Reformation Realities

As serious as the healthcare reform debate is, information dissemination has a saturation point. In the history of the republic, I don’t believe we have ever blogged something to death, but, alas, we did seek new frontiers. Our elected representatives seem to be much better at dealing with the acute problems produced by the recent Haitian and Chilean disasters than sustaining the journey toward systemic cures for chronic ills. Perhaps that is our nature: ready, shoot, aim.

Few, if any, would deny that if you need emergency medical care, then America is the place to be. Drop by your local community hospital and take a look at the “Avatar”-type equipment and feel secure that an emergency response team can manage any medical crisis with the expectation of a positive outcome. However, if you stay past the acute crisis, as CNN recently reported, you should count on paying upwards of $1,000 for an over-the-counter painkiller (hopefully a two-pill package). Nonetheless, your chances are good that our acute care system will expedite your recovery.
Deal and Move On
With our “can do” culture, we eagerly get after the short-term challenges with very sophisticated “thumb-in-the-dyke” responses. In contrast, our European colleagues are investing time contemplating the history of dykes with less concern for rising water in the basement. Americans expect quick solutions while Europeans seem to acknowledge that Rome really did take longer than a day to construct.
Our “can do and do it now” approach to healthcare reform caused some angst that will take a few months and perhaps an election or two to heal, but hardly anyone recalls the debate over prescription drugs, tax cuts, or even going to war with Iraq. The point is, we just tend to get over it and move on to the next crisis. To a large extent, the same applies in the correctional healthcare system.
Perhaps no state has spent more money to evaluate options for improving the medical services for inmates than California. Under the watchful eye and threatening jurisdiction of the federal courts, California methodically determined that at least 3 percent of the prison population, or 5,000 inmates, should be housed separately and treated for chronic medical issues. This excludes chronically mentally ill inmates, many of whom have medical problems that further complicate the treatment of mental illness.
Community Care
Conceived during more than three years, a plan to construct up to seven specially designed secure healthcare facilities, each at a cost in excess of $500 million, has been determined to be unaffordable to build and even more unaffordable to manage. Other approaches to a long-term solution to inmate healthcare are now under consideration. Just as the search for a national, long-term healthcare plan will involve a multitude of partners, so too will prison healthcare reform. Many correctional systems are more closely examining the role that state universities can play in long-term solutions.
Indeed, Gov. Arnold Schwarzenegger recently proposed that the University of California assume responsibility for healthcare services for state prison inmates. The proposal suggests that the U.C. system purchase or construct a central hospital to house and treat inmates with chronic diseases.
The centralized services potentially offered through the university, combined with the operation of decentralized acute-care infirmaries at each of the 33 facilities operated by the California Department of Corrections and Rehabilitation, would address both the acute- and chronic-care needs of the inmate population. Other state prison systems, including those in Iowa, Massachusetts and Missouri, have explored similar “gown and jumpsuit” models.
If the data used to define the chronic-care needs in California’s prisons are transferable, then state prison systems in the United States have more than 42,000 inmates with chronic medical conditions sever enough to justify separation from the general population. The provision of a constitutional minimum level of care would cost approximately $1.5 billion annually, according to conservative cost assessments that assume the requisite purpose-built physical plant is already in place.

Cost and Continuity
The majority of correctional practitioners understand the situation, but as with California, unless politicians grasp the seriousness and magnitude of the looming prison healthcare problem, the general public can anticipate more headlines reporting federal intervention in the provision of medical services. As demonstrated in California, state correctional systems cannot afford to solve the crisis alone. Partnerships with other public institutions and private organizations are essential.
The need for reform is often seen as only applying to the other guy. As scarred as we may be from the passage of national healthcare reform, at a minimum, the million or so corrections practitioners who deliver correctional services to inmates every day need a forum in which to engage in productive debate.
I don’t know the amount that California has spent under the federal court order to provide a constitutionally acceptable level of care to inmates, but a conservative estimate would place the cost at $100 million in the last three years alone. That translates to more than $20,000 per chronically ill inmate. While these realities aren’t easy to hear, that does not make them less of a priority.
For the first time in at least three decades, the number of individuals incarcerated in state prisons has declined. That’s good news, and the trend continues.
However, this reduction in prison population means that at least 200 chronically ill individuals (and I suspect many, many more) will now become eligible for healthcare services in their respective communities. Of course, the remaining 5,800 “healthy” inmates will also now qualify for some form of medical insurance coverage. If the long-anticipated prison reduction schemes could release healthier individuals, then coming home would represent more than transference of financial burden for healthcare services from one public agency to another. For this to occur, the debate on healthcare reform must continue.  
Stephen A. Carter, AICP, is principal of Carter Goble Lee LLC in Columbia, S.C., and a member of the Correctional News Editorial Advisory Board.