The Least That Money Can Buy

"I have nightmares about what I saw," a third-year medical student at the University of Texas Medical Branch said recently, after finishing her rotation at the prison hospital on Galveston Island. The student added that many serious conditions she saw at the hospital were the result of illnesses that could have been addressed simply and cheaply, early on, but had been allowed to fester. One of her classmates had described young male inmates with old men's diseases. That's what everyone says.

In part, it's the result of conditions in the Texas Department of Criminal Justice – nurses at UTMB report that despite recent reforms in prison health care, patients still complain of delays in getting care. But the persistent reason many inmates are chronically ill is the lingering effect of the lifestyles of those people who most often end up in jail. If you live on the streets – or live by the most tenuous profession imaginable, crime – it's a good bet that you haven't been having regular medical and dental checkups. These inmates are almost exclusively blue-collar criminals, robbers, and drug dealers, not the white-collar hustlers who rip off shareholders and live well – those people don't do hard time.

TDCJ is home to more than 145,000 prisoners and a workplace for 25,000 guards. It's also a huge health care network – the ultimate health maintenance organization for people who don't keep doctor's appointments – treating 44,000 individuals per week for everything from diabetes to hypertension, providing renal dialysis and psychiatric care, and, yes, delivering babies. In Texas alone, health care to state prisoners costs $300 million per year and is viewed by everyone involved in the corrections business as the next great prison crisis. Like the Texas prison system itself, the prison health care system gets mixed grades, but overall it is generally viewed as efficient and cost-effective, charging the state's taxpayers $6 per day to care for each inmate, compared to $15 in California and New York state. Most of that care takes place in 330 infirmary beds spread across the state – but also in a more acute setting on the east end of Galveston Island, at the 168-bed prison hospital, attached to the main UTMB complex.

Seventeen thousand inmates suffer from high blood pressure, with the accompanying risks of stroke and cardiac artery disease. There are 8,500 diabetics, who may go blind or lose a limb. (A few years ago, a death row inmate who was an amputee wanted an artificial leg so he could walk to his execution. He got his last needle instead.) The system is complicated because effective health care doesn't always conform readily to efficient incarceration and punishment. A warden raised that issue recently when he declared that medications could only be administered at certain hours of the day – doctors had to explain to him that a diabetic's need for insulin does not necessarily follow a regular schedule.

On the acquired immune deficiency front, HIV cocktails alone presently take up 40% of TDCJ's drug budget of $40 million, with cancer medication expenses closing fast. At the hospital in Galveston, on any given day, about 10% of the inmate-patients are receiving kidney dialysis treatments. Beds for manic-depressives on the units are full. Liver disease – mostly due to alcoholism and drug abuse – is also a big killer.

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Like Brack, Only More So

If you want to know how things got this way, the Capitol is a good place to start. Increased sentences and denials of parole – both heavily determined by the state's leadership, and subject to cyclical demands for prison space – have resulted in a quickly aging prison population, decades of life passing like a videotape on fast-forward. In the last four years, the percentage of TDCJ prisoners over 55 years of age has gone up 25%. It's a hard life in the Big House, and a 55-year-old prisoner is said to have the health of a 65-year-old on the outside.

Precisely this population – the elderly and infirm, though they might have been pretty tough mofos in their youth – throws the system into deficit. These aging men and women access prison health care at a rate five times more often, on average, than younger cons. So say the stats compiled at Medical Branch. Nonetheless, the Legislature is reluctant to release anybody, even though on the outside these older inmates would be eligible for Medicare.

Recently at the prison hospital at Galveston, two highly coveted intensive care unit beds were occupied, for months on end, by inmates in "persistent vegetative states," meaning they were no threat to anyone. Yet they could not be paroled and sent to a nursing home, because they were members of the infamous class of "G3 offenders" – found guilty of certain sex-related or violent crimes. The law says they can't be released – even to go home on a ventilator, unconscious, to die.

