Healthcare Behind Bars: A System Designed to Fail?

Authored by: Nora Sheu

Art by: Sophia Liu

Across the United States, prison healthcare systems are chronically underfunded and understaffed. Nearly 2 million prisoners in the United States are less healthy than the general population, an urgent problem that must be addressed as the number continues to grow [1]. A study examining the 170,215 Texas Department of Criminal Justice (TDCJ) inmates incarcerated between August 1997 and July 1998 revealed inmates’ increased risk for infectious diseases and mental disorders, as mentioned in the introduction [2]. Specifically, tuberculosis, hepatitis, and AIDS are reported to be substantially higher for prisoners than for their same-age peers in the general population [2]. Prison inmates are also found to exhibit elevated levels of affective disorders, schizophrenic disorders, and substance abuse, although there is a lack of information on many other medical conditions [2]. The scarcity of information has hindered effective healthcare delivery in prison systems. The ethnic makeup of the prison population is a contributing factor to these findings, as prison inmates are disproportionately black and Hispanic, groups more likely than white people to suffer from chronic diseases [1]. Examining prison healthcare reveals a system where medical neglect is normalized. Government oversight, accountability, and reform play a critical role in determining who receives care and who is left to suffer behind bars. 

To understand why prisoners are more susceptible to health issues, we must delve into the historic legislation and court rulings that shaped correctional healthcare. The absence of federal oversight for correctional healthcare dates back to the Social Security Act (SSA) Amendments of 1965, which authorized the creation of Medicare and Medicaid but specifically prohibited their implementation in jails and prisons [3]. The Supreme Court case in Estelle v. Gamble (1976) established that prisoners have a constitutional right to medical care [4]. Justices held the Court of Appeal’s ruling that “deliberate indifference by prison personnel to a prisoner's serious illness or injury constitutes cruel and unusual punishment, contravening the Eighth Amendment” [4]. In essence, states are obligated to provide prisoners with necessary care for known, serious medical needs [3]. In 2011, Brown v. Plata furthered prisoners’ constitutional right to healthcare by recognizing that a population limit is necessary to prevent prison overcrowding, as systemic failure to regulate population can amount to cruel and unusual punishment [5]. However, while Estelle v. Gamble and Brown v. Plata formally established legal rights for prisoners, the rulings don’t address the root of the systemic issues in correctional healthcare. 

Even for those who are not in prison, the way prisoners receive medical support should still be a concern. The widespread mistreatment of prisoners may not impact the general public directly, but it reveals how negative opinions towards incarcerated persons and eroded physician-patient relationships contribute to the problem. The public as a whole is apathetic to sick prisoners, considering healthcare for prisoners as a tax burden for an underserved group [1]. Perhaps this stems from the American ideology that a person’s moral worth is derived from their benefit to society. Additionally, internal obstacles to correctional healthcare don’t just come from public opinion, but also from within the prison. Patterns of prisoners seeking care they don’t need – either for drugs or to break the monotony of prison life – have led many medical professionals to react with suspicion at every complaint [1]. Prisoners also assume that available care is inadequate, thereby contributing to poor communication and ineffective care [1]. These patterns point to a growing disconnect between physicians and prisoner-patients, but the gap in communication and trust extends to non-prisoner patients as well. A physician’s top priority should be the health and well-being of their patients, regardless of whether they are incarcerated. While there have been increased efforts to educate physicians on their moral and ethical duties toward their patients, these conversations should expand to include prisoner care.

Flaws in the U.S. correctional healthcare system are creating a sicker prisoner population, reflective of institutional and policy gaps, but also deeply rooted negative perceptions of criminals. The latter is especially alarming and exposes the hateful, distrustful state of our society. However, there have been recent efforts to improve access to care. The Federal Bureau of Prisons, for instance, established several secure mental health step-down units, providing housing and treatment for inmates with mental illness [6]. While these initiatives signal progress, meaningful change will require more than isolated reforms, but also a confrontation of the belief that incarcerated people are undeserving of care. How we choose to confront the issue will mirror the values we choose to uphold as a nation. 

References:

1. Virtual Mentor. 2008;10(2):116-120. doi: 10.1001/virtualmentor.2008.10.2.msoc2-0802.

2. Baillargeon, Jacques, et al. “The Disease Profile of Texas Prison Inmates.” Annals of Epidemiology, vol. 10, no. 2, 2000, pp. 74–80, https://doi.org/10.1016/S1047-2797(99)00033-2.

3. Jolin, James René et al. “Correctional Healthcare - an Engine of Health Inequity.” Journal of General Internal Medicine, vol. 38, 1 (2023): 216-218. doi:10.1007/s11606-022-07741-9

4. Estelle v. Gamble, 429 U.S. 97 (1976)

5. Estelle v. Gamble, 429 U.S. 97 (1976)

6. Department of Justice Archive | Prison Reform: Reducing Recidivism by Strengthening the Federal Bureau of Prisons. (2016, November 29). https://www.justice.gov/archives/prison-reform