A report fromOct 2017

Andrew Burton/Getty Images

Prison Health
Care: Costs andQuality
How and why states strive for high-performing systems

Contents
1

Overview

3

Prison Health Care Is Integral to Achieving State Goals
Meet constitutional requirements 4
Strengthen public health 4
Protect public safety and reduce recidivism 5
Practice fiscal prudence 6

Common Ends, Varied Means

6

Persistent per-inmate spending variation 6
Variation drivers 9
No accounting for quality 9

Delivery Systems and Reasons for Spending Variation

9

Delivery system organizational structure 10
Evolution and trade-offs of outsourcing 11
Delivery systems dictate available policy levers 13
How states spend their prison health care dollars 14
Putting detailed spending data to use 16
State approaches to disaggregating spending 17
Data needs transcend delivery system 19
Accounting for staffing expenditures 19
Accounting for hospitalization expenditures, shifting costs 21
Health care prices that prisons pay 23
Hospital prices 23
Whom state prison health care dollars treat 23
Prevalence of costly chronic conditions 23
Dearth of data notwithstanding, prevalence is likely connected to costs 30
Accounting for quality of health care state prison dollars fund 30
National evolution of quality monitoring 31
How state prisons monitor care quality 32

44

Protecting Investments and ProgressThrough Care Continuity
Types of care continuity services 45
Medicaid enrollment 46
Maintaining medications 49
Linking to providers 49
Records sharing 50
Teaching skills for self-management of health 50ii

Targeting high-risk populations 50
HIV and AIDS 51
Hepatitis C 53
Substance use disorders 53
Mental illnesses 54

56

Conclusion

57

Appendix A: Methodology

64

Appendix B: State data notes

90

Appendix C: 50-state data

126 Endnotes

This report was updated on Dec. 8, 2017, to clarify state variation in the number of health professional employees forevery 1,000 inmates in custody.
This report was updated on Oct. 30, 2017, to reflect revised data submitted by the Mississippi Department of Corrections
pertaining to Medicaid enrollment.
On Oct. 27, 2017, the New Mexico Corrections Department (NMCD) reported to Pew researchers that its per-inmate
health care spending figures in this report are inaccurate, reflecting incorrect information provided earlier by department
officials. Pew has asked the state to supply in writing revised data and guidance; once these are submitted, Pew will
amend or update the report as necessary. Questions related to these data should be directed to NMCD.

iii

The Pew Charitable Trusts
Susan K. Urahn, executive vice president and chief program officer
Michael D. Thompson, vice president for state and local government performance

Project TeamKil Huh, senior director
Alex Boucher
Frances McGaffey
Matt McKillop
Maria Schiff

External reviewers
This report benefited from the insights and expertise of the following external reviewers: Jack Beck, director of
the Prison Visiting Project at the Correctional Association of New York; Cheryl L. Damberg, Ph.D., distinguishedchair in health care payment policy and principal senior researcher at the RAND Corp.; Trina A. Gonzalez,
program officer for the Milbank Memorial Fund; Robert B. Greifinger, M.D., correctional health care consultant;Justin Jones, former director of the Oklahoma Department of Corrections; Christopher F. Koller, president of the
Milbank Memorial Fund; Douglas McDonald, Ph.D., principal associate at Abt Associates; and Marc Stern, M.D.,
M.P.H., former chief medical officer for the Washington State Department of Corrections. Although they havereviewed the report, neither they nor their organizations necessarily endorse its findings or conclusions.

Acknowledgments
We express our gratitude to Christian Henrichson, Chris Mai, and David Cloud of the Vera Institute of Justicefor their invaluable partnership. We thank state officials and our project advisers for generously lending theirtime and expertise. (See Appendix A: Methodology.) We appreciate our colleagues Allan Coukell, Adam Gelb,
Sandra Nwogu, Henry Watson, Dan Rockey, Casey Ehrlich, Samantha Chao, Karen Font, and Betsy Towner Levine
for their assistance and guidance in the research process. We thank Rachel Gilbert, Kimberly Burge, Bernard
Ohanian, Carol Hutchinson, Liz Visser, Steve Howard, and David Lam for their editorial and production assistance.

Contact: Rachel Gilbert, senior associate, communications
Email: rgilbert2@pewtrusts.org
Project website: pewtrusts.org/correctionalhealth

The Pew Charitable Trusts is driven by the power of knowledge to solve today’s most challenging problems. Pew applies a rigorous, analytical
approach to improve public policy, inform the public, and invigorate civic life.

iv

Overview
Prison health care sits at the intersection of pressing state priorities. From protecting public safety to fighting disease
and promoting physical and behavioral health, and from fine-tuning budgets that trim waste to investing in costeffective programming with long-term payoffs, the health care that prisons provide to incarcerated individuals andthe care that prisons facilitate post-release is a critical linchpin with far-reaching implications.
On a typical day, state prisons house more than a million people, many of whom have extensive and communicablehealth ailments. The manner in which services are provided affects state budgets because of the expensive
treatments for some common conditions, the downstream costs of delayed or inadequate care, and the legal
and financial consequences of being found to violate inmates’ constitutional rights to “reasonably adequate”
care. Moreover, with nearly all incarcerated individuals eventually returning to society, treatment and dischargeplanning—especially for those with a substance use disorder, mental illness, or infectious disease—play an importantrole in statewide anti-recidivism and public health efforts. Taken together, these realities call for the attention ofpolicymakers and administrators.
Yet these officials often lack the information they require to build and maintain high-performing prison healthcare systems that proactively make the most of diagnostic and treatment opportunities and avert the harmful andexpensive consequences of inattention or missteps. They need to know how much money is being spent on what
services and why; what benefits are achieved for those dollars; and whether these benefits are preserved post-prison
through well-coordinated prison-to-community transitions.
This first-of-its-kind report, using data collected from two 50-state surveys administered by The Pew Charitable
Trusts and the Vera Institute of Justice, along with interviews with more than 75 state officials, updates previous
Pew research on spending trends in prison health care. The report also incorporates information on the operational
characteristics of states’ prison health care systems; whether and how states monitor the quality of care provided—
the critical counterpart to cost when assessing value; and common care continuity strategies for people leaving
prison. The aim is to begin to paint a comprehensive picture for policymakers, administrators, and other stakeholdersof how states fund and deliver prison health care, how they compare with one another, and some reasons fordifferences. These stakeholders can use such practical information and insights to help optimize policies andprograms in the service of incarcerated individuals, state residents, and taxpayers.
The first of the two surveys, for which every state except New Hampshire provided data, queried senior budget staff
of state departments of correction on expenditures, prison population demographics, the health care delivery system
employed, and staffing. The second survey, for which every state except Alabama, Kansas, and New Hampshire
provided data, collected information from senior health care staff of departments of correction on efforts to monitor
the quality of care provided, disease prevalence tracking, and services to facilitate care continuity at release.
Pew’s research found:•• Departments of correction collectively spent $8.1 billion on prison health care services for incarcerated individuals
in fiscal year 2015—probably about a fifth of overall prison expenditures.
•• Health care spending per inmate varied dramatically in fiscal 2015, as it had in past years—from $2,173 in
Louisiana to $19,796 in California. State officials across the country need to understand whether and how
these differences reflect meaningful discrepancies in value and performance. This knowledge helps states
determine if their prison health care systems assist or undermine their efforts to achieve universal goals: meeting
constitutional obligations, protecting public safety, strengthening public health, and practicing fiscal prudence.

1•• Knowing how money is spent, and how the spending distribution has changed over time, is critical tounderstanding interstate spending variation and evaluating cost-effectiveness. But with few exceptions, statedata systems preclude detailed, actionable analysis. Reporting limitations were most common among statesthat primarily or wholly outsource their prison health care delivery.
•• States reported dramatically different approaches to staffing by departments of correction and their vendor
and university partners in fiscal 2015. Not surprisingly, staffing levels appear to correlate with per-inmate
prison health care expenditures: Median per-inmate spending was more than double among the 10 states withthe highest staffing levels than among the 10 states with the lowest levels.
•• Along with how money is spent, knowing whom it is spent on is important to understanding costs. Treating
chronic conditions has emerged as a growing challenge and expense in state prisons, exacerbated by an aging
prison population. From fiscal 2010 to 2015, the share of older individuals in prison rose in all 44 states that
submitted prisoner age data to Pew and Vera.
•• The quality of care that prisons provide has a major impact on their contribution to the achievement of stategoals. Assessing the value that taxpayers get for their prison health care dollars—that is, whether desired
outcomes are achieved at sustainable costs—and how that value compares with other states requires quality
measurement and monitoring. Thirty-five states reported that they operated a prison health care quality
monitoring system in fiscal 2016. These systems took different shapes but shared four key characteristics:
They were grounded in data; established and overseen by state agencies; applied broadly and consistently
across facilities; and operated on an ongoing basis. However, of these 35 states, only Florida, Nebraska,
Nevada, New Jersey, New York, and Texas indicated that they take additional steps to formally require quality
monitoring and build in regular opportunities to incorporate the findings into decision-making and legislative
oversight, which can clarify priorities, bolster consistency amid personnel changes, and help ensure that
objectives are met.
•• Respondents from all except four of the 12 states without a quality monitoring system agreed or strongly
agreed that establishing such a system is necessary to achieve at least an adequate level of quality. A majority
also agreed or strongly agreed that this step would improve the quality of care provided in their system as wellas their state’s understanding of the value of its prison health care spending.
•• State departments of correction increasingly recognize the benefits and importance of facilitating care
continuity for individuals returning to the community. These departments take a variety of steps, often in
partnership with other state agencies, to smooth re-entry from a health care standpoint and preserve positive
outcomes from in-prison investments. These efforts include helping individuals acquire health coverage,
maintain medication regimens, identify and connect with outside providers, share health records, and learn
about safely managing their disease(s). Many states reported providing the bulk of surveyed services, thoughsome pointed to relatively few.
Well-run, forward-thinking prison health care systems are vital to state aims of providing care to incarcerated
individuals, protecting communities, strengthening public health, and spending money wisely. Likewise, poorly
performing systems threaten to make states less safe, less healthy, and less fiscally prudent. Put simply: The
stakes extend far beyond the confines of prison gates.

2

Prison Health Care Is Integral to Achieving State Goals
The last five decades have been transformational for prison health care. Dramatic advancements in theprofessionalization and sophistication of care provided generally brought care for prisoners into closer alignment
and integration with health care provided in the community. Litigation largely drove these improvements.
Incarcerated individuals and advocates began challenging substandard conditions, and courts responded bydefining legal rights and establishing minimum standards and accountability.
At the same time, correctional facilities increasingly became a setting in which individuals with serious healthconditions—especially infectious diseases, substance use disorders, and mental illnesses—were diagnosed andtreated. This was largely driven by the dual forces of the national war on drugs, which led to significant increases
in the number of persons convicted for drug offenses, and the closing of mental hospitals as part ofdeinstitutionalization efforts.1 In addition to the sheer growth of prison populations,2 this deteriorating inmate
health profile increased the demands on prison health care systems. But it also created occasion for policymakers
to incorporate these systems into statewide public health and public safety strategies because nearly all³ of thosein prisons eventually return to their communities.

Public safety is public health; public health is public safety.”
Richard H. Carmona, U.S. surgeon general, 2002-2006
Today, every state has an interest in delivering care that comports with constitutional requirements and leverages
opportunities to improve public health and reduce crime and recidivism. But executing this mission can comeat a steep cost. Indeed, states spent $8.1 billion on prison health care in fiscal 2015—probably about a fifth4of overall prison expenditures. (See Appendix C: Table C.1.) Such spending has grown rapidly over the last five
decades,5 and continued to do so more recently,6 increasing the footprint of health care in overall prison budgets.7
Therefore, it is critical that policymakers and correctional officials endeavor to achieve these objectives in a costeffective fashion. (See Figure 1.)

Figure 1

Universal State Interests

Meeting constitutional obligations

Strengthening public healthPrison Health Care
Protecting public safety© 2017 The Pew Charitable Trusts

3

Practicing fiscal prudenceMeet constitutional requirements
Before the 1970s, prison health care operated without what Justice Thurgood Marshall termed “standards ofdecency”8 and was frequently delivered by unqualified or overwhelmed providers, resulting in negligence andpoor quality.9 These conditions led to a stream of lawsuits. By January 1996, only three states had never been
involved in major litigation challenging conditions in their prisons. A majority were under court order or consent
decree to make improvements in some or all facilities.10
A series of federal court decisions established a legal basis under which state correctional authorities areconstitutionally obligated by the Eighth Amendment to provide prisoners with “reasonably adequate” healthcare.11 Today, care must be at “a level reasonably commensurate with modern medical science and of a quality
acceptable within prudent professional standards”12 and “designed to meet routine and emergency medical,
dental, and psychological or psychiatric care.”13 Specifically, prisoners are entitled to access to care for diagnosis
and treatment, a professional medical opinion, and administration of the prescribed treatment.14
States’ obligation and liability persist even if they use contractors to provide some or all medical services.15 The
Supreme Court has ruled that “contracting out prison medical care does not relieve the State of its constitutional
duty to provide adequate medical treatment to those in its custody.”16 The same is true when state prisoners areunder the custody of private prisons or local jails.17
Recent cases have reinforced states’ constitutional obligations. In Brown v. Plata, California was ordered to reduce
crowding because of the associated effect on the adequacy of health care. A federal court found that, as of 2005,
the state’s medical delivery system resulted in an “unconscionable degree of suffering and death” and that it
was “an uncontested fact that, on average, an inmate in one of California’s prisons needlessly dies every six toseven days due to constitutional deficiencies.”18 And in February 2015, in a class-action suit on behalf of morethan 33,000 individuals in Arizona’s state prisons, a federal court approved a settlement requiring the state toaddress deficiencies in its system and pay $4.9 million in attorneys’ fees and up to $250,000 per year for future
monitoring fees and expenses.19

Strengthen public healthEvery state strives to protect and advance the well-being of its residents. Improving health and wellness within
its borders, in part by freeing communities of preventable illness, is an important part of that mission, according
to the Association of State and Territorial Health Officials, the voice of all 50 states’ health chiefs.20 States aim toprevent and control the spread of infectious diseases by rapidly identifying and addressing new cases of infection,
supporting disease elimination, and thwarting emerging and re-emerging threats.
There are high rates of infectious disease among those in state prisons, and the vast majority of these individuals
will eventually return to their communities. Prisons also receive a continuous flow of staff and visitors in andout of their facilities. These circumstances make the health care that the prison population receives a criticalcomponent of states’ public health strategies. According to the federal Bureau of Justice Statistics, 20 percent
of state and federal prisoners report ever having an infectious disease, compared with 5 percent of the general
population.21 Prevalent conditions include sexually transmitted diseases,22 human immunodeficiency virus(HIV),23 and hepatitis C.24
While these high prevalence rates and the close confines of prisons present a challenge, they also offer a publichealth opportunity on which states can capitalize by screening, diagnosing, and treating these communicableconditions among a group that is frequently hard to reach in the community. “Public safety is public health; public4

health is public safety,” according to former U.S. Surgeon General Richard H. Carmona.25 Similarly, the World
Health Organization (WHO) has said that “good prison health is essential to good public health” and “goodpublic health will make good use of the opportunities presented by prisons.”26
The positive and negative spillover effects of correctional health care on communities, depending on the natureand quality of the care, have been substantiated by a growing body of evidence. Management of tuberculosis(TB) provides an example of the positive role correctional health care can play. Because the incarcerated
population is at an elevated risk for TB,27 the Centers for Disease Control and Prevention—and before it, theAdvisory Council for the Elimination of Tuberculosis—identified correctional facilities as a critical setting fordetection and treatment.28 Actions by correctional staff to screen, contain, monitor, and collaborate with publichealth partners paid off. The number of TB cases in correctional facilities fell by 66 percent from 1994 to 2014,29
helping the U.S. rate hit a 40-year low the same year.30

Protect public safety and reduce recidivism
Among the metrics by which prison systems are evaluated—and often explicitly judge themselves—is theireffectiveness at promoting public safety and reducing recidivism. The Ohio Department of Rehabilitation &Correction, for example, succinctly articulates a single mission: “Reduce recidivism among those we touch.” Its
director, Gary Mohr, says this is not simply done for its own sake, but also to “continue making Ohio communities
safer.”31 Ohio’s goal is not unique. The vision of the Minnesota Department of Corrections, for example, is
to “contribute to a safer Minnesota,” and its mission is to “reduce recidivism.”32 The Georgia Department ofCorrections aims to protect the public “by operating secure and safe facilities while reducing recidivism througheffective programming, education, and healthcare.”33
Nevertheless, recidivism remains a persistent challenge. Two seminal Bureau of Justice Statistics studies of state
prisoners released in 1983 and 1994 estimated that half of released individuals return to prison within three
years.34 More recent research by the bureau35 and Pew36 came to similar conclusions, suggesting that states
overall had not made progress.
Emerging research suggests that underlying health issues, particularly substance use disorders37 and mental
illness,38 contribute to incarceration and recidivism, and that treatment,39 combined with seamless care continuity
for individuals when they return to communities, can help prevent both. Given their high prevalence, behavioral
health conditions in correctional facilities40 have increasingly become a focal point for intervention.
For example, drug addiction treatments, combined with uninterrupted care continuity, have been found to beeffective in controlling substance use disorders and reducing recidivism.41 Notable models include therapeuticcommunities and opioid maintenance treatment (such as methadone maintenance). Participants in therapeuticcommunities are typically housed together and, under the supervision and monitoring of staff, engage inrunning the community by leading treatment sessions, monitoring rule compliance, maintaining the unit, andresolving disputes.42
The stakes for success are high because recidivism comes at great public safety and fiscal cost. By successfully
incorporating health care into anti-recidivism strategies, states increase the likelihood that they and theircorrections agencies will meet their crime-reduction objectives. Moreover, because of the significant expense
associated with imprisoning individuals, states also stand to save money by reducing recidivism. For example,
previous Pew research found that if states reduced their recidivism rates by 10 percent, the collective savings
from averted prison costs would be in the hundreds of millions of dollars annually.43

5Practice fiscal prudence
Operating high-performing prison health care systems that meet constitutional obligations and make the mostof opportunities to improve public health and public safety is in every state’s interest. However, doing so can be
costly, and all states operate with finite resources. Even as they have regained much of the fiscal and economic
ground lost in the Great Recession, a number of states have yet to get back to full strength and continue to facelong-term financial pressures, leaving little or no wiggle room in budgets.44 The importance of using taxpayer
dollars prudently has never been greater. Therefore, states need fiscally sound, sustainable systems that yieldpositive outcomes.
The pull of these two opposing dynamics—improving results while containing costs—has been the central
tension within prison health care for decades.45 The only way for policymakers and correctional administrators
to satisfy both is to continually appraise the value of their systems; that is, whether their states are achieving
desired outcomes at sustainable costs. To do that, officials need to rigorously collect and analyze detailed,actionable spending and quality data, use the information to identify strengths and weaknesses, and makerefinements. At the same time, they also need to facilitate seamless post-release care continuity to help ensurethat the benefits of care and the resources devoted to stabilizing individuals’ health while they are incarcerated
are preserved and not squandered upon release. Otherwise, these funds will be spent again and again wheninmates cycle back through the prison system or turn up in emergency rooms.

Common Ends, Varied Means
Although all 50 states share these interests—constitutional compliance, public health, public safety, and fiscal
prudence—the provision of state prison health care throughout the country varies significantly. There is nostarker evidence of this variation than the wide range in per-inmate expenditures among states. In fiscal 2015, theCalifornia Department of Corrections and Rehabilitation spent $19,796 per inmate on health care. Two thousand
miles to the east, its counterpart in Louisiana spent $2,173. And such divergences are not exclusive to outliers.
(See Figure 2.)
What drives these dramatic differences? To what extent do they reflect meaningful discrepancies in value andperformance that move some states closer to reaching their common ends, while pushing others further away?
The answers to these questions carry critical importance to any assessment of whether states are doing all they
can to protect their communities, strengthen public health, and spend money wisely.

Persistent per-inmate spending variation
According to data submitted to Pew and Vera, in fiscal 2015 the typical state department of corrections spent$5,720 per inmate to provide health care services including medical, dental, mental health, and substance use
treatment. However, departments in four states (California, New Mexico, Vermont, and Wyoming) spent morethan $10,000 per inmate, while five (Alabama, Indiana, Louisiana, Nevada, and South Carolina) spent less than
$3,500 per inmate.46 This ordering tracked closely with what states reported for prior years of the study period(fiscal 2010 to 2015).
The breadth of this variation continues a decades-long trend. The Bureau of Justice Statistics (BJS) found aroughly sixfold range in per-inmate medical spending in both fiscal 1996 and fiscal 2001.47

6

Comparing inflation-adjusted48 per-inmate health care spending changes over time shows similar variation.49
Most recently, from fiscal 2010 to 2015, real per-inmate spending rose by a median of 2 percent. But state
departments of correction had quite different experiences. (See Figure 2.) Per-inmate expenditures shrank in
Ohio and West Virginia by 27 percent and 25 percent, respectively. On the other end of the spectrum, spending
expanded50 in Tennessee (22 percent) and California (25 percent) over the five years.

Definition of Prison Health Care Spending
Following the example of the system used by the Centers for Medicare & Medicaid Services tomeasure national health care spending, Pew and Vera defined prison health care spending as
inclusive of on-site care, off-site care, outpatient medical products, long-term care, other health,residential, and personal care, and other expenditures funded by state revenue and federaltransfers. (See Appendix A: Methodology for a complete listing of categories.)
Though there was broad overlap in the scope of services funded by state departments ofcorrection (DOCs), some inconsistency in funding responsibility contributed to state-by-state
spending differences. For example, in some states, Medicaid agencies pay for the cost of
hospitalizations for enrolled individuals without reimbursement from the DOC. In others, state
mental health agencies cover some of the cost of treatment under their purview. While somesurvey respondents provided information on such spending, many could not or did not.

7

Figure 2$
4%
4,724 / $%5,089 Utah
Iowa
8%
$
Missouri14,909 / $4,942$$
Pennsylvania
-7%
6,860
/
5,023
Ohio
-27%
$
Utah
4%
4,404 / $4,560$
Arkansas-10%
Missouri1%4,909 / $4,942%$
4,913 / $4,548
Pennsylvania
-7
%
$
$
Texas
1%
Utah
4
4,404 / 4,560$
4,642 / $4,186
Arkansas $-10%
Florida-16%
4,913 / $4,548
Pennsylvania-7%$4,032 / $4,077
Texas
1%
$
West Virginia -25%
4,642 / $4,186
Arkansas-10%$
4,831 / $4,050
Florida-16%$
Mississippi-7%4,032 / $4,077
Texas
1%
%
$
West
Virginia-25
5,260 / $%3,970$
Kentucky
0
4,831 / $4,050
Florida-16%$
Mississippi$-7%
4,058 / $3,770-2%West Virginia -25%
5,260 / %$3,970 Oklahoma$
Kentucky$
0
3,747 / $$3,763
Illinois
4%
Mississippi-7%4,058 / $3,770%$
Oklahoma-23,779 / $3,706%%$$
Georgia-7
Kentucky
0
3,747 / $3,763$
Illinois
4%3,478 / $3,619$
Arizona-4%
Oklahoma-2%3,779 / $3,706$
3,871 / $3,610
Georgia$
-7%
%
%
$
South
Carolina
21
Illinois
43,478 / 3,619$
3,683 / $3,529
Arizona-4%%%$$
Indiana-12
3,871 / 3,610
Georgia
-7
%
$
$
South
Carolina
21
2,880
/
3,478
$
$
$
$
Nevada-21%
3,683 / 15,827
3,529 / 19,796
Arizona-4%$
3,678 / $3,246
Indiana
-12%
$
$
%
$
$
Alabama
1%
11,581/ 13,747
South Carolina 21
2,880/ 3,478$
Nevada-21%
4,126 / $3,246
%
$
$
%
$
$
Louisiana
56
12,293/
13,917
3,678 / 3,246
Indiana-12$
3,207 / $3,234
Alabama
1%$$
13,382$4,126/ 11,798
Nevada-21%/ $3,246$
Louisiana
56%
1,396 / $2,173
Alabama
1$%9,056 / $8,948$3,207 / $3,234
FY 2010 spending$ %$7,567 / $8,583
Louisiana
56
1,396 / $2,173$
FY 2010 spending
FY 2015 spending
7,225 / $8,456

4,404 / $4,560
4,913 / $4,548$
4,642 / $4,186$
4,032 / $4,077$
4,831 / $4,050$
5,260 / $3,970$
4,058 / $3,770$
3,747 / $$3,763$
3,779 / $3,706$
3,478 / $3,619$
3,871 / $3,610$
3,683 / $3,529$
2,880 / $3,478$
3,678 / $3,246$
4,126 / $3,246$
3,207 / $3,234$
1,396 / $2,173$$

Per-Inmate Spending on Prison Health Care Varied Greatly
Magnitude and change by state, FY 2010-15
State% change

California
25%
Vermont
19%
New Mexico-12%
Wyoming-12%
Massachusetts -1%
Nebraska
13%
Oregon17%
Delaware19%
Michigan
3%
Minnesota
10%
Montana13%
New Jersey
12%
Maine
-7%
Maryland11%
Alaska-14%
North Dakota
New York
5%
North Carolina -5%
Rhode Island
15%
Washington-6%
Colorado
14%
Tennessee
22%
Kansas2%
Virginia
9%
Wisconsin
2%49-state median
Idaho
14%
South Dakota
18%
Connecticut0%
Hawaii
-2%
Iowa
8%
Ohio
-27%
Missouri
1%
Utah
4%
Pennsylvania-7%
Arkansas
-10%
Texas
1%
Florida-16%
West Virginia -25%
Mississippi-7%
Kentucky0%
Oklahoma-2%
Illinois
4%
Georgia-7%
Arizona-4%South Carolina 21%
Indiana-12%
Nevada-21%
Alabama1%
Louisiana
56%
FY 2010 spending

8

7,092 / $8,408
FY 2010 spending
FY 2015 spending$
8,020 / $8,287$$
7,415 / 8,158$
7,156 / $8,084$
6,968 / $7,789$
7,965 / $7,397$
6,566 /$7,280$$8,428 / $7,239
$
7,049
$
6,701 / $7,047$
7,296 / $6,923$
6,016 / $6,902$7,156 / $6,705$
5,807 / $6,641$
4,911 / $6,001$
5,885 / $5,999$
5,438 /$5,937$
5,608 / $5,720
$
5,720
$
4,942 / $5,641$
4,781 / $5,626$
5,577 / $5,565$
5,550 / $5,422$
4,724 / $5,089$
6,860 / $5,023$
4,909 / $4,942$
4,404 / $4,560$
4,913 / $4,548$
4,642 / $4,186$
4,032 / $4,077$
4,831 / $4,050$
5,260 / $3,970$
4,058 / $3,770$
3,747 / $$3,763$
3,779 / $3,706$
3,478 / $3,619$
3,871 / $3,610$
3,683 / $3,529$
2,880 / $3,478$
3,678 / $3,246$
4,126 / $3,246$
3,207 / $3,234$
1,396 / $2,173$

FY 2015 spending

FY 2015 spending

FY 2015 spending
FY 2015 spending

FY 2015 spending

Notes: The 49-state median excludes New Hampshire,
which did not provide data.
All spending figures are in 2015 dollars. Nominal
spending data for fiscal 2010–15 were converted to2015 dollars using the Implicit Price Deflator for Gross
Domestic Product included in the Bureau of Economic
Analysis’ National Income and Product Accounts.
North Dakota did not report spending data for fiscal
year 2010.
In Louisiana, beginning in fiscal 2014, off-site medical
costs were included in the Department of Correction’sbudget, rather than Louisiana State University’s. This
shift resulted in a $20 million (44 percent) increasein health care spending by the department from fiscal
2013 to fiscal 2014 and contributed to the department’s
reported per-inmate health care spending increase fromfiscal 2010 to fiscal 2015.
(See Appendix C, Table C.3 for state data.)© 2017 The Pew Charitable Trusts

FY 2015 spendingVariation drivers
The Bureau of Justice Statistics points to several factors that possibly contribute to state-to-state spending
differences, including pre-incarceration access to adequate community care, regional medical prices, staffing andcompensation levels, facility capacity and related economies of scale, and incidences of high-risk behaviors andassociated disease burdens.51
Other researchers have examined some of these and additional factors. A National Institute of Corrections
study modeled the effect of numerous variables, including staffing levels, whether and how state corrections
departments and the Federal Bureau of Prisons engaged with contractors to deliver care, the provision of certain
screening procedures on a routine basis, the prevalence of particular high-cost populations (for instance,
inmates age 55 and over), and certain cost-containment strategies (such as requiring copayments to discourage
potentially unnecessary doctor visits).52
The model, which explained 60 percent of the documented spending variation, calculated some of the mostinfluential variables to be staffing totals of mid-level practitioners (physician assistants and nurse practitioners);
whether HIV screening is routinely provided during intake, thereby increasing the probability of identifying
and treating infected individuals; and the use of contractors on a capitated basis—or per-person fixed-rate
contracts—to conduct intake exams, examine sick individuals, and provide treatment for chronic illnesses. The
first two variables were correlated with higher spending, the last one with lower spending.

No accounting for quality
Crucially, the National Institute of Corrections study omitted two variables critical to any complete evaluation of
per-inmate spending: access to care and quality of care. That is, the model did not account for variation in either,treating them as equal in every state. This is probably because of the lack of uniform quality-of-care standards
and reporting for correctional systems and facilities, which would permit more complete comparisons acrossstates and facilities.53
The United Nations High Commissioner for Human Rights54 and the World Health Organization55 have eachpromulgated guidelines for prisoner health care, but they are not widely recognized or followed in the UnitedStates in an explicit fashion. Standards have also been developed by, among others, the American Public Health
Association,56 the American Medical Association,57 and, more recently, by the American Bar Association,58
American Correctional Association,59 and the National Commission on Correctional Health Care.60 Hundredsof state facilities have adopted them from the latter two and received accreditation. Still, little has been known
systematically about whether and how states measure and monitor quality in their prison health care systems.61
Even less is known about actual outcomes.
Despite the absence of such information, differences in per-inmate expenditures probably reflect, in part,differing levels of care provided.62

Delivery Systems and Reasons for Spending Variation
The next segment of this report explores new data on key attributes of states’ prison health care systems.
The data were collected through two 50-state surveys of corrections departments administered by The Pew
Charitable Trusts and the Vera Institute of Justice. Every state except Alabama, Kansas, and New Hampshire
responded to both surveys. (See Appendix A: Methodology.) Characteristics examined include:9•• States’ prison health care delivery systems. While these do not necessarily influence the effectiveness ofprison health care systems, they fundamentally govern paths to performance measurement and improvement.
•• Several factors behind interstate spending variation, such as how money is spent, prices prisons pay, whom
prisons treat, and the quality of care provided.
Accounting for these sources of variation helps provide comparable information that can be used to better
understand how and why state per-inmate prison health care spending differs and to map out avenues for any
necessary changes. This analysis does not capture an exhaustive set of cost drivers or cost containers. Rather,it seeks to highlight and provide some of the main information officials need about what is spent, how money isspent, on whom it is spent, and what outcomes are achieved for those dollars.
Importantly, higher spending is not necessarily an indication of either waste or good quality care; likewise,
lower spending is not necessarily a sign of efficiency or poor quality. Instead, weighing all of these factors andothers, policymakers must seek to continually appraise the value their systems achieve. That is, they must
determine whether their systems are cost-effectively and sustainably delivering care that abides by constitutional
requirements and makes the most of opportunities to improve public health and reduce crime and recidivism.
In some cases, especially with respect to spending distributions and the results of quality monitoring, states arewithout the information necessary to appropriately understand what they are getting for their prison healthcare dollars or have not taken important steps to cement their processes and act upon the data. Moreover, muchof what does exist lacks the level of uniformity and standardization necessary to appropriately make state-tostate comparisons.

Delivery system organizational structure
One fundamental difference in the systems states use to deliver health care in prisons pertains to whether
the provision of on-site care is primarily the charge of state-employed clinicians and staff, or whether those
responsibilities are outsourced. Most states operate not exclusively on one pole or the other, but rather on acontinuum between the two.
In 17 states, the majority of health care services were directly provided by department of corrections staff in fiscal
2015. (See Table 1.) These states frequently looked to contractors to provide some care at a handful of facilities
or for discrete services, especially mental health treatment and pharmacy management, but the bulk of care wasmanaged and provided by the state.
On the other side of the spectrum, 20 states contracted out most health care service delivery. The scope ofservices provided differs across three primary dimensions: (1) whether individual contractors provide one or more
specific clinical services or a comprehensive set; (2) whether they only provide clinical services or also take on
managerial functions; and (3) whether they provide services in one, several, or all prisons in a state.63
In eight hybrid states (Colorado, Louisiana, Michigan, Minnesota, Montana, Pennsylvania, Rhode Island, andVirginia), care was provided by a roughly even mix of state employees and contracted vendors. Hybrid states
typically blend their delivery system model within facilities—with some clinicians working directly for the
department of corrections and others working for the contractor—but Virginia differentiates by facility.
Finally, four states (Connecticut, Georgia, New Jersey, and Texas) pair their corrections department with a state
medical school or affiliated organization.

10

Table 1

Delivery System Organizational Structures Vary
Delivery systems, fiscal 2015
Delivery System

StatesNumber of States

Direct-provision

AK, CA, HI, IA, NC, ND, NE, NV, NY, OH,
OK, OR, SC, SD, UT, WA, WI

17 states

Contracted-provision

AL, AZ, AR, DE, FL, ID, IL, IN, KS, KY, MA,
MD, ME, MO, MS, NM, TN, VT, WV, WY

20 states

HybridCO, LA, MI, MN, MT, PA, RI, VA

8 states

State university

CT, GA, NJ, TX

4 states

Note: New Hampshire did not provide data.
© 2017 The Pew Charitable Trusts

Evolution and trade-offs of outsourcing
Until the late 1970s, every state provided prison health care directly. Pivotal court decisions that orderedthat health care deficiencies be remedied caused many states to turn to contractors to swiftly improve theirsystems.64 Many needed to quickly recruit greater numbers of qualified staff, as physicians, nurses, and otherprofessionals were frequently in short supply, especially in the rural locations of many facilities.65 Whilefew states are under pressure to move so rapidly today, staff recruitment and retention challenges remain awidespread motivation for outsourcing. Many states that rely heavily on private vendors reported to Pew and
Vera that adequate numbers of mental health providers and nurses are particularly hard to attract. Vendors havean easier time attracting workers with specific skills and experience in some places, respondents said, because of
greater employment and compensation flexibility.

