Prison Health Care:
Healing a Sick System through Private Competition
2003-08
The primary function of government is to protect the lives, liberty and property of its citizens. Public safety is thus essential to the continuance of civil society. Public safety depends on a reliable and effective criminal justice system, and central to the administration of justice is a humane, secure and efficient prison system.
In Washington state, the cost of maintaining the state-run prison system is becoming increasingly unsustainable. The Washington State Department of Corrections (WSDOC) budget has more than doubled over the last ten years, rising from $502 million in the 1991-1993 biennium to $1.07 billion in the current biennium. The increasing cost of operating the state prison system has outpaced the rise in total General Fund spending and the rate of inflation in every biennium in the 1990’s, and is now one of the fastest growing areas of state spending.
A key component of the high cost of incarceration is inmate health care. Throughout the 1990s, for each dollar spent on corrections in America, an average of eleven cents went towards health care, which includes physical, mental and dental services. With the growing number of physically and mentally ill people entering the criminal justice system, and the increasing focus on treatment and rehabilitation for substance abusers, that number is likely to grow.
In Washington state the high cost is particularly apparent. The State Department of Corrections spends more than $60 million each year to provide medical care for about 15,000 inmates -- roughly $4,000 per inmate. At the county level, costs are similarly high. In King County inmate health care costs taxpayers more than $22 million a year, far greater than the cost of the County’s entire public parks system.
The rising cost of health care is not the only factor threatening the viability of the state’s monopoly prison system. The quality of health services are also suffering as a result of overstretched facilities, inadequate staffing and an inflexible work environment common to government bureaucracies. Faced with similar problems, prison officials in other states are turning to the private sector for quality, cost effective alternatives for managing the health care needs of the growing inmate population.
Unfortunately, the full advantages of private competition are not available to state prison officials. Jobs with the State of Washington are protected by strict civil service rules that outlaw private alternatives. While WSDOC regularly contracts with private medical professionals for some services, it is only an option of last resort. Prison officials continue to maintain a costly army of full-time doctors, nurses, psychologists, counselors and dentists to meet the demanding medical requirements of the inmate population.
A modern prison system must provide adequate medical care to inmates. Elected leaders and prison officials must now decide the best way to provide that medical care. Changing state law to let prison managers contract with full-service private hospitals, clinics and doctors would lower cost and improve the quality of inmate care. Many other states are already using private contractors to trim costs and improve flexibility and performance, and the existence of a vibrant and prestigious local health care market offers a unique and promising opportunity for achieving similar results.
The practice of working with private health care organizations is not new. At the beginning of 1997, 12 states had contracts with private firms to provide health care to their entire prison system, and another 20 states had contracted health care for part of their systems -- a total of 498 prisons in the 32 states. By 2000, 34 states had some privatized health care for inmates while in 24 states inmate health care systems were run completely by private contractors.
In one example, prison officials in Illinois began contracting for health care services in the early 1980’s to help contain growing corrections costs. Today, three competing companies run the entire state system. As a result, the state’s health costs, at just under $1,700 per inmate a year, are lower today than they were in 1991 and are the second lowest in the nation. Mississippi, Indiana, New Jersey and Washington D.C. also began using private health care providers during the 1990’s, all with similar positive results.
In the federal system, private doctors are being used to supplement the similarly overstretched prison infrastructure. In a 1996 study, six large federal facilities with similar prison populations were analyzed. Between 1989 and 1990 five had health care cost increases of more than 15 percent a year, while the sixth, using private competition for health care services, saw an average increase of only three percent per year. As a result, nearly every federal prison now has some level of competition for health care services.
Some critics claim that private companies may have little incentive to provide quality care. Indeed, in at least one case, prison officials terminated a contract with a private company because of poor care. But this is the exception rather than the rule. In fact, several cases of government medical care were so bad that courts found they violated inmates' rights and ordered jails to hire a private company. Recognizing this concern, many states require private contractors to achieve and maintain accreditation through the highly regarded National Commission on Correctional Health Care.
The promising results of prison health care privatization do not mean that full privatization of all correctional health care is always best, but authorizing prison officials to make the decision to introduce competition freely, without the civil service barriers in place today in Washington state, offers a preferable alternative to the traditional state monopoly.
With competition, state officials would likely find savings of ten to twenty percent. Forty-seven states, including Washington and the federal government face staggering budget deficits in the coming year. By allowing competition for prison health services, policymakers can reduce cost and improve quality at all levels of the corrections system.