California's ill and aging prison population needs improved health care — not just as a matter of compassion, but to protect the health and safety of the rest of us.
The state seldom locks away prisoners and throws away the key. Most California prisoners are eventually released after serving their sentences. If they have untreated illnesses and mental health problems they bring those back into communities around the state, and when this happens we're all at greater risk.
Sick former prisoners strain the already overburdened public health care system in California, where funds are short and lines are long. Untreated infectious diseases carried by former prisoners can be spread to others. Released prisoners with mental health problems have a hard time finding jobs, some wind up committing new crimes and some become homeless.
The problem is compounded because prisoners in California — and elsewhere across the United States — are disproportionately sicker than the general public. Prisoners are more than eight times as likely to be infected by HIV, four times as likely to have active tuberculosis, and more than nine times as likely to have hepatitis C.
Data from the National Commission on Correctional Health Care show that similar trends occur for mental illnesses. Prison inmates have rates of schizophrenia and other psychotic disorders that are three to five times greater than the general population. Their incidence of bipolar disorder is up to three times greater than people outside prisons. And prisoner rates of drug and alcohol abuse are also higher.
Adding to these challenges is the fact that the prison population is getting older. In the past 20 years the proportion of California prisoners who are 50 years or older has more than doubled. These older prisoners now account for about 11 percent of the roughly 172,000 inmates in the state prison system.
This demographic shift means that prisoners in the future may have fewer acute illnesses but will increasingly suffer from chronic diseases such as diabetes, arthritis and high blood pressure that often require expensive lifelong treatment and medications.
In 2005, the California prison health care system was placed in federal receivership to address gross inadequacies with the health care being provided and to prevent further unnecessary deaths from occurring.
Building on proposals by Gov. Arnold Schwarzenegger to reform prisons and health care, California would save money in the long run by providing prisoners with needed health care while they remain in custody. Postponing treatment or shifting care to other settings where prisoners will seek health care after being released is more costly in the long run.
One effective way of dealing with the health care crisis now gripping California's prison system would be to improve screening, prevention and treatment programs for inmates to keep many from getting sick — or getting sicker — while imprisoned.
Another step would be to do more advanced planning for inmates with special health care needs before the prisoners are released.
Improved screening and treatment could be expensive for the prison health care system because it is likely to increase the number of inmates receiving health care services. Moreover, it could lead to greater liability for the prison health system. For example, screening could demonstrate that some inmates were infected with HIV while imprisoned, opening the way for prisoner lawsuits.
Improved screening also means there would be more prisoners whose care would need to be transferred to community health care providers once their sentences are complete. For this to work, coordination between public health officials and the prison health care system must be improved.
Discussions are under way between prison, public health, behavioral health and community organizations to find ways to improve the care provided to prisoners who are being released back into the community. Pilot re-entry programs being tried across the country should provide important lessons about how to improve efforts in California. Deciding how to pay for all these improvements is a structural problem that the prison health system reform will need to address.
To achieve the goal of comprehensive health care reform in California, state government should address the public health challenges associated with ex-offenders and help communities meet the needs of this subgroup of the uninsured. The governor's health care proposal would help do this by redirecting revenues from wealthy communities to subsidize medical care in poorer communities — the kinds of communities where ex-offenders often reside.
In addition, health care reform ought to include funding for community organizations that work with the ex-offender population. With resources to effectively educate and enroll them in health care insurance programs and in prevention services, the payoff over the long term would be significant in improving public health of California.
Davis is a senior policy researcher at the RAND Corp., a nonprofit research organization.
This commentary originally appeared in San Diego Union-Tribune on July 12, 2007. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.