From Public to Private Care The Historical Trajectory of Medical Services in a New York City Jail

Abstract

Over the past 25 years, incarceration rates in the United States have more than tripled. Providing health care services for this growing number of inmates poses immense medical and public health challenges. Focusing on the administrative and financial shifts in health care delivery, I examined the history of medical services in one of the nation's largest correctional facilities, Rikers Island in New York City. Over time, medical services at Rikers have become increasingly privatized. This trend toward privatization is mirrored nationwide and coincides with the rising prevalence of incarceration.

OVER THE PAST 25 YEARS, incarceration rates in the United States have increased dramatically (Figure 1). At midyear 2006, 2.2 million people were held in jails and prisons nationwide, yielding an incarceration rate of 750 inmates per 100 000 residents.¹ At present, the Unites States has the highest rate of incarceration in the world; it is between 4 and 10 times higher than that of other industrialized nations.² According to the US Bureau of Justice Statistics, rates of incarceration in federal and state prisons doubled between 1980 and 1990 and increased by more than 50% between 1990 and 2005.^3,4 The rates of imprisonment in 1985, 1995, and 2005 were 313, 601, and 737 per 100 000 residents, respectively.^5,6 This unprecedented rise in imprisonment has been described in the social science literature as a phenomenon of “mass incarceration.”^7,8

FIGURE 1.

Incarceration rate and number of persons in prisons and jails: United States, 1980-–2006.

Source. Bureau of Justice Statistics³ and Pastore and Magure.⁴

In 2006, 92% of US prison inmates and 87% of jail inmates were men.¹ Black men were 6.5 times more likely than were White men to be incarcerated; Black women were 3.8 times more likely to be incarcerated than were White women³ (Figure 2). More than 10% of Black men aged 25 to 29 years were incarcerated at midyear 2006.¹ About half of the nation's jail inmates have less than a high school education, and 14% lived in an institution or in foster care as children.⁹

FIGURE 2.

Jail incarceration rates by race and ethnicity: United States, 1990–2006.

Source. Bureau of Justice Statistics.³

In addition to these socioeconomic markers, prisoners bear a disproportionately high burden of chronic and infectious disease. Human immunodeficiency virus (HIV) seroprevalence in prison populations is estimated at 1.8%, about four times higher than in the general population.¹⁰ Prevalence of hepatitis C infection in prisons is estimated to be between 15% and 25%.¹¹ In jail inmates, rates of substance use disorders in the year before incarceration are approximately 70%.¹² Thus, the prisoner population is composed predominantly of poor men from minority groups, who have complex medical and mental health needs. Delivering medical care to this population poses immense medical and public health challenges.

I performed a historical case study of the evolution of medical services in one of the nation's largest correctional facilities, Rikers Island in New York City. My objective was to describe the trajectory of medical services at Rikers Island and thus elucidate key issues in the intersection between criminal justice policy and health care delivery. I used ethnographic methods, including archival review, qualitative key informant interviews, and media content analysis. I obtained primary sources from the New York city hall library, municipal archive, and the Montefiore Medical Center archive. These materials include reports from the Department of Health (DOH), Department of Correction (DOC), mayor's correspondence, and city budgets and contracts. Policy papers, health statistics, and administrative records served as secondary sources. The New York Times database provided a source of media coverage. I conducted semistructured qualitative interviews with directors of the Montefiore Rikers Island Health Service.

RIKERS ISLAND HEALTH CARE DELIVERY

The Rikers Island Penitentiary was inaugurated in 1932. It is located on an island in New York City's East River and is connected to the rest of the city by a single bridge. Rikers Island is among the largest correctional facilities in the world. It is composed of several detention centers, which I refer to collectively. Its current average daily census is 13 000, and its capacity is 17 000. About 100 000 admissions are processed yearly, of which approximately 70% are pretrial detainees.^13,14 Ninety percent of inmates at Rikers are Black or Latino, and 85% are men.¹⁴ About 50% of New York State prisoners are processed through Rikers Island.¹⁵ In 2005, 10.6% of women and 4% of men in New York State prisons were HIV positive.¹⁶

The historical record detailing medical services at the facility is sparse. However, based on the primary sources found, I divided the past 75 years into 3 distinct periods from the perspective of health care delivery. The first period, 1932 to 1973, I designated the “direct service” era. During this time, a number of city agencies provided medical services. In the second period, 1973 to 1996, the academic “affiliation contract” emerged. A university-affiliated, nonprofit medical center provided care to inmates under contract with the city. And finally, from 1996 to the present, in a period of “managed care,” for-profit corporations entered the arena of jail health care delivery in New York City.

