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Checking Up on Prison Healthcare: What kind of services should the state provide for inmates?

Medical Problems Reported by State Inmates
2001 Bureau of Justice Statistics report, based on a 1997 survey

Picture a pristine waiting room with two patients lying quietly on cots. Next door, a doctor checks someone who has a sore throat, while a nurse treats a man who complains of stomach pains. Just down the hall, patients file in and out of a dentist's chair for regular checkups.

Then picture another waiting room. This one is overflowing with patients, sprawled out on cots, across the floor and into the hallway. Nurses check on several men who complain of headaches and chills, but they can't be treated because the staff has run out of aspirin. The groaning of the sick can be heard down the hall, and some have spent days waiting for attention.

These two imagined scenes would seem to come from vastly different locales, but critics contend they can both be found in Illinois - in prisons run by the state Department of Corrections. While some Illinois inmates receive quick treatment from well-trained medical units, they argue, others, housed in prisons that lack adequate resources, must endure inferior care.

In fact, over the past year, a number of prison nurses have begun to complain about poor health services in some of the state's prisons, notably at Robinson Correctional Center in Crawford County in the eastern section of the state and Big Muddy River Correctional Center in Jefferson County in southern Illinois. Further, they've managed to enlist the support of a handful of state lawmakers.

These critics put responsibility for shoddy prison medical care on private contractors who oversee health services for all Illinois inmates. They maintain that at some prisons private contractors don't provide enough supplies to treat inmates and restrict treatment for inmates with serious health problems. And they charge that when medical staff complain, they're rebuked, even punished, for insubordination.

Such complaints served to concentrate Illinois officials' attention on a couple of related questions: What kind of health care should the state provide for its inmate population? And what kind of services can the state afford?

Illinois is hardly alone in wrestling with these questions. Wisconsin officials, for example, are auditing that state's entire prison health care system in response to questionable circumstances surrounding treatment of inmates who died. Indeed, prison officials everywhere are worried, though they're shelling out an increasing number of taxpayer dollars to provide mandatory health care opportunities for prisoners. 

Fifteen years ago, privatization was seen as a way to provide good health care for inmates at a reasonable cost. Illinois prison officials joined a growing number of states that hired private health care companies. But the results of that trend have been mixed. Some states report significant cost savings through privatization, while others report that private contractors cut too many corners and even go bankrupt, leaving public officials with the bills.

Concern is on the rise among Illinois prison staff and lawmakers. Nevertheless, even some critics allow that problems associated with prison health care may never be eliminated. That's because growing health care demands will always bump up against limited public resources. 

Still, lawmakers have begun exploring ways to provide quality prison health care at the lowest possible cost. One proposal would require corrections officials to show that private contractors are living up to their agreements, especially at the handful of prisons where poor health care and high contractor turnover exist.

"The core issue is who is running the place," says state Rep. Tom Dart, the Chicago Democrat who co-chairs the Illinois House Prison Management Reform Committee. "I think it's quite open to question who is."

States' per day per inmate health-care costs
Credit 2000 U.S. Department of Justice study, based on a surveyor 1998 data
2000 U.S. Department of Justice study, based on a surveyor 1998 data
States' per day per inmate health-care costs

There's no question that corrections has faced staggering growth in the cost of inmate health care. That increase can be attributed to a boom in the prison population, the rising number of inmates who are living longer and a trend toward more serious ailments among inmates. To stem the tide of bills, state prison officials began hiring health care contractors in the mid-1980s who promised better care for inmates and staff and reduced administrative costs.

Corrections officials say the move lets them concentrate on overseeing prisoners while health care specialists handle a population of patients with special needs. Administrators also wanted to standardize health care and keep some monitoring of the system.

In fact, corrections officials have been so pleased with privatization that prison health care units are now exclusively handled by contractors. The state expects to pay three private companies more than $76 million this year to take care of nearly 45,000 inmates at its 36 adult and juvenile prisons ? an average of nearly $1,700 spent for each inmate this year. Those companies are Illinois-based Addus Health Care Inc. and Health Professionals Ltd. and Pennsylvania-based Wexford Health Sources. All three also serve a host of other states.

While the total cost of prison health care continues to grow each year, the average amount spent on each prisoner has remained consistent for a decade. In 1991, the state spent a little more than $50 million for health care, an average of $1,736 per inmate each year.

The average amount Illinois spends on each inmate is among the lowest nationwide, according to a 2000 study commissioned by the U.S. Department of Justice. That report's calculation of average daily spending in 1998 on health care for each inmate ranks Illinois second lowest among the states at $3.45. Alabama was the lowest at $2.74 per day. Massachusetts was the highest at $11.96. 

