Sunday, June 12, 2011

On reentry, healthcare, privatization, sheep and goats

While I was on vacation last week, the state of Texas' prison healthcare was a big topic of discussion. A well-done story at the Fort Worth Star-Telegram yesterday focused on continuity of care for HIV positive inmates when they leave Texas prisons. Reporter Alex Branch wrote that:
studies show that HIV-positive prison inmates still regularly experience dangerous lapses in treatment after discharge.

[According to a study from several years ago,] 20 percent of inmates enrolled in an HIV clinic within 30 days of their release, and only 28 percent did so within 90 days.

It's a problem with consequences beyond the personal health of the offenders. Interruptions in medication increase the risk of transmission, can lead to medication-resistant strains of HIV and often require more costly treatment later.

Health officials have launched initiatives to end the lapses, including using telemedicine to connect HIV-positive prisoners with local AIDS organizations that can assist them when they return to their communities.
Why do inmates fail to keep up with their meds on the outside? Though the writer at one point says the problem is a lack of "personal responsibility," which I'm sure plays a role, the larger public policy reasons are fairly predictable:
Former prisoners report several obstacles to getting medication, AIDS outreach workers say. Many are unsure where they will live after discharge, lacking homes and families to which they can return.

Some don't even complete the bus trip home, using the $50 they are given at discharge to fall into previous bad behaviors, they say.

Those who have been incarcerated for a long time have little experience making doctor's appointments, filling prescriptions and understanding bureaucracies, said Shannon Hilgart, associate executive director at the AIDS Outreach Center.

"Navigating a hospital system is daunting if you have been incarcerated since 19 and never had to deal with it," she said. "Getting to a clinic, getting through the paperwork. ... It's a whole new learning process."
It's a "learning process," though, that until recently didn't begin until release, and then the inmate was on their own. Recent changes thanks to a renewed focus on reentry services for prisoners begun in 2009 have somewhat mitigated the problem, reported Branch:
State officials held a summit to discuss the issue and agreed on several strategies to link services offenders received in prison with those provided by organizations in communities, said Janina Daves, re-entry coordinator for the Texas HIV Medication Program, which spends $90 million annually supplying HIV medication to low-income Texans.

Prison officials are using medical discharge planners to help inmates complete applications for treatment programs before they're released, she said. Inmates are told how to contact the AIDS service organizations and given phone numbers to call if they run into difficulties.
As a result, "Since the state made changes, the agency has had more success in getting ex-offenders to continue medical regimens, officials said. Case managers, mental health counselors and nutritionists help clients set up medical appointments and live healthy lifestyles." Hopefully cuts to reentry services this legislative session won't roll back this successful and important effort. If they do, it will merely shift costs to local emergency rooms who will then have to deal with much sicker, more expensive patients down the line.

In other prison health news, Mike Ward at the Austin Statesman reports that legislators this week beat back a proposal to give the Governor control over decisions whether to privatize the prison healthcare system, after "critics of privatization feared that it would have allowed Perry to push ahead with outsourcing of the nearly $1 billion-a-year system, which has been plagued for years by mushrooming costs."

Ironically, though, private prison health providers have said they couldn't operate the system if the TDCJ health budget was slashed, which of course it was by 14%. So by most accounts, privatizing prison healthcare would cost more than the state has budgeted for the next biennium. Not only do most private vendors not have UTMB's telemedicine system, enabling access to health providers outside the unit, but they must build profit into their costs while the universities providing healthcare can do so covering only the cost of services.

Texas already has among the lowest per-inmate healthcare costs in the country. And carceral institutions elsewhere that have privatized health services have sometimes generated pitiful results. Plus, privatization of Medicaid and Medicare services has resulted in widespread fraud. At a minimum privatization would require a great deal more state oversight and supervision than  the Correctional Managed  Healthcare Committee affords now.

Finally, both last and least, attorney Edward Lane at the "Wichita Falls Law Enforcement Examiner" this week complained that, even if the Lege passes a $100 per year healthcare fee to be taken from prisoners' commissary accounts, it's still an outrage for prisoners to receive medical care at all, writing:
Many Texas residents who are law abiding citizens would be very happy to pay $100.00 a year for healthcare for their children and themselves. These same people are probably asking themselves why convicted criminals are getting such a good deal and they aren't.

As it stands now, the Texas Constitution  only guarantees one group of people in the Lone Star State healthcare......prisoners.

One Wichita Falls man was appalled to discover that prisoners receive free health and dental care.

"Why do convicted murderers and other felons get better healthcare than those of us on the outside of prison walls?  A person has to make less than $434 a month in the state of Georgia where I just moved from to receive free healthcare. There's something wrong with this picture!"