An inmate is examined by a New York City Department of Correction physician.

Source. Department of Correction Annual Report, 1966. Courtesy of City Hall Library, Department of Records and Information Services, City of New York.

Direct Service, 1932 to 1973

During Rikers Island Penitentiary's first few decades, the New York City DOH was the titular administrator of health services in New York City jails, and the DOC was charged with directly providing care to its own inmates. Although the DOC was operating under the aegis of the DOH and the Health Services Administration, DOC officials, including wardens and correctional officers, de facto controlled the daily management of medical services.

Documents at New York City municipal library reveal that the city, as well as the federal government, commissioned a number of investigations into medical conditions in New York's jails. The earliest available report is titled A Brief History and Report of the Activities of the Medical Advisory Board of the Department of Correction.¹⁷ Anna M. Kross, commissioner of correction from 1954 to 1965, requested this report, which contains a two-year review (1956–1958) of all city correctional facilities, including Rikers Island. Average citywide daily census at this time was 8000 inmates 40% above system capacity. The report offers the following summary:

“The Department of Correction is not now in background, equipment, or personnel capable of giving modern medical care—whether preventative or therapeutic—to the prisoner.”¹⁷

This blanket condemnation is followed by identification of the three most critically lacking areas: staffing, medical records, and oversight of medical care. The report suggests that the DOC enter into an affiliation with a “teaching hospital or medical school”¹⁷ to guarantee standard of care health services. This report also contains a series of testimonials from board members, one of which explicitly questions the relation between incarceration and the control of disease:

Why is it that a man who is apprehended because he stole five hundred dollars somewhere, why does he become a patient at all? Why, when he is apprehended, must he be examined at all? Well, the answer is that when he is apprehended he is taken out of the society in which he has been living and catapulted into another society, the prison life. I think if a man with an open tuberculosis steals five hundred dollars, the community would be much better off if he were not apprehended, because he is not examined well enough to recognize it.^17(pA2–A3)

This statement suggests that routine medical services at the city jails were so inadequate that imprisonment produced more social damage than did the original crime. The passage documents a system in which confinement magnified medical risk by establishing an artificial and superficial medical process.¹⁸

I was unable to find a response to the advisory board's 1958 report within the city archives or in the press. At that time, press coverage of the city jails focused on overcrowding and narcotics addiction. Despite the findings of the report, the DOC retained control of medical services at Rikers Island and other city jails.

The DOH commissioned the next extensive evaluation of medical services of city jails, the Special Task Force for the Study of Department of Corrections Medical Programs, in 1965.¹⁹ The introductory page of the task force's report offers insight into the then prevailing ethics of prisoner care:

It remains for the medical service to provide care for this population characterized by serious psycho-social problems, deprivation, mobility, recidivism, unpredictable exposure to care and ruled by security-oriented wardens with little regard for health needs… . [W]e were not able to elicit from the medical or correctional staff any feeling of responsibility for the “medical care,” in the comprehensive sense, or for the “health” of inmates.^19(p1)

The report opens with a clear statement of the untenable conflict created by correctional oversight of inmate health. At that time, the DOC was responsible for maintaining all medical facilities, overseeing administrative issues, and hiring nursing and allied staff. Its budget combined monies from the Health Services Administration and the DOC, but the DOC retained budgetary control. The result was a situation in which the incarcerator doubled up as caregiver, creating a conflict of interest between ensuring security and providing health care. The task force described the bureaucratic morass, lack of centralization, and absent oversight of prison medical services and suggested better integration with and support from the DOH.

Ultimately, historical events rather than official reports changed the structure of medical care within the city's correctional facilities. In the early 1970s, a series of prison revolts erupted in New York State (and beyond), culminating in the Attica prisoner uprising in September 1971. The Manhattan House of Detention erupted in protest over inmate rights and grievance procedures in October 1970. Some of these grievances revolved around access to medical care. These events turned a national spotlight on the conditions in US prisons; health was but one element in a series of systemic violations of basic human and civil rights. In the aftermath of the civil rights and Black power movements, the inseparability of racism from the correctional project became widely visible. At that time, more than 50% of state prison inmates were Black or Puerto Rican; in New York City the rate was approximately 90%.²⁰

In May 1971, the newly formed Health and Hospitals Corporation (New York City's public health care system) published Post Riot Prison Health Services.²¹ The report was based on a three-week on-site survey of city correctional facilities. The Health and Hospitals Corporation concluded that (1) prison health facilities were “ultradecentralized,” (2) the prison health program was “overwhelmed by the influence of the Department of Correction's obsession with custody and discipline,”^21(p1) and (3) the medical staff had attained a deserved image of “senility and incompetence.”^21(p1)

It was in this political and bureaucratic context that the New York City DOH took over the administration of prison medical services from the DOC. Between April and September 1971, authority over the management of prison health care was transferred to a newly created DOH agency, Prison Health Services. Prison Health Services set out to standardize and improve the health care delivered to the city inmates. In addition to administrative reconfiguration, they hired physicians and nurses directly out of DOH funds, thus assuring that health providers were not financially beholden to the DOC.

