By Rachel Getz
While facilitating health education classes at a local jail, I was personally struck by this simple truth: People while incarcerated don’t have the freedom to take control of their health.
No matter how well I taught about analyzing nutrition labels, they were still given the same carbohydrate and fat-heavy foods. No matter how passionately I described the importance of fitness, they were still not allowed to use exercise equipment and had a single circular track to share with 950 individuals.
This truth is even more startling given the ongoing pandemic of COVID-19. There are recent images of a California prison with beds only 3 feet apart, men separated by an arm’s distance, wheelchairs side-by-side, and stained, out-of-repair bathrooms. Positive COVID-19 cases are quickly spreading among the incarcerated and correctional staff, and we have already seen the first fatality: a 49-year-old incarcerated man in Louisiana.
The CDC and state public health departments have issued guidance for these facilities, but the reality is that these vulnerable men and women are not able to practice safe physical distancing. They do not have control over regularly washing their hands as soap and hand sanitizer are in short supply. When someone develops a cough or cold symptoms, there are not enough masks and face shields nationally to protect the incarcerated population. And incarcerated individuals generally present late to medical care because they must navigate a bureaucracy before nurses and doctors can see them. With a virus that is becoming known for rapid respiratory distress, these barriers could mean life or death for those infected behind bars. Public alarm has been raised as we realize that correctional facilities are a breeding ground for an uncontrolled outbreak, and many human lives are at stake.
The current crisis lays bare the sickness of the American criminal justice system. Indeed, the US leads the world in incarceration, accounting for 21 percent of the world’s prisoners, with 2 million people behind bars. This has led to overcrowding with some facilities at greater than 130 percent of capacity. Many of these individuals are older and sicker, the very communities most vulnerable to COVID-19.
Among federal prisons, 11.5 percent of the population is 56 or older, a group that has tripled in size over the last two decades. People in jails and prisons are significantly more at risk for both chronic and infectious disease. They are about 20 percent more likely to have high blood pressure, 35 percent more likely to have asthma, 50 percent more likely to have arthritis, and 400-500 percent more likely to have cervical cancer, even when adjusted for age and socioeconomic factors. Greater than 50 percent report a mental health problem, and greater than 65 percent meet the diagnostic criteria for substance use disorder. Compared to five percent among the general population, 15 percent of people in jail and 22 percent of people in prison have been infected with tuberculosis, Hepatitis B, Hepatitis C, HIV, or a sexually-transmitted disease.
The current crisis lays bare the inequities of the criminal justice system. America didn’t suddenly wake up to a correctional system that overcrowds older, sicker, and disproportionately people of color by accident. The system has been engineered to produce an unjust result.
The war on drugs and deinstitutionalization of mental illness has led to higher incarceration rates and lengthy sentences. Once locked up, health care becomes a financial line item rather than a human right. When a person enters jail or prison, they lose their private and public health insurance. The Social Security Act expressly prohibits any federal payments to “an inmate of a public institution,” called the Inmate Exclusion Policy. As a result, the price tag for correctional health care is astronomically high, and payment falls upon the shoulders of taxpayers through correctional department budgets.
Instead of providing the essential services as described by the Affordable Care Act, incarcerated people are afforded care only “at a level reasonably commensurate with modern medical science and of a quality acceptable within prudent professional standards.” “Reasonable” care does not have to be the standard of care that any American would be given if they strolled into the doctor’s office. In fact, the determination of what services are given are often dictated by cost and achievement of a minimal standard so as not to be deemed “cruel or unusual punishment” as prohibited in the 8th Amendment.
In addition to being entitled to less care, incarcerated people have higher barriers to seeing a doctor. This includes turning in sick slips and nurses in-house who act as gate keepers for medical appointments. Even if an incarcerated person does overcome these hurdles, they will likely be charged a co-pay with their visit. When studied, this practice furthers health inequities—leading to less medical care with almost no effect on cost.
It is no surprise that people leave prison and jail sicker than when they entered. Within 90 days of release, 1 in 12 people are hospitalized for a suddenly worsening medical condition. During the first two weeks after release from prison, people are 12.7 times more likely to die compared the general population. The leading causes of death: drug overdose, cardiovascular disease, homicide, and suicide.
The level of untreated or undertreated illness in correctional facilities is a moral stain to the American identity and an impending tragedy during this time of pandemic. There is no corrective purpose served in allowing such physical and emotional suffering, and it is our duty to act rapidly. US Attorney General William Barr and several governors have started releasing non-violent, at risk individuals from prisons and jails, but these measures are unlikely to make a significant impact in “flattening the curve.” We must prioritize the delivery of personal protective equipment and soap and waive institutional barriers to care.
In times of crisis, the true character of a nation is unmasked. How much are Americans willing to do in our own lives to protect the most vulnerable? How will our compassion (or apathy) be baked into the policies and institutions we pay for?
We can rise out of this disaster a better nation. Now is the time to recognize that people who are incarcerated are people first. They deserve the same basic health care that we are all afforded. The Inmate Exclusion Policy must be reversed so people can keep their health insurance or enroll in Medicaid. We must eliminate inmate co-pays that systematically suppress high-value, preventative care. In the short-term, these reforms may increase health care spending, but in the long term, we will save lives, prevent costly hospitalizations, and build a system of health that is resilient to the next crisis. A virus does not distinguish between a freed individual and one behind bars; neither should our health care laws.
Rachel Getz is a 3rd year MD/MPH student at Tufts University School of Medicine. For over a year, she has been involved in health education classes with men housed at South Bay House of Corrections in Boston, Massachusetts.