The Lege is not alone in bad judgment. Local jurisdictions and the state's judges often join it. Who, for instance, would send a pregnant woman to do hard time?

Of the 284 women who gave birth in TDCJ last year, only about two dozen committed violent crimes – most were convicted of drug offenses, various forms of fraud, or prostitution. Presentencing reports inform the judge of the woman's condition, if she herself knows, but in some cases the judge's hands are tied, especially if the lady has been in trouble before. According to prison officials, some women get pregnant, intentionally, if they know they're going to be sentenced to prison, in hopes of a smoother ride inside. But in many cases, harsh sentences were sought by Texas' famous get-tough prosecutors, especially those in Houston. Of the 284 births last year, 97 were to women from Harris County (a jurisdiction that alone accounts for about one-fifth of TDCJ prisoners). Dallas County is a distant second at 24, and San Antonio third at 18.

It's not simply a question of county population. It's more about compassion, and – yes, sentiment. Common sense is in the mix as well.

A high-ranking prison official, who asked not to be identified, went out of his way to praise Travis Co. District Attorney Ronnie Earle: "Ronnie doesn't ask for those kinds of sentences," meaning that Austin prosecutors think twice about sending a mother-to-be to prison. Travis Co. accounted for only nine of the pregnant-mom cases last year – one more than Denton County, at half Travis' population, and two less than Potter County, home to that great metropolis Amarillo.

"We go for what works," Earle said in a brief interview, noting that his office has less interest in punishment in itself than in making sure someone doesn't commit crime again.

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Diminishing Returns

The state's prison-building spree in the 1980s and early Nineties was administered as law-and-order, political patronage, and rural economic development. No one thought to ask whether health professionals would want to live in Small Town-on-the-Lockup, Texas. But it's not just location, location, location. "We have major salary issues," said Dr. Lanette Linthicum, TDCJ's medical director. "It's getting very hard for us to compete because, as you know, a lot of free-world hospitals are offering nurses $5,000 or $10,000 sign-on bonuses, in addition to their salaries."

In stir, the nursing shortage – which affects all health care in this country – is now accompanied by a shortage of midlevel practitioners, like physicians' assistants. A recent effort to hire more prison nurses by offering them time-and-a-half, plus a $10-an-hour bonus, had few takers. The result is reduced hours of medical coverage on the units. Nurses have also been pressed into functions they didn't learn in nursing school. In some cases they have to take fingerprints from inmates who are new to the prison system, and draw blood for DNA tests – unless the inmate refuses, at which time a less user-friendly team of guards takes the sample. DNA is sent to the Department of Public Safety, which is building a genetic library for use by the Texas Rangers' cold case squad.

The big issue is, though, that the money for proper care just isn't there. Overall, prison health costs are rising at about 7% per year. There was a $10 million deficit in the system last year, which doesn't sound like much, but – as for those two patients on ventilators in ICU – the prognosis is not good. A legislatively mandated co-pay of $3, taken from Joe Felon's commissary account, hasn't balanced the books either.

Texas Tech, the major health provider for prisons in the western part of the state, is already questioning its participation in the system. Tech handles only about one-quarter of the inmates, because there are fewer prisons in the west, and most seriously ill inmates still go to the Galveston hospital, which belongs to UT. But Tech Chancellor David Smith warned recently that his institution may be riding toward the last roundup. He said Tech can't afford to subsidize prison health care.

"We're very concerned about the cuts we've had to absorb," Smith said. "With the revenue streams we have right now, if we don't pay attention we will have a crisis. Our costs are going up exponentially, related to the aging inmate."

Chancellor Smith has some knowledge on the matter of correctional medicine. He's an MD by training, and a former state commissioner of health. Also, in a former life, he helped put together the present system of TDCJ patient care, and spent a good deal of time in a federal courtroom in Austin, explaining to a judge how it all works.