The city, however, sought to replace this “direct service” model of health care delivery (i.e., the provision of services directly by a city agency). Under the liberal administration of Mayor John Lindsay, the city began planning for an “affiliation contract” with a teaching hospital. Such affiliation contracts were modeled on existing contracts between city hospitals and medical teaching centers (e.g., Bellevue Hospital and New York University). Advocates of the affiliation contract argued that it would improve medical care by using the hospital's resources, recruiting medical staff, and raising professional standards.²²

Affiliation Contract, 1973 to 1996

When the city requested bids for medical care at Rikers Island, Montefiore Hospital, a private, nonprofit hospital in the Bronx, New York, was the only bidder (E. Bellin, MD, medical director Montefiore Rikers Island Health Service, 1994–1997, oral communication, February 2006). Montefiore Hospital had a unique history of community-oriented programs.²³ At the time, Montefiore was already providing medical care to adolescent detainees at the Spofford Juvenile Center in the Bronx (E. Drucker, PhD, professor of epidemiology and social medicine, Albert Einstein College of Medicine, oral communication, January 2006).

In October 1973, the City of New York and Montefiore Hospital signed an affiliation contract for medical care at Rikers Island. This agreement set a precedent by establishing the “contractual affiliation” as a model for prison health services at a time when nationwide most of these services were provided directly by public agencies. Under the contract, Montefiore Hospital established the Montefiore/Rikers Island Health Service (MRIHS) to provide inmates with 24 hours a day, on-site physicians, ambulatory primary care clinics, and specialty clinics (mental health and dental services were excluded and continued to be provided by the DOH).

The original three-year contract was renewed in 1976 for $11.7 million over three years.²² Thereafter, MRIHS provided ambulatory care for the next 25 years. The positive effect on medical care was noted early. A report published in 1976 by the Community Service Society of New York noted improvements in the delivery of many services, particularly women's health, information management, and access to specialty clinics.²⁴ In addition, the report argued that inmates trusted hospital personnel more than they did city agency staff and that Montefiore staff functioned as “advocates for better prison conditions.”^24(p15) A series of published articles describes the epidemiological and clinical work undertaken by the MRIHS in several fields, notably methadone maintenance and tuberculosis treatment.^25–27

Legal and epidemiological landmarks punctuated the initial period of the affiliation contract. In 1973, the Rockefeller drug laws established harsh mandatory minimum sentences for the possession and sale of drugs. These led to a large increase in the number of persons incarcerated on drug-related charges: from 10% of New York State prisoners in 1980 to a peak of 47% in 1997.²⁸ In 1976, the Supreme Court's landmark decision Estelle v. Gamble guaranteed inmates the constitutional right to standard of care medical services, creating a rush to improve and standardize medical care within these facilities.²⁹ On a local level, beginning in the 1970s, city inmates were centralized on Rikers Island through the gradual closing of the smaller, local jails known as Borough Houses of Detention.³⁰

Beginning in the mid-1980s, the emerging epidemics of HIV and tuberculosis changed the landscape of medical care on Rikers Island. The HIV and tuberculosis crisis, which reached its zenith in the early 1990s, obscured an assessment of the affiliation contract simply on its own merit.^31,32 The director of MRIHS at the time noted

Basically before HIV, even though the rates of incarceration in America are so gargantuan, the men were essentially healthy. Once you had 20% of Rikers with HIV it all changed… . [T]here was a financial crisis and nobody wanted to hear that TB was threatening the population. I mean they didn't care about inmates. Because it cost money. (S. Safyer, MD, executive director MRIHS, 1985–1993, oral communication, October 2005)

The citywide HIV and tuberculosis crisis was accompanied by a series of lawsuits brought by the Legal Aid's Prisoners’ Rights Project and, ultimately, the issuance of consent decrees mandating the city to improve care on Rikers Island. A notable example was the construction of an on-site tuberculosis hospital, equipped with negative pressure rooms, sputum-induction facilities, and a directly observed therapy program (E. Bellin, MD, medical director MRIHS, 1994–1997, oral communication, February 2006).

