The News Journal
03/26/2006
When William J. Keichline, 69, gets together with his friends, the discussion often turns to a common topic among senior citizens.
"We talk about our medications -- what we're taking," said Keichline, who has a catalog of health problems, including diabetes, high blood pressure, obesity, psoriasis and coronary artery disease that led to a triple-bypass surgery. "I'm old and the parts are wearing out. It's like I'm going down to Florida on bald tires."
But Keichline won't end his days in a waterfront condo in the Sunshine State. Keichline is serving eight consecutive life sentences in Delaware Correctional Center near Smyrna for child molestation. He won't be eligible for parole until 2086.
Keichline is one of a growing number of aging prisoners nationally who are growing old and sick behind razor wire. Delaware has 259 lifers who are 55 and older. Three prisoners are in their 80s. All are entitled to taxpayer-supported medical care.
"The [prison] population is getting more senior every day," Keichline said. "The [prison] terms in here would knock your socks off -- these guys will be here until they put a toe tag on them."
Delaware already faces the specter of a big financial hit for prison health care now that the U.S. Department of Justice has launched an investigation of inmate medical care at the Delaware Department of Correction.
The federal probe comes on the heels of a six-month News Journal investigation of prison health care.
Regardless of what the federal investigation concludes, Delawareans and taxpayers in other states are headed toward a day of reckoning in paying for medicine behind bars, experts said.
An aging inmate population is just one financial burden the state correctional system poses for taxpayers. Prisons have become the main lockup for the mentally ill. Added to this are high rates of hepatitis C, HIV, sexually transmitted disease and tuberculosis. It's estimated that $7 billion is spent annually in the United States on medical care administered to inmates.
"It's going to be a real bank-breaker for some states," said David Doolen, executive director of the Correctional Medical Directors Association and editor of "Positive Populations," a newsletter about prison health care issues. "We like to lock people up -- that's our thing. But we tend not to think of the consequences."
While ordinary citizens have no guarantee of adequate health care, inmates have a constitutional right to medical care, the courts have ruled.
Delaware has already gotten a taste of the financial burden to come. Consider that the $226 million proposed budget for the Department of Correction in 2007 is about equal to the amount proposed for higher education. The amount spent on inmate health care has risen from $5.14 a day in 1997 to $9.88 a day in 2005.
What's more, unless there is "some form of release mechanism for the aging and infirm," the state will have to build more infirmaries for geriatric inmates, said DOC Commissioner Stan Taylor. Other states have already begun doing just that.
William J. Rold, a New York civil rights attorney and consultant on correctional health care and the law, estimates that states today pay as much as $100,000 per inmate to "these little towns we call prisons." That figure includes the cost to construct prisons, as well as the cost to feed, clothe and care for the prisoners' medical needs.
The fastest-growing cost in the prison budget is medical care. Since 1996, the amount of money Delaware has spent on prison medical services has more than tripled, from $9.3 million in 1996 to $28.7 million recommended in the 2007 budget.
Public officials never envisioned the high cost of caring for a very sick or aging population behind bars, Rold said. "The notion of comfort and care is not something prisons were set up for," he said.
The daunting challenge for Delaware and other states will be finding the best way to deliver good medical care while managing costs, experts said.
Care often outsourced
Managing the problem could be easier for Delaware because of the state's small size and the fact it has a unified system, Doolen said.
In Delaware, this single system means that any person under any kind of correctional supervision falls under the jurisdiction of the state Department of Correction. About 6,800 adult men and women are serving time in a Delaware correctional facility. Delaware has five prisons, four for men and one for women.
By contrast, California has 33 state prisons and county jails in all 58 counties.
Since 1980, Delaware has outsourced inmate health care to private contractors, such as Correctional Medical Services of St. Louis and Prison Health Services in Brentwood, Tenn. But some states, such as California -- which is among the largest state correction systems in the country -- have continued to handle it through public agencies and employees.
Both models have had problems.
Private companies have been accused of skimping on care to pump up the bottom line. Sometimes these companies hire nurses and physicians who have not worked in prison health, so care suffers during the learning curve, Doolen said. Other times, companies run into trouble paying hospital bills and staff salaries when the states are slow to pay them, Doolen said.
Putting health care providers on the public payroll doesn't always work, either. In 2005, a federal judge found that medical care to the roughly 169,000 inmates in California prisons, which had been provided by state Department of Corrections and Rehabilitation, was so defective it violated the Constitution's ban on cruel and unusual punishment. The judge in February handed control of the $1.2 billion prison health care system to a federal receiver.
"You have horror stories anytime you try to manage or ration health care. It's going to happen," Doolen said.
Today, it's estimated that 40 percent of prison health care is outsourced, said Patrick Swindle, a research analyst who follows the private sector prison health industry for Avondale Partners in Nashville, Tenn.
Experts predict an increasing debate about prison health care, including how health care dollars are consumed. For example, should a prisoner get a heart transplant that costs more than $1 million, as was the case in California last year? A liver transplant can run $250,000, Doolen said. Bypass surgery can cost nearly $100,000.
Lawrence H. Pomeroy, senior vice president of Prison Health Services, a for-private provider of correctional health care services, said the sheer cost of certain medical procedures forces the question of whether the public should pay.
"You've got a limited set of resources chasing virtually unlimited needs," he said.