Balancing trade-offs of outsourcing
States balance several factors—not all of which are covered in this report—when deciding whether to provide
care directly or to utilize contractors to deliver some or all services. On the one hand, contracting transfers some
control to vendors, even while states retain accountability for fulfilling their core responsibilities and interests.
As Rodney Ballard, former commissioner of the Kentucky Department of Corrections, said, “States cannot
privatize or outsource their responsibility.”66 Associated risks can be compounded if cost-saving incentives are
not balanced by agreements that clearly specify performance expectations, incorporate incentives for quality, andprovide for rigorous oversight and performance-improvement procedures.67

11

On the other hand, outsourcing offers the possibility of upgrading a state’s system. It can also free correctional
administrators from day-to-day pressures, affording them more time to scrutinize the results of theirsystems,68 and potentially opens up access to specialized skills and expertise, as well as economies of scale.
Finally, depending on the parameters of states’ payment models, contracting out can allow for greater budget
predictability and financial risk sharing.
Contractual payment models
The way in which payments are tied to care affects several elements of prison health care system management.
Like other areas of health care financing, including federal-state Medicaid programs for low-income and othervulnerable populations, payment models broadly break down into either “cost-plus”—similar to fee-for-service
arrangements—or capitation. Contracts built on a cost-plus approach pass through each expense from thevendor to the state, plus an additional charge for arranging and managing care. In contrast, capitation-based
contracts establish a fixed per-person payment that vendors receive for all individuals under their care. This
was the most prevalent model in fiscal 2015, with all but nine (Alabama, Colorado, Louisiana, Maine, Michigan,
Montana, Pennsylvania, Rhode Island, and West Virginia) of the 28 contracted-provision or hybrid states
employing this approach. Montana and Pennsylvania reported using a cost-plus model and the rest of the ninestates indicated that theirs did not fall neatly into either of the two buckets. (See Appendix C, Table C.5.)
States weighing the trade-offs of the two models consider several interrelated factors: how to assign the financial
risk associated with utilization; how to arrive at suitable levels of spending predictability and transparency; andhow to incentivize quality and efficiency. (See Table 2.)
In their purest form, cost-plus contracts place all financial risk and reward on the state. That is, the state is
the primary beneficiary of cost savings when inmates collectively utilize fewer or less expensive services thanbudgeted. Likewise, the reverse is also true. Capitated models shift the financial risk and reward exposure tocontractors. If spending collectively amounts to less than the sum of capitated payments, contractors profit. But
they are also at risk of financial losses if spending exceeds projections.
Some states take steps to blend these approaches and share risk and rewards with vendors. For example,
Michigan, which employs nurses and dentists directly and contracts with a private vendor for doctors,
psychiatrists, and other positions, starts from a base capitated rate for the care provided by the latter. In cases
where the vendor’s actual costs—including its management fee—for certain services are lower or higher than thebase rate, the difference was divided between the contractor and the state in fiscal 2015.69 This division follows
a formula that caps the state’s exposure to cost overruns. Off-site hospitalizations are a common domain for risk
sharing, in large part because of their potential to generate substantial expenses.
Alongside financial exposure is spending predictability and transparency. By using a pure capitated approach,states are closed off from potential savings and overages, but have a relatively clear picture of what their total
spending will be, absent unexpected fluctuations in the prison population. However, because capitated payments
encompass a basket of health care services (such as on-site tests, primary care visits, and medication), states
may sacrifice some access to underlying, disaggregated cost data unless they require the contractor to provide
it or statistics on individuals’ use of services. This opacity can be mitigated during the procurement process if
states require bidders to detail and report the cost of providing certain services.70 Cost-plus payments can makespending more transparent, though also leaving states more open to financial risk and reward, and may makespending projections somewhat more challenging.

12Finally, states must consider the incentives created by the two payment models with respect to care delivery.
Because cost-plus systems pay contractors based on the volume of care provided, and not on the outcomesachieved, they can inadvertently incentivize excessive use of low-value services.71 Capitated payment models
create a different incentive structure by placing a greater premium on economizing. Whichever model is used,states must be vigilant in their oversight to ensure that savings are not the result of poor or inadequate care,running the risk of producing adverse long-term outcomes.

Table 2Contract Payment Model Decisions Balance Several Factors
Cost-Plus

Factors

Capitation

More state exposure

Financial risk/reward

Less state exposure

Less predictable

Spending predictability

More predictable

More transparent

Spending transparency

Less transparent

Less incentive

Incentivized economizing

More incentive

Necessary

Quality monitoring/oversight

Necessary© 2017 The Pew Charitable Trusts

Delivery systems dictate available policy levers
All states seek to build and maintain high-performing prison health care systems that help fulfill core interests:
constitutional compliance, protecting public safety, strengthening public health, and practicing fiscal prudence.
The design of their delivery systems—whether they keep the management and provision of care largely in-houseor outsource it—does not alter that common aim. To date, no systematic evaluations have definitively concluded
which approach is most cost-effective. A primary reason for this is the lack of comparable measures of prison
health care outcomes, and of service quality generally.72

States cannot privatize or outsource their responsibility.”
Rodney Ballard, former commissioner, Kentucky Department of Corrections
What is clearer is that the design of delivery systems has an important effect on the policy levers available inthe service of meeting objectives. For example, in states where the corrections department directly provides amajority of services, the onus to establish care protocols, retain a staff with sufficient capacity and expertise, anddesign rigorous systems for monitoring cost and quality falls squarely on state administrators and policymakers.
On the other hand, states that contract out a greater portion of their system need to take different steps tofacilitate effective decision-making, oversight, and performance improvement, including crafting contracts
that balance cost and quality incentives by pairing payment models with specific requirements, and vigilantly
monitoring and enforcing them.

13

Custody Arrangements
Nearly nine in 10 inmates under the legal authority of state departments of correction in fiscal
2015 were housed in state-run prisons. The operation of these facilities, including healthcare, is directly managed by state officials and carried out by a mix of state employees andprivate vendors.
A majority of states also put some of their incarcerated population under the physical custodyof privately owned and operated institutions or local jails. Private prisons are for-profit entities
that manage all correctional functions. Jails primarily contain people awaiting trial and thoseconvicted of misdemeanors who are serving sentences of less than one year.
State decisions about when and how best to make use of these alternative settings result froma number of considerations, including cost and space. States retain legal liability for health careprovided to those under their jurisdiction, even when the services are provided outside state-run
facilities. States lose some direct control and influence over the care that is provided—though
they can seek to track performance against established quality requirements—and typicallyhave less access to detailed cost and spending data, as health care costs are subsumed into
correctional per diem payment totals.

How states spend their prison health care dollars
Spending distributions must be examined to understand variation in per-inmate expenditure totals and trends,
as well as to evaluate the cost-effectiveness of care. In addition to information on deployed resources, the natureand extent of care needs, how resources and needs are matched, and the outcomes achieved, policymakers andprison health care administrators must know the cost of services in order to successfully manage their systems.73
Beyond top-line spending data, officials benefit from actionable, disaggregated accounting of how money isspent and how that apportionment has shifted over time. As with any budget area, the collection and analysis ofsuch material support vital management activities, such as identifying and tracking cost drivers and evaluating
the results of cost-containment strategies and other policy decisions.
To gain greater insight into this breakdown on a 50-state basis, Pew and Vera asked respondents to separate
their total spending into 22 line items, modeled after those used by the Centers for Medicare & Medicaid
Services to examine and report national health care expenditures writ large. These categories fell into six distinct
classifications: on-site care; off-site care; outpatient medical products; long-term care; other health, residential,
and personal care; and other expenditures. (See Figure 3.)
Building on what previous Pew research found, many states continue to report having a limited ability to dig deep
into their spending data. No state submitted data for all 22 categories requested. Thirty-three states said they
were unable to provide data across the categories, with a majority of them citing as barriers systems that do notallow for parsing spending in this fashion or a lack of access to detailed spending records from contractors. Nine
states did not clearly indicate whether they could disaggregate expenditures as outlined.

14

Seven states (Kansas, Kentucky, Maine, Missouri, New York, Ohio, and South Dakota) did use the provided
categories to report partial data, and additional states submitted data using their own approaches, which only
marginally aligned with surveyed categories. Among these seven states, four (Maine, New York, Ohio, andSouth Dakota) provided information for more than half of the categories, with each state’s breakout summing
to their total expenditures for at least three years. All but Maine provide care directly. The other three states(Kansas, Kentucky, and Missouri) populated data for eight or fewer categories, which did not add up to their total
expenditures.
The categories these seven states were most likely to report data for were spending on prescription drugs,
durable medical equipment (such as eyeglasses, hearing aids, and wheelchairs), nondurable products andsupplies (over-the-counter medications, medical instruments, needles, thermometers), residential mental healthtreatment, and compensation for on-site providers.
With so few states reporting complete disaggregated expenditures using the categories provided, it is notpossible to thoroughly analyze and compare states’ spending distributions and trends. However, some insights
do emerge from the four standout states. For example, compensation for nurses and prescription drugs wereamong the three largest spending categories for each in fiscal 2015. And in Maine, New York, and South Dakota,prescription drugs were among the categories that grew the most between fiscal 2010 and 2015.

15

Figure 3

Surveying the Distribution of State Prison Health Care Spending••••

On-site care

Off-site care

PrisonHealth Care
Spending• Inpatient• Outpatient• Emergency• Dialysis• Medical and diagnostic labs

Outpatient medical
products

Physician compensation
Nurse compensation
Dental compensation
Other provider
compensation• Administrationcompensation• Medical and diagnostic labs

• Prescription drugs(excluding medicationassisted treatment)• Medication-assisted
treatment• Durable medical
equipment• Nondurable medical
products/supplies

Long-term care

Other health, residential,
and personal care

• On-site dialysis• Hospice• Residential mental healthtreatment• Residential substance abuse
treatment• Other

Other expenditures
Note: These categories were modeled after the Centers for Medicare & Medicaid Services’ National Health Expenditure Accounts. The
22 categories surveyed encompass each bulleted line item, as well as long-term care and other expenditures. Long-term care includes
expenditures for relevant skilled nursing, inpatient nursing, medication, medical equipment and supplies, and intravenous therapy.
© 2017 The Pew Charitable Trusts

Putting detailed spending data to use
New York and Maine each reported using expenditure analyses to inform decision-making. In April 2012, NewYork replaced its statewide financial system. Building on the old technology’s capabilities, the upgrade allows
for tracking specific expenditure categories and analyzing trends and variations in high-cost areas. Recently, the
New York Department of Corrections and Community Supervision has been monitoring increases in spending forhepatitis C treatment, informing a targeted increase in the department’s health budget.74 The uptick is apparent
in the data provided to Pew and Vera, with a roughly 60 percent increase in prescription drug expenditures fromfiscal 2013 to 2015, a trend state officials attribute mostly to purchases of new hepatitis C medications.
Maine revamped its system in fiscal 2013, empowering officials to run more finely grained analyses. Financial
data for the Department of Corrections and other agencies are now gathered together and can be parsed andsifted according to queries by analysts and administrators. Officials report that the system and the information
it produces allow for data-driven budgeting by helping to establish historical cost trends, recognize emerging
changes, and determine whether they are likely to require temporary or permanent adjustments.75

16

The categorical spending data Maine submitted to Pew and Vera show that a significant spending jump fromfiscal 2013 to 2015 was partly driven by an increase in prescription drugs, more than offsetting a drop in inpatient
hospitalization costs. Officials attribute the uptick to more inmates requiring medication for HIV, cancer, andkidney disease and the establishment of an intensive mental health unit at a correctional facility for individuals
previously housed in a state mental health hospital.76

Thirty-three states reported that they were unable to provide spending data
for the categories Pew and Vera surveyed, with a majority of them citing as
barriers systems that do not allow for parsing spending in this fashion or alack of access to detailed spending records from contractors.
State approaches to disaggregating spending
As an alternative to populating the spending categories provided by Pew and Vera, states were also invited tobreak out spending based on their own approaches. Twenty-seven states provided such information, leaving
17 states providing no disaggregated data. As with the states that reported the most complete data using thescheme Pew and Vera provided, the group of 27 was made up largely of states that provide services directly.
Additionally, all four states that partner with medical schools or affiliated organizations provided such data. A
majority of the contracted-provision states reported no detailed data at all. (See Appendix C, Table C.6.)
The number of line items states used ranged from four in Michigan (health care, mental health, substanceabuse, and federal funding) to 29 in Washington, which tracked salaries and wages, employee benefits,professional service contracts, travel, capital outlays, debt service, interagency reimbursements, and intra-agency
reimbursements. Washington also dove deeply into goods and other services (such as prescription drugs) andgrants, benefits, and client services (inpatient and outpatient provider payments). (See Table 3.)
The categories states track suggest a mixed picture with respect to the analytic opportunities they offer. Amongthe 27 states that submitted their own spending breakouts, figures in seven did not add up to their total reported
expenditures, indicating that at least some trends of health care spending by the corrections department may gounmonitored. Additionally, several states reported a set of classifications that may hinder a deep examinationof spending drivers. In some cases, this was because the categories were not germane to specific services or
domains of services (for instance, a department tracking “Personal Services,” “Travel,” “Services,” “Commodity,”and “Equipment”). Others included among their classifications one or two that contain large portions—sometimes more than 90 percent—of spending.
Given the potential magnitude and volatility of expenditures on prescription drugs and off-site care, they can be
two particularly useful areas for departments to track. Of the 27 states, 10 track both, with an additional sevenmonitoring pharmaceuticals but not hospitalizations and other off-site care.
Among the states that submitted disaggregated data according to their own approach, Connecticut, New Jersey,
South Carolina, Washington, and Wisconsin stood out as employing especially actionable methods that lendthemselves to trend analyses. (See Table 3.) In each state’s submission, disaggregated expenditures were equal
to total spending, and categories were relatively narrow, germane to decision-making, and allowed for parsing
costs for pharmaceuticals and off-site care.

17

Table 3

Other

Other health, residential,
and personal care

Outpatient medical
products

Off-site careOn-site care

Select Approaches to Spending Disaggregation
Connecticut

New Jersey

South Carolina

Washington

Wisconsin

Medical salary

Medical/dental
compensation

Employeecompensation

Salaries and wages

SalaryMental health salary

Mental healthcompensation

Contractors—nurses,
dentists, and dental
assistants

Employee benefits

Fringe benefits

Pharmacy salary

Medical/dental fringe
benefits

Medical service
consultants

Professional service
contracts

Limited term employees

Professional medical
services

University of Wisconsin
Hospital and clinics

Labs/radiology

Mental health fringe
benefits

Diagnostic radiology

Grants, benefits, client
services (e.g., physician
assistant/nurse
practitioner/physician
and specialist on-site)

Inpatient hospitalization

Hospitalization

Inpatient hospitalization

Grants, benefits, client
services (e.g., specialist
off-site and hospital
outpatient)

Emergency
hospitalization

Outpatient emergency
services

Waukesha Memorial
Hospital

Outpatient

Hospital medical
services

Local hospital

Drugs

Medical/dental
pharmaceuticals

Medical supplies

Mental healthpharmaceuticals

Dialysis

Residential substanceabuse treatment

Addiction services

Department of Human
Services—mental
health civilly committed

Smoking cessation

Medical/dental other

Administration

Other

Prescription drugs

Goods and otherservices (e.g., over-thecounter medicine andprescription medicine)

Pharmaceuticals

Dialysis on-site

Grants, benefits, client
services (provider
payments, chemical
dep. treatment)

Medical/dental
overhead

Other services

Capital outlays

Vestica (third party
administrator)

Mental health overhead

Miscellaneous
expenses

Grants, benefits,client services (e.g.,client payments andemergency transport)

Other

Note: This table presents a condensed sample of spending categories that states reported tracking.
© 2017 The Pew Charitable Trusts

18

Supplies and services

Data needs transcend delivery system
Policymakers and correctional administrators in every state grapple with similar managerial considerations,
including resource allocation, delivery system optimization, and program and budget planning.77 These concerns
are present regardless of whether a state provides care directly, procures services through a comprehensive
contract, or takes a hybrid approach. Therefore, every state benefits from access to some level of detailed
spending data. If care is provided directly, evaluating cost-effectiveness is the sole responsibility of thedepartment. If the provision is contracted, such information is necessary for proper oversight and negotiation,
though there is some evidence that these states are less likely to have access to it.
Data needs in states procuring comprehensive contracts are somewhat analogous to so-called encounter datathat states receive from Medicaid managed care organizations (MCOs). Some states contract with MCOs todeliver Medicaid benefits to certain patients for a fixed payment per enrollee. Whereas states use patient claims
data under a fee-for-service system to monitor utilization and costs, under a capitated system, MCOs provide
state Medicaid agencies with encounter data that detail specific services provided to an enrollee by a provider
and corresponding payment information.78 States use the data for a variety of purposes, including setting
capitation rates, evaluation of MCO performance, and informing policy decision-making.79

Accounting for staffing expenditures
What states spend on prison health care, and how spending compares from state to state, is influenced by
the number and type of staff they employ or secure through procurement—in total and relative to inmate
populations. The Bureau of Justice Statistics has consistently found that employee salaries, wages, and benefits
represent between half and two-thirds of overall prison operating expenditures.80 Likewise, it has consistently
observed a clear relationship between total operating costs per inmate and staff-to-inmate ratios. Low ratios(that is, fewer staff relative to inmates in custody) have been most common in states reporting low average costs
per inmate, while high ratios predominated in states with high per-inmate expenditures.81
It makes sense that a similar connection would be found within the prison health care sphere, and research by
the bureau82 and the National Institute of Corrections has indicated as much.83 Like other health care settings, aswell as the country’s health care spending as a whole,84 personnel costs represent a substantial portion of states’
prison health care spending. Among the four states that reported complete disaggregated spending data using
the categories Pew and Vera surveyed, the provider and administrator compensation categories accounted fora median of 38 percent of expenditures in fiscal 2015. Similarly, of the states that submitted data based on theirown classifications, eight broke out personnel costs in some fashion, and they represented the largest categoriesof spending in each state.
In fiscal 2015, states and their vendor and university partners, as applicable, took dramatically different
approaches to staffing, according to data reported to Pew and Vera. The number of health professional
employees—measured as the number of full-time equivalents (FTEs) to account for part-time and full-time
employees—for every 1,000 inmates in custody ranged from 18.6 in Oklahoma85 to 86.8 in New Mexico, with a
median of 40.1 FTEs. Four states had fewer than 25 FTEs for every 1,000 inmates; 26 states had between 25 and50; and 13 states had more than 50.86 (See Appendix C, Table C.7.)
There was greater consistency in the composition of staff. Nurses—combining licensed practical nurses andregistered nurses—were far and away the most common FTE type. They represented the largest share of
FTEs in 33 of 37 states that provided comparable staff composition data87 and the second largest group in theremaining four. Mental health professionals who were not psychiatrists (e.g., psychologists, mental health19

counselors, clinical social workers, psychiatric technicians) were typically the second largest group, followedby administrative staff and paraprofessionals (e.g., nurse technicians, certified nursing assistants, medical
assistants, orderlies, aides, dental assistants, pharmacy technicians). Variation in states’ composition tended
to be especially narrow in high-skill, high-cost professions (e.g., physicians, psychiatrists, dentists, physician
assistants, nurse practitioners, pharmacists), which represented a small portion of staffing in every state. (SeeAppendix C, Table C.8.)
Health care staffing levels appear to correlate with per-inmate prison health care expenditures, though testing
the causal relationship was beyond the scope of this research. States with relatively high staffing levels in fiscal
2015 tended to have higher per-inmate spending. For instance, median per-inmate spending was more thandouble among the 10 states with the highest staffing levels than among the 10 states with the lowest levels.88(See Table 4.)

Table 4Per-Inmate Spending Increases With Health Staff

States with the lowest and highest health staffing levels, fiscal 2015
Bottom 10

Top 10FTEs per 1,000
inmates, FY
2015

Per-inmate
spending, FY
2015

FTEs per 1,000
inmates, FY
2015

Per-inmate
spending, FY
2015

Oklahoma

18.6$3,706Maryland

54.2$7,280Illinois

19.3$3,619Wyoming

57.7$11,798

Louisiana

23.4$2,173

Delaware58.6$8,408

Nevada24.5$3,246

Tennessee

58.7$6,001

South Carolina

25.0$3,478Minnesota

59.1$8,158

Alabama

25.3$3,234Massachusetts

60.2$8,948

Indiana

25.4$3,246

California

69.9$19,796Pennsylvania

25.7$4,548

Hawaii

72.3$5,422

Arizona

26.6$3,529

Maine

79.3

$7,397

Texas

27.2

$4,077

New Mexico

86.8$12,293Median25.2$3,504

Median59.6$8,283

Notes: Six states (Florida, Iowa, Rhode Island, Utah, Virginia, and Wisconsin) were excluded from this analysis because they submitted
staffing data that were incomplete or not comparable.
Staffing figures include health professionals employed directly by the state and those secured through contracting.
This analysis compares the number of health professional employees—measured as the number of full-time equivalents to account for
part-time and full-time employees—per 1,000 inmates under the custody of the corrections department to spending per inmate under thejurisdiction of the corrections department. In most states, the vast majority of inmates under their jurisdiction are also under their custody.
In states that make greater use of local jails or private prisons, where inmates are not under the custody of the state, it is possible that perinmate health care figures would differ if calculated based solely on spending in state-run facilities for inmates under state custody.
© 2017 The Pew Charitable Trusts

20Importantly, states’ filled positions may not entirely reflect their desired or budgeted staffing levels. Some states
reported difficulty in recruiting and retaining health care staff, especially mental health providers and nurses,
most frequently experiencing these challenges in remotely located prisons. Nevada, Oklahoma, and South
Carolina, for example, all reported relatively large vacancy levels, though filling all their empty positions would
only marginally increase their staff-to-inmate ratios.
There is no available one-size-fits-all template for staffing. Every state must weigh numerous factors when
determining what size and composition is appropriate. An important consideration is what returns theirpersonnel investments generate. States must determine whether the health professionals they employ or securethrough procurement position them to cost-effectively and sustainably meet constitutional requirements—
including by following state guidelines for the procedures, actions, and processes a practitioner is licensed toundertake89—and improve public health and reduce recidivism. An important tool in that assessment is a rigorous
and actionable quality monitoring system.

Accounting for hospitalization expenditures, shifting costs
State prison systems typically provide primary care and basic outpatient services in-house.90 Some havespecialized medical facilities, including fully equipped infirmaries or hospitals, to care for individuals with acuteor chronic illnesses that do not require off-site hospitalization. But nearly every system’s facilities are at least
somewhat limited in the care that can be provided—specialized diagnostic equipment is a common example
because its demand is deemed too small to justify its expense—so prison systems must rely to some degree on
off-site hospitals for specialist consultations, diagnoses, and observation; surgery; and other services.91
Because of their inherent duration and intensity, hospitalizations represent a significant health care cost.
Nationwide, inpatient care provided in hospitals accounts for a quarter of what the country spends on health careas a whole.92 Therefore, it is an important category of spending for correctional staff to monitor closely.
In recent years, state departments of correction, working with Medicaid agency partners, have increasingly
looked to the federal-state Medicaid program as a way to save money in this area. But states’ use of this savings
strategy has been uneven, contributing to per-inmate spending differences.
States are not precluded by inmates’ incarceration status from enrolling them in Medicaid. The federal Centers
for Medicare & Medicaid Services has long held that individuals who meet states’ Medicaid eligibility criteria“may be enrolled in the program before, during, and after the time in which they are held” in jail or prison.93
However, most inmates could not enroll in years past because, as nondisabled adults without dependent children,
they did not meet many states’ categorical eligibility criteria despite their low income.
Beginning in January 2014, the Affordable Care Act (ACA) created an opportunity for states to change thissituation by providing additional federal money to those that elect to expand their eligibility criteria for Medicaid
coverage to all individuals under age 65 who earn up to 138 percent of the federal poverty level ($16,643 for asingle adult in 2017).94 This expansion removed a key barrier that frequently prevented states and localities fromenrolling inmates—or keeping them enrolled during incarceration with suspended coverage—and seeking federal
Medicaid reimbursement for certain services provided to inmates. Thirty-one states and the District of Columbia
had expanded their criteria in accordance with the ACA as of the writing of this report.95
Under long-standing federal regulation, states may provide Medicaid coverage only to inmates for inpatientcare delivered outside the prison, such as at a hospital. Under these circumstances, states can obtain federal
reimbursement that covers at least 50 percent—and much more, if the person is newly Medicaid-eligible—of21

prisoners’ off-site inpatient costs, as long as they are eligible and enrolled in the program at the time of thehospitalization or soon thereafter.96
States that expanded their Medicaid eligibility under the ACA generally realize the largest savings from thisoption because most inmates, as nondisabled adults without dependent children, are eligible for coverage only
under the expansion. Moreover, payments for these newly eligible individuals trigger the enhanced federal matchof at least 90 percent.
By sharing the cost of some of their most expensive services with the federal government, some states havesaved significant sums of money. But the uneven use of this strategy, stemming in part from variation in states’
decisions regarding the expansion of eligibility criteria, must be considered when comparing fiscal 2014 and 2015
prison health care spending levels.
Take the Ohio Department of Rehabilitation and Correction, which saw its inflation-adjusted per-inmate spending
fall by 9 percent from fiscal 2013 to 2015. In anticipation of Medicaid expansion, the department began working
with the state’s Medicaid agency in 2013. By July 2013, Ohio was activating Medicaid coverage for inpatient
hospitalizations of inmates younger than age 21, over age 64, or pregnant—cohorts whose eligibility predated
the ACA. This was extended to all inmates in March 2014 after expansion had taken effect.97 According to state
officials, a drop in hospital spending by more than half was the largest contributor to the department’s overall
health care spending decline and the use of Medicaid financing was a leading reason.98
Similarly, New Jersey attributed a 20 percent reduction in the department’s hospitalization costs—from $12.2
million in fiscal 2014 to $9.8 million in fiscal 2015—to its efforts to enroll eligible individuals in Medicaid.

Agency Responsibility for State Medicaid and Off-Site Care Costs Varies
When departments of correction partner with Medicaid agencies, states take different
approaches as to which agency covers the state’s share of costs. In some states, the departmentof corrections pays for the remaining balance after federal reimbursement, whereas Medicaid
agencies do so in others. This is primarily a decision of how best to administer the program withrespect to inmates; the state’s obligation remains the same in either scenario.
Some states have entities besides their department of corrections pay for all off-site care.
For example, the University of Iowa Hospitals and Clinics receives state money to cover all
inpatient, outpatient, and diagnostic care provided to incarcerated individuals within university
facilities. Similarly, until fiscal 2014, Louisiana State University provided and paid for all off-site
medical care.
Different arrangements contribute to variation when comparing health care spending bydepartments of correction, but do not necessarily result in differences in prison health careexpenditures from the standpoint of state budgets as a whole.
Sources: Lettie Prell, director of research, Iowa Department of Corrections, interview with The Pew Charitable Trusts,
Aug. 29, 2016; Jodi Babin, assistant budget director, Louisiana Department of Corrections, interview with The Pew
Charitable Trusts, Jan. 26, 201722

Importantly, states need not expand their Medicaid programs in accordance with the ACA to make coverageavailable to inmates. Those with more traditional eligibility requirements will have some inmates who qualify.
Wisconsin, for example, has not adopted the ACA’s Medicaid expansion but provides coverage to nondisabledchildless adults whose incomes do not exceed 100 percent of the federal poverty level.99 The state receives thesame level of federal support for covering this population as it does for other eligible enrollees.

Health care prices that prisons pay
Health care spending—and therefore spending variation—in any setting reflects the combined effects ofutilization (the quantity, intensity, and mix of services) and price, the amount paid per unit of health care service.
Price variation is attributable to two factors: input prices, such as wages, rent, and other labor, capital, andoverhead costs; and negotiated provider profit margins.100 The first reflects geographic differences in the cost of
doing business; the second is driven by imbalances in the relative negotiating power of payers and providers.
With spending data alone—without information on utilization and prices paid for comparable services—it is
impossible to definitively know the extent to which price differences contribute to per-inmate spending variationor how particular states are affected. However, in the absence of standardized, nationwide price baselines, it islikely that prices play some role in spending differences. For example, median salary differences for cliniciansby geographic region could have a marginal effect on spending, as could variances in the accessibility of certain
specialists and services.

Hospital prices
There is some evidence that hospitalization prices contribute to per-inmate spending differences. Departments
in many states negotiate their own rates with hospitals for inpatient and outpatient care. But some, including
those in Connecticut, Texas, Washington, and West Virginia, adopt the price schedule negotiated by their state’s
Medicaid agency, even for care of individuals who are not enrolled in Medicaid (which can cover inpatient
hospitalizations for eligible inmates). Because Medicaid typically negotiates the most advantageous provider
rates among payers in a state,101 the departments that take this approach may be paying less than departments inother states for comparable services.
Departments in other states (such as Indiana) reported benchmarking their rates close to Medicare or by what
the state’s employee health plan pays (in Oklahoma and South Carolina).

Whom state prison health care dollars treat
For any health care payer—employer-sponsored insurance plans, Medicare, Medicaid, or others—thecomposition of individuals covered can have a dramatic effect on costs. Key interrelated predictors include age,gender, and health status. The same holds true for state prison health care systems. In addition to high rates
of infectious diseases, mental illness, and substance use disorder, chronic conditions such as hypertension,
diabetes, and heart disease have emerged as a growing challenge and expense. One of the trends contributing tothis circumstance is the aging of state prison populations.102

Prevalence of costly chronic conditions
In the U.S. health care system, chronic diseases and the behaviors that cause them account for most healthcare costs.103 Indeed, nearly 9 in 10 health care dollars nationwide go to treat people with at least one chronic
condition. Because they tend to visit the doctor more frequently, fill more prescriptions, and experience more23

hospitalizations, among other drivers, annual spending is more than double for those with one chronic condition,and more than five times as much for individuals with three.104
In 2011-12, according to the Bureau of Justice Statistics, half of state and federal prisoners reported ever having
a chronic condition, and 40 percent reported having a current one.105 This percentage was far greater thanin the general population, even after controlling for sex, age, and race. Hypertension, a chief risk factor for
cardiovascular disease, was the most commonly reported condition, followed by asthma and arthritis. Nearly
three-quarters of all persons in prison were overweight, obese, or morbidly obese, perhaps reflecting poor
nutrition or a lack of exercise or physical activity, leading causes106 of chronic diseases in the community. As in
the general population, older individuals (73 percent) were most likely to report a chronic condition. A majority ofwomen (63 percent) also reported having one or more.
A robust probing of state-to-state spending variation per inmate would require accounting for differences in theincidence of costly conditions, including chronic disease. Unfortunately, comparable disease burden data are
not available state by state, in part because of the absence of regular reporting and inconsistency in prevalence
tracking practices.
Pew and Vera asked states whether they track the prevalence of several serious conditions common among
incarcerated populations. Nearly all states reported that they track HIV/AIDS, active tuberculosis, and chronic
hepatitis C. However, there was greater variability with respect to chronic and behavioral health conditions. And
despite the aging of the prison population, states were least likely to track the prevalence of two associatedconditions: cognitive impairment and dementia. (See Figure 4.)24

Figure 4

Infectious Disease Prevalence Tracking Most Common;
Geriatric Conditions Least Common
Number of states tracking select conditions, fiscal 2016
HIV/AIDS

46

Active tuberculosis

45

Chronic hepatitis C

42

Diabetes

38

Hypertension

35

Asthma32

Cardiovascular diseases and stroke

31

Anxiety disorders

28

Mood disorders

28

Substance use disorder

28

Cancers

27

Chronic obstructive pulmonary disease (COPD)

27

Developmental disabilities

25

Cognitive impairment

19

Dementia

18

0

5

10

15

20

25

Infectious
diseaseDevelopmental
disabilities

Chronic
diseaseBehavioral healthcondition

30

35

40

45

50

Condition associatedwith aging

Note: Forty-seven states provided data on their prevalence tracking practices to Pew and Vera. (See Appendix C, Table C.11 for state data.)© 2017 The Pew Charitable Trusts

Still, some insights can be gleaned from examining the presence of certain groups disproportionately likely tohave expensive care needs, including older individuals and women.

Aging prison populations
The amount of older individuals behind prison bars has grown over time, and so have the resources required totreat them. From 1999 to 2015, the number of people age 55 or older in state and federal prisons—a common
definition of “older” individuals in prison—increased 264 percent.107 During the same period, the number ofinmates younger than 55 grew much more slowly: up 5 percent. (See Figure 5.) As a result, older inmates swelledfrom 3 percent of the total prison population to 11 percent.

25

Figure 5

The Number of Older Prisoners Grew by 264%, 1999-2015
Percentage change in sentenced prison populations by age group300%

157,500
prisoners 55 and older

Percentage change from 1999

250%

200%

150%

100%

50%

43,300
prisoners 55 and older
1,256,400
prisoners under 55

1,315,900
prisoners under 55

0%
1999

00

01

02

Prisoners 55 and older

03

04

05

06

07

08

09

10

11

12

13

14

2015

Prisoners under 55

Note: The Bureau of Justice Statistics estimates the age distribution of prisoners using data from the Federal Justice Statistics Program andstatistics that states voluntarily submit to the National Corrections Reporting Program. State participation in this program has varied, which
may have caused year-to-year fluctuations in the bureau’s national estimates, but this does not affect long-term trend comparisons. From
2009-10, the number of states submitting data increased substantially, which might have contributed to the year-over-year increase in thenational estimate between those years.
Source: U.S. Department of Justice, Bureau of Justice Statistics© 2017 The Pew Charitable Trusts

State prison populations account for the vast majority of these totals.108 Previous Pew research found that, fromfiscal 2007 to 2011, the share of individuals age 55 and over increased in nearly every state prison system.
More recently, among 44 states that reported population data by age to Pew and Vera,109 the number of older
individuals increased by a median of 41 percent from fiscal 2010 to fiscal 2015, expanding from 7 percent of thetotal to 10 percent. Indeed, the share of older prisoners increased in every state that provided data, topping out infiscal 2015 at a range of less than 8 percent in Connecticut, Indiana, Kentucky, New Jersey, and North Dakota tomore than 12 percent in Massachusetts, Nevada, Oregon, West Virginia, and Wyoming. (See Figure 6.)
Looking ahead, the proportion of inmates age 40 to 54 is an indication of how prison populations may continue
to age. In fiscal 2015, this group accounted for a quarter of the population in Delaware, North Dakota, and South
Dakota, and as much as a third in Hawaii and Massachusetts. Of course, not all of these individuals will remain
in—or return to—prison when they are age 55 or older.

