While most people seem to agree that prisoners should have access to basic healthcare while incarcerated, there is tremendous variation about what type of healthcare constitutes basic care. The reality is that many prison inmates receive a better quality of healthcare than non-incarcerated working-class individuals, but many inmates also suffer consequences because of significant medical neglect. For the federal prison system, the Federal Bureau of Prisons (BOP) is the agency given broad oversight over healthcare in prison. In fact, the BOP is in charge of all aspects of inmate care for all inmates in the federal prison system.
The BOP is part of the Department of Justice (DOJ). It was established in 1930 to regulate the federal prison system. The BOP's job is not limited to healthcare. Instead, it has responsibility for the entire federal prison system, which "currently includes 114 prisons, 6 regional offices, 2 staff training centers and 28 community corrections offices" (Wallechinsky, 2012). The BOP is responsible for all aspects of the custody and care of any federal inmates, including those incarcerated in private prisons (Wallechinsky, 2012). The Health Services Division in the BOP, is the division directly responsible for the medical, dental, and mental health care services provided to inmates. In addition, it oversees occupational health and safety issues for workers, as well as the food nutrition programs at the prisons.
The federal prison system remained relatively small and consistent in size from the 1930s through the 1980s. However, changes in laws, most specifically the Sentencing Reform Act of 1984, led to changes in sentencing, which led to a dramatic increase in the federal prison population. The current prison population is more than five times greater than the prison population at the beginning of the 1980s (Wallechinsky, 2012). With this increase in population has come an increasing need to focus on inmate health, as prison crowding leads to unsanitary conditions that promote the spread of disease, and reduced parole options mean an aging inmate population. What these two factors, combined, have meant is that the BOP has seen a dramatic increase in the need for healthcare for prisoners, so that supervising healthcare delivery has become a critical component of the BOP's duties.
The BOP utilizes multiple models to deliver healthcare to inmates. Two of those models make up the majority of its healthcare services. First, it uses in-house medical providers, who may be employees of the BOP or may be employees of the Public Health Service who are assigned to the BOP. Second, it uses contract medical-care providers (DOJ, 2008). While the BOP is responsible for ensuring that inmates get medically necessary care, it also operates with a limited budget and is responsible for keeping healthcare costs as low as possible. What is interesting is that the BOP has incorporated projected healthcare expenditures into its entire imprisonment process. For example, "the BOP's on-going initiatives include assigning most inmates to institutions based on the care level required by the inmate, installing an electronic medical records system that connects institutions, implementing tele-health to provide health care services through video conferencing, and implementing a bill adjudication process to avoid costly errors when validating health care-related invoices" (DOJ, 2008).
The BOP's impact on healthcare varies from inmate to inmate. Overall, the BOP has done an adequate job of keeping down healthcare costs while encouraging programs that would provide basic preventative and medically necessary care for inmates. However, these programs have a pretty significant failure rate, so that, in a DOJ audit, "for almost half of the preventive health services we tested, more than 10% of the sampled inmates did not receive the medical service" (DOJ, 2008). A ten percent failure to administer medical care to inmates means that the BOP is not meeting its obligation to provide basic healthcare for a substantial portion of the inmates under its care.
Furthermore, it appears that the BOP encounters some problems with outside providers. These problems have led to contract-administration deficiencies. In many instances, it seems that these problems could result in over-paying for medical services. However, because the problems are systemic, it is also possible to see how they could result in a lack of service to ill inmates or inmates in need of preventative medical services (DOJ, 2008).
One of the ways that the BOP has attempted to meet inmate healthcare needs is through the establishment of the Medical Designations Program. "This initiative involves: (1) assigning each inmate a care level from 1 to 4, with 1 being the healthiest inmates and 4 being inmates with the most significant medical conditions; (2) assigning each BOP institution a care level designation from 1 to 4 based on the inmate care level that the institution is staffed and equipped to handle; (3) staffing each institution based on its designated care level; and (4) moving inmates between institutions to match each inmate's care level to the care level of the institution" (DOJ, 2008). By attempting to ensure that inmates are incarcerated at facilities that are equipped to deal with their particular medical issues, the DOJ is attempting to ensure that patients who need care for chronic conditions have access to that care, without wasting resources on providing for that type of care at all facilities.
It is difficult to describe the BOP's regulatory authority in relation to health care, mainly because the BOP's regulatory authority is not limited to health care. Broadly speaking, the BOP has the ultimate regulatory authority in relation to health care, because it is responsible for the overall well-being of all inmates in the federal prison system. However, it would be erroneous to suggest that the BOP has authority without oversight from other federal agencies. On the contrary, the BOP is supervised by the DOJ. The DOJ seeks to ensure that the BOP is complying with the applicable guidelines that govern the provision of healthcare to prisoners.
However, the BOP is the agency directly responsible for establishing clinical practice guidelines regarding the healthcare services that inmates will receive. These guidelines cover medical, dental, and mental health services for all inmates in the federal prison system. " The BOP has also established 16 clinical practice guidelines containing diagnostic procedures for specific medical areas, such as preventative health care, coronary artery disease, and hypertension" (DOJ, 2008). While these practice guidelines are informed by medical decision and policies and procedures outside of the prison environment, the BOP has the ultimate decision-making authority regarding the creation of those guidelines. The only real means of testing that authority is for a prisoner who feels that he or she has not experienced appropriate medical care to bring a lawsuit challenging the care that was received. This is a viable solution in instances where an inmate may be experiencing a chronic illness, so that a lawsuit is likely to result in a change in standard of care for that inmate, but is not a viable solution for inmates experiencing acute medical care emergencies.
Furthermore, it is interesting to note that the BOP's guideline-making authority is self-limited. First, the guidelines are only guidelines; they have not been made into an official policy. While BOP institutions are expected to follow the guidelines, they also "have discretion in whether to follow the guidelines on a case-by-case basis" (DOJ, 2008). When an institution deviates from the BOP guidelines, it "must request and receive approval from the Medical Director to not implement a specific guideline requirement" (DOJ, 2008). However, all of these exceptions make it impossible to determine whether inmates are actually receiving the care discussed in the guidelines. A DOJ audit revealed significant deviation from the guidelines at official BOP facilities (DOJ, 2008).
The BOP does not have a single process for accreditation, certification, and authorization. That does not mean that it does not require…