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July 27, 2020

Aligning Correctional Health Standards With Medicaid-Covered Benefits

Author Affiliations
  • 1University of Minnesota Medical School, Minneapolis
  • 2National Clinician Scholars Program, University of Pennsylvania, Philadelphia
  • 3Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
  • 4Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 5Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota
  • 6Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
JAMA Health Forum. 2020;1(7):e200885. doi:10.1001/jamahealthforum.2020.0885

The coronavirus disease 2019 (COVID-19) pandemic has taught the US that our nation is only as healthy as those in our weakest institutions. Jails and prisons, which disproportionately incarcerate Black people, Indigenous people, and people of color and individuals with chronic health conditions, have been identified as key sites of viral transmission during the pandemic. The result has been needless illness and death among people who are incarcerated, as well as increased community transmission. While much of the discussion around COVID-19 outbreaks in jails and prisons has highlighted the inability of individuals who are incarcerated to socially distance or access basic necessities, such as soap or hand sanitizer, little attention has been focused on the foundational fragility of correctional health care and the lack of clear standards of care defined by law and enforced by regulations.

Correctional Health Standards—Piecemeal and Poorly Defined

In the US, correctional health care standards have been determined in a piecemeal and reactive manner, often through litigation. In a 1976 Supreme Court case, Estelle v Gamble,1 the court ruled that people who are incarcerated are entitled to reasonably adequate health care with “services at a level reasonably commensurate with modern medical science and a quality acceptable within prudent professional standards.” This foundational case and other cases that followed established that the denial of basic health care for individuals who are incarcerated constitutes cruel and unusual punishment and is therefore unconstitutional under the Eighth Amendment. While these rulings prohibit correctional facilities from deliberately withholding care, they do not define what constitutes reasonably adequate care in correctional facilities.

Several nonprofit organizations, such as the National Commission on Correctional Health Care and the American Correctional Association, provide voluntary accreditation for correctional health care facilities. These accreditation standards are often cited in court cases in which the quality of health care in correctional facilities is questioned. However, unlike widespread adoption and strict enforcement of Joint Commission standards among clinics and hospitals in the community, few correctional facilities have formal accreditation, and even accredited facilities do not always meet constitutional requirements.2

While some states mandate basic health services provisions, such as an initial physical examination on entry to a correctional facility, many state statutes lack explicit details and often delegate the task of defining adequate health care to departments of corrections. Rarely do regulations establish details akin to the required summary of benefits and coverage that one receives when enrolling in a health insurance plan. Poorly defined benefits, compared with the details provided by a community health plan, lead to inconsistent and frequently inadequate care.3

Using Medicaid as the Model

The Medicaid program was designed to improve public health by providing coverage for essential health services to low-income populations. The Social Security Amendments of 1965 prohibited the use of federal funds for medical care provided to “an inmate of a public institution.”4(p71) Decades later, this policy, known as the Medicaid Inmate Exclusion Policy, still prohibits Medicaid from financing care while individuals are incarcerated. However, the services that Medicaid covers could serve as a model for a reasonable set of mandated health services within correctional facilities to ensure care in these institutions is commensurate with care available in the community. We propose mandating that correctional facilities provide access to all health care services covered by Medicaid in the community through legislation by federal, state, and local authorities that oversee health care provided in correctional facilities within their respective jurisdictions. Such mandates would provide uniform standards across local, state, and federal correctional facilities, fulfill Eighth Amendment rights, improve continuity of care for individuals receiving Medicaid-funded care prior to incarceration, and facilitate smooth transitions at release.

