Managed Health Care in Prisons as Cruel and Unusual Punishment
Robbins, Ira P., Journal of Criminal Law and Criminology
Billy Roberts, a prisoner in an Alabama state prison, had a history of severe psychiatric disorders.(1) He was often put on suicide watch, and received large doses of psychotropic drugs.(2) A managed health care company, Correctional Medical Services (CMS), was responsible for the health care at the prison.(3) After Roberts had a suicidal episode, CMS's statewide mental health care director reportedly put Roberts in an isolation cell rather than a psychiatric care unit.(4) The mental health care director also ordered that Roberts' medication be discontinued pursuant to an alleged policy of CMS to get as many prisoners off psychotropic drugs as possible in order to keep costs down.(5) Six days later, Billy Roberts hanged himself.(6)
This is not an isolated case. In an effort to cut costs or to provide constitutionally adequate health care to inmates, an increasing number of prisons have been using managed care systems to provide health care.(7) Although the use of managed care has saved states money, the quality of health care arguably has decreased. Inadequate care has been a recurring problem in prisons run by private managed health care firms. Consequently, prisoners and staff continue to complain, and prisoners are filing suits asserting that their constitutional rights have been violated.(8)
Courts have evaluated claims of constitutional violations in cases in which prisoners have challenged the adequacy of their medical treatment under the "deliberate indifference" standard, first announced by the Supreme Court in 1976, in Estelle v. Gamble.(9) In Estelle, the Supreme Court established that, when prison officials are deliberately indifferent to the serious medical needs of prisoners, the prisoners' Eighth Amendment right to be free from cruel and unusual punishment has been violated.(10) In Ancata v. Prison Health Services,(11) for example, the United States Court of Appeals for the Eleventh Circuit held that, "if necessary medical treatment has been delayed for non-medical reasons, a case of deliberate indifference has been made out."(12) Financial considerations constitute "non-medical reasons."(13) Thus, the use of managed care in prisons with the intent of cutting costs may constitute an institutional deliberate indifference on the part of the prisons.
This Article examines the use of managed care in prisons and discusses some of the legal issues surrounding managed care practices. The Article argues that the use of managed care may result in an overemphasis on costs that in certain instances rises to the level of deliberate indifference, thereby violating the Eighth Amendment.
II. MANAGED HEALTH CARE IN PRISONS
The goal of managed health care is to have a health care system that operates more cost-effectively than the traditional fee-for-service system.(14) In managed health care systems, however, this goal is often achieved through cost-cutting measures.(15) Thus, managed health care can result in inadequate treatment for patients. Concerns regarding inadequate health care are magnified in a prison setting, in which inmates have no choice about health care and cannot seek outside advice. They are left to the discretion of the health care provider chosen by the county or state.(16) In addition, since prisoners themselves are not usually paying customers,(17) health care providers have even less of an incentive to provide quality care.
To understand how managed health care works in prisons, it is first necessary to consider why counties or states would choose managed health care for their prisons. While some of the reasons are logistical, the primary concern is always financial.(18)
A. MANAGED CARE
There are three major components of a managed care system: (1) the managed care organization (MCO), which acts as an insurer and finances the health care of the members of its health care plans;(19) (2) the health care provider, which can be a physician, a group of physicians, a hospital, or a physician-hospital association;(20) and (3) the health plan member or patient. …