Dr. Smith said that prison health care contracts, farmed out to West Texas' small regional hospitals, do help to maintain the viability of public medicine, especially in the Trans Pecos, and among the depopulating counties of the Panhandle. But he's not sure how long that will last. The Legislature, which originally promised the universities that they could keep savings from taking over prisoner care, has since been sucking money back into general revenue. Funds for hepatitis B inoculation of inmates – provided by the Legislature during a rare fit of clear thinking – have recently run out too.

UTMB, on the other hand, is much more attached to the prison contract, and depends heavily on prisoners brought to the island. The viability of any teaching institution is not just budget and faculty – but having a good (in this context, that means sick) patient pool to work on. That's the big role the prison hospital plays on the island, and UT is therefore less likely to want to opt out.

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Malign Neglect

"The Supreme Court has already dealt with physical health care issues," says State Rep. Ray Allen, R-Grand Prairie, chairman of the House Corrections Committee, "and we're now living under law that says inmates have a constitutional right to adequate health care treatment, that is not enjoyed by people on the street who are in many cases [members of the] taxpaying public. My mother-in-law has less availability and access to health care than inmates in the prison system."

That may be a bit over the top, but the representative is right that inmates have a rare advantage. Writ-writers are often able to hold the state hostage to the law. There are, at any given time, about 1,100 lawsuits pending against the state prison system. Every day, on average, one lawsuit is disposed of and a new one is filed. Most of these court cases involve the same three areas – use of administrative segregation (the prison version of time out, which can last for years), other punishments, and access to health care. "We're still concerned with the possibility for lawsuits," Rep. Allen says, "and that our prisons are becoming facilities for treatment of first resort rather than last resort."

The health issue is all encompassing, inescapable, and growing fast. TDCJ estimates its mentally ill population, for example, at about one-quarter of the total population. National correctional officials place the average "mental disorders of some kind" at closer to 70%. The courts are just beginning to address issues of the mentally ill and mentally retarded held behind bars, which has Texas policymakers worried. (The current judicial consensus is, for example, that we can execute the mentally ill but not the mentally retarded.) Some of the same decisions are now being made about prison mental health care. What can be ignored, and what must be treated? Whatever the result, it's likely to mean even greater expense to the state.

"It opens Pandora's box when we start talking about effective treatment for mental health," James Gondles, executive director of the American Corrections Association, warned Rep. Allen's committee last year, "because it is exceedingly expensive and in many cases you can't see results for years and years. I think [mental health] is going to be the first chapter of the first decade of the 2000s' [premier] legal issue." Yet there is a persistent rumor that TDCJ has stopped certain screening tests of new inmates for mental impairments. TDCJ spokesman Mike Viesca says that screening methods remain unchanged.

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Counting Time

Is the health care provided to Texas prisoners the best that money can buy? No. No organ transplants are performed, for example.

But the care is probably the best that can be provided for what the Texas Legislature is willing to pay. The marching orders to prison administrators are basically to provide the minimum amount of health care above what would draw the interest of a federal judge. The doctors and nurses and therapists, in general, do the best they can with what they have.

At the prison hospital, the students are the difference. Young nurses and doctors will spend more time with patients than will a hurried professional. But this is an unfashionable and ill-rewarded side of medicine that few want to pursue when they graduate. At the Galveston hospital, for example, seven times a day, there are prisoner counts. All care stops, theoretically, unless some kind of immediate life-preserving procedure is taking place. Doctors report they once had to stabilize a suicidal patient, just to send him back to Huntsville for a prompt appointment with the executioner.

Earlier this year, there was a particularly bad case. A convicted murderer, doing life, who was also a self-abuser – scars everywhere – came in on a suicide watch. Still, he managed to hang himself. Prisoners can be very resourceful. This guy was pretty messed up, inside and out, but he still had game. Of course, somebody on watch may have screwed up.

But in this patient population – more than any other – shit happens.

Editor's Note: Staff writer Lucius Lomax is a student in the UTMB School of Nursing.