Doctors Treating Prison Inmates: How Would You Feel Doing It?

Shelly Reese

Disclosures

May 30, 2019

David Allred, DO, a family physician, remembers his first conversation with an inmate after joining the medical staff at a federal prison in Virginia.

"What is your philosophy on treating inmates?" the prisoner asked.

A veteran of Desert Storm with 38 years of military experience, Allred hadn't considered the question. "I came from the military where everyone had titles—sergeant, general, etc. I thought: I am the doctor, you are the inmate. So I told him, 'I don't have one. I just started.'"

But Allred, who now serves as clinical director at a medium-security federal prison in Herlong, California, says experience has changed his attitude. Like many physicians who practice medicine in jails, prisons, detention centers, and other correctional facilities, he says the job doesn't lend itself to such easy classifications. He says he's treated bad people and good people who have made bad decisions. He has been threatened and thanked, heartbroken and gratified.

"I've had 15 years to think about that question," he says. "My patients are incarcerated, but they are human beings; and I'm their doctor, not their judge." he says. "I call everybody 'mister.' Their title is mister."

What Is Correctional Medicine?

Nearly 2.3 million people are incarcerated in US correctional facilities. More than half (57%) are housed in state prisons, roughly a quarter (27%) are in local jails, and 9% are in federal prisons and jails.[1] The rest are held in a variety of facilities, including juvenile correctional facilities, Indian Country jails, military prisons, immigration detention facilities, civil commitment centers, state psychiatric hospitals where they have been involuntarily committed, and prisons in the US territories.

Because the facilities fall under many different jurisdictions and range from massive federal prisons to local jails with only a couple of cots, it's hard to make generalizations about correctional healthcare. But there's one notable exception: All prisoners are entitled to it.

A 1976 Supreme Court ruling held that incarcerated individuals have a right to adequate healthcare under the Eighth Amendment, which prohibits cruel and unusual punishment. In so ruling, the court established inmates as the only group of people in the United States with a constitutional right to healthcare.

While subsequent rulings have established "adequate" healthcare as "services at a level reasonably commensurate with modern medical science and of a quality acceptable within prudent professional standards," how that care is delivered, how much is spent, and who provides it varies widely.[2]

Some agencies deliver care directly. Others contract with private healthcare providers or university health systems. Some facilities are run by for-profit companies and provide healthcare themselves. While taxpayers ultimately pay for inmate care, some facilities charge inmates modest copays to discourage unnecessary medical visits. Some facilities pay physicians using a fee-for-service arrangement. Others use a capitation model.

As for how much they spend, that's even more variable. A 2017 report on state prisons by the Pew Charitable Trusts found that the typical state department of corrections spent $5720 per inmate on medical, dental, mental health, and substance use treatment in fiscal 2015, but that ranged from a high of nearly $19,800 in California to a low of less than $2200 in Louisiana.[3]

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