Proponents of the state's being the single payer of medical care reimbursement for U.S. residents often quip that prisoners are assured necessary care while law-abiding citizens are not. They make the argument that such a dichotomy is morally intolerable and that all U.S. residents (citizens and non-citizens alike) should also be assured health care. The challenges of providing health care to all U.S. residents are complex and continue to be debated nationwide. A few states have legislation that approaches universal coverage, but implementation requires political will and an agreement on the part of the public to finance the care of large groups of residents—including noncitizens—with low or moderate incomes.
There are legal, ethical, social, and public health reasons why prisoners, as wards of the state, must be supplied with health care. The legal reasons for providing health care to prisoners were stipulated in the 1976 Supreme Court Estelle v. Gambledecision, in which the Court held that deprivation of health care constituted cruel and unusual punishment , a violation of the Eighth Amendment to the Constitution. This interpretation created a de facto right to health care for all persons in custody, whether convicted (prisoners) or not (pretrial detainees). The decision also brought forth the concept of "deliberate indifference," a legal definition that prohibits ignoring the plight of prisoners who need care and translates into a mandate to provide all persons in custody with access to medical care and a professional medical opinion. Correctional authorities and health care professionals who infringe this right do so at their peril and may be prosecuted in federal or state courts .
Beyond the legal mandate, there are fundamental ethical reasons why prisoners should be given medical care. Free persons may or may not have health insurance, based, at least in part, on their decisions about how to prioritize the use of their money. Some who decide against buying insurance have the option to pay cash for the health services they seek. The very poor, the aged, and the disabled are generally provided with assistance in the form of federal and state Medicare and Medicaid programs. Even the so-called "working poor," loosely defined as those who earn too much to qualify for assistance and too little to afford to pay for health care, have the option to use or borrow cash when they need medical treatment. Moreover, federal law requires that hospitals provide medically necessary emergency health services regardless of a patient's health insurance status or ability to pay.
My point is not that all U.S. residents have the resources they need to cover their medical care; certainly many do not. My point is that prisoners have none of the choices just enumerated. If the correctional institution's staff denied care, the inmate would have no alternatives. In the past two decades, a substantial number of prisons and jails have decreed that prisoners must pay at least part of the bill for their medical services . These policies always include the provision that indigent prisoners will receive medically necessary, urgent care regardless of their financial status. It is evident that society has embraced the concept that, when incarcerated, a person cannot see to his or her own medical needs, and, therefore, society must do so.
Health care is given to prisoners for social reasons too. The vast majority of inmates will return to society within a few years. Proper care helps to preserve their physical function, which makes it possible for ex-inmates reintegrating into society to embark on productive activities and avoid becoming a burden to all. For example, hypertension and diabetes treatment are known to prevent strokes, heart attacks, and other sequelae that would burden society with long-term care of disabled persons. It is in society's best interest that recently released prisoners be free of disabling diseases.
Public health reasons for providing care to prisoners are so strong that many view correctional medicine and public health medicine as essentially two approaches to the same problem . As a class, prisoners include a larger share of risk-taking individuals than a similar sampling of free persons, and statistics show that they have a larger proportion of the health problems associated with risk taking—hepatitis B and C, HIV, TB, and syphilis, to name a few [4-6]. If any of these diseases is to be eradicated, or even contained, it makes sense that public health officers would develop prevention strategies in the prisons and jails, where large numbers of infected subjects reside. Disease prevention education, vaccination where appropriate, and disease surveillance are basic public health tools that can be used in the correctional setting with public health goals in mind.
I have shown that it makes sense from a legal, ethical, social, and public health point of view to provide health care to prisoners, but doing so creates the perceived injustice that those who behave badly are rewarded with free medical care, while those who soldier on working for low pay and resist the temptation to resort to crime are punished by not receiving free care. Why is it, we ask, that the health of prisoners seems more important to the state than the health of other U.S. residents? I have no solution to the apparent paradox. And the inequity does not even stop there. Under U.S. law, prisoners have the right to food, clothing, shelter, and so on. None of these rights applies to free persons.
Prisoners are expensive to maintain. The average prisoner in a southern state institution costs about $34,000 a year. Of note, about 16 percent of that sum is allocated to health care. Why, then, is this relatively small amount of a prison system's budget a lightning rod? I believe that the public's desire for affordable or free health insurance as part of a societal package for all is deep-seated and leads us to envy for the prisoner's status, if only because of medical care coverage. Civilized, highly developed countries such as England, Canada, Germany, and the Scandinavian countries have long endowed all their residents with medical care coverage. The fact that the U.S. lags behind riles a number of people, and especially those who understand how universal coverage applies to all U.S. prisoners. This dilemma will persist until health insurance is available to all U.S. residents. Meanwhile, coverage of all U.S. prisoners continues and it is a good thing.
Rold WJ. Legal considerations in the delivery of health care services in prisons and jails. In: Puisis M. Clinical Practice in Correctional Medicine. 2nd ed. Philadelphia, PA: Mosby-Elsevier; 2006:520-528.
National Commission on Correctional Health Care. Standards for Health Services in Prisons. Chicago, IL: National Commission on Correctional Health Care; 2003.
Greifinger R, ed. Public Health Behind Bars: from Prisons to Communities. New York, NY: Springer Books; 2007.