26

Greater need, greater expense
Like senior citizens outside prison walls, older individuals in prison are more likely to experience dementia,
impaired mobility, and loss of hearing and vision.110 In prisons, these ailments present special challenges and cannecessitate increased staffing levels and enhanced officer training, as inmates may have difficulty complying withorders from correctional officers. They can also require structural accessibility adaptions, such as special housing
and wheelchair ramps.
Additionally, as the Bureau of Justice Statistics found, older inmates are more susceptible to costly chronic
medical conditions. Medical experts say inmates typically experience the effects of age sooner than people
outside prison because of issues such as substance use disorder, inadequate preventive and primary care prior toincarceration, and stress linked to the isolation and sometimes violent environment of prison life.111
For all of these reasons, the older inmate population has a deepening impact on prison budgets. Estimates of
the increased cost vary. The National Institute of Corrections pegged the annual cost of incarcerating prisoners
age 55 and older with chronic and terminal illnesses at, on average, two to three times that of the expense for allothers.112 More recently, other researchers have found that the cost differential may be wider.113
At the federal level, an assessment by the Department of Justice’s inspector general found that, within the Federal
Bureau of Prisons, institutions with the highest percentages of aging inmates spent five times more per inmate
on medical care—and 14 times more per inmate on medication—than institutions with the lowest percentage of
aging inmates.114
Why state prisons are aging
The graying of state prisons stems from an increase in admissions of older inmates to prison and the use of
longer sentences as a public safety strategy.115 From 2003 to 2013, admissions increased by 82 percent for thoseage 55 or older—faster than overall population growth for that age group—even as they declined for younger
individuals. A majority of these admissions were for new court commitments, which generally carry longer
sentences than parole violations.
Across all ages and offense types, the average time expected to be served on a new court commitment rose from
29 months in 1993 to 39 months in 2013. Among those age 55 or older in 2013, 40 percent had served 10 years
or more, up from just 9 percent who had served that long in 1993. As a result, individuals became more likely togrow old in prison. Six in 10 older inmates in 2013 had aged into that cohort, nearly double the share from 1993.
An additional explanation for the lengthy sentences is the nature of the crimes committed. Many of today’s older
inmates were convicted of serious, violent felonies in their younger years. Between 1993 and 2013, two-thirds ofpeople in state prison age 55 or older were sentenced for a violent crime, such as assault, rape, or murder. This
was the highest percentage among all age groups. Similarly, violent offenses were consistently the most common
reason for new commitments among this group.

27

Figure 6

Prison Population Age Distribution by State, Fiscal 2015
Massachusetts

14.4%

Nevada

13.1%

31.7%

West Virginia

13.0%

29.0%

Oregon

12.6%

30.9%

Wyoming

12.4%

California

12.0%

30.3%

Florida

12.0

28.0%

Montana

12.0%

Pennsylvania

11.3%

28.6%

Utah

%

11.3

29.8%

Texas

11.2%

31.1%

Hawaii

11.0%

34.0%

Kansas

%

11.0

29.0%

Oklahoma

11.0%

31.0%

Vermont

11.0%

27.0%

Louisiana

%

10.9

30.3%

Colorado

10.6%

29.5%

Washington

10.5%

30.6%

Arkansas

%

10.4

30.2%

North Carolina

10.3%

31.3%

Ohio

10.3%

26.7%
29.8%

33.1%

%

Wisconsin

10.3

Missouri

10.2%

29.4%

Maine

10.0%

27.0%

%

Virginia

10.0%

32.0%

Alaska

9.9%

27.4%

Nebraska

9.9%

27.7%
28.7%

South Carolina

9.9South Dakota

9.7%

25.2%

Georgia

9.6%

29.1%

New Mexico

9.4%

28.7%

Mississippi

9.3%

27.1%

Idaho

9.0%

28.0%
29.0%

%

Maryland

9.0%

New York

9.0%

31.0%

Delaware

8.9%

25.2%

Rhode Island

8.8%

27.5%

Arizona

8.7%

29.1%

Tennessee

8.7%

28.4%

Illinois

%

8.5

29.7%

Minnesota

8.0%

27.0%

New Jersey

7.9%

29.1%

Kentucky

7.7

%

26.6%

North Dakota

7.6%

23.9%

Indiana

7.6%

25.5%

Connecticut

6.8

27.1%

%

0%
Age 55+10%

20%

Age 40-54

30%

40%

50%

60%

70%

80%

90%

100%

Age 18-39

Note: Three states (Alabama, Iowa, and Michigan) either did not track inmates by the age brackets surveyed or did not report data to Pew
and Vera for fiscal 2015. Montana and Wyoming reported data only for the proportion of inmates age 55 and over. New Hampshire provided
no data at all. Percentages reflect all inmates under the jurisdiction of state departments of correction (i.e., those under the legal authority ofthe state, regardless of where the prisoner is held). (See Appendix C, Table C.9 for state data.)© 2017 The Pew Charitable Trusts

28

Women in prison
Like older individuals, women make up a small portion of state prison populations, but tend to have outsized andsometimes costly health needs. As the Bureau of Justice Statistics found, they are more likely than prisoners
overall to report a current or past chronic condition. And their rates of mental illness are substantially greater, inpart because of high rates of childhood sexual abuse and post-traumatic stress disorder.116
Also similar to older individuals, their numbers relative to state prison populations overall vary across the country.
In California, Maryland, New Jersey, New York, and Rhode Island, women represented less than 5 percent ofincarcerated individuals under state jurisdiction in 2015, whereas their share was above 11 percent in Hawaii,
Idaho, Kentucky, North Dakota, South Dakota, West Virginia, and Wyoming.117 (See Figure 7.)

Figure 7

Relative Number of Women in State Prisons Varies
Female share of state prison populations, 2015
WA
8.0%
OR
8.6%

ID
12.2%

NV
8.9%
CA
4.5%

WY
11.0%
UT
7.9%

AZ
9.3%

ME
9.1%

ND
11.6%

MT
10.6%

CO
9.2%

MN
7.1%
WI
6.1%

SD
11.7%
IA
9.1%

NE
8.0%
KS
8.5%

TX
8.8%

OH
8.5%

IN
9.3%

PA
5.7%
WV VA
12.2% 8.4%
NC
7.3%

TN
9.4%

AR
7.9%

LA
5.6%

MI
5.3%

KY
11.9%

MO
10.1%

OK
10.7%

NM
9.8%

IL
5.8%

NY
4.6%

MS
7.0%

AL
8.4%

GA
6.9%

SC
6.5%

FL
6.8%

AK
10.8%

VT

8.6%

NH

8.1%

MA

6.6%

RI

4.5%

CT

7.1%

NJ

4.4%

DE

8.1%

MD

4.4%

HI
11.9%
50-state median
4.4%

8.4%

12.2%

8.4

%

50-state
medianNote: Percentages represent those under jurisdiction of state correctional authorities on Dec. 31, 2015. Percentages were imputed for Nevada
and Oregon, which did not submit 2015 data to the Bureau of Justice Statistics. Percentages for Alaska, Connecticut, Delaware, Hawaii,
Rhode Island, and Vermont reflect jail and prison populations, as prisons and jails form one integrated system. (See Appendix C, Table C.10
for state data.)
Source: U.S. Department of Justice, Bureau of Justice Statistics© 2017 The Pew Charitable Trusts

29

Dearth of data notwithstanding, prevalence is probably connected to costs
Without standardized and universal procedures for tracking and reporting the prevalence of expensive medical
conditions, or a comprehensive understanding of differences in the practice patterns employed to treat them(such as using more or fewer tests or prescription drugs), it is not possible to know with precision how theirpresence affects prison health care spending state to state. But, as is true for every health care setting and payer,
it is likely that both prevalence and practice patterns play a part in what is spent, how spending changes overtime, and the observed variation across the country. With some states caring for more than twice the percentageof older inmates as their counterparts, and others imprisoning relatively fewer women than their neighbors,states face different challenges with respect to care needs, and their treatment responses are embedded in theirper-inmate expenditures.

Accounting for quality of health care that state prison dollars fund
The nature of the health care prisons provide affects inmates’ well-being and has a major impact on whether
states are able to cost-effectively and sustainably abide by constitutional obligations and make the most ofopportunities to improve public health and reduce crime and recidivism. Indeed, it was poor quality that led tothe establishment of legal requirements. Providing inadequate treatment for infectious diseases and behavioral
health conditions, among others, forecloses chances for prison health care to pay dividends in the communities
to which individuals return. And any value assessment of what taxpayers are getting for their prison health caredollars—and how it compares to other states—is critically dependent on an evaluation of the care provided.
Nevertheless, policymakers and administrators do not always have the information they need—or regularly
use what they do have—to proactively identify shortcomings and make improvements. If they do not basetheir decision-making on complete facts, they risk spending scarce resources unwisely and missing out on
opportunities to meet their objectives and obligations.

We really believe the way to provide cost-effective health care isby providing great quality care. So we put a lot of emphasis on
performance measures and clinical quality metrics.”
Michael Mitcheff, chief medical officer, Indiana Department of Correction
Source: Michael Mitcheff, chief medical officer, Indiana Department of Correction, interview with The Pew Charitable Trusts,
Aug. 26, 2016

To date, there are no uniform quality-of-care standards for correctional systems and facilities, nor a mechanism
for reporting comparable performance data.118 Standards have been developed by accreditors and other bodies,and hundreds of state facilities have adopted them. Nevertheless, little is known systematically about whether
and how states measure and monitor quality in their prison health care systems.119 Even less is known about
actual outcomes.
Therefore, Pew and Vera surveyed senior medical staff in state corrections departments to better understandwhether states have a quality monitoring system in place; its origins, design, and scope; and how the system
is used to continuously identify shortcomings, improve the value of care, and inform policymaking. Every state
except Alabama, Kansas, and New Hampshire provided data.

30

National evolution of quality monitoring
Recent decades have seen a movement to develop and implement measures and systems for monitoring thequality of health care, largely in response to growing evidence of disparities and deficiencies.120 Several bodies,including the National Committee for Quality Assurance (NCQA), the American Medical Association, theNational Quality Forum, and the Centers for Medicare & Medicaid Services have stepped forward to provide
guidance about how this can best be done. Today, most health insurance plans in the U.S. undergo annual
quality measurement and public reporting of results using NCQA’s performance measures from its Healthcare
Effectiveness Data and Information Set (HEDIS).121

Measuring care quality
The Institute of Medicine (IOM) defines quality of care as “the degree to which health services for individuals
and populations increase the likelihood of desired health outcomes and are consistent with current professional
knowledge.”122 IOM separates care quality into a framework of six dimensions: safety, effectiveness, patientcenteredness, timeliness, efficiency, and equity.123 (See Figure 8.) Existing measures primarily address effectivenessor safety, with fewer examining timeliness and patient-centeredness. Few assess efficiency or equity.124
Within this framework, each dimension can be evaluated based on structure, process, and outcome.125 Structuralcomponents represent relatively fixed inputs of care, such as the number of beds or the presence of an electronic
health records system. Process measures relate to the actions of providers and their interactions with patients,
while outcomes pertain to near- and long-term effects of providing care.126 According to the IOM, process
measures should be backed by evidence that better processes lead to better outcomes. Likewise, outcome
measures should be tied to processes, ensuring that they are measuring effects over which the health caresystem has influence.127

Figure 8

Health Care Quality Measurement Framework
Care Quality Measures

Safe

Effective

Patient-centered

TimelyEfficient

Equitable

Preventing actualor potential
bodily harm.

Providing care
processes andachieving outcomesas supported byscientific evidence.

Meeting patients'
needs andpreferences andproviding educationand support.

Obtaining neededcare while
minimizing delays.

Maximizing
the quality of acomparable unit ofhealth care deliveredor unit of healthbenefit achieved fora given unit of healthcare resources used.

Providing healthcare of equal quality
to those who may
differ in personal
characteristics
other than theirclinical condition or
preferences for care.

Structure

Source: Institute of Medicine; RAND Corp.
© 2017 The Pew Charitable Trusts

31

Process

Outcome

How state prisons monitor care quality
As health care quality measurement and monitoring has matured in the community, some state prison healthcare systems—alongside their colleagues in state Medicaid128 and employee health plan129 agencies—have begun
integrating such activities into their operations. Still, little has been known about whether and how they do so.
The scope of past research has been limited to individual states or small samples, preventing policymakers andother stakeholders from drawing broad-based, comparable conclusions and lessons.
For example, in 2009, the RAND Corp. reviewed the systems of Missouri, New York, Ohio, Texas, Washington,
and the Federal Bureau of Prisons regarding what measures were being used by state and federal institutions, therelative comprehensiveness of those measures, and barriers and facilitators to quality measurement for prison
systems.130 RAND found that while each of these departments was doing something to monitor quality, there wassubstantial variation in the number, types, and origins of measures being used, as well as in the developmental
phase of the underlying system enabling quality data collection. Covering a wide range of domains and clinicalareas (for example, infectious disease, screening, preventive services, access, prevalence), most systems
emphasized measurement of processes over outcomes.
RAND researchers also found that most systems they reviewed had facilities that were accredited by theAmerican Correctional Association or the National Commission on Correctional Health Care. Both accreditors
make site visits to conduct interviews and review patient charts and administrative documentation (suchas policies, relevant meeting minutes, training curricula, and patient grievances) to test compliance withaccreditation standards. RAND argued, like researchers before them,131 that while many of the standards haveprocess measures associated with them, such as how quickly services are delivered, they are not designed toassess whether evidence-based recommended care is provided and whether desired outcomes are achieved.

32

Examples of a Quality Measure
Quality measures can be used to determine whether patients with a particular health condition
received appropriate and timely care. The following examples are meant to be illustrative, notprescriptive:•• Screening: Percentage of inmates who received a physical examination within the first weekof incarceration.
•• HIV/AIDS: Percentage of inmates—in the facility at least 12 months—diagnosed with HIV
whose viral load is controlled to target.
•• Diabetes: Percentage of inmates—in the facility at least 12 months—diagnosed with diabetes
whose hemoglobin A1c is maintained at target.
•• Hypertension: Percentage of inmates—in the facility at least 12 months—diagnosed withhypertension whose blood pressure is controlled to target.
•• Mortality review: Peer-review process, often involving a broad set of staff, to identify
potential problem areas associated with care.

A 50-state survey of prison quality monitoring systems
For the purposes of this study, a quality monitoring system was defined as a uniform, standardized, and ongoing
set of policies, metrics, benchmarks, and data sources used and monitored by state officials—whether care wasprimarily provided directly or outsourced. To meet this definition, state quality monitoring efforts had to meetfour criteria. (See Table 5.) They had to be:•• Grounded in data;•• Established and overseen by state agencies;•• Applied broadly and consistently; and,•• Operated on an ongoing basis.
Thirty-five states reported that they operated a prison health care quality monitoring system in fiscal 2016, with
12 responding that their efforts did not meet the criteria. (Three states—Alabama, Kansas, and New Hampshire—
did not respond to the survey.) (See Figure 10.) All but one of the 35 states indicated that their monitoring
systems were applied to every facility (Kentucky applies its system to more than three-quarters of facilities).
Nearly every state with a system assigns responsibility for monitoring quality to its corrections department. Someshare responsibility with departments of health or public health (Arkansas, California, Indiana, Massachusetts,

33

Nevada, New York, and Washington) or the Office of Inspector General (California). South Dakota was the only
state to report that operation of its monitoring system was entirely outside of its corrections department. Quality
is monitored by its Department of Health, which provides medical, dental, and optometry services in the prison.
Its Department of Social Services manages mental health care.

Table 5Characteristics of a State Prison Health Care Quality
Monitoring System
Characteristic

Definition

ExampleGrounded in data

The system uses a set of measures toassess the quality of care delivered incorrectional facilities.

California Correctional Health Care Services
established a systemwide online dashboardthat uses clearly defined quality measures
to assess whether certain processes andoutcomes are followed and achieved.

Established and overseen bystate agencies

The system is overseen by one or morestate agencies. It is distinct from systems
overseen by contracted vendors, though it
may interact with them by incorporating
measures monitored internally by vendors
and/or collect data on particular measuresfrom vendors to populate its own system.
States may use their system to oversee theperformance of vendors.

As in many states, Maryland’s contracted
health care providers have their own quality
improvement processes. Layered on top is aquality monitoring process of the state thatinvolves both chart reviews and site visits bystaff of the Department of Public Safety &Correctional Services, as well as a separate
process for monitoring contract compliance.

Applied broadly and consistently

The system is applied to more than half ofstate prison facilities, and more thanhalf of the measures used across facilities
are identical.

All facilities in Washington state mustmonitor a core set of measures, butfacilities may add additional metrics if
there is an area of care they want to monitor
more closely.

Ongoing process

Quality is monitored on a regular schedule,
not in a point-in-time snapshot fashion.
This allows for tracking both continuous
operations and the quality of the resultsof services.

Every Sunday, the New Jersey Departmentof Corrections generates a report thatshows whether its provider is meeting
performance thresholds.

© 2017 The Pew Charitable Trusts

34Quality monitoring system objectives
When queried about their most significant objectives for quality monitoring systems, states spoke to a variety of aims.
Tool for organized, methodical quality improvement. For the Missouri Department of Corrections, its system
is meant “to provide a planned, systematic and collaborative approach to designing, measuring, assessing, andimproving the delivery of health services.” Quality monitoring by the Mississippi Department of Corrections ismeant “to identify, analyze, and correct problems which may potentially impede the quality of inmate health care.”Maximize value through the twin goals of adequacy and efficiency. Tony Washington, correctional healthservices administrator for the Utah Department of Corrections’ Clinical Services Bureau, reported his state’s
primary objective in monitoring quality is providing “constitutionally mandated offender health care in acompetent, caring, and cost-effective fashion.” Pennsylvania’s chief of clinical services for the Department ofCorrections, Dr. Paul Noel, said his system’s principal objective was to “provide necessary medical care forinmates in a clinically appropriate manner, organized for the most efficient use of resources.”
Meeting constitutional obligations and accreditation standards. Mississippi said that alongside identifying,
analyzing, and correcting problems, its system seeks “to ensure [that] the provision of inmate health care[is] consistent with applicable American Correctional Association (ACA) standards, National Commission
on Correctional Health Care standards, and constitutional standards governing health care service delivery.”Oklahoma’s respondent also cited ACA standards, while those from New Jersey and Tennessee cited “legal
requirements” and a goal to “reduce liability.”
Vendor oversight. Kenneth Williams, chief medical officer of the Tennessee Department of Correction, said that a
principal objective of his state’s quality monitoring system is to “hold [the department’s] vendor accountable.”
Georgia, Missouri, Pennsylvania, and Washington stand out for reporting an especially expansive and consistent
set of objectives. (See Table 6.) By seeking to marshal reliable evidence to measure quality and employ effective
feedback loops to inform and execute performance-improvement plans, the states aim to use their monitoring
systems to meet standards effectively and efficiently.

35

Table 6

Select Objectives of Quality Monitoring Systems
Georgia

MissouriPennsylvania

Washington

Ensure adequate
standards for health carewithin each facility.

Provide a planned,
systematic, andcollaborative approachto designing, measuring,assessing, and improving
delivery of health services.

Provide necessary
medical care for inmatesin a clinically appropriatemanner, organized forthe most efficient use ofresources.

Ensure that healthservices provided areaccessible, safe, effective,
patient-centered, timely,
efficient, [and] equitable.

Data-driven
measurement

Define indicators used tomeasure the quality andeffectiveness of all healthcare services.

Utilize an approach toquality assurance andquality improvement thatgenerates and relies onobjective data to identify
and monitor problems
and to document progressin their remediation.

Monitor quality throughdata, performancemeasures, direct
inspection, and ongoing
dialogue.

Clinical outcomesand standards

Attain desired clinicaloutcomes and maintain
optimal level of health topatients.

Continuous quality
improvement

Continuous improvement
through the use ofevidenced-based
methods.

Overarching
purposeBettermanagement

Ensure that all decisions
related to delivery of,access to, or quality ofhealth care [are] made byqualified personnel.

Constructive
communication

Targeted priorities

Monitor availabilityof health services
appointments within a
specific time frame.

Develop mechanisms toensure and improve thequality of care delivered,addressing elementsof structure, process,outcome, and resources.
Develop consistentpolicies and procedures
related to credentialing,
professional education,communicable disease
surveillance, audit ofclinical processes andoutcomes, disease
prevention, and clinicalsupervision.

Allocate appropriate
resources regarding
staffing and equipment toensure that needs are met.

Promote ongoing
communication between
the facility administrative
staff and the facility
medical staff to ensurethat services can bedelivered efficiently andeffectively.

Promote standardized,
evidence-based practice.

Facilitate change
and improvement,interpretation andcommunication of resultsmust be thoughtful, clear,
prompt, and operationallypractical.
Examine high-risk, highvolume, and problemprone aspects of care.

Note: This table presents a lightly edited and condensed sample of objectives that states reported.
© 2017 The Pew Charitable Trusts

36

Identify systemic gaps.

Ensure clinicalcompetency throughformal clinical oversightprocesses.
Empower all staff asactive participantsin continuous quality
monitoring andimprovement.

Promote safe, honest,
frank discussion of nearmisses and identified
deficiencies.

Monitor population
health; systematicallymanage chronic disease.

Scope and focus of quality monitoring systems
The scope and focus of monitoring systems varied somewhat across the states. To gain insight into whatstates with systems measure, Pew and Vera asked each whether their monitoring covered one or more of six
clinical domains:•• Access to care and utilization of services.
•• Screening and prevention services.
•• Infectious diseases.
•• Chronic diseases.
•• Behavioral health conditions.
•• Geriatric conditions or services.
Two-thirds of the states with systems (24 of 35) reported covering every domain except for geriatric conditions
or services; just 14 states include those in their quality monitoring. Twelve states (Arizona, Georgia, Indiana,
Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, New York, and Utah) reported
monitoring every domain. Florida’s system incorporated the fewest: only screening and prevention.
There was some variation with respect to sub-domains. For example, within the access and utilization domain, 32
states said they track measures related to access to care, whereas 24 look at grievance response time. Similarly,
within infectious diseases, tuberculosis is monitored more widely (27 states) than gonorrhea (15 states). (SeeFigure 9.) (See Appendix C, Table C.13 for state-specific data.)

37

Figure 9

States’ Use of Quality Measures Varies by Clinical Domain
Number of states tracking measures by clinical area, fiscal 2016
Access or utilization

34

Timely access to care
Triage response time

29

Timely and appropriate use of specialty care28

32

Timely and appropriate use of labs and imaging

26

Grievance response time

24

Other

4

Screening or prevention

33

Routine physical examinations

27

Vaccinations

23

Cancer screening

19

Other
Infectious disease

932

HIV/AIDS

29

Tuberculosis

27

Hepatitis C

26

Syphilis

19

Gonorrhea

15

Behavioral health
Suicide and self-harm30
28

Psychotic disorders (e.g., delusions/hallucinations, schizophrenia)

23

Mood disorders (e.g., major depressive disorder, bipolar disorder)

21

Substance use disorder (e.g., alcohol, drugs)

21

Anxiety disorders (e.g., panic disorder, post-traumatic stress disorder)

19

Other

1

Chronic disease
Metabolic diseases (e.g., diabetes)28
28

Cardiovascular diseases (e.g., hypertension, high cholesterol)

27

Pulmonary diseases (e.g., asthma, COPD)

25

Seizure disorders (e.g., epilepsy)

22

End-stage renal disease

19

Geriatric conditions or services

14

Palliative care9

Hospice7

Dementias and cognitive impairments
Pressure ulcers

6
6

Falls

5

Movement disorders (e.g., Parkinson’s disease)4

Urinary incontinence

3
0

5

10

15

20

25

30

35

40

Note: This figure captures the 35 states that reported operating a prison health care quality monitoring system in fiscal 2016. Twelve states(Alaska, Connecticut, Delaware, Hawaii, Iowa, Montana, North Carolina, North Dakota, Oregon, Rhode Island, Virginia, and West Virginia)
reported that their efforts did not meet Pew’s criteria. Three states (Alabama, Kansas, and New Hampshire) did not provide Pew and Vera
with data on their quality monitoring activities.
© 2017 The Pew Charitable Trusts

38

Facilitators and barriers to monitoring quality
When RAND asked its sample of state prison health care systems about the most significant facilitators to using
their measures, several spoke to the availability of disease management guidelines and evidence-based practiceguidelines. Health information technology, including electronic health records, was also mentioned, but most
systems were still at an early stage of implementation.
States continue to coalesce around these facilitators, which they cite as significant to establishing and using aquality monitoring system. Numerous respondents to the Pew/Vera survey cited working information systems,
signaling their maturation in recent years. According to one state official, having an electronic health record
system is instrumental to assessing the care being delivered in prison facilities. “It’s certainly revolutionizedwhat I do for a living because I can sit down and push a couple of buttons and see who is having problems,” theofficial said.
Though potentially valuable, an electronic health records system is not a precondition for monitoring quality.
Overall, 17 states that reported having a quality monitoring system also reported not using electronic records.
California, for example, posts a monthly online dashboard of performance indicators132 produced by aggregating
data from several primary sources, such as laboratory results, pharmacy information systems, and claims from
hospitalizations and other off-site services. Some data are extracted from scanned health records. At the time ofthis research, the state was in the process of launching an electronic health records system.133
Other commonly referenced facilitators included accreditation and other standards, as well as employing orcontracting with qualified, experienced staff committed and dedicated to monitoring quality.
In contrast, RAND found that scarce resources and competing priorities were common barriers. This is still verymuch the case. Tight staffing and related constraints, such as turnover, inexperience with monitoring quality, andfew training opportunities, were far and away the most frequently mentioned barriers. Speaking about navigating
staff shortages, one senior medical official said, “Care is always going to be primary, and sometimes the data
gathering is going to be secondary out of necessity.” Inadequate—or absent—electronic health records were also
commonly mentioned. Community providers face similar challenges, struggling with appropriately allocating
staff time to measurement activities, engaging staff in quality efforts, and fostering relevant expertise among
front-line workers.134
Informing spending and management decisions
States reported a number of ways in which results from their quality monitoring systems informed budget andadministrative deliberations.
Adjusting staffing and medication resources. Monica Gipson, director of health care services for the Indiana
Department of Correction, said her state uses its system to monitor persistent care backlogs and, as necessary,
add or redeploy staff. She also reported being better equipped to project future costs by closely monitoring
infectious disease control, particularly for hepatitis C and HIV. Dr. Noel of Pennsylvania reported that his systemprompted an increase in the number of psychiatric nurses in certain facilities after measures pertaining to
psychotropic medication compliance signaled underperformance.
Prisons also reported using prevalence data, especially for infectious diseases, to inform staffing and budgeting
decisions that affect treatment capacity. For example, by tracking the numbers of patients with chronic
hepatitis C and HIV, Indiana reported that it was better able to predict the need for costly medications to treat
these conditions.

39

Enforcing vendor requirements. All states that primarily outsource prison health care, whether they had a quality
monitoring system or not, reported that they include standards in a majority of their requests for proposal and/or
contractual agreements and use quality metrics to track compliance. A heavy majority enforce the standards withfinancial penalties. Some use both penalties and incentives, while others use neither. No state reported relying
exclusively on incentive payments. (See Appendix C, Table C.14.)
Vermont’s health services contract includes a set of performance metrics that are linked to monthly financial
incentives and penalties. Two process measures monitored are:•• Percentage of patients who received routine medication within designated time frames among all patients due
to receive routine medication.
•• Percentage of patients who received an electrocardiogram after complaining of chest pains among all patientscomplaining of chest pains.
Indiana writes specific health care outcome metrics into its contract. For example, if less than 90 percent ofdiabetic individuals are found to be properly controlled, the contractor has one month to achieve compliance
before being penalized.
Cost-effectiveness and cost containment. Michigan’s quality monitoring system has been used to spotlightinefficiencies and initiate actions to improve the cost-effectiveness of care delivery, especially as it relates
to pharmacy costs and treatments for cancer and hepatitis C. State officials credit successes, in part, to theinclusion of a financial analyst in its quality monitoring unit.135
The New Mexico Corrections Department said: “By monitoring the quality of care, we believe we can bend thecost curve. Managing care and delivering the care to the right [inmate] at the right time in the most efficient way
reduces health care costs. If we proactively engage in health management, we can improve health outcomes andreduce need for sick calls, chronic care clinic visits, and medications, thereby reducing pharmaceutical spending.”
No translation to spending and management decisions. While most states with quality monitoring systems
pointed to ways in which they are linked to spending and management decision-making, some reported that they
were not. Respondents either saw no applicable connection, or had not yet used the system in such a manner,highlighting one area in which the utility of monitoring quality may not be fully realized.
Few states codify and formally integrate systems into oversight and performance improvement
Even while 35 states reported operating a prison health care quality monitoring system that met the criteria set
for this study—data-driven, state-overseen, broadly and consistently applied, ongoing—far fewer indicated thatthey take the additional steps of formally requiring quality monitoring and building in regular opportunities toincorporate findings into oversight and performance-improvement activities.
Establishing requirements provides clarity for what shape a quality monitoring system should take, including
priority areas of focus, and bolsters consistency amidst personnel changes. Activating a recurring feedback loop
wherein performance is overseen and strengths and weaknesses can be identified, analyzed, and addressed
helps ensure that quality monitoring systems meet their ultimate objectives. These actions were measured inseveral ways:•• Codification. States met this condition if their quality monitoring system was required by state legislation,
executive order, or regulation.

40

•• Making quality monitoring outcome data accessible for oversight. States met this condition if theirdepartment of corrections routinely shares quality data with the legislature or the public.
•• Presence of a widespread continuous quality improvement (CQI) policy. CQI is a structured process designed
to continuously improve health care services by identifying problems, implementing and monitoring corrective
actions, and assessing their effectiveness. States met this condition if they reported having a statewide CQI
policy applied to all facilities.
Just six states (Florida, Nebraska, Nevada, New Jersey, New York, and Texas) were leading the way in generatingmuch-needed answers, formally requiring them, and ensuring that decision-makers consider the information.
(See Figure 10.) Florida, Nebraska, New York, and Texas have legislation on the books, whereas the systems of
Nevada and New Jersey are governed by regulation. Each had a statewide continuous quality improvement policy
in fiscal 2016. And each routinely shares outcome data with their legislature; Nevada, New Jersey, and Texas also
make it public.

By monitoring the quality of care, we believe we can bend
the cost curve.”
The New Mexico Corrections Department
Texas’ legislation requires its Correctional Managed Health Care Committee, a cross-stakeholder division of
the Texas Department of Criminal Justice set up in 1993 to address rising costs and operational challenges,136 toestablish a procedure for monitoring quality.137 The department must provide the results of this monitoring andany corrective action plans to the committee and the Texas Board of Criminal Justice, which also oversees thedepartment. In turn, the committee is required to submit a quarterly report with data on expenditures and healthcare utilization and acuity to the governor and the Legislative Budget Board, a committee that develops budget
and policy recommendations, completes fiscal analyses for proposed legislation, and conducts evaluations andreviews of state and local operations.138 The committee is also required to share “quality assurance statistics anddata, to the extent permitted by law,” with the public.139
Nevada promulgated a regulation in effect since 2012 that established a Medical Quality Management Program,which the state describes as a “structured process to monitor and improve health care delivery to inmates.” The
state convened central office and institutional-level committees to collect and review data to measure
the “effectiveness of the health care delivery system in the institution and if expected outcomes in patient care
are achieved.”140

41

Figure 10

Prison Health Care Quality Monitoring Across the United States

35 states have systems, six formally require and integrate them into decisionmaking and oversight
WA
OR

ID

WA

ID

NV
CA

NV

UT

CA

CO

CO

AZ
AZ

MN

NE

KS CA

KS

MO
OK

NM

TX

AK

MS SCAL

IL

VA
KS

NC

VA
TN
NC
NM

IA

NE

SC

OK

MO

QualityQuality
monitoring
system system
No quality monitoring systemmonitoring

FL
FL

Quality monitoring system
Data not available© 2017 The Pew Charitable Trusts

Activities of states without quality monitoring systems
States without quality monitoring systems reported engaging in a wide range of related activities. (Some stateswith systems also take these steps.) Most frequently, respondents said that while there was no standardized
statewide system, some facilities monitored quality. Slightly less frequent was for states and their facilities tohave no systems at all.

•• Maintaining accreditation.

42

N

AL

GA

LA

Data not available•• Regular audits of practices and protocols.

V

SC

NoThreequalitymonitoring
systemavailabledid not provide Pew and Vera with data on their quality monitoring activities. See
Note:states(Alabama,
Kansas, andData
New not
Hampshire)
Appendix C, Table C.12 for state data.

Common monitoring activities included:

WV

AR
MS

TX

IN

TN

GA

GA

PA

OH
KY

HI
Quality monitoring system,
codification, feedback loop

No quality monitoring system

WV

MI

HI
HI

Qualitymonitoring
system,Qualitymonitoring
system,codification,
feedback
loop loop
codification,
feedback

CO

LA
AK

AK

WV

AR AZ
AL
MS LA

PA

KY

KY

AR

TX

PA

UT
OH

TN

OK

NM

IL

MO
IN

IN

WI

SD

WY
NYOH

IL

NY MN

ME

MI

MI

NV

IA

NE

ID

IA

WI

ND

MT

WI

OR

MN

SD

UTWY

WA

SD

ND

WY

MT
OR

ME

ND

MT

FL

•• Continuous quality improvement programs, sometimes informed by episodic quality measurement.
•• Site visits and medical and mental health chart reviews, a process in which senior staff retroactively scrutinize
the care provided to a purposeful or random sample of patients.
•• Inmate grievance investigations.
•• Mortality reviews.
Inmate grievance investigations are distinct from tested and validated patient satisfaction or experience surveys,
which are frequently used in the community.141 Fewer than half of states reported using such instruments. Somecorrectional officials doubt that, owing to the circumstances of their incarceration, respondents would provide
unbiased feedback.142 But Connecticut and New Jersey, for example, have used them to positive effect.143
Mortality reviews, which involve peer review from a broad set of staff, are ubiquitous for states with and without
quality monitoring systems. In 2014, illness caused 87 percent of deaths in state prisons, with cancer andheart disease accounting for more than half of all deaths.144 Like hospitals, where death is a regular occurrence,
prison health care systems take stock after a patient death to determine whether it could have been prevented.
Such a process involves a review of the actions taken by the clinical team prior to the death in order to identify
opportunities for improvement. Only Connecticut, North Dakota, Virginia, and Washington do not formallyrequire such a review, though they do investigate deaths on an informal basis. Eighteen states reported having
a standard definition of medical preventability, with the rest solely relying instead on a peer-review process145 to
identify potential problem areas associated with care and undertake corrective action.
Some states have found that mortality reviews trigger important process changes that could save lives orotherwise improve patient outcomes. For example, one noted that, while it had procedures in place to put
inmates under suicide watch when denied parole by the parole board, no such procedure existed for when suchdecisions came from courts. This unfortunately resulted in an inmate committing suicide after a judge’s decision.
Following this death, the state has made efforts to communicate proactively with the courts regarding suchdecisions so that affected inmates can be put under greater surveillance.
Broad agreement over virtues; less so over barriers and plans
A majority of states without a quality monitoring system agreed or strongly agreed that establishing one isnecessary to achieve at least an adequate level of quality; would improve the quality of care provided in theirsystem; and would improve the states’ understanding of the value of their prison health care spending. Steve
Shelton, former chief medical officer of the Oregon Department of Corrections, put it this way: “I can tell thelegislature exactly where every penny went, how much we’re paying for generic medications, what percent [isspent] on generics, how much we’re spending on per patient, per month, what went to outpatient
hospitals, how much went to staff. I can tell them where the buck went. But without outcome and quality
monitoring systems, I can’t tell them what they get for that buck.”146

I can tell them where the buck went. But without outcome and quality
monitoring systems, I can’t tell them what they get for that buck.”
Steve Shelton, former chief medical officer of the Oregon Department of Corrections

43

States were more ambivalent with respect to barriers and plans, with some of the differences breaking downalong delivery system lines. States without monitoring systems that primarily rely on contractors to provide careagreed that they were held back by the lack of national guidelines or a standard for quality monitoring, whereas
states that provide care directly generally did not share this view. Likewise, contracted-provision states were farless likely to see cost as a primary roadblock. There was wider agreement over inadequate data infrastructureserving as a hindrance.
Looking to the future, most direct-provision states had plans underway to establish a system. The opposite wastrue of contracted-provision states, all of whom said that monitoring quality was the responsibility of contracted
vendors and that the department of corrections monitored their performance in a way that did not meet thisstudy’s definition of a quality monitoring system. Nevertheless, like their direct-provision counterparts, a majority
agreed or strongly agreed that establishing a system is necessary to achieve at least an adequate level of quality;
would improve the quality of care provided; and would improve the states’ understanding of the value of theirprison health care spending.

