A Three-Dimensional Action Plan to Raise the Quality of Care of US Correctional Health and Promote Alternatives to Incarceration

The United States has the world’s highest incarceration rate. Nonetheless, health care provided during approximately 12 million annual incarcerations remains disconnected from the rest of the nations’ health apparatus. Care delivered to the incarcerated disproportionately impacts the poor, people of color, and those with behavioral health problems. The scope and quality of this care is inconsistent and often directed by security leadership, not health professionals. Additionally, vital information gathered in these settings is rarely used to coordinate care with community providers or consider alternatives to incarceration. To increase the quality and coordination of correctional health care, three key areas must be addressed: the funding model, the scope of services, and correctional health staff.

THE FUNDING MODEL

Health care has been a legal right for the incarcerated because of the US Supreme Court Decision Estelle v. Gamble in 1972.¹ However, these health services are generally not Medicaid-reimbursable, and except for the Federal Bureau of Prisons, costs fall on cities, counties, and states. Despite widespread litigation and investigation regarding correctional health, deficiencies remain even in settings with comparatively more resources and attention.^2,3 For Sheriffs and Departments of Correction, who oversee virtually all correctional health care in the United States, spending on health costs must be weighed against security staffing and other institutional commitments. Despite some public health models in larger cities, the most common model of correctional health care in the US consists of for-profit vendors with contracts designed and monitored by security authorities.⁴ Accrediting organizations, such as the National Commission on Correctional Health Care, may promote evidence-based practices; however, participation is voluntary and performance is unrelated to funding. One new source of the Centers for Medicare & Medicaid Services (CMS) funding is newly available “Meaningful Use” funds to help correctional health providers implement electronic medical records (EMRs) in an evidence-based manner.⁵ This funding can help correctional settings adapt community EMRs to promote evidence-based care while also increasing transparency on health outcomes for the incarcerated.

A key funding opportunity could involve Medicaid waivers to reimburse provision of chronic care inside jails and prisons that was initiated in a community setting, particularly for aspects of care that can reduce postrelease morbidity and mortality. For example, the high prevalence of patients with HIV, hepatitis C, and substance use disorders in correctional settings could render funding of cost-effective treatments for these conditions worthwhile to CMS. Such an approach would not only benefit these individual patients, but the community health systems and CMS, which bear the financial and management burdens of treatment interruptions and postrelease mortality and morbidity.⁶ In the case of hepatitis C, jails routinely admit patients during the course of their CMS-funded hepatitis C treatment.⁷ Local jail pharmacy budgets will not be able to continue this costly care under the current model, and the CMS investment for the community portion of the regimen (typically tens of thousands of dollars) may be lost.

SCOPE OF SERVICES

Most correctional health systems focus their work on brief intake screenings and responding to acute complaints. A small number of settings have secured funding for a correctional public health model, with expanded clinical services, Medicaid enrollment, and improved health outcomes associated with discharge planning.^8–10 In these settings, additional resources are dedicated to preventive and chronic care, not simply avoiding morbidity and mortality during incarceration.¹¹ One related innovation is that many states altered Medicaid eligibility so that persons experiencing short-term incarceration have their Medicaid coverage suspended, rather than terminated, to permit rapid reactivation.¹²

Aside from broadening the scope of in-jail services, correctional health can expand to the prearraignment process, where newly arrested persons may be screened to determine their fitness to pass through to arraignment and incarceration. In these settings, correctional health staff can help triage care for the jail-bound (e.g., persons with a history of alcohol withdrawal), especially if they have access to the correctional EMRs. Health staff in the prearraignment setting can also notify partner organizations about diversion potential for persons who meet criteria for local programs, including serious mental illness. This approach is being piloted in the New York City jail system, and one of the early lessons is the utility of the jail EMRs.¹³ The frequent incarceration of persons with behavioral health problems has resulted in a significant amount of their critical health information being held in jail health records, making the correctional health system a critical resource for acting on new diversion opportunities.

STAFF

Recruiting and retaining mission-driven health staff to work in jails and prisons is a core barrier to improving correctional health care.^14,15 Correctional health has sometimes been thought of as a career of last resort, and correctional health professionals provide care in extremely difficult settings, where their decisions are often questioned by patients and security staff alike. Correctional health staff often experience strong dual loyalty pressures that can impact the care they provide as well as their willingness to speak out when they encounter patient abuse or neglect.¹⁶ The overwhelming pressures of working in a security setting lead some health staff to stop believing their patients, with dramatic impact on patient care and clinical outcomes. Without a willingness to engage and support staff in these and other areas of human rights, the daily realities of correctional health staff quickly become disconnected from outside perceptions about their ability or willingness to provide high-quality care.

Correctional health can also improve by recruiting a new generation of mission-driven physicians and other staff. The predominance of for-profit organizations in US correctional health is a clear concern for some who might otherwise be drawn to this area of work. The larger issues of mass incarceration, human rights, and social determinants of health are now woven into medical training, and a growing cohort of young doctors are eager to help remake a forgotten area of US medicine and public health. To entice them, new models may be required. Organizations like Doctors Without Borders and Partners in Health are able to recruit outstanding clinical staff to work in extremely challenging settings.^17,18 Staff who work for these organizations share a sense of mission and know that their organization supports them and their patients as part of a broad commitment to address health in a social context. Recruiting this caliber of staff to correctional health may require development of mission-driven, not-for-profit organizations that can address the quality void as well as assist partners to rethink conditions of confinement and opportunities for diversion.

TRANSFORMING CORRECTIONAL HEALTH

Transforming correctional health will require local interest in improving care and national policy changes to allow for some efforts to expand reimbursement opportunities. If Medicaid waivers can be developed to allow some settings to explore reimbursement for aspects of care in jail or prison settings, then the potential cost and quality benefits can be explored. Similarly, in settings where correctional and community health systems and state insurance programs forge partnerships to improve continuity of insurance, the benefits of access and coverage will be revealed. Also, working to establish a correctional health foothold in the prearraignment setting will allow the entire criminal justice system in that city or county to explore the benefits of diversion based on reliable health information. Finally, correctional health must become viewed as a noble and rewarding career path for those who seek to bring high quality care to patients in dire need. While these three domains are not the only systemic concerns facing correctional health, they do represent an action plan that can improve the quality and coordination of care and inform opportunities for alternatives to incarceration.