Shifting Correctional Health Care Oversight

A declaration from the World Health Organization and the United Nations Office on Drugs and Crime recommends correctional health care be provided by health agencies to improve the health of individuals who are incarcerated and the public health of entire communities.5 According to international public health experts, health and corrections authorities should operate with “clearly defined separation of professional roles and tasks” to provide effective and ethically sound health care.6 In the US, however, correctional health care is overseen at the federal level by the Bureau of Prisons in the Department of Justice and at the state and local level typically by correctional agencies, not health departments. This approach does not align with World Health Organization–United Nations Office on Drugs and Crime guidance or other expert guidance.5,6 If correctional health services were aligned with Medicaid-eligible services, a prudent complimentary step would be to transfer authority to departments of health to oversee correctional facility health services.

Financing Robust Correctional Health Care

Expanding services in jails and prisons would further stretch correctional health care budgets, yet the innovation required during the COVID-19 pandemic has illustrated several possible solutions. Jails across the country have reduced censuses, in some cases by more than half, allowing many individuals to access care in the community while awaiting a court date. Several states have also applied for Section 1115 waivers that allow Medicaid to cover health care costs in jails and prisons as an exception to the Medicaid Inmate Exclusion Policy. Decreasing the number of individuals held in jails and eliminating the Medicaid Inmate Exclusion Policy, either through an act of Congress or by states individually submitting Section 1115 waivers, are potential measures to reduce the considerable correctional health care costs that would occur with improved access to essential health services. Although expanding benefits for persons who are incarcerated has historically lacked political support, the exponential growth of incarceration because of structural racism, coupled with the vulnerabilities revealed by the COVID-19 pandemic, have made it clear that health care provided inside jails and prisons is essential to reducing inequities and improving the public’s health.

Enforcing Care Standards to Save Lives, Now and After the Pandemic

Correctional facilities in the US lack universal guidance on what health care services ought to be covered. The scope and quality of health care in correctional facilities vary substantially across states and counties and sometimes fail to meet minimum standards. Mandating essential health services that are comparable with those covered by Medicaid can ensure the fulfillment of constitutional requirements to provide care to people who are incarcerated and encourage better oversight from local and state health authorities. Improving health care in correctional facilities can help to address numerous public health crises associated with infectious disease, substance use, chronic disease, and mental health among some of the nation’s most vulnerable populations. The COVID-19 pandemic requires a reexamination of correctional health care to ensure jails and prisons provide uniform care comparable with community standards. Most people who are incarcerated return to the community. It is in our nation’s best interest to promote their health and success.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Tyler N. A. Winkelman, MD, MSc, Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, 701 Park Ave, Ste S2.309, Minneapolis, MN 55415 (tyler.winkelman@hcmed.org).

Conflict of Interest Disclosures: Dr Khatri is funded by the Department of Veterans Affairs through the National Clinician Scholars Program. No other disclosures were reported.

Additional Contributions: We thank Becky Ford, PhD, Hennepin Healthcare Research Institute, for her thoughtful feedback on an earlier draft of the manuscript.

Additional Information: The contents do not represent the views of the US Department of Veterans Affairs or the United States Government.

Estelle v Gamble, 429 US 97 (1976).
Gates v Cook, 376 F3d 323 (5th Cir., 2004).
Wilper  AP, Woolhandler  S, Boyd  JW,  et al.  The health and health care of US prisoners: results of a nationwide survey.   Am J Public Health. 2009;99(4):666-672. doi:10.2105/AJPH.2008.144279PubMedGoogle ScholarCrossref
Social Security Act Amendments of 1965, Pub L No. 97, 42 USC §1396d (April 9, 1965).
Enggist  S, World Health Organization Regional Office for Europe, United Nations Office on Drugs and Crime. Good governance for prison health in the 21st century: a policy brief on the organization of prison health. Published 2014. Accessed July 16, 2020. https://www.euro.who.int/__data/assets/pdf_file/0017/231506/Good-governance-for-prison-health-in-the-21st-century.pdf
Pont  J, Enggist  S, Stöver  H, Williams  B, Greifinger  R, Wolff  H.  Prison health care governance: guaranteeing clinical independence.   Am J Public Health. 2018;108(4):472-476. doi:10.2105/AJPH.2017.304248PubMedGoogle ScholarCrossref
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