A Note on Conflating Quality Monitoring With Actual Performance
In this study, if a state does not have a monitoring system, its prison health care—whether
provided directly or procured—is not necessarily of poor quality. Conversely, having a systemdoes not necessarily mean that a state is providing high-quality care. States were assessed onwhether they monitor quality systematically, not on the merits of their systems nor the qualityof the care they provide.

Protecting Investments and Progress Through Care Continuity
At least 95 percent of those in state prisons eventually leave;147 more than half a million individuals do so in a
typical year.148 So prisons and communities are constantly reintegrating returning residents, a disproportionate
share of whom have a chronic disease, including a behavioral health condition or an infectious disease. Therefore
their prospects for a successful re-entry are affected by the seamlessness of their health care transition.
The time immediately following release can be especially dangerous and even deadly.149 Overdose is the greatest
health risk,150 often because—it is hypothesized—individuals lose their tolerance for opiates during periods ofabsolute or relative abstinence.151 Suicide and deaths related to cardiovascular disease are common as well.
In addition to concern for individuals’ well-being, prison health care systems and outside communities sharea strong interest in facilitating coordinated care continuity at the time of release due to the significant sums
devoted to incarceration, the public health and safety implications of prevalent conditions, as well as thelikelihood that poorly managed chronic diseases can result in avoidable and costly emergency room visits
and hospitalizations.152

44

Access to quality health care post-release is an important publichealth issue … and can help lower health care costs, hospitalizations
and emergency department visits, as well as decrease mortality andrecidivism for justice-involved individuals.”
U.S. Department of Health and Human Services
Source: U.S. Department of Health & Human Services, “New Medicaid Guidance Improves Access to Health Care for JusticeInvolved Americans Reentering Their Communities” (April 28, 2016), https://enewspf.com/2016/04/28/new-medicaidguidance-improves-access-to-health-care-for-justice-involved-americans-reentering-their-communities

If treatment is not continued outside prison gates, the recidivism-reduction and public health effects of evenwell-designed and -executed health programs delivered in facilities can be undermined. For example, being
uninsured upon release—true of nearly 80 percent of individuals in past years, according to some estimates153—
can serve as a major barrier to further care and is predictive of recidivism and associated with shorter times tore-incarceration.154 Similarly, in-prison treatments for substance use disorders and mental illness deliver betterand more durable results when patients are handed off to community providers.155 Likewise, case management
for high-risk cohorts can help avert emergency department utilization.156 And HIV-infected individuals whose
antiretroviral therapy is interrupted after release can develop higher viral loads that increase their risk of diseaseprogression and transmission to others.157
Continuity of care helps ensure that the benefits of treatment and the investment of resources devoted tostabilizing individuals’ health while they are incarcerated are preserved and not squandered upon release—only
to be spent again and again when inmates cycle back through the corrections system or turn up in emergency
rooms. Nevertheless, discharge planning from state prisons has historically been sparse or nonexistent, with only
10 percent of departing persons receiving any at all as recently as 2006.158 But this is beginning to change. States
are increasingly recognizing its benefits and importance—alongside robust community health systems to receive
those individuals.
Pew and Vera surveyed senior medical staff in state corrections departments to better understand the type ofcare continuity services offered, the timing of services, which populations, if any, are targeted, the nature ofinteragency and other cross-stakeholder partnerships, and associated outcomes. Every state except Alabama,Kansas, and New Hampshire provided data. Care continuity services can also be applied when individuals enter
prison, are transferred among prisons, or are transferred between prison and an off-site health care provider, but
this study focused on those pertaining to discharge.

Types of care continuity services
State prison systems, sometimes in partnership with other state agencies and community stakeholders, take avariety of steps to smooth re-entry from a health care standpoint. (See Figure 11.) Most fundamentally, many
make an effort to help individuals acquire health coverage, which serves as a vehicle for accessing care. Because
most formerly incarcerated individuals experience at least a temporary period of unemployment, and because
few have the resources to pay for commercial insurance, coverage often takes the form of Medicaid. Additional
actions include helping people maintain critical medication, connect with providers on the outside, and learn
about how to safely manage their disease(s).

45Many systems reported providing most or all of the surveyed services, though some pointed to relatively few.
(See Appendix C, Table C.16.) Likewise, some provide their full suite of services to every returning resident, whileothers employ a more targeted approach, often prioritizing those with infectious diseases or behavioral
health conditions.
Partnerships are common with colleagues in Medicaid and behavioral health agencies, as well as parole officers,
who can serve as de facto case managers. Behavioral health agencies administer services funded in large part by
the federal Community Mental Health Services Block Grant and the Substance Abuse Prevention and Treatment
Block Grant.159 These play a particularly important role in serving the uninsured.
Information sharing can also be a useful tool. As with anyone switching doctors, care continuity can be improved
after release by the transfer of medical records between prison health care systems and community providers.
Records sharing—whether paper-based or through electronic means—can save time and money by conveying
critical patient information that improves the likelihood that successful treatment plans are continued without
delay or disruption.

Figure 11

Facets of Care Continuity Planning
Healthcoverage

Providerlinkages

Medication
maintenanceCare Continuity

Records
sharing

Patient
education© 2017 The Pew Charitable Trusts

Medicaid enrollment
Health insurance is a key ingredient of access to quality care for all Americans, including individuals involved withthe criminal justice system. But many in prison have historically returned to their communities uninsured because
they were initially without access to employer-sponsored insurance, unable to afford insurance in the individual
market, or did not qualify for Medicaid.160 This erected a barrier to consistent care and threatened to strain the
resources of providers who treat the medically indigent.

46

States have never been precluded by inmates’ incarceration status from enrolling them in Medicaid,161 the primarymeans through which they provide health care access to low-income and other vulnerable populations. However,most inmates could not enroll in years past because, as nondisabled adults without dependent children, they did
not meet many states’ categorical eligibility criteria despite their low income. The Affordable Care Act (ACA)
created an opportunity for states to change this situation by expanding eligibility criteria, removing a key barrier
to enrolling individuals in prison or keeping them enrolled during incarceration with suspended coverage.
The federal government has strongly urged states and localities to incorporate Medicaid enrollment into theircorrectional discharge planning efforts. In April 2016 guidance to states, the U.S. Department of Health & Human
Services (HHS) noted that Medicaid “connects individuals to the care they need once they are in the communityand can help lower health care costs, hospitalizations and emergency department visits, as well as decreasemortality and recidivism for justice-involved individuals,”162 people under community supervision (e.g., parole), or
incarcerated in prisons or jails. The Centers for Medicare & Medicaid Services (CMS) encouraged “correctional
institutions and other state, local, or tribal agencies to take an active role in preparing inmates for release by
assisting or facilitating the application process prior to release.”163
Richard Frank, former HHS assistant secretary for planning and evaluation, said that health coverage after releaseis “critical to our goal of reducing recidivism and promoting the public health.”164 Former director of national drug
control policy Michael Botticelli drew an even bolder point: Immediate Medicaid coverage upon release “canmean the difference between … life and death.”165
Nearly all responding states reported to Pew and Vera that, as part of their re-entry planning in fiscal 2016,
potentially eligible inmates were assisted with applying for Medicaid in some or all facilities. Alaska, Hawaii,
Mississippi, Oklahoma, and South Dakota were the only exceptions.
States’ collective efforts are having a measurable effect. Researchers at Johns Hopkins University found thatthe uninsured rate for adults in the community with a substance use disorder and with prior-year involvementwith the criminal justice system (having been arrested and booked or on probation or parole in the previous 12
months) fell from a consistent 38 percent from 2004-13 to 28 percent in 2014, the first year of the ACA Medicaid
expansion. The change was mainly due to increased Medicaid enrollment.166 These new enrollees are likely to
use their coverage to access care. A study in Massachusetts found that, after the state expanded its Medicaid
eligibility and began enrolling returning inmates and connecting them with a primary care physician in theircommunity, 84 percent of enrollees used at least one covered service, including medical care, behavioral healthtreatment, and prescription drug medication.167(See Pew’s August 2016 brief on how and when Medicaid covers people under correctional supervision for
additional explanation of federal guidelines, their practical impact for state and local policymaking, and how somejurisdictions have navigated this terrain.)

Pairing enrollment with managed care discharge planning
Some states contract with Medicaid managed care organizations (MCOs) to deliver benefits and additional
services to certain patients for a negotiated per-enrollee payment. The Ohio Department of Rehabilitation andCorrection partners with the state’s Medicaid agency on enrollment and facilitates selection of a Medicaid
managed care plan 90 days before release. Additional care management services are provided to enrollees with“chronic risk indicators,” defined as having hepatitis C or HIV, being pregnant, or having been diagnosed with two
or more of the following: a chronic condition, a mental illness, or a substance use disorder. The medical historiesof these individuals are shared with managed care staff who develop pre-release transition plans, review and47

refine them with enrollees via videoconference, and follow up within five days of release.168 Corrections officials
believe Medicaid coverage and these services will help those leaving prison more successfully accessappropriate medical, mental health, and substance use disorder services, which they view as having the potential
to reduce recidivism.169
Louisiana launched a similar effort in January 2017, with a target population of those exiting with a serious mental
illness, a severe or moderate substance use disorder, cancer, HIV, or a disability. In addition to pre-release casemanagement from its managed care organizations, the state also leverages the influence and contact parole officers
have with returnees.170
These states are somewhat unusual. Even as a large and growing majority of states contract with Medicaid MCOs,171
only Arizona, Louisiana, Ohio, Utah, and South Carolina reported requiring their MCOs to provide care continuity
services. This may represent a missed opportunity. Because payments to MCOs are fixed, they share an incentive
with the state to keep individuals’ health stabilized, thereby averting avoidable hospitalizations, public health risks,and recidivism. (See Appendix C, Table C.17 for state-by-state data.)

Enrollment programs defined by state Medicaid policies
Whom departments of correction can enroll—and therefore how many—as well as the process they use is controlledin key ways by state Medicaid policies.
Eligibility
The most straightforward and significant is eligibility parameters. In the 31 states that have elected to expand theircriteria in accordance with the ACA as of the writing of this report, nearly all imprisoned persons are eligible forthe program because their incomes fall below the threshold. (See Appendix C, Table C.17.) In states that have notexpanded, fewer are eligible for the program, and those who are—typically those in traditional pregnant, aged,
blind, or disabled categories—do not trigger the enhanced federal reimbursement. This may influence the scopeof enrollment activities, though 11 non-expansion states (Georgia, Louisiana,172 Maine, Missouri, Nebraska, North
Carolina, South Carolina, Tennessee, Virginia, Wisconsin, and Wyoming) reported that all of their prisons facilitate
enrollment for eligible individuals nearing release.
Application process
Accepted application documentation is a second variable. States set rules about necessary documentation (such as adriver’s license or a birth certificate, as well as proof of income), which can pose a barrier for inmates who do not haveaccess to some or all of them. Nineteen states reported addressing this by permitting alternative documentation.
In Kentucky, Montana, New York, South Carolina, Texas, and Utah, a state-issued inmate ID is accepted. Colorado,
North Carolina, and Washington use their internal correctional system databases, rather than a physical form of ID.
Finally, in 16 states, the majority of prison facilities make use of “presumptive eligibility.” This is a policy that allows anindividual to be temporarily enrolled in Medicaid prior to an official determination of eligibility based on key pieces
of information. For example, in Connecticut, applicants released unexpectedly complete a condensed application
and receive a voucher, which allows them to at least fill prescriptions while their full application is being reviewed.173
With only nine states (Colorado, Louisiana, Massachusetts, Michigan, Minnesota, New Mexico, Ohio, West Virginia,
and Wisconsin) reporting that enrollees typically leave their facilities with a Medicaid card in hand (a number of
respondents said the corrections department does not track when Medicaid enrollment is completed), presumptive
eligibility can be a useful tool for expediting coverage. (See Appendix C, Table C.17 for state-by-state data.)

48

Suspending or terminating coverage
CMS has long encouraged states not to terminate coverage for enrollees during their time in correctional
facilities, but rather to temporarily suspend it until release or until enrollees receive off-site inpatient care.
Suspension allows coverage of all Medicaid services to resume seamlessly upon re-entry to the community.
Twenty-four states reported that Medicaid enrollment is generally suspended—at least temporarily—when aperson enters prison. Seven reported generally suspending coverage for a specific time period, such as the first
30 days or the first year of incarceration. An additional 17 states reported generally suspending coverage for thefull duration of time spent in correctional facilities. Twenty-two states said they generally terminate coverage,
including 13 (Arkansas, Colorado, Delaware, Hawaii, Illinois, Iowa, Maryland, Michigan, Minnesota, Nevada,North Dakota, Pennsylvania, and Washington) that had adopted the ACA expansion as of the writing of thisreport.174 (See Appendix C, Table C.17 for state-by-state data.)
Federal support is available to assist states with upgrading Medicaid eligibility and enrollment technology if theirsystems hinder or prevent them from suspending eligibility or coverage for incarcerated individuals.175

Maintaining medications
As in the community, prescription drugs play an important role in the health care delivered in prisons. Treating
prevalent conditions can necessitate use of medications, and continuation of these regimens can be criticalto preventing relapse and other adverse outcomes. Therefore, states take action to help ensure that there is
no gap or drop-off after release. Most commonly, 45 states reported providing a short supply of medication—
usually 14-30 days’ worth—that can serve as a temporary bridge until people can see a prescribing provider inthe community. In determining an appropriate quantity to release, prison health care systems weigh adequacy
against cost, as well as the potential for marketable medications to be diverted or sold.
To extend the duration, 30 states reported that they provide a prescription along with the bridge supply. The
Missouri Department of Corrections, for example, provides a 30-day supply. If the person runs out before
establishing a community provider, he or she can receive up to two 30-day refills from a nonprofit pharmacy withwhich the department partners.176 (See Appendix C, Table C.16 for state-by-state data.)

Linking to providers
Ultimately, health coverage and temporary medication supplies are of limited utility if individuals do not connect
with necessary providers. So states work to form such linkages in various ways, ranging from passive referrals
to actively facilitating opportunities for doctors to communicate with their future patients before release. Most
states reported offering referrals to both medical and mental health providers, while somewhat fewer do so for
substance use treatment clinics. Referrals can be as simple as advising people to seek care in the community, or
going further to provide a current list of providers that corrections officials know will see people newlyout of prison.
Some states try to schedule appointments, though they can face challenges, such as identifying offices willing to
see uninsured patients—especially in places where individuals do not qualify for states’ Medicaid programs—andlimited availability, even for the insured. Officials reported that success can sometimes be community-dependent,
reflecting capacity differences and other variables. Having dedicated discharge planners who develop familiarity
and relationships with providers across the state can mitigate these barriers.

49Pre-release sessions are rarer, but do occur. In Maryland, for example, HIV-infected individuals meet withoutreach workers from community clinics before release in an effort to improve the likelihood that they willcontinue receiving their medication without interruption.177 (See Appendix C, Table C.16 for state-by-state data.)

Records sharing
Records sharing can save time and money by relaying medical histories, diagnoses, current medications, andlaboratory test results, and helps prevent the delay or disruption of successful treatment plans. Community
providers who see patients after they have left the California Department of Corrections and Rehabilitation told
researchers of the RAND Corp. that a lack of medical records weakened care continuity. Relying on individuals toprovide a detailed medical history was found to be a poor substitute because, as one provider noted, in general,“patients are not good historians.”178
Twenty states reported to Pew and Vera that they routinely provide records to individuals leaving prison or totheir community provider. Some go further by enabling multiple agencies and providers to access at least some
information, mindful of the Health Insurance Portability and Affordability Act’s (HIPAA) privacy and consent
requirements.179 Correctional health providers in Delaware query information from a statewide health informationexchange (HIE), for example, and the state is working on making correctional health records available to outside
providers as appropriate.180 Similar efforts are underway to connect the Kentucky Department of Corrections
with the state’s robust HIE.181 And electronic health records in Indiana, Iowa, New Jersey, and Vermont areinteroperable with certain community providers, meaning that at least some practitioners outside the prison
walls can use electronic health information populated by prison staff. (See Appendix C, Tables C.16 and C.19 forstate-by-state data.)

Teaching skills for self-management of healthAll people, whether in prison or not, play a large role in managing their own health. Hypertension and diabetes
control requires healthful eating and exercise. Diabetic patients sometimes monitor glucose levels and, if
necessary, self-administer insulin. Controlling HIV requires following a precisely scheduled medication regimen.
To equip individuals with skills to successfully manage their conditions, 40 states reported offering general
educational opportunities prior to release.
However, just over half (29 states) provide overdose prevention classes. These can be important, as reduced
tolerances after periods of abstinence can lead to inadvertent overdose and death. Effective drug addiction
treatment during and after incarceration can help prevent reuse altogether. Both approaches may be important
tools as states work to combat their opioid crises. (See Appendix C, Table C.16 for state-by-state data.)

Targeting high-risk populations
Given the organizational challenges of coordinating care continuity upon re-entry, many states prioritize
individuals with particular conditions, rather than offering the same suite of services to everyone. (See Figure12.) Services are commonly targeted to individuals with HIV and AIDS, hepatitis C, substance use disorders, andmental illnesses. Prioritization can take the form of either providing a baseline set of services to all as appropriate
as well as additional actions for a select group (26 states), or only providing care continuity services to inmateswith certain diagnoses (14 states). (See Figure 13.)50

Figure 12

Number of States Offering Select Care Continuity Services,
Fiscal 2016
Bridge medication

26

Referrals to mental health treatment

19

14

Referrals to medical providers

30

11

Patient education for disease prevention and management32
16

Referrals to substance use disorder treatment

24

10

Written prescriptions

26

12

Confirmed appointments with substance use disorder treatment providers

19

3

28

Referrals to peer recovery programs for substance use disorder8

Confirmed appointments with medical providers

22

6

Overdose education

6

Confirmed appointments with mental health treatment providers

4

22
22
23

Communication with provider prior to release 2
0

20

5

10

Offered to all

15

20

25

30

35

40

45

50

Offered to those withcertain conditions

Note: Forty-six states provided data on their care continuity services to Pew and Vera.

States represented in the blue bars do not provide these services to every inmate. For example, appointments for mental
health or substance use disorder treatment are scheduled as appropriate. Rather, these states reported that they offer these
services to every departing inmate, as appropriate, whereas states represented in the orange bars offer these services to only
those with certain conditions.
© 2017 The Pew Charitable Trusts

HIV and AIDS
Most of the states that reported prioritizing particular populations focus at least on inmates with HIV/AIDS.
Centers for Disease Control and Prevention (CDC) guidelines recommend that patients in this group receive
confirmed appointments with community clinicians as well as a supply of medication, a copy of their medical
records, and enrollment in safety-net programs or a medication assistance program, as applicable.182 Without
adequate medication, individuals’ health deteriorates and they can become more infectious, increasing the riskof transmission to others.
Still, a 2012 survey by Abt Associates and Brown University found that only eight of 43 responding prison healthcare systems followed the CDC guidelines.183 Even with assistance, it can take more than 90 days post-release for
an inmate to have a first appointment.184
Florida, which has one of the highest rates of HIV infection in the country,185 is one state with a formal policy tofollow CDC guidelines. By law, the state must educate HIV-infected incarcerated individuals about preventing
transmission and the importance of receiving follow-up care and treatment, complete written discharge plansincluding information on the county health department and nearby HIV care, and provide a 30-day supply of
previously prescribed HIV/AIDS medication.186

51

Funding is available from the federal Ryan White HIV/AIDS Program to help states pay for such programs. Amongother elements, this program provides funding to states to cover medical care, medication, and support services
to people with HIV/AIDS.187 Through the support services provision, states can pay for case management forpatients leaving prisons. These patients can also receive medications through Ryan White funds once they are nolonger incarcerated, a crucial benefit for those who do not qualify for Medicaid or other health insurance.
Virginia has used Ryan White funding to create a care coordination program. Care coordinators work with
Department of Corrections health care providers and community-based organizations to ensure that individuals’
needs are met, including access to medication, primary care, and support services. Clients of the program arefollowed for 12 to 18 months.188

Figure 13

Care Continuity Services Stratified by Condition in Many States
Targeting approach by state, fiscal 2016
WA
OR

ID

MN
MI
IA

NE
UT

CA

AZ

CO

NY

WI

SD

WY
NV

ME

ND

MT

IL

KS
OK

NM

WV

VA

KY

NC

TN
SC

AR
MS

TX

IN

MO

PA

OH

AL

GA

LA
FL

AK
HI

Same services, regardlessof condition

Same baseline services,
some targeted

All services are targeted

Data not available

Note: Four states (Alabama, Kansas, New Hampshire, and West Virginia) did not provide Pew and Vera with dataon their care continuity services. (See Appendix C, Table C.15 for state-by-state data.)© 2017 The Pew Charitable Trusts

52

Hepatitis C
As with HIV/AIDS, coordinating treatment for individuals with hepatitis C can improve their prospects and help
prevent spread of the disease.189 A key difference, however, is that hepatitis C is curable. Transformative advancesin drug treatments have made them more effective and easier for patients to take. For decades, the only option
was interferon-based injections, which made patients feel ill, required up to a year of treatment, and cured only
40 to 50 percent of recipients. New pill-based therapies have doubled the cure rate and shortened the durationof treatment to three months.190
However, the drugs are expensive,191 and they are provided in a course of therapy that, if interrupted, risks leading toa medication resistance. For both reasons, state prisons are hesitant to start someone on the drugs unlesshe or she will be able to complete them before departing, making them less likely to provide bridge medications forthe treatment of hepatitis C than other illnesses. This makes referrals and scheduled appointments
especially important.

Substance use disorders
Twenty-three states reported prioritizing services for individuals diagnosed with a substance use disorder. Somestates use federal funds from the Residential Substance Abuse Treatment for State Prisoners (RSAT) program
to help fund care after release. Run by the Department of Justice, this program administers grants to states toprovide treatment in correctional and detention facilities and community-based services for probationers
and parolees.192

Medication-assisted treatment (MAT)
States can also provide medication-assisted treatment (MAT)—a combination of psychosocial therapy (suchas counseling or cognitive behavioral therapy) and U.S. Food and Drug Administration-approved medication(methadone, buprenorphine, and naltrexone)—to help inmates stay off drugs as they return to the community.
Research shows that this is the most effective intervention to treat opioid use disorder and is more effective thaneither behavioral interventions or medication alone.193 MAT significantly reduces illicit opioid use compared with
nondrug approaches,194 and increased access to these therapies can reduce overdose fatalities.195 By reducing risk
behaviors such as injection of illicit drugs, it also decreases transmission of HIV and hepatitis C.196
Emerging evidence has shown MAT to be effective for individuals leaving prison. One study found that
naltrexone, which blocks the effect of opioids without producing physical dependence, made relapse less likely.197
Another found that methadone and counseling post-release reduced heroin use and participation in criminal
activity for at least six months.198 Similar results have been seen with buprenorphine treatment.199
Nevertheless, just 20 states reported facilitating access to MAT upon re-entry. (See Figure 14.) Fewer provide themedication directly—13 states make available a supply of naltrexone; three provide a supply of buprenorphine.200
This may reflect, in part, the newness of the medications. A number of states noted that they were exploring theissue and/or developing a program. Others reported that relatively few individuals in their prisons had opioid
addictions. Expense may be a barrier for some, but federal assistance is available. States can use RSAT funds
to pay for this treatment, and the federal government has reportedly made dedicated funds available to somestates to help them create naltrexone programs for exiting offenders.201 (See Appendix C, Table C.18 for state-bystate data.)

53

Figure 14

Few State Prisons Facilitate MAT Upon Re-Entry
MAT policy by state, fiscal 2016
WA
OR

ID

MN
MI
IA

NE
UT

CA

AZ

CO

NY

WI

SD

WY
NV

ME

ND

MT

IL

KS
OK

NM

MO

IN

WV

VA

KY

NC

TN
SC

AR
MS

TX

PA

OH

AL

GA

LA
FL

AK
HI

Some MAT at re-entry

No MAT at re-entry

Data not available

Note: A state is shown as facilitating medication-assisted treatment at re-entry if it provides a prescription, a
supply of medication, an injection of naltrexone, or a referral to a prescriber.
© 2017 The Pew Charitable Trusts

Mental illnesses
Twenty-nine states reported that they prioritize re-entry services for individuals with at least one mental
health disorder. Each pays particular attention to those with psychotic disorders (delusions/hallucinations,schizophrenia), and 24 also prioritize mood disorders (major depressive disorder, bipolar disorder). Re-entry
services were less likely to be prioritized for those with personality or anxiety disorders.
Among all reporting states—those that stratify care continuity services and those that do not—referrals tomental health treatment in the community is common, with 44 states reporting that they offer this service to atleast some mentally ill persons. Providing confirmed appointments is less common (28 states). (See Appendix C,
Table C.16 for state-by-state data.)
The Louisiana Department of Public Safety and Corrections has made the provision of confirmed appointments
such a priority that one of its strategic plan performance indicators is the percentage of soon-to-be-released54

individuals on psychotropic medication who have been scheduled for a follow-up appointment in thecommunity.202 But their success can be complicated by a scarcity of capacity. “We do such good work indiagnosing, identifying, screening, assessments, treatment, stabilizing, but most of them get released, andconnecting them to the community providers, to ensure continuity of care, is a very challenging task,” said Raman
Singh, medical director for the department.203
Since 2006, the Oklahoma Department of Corrections has partnered with the state’s Department of Mental
Health and Substance Abuse Services to operate a targeted case management program for seriously mentally
ill individuals, assisting their transition to community-based services. A state assessment found that, after 36
months, recipients were less likely to return to prison or have an inpatient hospitalization, and more likely to use
outpatient and other community services and be enrolled in Medicaid.204
New York requires such planning by law. All inmates who received mental health treatment in the statecorrectional system within three years of parole must receive discharge planning. If necessary, they must also
receive an appointment with a prescribing provider and bridge medications that will last until that provider
can be seen.205
As part of California’s parolee program for the mentally ill, participants receive tailored release planning before
leaving the prison and are connected to treatment in specialized parole outpatient clinics, which provide
medication management, group therapy, individual therapy, and case management. Those who visited the clinic
at least once reduced their odds of returning to custody in one year by more than half.206
In Colorado, seriously mentally ill parolees are assigned to behavioral health clinicians who work with them toensure that their psychiatric, substance use, and housing needs are addressed. These specialists meet with theirclients at parole offices, provide case management, make referrals to service providers, help navigate obstacles toobtaining medication, and assist with mental health crises.207

Including parole officers in care continuity
As the overall health profile of incarcerated individuals has deteriorated, health care has become an increasingly
important element of parole officers’ portfolios. This is especially true for mentally ill parolees. “A lot of thepatients, especially our mental health patients, don’t necessarily have family … that wants them to come home.
So they’ll go to a shelter. But then the probation and parole officer will be the individual that actually takes the …
patient to their appointments, helps them get their medication, and kind of helps them get re-established in thecommunity,” said Terri Catlett, deputy director for health services of the North Carolina Department of
Public Safety.208
In some cases, this has required parole officers to adapt to their broadening roles. In Alaska, parole officers who
work with mentally ill individuals required to seek treatment as a condition of their release receive extensive
training on how to interpret and respond to setbacks. Laura Brooks, director of Health & Rehabilitation Services
for the Alaska Department of Corrections, said that success requires understanding that “just because thisperson didn’t show up for two … appointments in a row, doesn’t mean you have to issue a warrant for him,”
because he might be experiencing a mental health crisis rather than simply being noncompliant.209
Overall, staff from prisons in 29 states reported working with community supervision staff in some health care
continuity fashion.

55

Conclusion
Policymakers in every state are charged with thinking about and searching for ways to make their constituentssafer and healthier, and to spend taxpayer dollars more prudently. Those are complicated, multifaceted
responsibilities. But it is clear that prison health care systems have an important role to play in these efforts.
With state prisons housing so many individuals with extensive health conditions—some of which threaten to
spread to others inside and outside prison gates or contribute to costly and dangerous recidivism—and withnearly all of them destined to return to their communities, the manner in which care is provided in prison andhanded off after release carries high stakes. High-performing systems require good data on what is spent and thefactors driving costs, what outcomes are achieved, and whether the returns on investments are preserved—alongwith processes to continuously use these data to make enhancements.
This study provides and points to some of the information policymakers and administrators need to proactively
make the most of opportunities and avert the harmful and expensive consequences of missteps. Despite states’
uniform interests, their provision of prison health care—and the material they produce to inform decisionmaking—is characterized by significant variation. Going forward, all stakeholders will need to do more to better
understand whether this variation reflects meaningful discrepancies in value, and what can be done to improvecost-effectiveness.

56

Appendix A: Methodology
To collect data for this report, The Pew Charitable Trusts conducted two surveys in 2015-16 in partnership with
the Vera Institute of Justice. These instruments were developed with the guidance of a panel of advisers:•• B. Jaye Anno, Ph.D., co-founder of the National Commission on Correctional Health Care and correctional
health care consultant.
•• Jack Beck, J.D., director of the prison visiting project at the Correctional Association of New York.
•• Ingrid Binswanger, M.D., M.P.H., M.S., senior investigator, Kaiser Permanente Institute for Health Research,
Denver, and associate professor, University of Colorado School of Medicine.
•• Cheryl L. Damberg, Ph.D., distinguished chair, health care payment policy, and principal senior researcher,
RAND Corp.
•• Warren J. Ferguson, M.D., professor and vice chair, community health, department of family medicine andcommunity health, and director of academic programs, health and criminal justice program, University of
Massachusetts Medical School.
•• John Pulvino, P.A., senior director, quality and outcomes, University of Texas Medical Branch, Correctional
Managed Care.
•• Emily Wang, M.D., M.A.S., associate professor, Yale School of Medicine, and co-founder, Transitions
Clinic Network.
•• Brie Williams, M.D., M.S., professor of medicine, division of geriatrics, and founder and director, criminal
justice and health program, University of California, San Francisco.
The survey instruments were also pretested with pilot states. Feedback from these respondents helped improvethe clarity, relevance, and usability of the instruments.
All states except New Hampshire participated in the first survey, and all except Alabama, Kansas, and New
Hampshire participated in the second. Repeated invitations to participate were extended to these states over
several months.

Survey I: Spending, demographics, delivery systems, and staffing
The first survey, addressed to senior budget staff of state departments of corrections, queried them on their:•• Total and disaggregated expenditures for health care provided to adults under the jurisdiction of the state infiscal 2010-15.
Individuals under state jurisdiction are under the state government’s legal authority, regardless of where
they are housed. Such individuals may be in the custody of a local jail, another state’s prison, or a contracted
correctional facility (e.g., a privately owned prison). Expenditures were assumed to be inclusive of all settings
unless respondents indicated otherwise. (See Appendix B: State data notes.) Per-inmate spending calculations
accounted for all such individuals as appropriate.
State probationers and parolees—as well as individuals under state custody but under the jurisdiction of a
locality, another state, or the federal government—were excluded.
Health care spending—funded by state or federal funds—included on-site care (provider and administrativecompensation, medical and diagnostic lab services); off-site care (inpatient, outpatient, emergency, dialysis,
medical and diagnostic labs); outpatient medical products (prescription drugs, medication-assisted treatment,57

durable medical equipment, nondurable medical products/supplies); long-term care; and other health,residential, and personal care (dialysis, hospice, residential mental health and substance abuse treatment).
These categories were modeled after the Centers for Medicare & Medicaid Services’ National HealthExpenditure Accounts.
Respondents were asked whether they were able to provide disaggregated expenditures using categories
provided by Pew and Vera, and, if not, what challenges prevented them from doing so. Respondents were also
invited to report such data using the approach their departments used to track them.
States in which the corrections system is a combined jail-prison system—sometimes called a unified system—
were asked to provide the cost of health care for both pretrial and sentenced inmates under state custody.
These states were Alaska, Connecticut, Delaware, Hawaii, Rhode Island, and Vermont.
•• Prison population demographics for fiscal 2010-15, including:•• The average daily population of those under the custody of the state corrections department, private
prisons, and local jails, respectively. These subtotals were summed to reflect the total average daily
population under the jurisdiction of the state corrections department.
•• The proportion of those under the jurisdiction of the state corrections department who were ages 40-44,
45-49, 50-54, 55-59, 60-64, and 65 and older.
•• Health care delivery system in fiscal 2015. Departments were classified as:•• Direct-provision: Most health care services provided by non-university-based state employees.
•• Contracted-provision: Most health care services provided by contractor and contractor’s staff.
•• State university provision: Most health care services provided by state medical schools or affiliatedorganizations.
•• Hybrid: Most health care services provided by a combination of non-university state employees, contracted
employees, and/or state university employees.
Departments reporting any delivery system but direct-provision were further asked whether their contractual
payment model was:•• Cost-plus: Contractors bill the department for the cost of providing medical services plus a management fee.
•• Capitated (worded as “comprehensive” in the survey): Contractors receive a set per-inmate or annual payment.
•• Other.
•• Staffing in fiscal 2015 or the most recent year possible. Respondents were asked to provide the number ofhealth professional full-time equivalents (FTEs)—in total and by position category—providing health care toindividuals in prison, broken out, as applicable, between state employees (further broken out between thedepartment of corrections, state university, and other state agencies) and contract employees.
Health professionals included physicians (general practitioners, specialists, etc., except psychiatrists);
psychiatrists; dentists; physician assistants and nurse practitioners; other clinical mental health professionals(psychologists, mental health counselors, clinical social workers, psychiatric technicians, etc.); pharmacists;
nurses (licensed practical nurses, registered nurses, etc.); other clinically trained staff (occupational therapists,
physical therapists, recreational therapists, radiology technicians, lab technicians, etc.); paraprofessionals(nurse technicians, certified nursing assistants, medical assistants, orderlies, aides, dental assistants,
pharmacy technicians, etc.); and health care administrative staff.