Another  Wichita Falls man exclaimed in anger,  "The worst of it is we (the taxpayers) have to pay their (convicts) medical bills after they've committed some crime."
These are common, if utterly uninformed sentiments. For starters, TDCJ doesn't provide healthcare for prisoners' children. And contrary to Lane's claim, there's nothing in the Texas Constitution about prisoner healthcare, which is requirement derived from the 8th Amendment by federal courts. That's not just for inmates' benefit, but for everyone's. Prisons are breeding grounds for disease and most inmates eventually get out (more than 70,000 per year are released from Texas prisons), meaning untreated illnesses will inevitably be spread into the free world.

The $100 fee is not a particularly major change: Mostly it shifts costs from sicker inmates to healthier ones: It a) replaces a $3 per visit copay already in place and b) doesn't apply if the inmate has no money in their commissary account, which their families pay for, not them. The sickest inmates' families might pay more than $100 per year at $3 a pop, under the old system, while a younger, healthier inmate would not normally reach that threshold. But given what healthcare actually costs, these are small amounts.

If many people in Wichita Falls are "appalled" or "angry" that the state pays for inmate healthcare, the writer should have also added that those same people are "ignorant" and "foolish." Grits has mentioned before on this question that Christ taught compassion for sick prisoners is one of the criteria by which, eventually, the sheep will be separated from the goats; I'd always considered Wichita Falls a church-going town, but those quoted in this story all appear to fall in the latter category. Are Wichita Falls residents also "appalled" that inmates don't get paid for their labor? That's the only way it'd be possible for them to pay for their own healthcare.

In any event, as California is learning, the US Supreme Court has long said that if the state chooses to incarcerate someone - to restrict their liberty, in other words - they're liable for their health needs. Want to pay less for inmate healthcare? Lock up fewer people or stop holding them as long.

What a stupid column, particularly coming from an attorney. I suggest Mr. Lane contact Baylor University and demand his law school tuition back.


Don said...

Amen!! Welcome back, Scott.

Anonymous said...

Hope you had a great time. Missed you and glad your back. Maybe you should take more vacations so we can appreciate you more. Thanks from a devoted reader.

Prison Doc said...

Welcome back. I didn't realize what a big part of my daily reading this blog is.

Don't get so excited about Mr. Lane's unusually ignorant column, at least he isn't "anonymous".

Regarding the TDCJ medical changes, at this writing it's safe to say that no medical providers or nurses in the rank-and-file know ANYTHING about what is going on, and all are waiting with bated breath to hear something.

Like your conclusion points out, the obvious answer is to lock up fewer folks for less time. Got a new patient in the other day with enormously high chronic medical expenses, serving 20 years for a DUI. The beat goes on.

S and C said...

First and foremost, welcome back Grits! We missed you!
Also, a libertarian friend of mine echoed your sentiments at the end of the blog a while back...he and I were discussing the (many) flaws in the TDCJ and county systems and he said, "When you take away someone's liberty, you are then responsible for their safety." Sometimes I wonder if the people making decisions for TDCJ and county systems realize or care about that...if they don't want that responsibility, like you and Prison Doc said, they should either lock fewer people up for less time. Alas, that would make too much sense...

Anonymous said...

I work in the medical part of the correctional system. The change from $ 3 co-pay to a $100/yr payment for all offenders

(except indigent) will perhaps create a new demand with medical services. I see this as a monetary item number game with

the legislature (160,000 x $ 100 = $ 16 million). What may happen, is those who have never used medical services may

feel the need to now use the system, since they are paying for it. Hence, placing more demand on a system that is being

reduced in manpower.

Anonymous said...

I agree that the $ 100 co pay is going to increase demand for healthcare services on a system that is already overwhelmed.It is a bad idea. They should stick to the $ 3 copay system, or increase it to $ 5. We in healthcare are
already seeing more patients because the inmates realize change is coming, and it is over menial problems they would ignore outside.

Charlie O said...

I'm never surprised at the callousness of the so-called "christian" citizens of the state of Texas. They are appalled that their tax dollars go to pay for health care for people who are essentially wards of the State. Maybe it's time for all the hardcore "law n order" Texans to start realizing the financial repercussions of their "lock'em up and throw away the key" policies. There's a cost for such callousness. Change the system or shut the hell up.

Don said...

Prison Doc: I understand what you are getting at, but hyperbolic statements like this don't help our message. Your patient wasn't serving 20 years for "A DUI." Perhaps he was serving 20 for a Whole Bunch of dWi's. (there is no such thing as a DUI in Texas, except as a minor.) A (one) DWI is a class B misdemeanor that nobody goes to prison for. Even a 3rd offense felony only gets maximum of 10, and rarely does that happen. The only way a DWI can get 20 years is Intoxication Manslaughter. Don't mean to be picky, but these things are important. A lot of people who do not know better would think you could get 20 years in prison for a single DWI. (not DUI)

Gritsforbreakfast said...

