This is the fourth analysis in a series examining how health care is funded and delivered in state-run prisons, as well as how care continuity is facilitated upon release.
Every state has an interest in delivering health care in its prisons that conforms to constitutional requirements and leverages opportunities to improve public health and reduce crime and recidivism. Nevertheless, the provision of care throughout the country varies significantly. There is no starker evidence of this dissimilarity than the wide range in what states spend per inmate. (See graphic below.)
What drives these dramatic differences? To what extent do they reflect meaningful discrepancies in value and performance that move some states closer to reaching their common ends, while pushing others further away? The answers to these questions provide critical information for any assessment of whether states are doing all they can to protect their communities, strengthen public health, and spend money wisely.
In fiscal year 2015, the typical state department of corrections spent $5,720 per inmate to provide health care services, including medical, dental, mental health, and substance use treatment. However, departments in four states (California, New Mexico,1 Vermont, and Wyoming) spent more than $10,000 per inmate, while five (Alabama, Indiana, Louisiana, Nevada, and South Carolina) spent less than $3,500 per inmate. This ordering and breadth of variation tracked closely with prior years.
Note: For state data and data notes, see Figure 2 and Appendix C, Table C.3 of “Prison Health Care: Costs and Quality.”
The Bureau of Justice Statistics has pointed to several factors that possibly contribute to state-to-state spending differences, including pre-incarceration care, regional medical prices, staffing and compensation levels, facility capacity and related fixed costs or bulk purchasing, and incidences of high-risk behaviors and associated disease burdens. Other researchers have examined additional reasons, including contracting practices, screening procedures, and cost-containment strategies.
Crucially, studies have omitted two variables critical to any complete evaluation of spending: access to care and quality of care. This is probably because of the lack of uniform quality-of-care standards and reporting for correctional systems, which would permit more complete comparisons across states and facilities. Little has been known systematically about states’ quality monitoring activities and actual outcomes.
A first-of-its-kind report by The Pew Charitable Trusts explores several factors behind interstate spending variation, such as how money is spent, prices prisons pay, the people they treat, and the quality of care provided. The report highlights some of the main data officials need to determine what outcomes are achieved with prison health care dollars, and to map out avenues for any necessary changes. Information is provided on:
In some cases, states lack the information necessary to fully understand what they are getting for their prison health care dollars or have not taken important steps to cement their processes and act upon the data. Moreover, much of what does exist lacks the level of uniformity and standardization necessary to appropriately make state-to-state comparisons.
Higher spending is not necessarily an indication of either waste or good quality care. Likewise, lower spending is not necessarily a sign of efficiency or poor quality. Instead, policymakers must seek to continually appraise the value their systems achieve.
Matt McKillop is an officer with the states’ fiscal health project of The Pew Charitable Trusts.