58

Respondents were asked to report only filled FTEs—on-site and via telehealth—based both in correctional
facilities and administrative offices, even if additional FTEs were budgeted but unfilled. Inmates performing
medical work assignments were excluded.
Respondents were also asked to report the number of vacant FTEs by position, as well as describe the typicalduration of vacancies, how vacancy durations vary by position, and challenges the department faces in filling staff
positions.
•• Cost-containment strategies, including whether the department uses the state Medicaid program’s
negotiated provider rates for off-site hospitalizations.

Survey II: Prevalence tracking, quality monitoring, care continuity
The second survey, addressed to senior health care staff of state departments of corrections, queried
departments as of fiscal 2016 on their:•• Disease and condition prevalence tracking. This included anxiety disorders, asthma, cancers, cardiovasculardiseases and stroke, chronic obstructive pulmonary disease, cognitive impairment, dementia, developmental
disabilities, diabetes, hepatitis C (chronic), HIV/AIDS, hypertension, mood disorders, substance use disorder,
and tuberculosis (active).
•• Health care quality monitoring. Respondents were asked whether their state had established a prison healthcare quality monitoring system, defined as a uniform, standardized, and ongoing set of policies, metrics,
benchmarks, and data sources used and monitored by state officials—whether health care services aredelivered directly by the state or by contracted vendors.
For the purposes of this study, a quality monitoring system refers only to one used by the state and does notinclude quality controls contracted vendors use internally. States in which contracted vendors deliver someor all health care services may use their quality monitoring system to oversee the performance of vendors. A
state may elect to incorporate measures monitored internally by contracted vendors into its own system. A
state may also rely on contracted vendors to submit data pertaining to quality measures to populate its
own system.
To meet the study’s definition of a quality monitoring system, state efforts had to meet four criteria:•• Grounded in data. The system uses a set of measures to assess the quality of care delivered incorrectional facilities.
•• Established and overseen by state agencies. The system is overseen by one or more state agencies. It isdistinct from systems overseen by contracted vendors, though it may interact with them by incorporating
measures monitored internally by vendors and/or collect data on particular measures from vendors topopulate its own system. States may use their system to oversee the performance of vendors.
•• Applied broadly and consistently. The system is applied to more than half of state prison facilities and morethan half of the measures used across facilities are identical.
•• Ongoing. Quality is monitored on a regular schedule—not in a point-in-time snapshot fashion.
States that reported having an established system were further asked about its basis, overseeing agency,
scope across facilities, objectives, uses, facilitators and barriers to establishment, data sharing, and breadthof focus across key domains: access to care and utilization; screening and prevention services; infectious
diseases; chronic diseases; behavioral health conditions; and geriatric conditions or services.

59

States that reported not having an established system were invited to describe their related efforts and wereasked about potential barriers, uses for quality data, and future plans.
Finally, all respondents were asked about the presence of a formal death review process and a standard
definition of medical preventability. And all respondents were asked, as applicable, whether required quality
metrics are included in a majority of their department’s requests for proposal and/or contractual agreementswith private vendors, and whether associated financial incentives or penalties are used.
•• Continuous quality improvement (CQI) programing. CQI was defined as a structured process designed tocontinuously improve health care services by identifying problems, implementing and monitoring corrective
actions, and assessing their effectiveness.
•• Care continuity services. For the purposes of this study, care continuity services were defined as programs,
policies, or procedures that are intended to facilitate medical and behavioral health services for people
transitioning from correctional to community settings. Care continuity services can also be applied when
individuals enter prison, are transferred among prisons, or are transferred between prison and an off-site
health care provider, but this study focused on those pertaining to discharge.
Respondents were queried about:•• The scope across facilities of care continuity services;•• Practices to suspend or terminate pre-existing Medicaid enrollment during incarceration and assist
potentially eligible individuals with new Medicaid applications as part of re-entry planning;•• Patient health records sharing;•• Variation in services by conditions;•• Collaboration with community supervision personnel (e.g., probation officer, parole officer);•• Facilitating access to medication-assisted treatment for opioid use disorder at re-entry;•• Bridge medication and prescriptions;•• Referrals to providers and scheduled appointments;•• Pre-release provider consultation; and•• Self-management of health and overdose prevention trainings.

Assuring data quality
Two rigorous phases of quality assurance were conducted to strengthen the integrity of the data and improve anddeepen Pew’s understanding of states’ operations. During the first phase, researchers systematically inspected
every returned survey to identify incomplete responses, inconsistencies, and apparent data entry errors.
Additionally, spending and demographic data were compared to applicable responses to a previous Pew/Verasurvey in order to reconcile material discrepancies. Following this inspection, respondents were contacted andgiven the opportunity to complete or correct their submissions.
During the second phase, researchers critically reviewed the cleaned data set to identify remaining
inconsistencies within and across states, unclear responses, unexplained anomalies, and potentially promising
practices. Following this review, interviews were conducted to ensure that states’ responses accurately reflect
their operations and to gather additional insights into how state prison health care is managed.
Respondents were provided with an opportunity to verify all data changes.

60Analytical notes
State fiscal years. Each state was asked to report data for Survey I for their own fiscal year. For example, for every
state, fiscal 2010 in the survey was the fiscal year that ended in 2010. State fiscal years end June 30 in all but fourstates: New York (March 31), Texas (Aug. 31), and Alabama and Michigan (Sept. 30).
Per-inmate spending calculations and comparisons. Per-inmate health care spending was calculated ascorrections department health care expenditures divided by the total average daily population under thejurisdiction of the corrections department, including individuals under state jurisdiction held in the custody ofprivate prisons and local jails.
Owing to the limitations of state data submissions, there were several where per-inmate spending excluded
certain individuals within the jurisdiction of the corrections department and one (Maryland) that included
individuals outside of the jurisdiction of the corrections department:•• There were nine states (Colorado, Florida, Hawaii, Idaho, Louisiana, New Mexico, Ohio, Oklahoma, and Virginia)
that reported individuals under the jurisdiction of the state corrections department and held in the custody ofprivate prisons, but did not report health care spending for these individuals. In these states, the average daily
population in the custody of private prisons was removed from the per-inmate spending calculation.
•• Arizona reported individuals under the jurisdiction of the state corrections department housed out of state in
temporary beds for fiscal 2010 and 2011, but did not report health care spending for those individuals. These
individuals were removed from the per-inmate spending calculation.
•• Mississippi reported individuals under the jurisdiction of the state corrections department and held in thecustody of private prisons, but did not report health care spending for those individuals for fiscal 2010, 2011, and2012. The average daily population in the custody of private prisons was removed from per-inmate spending
calculations for fiscal 2010 through 2012, but included in calculations for fiscal 2013 through fiscal 2015.
•• There were 15 states (Arizona, Florida, Illinois, Kansas, Maryland, Minnesota, Mississippi, Missouri, Oklahoma,
Oregon, South Dakota, Tennessee, Virginia, West Virginia, and Wisconsin) that reported individuals under thejurisdiction of the state corrections department and held in the custody of local jails, but did not report healthcare spending for these individuals. In these states, the average daily population in the custody of local jails
was removed from the per-inmate spending calculation.
•• Maryland’s reported corrections department spending included spending for individuals detained by thefederal government and individuals detained by the City of Baltimore that were held in state-run facilities.
There were four states (Colorado, Maryland, Massachusetts, and Montana) that reported the statecorrections department was responsible for only some portion of health care provided to individuals held in
local jails (Colorado and Maryland), private prisons (Montana), or other states’ facilities and federal facilities(Massachusetts). Therefore, per-inmate spending in these states does not necessarily reflect all health careprovided to individuals within the jurisdiction of the state corrections department.
(See Appendix B: State data notes.)
Spending trend inflation adjustments. To analyze changes in state prison health care spending over time, data
for fiscal 2010 to 2014 were converted to 2015 dollars using the Implicit Price Deflator for Gross Domestic
Product included in the Bureau of Economic Analysis’ National Income and Product Accounts.

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Staffing level calculations and comparisons. Staffing figures include health professionals employed directly by
the state and those secured through contracting.
States differed slightly in how they reported staffing data:•• This analysis compares the number of health professional FTEs per 1,000 inmates under the custody of thecorrections department to spending per inmate under the jurisdiction of the corrections department. In moststates, the vast majority of inmates under their jurisdiction are also under their custody. In states that makegreater use of local jails or private prisons, where inmates are not under the custody of the state, it is possiblethat per-inmate health care figures would differ if calculated based solely on spending in state-run facilities forinmates under state custody.
•• Most states reported either a one-day snapshot or average daily FTE totals, with a small minority basing someor all of their staffing figures on the number budgeted for in contracts.
•• Most states provided data for fiscal 2015, but 13 provided them for fiscal 2016.
Six states (Florida, Iowa, Rhode Island, Utah, Virginia, and Wisconsin) were excluded from the staffing-level
analysis because they submitted staffing data that were incomplete or not comparable. An additional six
states (Alabama, Arkansas, Louisiana, Nebraska, South Dakota, and West Virginia) were removed from thecompositional analysis because they provided incomplete or no data by staff position.
(See Appendix B: State data notes.)
Demographic calculations and comparisons.
Age distributions
Age distribution data reflect proportions of the average daily population under the jurisdiction of the statecorrections department, including individuals held in private prisons or local jails.
Five states (Alabama, Iowa, Michigan, South Dakota, and Tennessee) were excluded from Pew’s trend analysis
because they either did not track inmates by the age brackets surveyed or did not report data to Pew and Verafor fiscal 2010 and 2015. Fiscal 2010 data for Kansas were reported for a prior survey by Pew and Vera. New
Hampshire provided no data at all. (See Appendix B: State data notes.)
To analyze national, long-term changes in the age of state and federal inmates, Pew collected data from the
Bureau of Justice Statistics (BJS). BJS estimates the age distribution of prisoners using data from the Federal
Justice Statistics Program and statistics that states voluntarily submit to the National Corrections Reporting
Program. State participation in this program has varied, which may have caused year-to-year fluctuations in thebureau’s national estimates, but this does not affect long-term trend comparisons. From 2009-10, the number ofstates submitting data increased substantially, which might have contributed to the year-over-year increase in
the national estimate between those years. This does not affect state-specific demographic data Pew and Veracollected from states.
Sex distribution
To analyze the percentage of state prison populations that are female, Pew collected data from BJS. Percentages
represent those under jurisdiction of state correctional authorities on Dec. 31, 2015. BJS imputed percentages for
Nevada and Oregon, which did not submit 2015 data. Percentages for Alaska, Connecticut, Delaware, Hawaii,
Rhode Island, and Vermont reflect jail and prison populations, as prisons and jails form one integrated system.

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Limitations
This research relied nearly exclusively on self-reported data and information from state officials. Researchers
went to great lengths to develop clear, widely relevant, and adaptable survey instruments, rigorously inspect
responses for possible inaccuracies, and probe respondents for corrections and greater clarity and explanation.
But it was not possible for researchers to independently verify every data point. Researchers did independently
confirm responses that prison health care quality monitoring systems were required by state legislation,
executive order, or regulation, and that monitoring results were made publicly available.

63

Appendix B: State data notes
Alabama
Staffing•• Alabama reported staffing data for fiscal year 2015. Amounts were reported as an average daily number ofhealth professional full-time equivalents.
•• Alabama was removed from the compositional analysis of staffing data because the state did not report the
number of health professional full-time equivalents by medical profession.
Age distribution•• Alabama was not included in the age distribution analysis. The state does not track inmates by the age
brackets surveyed.
AlaskaCustody arrangements•• Alaska is one of six states where the state manages both prisons and jails under a unified corrections system.
The other states are Connecticut, Delaware, Hawaii, Rhode Island, and Vermont.
•• In addition to Alaska’s state-run corrections system, there are also 15 community jails throughout the statethat are operated by local departments of public safety, borough governments, and city police departments.
Disaggregated spending•• Alaska’s disaggregation of spending did not sum to the state’s reported total health care expenditures.
Staffing•• Alaska reported staffing data for fiscal year 2016. Amounts were reported as an average daily number ofhealth professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Alaska’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any remaining
state share of costs after federal reimbursement.
Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, it did report thatplans were underway to establish a system and launch it by July 2017.
Care continuity services•• The amount of bridge medication provided varies from seven days to 30 depending on the amount remaining
on an inmate’s prescription.

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Arizona
Per-inmate health care spending•• Arizona’s per-inmate health care spending does not include those individuals in the jurisdiction of the statecorrections department who are held in short-term contracted facilities outside of Arizona. There were 4,045
such individuals in fiscal 2010 and 463 in fiscal 2011, accounting for 10.0 percent and 1.2 percent of theaverage daily population in the jurisdiction of the corrections department.
Staffing•• Arizona reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Arizona’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
Care continuity services•• Medicaid enrollment is suspended for individuals entering the prison system with a year or less remaining on
their sentence. For all others, enrollment is terminated.
Arkansas
Staffing•• Arkansas reported staffing data for fiscal year 2015. Amounts were based on staffing requirements from thecontract with the state’s private vendor.
•• Arkansas was removed from the compositional analysis of staffing data because the state did not report the
number of health professional full-time equivalents (FTEs) by medical profession.
Quality monitoring•• The system does not include measures for screening and prevention services in the areas asked about inthe survey (vaccinations, routine physical examinations, and cancer screening), but does include measurespertaining to the frequency of chronic care clinics (i.e., dedicated times for monitoring and managing patientswith particular conditions).
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
•• The respondent reported that the Department of Corrections is not aware of any requirements for
Medicaid managed care plans to provide care continuity programs/services to inmates transitioning fromprison to the community.
•• The amount of bridge medication provided to inmates varies. All inmates on medication are to be provided
with a minimum supply of seven days of medication, and those with chronic conditions or mental health needs
are to receive a 30-day supply.

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California
Survey respondents•• Survey I was filled out by California’s Legislative Analyst’s Office with assistance from the California
Department of Corrections and Rehabilitation (CDCR). Survey II was filled out by CDCR.
Staffing•• California reported staffing data for fiscal year 2015.
Agency responsibility for state Medicaid, off-site care costs•• California’s corrections department pays for the inpatient hospitalizations of all prisoners. The corrections
department submits claims to the state Medicaid agency for federal reimbursement of eligible costs.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to thecommunity.
•• The respondent noted that the time release planning begins varies. No further detail was provided.
•• The respondent did not know the prevalence of coordination between prison facilities and community
supervision personnel.
•• The respondent reported limited information on the supply of bridge medication provided to departing
inmates. The respondent did not know the duration typically provided to inmates with HIV/AIDS and did not
answer questions regarding the duration of bridge medications for other conditions.
Colorado
Per-inmate health care spending•• Colorado’s per-inmate health care spending does not include health care provided to those individuals in
the jurisdiction of the state corrections department who are held in the custody of private prisons. There
were 3,914 such individuals in fiscal 2015, accounting for 19.1 percent of the average daily population in thejurisdiction of the corrections department.
•• Colorado’s per-inmate health care spending only includes extraordinary medical expenditures for thoseindividuals in the jurisdiction of the state corrections department who are held in the custody of local
jails. There were 139 such individuals in fiscal 2015, accounting for less than 1 percent of the average daily
population in the jurisdiction of the corrections department.
Staffing•• Colorado reported staffing data for fiscal year 2016. Amounts were reported as an average daily number ofhealth professional full-time equivalents.

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Agency responsibility for state Medicaid, off-site care costs•• Colorado’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Quality monitoring•• In the area of screening and prevention, Colorado’s quality monitoring system includes tuberculosis testing in
addition to vaccinations.
Care continuity services•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to
the community.
Connecticut
Custody arrangements•• Connecticut is one of six states where the state manages both prisons and jails under a unified corrections
system. The other states are Alaska, Delaware, Hawaii, Rhode Island, and Vermont.
Staffing•• Connecticut reported staffing data for fiscal year 2016. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Connecticut’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Care continuity services•• Community providers receive partial health records at release.
•• Re-entry planning typically starts one year before release for those with a serious mental illness. For all others,
it begins 31-60 days before release.
DelawareTotal health care spending•• About $4.3 million, or 7.5 percent, of Delaware’s reported total health care spending is paid through the state’s
substance abuse budget, not the corrections department.
Custody arrangements•• Delaware is one of six states where the state manages both prisons and jails under a unified corrections
system. The other states are Alaska, Connecticut, Hawaii, Rhode Island, and Vermont.

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Staffing•• Delaware reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Delaware’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
•• The respondent did not know the prevalence of coordination between prison facilities and community
supervision personnel.
FloridaPer-inmate health care spending•• Florida’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of private prisons. There were 10,163 suchindividuals in fiscal 2015, accounting for 10.1 percent of the average daily population in the jurisdiction of thecorrections department.
•• Florida’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of local jails. There were no such individuals
in fiscal 2015, but 67 in fiscal 2010 and fiscal 2011, accounting for less than 1 percent of the average daily
population in the jurisdiction of the corrections department.
Disaggregated spending•• Florida’s disaggregation of spending summed to about 1 percent of the state’s reported total health careexpenditures. The state was removed from all analysis of disaggregated spending.
Staffing•• Florida did not report the number of contracted health professional full-time equivalents. Because the majorityof the state’s health care services are provided by contractors, the state was removed from all staffing
analyses.
Prevalence tracking•• Though the respondent reported that the prevalence of only one of the conditions surveyed (cardiovasculardiseases and stroke) is tracked, the state’s chronic illness clinics (immunity, cardiac, gastrointestinal,
respiratory, endocrine, tuberculosis, neurology, oncology, and miscellaneous) allow for prevalence tracking ofbroader sets of conditions. For example, patients with HIV/AIDS would be enrolled in the immunity clinic andthose with hepatitis C would be enrolled in the gastrointestinal clinic.

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Care continuity services•• The respondent did not reply to several questions regarding Medicaid enrollment, including the percentage offacilities providing Medicaid enrollment application assistance, whether inmates typically leave prison with a
Medicaid card, and whether Medicaid managed care plans are required to provide care continuity programs/
services to inmates transitioning from prison to the community.
•• In general, inmates do not continue working with providers who are dually based in the prison and thecommunity after release. Inmates with HIV may do so, however. Through Ryan White funds, these inmates areseen by county health departments and may continue to see these providers after release.
•• The respondent did not reply to the survey question regarding whether inmates and/or their community
providers receive a copy of health records after release.
•• The respondent noted that the timing varies by condition as to when care continuity planning begins. In somecases, it begins up to six months before release.
Georgia
Disaggregated spending•• Georgia’s disaggregation of spending did not sum to the state’s reported total health care expenditures.
Staffing•• Georgia reported staffing data for fiscal year 2016. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that thecorrections department does not track this information.
•• The supply of bridge medication provided varies by condition and how quickly individuals can be seen by
a community provider. The respondent did not answer questions about the duration of bridge medication
provided to those with anxiety, mood, or personality disorders.
Hawaii
Per-inmate health care spending•• Hawaii’s per-inmate health care spending does not include health care provided to those individuals in
the jurisdiction of the state corrections department who are held in the custody of private prisons. There
were 1,341 such individuals in fiscal 2015, accounting for 23.7 percent of the average daily population in thejurisdiction of the corrections department.
Custody arrangements•• Hawaii is one of six states where the state manages both prisons and jails under a unified corrections system.
The other states are Alaska, Connecticut, Delaware, Rhode Island, and Vermont.

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Staffing•• Hawaii reported staffing data for fiscal year 2016. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Hawaii’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any remaining
state share of costs after federal reimbursement.
Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, it did report thatplans were underway to establish a system and launch it by July 2017.
Care continuity services•• The corrections department reportedly refers individuals to a methadone treatment provider only if they wereprescribed methadone during their incarceration in order to continue treatment begun in the community.
•• In addition to providing care continuity services for those with mood and psychotic disorders, the stateprovides services to anyone hospitalized at the time of release.
•• The state provides bridge medication only for mood and psychotic disorders.
Idaho
Per-inmate health care spending•• Idaho’s per-inmate health care spending does not include health care provided to those individuals in
the jurisdiction of the state corrections department who are held in private prisons. There were 653 suchindividuals in fiscal 2015, accounting for 8 percent of the average daily population in the jurisdiction of thecorrections department.
Staffing•• Idaho reported staffing data for fiscal year 2016. Amounts for the corrections department were reported asa one-day snapshot of the number of health professional full-time equivalents. Amounts for contracted staff
were reported as the total number of contracted employees.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that thecorrections department does not track this information.
•• The respondent noted that the timing of the beginning of care continuity planning varies by condition.
Illinois
Per-inmate health care spending•• Illinois’ per-inmate spending does not include health care provided to individuals in the jurisdiction of the statecorrections department who are held in local jails. There were 229 such individuals in fiscal 2015, accounting
for less than 1 percent of the average daily population in the jurisdiction of the corrections department.

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Staffing•• Illinois reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Illinois’ Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any remaining
state share of costs after federal reimbursement.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that thecorrections department does not track this information.
•• The respondent reported that most inmates receive a two-week supply of bridge medication and then aprescription for an additional two weeks. Those with HIV are given a full 30-day supply at release.
Indiana
Agency responsibility for state Medicaid, off-site care costs•• Indiana’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any remaining
state share of costs after federal reimbursement.
Staffing•• Indiana reported staffing data for fiscal year 2015. Amounts were reported as an average daily number ofhealth professional full-time equivalents.
Age distribution•• Indiana’s age data were reported based on a one-day snapshot at the end of the state fiscal year, not as anaverage daily population.
Iowa
Total health care spending•• The University of Iowa Hospitals and Clinics covers all inpatient and outpatient services delivered toprisoners at the university. The costs of these services are not included in either the state’s total health careexpenditures or per-inmate health care expenditures.
Staffing•• Iowa did not provide the number of health profession full-time equivalents for the University of Iowa Hospitals
and Clinics. Because the university provides a number of health care services, the state was removed from all
staffing analyses.
Agency responsibility for state Medicaid, off-site care costs•• See note about University of Iowa Hospitals and Clinics above.

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Age distribution•• Iowa was not included in the age distribution analysis. The state does not track inmates by the age brackets
surveyed.
Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, the respondent did
report that plans were underway to establish a system. The launch date of this system was undefined.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
•• The respondent did not know the prevalence of coordination between prison facilities and community
supervision personnel.
KansasPer-inmate health care spending•• Kansas’ per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who were held in local jails. There were 58 such individuals in fiscal
2015, accounting for less than 1 percent of the average daily population in the jurisdiction of the corrections
department.
Delivery system organizational structure•• Kansas reported that its delivery system is best described as a hybrid model. Given responses elsewhere in
the survey, which suggest that the bulk of health care services is provided by a single contractor, Corizon,
researchers changed Kansas’ response to “contracted model.”Disaggregated spending•• Kansas’ disaggregation of spending did not sum to the state’s reported total health care expenditures.
Staffing•• Kansas reported staffing data for fiscal year 2015. Amounts were reported as an average daily number ofhealth professional full-time equivalents.
•• Kansas’ numbers reflect health profession full-time equivalents for both adult and juvenile correctional
facilities.
Age distribution•• Kansas’ proportion of inmates over the age of 55 under the jurisdiction of the corrections department for fiscal
2010 was taken from Kansas’ response to a previous Pew/Vera survey administered in 2013.

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Kentucky
Staffing•• Kentucky reported staffing data for fiscal year 2015. Amounts were reported as an average daily number ofhealth professional full-time equivalents.
Care continuity services•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to thecommunity.
Louisiana
Total health care spending•• Prior to fiscal 2014, off-site medical costs were included in Louisiana State University’s budget. After fiscal
2014, these costs were included in the corrections department’s budget, resulting in a $20 million, or 44
percent, increase in health care spending from fiscal 2013 to fiscal 2014. This change contributes to increases
in both total health care spending and per-inmate health care spending from fiscal 2010 to fiscal 2015.
Per-inmate health care spending•• Louisiana’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of private prisons. There were 2,877 suchindividuals in fiscal 2015, accounting for 7.7 percent of the average daily population in the jurisdiction of thecorrections department.
Staffing•• Louisiana reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents (FTEs).
•• Louisiana was removed from the compositional analysis of staffing data because the state did not report the
number of contracted health professional FTEs by medical profession.
Agency responsibility for state Medicaid, off-site care costs•• Louisiana’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Quality monitoring•• Louisiana did not report whether its quality monitoring system incorporates formal, standardized assessments
of inmates’ satisfaction with their health care experience (e.g., patient satisfaction surveys).
Care continuity services•• In addition to those with the conditions surveyed, the respondent reported that those with “a significant
disability,” such as “hearing or visual impairment,” are targeted for care continuity services.

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MaineStaffing•• Maine reported staffing data for fiscal year 2015. Amounts for contracted staff were reported as the total
number of contracted employees.
Agency responsibility for state Medicaid, off-site care costs•• Maine’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any remaining
state share of costs after federal reimbursement.
Maryland
Per-inmate health care spending•• Maryland’s per-inmate spending includes health care provided to approximately 500 individuals detained by
the federal government and held in state-run facilities, along with 2,500 individuals detained by the city ofBaltimore and held in state-run facilities. Health care for these individuals is covered under the state’s medical
contract.
•• Maryland’s per-inmate spending does not include spending for individuals under the jurisdiction of the statecorrections department who are held in the custody of local jails. There were 178 such individuals in fiscal
2015, accounting for less than 1 percent of the average daily population in the jurisdiction of the corrections
department. Local jails are responsible for covering the costs of medical care for these individuals up to $25,000
for a single incident. The state is financially responsible for single-incident costs that exceed $25,000.
•• The state reported that individuals in the jurisdiction of the state corrections department who are held inprivate prisons are returned to Maryland facilities for all medical care. Health care costs for these individuals
are included in Maryland’s per-inmate health care spending.
Disaggregated spending•• Maryland disaggregation of spending did not sum to the state’s reported total health care expenditures.
Staffing•• Maryland reported staffing data for fiscal year 2016.
Care continuity services•• Though neither the inmate nor the community provider receives a copy of health records at release, information
on an inmate’s medication and chronic care needs are entered into the state’s health information exchange.
Massachusetts
Per-inmate health care spending•• Massachusetts’ per-inmate spending includes nonroutine health care (e.g., surgery, lab testing, medical
devices) for 70 to 90 individuals in the jurisdiction of the state corrections department who are held in thecustody of other states’ facilities and/or federal facilities. Routine health care spending for these individuals is
not included.

74•• Massachusetts’ per-inmate spending includes nonroutine health care provided to those individuals in thejurisdiction of the state corrections department who are held in the custody of local jails. Routine health carespending is not included. There were 310 such individuals in fiscal 2015, accounting for 2.8 percent of theaverage daily population in the jurisdiction of the corrections department.
Staffing•• Massachusetts reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of
the number of health professional full-time equivalents.
Quality monitoring•• Massachusetts did not report whether its quality monitoring system incorporates formal, standardized
assessments of inmates’ satisfaction with their health care experience (e.g., patient satisfaction surveys).
Care continuity services•• The respondent reported that the corrections department is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to thecommunity.
•• The respondent did not know the prevalence of coordination between prison facilities and community
supervision personnel.
•• Bridge medication supplies are determined by health care personnel on a case-by-case basis.
MichiganAge distribution•• Michigan did not report age distribution data for fiscal 2014 and fiscal 2015.
Staffing•• Michigan reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Michigan’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Care continuity services•• Though care continuity services are offered to inmates with only certain conditions, the respondent did notindicate which conditions those were.
Minnesota
Per-inmate health care spending•• Minnesota’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of local jails. There were no such individuals
in fiscal 2014 or fiscal 2015, but 40 in fiscal 2013, accounting for less than 1 percent of the average daily
population in the jurisdiction of the corrections department.

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Staffing•• Minnesota reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Minnesota’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
Care continuity services•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to
the community.
Mississippi
Per-inmate health care spending•• Mississippi did not report health care spending for those individuals in the jurisdiction of the state corrections
department who are held in the custody of private prisons for fiscal 2010, 2011, and 2012. The state did report
spending for these individuals for fiscal 2013, 2014, and 2015. These individuals are not included in per-inmate
spending calculations for fiscal 2010 through 2012, but included for calculations for fiscal 2013 throughfiscal 2015. From fiscal 2010 to fiscal 2015, the corrections department, on average, held 22 percent of the
population under its jurisdiction in private prisons.
Staffing•• Mississippi reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Mississippi’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
Missouri
Per-inmate health care spending•• Missouri’s per-inmate spending does not include health care provided to those individuals in the jurisdiction of
the state corrections department who are held in the custody of local jails. There were 365 suchindividuals in fiscal 2015, accounting for 1.1 percent of the average daily population in the jurisdiction of thecorrections department.
Staffing•• Missouri reported staffing data for fiscal year 2016. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.

76Care continuity services•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to
the community.
•• The respondent did not answer questions regarding access to buprenorphine, methadone, or naloxone after release.
Montana
Per-inmate health care spending•• Montana’s per-inmate spending includes off-site, but not on-site, health care provided to those individuals
in the jurisdiction of the state corrections department who are held at the privately operated Crossroads
Correctional Center in Shelby, Montana. The facility holds about 540 inmates.
Staffing•• Montana reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
•• Montana did not report the number of contracted health professional full-time equivalents. Because themajority of the state’s health care services are provided by corrections department staff, the state wasincluded in all staffing analyses.
Agency responsibility for state Medicaid, off-site care costs•• Montana’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Age distribution•• Montana reported only the proportion of inmates under the jurisdiction of the state corrections department
who were 55 and older. The state did not report data for other age brackets.
Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, it did report thatplans were underway to establish and launch a system by July 2017.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to
the community.

77Nebraska
Staffing•• Nebraska reported staffing data for fiscal year 2016. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
•• Nebraska was removed from the compositional analysis of staffing data because the state did not report the
number of health professional full-time equivalents by medical profession.
Quality monitoring•• Nebraska did not report whether its quality monitoring system incorporates formal, standardized assessments
of inmates’ satisfaction with their health care experience (e.g., patient satisfaction surveys).
Care continuity services•• The respondent did not indicate whether Medicaid managed care plans are required to provide care continuity
programs/services to inmates transitioning from prison to the community.
•• The respondent did not indicate whether a majority of prison facilities generally make use of presumptive
eligibility when inmates apply for Medicaid.
•• The respondent did not indicate whether individuals or their community providers receive a copy of healthrecords at release.
NevadaStaffing•• Nevada reported staffing data for fiscal year 2016. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Nevada’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. Prior to fiscal 2014, thecorrections department covered the remaining state share of costs after federal reimbursement. These costs
have been paid by the state Medicaid agency since fiscal 2014.
Age distribution•• Nevada did not report age distribution data for fiscal 2011 and fiscal 2012.
New Hampshire
Data were not submitted by New Hampshire.
New Jersey
Per-inmate health care spending•• New Jersey’s per-inmate health care spending does not include health care provided to those individuals in thejurisdiction of the state corrections department who are held in county jails.

78

Staffing•• New Jersey reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• New Jersey’s corrections department pays for the inpatient hospitalizations of all prisoners. The corrections
department submits claims to the state Medicaid agency for federal reimbursement of eligible costs.
Care continuity services•• The respondent reported only the duration of bridge medication provided to inmates with HIV/AIDS.
Information on the duration of bridge medication provided to those with other conditions or health needs was
not reported.
New Mexico
Per-inmate health care spending•• New Mexico’s per-inmate spending does not include health care provided to those individuals in thejurisdiction of the state corrections department who are held in the custody of private prisons. There were3,509 such individuals in fiscal 2015, accounting for 50.2 percent of the average daily population in thejurisdiction of the corrections department.
Staffing•• New Mexico reported staffing data for fiscal year 2015. Amounts were reported as an average daily number ofhealth professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• New Mexico’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Care continuity services•• The respondent did not know the prevalence of coordination between prison facilities and community
supervision personnel.
New York
Staffing•• New York reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
•• New York’s disaggregated staffing data do not include psychiatrists from the state Office of Mental Health(OMH) that provide care to individuals under the jurisdiction of the state corrections department. The state
did not report a count for these employees.
•• New York’s reported data for dentist FTEs include dental hygienists and assistants, and its reported data forpharmacists include pharmacy aides.

79Agency responsibility for state Medicaid, off-site care costs•• New York’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
Care continuity services•• While a 30-day supply of bridge medication is provided for most prescription medications, a 14-day supply isprovided for any controlled substance.
North Carolina
Disaggregated spending•• North Carolina’s disaggregation of spending did not sum to the state’s reported total health care expenditures.
Staffing•• North Carolina reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of
the number of health professional full-time equivalents.
Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, the state didreport that plans were underway to establish and launch a system by January 2017.
Care continuity services•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to thecommunity.
North Dakota
Total health care spending•• North Dakota did not report total health care spending for fiscal 2010 and fiscal 2011. Per-inmate spending
cannot be calculated for these years.
Staffing•• North Dakota reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• North Dakota’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, the state didreport that plans were underway to establish a system. The launch date of this system was undefined.

80

Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to thecommunity.
Ohio
Per-inmate health care spending•• Ohio’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of private prisons. There were 4,435 suchindividuals in fiscal 2015, accounting for 8.8 percent of the average daily population held in the jurisdiction of
the corrections department.
Staffing•• Ohio reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of the numberof health professional FTEs.
•• Ohio did not report the number of contracted health professional full-time equivalents. Because the majorityof the state’s health care services are provided by corrections department staff, the state was included in all
staffing analyses.
Agency responsibility for state Medicaid, off-site care costs•• Ohio’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any remaining
state share of costs after federal reimbursement.
Care continuity services•• A 14-day supply of bridge medication and a 90-day prescription is provided for most prescription medications.
For HIV and mental health medications, a 30-day supply is provided along with the 90-day prescription.
Oklahoma
Per-inmate health care spending•• Oklahoma’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of private prisons. Health care expenditures
for these individuals were not reported for fiscal 2010 through fiscal 2013. There were 5,814 such individuals
in fiscal 2015, accounting for 21.4 percent of the average daily population in the jurisdiction of the corrections
department.
•• Oklahoma’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of local jails. There were 1,946 suchindividuals in fiscal 2015, accounting for 7.1 percent of the average daily population in the jurisdiction of thecorrections department.

81

Staffing•• Oklahoma reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
•• Oklahoma’s ratio of health professional FTEs for every 1,000 inmates does not include University of Oklahoma
employees who provide telemedicine services.
Agency responsibility for state Medicaid, off-site care costs•• Oklahoma’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
OregonPer-inmate health care spending•• Oregon’s per-inmate spending does not include health care provided to those individuals in the jurisdiction of
the state corrections department who are held in the custody of local jails. There was one such individual infiscal 2015.
Staffing•• Oregon reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Oregon’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any remaining
state share of costs after federal reimbursement.
Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, the state didreport that plans were underway to establish a system. The launch date of this system was undefined.
Care continuity services•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to thecommunity.
•• The respondent did not know the prevalence of coordination between prison facilities and community
supervision personnel.
•• In addition to expanded care continuity services being offered to those with HIV/AIDS, active tuberculosis,
psychotic disorders, end-stage renal disease, dementias or neurodegenerative diseases, cancers, thoseneeding palliative care or hospice, or those in danger of suicide and self-harm, such services are offered tothose with “severe medical condition[s]” and those requiring nursing home placements.

