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Paper 3 (15%) – Budget and Policy Realities: Inmate Medical Care (7 pages, 5 References)

Background: Paper #1 focused on the growth of adult correctional populations in the United States in general terms. This paper will fine tune that discussion, and apply it to a practical, real world management problem facing every prison system. This paper targets medical programs and specifically addresses the consideration of inmate populations, budget constraints and policy alternatives for top- level management to consider. The topic of this paper involves the thorny legal, fiscal and political policy arena of controlling inmate medical care cost. The objective of this assignment is to apply what you have learned thus far concerning the impact of population and budget constraints on a specific program area within a prison system: medical care.

Background information for the essay:
The following real budget numbers from a prison system will be used for this exercise. This reflects the results of budget negotiations that took place reducing the original budget request to insure that the state budget remained within the projected revenue, which is a requirement of state law. This state cannot appropriate more funds than it receives in revenues (taxes are the bulk of the revenue). You may use the following data to illustrate your discussion and argument in this case. This is an approximation of the budget expenses of what might be a typical small prison system. These numbers add some reality to the essay and the question scenario. For example, you cannot exceed the annual budget of the institution. There is always room to make adjustments, but those adjustments have to be articulated. If a director/commissioner makes a decision that will increase the medical cost per inmate dramatically, then money must be transferred from one of the other categories into the medical budget or face the unpleasant reality of having to appear before the legislature for a supplemental appropriation (which requires the Governor’s approval).
Prison average population: 13,696 inmates
Annual budget:
282.9 million dollars
Average yearly cost per inmate: $20,656
Average yearly medical cost per inmate: $3,544

75% PERSONNEL (hiring, training and retention costs)
15% MEDICAL (total inmate medical expense)
5% INMATE DRIVEN (items such as food and clothing which is allotted per inmate in the system) 2% OPERATING AND ASSESSMENTS (utilities, etc.)
2% BUILDING MAINTENANCE AND EQUIPMENT. (Repairs, replacement , routine maintenance, etc.)

The Problem:
In a study of the screening results of a random population of 469 prisoners for the Hepatitis C Virus Infection (HCV) by Fox et al in 2015 of the California state correctional system, here are the article findings and conclusions (excuse the inability to indent these two paragraphs properly in this text box): “Results. The prevalence of HCV infection was
34.3% overall (95% confidence interval [CI], 30%-38%) and was 65.7% among those with a history of injection drug use (IDU), compared with 10.2% among those with no history of IDU (odds ratio [OR], 17.24; 95% CI, 10.52-28.25). Significant differences in HCV antibody positivity were found in association with age at first detention but not with the nature of the crime. Independent correlates of HCV infection included age, history of IDU, cumulative time of incarceration, biological sex (OR for females subjects compared with males subjects, 0.35; 95% CI, 0.13-0.96), and a history of having sex with a male IDU (OR, 4.42; 95% CI, 1.46-13.37). We identified significant differences in risk factors between male and female subjects-notably, that the risk of HCV infection was significantly elevated among female non-IDUs who reported having sexual partners with a history of IDU. Among non-IDUs, correlates of HCV infection included history of receipt of blood products and cumulative years of incarceration.

Conclusions. HCV infection is pervasive among the California prison population, including prisoners who are non-IDUs and women with high-risk sexual behavior. These results should promote consideration of routine HCV antibody screening and behavioral interventions among incarcerated men and women.” (p. 177)

” A US population-based survey showed that 1.8% of the general population has been infected with hepatitis C virus (HCV) [1]. This study, however, omitted incar- cerated persons, among whom the prevalence of HCV infection is projected to be much higher, because many of them originate from high- risk backgrounds and have a history of risk behaviors for bloodborne infection- in particular, injection drug use (IDU). Addressing the risk behaviors and medical needs of the incarcerated population is important because the frequency of in- carceration is alarmingly high. In 2002, in the United States > 2 million people were in prison or jail (1 of every 146 persons), and > 4.5 million people were on probation or parole. It is projected that 1 of every 20 individuals in the United States will serve time in jail or prison during their lifetime.” (p. 177)

Use this infection rate for the purposes of this question.
The Hepatitis C Virus Infection (HCV) is a very slow developing virus and most often one is not symptomatic. There are cures for this virus now, and they are expensive. There are cures, but no vaccines against future infection. Thus, the rate of infection with injection drug use of other high-risk behavior may be important to this question.
Assignment: Research the cost for a vaccine for Hep C (there are a number available) and then respond to the following issues in an essay that is a minimum of 5 pages of text with at least 3 peer review or academic journals. Remember not to use an abstract or subheadings and do not simply “list” responses to these issues. Include them in a thoughtful essay response:
• Would you screen all inmates coming into the system for this disease? Do not discuss that you would implement medical examinations for all incoming inmates. Every state already does this. Medical examinations are included in the current operational costs of every system. Screening for a particular disease is a different issue with unique costs. Some systems test for this disease and some do not. That is worthy of discussion.
• How would you medically respond to inmates who test positive for Hep C or are symptomatic for the disease? There is a distinct difference between these two issues.
• Consider the cost of this treatment based upon the budget numbers provided in this question.
• Insure you are aware of the need to remain within budget constraints and analyze what this would do to your budget request.
• Consider who you would not treat and why. (if any).
• These vaccines can in fact cure the disease but they cannot protect from future infection. Does this aspect of treatment affect your decision on testing and treatment?
• Do not discuss private insurance for individual inmates to pay for testing or treatment. Some students mention this and treatment must be provided by the state or the Federal government. Only discuss the costs associated for the inmates who are in the prison, not the ones who are released on parole. These are two separate budgets entirely, and rarely is medical care provided for parolees. At that point, they may take advantage of private insurance or public programs such as Medicaid, the Affordable Care Act, etc.
• Do not waste time discussing the fact that prisons must provide adequate medical care. That is a given and every state does provide medical care. The question here would be at what point is an administrator legally required to provide care and what level of care must be provided for this particular disease. If you discuss the concept of inadequate medical care or deliberate indifference, insure that you provide a proper legal definition of the terms and cite a reputable source for the definitions (do not rely upon a web site for a definition such as this).

This is a real medical and budget crisis that faces upper management in correctional facilities. The Eighth Amendment protections must be balanced against the availability of funding. How do you provide adequate medical care and still provide a rational and cost effective delivery of medical care? You may want to consider the rationale of community standards in a case like this. Remember not to include any charts or graphs or to use subheadings. This is an essay so use good rhetoric to make your point.

Fox, R., Currie, S., Evans, J., Wright, T., Tobler, L., Phelps, B., Busch, M., & Page-Shafer, K. (2015, July). Hepatitis C virus infection among prisoners in the California state correctional system. Clinical Infectious Diseases, 41(2), 177-186.