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  1. Denise DeShields, MD Executive Medical Director Texas Tech University HSC CMHC CORRECTIONAL MANAGED HEALTH CARE

  2. Patient Advocacy: Prison Healthcare and the Offender Patient

  3. Vital Statistics • No country incarcerates a higher percentage of it’s population than the United States. • The U.S. incarceration rate is 716/100,000 population (according to the International Center for Prison Studies).

  4. Countries with the largest number of prisoners per 100,000 of the national population, as of 2013

  5. State & Federal Prison Population by Offense

  6. State Expenditures on Corrections, 1985-2012

  7. United States Prison StatisticsIn 2012 there were 6,937,600 offenders under the supervision of the adult correctional system (i.e. parole, probation, or under the custody of state, federal prisons and local jails). Of that, 1,571,013 were incarcerated (22%). • In 2012 the states with the highest incarceration rates: Louisiana (893/100,000) Mississippi (717/100,000) Oklahoma (684/100,000) Texas (601/100,000) • In 2012 the states with the lowest incarceration rates: Maine (145/100,000) Minnesota (184/100,000) Rhode Island (190/100,000)

  8. Lifetime Likelihood of Imprisonment

  9. U.S. Offender Population Has Grown Every Year Between 1978-2009 • The national imprisonment rate for males is 14x that of females.

  10. Correctional Populations in the United States, 2012 • In 2012 about 1 in every 35 adults in the United States or 2.9% of adult residents, was on probation or parole or incarcerated in prison or jail. • The decrease during 2012 was the fourth consecutive year of decline in the U.S. correctional population. • Although the correctional population declined by 0.7% during 2012, this was the slowest rate of decline observed since 2009. • More than half (56%) of the decrease in the U.S. correctional population during 2012 was attributed to a drop in California’s correctional population, a decline driven by the state’s Public Safety Realignment Act of 2011.

  11. Total population under the supervision of adult correctional systems and annual percentage change, 2000-2012. Annual percent change Population- Note: See Methodology for information on the methods used to calculate annual change in the correctional population. Sources: Bureau of Justice Statistics, Annual Probation Survey, Annual Parole Survey, Annual Survey of Jails, Census of Jails, and National Prisoner Statistics Program, 2000-2012.

  12. Texas Department of Criminal Justice The mission of the Texas Department of Criminal Justice is to provide public safety, promote positive change in offender behavior, reintegrate offenders into society, and assist victims of crime.

  13. TDCJ History • 1848 Texas Legislature passed an act establishing a State Penitentiary. • The prison system began as a single institution in Huntsville. Over time, more prisons were built primarily in the historic cotton/slavery belt of Texas (Stephen F. Austin’s Colony). • In 1921 George W. Dixon of The Prison Journal published a report on the Texas Prison System facilitiesstating that it was one of the most "brutal" in the world. He reported that “convicts” were subject to whippings, beatings, and isolation. • Before 1972, there were 18 prisons, 16 for males, 2 for females with 25,000 offenders. • In the 1980’s Texas embarked on a massive prison construction project. There are now 109 TDCJ Units, that incarcerate over 150,000 offenders. • In 1989, The Texas Department of Criminal Justice was created absorbing the functions of The Texas Department of Corrections, The Texas Board of Pardons and Paroles, and the Texas Adult Probation Commissions.

  14. TDCJ Employees Over 37,000 employees Over 32,000 work in a confinement facility Over 23,000 of those are Correctional Officers Additionally, there are 3,900 contracted health care staff serving 114 facilities (109 TDCJ facilities, 5 private facilities)

  15. Offender Population Trends in Texas

  16. Census/CapacityTexas currently operates the largest prison system in the United States. Capacity: 162,057 Operational Capacity: 155,575 Current Census: 151,273

  17. Census/Capacity – Cont’d

  18. Census Capacity Capacity 162,057 Operating Capacity 155,575 Population 151,080 Percent of Capacity 93.34%

  19. TDCJ FACTS • TDCJ manages offenders in 109 state and 5 privately operated facilities. • 56% of offenders have a violent offense of record • Nearly 27,000 sex offenders • Average IQ score is 90.7 • 12,174 female offenders • Average Educational Achievement score 8.2 • 15,420 offenders are 55 years of age or older • 275 offenders on death row • In fiscal Year 2013, 71,713 offenders received and 72,071 offenders released.