82

Pennsylvania
Staffing•• Pennsylvania reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Pennsylvania’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
Care continuity services•• A 30-day bridge supply is provided for most medications, and a 60-day supply of psychiatric medications isprovided.
Rhode Island
Custody arrangements•• Rhode Island is one of six states where the state manages both prisons and jails under a unified corrections
system. The other states are Alaska, Connecticut, Delaware, Hawaii, and Vermont.
Staffing•• Rhode Island did not report the number of university or contracted health professional full-time equivalents.
Because many of the state’s health care services are provided by university and contracted staff, the state wasremoved from all staffing analyses.
Agency responsibility for state Medicaid, off-site care costs•• Rhode Island’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, the state didreport that plans were underway to establish a system. The launch date of this system was undefined.
Care continuity services•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to
the community.
•• A minimum seven-day supply of bridge medication is provided, with up to a 20-day supply provided on acase-by-case basis.
South Carolina
Staffing•• South Carolina reported staffing data for fiscal year 2015.

83Agency responsibility for state Medicaid, off-site care costs•• South Carolina’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Quality monitoring•• The state’s continuous quality improvement policy was in development at the time of survey deployment.
•• Although the respondent reported monitoring only behavioral health at the time of the survey, additional
measures in other areas were reportedly in development.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
South Dakota
Per-inmate health care spending•• South Dakota’s per-inmate spending does not include health care provided to those individuals in thejurisdiction of the state corrections department who are held in the custody of local jails. There were 49 suchindividuals in fiscal 2015, accounting for 1.3 percent of the average daily population in the jurisdiction of thecorrections department.
Staffing•• South Dakota reported staffing data for fiscal year 2015. Amounts were reported as an average daily numberof health professional full-time equivalents.
•• South Dakota was removed from the compositional analysis of staffing data because the state did not report
the number of health professional FTEs from the Department of Social Services by medical profession.
Age distribution•• South Dakota did not report age distribution data for fiscal 2010, 2011, and 2012.
Tennessee
Per-inmate health care spending•• Tennessee’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of local jails. There were 9,285 suchindividuals in fiscal 2015, accounting for 31.3 percent of the average daily population in the jurisdiction of thecorrections department.
Staffing•• Tennessee reported staffing data for fiscal year 2016. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.

84Age distribution•• Tennessee did not report age distribution data for fiscal 2010, 2011, 2012, and 2013.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
•• Bridge medication supplies of either 14-30 days or more than 30 days are provided, depending on an
individual’s condition(s). Tennessee indicated that neither supply duration is more prevalent than the other.
Texas
Disaggregated spending•• Texas disaggregation of spending did not match the state’s reported total health care expenditures.
Staffing•• Texas reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of the numberof health professional full-time equivalents.
Care continuity services•• When asked when Medicaid enrollment was generally completed, the respondent reported that the
department of corrections does not track this information.
•• Care continuity planning begins once the inmate’s release date is known or parole vote is received.
•• The supply of bridge medication provided varies by condition. Controlled substances are not provided. The
respondent did not know the duration of medication typically provided for chronic hepatitis C.
Utah
Staffing•• Utah did not report the number of health professional full-time equivalents (FTEs) from the University of Utah.
The state was removed from all staffing analyses.
Agency responsibility for state Medicaid, off-site care costs•• Utah’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners. The corrections
department pays for the remaining state share of costs after federal reimbursement.
Quality monitoring•• In the area of screening and prevention, Utah’s quality monitoring system includes chronic care visits inaddition to vaccinations, routine physical examinations, and cancer screening.

85

Care continuity services•• Release planning begins one to 20 days before release for Medicaid applications, and over 90 days fromrelease date for those with chronic noncommunicable and infectious diseases.
•• A 30-day bridge supply of psychiatric medication, and a 14-day supply of medication for chronic medical
conditions, is provided.
Vermont
Custody arrangements•• Vermont is one of six states where the state manages both prisons and jails under a unified corrections
system. The other states are Alaska, Connecticut, Delaware, Hawaii, and Rhode Island.
Staffing•• Vermont reported staffing data for fiscal year 2015. Amounts were reported as a one-day snapshot of thenumber of health professional full-time equivalents.
Agency responsibility for state Medicaid, off-site care costs•• Vermont’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Virginia
Population•• Virginia reported population numbers as a one-day snapshot on June 30 of each year, not as an average
daily population.
Delivery system organizational structure•• The Virginia corrections department contracts with private vendors to provide and manage health care atcertain facilities, while retaining responsibility for care and management at other facilities.
Per-inmate health care expenditures•• Virginia’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of private prisons. There were 1,551 suchindividuals in fiscal 2015, accounting for 4 percent of the average daily population in the jurisdiction of thecorrections department.
•• Virginia’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in the custody of local jails. Local jails are responsible for all
medical expenses for these individuals. There were 8,362 such individuals in fiscal 2015, accounting for 21.6
percent of the average daily population in the jurisdiction of the corrections department.
Staffing•• Virginia did not report the number of contracted health professional full-time equivalents. Because many of
the state’s health care services are provided by contractors, the state was removed from all staffing analyses.

86Quality monitoring•• Though the state reported not having a quality monitoring system at the time of the survey, it did report thatplans were underway to establish and launch a system by July 2018.
Care continuity services•• In addition to the care continuity services in the survey, Virginia provides case management for
HIV-positive offenders.
Washington
Staffing•• Washington reported staffing data for fiscal year 2016. Amounts were reported as a one-day snapshot.
Corrections department amounts were equal to the number of funded, not filled, health professional fulltime equivalents.
•• Washington reported about 80 percent of contracted health professional FTEs. Because most health careservices are provided by corrections department staff, the state was included in all staffing analyses.
Agency responsibility for state Medicaid, off-site care costs•• Washington’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Quality monitoring•• The respondent noted that Washington’s system monitors behavioral health conditions, but not thoseincluded in the survey.
West Virginia
Per-inmate health care expenditures•• West Virginia’s per-inmate spending does not include health care provided to those individuals in thejurisdiction of the state corrections department who are held in the custody of local jails. Local jails are
responsible for all medical expenses for these individuals. There were 1,024 such individuals in fiscal 2015,
accounting for 14.8 percent of the average daily population in the jurisdiction of the corrections department.
Disaggregated spending•• West Virginia’s disaggregation of spending did not sum to the state’s reported total health care expenditures.
Staffing•• West Virginia reported staffing data for fiscal year 2015. Amounts were reported as an average daily numberof health professional full-time equivalents.
•• West Virginia was removed from the compositional analysis of staffing data because the state did not reportcomplete data for the number of health professional FTEs by medical profession.

87

Agency responsibility for state Medicaid, off-site care costs•• West Virginia’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Care continuity services•• The respondent reported that the department of corrections is not aware of any requirements for Medicaid
managed care plans to provide care continuity programs/services to inmates transitioning from prison to
the community.
•• The respondent did not know whether facilities have care continuity programs/services.
Wisconsin
Per-inmate health care expenditures•• Wisconsin’s per-inmate spending does not include health care provided to those individuals in the jurisdictionof the state corrections department who are held in local jails. Local jails are responsible for all medical
expenses for these individuals. There were 30 such individuals in fiscal 2015, accounting for less than 1 percentof the average daily population in the jurisdiction of the corrections department.
•• Wisconsin’s per-inmate health care spending does not include the cost for a small number of mental healthprofessionals who provide care to individuals under the jurisdiction of the corrections department. These
positions are included in staffing totals.
Staffing•• Wisconsin reported the total number of open positions, not just filled positions, for the Department of
Health Services. Given the role that this department plays in providing health care for individuals under thejurisdiction of the state corrections department, the state has been removed from all staffing analyses.
Agency responsibility for state Medicaid, off-site care costs•• Wisconsin’s Medicaid agency covers inpatient hospitalization costs for eligible prisoners, including any
remaining state share of costs after federal reimbursement.
Prevalence tracking•• Rather than the prevalence of specific conditions, the prevalence of condition groupings by severity of mental
illness is tracked.
Quality monitoring•• Wisconsin did not report which chronic conditions, if any, are monitored by its quality monitoring system.
Care continuity services•• The respondent did not indicate whether Medicaid managed care plans are required to provide care continuity
programs/services to inmates transitioning from prison to the community.
•• Although medical records are not provided to individuals or their community providers at re-entry, individuals
do receive a discharge summary.

88•• The respondent did not indicate whether coordination occurs between prison facilities and community
supervision personnel.
•• In addition to targeting those with HIV/AIDS, chronic hepatitis C, mood disorders, personality disorders, andpsychotic disorders, the department also targets care continuity services for those with “complex medical needs.”
Wyoming
Staffing•• Wyoming reported staffing data for fiscal year 2015. Amounts were reported as an average daily number ofhealth professional full-time equivalents.
Age distribution•• Wyoming reported only the proportion of inmates under the jurisdiction of the state corrections department
who were 55 and older. The state did not report data for other age brackets.

89Appendix C: 50-state data
Table C.1

Total Corrections Department Health Care Spending,
Adjusted for Inflation
FY 2010-15
State

FY 2010

FY 2011

FY 2012FY 2013

FY 2014

FY 201549-state total––$7,959,437,365$7,642,992,922$7,828,239,670$8,069,053,935

48-state total$8,253,169,449$8,075,978,508$7,950,109,197$7,633,512,804$7,817,135,653$8,057,098,103

AK$45,881,819$41,484,528$40,413,031$40,569,305$40,920,150$43,412,600

AL$102,543,966$103,561,954$106,594,659$91,724,816$94,587,648$100,785,027

AR$68,700,458$70,868,117$71,918,511$71,833,856$67,632,379$73,508,037

AZ$134,048,733$122,144,333$143,211,277$131,249,028$140,315,109$148,662,395

CA$2,418,299,852$2,313,954,985$2,339,734,009$2,038,628,297$2,167,408,767$2,340,203,000

CO$102,245,637$105,781,249$102,281,754$114,422,568$107,848,023$110,335,557

CT$108,994,271$105,275,359$98,820,125$90,520,643$94,057,511$96,348,893

DE$47,973,022$48,761,438$53,129,074$56,787,562$54,828,688$57,682,085

FL$450,621,676$435,708,724$427,195,599$406,295,699$392,107,310$366,124,529

GA$226,592,309$220,973,440$211,102,773$206,015,183$204,407,926$199,359,072

HI$20,717,894$19,974,332$20,702,908$21,149,064$20,441,347$23,465,881

IA$39,601,878$40,140,611$38,604,672$38,669,387$39,353,931$41,704,035

ID$27,009,166$26,808,516$28,270,268$30,118,733$32,356,314$42,121,101

IL$155,620,713$163,861,898$152,962,376$147,336,517$164,302,129$171,468,287

IN$104,218,321$113,921,885$102,766,903$105,932,532$103,263,215$93,019,644

KS$51,138,351$51,495,060$51,968,725$52,565,053$54,673,901$57,822,490

KY$76,595,848$77,245,531$75,975,624$78,043,175$77,684,600$79,253,567

LA$51,527,340$51,263,303$51,319,107$47,159,065$66,906,062$74,791,140

MA$104,000,220$102,802,451$103,724,975$102,578,073$93,895,493$96,447,502

MD$166,087,180$174,030,278$172,770,890$166,247,521$169,460,407$169,197,222

ME$16,837,384$18,153,028$17,522,971$12,978,479$13,977,402$15,534,162

MI$366,135,428$351,528,100$386,940,853$399,983,869$376,912,882$368,557,916

MN$66,938,702$70,128,664$69,477,393$70,488,561$71,164,361$75,897,019

MO$147,947,131$152,305,833$157,655,955$160,316,020$166,867,566$156,965,966

MS$58,683,872$54,609,456$54,694,795$66,154,638$72,880,143$67,770,994

MT$30,370,984$31,266,340$35,046,710$35,165,086$34,134,311$37,113,391

NC$292,589,842$271,638,213$253,011,419$255,682,229$256,569,387$261,634,369

Continued on next page

90

StateFY 2010

FY 2011

FY 2012FY 2013

FY 2014

FY 2015ND

No data provided

No data provided$9,328,168$9,480,118$11,104,017$11,955,832

NE$33,761,791$34,576,217$36,681,672$36,831,845$41,716,129$46,175,690

NH

No data provided

No data provided

No data provided

No data provided

No data provided

No data provided

NJ$164,693,969$158,182,983$155,587,756$165,897,151$168,232,851$163,305,683

NM$50,128,865$47,765,456$46,897,835$41,750,370$42,780,830$42,865,600

NV$51,690,529$49,558,008$43,499,868$46,141,084$45,862,425$41,270,369

NY$396,952,963$383,905,151$357,727,447$366,068,163$353,898,077$374,745,588

OH$319,812,253$296,819,776$258,089,776$250,891,745$241,059,384$231,124,783

OK$68,585,943$66,750,143$68,050,630$70,701,504$71,915,070$71,501,736

OR$99,823,233$110,556,426$103,700,041$120,149,646$111,563,183$122,936,099

PA$251,926,837$261,941,981$251,145,756$226,812,166$239,828,626$231,123,000

RI$21,069,306$20,488,469$21,666,415$20,973,375$20,740,523$21,960,881

SC$71,156,074$67,226,401$69,905,914$68,519,327$70,509,938$75,728,018

SD$16,340,313$16,429,125$15,098,228$16,383,706$19,250,248$19,910,914

TN$99,265,839$102,179,420$104,050,481$110,785,948$127,000,379$122,114,655

TX$622,158,263$619,196,843$548,393,074$559,682,505$593,363,318$608,068,075

UT$29,260,244$28,635,305$29,173,488$29,183,014$29,426,244$31,797,675

VA$159,118,426$159,548,884$162,234,807$163,798,021$153,376,913$171,281,948

VT$18,275,196$23,707,285$20,669,489$22,102,909$22,341,511$22,132,931

WA$122,349,010$113,056,865$115,358,267$108,398,351$111,822,013$115,311,761

WI$123,347,318$125,296,353$124,698,612$121,257,833$124,545,936$126,202,347

WV$26,571,441$24,648,300$21,962,348$22,021,473$23,910,778$23,377,603

WY$24,959,643$25,821,490$27,699,938$26,547,711$25,034,314$24,976,866

Notes: Spending—funded by state or federal funds—includes health care provided to individuals under the jurisdiction of the corrections
department, counting: on-site care (provider and administrative compensation, medical and diagnostic lab services), off-site care (inpatient,outpatient, emergency, dialysis, medical and diagnostic labs), outpatient medical products (prescription drugs, medication-assisted
treatment, durable medical equipment, nondurable medical products/supplies), long-term care, and other health, residential, and personalcare (dialysis, hospice, residential mental health, and substance abuse treatment).
Amounts are in 2015 dollars. Nominal spending data for fiscal 2010-2014 were converted to 2015 dollars using the Implicit Price Deflator for
Gross Domestic Product included in the Bureau of Economic Analysis’ National Income and Product Accounts.
The 49-state total excludes New Hampshire. The 48-state total excludes New Hampshire and North Dakota. New Hampshire did not respondto the survey, and North Dakota did not report values for fiscal year 2010 or 2011. See Appendix B: State data notes for further information.
© 2017 The Pew Charitable Trusts

91

Table C.2

Total Average Daily Population Under the Jurisdiction of
Corrections Departments
FY 2010-15
State

FY 2010

FY 2011

FY 2012FY 2013

FY 2014

FY 201549-state total

1,362,996

1,358,852

1,345,203

1,326,215

1,325,179

1,312,742

31,97532,31632,55432,52331,99931,162

Alabama
Alaska

5,444

5,673

5,774

5,922

6,065

5,997

Arizona

40,45940,22740,01140,04741,085

42,131

Arkansas

14,80015,742

14,78914,405

16,51017,562

California

152,799

147,438

137,463

123,572

122,563

118,215

Colorado

22,801

22,69021,891

20,402

20,303

20,528Connecticut

19,54519,09818,392

17,694

17,812

17,312

Delaware

6,764

6,612

6,685

6,920

6,988

6,860

Florida101,391

102,094

100,928

100,142

100,768

100,567

Georgia

58,54056,67057,32258,15055,60055,222

Hawaii

5,673

5,746

5,802

5,535

5,500

5,669

Idaho

7,495

7,578

8,097

8,177

8,293

8,120

Illinois

44,97947,43147,582

48,281

47,98847,612

Indiana

28,332

28,19728,09828,40529,34228,656

Iowa

8,384

8,816

8,574

8,213

8,161

8,195

Kansas

8,689

9,025

9,267

9,507

9,598

9,697

Kentucky

20,44320,09420,854

21,155

20,29721,062

Louisiana

39,822

39,68340,46039,92639,06237,300

Maine

2,114

2,067

1,983

1,955

2,089

2,100

Maryland

25,46925,71725,19324,50024,14523,419Massachusetts

11,484

11,594

11,864

11,529

11,101

10,779Michigan

45,65244,26244,02544,42344,70244,475

Minnesota

9,162

9,230

9,123

9,278

9,201

9,303

Mississippi

21,33621,01921,56922,30821,787

19,499

Missouri30,44730,59530,914

31,24531,67032,124Montana

4,244

4,309

4,365

4,481

4,546

4,591

Nebraska

4,462

4,552

4,609

4,760

5,039

5,380

Nevada12,52912,466

12,42812,605

12,73912,714

New Hampshire

No data

No data

No data

No data

No data

No data

New Jersey

23,63523,73323,203

22,574

21,836

20,966

New Mexico

6,455

6,599

6,590

6,643

6,819

6,996

New York

59,23757,05455,932

54,98154,04953,181

North Carolina

40,102

41,03038,38537,46937,66537,794

North Dakota

1,479

1,477

1,459

1,527

1,567

1,696

Continued on next page92

StateFY 2010

FY 2011

FY 2012FY 2013

FY 2014

FY 2015

Ohio

48,796

48,60250,09249,75250,33550,452

Oklahoma

24,54924,511

24,257

24,83125,64527,051

Oregon13,817

14,116

13,947

14,282

14,554

14,539Pennsylvania

51,27551,27051,53351,35551,36850,816

Rhode Island

3,502

3,273

3,191

3,160

3,214

3,182

South Carolina

24,71023,93923,334

22,68022,315

21,773

South Dakota

3,450

3,434

3,546

3,623

3,627

3,588

Tennessee

28,20628,822

29,99730,71330,67029,634

Texas

154,315

155,830

154,933

151,116

150,620

149,159

Utah

6,645

6,876

6,908

7,025

7,163

6,973

Vermont

1,578

1,554

1,582

1,579

1,620

1,610

Virginia

38,17837,98337,84938,33938,871

38,761

Washington

17,097

17,04417,004

17,406

17,346

17,198

West Virginia

6,186

6,704

6,887

7,073

6,807

6,912

Wisconsin

22,684

22,15521,992

22,03622,06022,094

Wyoming

1,865

1,906

1,966

1,991

2,075

2,117

Notes: With some exceptions (See Appendix B: State data notes), totals reflect the population under the jurisdiction of the corrections
department, including those individuals held in the custody of private prisons and/or local jails.
© 2017 The Pew Charitable Trusts

93

Table C.3

Per-Inmate Corrections Department Health Care Spending,
Adjusted for Inflation
FY 2010-15
State

FY 2010

FY 2011

FY 2012FY 2013

FY 2014

FY 2015

Percentagechange49-state
median––$5,596$5,510$5,467$5,720–48-state
median$5,563$5,521$5,484$5,456$5,420$5,6802%

Alabama$3,207$3,205$3,274$2,820$2,956$3,234

1%

Alaska$8,428$7,313$6,999$6,851$6,747$7,239-14%

Arizona$3,683$3,072$3,579$3,277$3,417$3,529-4%

Arkansas$4,642$4,502$4,863$4,987$4,096$4,186-10%

California$15,827$15,694$17,021$16,497$17,684$19,796

25%

Colorado$5,807$5,819$5,776$6,941$6,532$6,641

14%

Connecticut$5,577$5,512$5,373$5,116$5,281$5,5650%Delaware$7,092$7,375$7,948$8,206$7,846$8,408

19%

Florida$4,831$4,699$4,702$4,513$4,325$4,050-16%

Georgia$3,871$3,899$3,683$3,543$3,676$3,610-7%

Hawaii$5,550$4,897$5,019$5,133$4,941$5,422-2%

Idaho$4,942$5,129$4,983$5,308$5,467$5,641

14%

Illinois$3,478$3,471$3,231$3,067$3,439$3,6194%

Indiana$3,678$4,040$3,657$3,729$3,519$3,246-12%

Iowa$4,724$4,553$4,503$4,708$4,822$5,0898%

Kansas$5,885$5,706$5,641$5,558$5,696$5,9992%

Kentucky$3,747$3,844$3,643$3,689$3,827$3,7630%Louisiana$1,396$1,394$1,368$1,282$1,864$2,17356%

Maine$7,965$8,782$8,837$6,639$6,691$7,397-7%

Maryland$6,566$6,813$6,908$6,841$7,071$7,28011%

Massachusetts$9,056$8,867$8,743$8,897$8,458$8,948-1%Michigan$8,020$7,942$8,789$9,004$8,432$8,287

3%

Minnesota$7,415$7,657$7,616$7,630$7,734$8,15810%

Mississippi$4,058$3,873$3,683$3,296$3,691$3,770-7%

Missouri$4,909$5,027$5,156$5,185$5,325$4,942

1%Montana$7,156$7,256$8,029$7,848$7,509$8,08413%

Nebraska$7,567$7,596$7,959$7,738$8,279$8,583

13%

Nevada$4,126$3,975$3,500$3,661$3,600$3,246-21%

New Hampshire

No data

No data

No data

No data

No data

No data-

New Jersey$6,968$6,665$6,706$7,349$7,704$7,789

12%

New Mexico$13,917$12,833$12,696$11,464$12,054$12,293-12%

Continued on next page94

StateFY 2010

FY 2011

FY 2012FY 2013

FY 2014

FY 2015

PercentagechangeNew York$6,701$6,729$6,396$6,658$6,548$7,047

5%

North Carolina$7,296$6,620$6,591$6,824$6,812$6,923-5%

North Dakota

No data

No data$6,394$6,208$7,086$7,049-Ohio$6,860$6,395$5,596$5,535$5,251$5,023-27%

Oklahoma$3,779$3,704$3,790$3,939$3,962$3,706-2%

Oregon$7,225$7,832$7,435$8,413$7,665$8,45617%

Pennsylvania$4,913$5,109$4,873$4,417$4,669$4,548-7%

Rhode Island$6,016$6,260$6,790$6,637$6,453$6,902

15%

South Carolina$2,880$2,808$2,996$3,021$3,160$3,47821%

South Dakota$4,781$4,835$4,311$4,569$5,373$5,62618%

Tennessee$4,911$5,002$5,142$5,402$5,978$6,00122%

Texas$4,032$3,974$3,540$3,704$3,939$4,0771%

Utah$4,404$4,165$4,223$4,154$4,108$4,5604%

Vermont$11,581$15,256$13,065$13,998$13,791$13,747

19%

Virginia$5,438$5,530$5,764$5,761$5,332$5,937

9%

Washington$7,156$6,633$6,784$6,228$6,447$6,705-6%West Virginia$5,260$4,840$4,261$4,146$4,225$3,970-25%

Wisconsin$5,608$5,772$5,702$5,510$5,655$5,7202%

Wyoming$13,382$13,548$14,087$13,332$12,066$11,798-12%

Notes: Amounts are in 2015 dollars. Nominal spending data for fiscal 2010-15 were converted to 2015 dollars using the Implicit Price Deflator
for Gross Domestic Product included in the Bureau of Economic Analysis’ National Income and Product Accounts.
Per-inmate spending includes health care provided to those individuals under the jurisdiction of the state corrections department who areheld in the custody of private prisons and/or local jails. In Arizona, Colorado, Florida, Hawaii, Idaho, Illinois, Kansas, Louisiana, Maryland,
Massachusetts, Minnesota, Mississippi, Missouri, Montana, New Jersey, New Mexico, Ohio, Oklahoma, Oregon, South Dakota, Tennessee,
Virginia, West Virginia, and Wisconsin, per-inmate spending either excludes certain individuals under the jurisdiction of the state corrections
department or includes individuals outside of that jurisdiction. (See Appendix B: State data notes.)
The 49-state total excludes New Hampshire. The 48-state total excludes New Hampshire and North Dakota. New Hampshire did not respondto the survey, and North Dakota did not report total spending for fiscal years 2010 and 2011.
© 2017 The Pew Charitable Trusts

95

Table C.4

Health Care Services Delivery System for Inmates Under State
Custody, FY 2015
State

Direct-provision

Contractedprovision

State university

Hybrid

17 states

20 states

4 states

8 states

No dataprovided

No dataprovided

No dataprovided

No dataprovided

Alabama
AlaskaArizona
Arkansas
California
Colorado
Connecticut
Delaware
FloridaGeorgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KansasKentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontana
Nebraska
NevadaNew Hampshire
New Jersey
New Mexico
New York
North Carolina
Continued on next page96

StateDirect-provision

North Dakota
Ohio
Oklahoma
OregonPennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming© 2017 The Pew Charitable Trusts

97

Contractedprovision

State university

HybridTable C.5

Contractor Payment Models, FY 2015
State

Capitation

Cost-plus

Other

19 states

2 states

7 states

Alabama
Arizona
Arkansas
Colorado
Delaware
FloridaIdaho
Illinois
Indiana
KansasKentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontana
New Mexico
Pennsylvania
Rhode Island
Tennessee
Vermont
Virginia
West Virginia
Wyoming
Note: These data reflect reported payment models for contracted-provision and hybrid states, excluding direct-provision and states thatpartner with medical schools or affiliated organizations. New Hampshire did not provide data.
© 2017 The Pew Charitable Trusts

98Table C.6

Disaggregated Spending Submission
State

Provided disaggregateddata using categories
provided

Provided disaggregateddata using own
categories

Provided nodisaggregated data

7 states

27 states

17 states

No dataprovided

No dataprovided

No dataprovided

Alabama
AlaskaArizona
Arkansas
California
Colorado
Connecticut
Delaware
FloridaGeorgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KansasKentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontana
Nebraska
NevadaNew Hampshire

Continued on next page99

StateNew Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
OregonPennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming© 2017 The Pew Charitable Trusts

100

Provided disaggregateddata using categories
provided

Provided disaggregateddata using own
categories

Provided nodisaggregated data

Table C.7

Number of Health Professional FTEs Per 1,000 Individuals Under
State Custody, FY 2015
State

FTEs for every 1,000 inmates in custody

43-state median

40.1

Alabama

25.3

Alaska36.8

Arizona

26.6

Arkansas

32.3

California

69.9

Colorado

43.9

Connecticut

48.6

Delaware58.6

Florida–Georgia

32.1

Hawaii

72.3

Idaho

36.6

Illinois

19.3

Indiana

25.4

Iowa

–

Kansas51.3

Kentucky

35.7

Louisiana

23.4

Maine

79.3

Maryland

54.2

Massachusetts

60.2

Michigan

36.8

Minnesota

59.1

Mississippi

38.1

Missouri

29.1

Montana

50.7

Nebraska

44.0

Nevada24.5

New Hampshire

No data provided

New Jersey

46.5

New Mexico

86.8

New York

35.9

Continued on next page101

StateFTEs for every 1,000 inmates in custody

North Carolina

45.3

North Dakota

44.9

Ohio

27.4

Oklahoma

18.6

Oregon35.8

Pennsylvania

25.7

Rhode Island–

South Carolina

25.0South Dakota

44.8

Tennessee

58.7

Texas

27.2

Utah

–

Vermont

52.2

Virginia–

Washington

43.0West Virginia

40.1

Wisconsin–

Wyoming

57.7

Notes: This table reflects the number of health professional employees—measured as the number of full-time equivalents to account for
part-time and full-time employees—per 1,000 inmates under the custody of the corrections department. In most states, the vast majority ofinmates under their jurisdiction are also under their custody.
Most states reported either a one-day snapshot or average daily FTE totals, with a small minority basing some or all of their staffing figures on
the number budgeted for in contracts.
Most states provided data for fiscal 2015, but 13 provided them for fiscal 2016.
Six states (Florida, Iowa, Rhode Island, Utah, Virginia, and Wisconsin) were excluded from the staffing-level analysis because they submitted
staffing data that were incomplete or not comparable.
(See Appendix B: State data notes.)© 2017 The Pew Charitable Trusts

102Table C.8

Number of Health Professional FTEs by Medical Profession
Physician
Other clinicalassistants
mental healthand nurse
professionals
practitioners

State

Physicians

Psychiatrists

Dentists

Pharmacists

Alabama

–

–

–

–

–

–

Alaska

3

3

2

13

40

1

Arizona

11

9

18

27

125

0

Arkansas

–

–

–

–

–

–

California

315

0

0

61

657

174

Colorado

8

18

10

38

219

4

Connecticut

18

10

13

14

108

13

Delaware

9

4

7

20

43

5

Florida

–

–

–

–

–

–

Georgia

57

24

24

49

210

23

Hawaii

6

7

1

2

42

0

Idaho

3

2

5

12

66

0

Illinois

42

17

33

22

85

4

Indiana

32

7

16

3

82

0

Iowa

–

–

–

–

–

–

Kansas

8

10

22

0

148

1

Kentucky

9

33

10

20

125

0

Louisiana

–

–

–

–

–

–

Maine

3

4

2

6

43

0

Maryland

74

45

24

64

101

8

Massachusetts

11

17

7

20

144

1

Michigan

45

46

39

66

142

2

Minnesota

15

5

14

8

205

0

Mississippi

14

11

8

11

27

2

Missouri

34

18

27

9

162

1

Montana

3

1

3

3

13

0

Nebraska

–

–

–

–

–

–

Nevada

11

6

8

1

61

3

No data

No data

No data

No data

No data

No data

New Jersey

57

5

19

20

327

1

New Mexico

9

7

7

13

49

1

New York

90

0

156

40

66

100

North Carolina

45

15

32

26

108

97

North Dakota

1

0

1

3

32

2

Ohio

43

19

1

50

299

0

New Hampshire

Continued on next page103

StatePhysician
Other clinicalassistants
mental healthand nurse
professionals
practitioners

Physicians

Psychiatrists

Dentists

Pharmacists

Oklahoma

20

9

18

19

47

1

Oregon

15

4

22

20

52

7

Pennsylvania

40

29

33

70

33

0

Rhode Island

–

–

–

–

–

–

South Carolina

9

6

18

8

61

5

South Dakota

–

–

–

–

–

–

Tennessee

22

3

15

29

144

4

Texas

77

23

84

161

283

45

Utah

–

–

–

–

–

–

Vermont

8

2

3

4

14

0

Virginia

–

–

–

–

–

–

Washington

15

8

22

46

125

12

West Virginia

–

–

–

–

–

–

Wisconsin

–

–

–

–

–

–

Wyoming

3

1

4

3

20

0

State

NursesOther clinicallytrained staff

Paraprofessionals

Health careadministrative
staff

Other
staff

Alabama

–

–

–

–

–

Alaska

133

3

5

15

0

Arizona

358

15

180

186

0

Arkansas

–

–

–

–

–

California

3,535

58

493

602

2,365

Colorado

274

8

29

30

86

Connecticut

406

18

24

123

94

Delaware

180

10

49

23

0

Florida

–

–

–

–

–

Georgia

512

26

110

325

0

Hawaii

76

9

7

12

0

Idaho

113

3

24

26

0

Illinois

450

20

134

106

0

Indiana

283

139

65

76

0

Iowa

–

–

–

–

–

Kansas

184

63

70

10

0

Kentucky

201

6

4

24

0

Louisiana

–

–

–

–

–

Maine

64

0

4

40

0

Maryland

664

11

37

229

0

Continued on next page104

StateNursesOther clinicallytrained staff

Paraprofessionals

Health careadministrative
staff

Other
staff

Massachusetts

211

18

80

117

0

Michigan

520

26

141

610

0

Minnesota

178

4

17

103

1

Mississippi

201

3

70

20

0

Missouri

457

181

0

34

0

Montana

35

1

16

9

0

Nebraska

–

–

–

–

–

NevadaNew Hampshire
New Jersey

145

7

33

37

0

No data

No data

No data

No data

No data

287

16

103

96

44

New Mexico

134

3

29

51

0

New York

798

28

263

41

327

North Carolina

850

29

221

117

172

North Dakota

26

0

8

3

0

Ohio

727

30

0

93

0

Oklahoma

151

0

44

49

0

Oregon

222

3

71

99

6

Pennsylvania

685

49

71

261

0

Rhode Island

–

–

–

–

–

South Carolina

311

8

57

48

0

South Dakota

–

–

–

–

–

Tennessee

470

8

66

128

0

Texas

1,373

95

740

881

0

Utah

–

–

–

–

–

Vermont

65

6

8

14

2

Virginia

–

–

–

–

–

Washington

276

15

80

140

1

West Virginia

–

–

–

–

–

Wisconsin

–

–

–

–

–

Wyoming

48

12

11

16

0

Notes: Most states reported either a one-day snapshot or average daily FTE totals, with a small minority basing some or all of their staffing
figures on the number budgeted for in contracts. Most states provided data for fiscal 2015, but 13 provided them for fiscal 2016. Twelve states(Alabama, Arkansas, Florida, Iowa, Louisiana, Nebraska, Rhode Island, South Dakota, Utah, Virginia, West Virginia, and Wisconsin) were
removed from the table because they provided incomplete or no data by staff position.
The reported amounts include corrections department, state university, and other state agency employees, as well as contracted staff. They
include staff based both in correctional facilities and administrative offices. Amounts are rounded to the nearest FTE. Other clinical mental healthprofessionals included psychologists, mental health counselors, clinical social workers, and psychiatric technicians. Nurses included licensed
practical nurses and registered nurses. Other clinically trained staff included occupational therapists, physical therapists, recreational therapists,
radiology technicians, and lab technicians. Paraprofessionals included nurse technicians, certified nursing assistants, medical assistants, orderlies,
aides, dental assistants, and pharmacy technicians. New York’s disaggregated staffing data do not include psychiatrists from the state Office ofMental Health (OMH) who provide care to individuals under the jurisdiction of the state corrections department. The state did not report a countfor these employees. (See Appendix B: State data notes.)© 2017 The Pew Charitable Trusts

105Table C.9

State Prison Population Distribution by Age
State

Proportion of
inmates age 55+, FY
2010

Proportion of
Change in number ofinmates age 55+, FY
inmates age 55+,
2015
FY 2010-15

