagnosed. The National Commission for Correctional Health Care (NCCHC) has officially opposed instituting co-pays since 1996.
  3. Substitute generic medicines – A very common cost-cutting strategy is to substitute generic medicines for more expensive, brand-name medications. Unfortunately, generic medicines do not automatically duplicate the medical effects of a similar but more expensive medication. Prisoners subjected to substitutions may not experience the same results from generic medicines, and their health often deteriorates. Also, medications for many serious illnesses (like HIV/AIDS and Hepatitis C) do not have effective generic counterparts.
  4. Eliminate 24-hour services – Many prisons and jails have cut back on staffing hours, resulting in an absence of medical staff and emergency medical services when needed. Emergency room services and ambulance costs are expensive and require guards to accompany prisoners, so they are rarely accessed.
  5. Charge prisoners for medications – Many prisons and jails now require prisoners to buy their own medicine, including over-the-counter meds like aspirin or allergy medication. Most people in prison simply do not have incomes that allow these purchases, so prisoners are going untreated for minor illnesses that nonetheless cause them unnecessary pain and suffering.
  6. Divert or release sick and elderly individuals – Aging prisoners are one of the main causes of increased prison health care costs. People with life-threatening or serious illnesses, including mental illness, should not be incarcerated in the first place, as the prison environment is not conducive to good physical or mental health. Although many states and the Federal government have compassionate release programs for terminally ill prisoners, these programs are generally ineffective. Their guidelines are difficult to meet, requiring medical opinions that a person has 6 months or less to live, and posing procedural hurdles that are difficult to overcome.
  7. Reduce the number of referrals to outside hospitals and specialists – Transportation is a large part of the cost of referrals to outside hospitals, averaging $2000 per 24-hour period per inmate. Reducing the number of visits to outside providers also means that people are being denied access to necessary specialists and medical procedures.

Companies
Most of the companies in the health services sector are privately-owned. Corizon, the largest company in the sector, with an annual revenue of $1.5 billion, has operations in over 29 states and is three times the size of its next largest competitor. Corizon has contracts in the jails of major cities, including New York, Philadelphia, and Atlanta.

Centurion Managed Care is a joint venture of MHM Services and Centene Corporation, both publicly-held companies. Centurion provides health care services to five state prisons systems through subsidiaries in each state. In 2018, Centene announced it would acquire MHM Services.