Despite these challenges, the city's shift to a private, nonprofit, affiliation contract yielded overall positive results, as described here. The MRIHS was the first correctional medical program in the country to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (L. King, MD, medical director MRIHS, 1982–1984, oral communication, October 2006). In 1997, when the contract with Montefiore dissolved, the issue at stake was not quality of care but cost containment.³³

Managed Care, 1996 to the Present

In 1996, the Health and Hospitals Corporation (then under contract with the DOH to administer jail-based health services) issued a request for proposals for managed care in its jail facilities. The proposal called for a “capitated rate per inmate per day” to include both outpatient and inpatient costs.³⁴ The MRIHS had operated under a “cost-plus” contract with the city, which allowed flexible spending under a “capitated outpatient” model. From the city's perspective, this contract promoted uncontrolled spending with minimal incentives for cost control. In 1996, the annual budget for MRIHS was approximately $65 to $70 million (E. Bellin, MD, medical director MRIHS, 1994–1997, oral communication, February 2006).

The city was interested in lowering expenditures, predominantly by shifting inpatient costs to the ambulatory contractor. However, the city did not find a contractor until the following year after an additional round of bidding. In the second round, Montefiore did not submit a proposal and the quarter century–long contract between the hospital and the city dissolved. The reasons for the dissolution are complex and multifactorial. Contributing to the end of the contract were the rising costs of jail medical care coupled with the cost-saving and law-and-order priorities of the administration of Mayor Rudolph Giuliani as well as tensions between the city and Montefiore over an affiliation with a Health and Hospitals Corporation hospital.³⁵

In 1997, the city selected the lowest bidder, St Barnabas Hospital of the Bronx, to serve as a health maintenance organization (HMO) for Rikers and other city inmates.³⁶ The 3-year contract with St Barnabas was the largest of its kind in the history of correctional medicine; it was valued at $350 million over 3 years on a fixed per inmate per annum basis. Although the city projected a 25% drop in health care costs systemwide, these savings did not materialize. Rather, fears that such a contract would create financial disincentive to provide comprehensive care and inpatient admissions were quickly borne out. The reported profit margin for St Barnabas in the first few months of operation was 14%, two to three times higher than the national average for profit-making hospitals.³⁷ The city did not renew its contract with St Barnabas in 2000 because of concerns over cost-cutting measures, excessive profits, and reports of negligent care.³⁸

After the failure of the first HMO contract, the city hired Prison Health Services, Incorporated (PHSi), a for-profit, managed care corporation specializing in correctional health. PHSi is the largest for-profit correctional health corporation in the country and provides medical care in prisons and jails nationwide. The company was established in 1978,³⁹ in the era when a specialized, for-profit managed correctional care industry emerged (L. King, MD, medical director MRIHS, 1982–1984, oral communication, October 2006).

PHSi's first year of service at Rikers Island was marked by reports of inadequate care, most notably in the areas of HIV screening, sexually transmitted disease treatment, infection control, and staff retention.^40,41 The New York State Commission of Corrections has criticized PHSi for aggressive corporate management practices and cost cutting at the expense of medical services.⁴² A comprehensive investigation in the New York Times exposed patterns of medical negligence.^42,43 Nevertheless, the company continues to provide medical care to inmates at Rikers Island. The most recent three-year, $306 million contract, covering Rikers Island and the Manhattan Detention Complex, began in January 2005. The DOH closely supervises this contract through its Correctional Health Services unit. Over the past few years, the DOH has described improvements in care, notably in the areas of HIV primary care, preventive care for diabetics, and to some extent, mental health services.⁴⁴ Nevertheless, recent reports continue to show that PHSi fails to meet most standards set by the DOH.^45,46

In 2006, the DOH issued a concept paper announcing a forthcoming request for proposals to revamp the city's jail health services.⁴⁷ The document introduces a plan to diversify the number of health care contractors in the city jail system and suggests that multiple contractors be used on Rikers Island. This shift is occurring simultaneously with efforts to decrease the census at Rikers and reopen the Borough Houses of Detention.⁴⁸ In addition, the request for proposals emphasizes the DOH's preference for a local bidder with experience in delivering care within the city's communities. It notes the centrality of discharge planning to the “new concept” of correctional health. These priorities create a clear disadvantage for the for-profit bidder. Discharge planning is costly and labor intensive and requires coordination among multiple community agencies. Correctional medical corporations such as PHSi have no experience in the local community. They generally have corporate headquarters that are distant from the site of service (PHSi headquarters are located in Tennessee). New York City is again seeking a change in the delivery of medical services to its inmates and has an unstated but apparent preference for a move away from the for-profit sector.