Proportion of
inmates age 40-54,
FY 2015

Alabama

–

–

–

–

Alaska

6.8%

9.9%

60.3%

27.4%

Arizona

6.0%

8.7%

51.0%

29.1%

Arkansas

7.6%

10.4%

62.4%

30.2%

California

8.0%

12.0%

16.0%

30.3%

Colorado

7.1%

10.6%

34.7%

29.5%

Connecticut

4.5%

6.8%

32.0%

27.1%

Delaware

5.8%

8.9%

54.2%

25.2%

Florida

8.0%

12.0%

48.8%

28.0%

Georgia

6.8%

9.6%

33.2%

29.1%

Hawaii

8.0%

11.0%

37.4%

34.0%

Idaho

7.0%

9.0%

39.3%

28.0%

Illinois

5.6%

8.5%

60.7%

29.7%

Indiana

5.5%

7.6%

39.3%

25.5%

Iowa

–

–

–

–

Kansas

7.1%

11.0%

72.9%

29.0%

Kentucky

6.4%

7.7%

23.5%

26.6%

Louisiana

7.2%

10.9%

41.1%

30.3%

Maine

9.0%

10.0%

10.4%

27.0%

Maryland

6.1%

9.0%

35.7%

29.0%

Massachusetts

10.4%

14.4%

30.0%

33.1%

Michigan

9.4%

–

–

–

Minnesota

5.0%

8.0%

62.5%

27.0%

Mississippi

5.7%

9.3%

49.3%

27.1%

Missouri

6.7%

10.2%

60.6%

29.4%

Montana

8.0%

12.0%

62.3%

–

Nebraska

7.3%

9.9%

63.5%

27.7%

Nevada

9.6%

13.1%

37.5%

31.7%

New Hampshire

No data

No data

No data

No data

New Jersey

5.3%

7.9%

31.1%

29.1%

New Mexico

7.2%

9.4%

41.5%

28.7%

New York

7.0%

9.0%

15.4%

31.0%

North Carolina

6.4%

10.3%

51.7%

31.3%

North Dakota

6.4%

7.6%

37.4%

23.9%

Ohio

7.1%

10.3%

50.0%

26.7%

Oklahoma

8.0%

11.0%

51.5%

31.0%

Continued on next page106

StateProportion of
inmates age 55+, FY
2010

Oregon

10.0%

12.6%

32.1%

30.9%

Pennsylvania

7.9%

11.3%

41.8%

28.6%

Rhode Island

5.8%

8.8%

37.9%

27.5%

South Carolina

6.4%

9.9%

36.3%

28.7%

South Dakota

–

9.7%

–

25.2%

Tennessee
Texas

Proportion of
Change in number ofinmates age 55+, FY
inmates age 55+,
2015
FY 2010-15

Proportion of
inmates age 40-54,
FY 2015

–

8.7%

–

28.4%

8.2%

11.2%

32.0%

31.1%

Utah

8.4%

11.3%

41.6%

29.8%

Vermont

8.0%

11.0%

40.3%

27.0%

Virginia

7.0%

10.0%

45.0%

32.0%

Washington

7.8%

10.5%

35.2%

30.6%

West Virginia

11.0%

13.0%

32.1%

29.0%

Wisconsin

6.9%

10.3%

45.4%

29.8%

Wyoming

9.2%

12.4%

53.0%

–

Notes: Age distribution data reflect proportions of the average daily population under the jurisdiction of the state corrections department,
including individuals held in private prisons or local jails.
Five states (Alabama, Iowa, Michigan, South Dakota, and Tennessee) either did not track inmates by the age brackets surveyed or did notreport data to Pew and Vera for fiscal 2010 and 2015. Montana and Wyoming reported data only for the proportion of inmates age 55 andover. Kansas’ data for fiscal 2010 were reported from a prior survey by Pew and Vera. New Hampshire provided no data at all. (See Appendix
B: State data notes.)© 2017 The Pew Charitable Trusts

107Table C.10

Female Share of State Prison Population, 2015
State

Percentage of females

50-state median

8.4%

Alabama

8.4%

Alaska10.8%

Arizona

9.3%

Arkansas

7.9%

California

4.5%

Colorado

9.2%

Connecticut

7.1%

Delaware

8.1%

Florida6.8%

Georgia

6.9%

Hawaii

11.9%

Idaho

12.2%

Illinois

5.8%

Indiana

9.3%

Iowa

9.1%

Kansas8.5%

Kentucky

11.9%

Louisiana

5.6%

Maine

9.1%

Maryland

4.4%

Massachusetts

6.6%

Michigan

5.3%

Minnesota

7.1%

Mississippi

7.0%

Missouri

10.1%

Montana

10.6%

Nebraska

8.0%

Nevada8.9%

New Hampshire

8.1%

New Jersey

4.4%

New Mexico

9.8%

New York

4.6%

North Carolina

7.3%

Continued on next page108

StatePercentage of females

North Dakota

11.6%

Ohio

8.5%

Oklahoma

10.7%

Oregon8.6%

Pennsylvania

5.7%

Rhode Island

4.5%

South Carolina

6.5%South Dakota

11.7%

Tennessee

9.4%

Texas

8.8%

Utah

7.9%

Vermont

8.6%

Virginia

8.4%

Washington

8.0%West Virginia

12.2%

Wisconsin

6.1%

Wyoming

11.0%

Notes: Percentages represent those under jurisdiction of state correctional authorities on Dec. 31, 2015. Percentages were imputed by the
Bureau of Justice Statistics (BJS) for Nevada and Oregon, which did not submit 2015 data to BJS. Percentages for Alaska, Connecticut,
Delaware, Hawaii, Rhode Island, and Vermont reflect jail and prison populations, as prisons and jails form one integrated system.
Source: U.S. Department of Justice, Bureau of Justice Statistics© 2017 The Pew Charitable Trusts

109Table C.11

Disease Prevalence Tracked, FY 2016

Arizona
Arkansas
California
Colorado
Connecticut
Delaware
FloridaGeorgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontanaContinued on next page110

Cognitive impairment

Geriatric Developmental
conditions
disabilities

Dementia

Substance use disorderAnxiety disorders

Hypertension

Diabetes

Cancers

Cardiovasculardiseases and stroke

Chronic obstructive
pulmonary disease

Mood disorders

Behavioral
healthconditions

Chronic diseases

AsthmaActive tuberculosis

HIV/AIDS
AlaskaChronic hepatitis C

Infectious
diseasesStateCognitive impairment

Geriatric Developmental
conditions
disabilities

Dementia

Substance use disorderAnxiety disorders

Hypertension

Diabetes

Cancers

Cardiovasculardiseases and stroke

Chronic obstructive
pulmonary disease

Mood disorders

Behavioral
healthconditions

Chronic diseases

AsthmaActive tuberculosis

Chronic hepatitis C

Infectious
diseases

HIV/AIDSState

Nebraska
NevadaNew Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
OregonPennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Notes: Though Florida reported that the prevalence of only one of the conditions surveyed (cardiovascular diseases and stroke) was tracked
by its department of corrections, the department’s chronic illness clinics (immunity, cardiac, gastrointestinal, respiratory, endocrine,
tuberculosis, neurology, oncology, and miscellaneous) facilitate prevalence tracking of broader sets of conditions. For example, individuals
with HIV/AIDS would be enrolled in the immunity clinic and those with hepatitis C would be enrolled in the gastrointestinal clinic.
In Wisconsin, rather than the prevalence of specific conditions, the prevalence of condition groupings by severity of mental illness is tracked.
© 2017 The Pew Charitable Trusts

111

Table C.12

State Prison Health Care Quality Monitoring Systems, FY 2016
Quality monitoring system attributes
State
AlaskaArizona
Arkansas
California
Colorado
Connecticut
Delaware
FloridaGeorgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontana
Nebraska
NevadaNew Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
OklahomaContinued on next page

112

Statewide
CQI policy

Mortality
review

Qualitymonitoring
systemData routinely
shared withlegislature or public

System required bylegislation, executive
order, or regulation

Quality monitoring system attributes
State

Statewide
CQI policy

Mortality
review

Qualitymonitoring
systemData routinely
shared withlegislature or public

System required bylegislation, executive
order, or regulation

OregonPennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Note: At the time of data collection, South Carolina reported that it was developing a statewide continuous quality improvement policy.
© 2017 The Pew Charitable Trusts

113

Table C.13

State Prison Health Care Quality Monitoring Systems: Domains
Monitored, FY 2016
AR

AZ

CA

CO

FL

GA

ID

IL

IN

KY

LA

MA

MD

ME

MI

MN

MO

MS

NE

NJ

NM

NV

NY

OH

OK

PA

SC

SD

TN

TX

UT

VT

WA

WI

WY

Timely access to care
Timely and appropriate use of labs and imaging

Access to care andutilization of services

Timely and appropriate use of specialty care
Triage response time
Grievance response time
Other
Vaccinations

Screening andprevention services

Routine physical examinations
Cancer screening
Other
HIV/AIDS
Hepatitis C

Infectious diseases

Tuberculosis
Syphilis
Gonorrhea
Cardiovascular diseases
Pulmonary diseases

Chronic diseases

Metabolic diseases
Seizure disorders
End-stage renal disease
Anxiety disorders
Mood disorders

Behavioral healthconditions

Psychotic disorders
Suicide and self-harm
Substance use disorder
Other
Dementias and cognitive impairments
Movement disorders

Geriatric conditions orservices

Urinary incontinence
Falls
Pressure ulcers
Hospice
Palliative care

114

114

Notes: Arkansas’s quality monitoring system does not include measures pertaining to the screening and prevention services queried by Pew
and Vera (vaccinations, routine physical examinations, and cancer screening), but does include measures pertaining to the frequency ofchronic care clinics (i.e., dedicated times for monitoring and managing patients with particular conditions).
In the area of screening and prevention, Colorado’s quality monitoring system includes tuberculosis testing in addition to vaccinations.
While South Carolina reported monitoring only behavioral health at the time of data collection, measures in other areas were reportedly indevelopment.
In the area of screening and prevention, Utah’s quality monitoring system includes chronic care visits in addition to vaccinations, routine
physical examinations, and cancer screening.
Washington reported that its system monitors behavioral health conditions, but not those queried by Pew and Vera (anxiety disorders, mooddisorders, psychotic disorders, suicide and self-harm, and substance use disorder).
Wisconsin did not report which chronic conditions, if any, are monitored by its quality monitoring system.
© 2017 The Pew Charitable Trusts

115

Table C.14

Health Care Contract Requirements, FY 2016
State

Contract(s) include
quality metric(s)Contract(s) include
financial incentive(s)Contract(s) include
financial penalty(ies)

Arizona
Arkansas
Colorado
Connecticut
Delaware
FloridaGeorgia
Idaho
Illinois
Indiana
KentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontana
New Jersey
New Mexico
Pennsylvania
Rhode Island
Tennessee
Texas
Vermont
Virginia
West Virginia
Wyoming
Notes: This table includes states with a prison health care system delivery model classified as contracted-provision, state university, or hybrid.
Alabama and Kansas, each classified as having a contracted-provision delivery system, did not provide data on their health care contract
requirements. Louisiana and Rhode Island did not indicate whether contracts include quality metrics.
© 2017 The Pew Charitable Trusts

116

Table C.15

Prison Health Care Continuity Service Targeting, FY 2016
Conditions targeted in states differentiating services by health status

FloridaSame baseline
services, sometargeted

Georgia

All services
are targeted

HawaiiAll services
are targeted

Illinois

Same baseline
services, sometargeted

Indiana

All services
are targeted

Iowa

Same baseline
services, sometargeted

KentuckySame baseline
services, sometargetedContinued on next page

117

Palliative care

All services
are targeted

Geriatric
conditions
andservices

Dementias

DelawareSubstance use disorderSame baseline
services, sometargeted

Suicide and self-harmriskConnecticut

Psychotic disorders

Same baseline
services, sometargeted

Personality disorders

Colorado

Mood disorders

Same baseline
services, sometargeted

Anxiety disorders

California

Behavioral health conditions

Cancers

Same baseline
services, sometargeted

ESRD

Arkansas

Diabetes

All services
are targeted

Cardiovascular diseases

Arizona

COPD

All services
are targeted

Chronic diseases

AsthmaAlaskaTuberculosis

Targetingapproach

Hepatitis C

State

HIV/AIDS

Infectious
diseasesNevadaSame baseline
services, sometargeted

New Jersey

Same baseline
services, sometargeted

New York

Same baseline
services, sometargeted

North Carolina

Same baseline
services, sometargeted

North Dakota

Same baseline
services, sometargetedOhio

All services
are targeted

Oklahoma

All services
are targeted

OregonSame baseline
services, sometargeted

Pennsylvania

Same baseline
services, sometargetedContinued on next page

118

Palliative care

Same baseline
services, sometargeted

Geriatric
conditions
andservices

Dementias

Nebraska

Substance use disorderSame baseline
services, sometargeted

Suicide and self-harmriskMississippi

Psychotic disorders

All services
are targeted

Personality disorders

Minnesota

Mood disorders

All services
are targeted

Anxiety disorders

Michigan

Behavioral health conditions

Cancers

All services
are targeted

ESRD

Massachusetts

Diabetes

Same baseline
services, sometargeted

Cardiovascular diseases

Maryland

COPD

Same baseline
services, sometargeted

Chronic diseases

AsthmaLouisiana

Tuberculosis

Targetingapproach

Hepatitis C

State

HIV/AIDS

Infectious
diseasesWashington

Same baseline
services, sometargeted

Wisconsin

Same baseline
services, sometargeted

Wyoming

Same baseline
services, sometargeted

Palliative care

Same baseline
services, sometargeted

Geriatric
conditions
andservices

Dementias

Virginia

Substance use disorderSame baseline
services, sometargeted

Suicide and self-harm
risk

Utah

Psychotic disorders

All services
are targeted

Personality disorders

Texas

Mood disorders

All services
are targeted

Anxiety disorders

Tennessee

Behavioral health conditions

Cancers

All services
are targeted

ESRD

South Dakota

Diabetes

Same baseline
services, sometargeted

Cardiovascular diseases

South Carolina

COPD

Same baseline
services, sometargeted

Chronic diseases

Asthma

Rhode Island

Tuberculosis

Targetingapproach

Hepatitis C

State

HIV/AIDS

Infectious
diseases

Notes: Hawaii reported also providing care continuity services to individuals hospitalized at the time of release from prison.
Louisiana reported also providing care continuity services to individuals with “a significant disability,” such as “hearing or visual impairment.”
Though Michigan reported providing care continuity services only to individuals with certain conditions, the survey respondent did not indicate
which conditions are targeted.
In Oregon, in addition to the conditions noted in the table, expanded care continuity services are offered to those with “severe medical
condition[s]” and those requiring nursing home placements.
Wisconsin reported also providing care continuity services to individuals with “complex medical needs.”© 2017 The Pew Charitable Trusts

119Table C.16

Prison Health Care Continuity Services, FY 2016
Coordination with
community supervision

AK

AR

AZ

x

x

x

Copy of medical
records typicallyreceived by individual

CA

CO

CT

x

x

GA

HI

IA

ID

IL

x

x

Bridge medication

x

x

x

Duration of typicalbridge medication
supply (days)

14

6

-

-

30

13

Referrals to medical
providersxx

Referrals to mental
health treatmentx

Confirmed
appointmentswith mental healthtreatment providers
Referrals to substanceuse disorder treatment

x

N/A

x

x

x

x

o

o

o

x

o

x

x

x

o

o

x

o

o

x

14

14

14

14

-

-

-

-

30

30

30

30

x

x

14

14

14

14

14

14

-

-

-

-

-

-

30

30

30

30

30

30

x

o

x

x

x

x

x

x

o

x

x

x

o

x

x

x

x

x

x

x

x

x

o

x

x

x

x

x

x

x

x

x

x

o

x

x

x

x

x

x

x

o

x

x

x

x

x

x

x

o

x

x

x

x

x

x

x

Communication with
provider prior toreleasex

Patient education for
disease prevention andmanagement

x

x

o

x

x

x

o

x

x

x

x

x

x

x

x

x

x

x

>30

ME

MI

MN

MO

x

x

x

x

x

x

x

x

x

x

>30

MD

x

x

x

MA

x

x

Confirmed
appointments with
substance use
treatment providers

N/A

LA

o

x

x

x

o

KY

o

Referrals to peer
recovery programs for
substance use disorder

x

IN
x

x

Written prescriptions

Overdose educationFLx

Copy of medical
records typicallyreceived by community
providerConfirmed
appointments withmedical providers

DE

x

o

NE

NJ

x

x

x

x

x

x

x

x

o

6
-

NM

NV

NY

x

x

x

x

x

x

OH

OK

x

o

o

o

o

o

o

o

x

o

14

14

14

14

14

14

14

-

-

-

-

-

-

-

13

30

30

30

30

30

30

30

OR

PA

RI

x

SC

SD

TN

TX

x

x

x

x

x

x

x

o

o

x

x

14

14

14

14

14

-

-

-

-

-

30

30

30

30

30

x

o

o

o

14

6

1

-

-

-

30

13

5

x

WA

WI

x

WY
x

x

x

x

x

x

o

x

o

x

x

o

o

o

o

o

6

14

14

14

14

14

-

-

-

-

-

-

13

30

30

30

30

30

14
30

x

x

o

o

x

x

o

x

x

o

o

x

x

o

x

x

x

x

x

14

-

-

30

30

x

x

o

x

x

o

x

o

o

x

x

x

x

x

x

x

x

x

o

x

x

o

x

x

o

x

x

o

o

o

o

x

x

x

x

o

x

x

x

o

o

o

x

x

x

o

x

x

o

o

x

x

x

x

o

o

o

x

o

x

x

x

o

x

x

x

o

x

x

o

x

x

x

o

x

o

x

x

x

x

o

x

x

o

x

x

x

x

x

x

x

x

x

x

x

x

o

x

x

o

o

o

x

x

x

o

x

x

x

x

o

o

o

x

x

o

x

x

o

x

x

o

o

x

x

x

x

x

x

o

x

x

x

x

o

x

o

x

x

x

x

o

x

x

o

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

o

x

x

x

x

x

x

o

o

x

x

x

o

o

x

x

o

x

x

x

x

o

o

o

x

o

x

x

o

x

x

x

x

x

≥14

x

x

x

x

0

o

o

o

>30

x

VT

14

N/A

o

x

o

VA
x

x

x

x

UT

o

o

x

ND

o

x

x

NC

x

x

x

x

x

MT

o

N/A

x

MS

x

x

x

x

x

x
x

x

x

x

o

x

o

o

x

x

o

O: Service provided to all individuals, as appropriate
X: Service provided only to individuals with certain conditions

120

120

Notes: Survey respondents in California, Delaware, Iowa, Massachusetts, New Mexico, and Oregon reported not knowing whether prisonsin their states coordinate with community supervision personnel to facilitate care continuity at release. In Wisconsin, the respondent did notindicate whether such coordination occurs.
In Connecticut, community providers reportedly receive partial health records at release. Florida and Nebraska did not report whether individuals
and/or their community providers receive a copy of health records at release. In Maryland, although medical records are not provided toindividuals or their community providers at the time of release, information on medication and chronic care needs are reportedly entered into thestate’s health information exchange. In Wisconsin, although medical records are not provided to individuals or their community providers at thetime of release, individuals do receive a discharge summary.
Data reported on the typical duration of bridge medication provided reflects the duration states most commonly reported providing for theconditions and health needs queried by Pew and Vera. However, these durations frequently vary based on numerous factors. See Appendix
B: State data notes for further information pertaining to bridge medication practices in Alaska, Arkansas, California, Georgia, Hawaii, Illinois,
Massachusetts, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, and Utah. Arizona, California, Massachusetts, andMichigan did not provide data on typical durations of bridge medication provided.
Besides the care continuity services queried by Pew and Vera, Virginia reported providing case management services to HIV-infected individuals.
Data for West Virginia are not included in this table because the state’s survey respondent reported not knowing whether prison facilities in thestate provide care continuity services.
© 2017 The Pew Charitable Trusts

121

Table C.17

Prison Health Care Continuity Services: Medicaid, FY 2016
AK

AR

AZ

CA

CO

CT

DE

FL

GA

HI

IA

ID

IL

IN

KY

LA

MA

MD

ME

MI

MN

MO

MS

MT

NC

ND

NE

NJ

NM

NV

NY

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VA

VT

WA

WI

WV

WY

ACA expansion
status

E

E

E

E

E

E

E

N

N

E

E

N

E

E

E

N

E

E

N

E

E

N

N

E

N

E

N

E

E

E

E

E

N

E

E

E

N

N

N

N

N

N

E

E

N

E

N

Coveragegenerallysuspended or
terminatedduringincarceration

S

T

S

S

T

S

T

S

S

T

T

T

T

S

S

S

S

T

S

T

T

T

T

S

S

T

S

S

S

T

S

S

T

S

T

S

T

S

S

S

T

T

S

T

T

S

T

1

1

1

1

-

-

100

100

100

100

Enrollment
application
assistanceprovided atre-entry
Percentage
of facilities
providingapplication
assistance

1
100

100

-

100

100

100

100

25

-

-

25

25

76
100

100

100

100

100

-

76
100

100

100

100

100

100

51
100

100

100

100

100

75

100

100

100

100

100

100

100

25

25

76
100

100

Inmates leave
with Medicaid
card
Presumptive
eligibility used
Alternative
documentation
permitted
MCOs engage
in dischargeplanning
E = Expanded

N = Not expanded

S = Suspended

T = TerminatedNotes: Data on Medicaid expansion status are as of June 2016.
Survey respondents in Arkansas, California, Delaware, Georgia, Idaho, Illinois, Iowa, Montana, North Dakota, South Carolina, Tennessee, andTexas reported that departments of correction in these states do not track when Medicaid enrollment is generally completed.
Survey respondents in Arkansas, California, Colorado, Kentucky, Massachusetts, Minnesota, Missouri, Montana, North Carolina, North Dakota,
Oregon, Rhode Island, and West Virginia reported that the corrections department was not aware of any requirements for Medicaid managed
care plans to provide care continuity programs/services to inmates transitioning from prison to the community. Respondents from Florida,
Nebraska, and Wisconsin provided no related information.
Source: Data on whether states adopted the Medicaid expansion under the Affordable Care Act are drawn from the Kaiser Family Foundation© 2017 The Pew Charitable Trusts

122

122

Table C.18

Prison Health Care Continuity Services: Medication-Assisted Treatment, FY 2016
AK

AR

AZ

CA

CO

CT

DE

FL

GA

HI

IA

ID

IL

IN

KY

LA

MA

MD

ME

MI

MN

MO

MS

MT

NC

ND

NE

NJ

NM

NV

NY

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VA

VT

WA

WI

WY

Referral
Buprenorphine

Medicationassisted
treatmentfor opioiduse
disorders

Prescription
SupplyReferral
Prescription

Naltrexone
SupplyInjection
Methadone

ReferralReferralOverdoseprevention

Naloxone

Prescription
SupplyOverdose prevention
education
Notes: Missouri provided no information regarding access to buprenorphine, methadone, or naloxone after release.
In Hawaii, individuals are reportedly referred to a methadone treatment provider only if they were prescribed methadone during theirincarceration in order to continue treatment begun in the community.
Data for West Virginia are not included in this table because the state’s survey respondent reported not knowing whether prison facilities in thestate provide care continuity services.
© 2017 The Pew Charitable Trusts

123

123

Table C.19

Prison Health Care Continuity Services: Electronic Health
Records, FY 2016
State

Majority of prison
facilities use electronic
health records

Electronic health record
is interoperable acrossfacilities

Electronic health record
is interoperable between
facilities and community
providers

AlaskaArizona
Arkansas
California
Colorado
Connecticut
Delaware
FloridaGeorgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontana
Nebraska
NevadaNew Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
OklahomaContinued on next page

124

StateMajority of prison
facilities use electronic
health records

Electronic health record
is interoperable acrossfacilities

Electronic health record
is interoperable between
facilities and community
providers

OregonPennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Note: A state’s electronic health record was designated as interoperable with community providers if any outside providers were able toexchange and use electronic health information from a majority of prisons without special effort by the community provider or prisons.
© 2017 The Pew Charitable Trusts

125Endnotes
1

Jeremy Travis, Bruce Western, and Steve Redburn, eds., The Growth of Incarceration in the United States: Exploring Causes andConsequences (Washington, DC: National Academies Press, 2014), 205-6.

2

The Pew Charitable Trusts, “One in 100: Behind Bars in America 2008” (2008), http://www.pewtrusts.org/~/media/legacy/
uploadedfiles/wwwpewtrustsorg/reports/sentencing_and_corrections/onein100pdf.pdf.

3

Jeremy Travis, “But They All Come Back: Rethinking Prisoner Reentry,” Sentencing & Corrections, National Institute of Justice (May
2000), https://www.ncjrs.gov/pdffiles1/nij/181413.pdf; “Reentry Trends in the United States,” Bureau of Justice Statistics, last modified
Aug. 24, 2017, http://www.bjs.gov/content/reentry/reentry.cfm.

4

In fiscal 2012, the most recent year for which data were available, total state prison expenditures were $38.6 billion. States’ prison
health care spending—$7.6 billion—represented 20 percent of this total. Prison health care probably represented a similar percentage
in fiscal 2015. Tracey Kyckelhahn, “Justice Expenditure and Employment Extracts, 2012—Preliminary,” Bureau of Justice Statistics,
February 2015, https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5239.

5

Douglas C. McDonald, “Medical Care in Prisons,” Crime and Justice 26 (1999): 451-54, http://www.journals.uchicago.edu/doi/
abs/10.1086/449301.

6

The Pew Charitable Trusts, “State Prison Health Care Spending,” July 2014, http://www.pewtrusts.org/~/media/assets/2014/07/
stateprisonhealthcarespendingreport.pdf; The Pew Charitable Trusts, “Managing Prison Health Care Spending,” October 2013, http://
www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2014/pctcorrectionshealthcarebrief050814pdf.pdf.

7

The Pew Charitable Trusts, “State Prison Health Care Spending”; The Pew Charitable Trusts, “Managing Prison Health Care Spending.”

8

Estelle v. Gamble, 429 U.S. 97 (1976), https://www.law.cornell.edu/supremecourt/text/429/97.

9McDonald, “Medical Care in Prisons,” 431; Newman et al. v. Alabama et al., 349 F. Supp. 278 (M.D. Ala. 1972), http://law.justia.com/
cases/federal/district-courts/FSupp/349/278/1501874/; University of Pennsylvania Health Law Project, Health Care and Conditions in
Pennsylvania’s State Prisons: A Report (1972), 8, 119.

10

McDonald, “Medical Care in Prisons,” 437.

11

Ibid.; Daniel E. Manville, “Federal Legal Standards for Prison Medical Care,” Prison Legal News, May 15, 2003, 1, https://www.
prisonlegalnews.org/news/2003/may/15/federal-legal-standards-for-prison-medical-care.

12

McDonald, “Medical Care in Prisons”; Manville, “Federal Legal Standards.”

13

McDonald, “Medical Care in Prisons”; Manville, “Federal Legal Standards.”

14

Robert B. Greifinger, “Thirty Years Since Estelle v Gamble: Looking Forward, Not Wayward,” in Public Health Behind Bars: From Prisons to
Communities, ed. Robert B. Greifinger et al. (New York: Springer, 2007), 2.

15

Manville, “Federal Legal Standards,” 1.

16West v. Atkins, 487 U.S. 42 (1988).

17

Amy Fettig, deputy director of the American Civil Liberties Union’s National Prison Project, interview with The Pew Charitable Trusts,
Feb. 23, 2017.

18

Marciano Plata et al. v. Arnold Schwarzenegger et al., Findings of Fact and Conclusions of Law Re Appointment of Receiver, No. C011351 TEH (N.D. Calif. 2005); Brown et al. v. Plata et al., 563 U. S. 493 (2011).

19

American Civil Liberties Union, “Court Approves Major Settlement Improving Health Care in Arizona Prisons” (Feb. 18, 2015),
https://www.aclu.org/news/court-approves-major-settlement-improving-health-care-arizona-prisons; Joe Watson and Derek Gilna,“Civil Rights Advocates Laud Healthcare Settlement with Arizona Prison System” Prison Legal News, Feb. 2, 2016, 56, https://www.
prisonlegalnews.org/news/2016/feb/2/civil-rights-advocates-laud-healthcare-settlement-arizona-prison-system.

20“About Us,” Association of State and Territorial Health Officials, accessed Feb. 1, 2017, http://www.astho.org/About/.

21

Laura M. Maruschak, Marcus Berzofsky, and Jennifer Unangst, “Medical Problems of State and Federal Prisoners and Jail Inmates,
2011–12,” Bureau of Justice Statistics (February 2015), https://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf.

22

Centers for Disease Control and Prevention, “STDs in Persons Entering Corrections Facilities” (December 2012), http://www.cdc.
gov/std/stats11/corrections.htm; Theodore M. Hammett, “HIV/AIDS and Other Infectious Diseases Among Correctional Inmates:
Transmission, Burden, and an Appropriate Response,” American Journal of Public Health 96, no. 6 (2006): 974–78, http://www.ncbi.nlm.
nih.gov/pmc/articles/PMC1470637; Maria R. Khan et al., “Incarceration, Sex with an STI- or HIV-Infected Partner, and Infection withan STI or HIV in Bushwick, Brooklyn, NY: A Social Network Perspective,” American Journal of Public Health 101, no. 6 (2011): 1110–17,
http://www.ncbi.nlm.nih.gov/pubmed/21233443.

126

23

Laura M. Maruschak, “HIV in Prisons, 2001-2010,” Bureau of Justice Statistics (September 2012), https://www.bjs.gov/content/pub/
pdf/hivp10.pdf;

24

Anne C. Spaulding et al., “Impact of New Therapeutics for Hepatitis C Virus Infection in Incarcerated Populations,” Topics in Antiviral
Medicine 21, no. 1 (2013): 27–35, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3875217.

25“Public Safety is Public Health; Public Health is Public Safety,” U.S. Department of Health and Human Services, last modified Jan. 9,
2007, https://www.surgeongeneral.gov/news/speeches/correctional10062003.html.

26

World Health Organization, “Health in Prisons: A WHO Guide to the Essentials in Prison Health” (2007), http://www.euro.who.int/__
data/assets/pdf_file/0009/99018/E90174.pdf.

27“TB in Correctional Facilities in the United States,” Centers for Disease Control and Prevention, last modified Nov. 30, 2015, https://www.cdc.gov/tb/topic/populations/correctional/default.htm.

28“Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC,” Centers for Disease
Control and Prevention, last modified June 22, 2006, https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm.

29“Epidemiology of Tuberculosis in Correctional Facilities, United States, 1993-2014,” Centers for Disease Control and Prevention, lastmodified Dec. 9, 2011, https://www.cdc.gov/tb/publications/slidesets/correctionalfacilities/default.htm.

30“TB Incidence in the United States, 1953-2015,” Centers for Disease Control and Prevention, last modified Dec. 26, 2016, https://www.
cdc.gov/tb/statistics/tbcases.htm.

31

Ohio Department of Rehabilitation & Correction, “Family Support,” accessed on March 4, 2017, http://www.drc.ohio.gov/.

32“Vision, Mission, Values and Goals,” Minnesota Department of Corrections, accessed on Aug. 24, 2017, https://mn.gov/doc/about/agency-background-history/vision-mission-values/.

33“Mission, Vision, and Core Values,” Georgia Department of Corrections, accessed on March 4, 2017, http://www.dcor.state.ga.us/
AboutGDC/Mission.

34

Allen J. Beck and Bernard E. Shipley, “Recidivism of Prisoners Released in 1983,” Bureau of Justice Statistics (April 1989), https://www.
bjs.gov/content/pub/pdf/rpr83.pdf; Patrick A. Langan and David J. Levin, “Recidivism of Prisoners Released in 1994,” Bureau of Justice
Statistics (June 2002), https://www.bjs.gov/content/pub/pdf/rpr94.pdf.

35

Matthew R. Durose, Alexia D. Cooper, and Howard N. Snyder, “Recidivism of Prisoners Released in 30 States in 2005: Patterns from2005 to 2010,” Bureau of Justice Statistics (April 2014), https://www.bjs.gov/content/pub/pdf/rprts05p0510.pdf.

36

The Pew Charitable Trusts, “State of Recidivism: The Revolving Door of America’s Prisons” (April 2011), http://www.pewtrusts.org/~/
media/legacy/uploadedfiles/pcs_assets/2011/pewstateofrecidivismpdf.pdf.

37

Washington State Institute for Public Policy, “Risk Need and Responsivity Supervision (for Individuals Classified as High- andModerate-Risk)” (May 2017), http://www.wsipp.wa.gov/BenefitCost/ProgramPdf/157/Risk-Need-Responsivity-supervision-forhigh-and-moderate-risk-offenders; Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes andConsequences, 196; Craig Dowden and Shelley L. Brown, “The Role of Substance Abuse Factors in Predicting Recidivism: A MetaAnalysis,” Psychology Crime and Law 8, no. 3 (September 2002): 243-264.

38

Doris J. James and Lauren E. Glaze, “Mental Health Problems of Prison and Jail Inmates,” Bureau of Justice Statistics (December2006), 7, https://www.bjs.gov/content/pub/pdf/mhppji.pdf; Jacques Baillargeon et al., “Psychiatric Disorders and Repeat
Incarcerations: The Revolving Prison Door,” American Journal of Psychiatry 166, no. 1 (January 2009): 103-9, http://ajp.psychiatryonline.
org/doi/abs/10.1176/appi.ajp.2008.08030416; James A. Wilson and Peter B. Wood, “Dissecting the Relationship Between Mental
Illness and Return to Incarceration,” Journal of Criminal Justice 42, no. 6 (November-December 2014): 527-537, http://www.
sciencedirect.com/science/article/pii/S0047235214000828; Seena Fazel et al., “Schizophrenia and Violence: Systematic Review
and Meta-Analysis,” PLoS Medicine 6, no. 8 (August 2009), http://doi.org/10.1371/journal.pmed.1000120; Amy Blank Wilson et al.,“Examining the Impact of Mental Illness and Substance Use on Recidivism in a County Jail,” International Journal of Law and Psychiatry
34, no. 4 (July–August 2011), 264-268, http://dx.doi.org/10.1016/j.ijlp.2011.07.004.