"The only way a DWI can get 20 years is Intoxication Manslaughter."

Not entirely accurate, Don. As I understand it they can also get that much time for four or more DWIs, which kicks it up to a 2nd degree felony, or 2-20 years. I've seen life (or 99 year) sentences for multiple DWIs with no intoxication manslaughter charges.

Don said...

They have to get a "habitual criminal" enhancement. Not in the statutes as written, for DWI. Anyway, thanks for the heads-up, but my point to Prison Doc remains.

Don said...

"Texas law does not provide for any increased punishment after DWI, third offense. If a person presents a DWI, fourth offense or beyond, the typical punishment is confinement in the penitentiary from two (2) to ten (10) years without probation being granted. In some cases SAFP may be granted upon proper request and showing that it is appropriate." From, a DWI Attorney site. Sec 49.09 of the Penal Code: "(b-1) An offense under Section 49.07 is a felony of the second degree if it is shown on the trial of the offense that the person caused serious bodily injury to a peace officer, a firefighter, or emergency medical services personnel while in the actual discharge of an official duty.

(b-2) An offense under Section 49.08 is a felony of the first degree if it is shown on the trial of the offense that the person caused the death of a person described by Subsection (b-1).

(b-3) For the purposes of Subsection (b-1):

(1) "Emergency medical services personnel" has the meaning assigned by Section 773.003, Health and Safety Code.

Can't find anything supporting what you're saying. Doesn't mean it doesn't exist. :)

Gritsforbreakfast said...

You're right, Don, my bad. I doublechecked and the "life" cases I was thinking of bumped up the charges using the habitual offender statutes. See, for example, the discussion here from the prosecutors user forum. On that string one ADA declared "I tend to chomp at the bit when it comes to enhancing cases," so they give each other advice on how to get creative to get super-long senteces. It's pretty common to see sentences longer than 20 years for multiple DWIs, as indicated by several ADA commenters there.

Prison Doc said...

I may be a doctor, but I'm not totally stupid...even I knew that a first or second DWI wouldn't get you 20 years...but Don I appreciate you and Grits supplying the FACTS which are often a scarce commodity in the blogosphere!

Don said...

Prison Doc: You are welcome. But I like this blog partially because it doesn't let a lot of non-facts go unchallenged. Anyway, I figured you knew the difference; my purpose was to keep someone who didn't know from getting it wrong.

Don said...

Scott, thanks, but if it's all the same to you, I won't read that prosecutor's forum post. I used to read it all the time, but kept getting nauseous when I read it. "chomping at the bit when it comes to enhancing cases" sounds like one of those things that probably caused the nausea. :)

MailDeadDrop said...

Perhaps folks believe that if the State has exercised the power to restrict their (the convicts') freedom, then the State also can and should restrict their other liberties, such as access to taxpayer-funded healthcare and security. I'm neither advocating that position nor justifying it, merely hypothesizing about the underlying mental models of those apparently advocating such as the Wichita Falls lawyer. But I must confess that the idea that a convict should be "rewarded" for their offense with taxpayer-funded perks like healthcare is galling.

MailDeadDrop said...

Follow-up: according to the Scripture you cite, the righteous need only visit the sick in prison, not provide healthcare. Any bets whether that requirement would be satisfactory for the Wichita lawyer and his ilk?

Nurseypooh said...

UTMB town hall meeting this week!

Prison doc do you have any clue what the agenda will be! They haven't released it yet and probably won't until afterward.

Gritsforbreakfast said...

MailDeadDrop, the King James Version says "visit." Other translations, like the New International Version, characterize it more broadly, e.g., "I was sick and in prison and you did not look after me." Not knowing ancient Greek, I can't say for sure which more accurately reflects the original. But I'll bet Mr. Lane and the folks he quotes don't make a lot of prison visits, either.

Nurseypooh said...

Town hall meeting today. Major cuts for UTMB! If some of you thought TDCJ/UTMB healthcare was bad just wait it's going to get a lot worse! They are only alotting $7.75 per day per offender.
165 positions will be eliminated, pink slips go out 6-29-11.

Anonymous said...

Just curious: How does the interruption of meds increase the risk of transmission? You are still HIV + with or without medication, aren't you?

Nurseypooh said...

HIV, your levels are lower on medication which reduces the amt. of virus currently in your bloodstream. yes you are still HIV +. It's not just HIV offender who stop treatment once out. Other offenders such as diabetes, high blood pressure etc. once they get out they are not taking care of themselves and get sicker or even die within 1 yr.