CONCLUSIONS

Over the past 75 years, medical services in New York City's largest correctional facility have undergone significant administrative and financial shifts. These shifts can be summarized as a movement toward increased privatization of medical care. The arc of services provided at Rikers Island may be described simply as the DOC providing profoundly inadequate care, followed by an academic affiliation yielding very good yet costly care, and ultimately a for-profit corporation providing cost wary, yet expensive and inconsistent care.

The move toward privatization at Rikers Island is mirrored state- and nationwide. It has been estimated that $3 billion in annual correctional health expenditures, or 40% of total expenditures, belong to the private sector.⁴⁹ Furthermore, the management and administration of correctional facilities has also been privatized. Seven percent of federal and state prison inmates were held in private facilities in 2006.¹ Private companies are replacing the traditional role of governmental agencies in the administration of the criminal justice system.⁵⁰ This corporate–correctional sector has been termed by criminologists and activists alike the “prison–industrial complex.”^51,52

Despite the general trends discussed in this study, Rikers Island is unique in a number of ways. In most correctional facilities nationwide, an “academic affiliation” has never existed and the DOC, a local DOH, or increasingly, a for-profit corporation provides care. In addition, New York City inmates benefit from the active oversight of a strong local DOH, a large public budget for correctional health services, and several vocal advocacy groups, including Legal Aid's Prisoner's Rights Project and the mayor-appointed Board of Corrections. Rates of disease, in particular infectious disease and substance use disorders, are higher in the New York City correctional system than in many other correctional systems. This makes the care of Rikers inmates both highly developed and particularly challenging.

I have provided an in-depth description of historical shifts in the arena of correctional medicine and raised numerous issues requiring further research and advocacy. Of these issues, the least investigated has been the effect of the for-profit correctional industry on the quality of care received by inmates. There is a notable paucity of data on the extent and quality of private care in the nation's jails and prisons. No systematic comparison of different programs of health care delivery in correctional facilities has been undertaken. Some see the for-profit sector as a potentialally in the quest to improve care to inmates.⁴⁹ In certain areas of the country, the arrival of for-profit medical corporations represents an expansion or improvement in jail health care. However, with a growing number of jurisdictions served by for-profit corporations, reports of negligent or substandard care continue to multiply.^42,53

A for-profit correctional industry and rising rates of incarceration in the United States are emerging simultaneously. A member of the National Commission on Correctional Healthcare and former MRIHS director observed that

The only way to talk about prison healthcare in the United States today is to talk about mass incarceration. Any little reforms miss the whole point. During the 70s and 80s there was a hope that increased correctional health care costs resulting from successful prison litigation would slow down, and perhaps reduce, the rapid expansion of the prison population. That didn't happen. (R. Cohen, MD, board member National Commission on Correctional Healthcare and MRIHS medical director, 1982–1986, oral communication, September 2007)

Instead, an expanding and competitive industry of for-profit corporations has filled the demand created by unprecedented incarceration rates. Prisoner advocates argue that for-profit corporations are anathema to the ethics of medical care in correctional facilities precisely because they abet and support the phenomenon of “mass incarceration.” However, in the current milieu of unprecedented incarceration rates, direct service and not-for-profit providers may also fail to guarantee quality care.⁵⁴

I have provided a glimpse at the challenges of providing medical care to inmates and one jurisdiction's attempts to deal with these challenges. New York City's search for a new medical provider for its jails reveals the increasing difficulty of this task. The search for a medical vendor with community-based experience and the emphasis on comprehensive discharge planning reflect an awareness that inmate health extends to the communities to which they return. Since the mid-1990s, the Bureau of Justice Statistics has estimated that 12 million admissions pass through the nation's jails annually, representing 10 million unique inmates.^55,56

The adverse effect of mass incarceration on the economic, mental, and physical health of poor communities is profound, disrupting family dynamics, earning potential, and social capital.^57–59 Furthermore, inmates are particularly vulnerable during the process of community reentry, as was recently documented in a study showing increased mortality in the early release period.⁶⁰ Even a perfect medical system in jails and prisons is unable to address the consequences of incarceration for inmates and their communities.

As the example of Rikers Island illustrates, the correctional setting poses tremendous challenges to the administration and delivery of health care. The high and rising prevalence of incarceration in the United States is a critical social policy issue and a key public health issue. Future research in this area should expand our understanding of the health impact of mass incarceration, quantitatively assess medical care in correctional facilities, describe the role and extent of government in providing oversight in privatized facilities, and develop strategies for improving care for inmates and their communities. More broadly, future study should explore the relation between incarceration rates and other markers of poor public health. Health professionals and policymakers should aim to provide the best care in correctional facilities, advocate to deflate current incarceration rates, and separate profit from the arena of criminal justice.