Universal Healthcare (in prison)

September 23, 2018 at 5:55 pm | Posted in Uncategorized | Leave a comment

For the last 3 years, I’ve been working in correctional medicine.  Yes.  Something I never even knew existed, back in medical school. But everyone needs health care, so there are niches of medicine everywhere you look, from the perspective of someone seeking to provide care. The question is, does everyone have a right to it?  And if it’s a right, then how can we charge different prices depending on who’s paying?  Isn’t that inherently discriminatory?

This job puts me smack in the middle of that debate. The funny thing is, the issue was decided way back in 1976, in a case called Estelle v Gamble. The Supreme Court ruled that failure to provide adequate healthcare to prisoners constitutes cruel and unusual punishment under the 8th Amendment. Yes, that’s right, prisoners are entitled to adequate medical care, for free.  Or at most, a week’s worth of loose change from your wallet.

So how do we justify our failure to provide adequate healthcare for all the people who haven’t committed a crime?  In the last 40 years, we’ve been on the declining slope of the Kuznets curve, if I can steal an economic principle and apply it to social justice. The problem is, we’re in a fight between those who’d have us climb back up the way we came, and those who’d have us press forward past this politically and socially incoherent period, toward a time where one doesn’t have to choose which basic rights to jeopardize in order to live a meaningful life.

Even in the face of Estelle v Gamble, the determination of what constitutes “adequate” health care is a controversial topic. The evidence says that x,y,z should be done, but what’s actually done is more like t, u, v, w, x, y, z.  And well, we didn’t check for a-s, and there IS a 0.01% that one of those things could be happening.

Is evidence the standard?  Or is it whatever is the usual practice of the community? Or do we conduct an exhaustive workup of everything? Because if it turns out to be c or d, well, we knew it could have been that, so how can we defend our failure to check?  Prisoners are among the most litigious patients in existence. They rarely sue outside specialists, but they will sue their in-house physicians like a cook throwing spaghetti at the wall. If nothing sticks, just wait a bit longer and try again.

There are many reasons for this. One is that prison is boring, and suing people occupies time and keeps the mind active.  Outside consultants nearly always find some nail to hammer, so we try to ensure that such a nail exists before we send a patient to them.  The patient experiences that as the in-house physician being the uncool parent, with the consultant as the cool parent.  Prisoners, in general, also do not grasp the concept of professional ethics, and tend to assign malicious intent to things that are a function of organizational limitations.

Prison health care is a balancing act between the health of an individual, and the safety of others. This creates many issues, both obvious and non-obvious. For example, it’s obvious that prisoners can’t just get in a car and drive to their cardiology appointment. They have to be accompanied by armed guards and taken in an adequately safeguarded vehicle. That means prisoners go individually on every trip, accompanied by two custody officers from the prison.  There is not an unlimited supply of custody officers to send, nor an unlimited number of cars to take.  So there is a hard limit on the number of prisoners who can go to see an outside consultant on any given day.

Prisoners also must wear 2-to-4 point restraints to prevent escape, anytime they are at an outside medical appointment. This can often prevent thorough evaluation of orthopedic and neurologic issues.  And what about the shoes they wear?  In prison, most prisoners wear the same brands of tennis shoes that you or I would. But they can’t wear them offsite, because it’s easy to hide things in them, and smuggle them into the prison.  So there has to be a really good reason for someone to need to wear them off site.

Even on site, there are limitations that you would not consider obvious.  You or I could go and buy a knee brace or a wrist brace and wear it wherever we want.  But most braces contain a piece of hard plastic or metal serving as a stabilizer.  That’s a potential shank.  Even a simple ACE wrap can be a problem.  It can be a noose, or it can shield a small metal object from a metal detector or a manual pat-down. Same with abdominal binders, knee and elbow sleeves, leg immobilizers, arm slings, etc.

Each decision about care has to be considered from many more perspectives than in a normal practice. To think otherwise is to compromise the safety of everyone working at the prison.

And yet, even within these restrictions, many prisoners are provided better care than they ever received on the outside. Not because prison medical providers are better clinicians, or more thoughtful diagnosticians, but because care is a right, and is provided without regard for ability to pay. But it would be a lie to expect that providing a minimum level of care for all does not compromise the ability to provide all the care that everyone needs. And that’s the struggle we have not solved, either in prison, or for the rest of society.