Prisoner growth a factor
The difficulty in managing care began in the early 1990s as a confluence of factors began to affect medical care in prisons.
The nation's incarceration rate rose 18 percent from 1995 to 2004 to 486 inmates per 100,000 Americans, according to the U.S. Justice Department.
What's more, women now constitute 7 percent of all inmates, up from 6.1 percent in 1995. About 5 percent of the women coming into prison are pregnant, according to a 2003 Centers for Disease Control and Prevention report.
This rise is due partly to the nation's get-tough-on-crime movement that began in the early 1980s, when lawmakers began requiring harsher sentences. Mandatory minimum sentences were imposed for certain drug offenses, crimes involving guns and sex offenses, Rold said.
Three-strike rules mandate jail time for certain third offenses. Truth-in-sentencing laws fixed the duration of a prison sentence at the sentencing phase, eliminating some of the discretion of parole boards, Rold said.
Life sentences also have been increasing, according to a survey by The New York Times. The newspaper found that the number of people serving life sentences in the United States almost doubled in the past decade.
Inmates aging, sicker
Then there is the fact that prisons are graying. And as the population ages, the prison takes on all the end-of-life costs of the inmate, said Dr. Roderic D. Gottula, former medical director of the Colorado Department of Corrections and past president of the American Correctional Health Services Association, a professional organization for people who work in correctional settings. Most of the lifetime costs of health care occur in the last years of life, he said.
Prisoners today also tend to be sicker.
"The lifestyle of a soon-to-be-inmate is not nice," Doolen said. "The lifestyle not only gets them in trouble with the law, but it tends to be bad for their health."
Mustafaa As-Salafi, who spent six years at Delaware Correctional Center near Smyrna, was released late last year from a prison in Pennsylvania. While health care behind bars is often lacking and delayed, he said, some inmates come into prison who never saw a physician on the outside.
"The little bit of what they get is better than what they had if they were homeless or drug addicts," As-Salafi said. "At least they're getting a physical once a year and things like glasses."
Inmates make an average of 12 visits to the medical unit every year, Gottula said.
"You have tremendous pressure on the system you don't see in the private system. Everybody wants to go to sick call," Gottula said.
Jackie Battaglia Moore, a Delaware native who pioneered the private, for-profit prison health care industry, recalled that when she first began working in a prison in Delaware County, Pa., in the early 1970s, archaic conditions prevailed.
"There was one big room with many, many cots," she said. "I was the only nurse there for 400 prisoners. There were no records -- there were index cards. There were two physicians past retirement age."
She treated things like sports or fight injuries, colds and high blood pressure.
"It was the things primary care doctors were seeing in their office," Moore said.
Today, prisons pay for the treatment of a variety of debilitating diseases, such as hepatitis C liver disease. Because the virus is spread through contact with human blood, people who injected street drugs are at risk, according to the Centers for Disease Control.
The annual cost of treating an inmate with hepatitis C can run $10,000 to $20,000, Doolen said. Delaware was unable to provide the number of inmates with hepatitis C.
"If you were to treat all the inmates eligible for hep C treatment, it would bankrupt the system," Gottula said.
Inmates with HIV also can be costly. Experts estimates some medications used to treat HIV can run as high as $20,000, although the cost is usually lower.
Mental illness a factor
Another costly health problem in prisons today is mental illness. About 17 percent of U.S. prisoners are mentally ill, with many of them suffering from serious psychiatric illness, such as schizophrenia, bipolar disorder and major depression, according to a 2003 report from Human Rights Watch. The California state system reports that 31,000 inmates, or 18 percent of the inmate population, are receiving mental health services.
The closing of state and local mental health hospitals has led to high rates of the mentally ill behind bars because there are no adequate alternatives to replace them, Human Rights Watch said.
"One of the largest mental health care providers in the nation is Los Angeles County jail system," Doolen said.
Prisons are now the nation's primary facilities for the mentally ill, with three times as many patients in prisons as in mental health hospitals, according to Human Rights Watch.
The cost to treat mental illness is significant. One mood-stabilizing drug, for example, costs $350 for a 30-day supply, Moore said.
Finally, there's the issue of rising prescription costs. Pharmaceutical costs have been rising by the double digits in recent years as drug makers spend more on development and marketing costs and face tougher federal regulations. Sometimes, states get together to buy medicines in bulk from one distributor and private companies can work deals. But supplying the pharmacies can represent as much of 12 percent to 15 percent of the total prison health care spending annually, Pomeroy said.
Prison budgets pinched
Rising medical costs have meant rising prison budgets. In Delaware, the proposed correction budget for 2007 is more than double that for 1996, while the medical services portion is triple.
But prison health care is a political hot potato, experts said.
"Prisons don't fare well in the competition with highways and schools," Rold said.
Moore agreed that most people don't care about the health of people behind bars.
"When's the last time we've seen a governor get elected because he ran on a platform of better health care for inmates?" Moore said.
Experts predict the situation eventually could lead to a push to reform the criminal justice system, including re-evaluating mandatory minimum sentences and three-strikes laws.
"I think what we're going to see is states taking a second look at who we put behind bars, for how long and why," Rold said.
Keichline, the prisoner in Delaware Correctional Center, agrees that sentencing policy is aggravating the problem.
"People are not going home. The sentencing some of these guys get would knock your hat off."
Contact Maureen Milford at 324-2881 or mmilford@delawareonline.com.