Corrections officials argue they've been able to keep the cost per inmate down by working closely with contractors. Tony Small, the department's deputy director of finance and administration, credits a competitive contract bidding process for helping keep costs low.

Administrators also point to a monitoring system that puts state officials in every prison to spot problems and to focus on those institutions where the care isn't up to par.

"At the present time, privatization has all of the strengths that the state created it for," says agency medical director Dr. Willard Elyea.

Expanded use of private companies in prison systems is not restricted to Illinois. More than 30 states now hire private health care services, paying out nearly $1 billion a year. Prison officials say the trend was spawned by a legal mandate to provide standard care. In 1976, the U.S. Supreme Court ruled that prisoners must get dental and medical care found necessary by normal community standards. That decision and subsequent decisions have determined that inmates deserve almost all types of noncosmetic treatment, everything from stitches and dental exams to X-rays and chemotherapy.

Illinois has faced its share of legal rulings. Court cases in the last 20 years involving prisoners at the Menard and Stateville prisons have forced Illinois officials to make substantial improvements. Those include regular patrolling by guards to increase the chances that ailing inmates will be discovered, hiring more doctors and nurses with better experience and even providing recreation periods for all inmates.

State officials say those demands present a perplexing dilemma: how to provide required health care for inmates while keeping costs at a minimum. Such issues are especially complex now, they say, because inmates are living longer and getting sicker. The increasing prevalence of HIV, AIDS and cancer in recent years has only added to the problem.

One staff member at a prominent prison watchdog group agrees that the challenges of prison health care are more serious and costly than ever. Yet Charles Fasano of the Chicago-based John Howard Association also contends that care of inmates is better than it was 20 years ago because of steps taken to safeguard inmates' rights.

But while Fasano says care is getting better, he believes complaints can never be erased entirely because prison administrators have to keep budgets in check. While his group wants to ensure inmates get the health care they're entitled to, he says contractors and the state have to make difficult financial decisions.

"It comes down to the issue of what's medically needed and what's elective," Fasano says. "The big question is, can we ask or insist that inmates begin getting better health care than what's available in the community. That's a very tough question."

But while prison officials search for ways to cut costs, a growing number of critics contend measures already in place are sacrificing inmate health to boost the profits of private companies.

Prison nurses throughout the state aired their concerns last October for Dart's prison reform committee. They detailed a variety of problems, including deteriorating care, lack of medical supplies and weak accountability from state officials and contractors. Their complaints were aimed mainly at Wexford, which is serving 19 Illinois facilities this year. 

Maria Somma of the Illinois Nurses Association, a lobbying group for state nurses, says privatization could have worked in the short term to solve nursing shortages. But as it has grown, she says, the goal of better health care has been lost. "It's a bad idea and a waste of money," Somma says. "It's a ridiculous waste of taxpayer money."

The nurses' association has lobbied hard to get changes through the legislature. So far, they haven't made much headway. Two years ago, with the help of Rep. Gary Hannig, a Litchfield Democrat, a measure to require the state to show that it is saving money by hiring contractors made it to Gov. George Ryan's desk. Ryan vetoed the idea.

Not that Hannig has given up on it. "We need to really look and see are we saving any money," he says. "I don't know that we are." Hannig's proposal may be just the beginning. The allegations of inmate neglect and poor staff support have members of the House committee seriously considering a number of reform alternatives. 

Rep. Chuck Hartke, a Democrat from Teutopolis and a committee member, has a few suggestions. Hartke, who helped organize the October hearing, believes private companies may not be entirely to blame for the problems. State prison officials draft complex contracts covering everything from required work hours to the types of clinical services that can be offered. But Hartke contends that more specific standards of care spelled out for each prison and better oversight provisions by prison administrators might cure some problems.

"This has clearly demonstrated that at certain facilities where health care services are provided by private contractors those contracts are probably being fulfilled to the letter of the contract," he says.

The Department of Corrections is Grafting its own report in an effort to reduce complaints. Corrections' Tony Small says the agency formed a committee in February that will meet with private contractors monthly until the end of June to review privatization and its problems and present agency Director Donald Snyder with a report.

Small acknowledges that having only three companies providing services can create problems, especially because past contractors have failed to pay bills and left a mess for their replacements. That's one issue the agency's committee will look at, he says.

Dart, the House prison committee chair, says oversight is key, and lawmakers may want to consider reinstituting state control of health care at prisons where problems seem perpetual. He says corrections officials will be pressured by lawmakers to take a serious look at reform.

"If they aren't going to do it, we will," Dart says. "We'll make the heat pretty hot."

Ryan Keith is a Statehouse reporter for The Associated Press.

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