  20. Texas Department of Criminal Justice Offender ProfileFY 2014 1st Quarter – November 2013

  21. Texas Department of Criminal Justice Offender ProfileFY 2014 1st Quarter – November 2013

  22. Texas Department of Criminal Justice Offender ProfileFY 2014 1st Quarter – November 2013

  23. Texas Department of Criminal Justice Offender ProfileFY 2014 1st Quarter – November 2013

  24. Recidivism 49.1% For prison offenders released in 1992 22.6% For prison offenders released in 2009

  25. Fiscal Year 2013 Total TDCJ Budget $3.071 billion Cost of Incarceration: $18,314.64 offender/year $50.04 offender/day

  26. Fiscal Year 2013 TDCJ Health Care Budget $429 million Cost of Health Care $9.26 offender/day

  27. Fiscal Year 2012Health Care Costs Affected By Age Offenders 55 years-old and older comprise 9.6% of the population but account for 39.1% of hospital costs in TDCJ

  28. Fiscal Year 2012Health Care Costs Affected By Dialysis • Average number of offenders requiring dialysis at any given time in 2012 was 213 (0.14% of the offender population). • Dialysis accounts for 1.11% of the annual budget • This approx 8 fold increase in costs does not include hospitalizations and clinic services not directly related to dialysis that are also more frequent in this population.

  29. Fiscal Year 2012Health Care Costs Affected By HIV Approx 1.6% of offenders are HIV (+) 48.24% of the pharmacy budget was spent on antiretroviral medication.

  30. Fiscal Year 2012Health Care Costs Affected By Mental Health The second largest categorical pharmacy cost in 2012 was psychiatric medications. 6.31% of pharmacy budget is spent on psychoactive medication.

  31. Prison Healthcare in Texas

  32. Ruiz vs. Estelle(June 1972) TDCJ inmate and prison reform activist David Ruiz leaving court in 1978 (with briefcase) Photo By Alan Pogue

  33. Full Footnote: “PRISON SYSTEM.” The Handbook of Texas Online., accessed Tue Sep 7 15:01:51 US/Central 2004 • Overcrowding – particularly the placement of two and even three inmates in cells designed for a single inmate • Inadequate security – claimed to be the result of too few guards, sometimes resulting in the handing over of supervision of whole sections of prisons to inmates (known as “building tenders”) who assisted guards • Inadequate healthcare – an insufficient number of professional medical personnel for the number of prisoners, the use of non-professional personnel to deliver professional medical care, and limited therapy for psychiatric patients • Unsafe working conditions – exposure of prisoners to unsafe conditions and lax enforcement of safety procedures • Severe and arbitrary disciplinary procedures

  34. December 1992 – Judge Justice signed Final Judgment in Ruiz. With regard to health care and psychiatric services, the Final Judgment imposed a series of additional reporting requirements in the short term, and in the long term imposed the following mandates: 1) maintain NCCHC accreditation of all unit and regional health care facilities; 2) Ensure that no prisoner is assigned to do work that is medically contraindicated; 3) Ensure full access to health care for all prisoners; 4) Ensure that nonmedical staff cannot countermand medical orders; and 5) Maintain medical, dental, rehabilitation and psychiatric staffing and facilities that enable timely delivery of health care to all prisoners, consistent with contemporary professional standards for correctional health care, vigorously recruit the required staff, and stay competitive in the recruitment of staff. TDCJ was not liberated from this Federal requirement until 2003! (1972-2003)

  35. Constitutional Right to Health Care • “having custody of the prisoner’s body and control of the prisoner’s access to medical treatment, the prison authorities have a duty to provide needed medical attention”. Ramsey v. Ciccone,. 310 F.Supp. 600 (W.D.Mo., 1970)

  36. Constitutional Right to Health Care – Cont’d • As early as 1970, the US Supreme Court first recognized the need for health care for those in prison. Since then through a series of decisions including Estelle v. Gamble (1976), access to adequate medical care has been held to be a constitutional right for inmates in correctional facilities.

  37. Constitutional Right to Health Care – Cont’d • The “intentional denial to a prisoner of needed medical treatment is cruel and unusual punishment and violates the Eighth (8th) Amendment to the United States.”. • Ramsey v. Ciccone,. 310 F.Supp. 600 (W.D.Mo., 1970)

  38. Constitutional Right to Health Care – Cont’d • The courts have found a right to medical treatment for prisoners in the due process clause of the Fourteenth (14th) Amendment and held that “Under totality of the circumstances, adequate medical treatment must be administered when and where there is reason to believe it is needed.” • Mills v. Oliver, 367 F.Supp. 77,79 (E.D.Va., 1973) • Fitzke v. Shappell, 468 F.2d 1072 (6th Cir. 1972).

  39. Estelle vs. Gamble “We therefore conclude that deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’ proscribed by the English (8th) Amendment. U.S. Supreme Court in Estelle vs. Gamble, 429 U.S. 98, 97 S.Ct. 285 (1976)