127

39

Travis, Western, and Redburn, Growth of Incarceration, 197; Martin Killias et al., “Effects of Drug Substitution Programs on Offending
Among Drug Addicts,” Campbell Systematic Reviews 5, no. 3 (2009), https://www.campbellcollaboration.org/library/drug-substitutionprogrammes-offending-drug-addicts.html; Ojmarrh Mitchell, Doris MacKenzie, and David Wilson, “The Effectiveness of IncarcerationBased Drug Treatment on Criminal Behavior: A Systematic Review,” Campbell Systematic Reviews 8, no. 18 (2012), https://www.
campbellcollaboration.org/library/effectiveness-of-incarceration-based-drug-treatment.html; Mark W. Lipsey, Nana A. Landenberger,
and Sandra J. Wilson, “Effects of Cognitive-Behavioral Programs for Criminal Offenders,” Center for Evaluation Research andMethodology (August 2007), https://www.researchgate.net/publication/252778703_Effects_of_Cognitive-Behavioral_Programs_for_
Criminal_Offenders; Nana A. Landenberger and Mark W. Lipsey, “The Positive Effects of Cognitive-Behavioral Programs for Offenders:
A meta-analysis of factors associated with effective treatment,” Journal of Experimental Criminology 1, no. 4 (2005): 451–476,
https://link.springer.com/article/10.1007/s11292-005-3541-7; Steve Aos, Marna Miller, and Elizabeth Drake, “Evidence-Based Adult
Corrections Programs: What Works and What Does Not,” Washington State Institute for Public Policy (2006), http://www.wsipp.
wa.gov/ReportFile/924.

40

Christopher J. Mumola and Jennifer C. Karberg, “Drug Use and Dependence, State and Federal Prisoners, 2004,” Bureau of Justice
Statistics (January 2007), https://www.bjs.gov/content/pub/pdf/dudsfp04.pdf; James and Glaze, “Mental Health Problems of Prison
and Jail Inmates.”

41

Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes and Consequences, 197; Killias et al.,“Effects of Drug Substitution Programs on Offending Among Drug Addicts”; Mitchell, MacKenzie, and Wilson, “The Effectiveness of
Incarceration-Based Drug Treatment on Criminal Behavior: A Systematic Review.”

42

Ojmarrh Mitchell, Doris MacKenzie, and David Wilson, “The Effectiveness of Incarceration-Based Drug Treatment on Criminal
Behavior: A Systematic Review.”

43

The Pew Charitable Trusts, “State of Recidivism.”

44“Fiscal 50: State Trends and Analysis,” The Pew Charitable Trusts, last modified Aug. 4, 2017, http://www.pewtrusts.org/en/researchand-analysis/collections/2014/05/19/fiscal-50-state-trends-and-analysis.

45

McDonald, “Medical Care in Prisons,” 430.

46

Where possible, per-inmate health care spending reflects health care provided to individuals under the jurisdiction of state corrections
departments. However, there are several states where amounts do not include certain individuals held in private prisons or local jails.
For the purposes of comparability, individuals outside of state custody were removed from the calculation in cases where states did notreport associated spending. (See Appendix A: Methodology and Appendix B: State data notes.)

47

James J. Stephan, “State Prison Expenditures, 1996,” Bureau of Justice Statistics (August 1999), https://www.bjs.gov/content/pub/
pdf/spe96.pdf; James J. Stephan, “State Prison Expenditures, 2001,” Bureau of Justice Statistics (June 2004), https://www.bjs.gov/
content/pub/pdf/spe01.pdf.

48

To analyze changes in state prison health care spending over time, data for fiscal 2010 to 2014 were converted to 2015 dollars using
the Implicit Price Deflator for Gross Domestic Product included in the Bureau of Economic Analysis’ National Income and ProductAccounts.

49

The Pew Charitable Trusts, “Managing Prison Health Care Spending,” 5; The Pew Charitable Trusts, “State Prison Health Care
Spending,” 5.

50Louisiana experienced the largest increase (56 percent), but that change reflected a budgeting adjustment that shifted certain healthcare costs from Louisiana State University to the corrections department and was not necessarily the result of actual changes in state
prison health care spending. See Appendix B: State data notes.

51

Stephan, “State Prison Expenditures, 1996,” 7; Stephan, “State Prison Expenditures, 2001,” 6.

52

Deborah Lamb-Mechanick and Julianne Nelson, “Prison Health Care Survey: An Analysis of Factors Influencing Per Capita Costs,”
National Institute of Corrections (2000), https://s3.amazonaws.com/static.nicic.gov/Library/015999.pdf.

53

Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes and Consequences, 215.

54

United Nations, “Human Rights and Prisons: Manual on Human Rights Training for Prison Officials,” Office of the United Nations HighCommissioner for Human Rights (2005), http://www.ohchr.org/Documents/Publications/training11en.pdf.

55

World Health Organization, “Health in Prisons.”

56“Correctional Health Care Standards and Accreditation,” American Public Health Association, accessed Feb. 6, 2017, https://www.
apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/02/12/07/correctional-health-carestandards-and-accreditation.

128

57

McDonald, “Medical Care in Prisons,” 438.

58

American Bar Association, ABA Standards for Criminal Justice: Treatment of Prisoners, 3rd ed. (Washington, DC: American Bar
Association, 2011).

59“Standards,” American Correctional Association, accessed Feb. 6, 2017, http://www.aca.org/ACA_Prod_IMIS/ACA_Member/Standards_and_Accreditation/StandardsInfo_Home.aspx?WebsiteKey=139f6b09-e150-4c56-9c66-284b92f21e51&hkey=7c1b31e595cf-4bde-b400-8b5bb32a2bad&New_ContentCollectionOrganizerCommon=1#New_ContentCollectionOrganizerCommon.

60“Standards: A Framework for Quality,” National Commission on Correctional Health Care, accessed Feb. 6, 2017, http://www.ncchc.
org/standards.

61

Cheryl L. Damberg et al., “A Review of Quality Measures Used by State and Federal Prisons,” Journal of Correctional Health Care 17, no. 2(2011): 123, doi: 10.1177/1078345810397605.

62

McDonald, “Medical Care in Prisons,” 452.

63

Douglas C. McDonald, “Managing Prison Health Care and Costs,” National Institute of Justice (May 1995), 62, https://www.ncjrs.gov/
pdffiles1/Digitization/152768NCJRS.pdf.

64

Ibid.

65

Ibid.

66

Rodney Ballard (former commissioner, Kentucky Department of Corrections), interview with The Pew Charitable Trusts, June 30, 2017.

67

McDonald, “Managing Prison Health Care and Costs,” 65.

68

Ibid., 64.

69

State of Michigan, “Contract NO. 071B9200147 between State of Michigan and Corizon,” http://www.michigan.gov/documents/
buymichiganfirst/9200147_266870_7.pdf; Terese London (financial specialist, budget and operations administration, Michigan
Department of Corrections), interview with The Pew Charitable Trusts, March 1, 2017.

70

McDonald, “Managing Prison Health Care and Costs,” 68.

71

Jason Furman and Matt Fiedler, “Continuing the Affordable Care Act’s Progress on Delivery System Reform Is an Economic Imperative”(blog), White House, March 24, 2015, https://obamawhitehouse.archives.gov/blog/2015/03/24/continuing-affordable-care-act-sprogress-delivery-system-reform-economic-imperative.

72

McDonald, “Medical Care in Prisons,” 471; Lamb-Mechanick and Nelson, “Prison Health Care Survey,” 24; Kelly Bedard and H.E. Frech
III, “Prison Health Care: Is Contracting Out Healthy?” (prepublication text, July 2008), 8-12, http://econ.ucsb.edu/~kelly/prison_health.
pdf.

73

McDonald, “Managing Prison Health Care and Costs,” 79.

74

Andrew Howland (chief budget analyst, New York State Department of Corrections and Community Supervision), interview with The
Pew Charitable Trusts, Feb. 3, 2017.

75

Kathleen Heath (financial analyst, Maine Department of Corrections), interview with The Pew Charitable Trusts, Feb. 9, 2017.

76

Ibid.

77

McDonald, “Managing Prison Health Care and Costs,” 80.

78

Jeremy Cunningham, Maureen Tressel Lewis, and Paul R. Houchens, “Encounter Data Standards: Implications for Medicaid
Agencies and Managed Care Entities from Final Medicaid Managed Care Rule,” Milliman Inc. (May 2016), http://us.milliman.com/
uploadedFiles/insight/2016/2238HDP_20160524.pdf.

79

Vivian L. H. Byrd and James Verdier, “Collecting, Using, and Reporting Medicaid Encounter Data: A Primer for States,” Mathematica
Policy Research (October 2011), 4, https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/
MedicaidDataSourcesGenInfo/Downloads/MAX_PDQ_Task_X_EncounterDataPrimerforStates.pdf.

80

Stephan, “State Prison Expenditures, 1996,” 5; Stephan, “State Prison Expenditures, 2001,” 4.

81

Stephan, “State Prison Expenditures, 1996,” 12; Stephan, “State Prison Expenditures, 2001,” 5.

82

Stephan, “State Prison Expenditures, 1996,” 7; Stephan, “State Prison Expenditures, 2001,” 6.

83

Lamb-Mechanick and Nelson, “Prison Health Care Survey,” 21.

84

Centers for Medicare & Medicaid Services, “National Health Expenditures 2015 Highlights,” https://www.cms.gov/Research-StatisticsData-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf.

129

85

Oklahoma’s ratio of FTEs per 1,000 inmates excludes staff of the University of Oklahoma who provide remote telemedicine services.
Some states included such providers in their totals. (See Appendix B: State data notes.)

86

States differed slightly in how they reported staffing data. Most states reported either a one-day snapshot or average daily FTE totals,
with a small minority basing some or all of their staffing figures on the number budgeted for in contracts. Most states provided data forfiscal 2015, but 13 provided them for fiscal 2016. Six states (Florida, Iowa, Rhode Island, Utah, Virginia, and Wisconsin) were excluded
from this analysis because they submitted staffing data that were incomplete or not comparable. (See Appendix B: State data notes.)87

Six states (Florida, Iowa, Rhode Island, Utah, Virginia, and Wisconsin) were excluded from the staffing analysis because theysubmitted staffing data that were incomplete or not comparable. An additional six states (Alabama, Arkansas, Louisiana, Nebraska,
South Dakota, and West Virginia) were removed from the compositional analysis because they provided incomplete or no data by staff
position. (See Appendix B: State data notes.)

88

This analysis compares the number of health professional FTEs per 1,000 inmates under the custody of the corrections department
to spending per inmate under the jurisdiction of the corrections department. In most states, the vast majority of inmates under theirjurisdiction are also under their custody. In states that make greater use of local jails or private prisons, where inmates are not under
the custody of the state, it is possible that per-inmate health care figures would differ if calculated based solely on spending in staterun facilities for inmates under state custody. (See Appendix B: State data notes.)

89

Patricia Blair et al., “Nurses’ Scope of Practice and Delegation Authority,” National Commission on Correctional Health Care (July
2014), http://www.ncchc.org/filebin/Resources/Nurses-Scope-2014.pdf.

90Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes and Consequences, 216.

91

McDonald, “Medical Care in Prisons,” 443-444.

92

Diana Farrell et al., “Accounting for the Cost of US Health Care: A New Look at Why Americans Spend More,” McKinsey Global
Institute (December 2008), 14-18, http://healthcare.mckinsey.com/sites/default/files/MGI_Accounting_for_cost_of_US_health_care_
full_report.pdf.

93

Centers for Medicare & Medicaid Services, “Ending Chronic Homelessness” (May 25, 2004), https://www.medicaid.gov/medicaid/
ltss/downloads/community-living/ending-chronic-homelessness-smd-letter.pdf.

94“Federal Poverty Level (FPL),” U.S. Centers for Medicare & Medicaid Services, accessed Aug. 24, 2017, https://www.healthcare.
gov/glossary/federal-poverty-level-FPL; “U.S. Federal Poverty Guidelines Used to Determine Financial Eligibility for Certain Federal
Programs,” U.S. Department of Health and Human Services, accessed Feb. 15, 2017, https://aspe.hhs.gov/poverty-guidelines.

95“Status of State Action on the Medicaid Expansion Decision,” Kaiser Family Foundation, last modified Jan. 1, 2017, http://kff.org/
health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0.

96

The Pew Charitable Trusts, “How and When Medicaid Covers People Under Correctional Supervision” (August 2016), http://www.
pewtrusts.org/en/research-and-analysis/issue-briefs/2016/08/how-and-when-medicaid-covers-people-under-correctionalsupervision.

97

The Ohio Department of Rehabilitation and Correction, “2014 Annual Report” (2014), 23-24, http://www.drc.ohio.gov/Portals/0/
Reentry/Reports/Annuals/Annual%20Report%202014.pdf?ver=2016-08-03-152618-967.

98

Stuart Hudson (managing director of health care and fiscal operations, Ohio Department of Rehabilitation and Correction), interview
with The Pew Charitable Trusts, September 30, 2016.

99

The Pew Charitable Trusts, “How and When Medicaid Covers People.”

100

Institute of Medicine, Variation in Health Care Spending: Target Decision Making, Not Geography (Washington, DC: National Academies
Press, 2013), 53.

101

McDonald, “Managing Prison Health Care and Costs,” 23.

102

Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes and Consequences, 211.

103

“Chronic Disease Overview,” Centers for Disease Control and Prevention (CDC), last modified June 28, 2017, https://www.cdc.gov/
chronicdisease/overview/.

104

Jessie Gerteis et al., “Multiple Chronic Conditions Chartbook: 2010 Medical Expenditure Panel Survey Data,” Agency for Healthcare
Research and Quality (April 2014), 7-13 https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf.

105

Maruschak, Berzofsky, and Unangst, “Medical Problems,” 2.

106

Chronic Disease Overview,” Centers for Disease Control and Prevention (CDC).

130

107

Allen J. Beck, “Prisoners in 1999,” Table 13. Number of Sentenced Prisoners Under State or Federal Jurisdiction, by Gender, Race,
Hispanic Origin, and Age, 1999, Bureau of Justice Statistics, https://www.bjs.gov/content/pub/pdf/p99.pdf; “Corrections Statistical
Analysis Tool (CSAT) – Prisoners,” Estimated Number of Sentenced Prisoners Under State and Federal Jurisdiction, by Age, Sex, Race,and Hispanic Origin, December 31, Bureau of Justice Statistics, accessed on May 8, 2017, https://www.bjs.gov/index.cfm?ty=nps.

108

Beck, “Prisoners in 1999”; E. Ann Carson and Elizabeth Anderson, “Prisoners in 2015,” Bureau of Justice Statistics (December 2016),
https://www.bjs.gov/content/pub/pdf/p15.pdf.

109

Age-distribution data reflect proportions of the average daily population under the jurisdiction of the state corrections department,
including individuals held in private prisons or local jails. Five states (Alabama, Iowa, Michigan, South Dakota, and Tennessee) either
did not track inmates by the age brackets surveyed or did not report data to Pew and Vera for fiscal 2010 and 2015. Fiscal 2010 data for
Kansas were reported for a prior survey by Pew and Vera. New Hampshire provided no data at all. (See Appendix B: State data notes.)

110

Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes and Consequences, 210-212.

111

Tina Chiu, “It’s About Time: Aging Prisoners, Increasing Costs, and Geriatric Release,” Vera Institute of Justice (April 2010), https://storage.googleapis.com/vera-web-assets/downloads/Publications/its-about-time-aging-prisoners-increasing-costs-and-geriatricrelease/legacy_downloads/Its-about-time-aging-prisoners-increasing-costs-and-geriatric-release.pdf.

112

B. Jaye Anno et al., “Correctional Health Care: Addressing the Needs of Elderly, Chronically Ill, and Terminally Ill Inmates, National
Institute of Corrections” (February 2004), https://s3.amazonaws.com/static.nicic.gov/Library/018735.pdf.

113

Cyrus Ahalt et al., “Paying the Price: The Pressing Need for Quality, Cost, and Outcomes Data to Improve Correctional Healthcare forOlder Prisoners,” Journal of the American Geriatrics Society 61, no. 11 (2013): 2013–19, doi:10.1111/jgs.12510.

114

Office of the Inspector General, “The Impact of an Aging Inmate Population on the Federal Bureau of Prisons,” U.S. Department ofJustice (February 2016), https://oig.justice.gov/reports/2015/e1505.pdf.

115

E. Ann Carson and William J. Sabol, “Aging of the State Prison Population, 1993–2013,” Bureau of Justice Statistics, (May 2016),
https://www.bjs.gov/content/pub/pdf/aspp9313.pdf.

116

Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes and Consequences, 212.

117

Carson and Anderson, “Prisoners in 2015,” table 2.

118

Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes and Consequences, 215.

119

Damberg et al., “A Review of Quality Measures,” 123.

120

Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: National Academy Press,
2001), 23-25.

121

Steven M. Asch et al., “Selecting Performance Indicators for Prison Health Care,” Journal of Correctional Health Care 17, no. 2 (2011): 139,
doi: 10.1177/1078345810397712.

122

Institute of Medicine, Crossing the Quality Chasm, 232.

123

Ibid., xi.

124“The Six Domains of Health Care Quality,” Agency for Healthcare Research and Quality, last reviewed March 2016, https://www.ahrq.
gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html.

125

Avedis Donabedian, “Evaluating the Quality of Medical Care,” Milbank Quarterly 83, no. 4 (December 2005):166-206, https://www.
ncbi.nlm.nih.gov/pmc/articles/PMC2690293.

126

Stephanie S. Teleki et al., “The Current State of Quality of Care Measurement in the California Department of Corrections andRehabilitation,” Journal of Correctional Health Care 17, no. 2 (2011): 103, doi: 10.1177/1078345810397498.

127

Institute of Medicine, Crossing the Quality Chasm, 232.

128

“State Quality Strategies,” Centers for Medicare & Medicaid Services, accessed on March 2, 2017, https://www.medicaid.gov/
medicaid/quality-of-care/medicaid-managed-care/state-quality-strategy/index.html.

129

Aaron McKethan, Terry Savela, and Wesley Joines, “What Public Employee Health Plans Can Do to Improve Health Care
Quality: Examples from the States,” Lewin Group (January 2008), http://www.commonwealthfund.org/usr_doc/McKethan_whatpublicemployeehltplanscando_1097.pdf.

130

Damberg et al., “A Review of Quality Measures,” 122-137.

131

131

McDonald, “Managing Prison Health Care and Costs,” 65, 82.

132“Health Care Services Dashboard,” California Correctional Health Care Services, accessed on March 22, 2017, http://www.cphcs.
ca.gov/dashboard.aspx.

133

Renee Kanan (chief quality officer, California Correctional Health Care Services), interview with The Pew Charitable Trusts, Oct. 25,
2016.

134

Mary Dixon-Woods, Sarah McNicol, and Graham Martin, “Ten Challenges in Improving Quality in Healthcare: Lessons from the HealthFoundation’s Programme Evaluations and Relevant Literature,” BMJ Quality and Safety 21, no. 10 (2012): 876-884, http://qualitysafety.
bmj.com/content/21/10/876.info.

135

Terese London (financial specialist, Michigan Department of Corrections), interview with The Pew Charitable Trusts, Nov. 15, 2016.

136“Correctional Managed Health Care Committee (CMHCC),” Texas Department of Criminal Justice, accessed on March 2, 2017, http://
tdcj.state.tx.us/divisions/cmhc/index.html.

137

Texas Statute § 501.150, http://www.statutes.legis.state.tx.us/Docs/GV/htm/GV.501.htm.

138

Texas Statute § 501.147, http://www.statutes.legis.state.tx.us/Docs/GV/htm/GV.501.htm; “About Legislative Budget Board,”
Legislative Budget Board, accessed March 2, 2017, http://www.lbb.state.tx.us/About_LBB.aspx.

139

Texas Statute § 501.155, http://www.statutes.legis.state.tx.us/Docs/GV/htm/GV.501.htm.

140

Administrative Regulation AR 601 as of Oct. 20, 2014, “Medical Quality Management Program,” http://doc.nv.gov/uploadedFiles/
docnvgov/content/About/Administrative_Regulations/AR%20601%20-%20No%20Changes.pdf.

141“About CAHPS,” Agency for Healthcare Research and Quality, last modified October 2016, https://www.ahrq.gov/cahps/about-cahps/
index.html.

142

Damberg et al., “A Review of Quality Measures,” 132-133.

143

Sandra Tanguay, Robert Trestman, and Connie Weiskopf, “Patient Health Satisfaction Survey in Connecticut Correctional Facilities,”
Journal of Correctional Health Care 20, no. 2 (2014):127-134; Jeff Dickert (former chief operating officer, University Correctional HealthCare, Rutgers), interview with The Pew Charitable Trusts, Oct. 14, 2016; Jeff Dickert, Lisa DeBilio, and Marci Masker, “Why We Should
Measure Patient Satisfaction in Correctional Healthcare.” (presentation, Academic and Health Policy Conference on Correctional
Health, 2011), http://www.correctionalhealthconference.com/sites/correctionalhealthconference.com/files/Why%20We%20
Should%20Measure%20Patient%20Satisfaction_DeBilio%20(2).pdf.

144

Margaret E. Noonan, “Mortality in State Prisons, 2001-2014 — Statistical Tables,” Bureau of Justice Statistics (2016), https://www.bjs.
gov/content/pub/pdf/msp0114st.pdf.

145

Damberg et al., “A Review of Quality Measures,” 133.

146

Steven Shelton (former chief medical officer, Oregon Department of Corrections), interview with The Pew Charitable Trusts, July 5,
2017.

147

Timothy Hughes and Doris James Wilson, “Reentry Trends in the United States,” Bureau of Justice Statistics (April 2004), https://www.bjs.gov/content/pub/pdf/reentry.pdf.

148

Carson and Anderson, “Prisoners in 2015,” table 2; E. Ann Carson, “Prisoners in 2014,” Bureau of Justice Statistics (September 2015),
Table 7, https://www.bjs.gov/content/pub/pdf/p14.pdf.

149

Ingrid A. Binswanger et al., “Release from Prison: A High Risk of Death for Former Inmates,” New England Journal of Medicine 356,
no. 2 (2007): 157-165; Anne C. Spaulding et al., “Prisoner Survival Inside and Outside of the Institution: Implications for Health-Care
Planning,” American Journal of Epidemiology 173, no. 5 (2011): 479-487.

150

Binswanger et al., “Release from Prison”; Spaulding et al., “Prisoner Survival.”

151

Travis, Western, and Redburn, The Growth of Incarceration in the United States: Exploring Causes and Consequences, 227.

152

Emily A. Wang, Yongfei Wang, and Harlan M. Krumholz, “A High Risk of Hospitalization Following Release from Correctional Facilities
in Medicare Beneficiaries: A Retrospective Matched Cohort Study, 2002 to 2010,” JAMA Internal Medicine 173, no. 17 (2013): 16211628; Joseph W. Frank et al., “Increased Hospital and Emergency Department Utilization by Individuals with Recent Criminal JusticeInvolvement: Results of a National Survey,” Journal of General Internal Medicine 29 (2014): 1226, doi:10.1007/s11606-014-2877-y.

132

153

Kamala Mallik-Kane and Christy A. Visher, “Health and Prisoner Re-Entry: How Physical, Mental, and Substance Abuse Conditions
Shape the Process of Reintegration,” Urban Institute Justice Policy Center (February 2008), https://www.urban.org/sites/default/files/
publication/31491/411617-Health-and-Prisoner-Reentry.PDF.

154

Jeannia J. Fu et al., “Understanding the Revolving Door: Individual and Structural-Level Predictors of Recidivism Among Individuals
with HIV Leaving Jail,” AIDS and Behavior 17 no. 2 (2013): S145–S155, http://doi.org/10.1007/s10461-013-0590-1; Nicholas Freudenberg
et al., “Coming Home from Jail: The Social and Health Consequences of Community Reentry for Women, Male Adolescents, andTheir Families and Communities,” American Journal of Public Health 98 no. 1 (2008): 191-202; Joseph P. Morrissey et al., “The Role ofMedicaid Enrollment and Outpatient Service Use in Jail Recidivism Among Persons with Severe Mental Illness,” Psychiatric Services 58,
no. 6 (2007): 794-801, http://dx.doi.org/10.1176/ps.2007.58.6.794.

155

James A. Inciardi et al., “An Effective Model of Prison-Based Treatment for Drug-Involved Offenders,” Journal of Drug Issues 27, no. 2(1997): 261-278; Gregory Theurer and David Lovell, “Recidivism of Offenders with Mental Illness Released from Prison to an Intensive
Community Treatment Program,” Journal of Offender Rehabilitation 47, no. 4 (2008): 385-406; David Lovell, Gregg J. Gagliardi, andPolly Phipps, “Washington’s Dangerous Mentally Ill Offender Law: Was Community Safety Increased?,” Washington State Institutefor Public Policy (March 2005), http://www.wsipp.wa.gov/ReportFile/900/Wsipp_Washington-s-Dangerous-Mentally-Ill-OffenderLaw-Was-Community-Safety-Increased_Full-Report.pdf; Stanley Sacks et al., “Randomized Trial of a Reentry Modified TherapeuticCommunity for Offenders with Co-Occurring Disorders: Crime Outcomes,” Journal of Substance Abuse Treatment 42, no. 3 (2012):
247–259.

156

Emily A. Wang et al., “Engaging Individuals Recently Released from Prison Into Primary Care: A Randomized Trial,” American Journal of
Public Health 102, no. 9 (2012): 22-29.

157

Lori Whitten, “HIV Treatment Interruption Is Pervasive After Release From Texas Prisons,” National Institute on Drug Abuse (March
1, 2011), https://www.drugabuse.gov/news-events/nida-notes/2011/03/hiv-treatment-interruption-pervasive-after-release-texasprisons.

158

Jeff Mellow and Robert B. Greifinger, “Successful Reentry: The Perspective of Private Correctional Health Care Providers,” Journal of
Urban Health 84, no. 1 (2007): 85–98.

159

The Pew Charitable Trusts, “Mental Health and the Role of the States” (June 2015), http://www.pewtrusts.org/en/research-andanalysis/reports/2015/06/mental-health-and-the-role-of-the-states; The Pew Charitable Trusts, “Substance Use Disorders and theRole of the States” (March 2015), http://www.pewtrusts.org/en/research-and-analysis/reports/2015/03/substance-use-disordersand-the-role-of-the-states.

160

Kamala Mallik-Kane and Christy A. Visher, “Health and Prisoner Re-Entry: How Physical, Mental, and Substance Abuse Conditions
Shape the Process of Reintegration.”

161

Centers for Medicare & Medicaid Services, “Ending Chronic Homelessness.”

162

U.S. Department of Health & Human Services, “New Medicaid Guidance Improves Access to Health Care for Justice-Involved
Americans Reentering Their Communities” (April 28, 2016), https://enewspf.com/2016/04/28/new-medicaid-guidance-improvesaccess-to-health-care-for-justice-involved-americans-reentering-their-communities.

163

Centers for Medicare & Medicaid Services, “To Facilitate Successful Re-entry for Individuals Transitioning From Incarceration to Their
Communities,” letter to state health officials, SHO # 16-007 (April 28, 2016), https://www.medicaid.gov/federal-policy-guidance/
downloads/sho16007.pdf.

164

Jay Hancock, “HHS Acts to Help More Ex-Inmates Get Medicaid,” Kaiser Health News, April 29, 2016, http://khn.org/news/hhs-actsto-help-more-ex-inmates-get-medicaid/.

165

Ibid.

166

Brendan Saloner et al., “Justice-Involved Adults With Substance Use Disorders: Coverage Increased but Rates of Treatment Did Not in
2014,” Health Affairs 35, no. 6 (2016): 1058–66, doi:10.1377/hlthaff.2016.0005.

167

Paul Kirby, Warren Ferguson, and Ann Lawthers, “Post-Release MassHealth Utilization,” UMass Medical School Center for Health
Policy and Research (2011), http://www.mesconference.org/wp-content/uploads/2012/08/Tuesday_Improving-Health_Chacon-etal.
pdf.

168

“Health Care Out from Behind Bars,” Alliance for Health Policy, accessed March 8, 2017, http://www.allhealthpolicy.org/health-careout-from-behind-bars-meeting-reentering-prisoners-needs-efficiently; Kara Miller, “Ohio Medicaid Pre-Release Enrollment Program”(presentation, 2017 Atlantic States Fiscal Leaders Meeting, Feb. 25, 2017), http://www.ncsl.org/Portals/1/Documents/fiscal/Kara_
Miller_Presentation.pdf.

133

169

Ohio Department of Rehabilitation and Correction, Fiscal Year 2015 Annual Report, http://www.drc.ohio.gov/Portals/0/Reentry/
Reports/Annuals/Annual%20Report%202015.pdf?ver=2016-08-03-152549-077.

170

Jed Lipinski, “State Prisons to Enroll Ex-Inmates in Medicaid Starting Jan. 1,” Times-Picayune, Dec. 12, 2016, http://www.nola.com/
health/index.ssf/2016/12/louisiana_medicaid_prison_re-e_1.html; Raman Singh (medical director, Louisiana Department ofCorrections), interview with The Pew Charitable Trusts, Sept. 16, 2016.

171“Medicaid Managed Care Market Tracker,” Kaiser Family Foundation, accessed March 10, 2017, http://kff.org/data-collection/
medicaid-managed-care-market-tracker/.

172

Louisiana, which expanded its Medicaid program effective July 1, 2016, is included in this total because it had not implemented the
expansion at the time of its survey response.

173

Sachini N. Bandara et al., “Leveraging the Affordable Care Act to Enroll Justice-Involved Populations in Medicaid: State and Local
Efforts,” Health Affairs 34, no. 12 (2015): 2044-2051.

174

Alabama, California, Kansas, and New Hampshire did not indicate to Pew and Vera whether they generally suspend or terminate
Medicaid benefits.

175

The Pew Charitable Trusts, “How and When Medicaid Covers People,” 3.

176

Deloise Williams (assistant division director for medical services at the Missouri Department of Corrections), interview with The Pew
Charitable Trusts, Sept. 16, 2016.

177

Sharon Baucom (director of clinical services, Office of Inmate Health and Clinical Services, Maryland Department of Public Safety &Correctional Services), interview with The Pew Charitable Trusts, Sept. 9, 2016.

178

Lois M. Davis et al., “Understanding the Public Health Implications of Prisoner Reentry in California: State-of-the-State Report,” RAND
Corporation (2011), https://www.rand.org/content/dam/rand/pubs/monographs/2011/RAND_MG1165.pdf.

179

Ben Butler and Judy Murphy, “The Impact of Policies Promoting Health Information Technology on Health Care Delivery in Jails andLocal Communities,” Health Affairs 33, no. 3 (2014): 487-492.

180

Ben Butler, “New HIE Funding Opportunities for Corrections: Health Information Technology’s Role in Reducing Mass Incarceration,”
Community Oriented Correctional Health Services (March 2016), http://www.cochs.org/files/CMS/New-HIE-Funding-Opportunities.
pdf.

181

Cookie Crews (administrator of adult institutions, Health Services Division, Kentucky Department of Corrections), interview with The
Pew Charitable Trusts, Aug. 25, 2016.

182

Centers for Disease Control and Prevention, “HIV Testing Implementation Guidance for Correctional Settings” (January 2009), https://www.cdc.gov/hiv/pdf/group/cdc-hiv-correctional-settings-guidelines.pdf.

183

Liza Solomon et al., “Survey Finds That Many Prisons and Jails Have Room to Improve HIV Testing and Coordination Of Postrelease
Treatment,” Health Affairs 33, no. 3 (2014): 434-442.

184

Brian T. Montague et al., “Systematic Assessment of Linkage to Care for Persons with HIV Released from Corrections Facilities Using
Existing Datasets,” AIDS Patient Care and STDs, 30, no. 2 (2016): 84-91.

185

Centers for Disease Control and Prevention, HIV Surveillance Report, 2015, vol. 27 (Atlanta: CDC, November 2016), https://www.cdc.
gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2015-vol-27.pdf.

186

The 2017 Florida Statutes, HIV Testing of Inmates Prior to Release, Title XLVII 945.355, http://www.leg.state.fl.us/statutes/index.
cfm?App_mode=Display_Statute&Search_String=&URL=0900-0999/0945/Sections/0945.355.html.

187

Health Resources and Services Administration Ryan White HIV/AIDS Program, “Part B: Grants to States and Territories” (2014),
https://hab.hrsa.gov/sites/default/files/hab/Publications/factsheets/partbfacts2014.pdf.

188

Virginia Department of Health, “Coordination: Implementation Manual” (October 2015), http://www.vdh.virginia.gov/content/
uploads/sites/10/2016/09/Imp-Manual-CARE-COORDINATION-10-7-15.pdf.

189

Tianhua He et al., “Prevention of Hepatitis C by Screening and Treatment in U.S. Prisons,” Annals of Internal Medicine 164, no. 2 (2016):
84-92.

190“Hepatitis C Treatments Give Patients More Options,” U.S. Food & Drug Administration, last modified May 10, 2017, https://www.fda.
gov/ForConsumers/ConsumerUpdates/ucm405642.htm.

191

John T. Nguyen et al., “A Budget Impact Analysis of Newly Available Hepatitis C Therapeutics and the Financial Burden on a State
Correctional System,” Journal of Urban Health 92, no. 4 (2015): 635-49.

134

192

All states are eligible for funding. In 2016, South Dakota did not apply for funding.

193

American Society of Addiction Medicine, “The ASAM National Practice Guideline for the Use of Medications in the Treatment of
Addiction Involving Opioid Use” (2015), http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensusdocs/asam-national-practice-guideline-supplement.pdf; U.S. Department of Health and Human Services, “Addressing Prescription
Drug Abuse in the United States: Current Activities and Future Opportunities” (2013), https://www.cdc.gov/drugoverdose/pdf/
hhs_prescription_drug_abuse_report_09.2013.pdf.

194

Richard P. Mattick et al., “Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence,”
Cochrane Database of Systematic Reviews 3 (2009): CD002209, http://www.ncbi.nlm.nih.gov/pubmed/19588333; Sandra D. Comeret al., “Injectable, Sustained-Release Naltrexone for the Treatment of Opioid Dependence: A Randomized, Placebo-Controlled Trial,”
Archives of General Psychiatry 63, no. 2 (2006): 210–8, http://jamanetwork.com/journals/jamapsychiatry/fullarticle/209312; and PaulJ. Fudala et al., “Office-Based Treatment of Opiate Addiction With a Sublingual-Tablet Formulation of Buprenorphine and Naloxone,”
New England Journal of Medicine 349, no. 10 (2003): 949–58, http://www.ncbi.nlm.nih.gov/pubmed/12954743.

195

Robert P. Schwartz et al., “Opioid Agonist Treatments and Heroin Overdose Deaths in Baltimore, Maryland, 1995-2009,” American
Journal of Public Health 103, no. 5 (2013): 917–22, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670653.

196

Schwartz et al., “Opioid Agonist Treatments”; Judith I. Tsui et al., “Association of Opioid Agonist Therapy with Lower Incidence of
Hepatitis C Virus Infection in Young Adult Injection Drug Users,” JAMA Internal Medicine 174, no. 12 (2014): 1974–81, http://archinte.
jamanetwork.com/article.aspx?articleid=1918926; and David S. Metzger et al., “Human Immunodeficiency Virus Seroconversion
Among Intravenous Drug Users In- and Out-of-Treatment: An 18-Month Prospective Follow-Up,” Journal of Acquired Immune Deficiency
Syndromes 6, no. 9 (1993): 1049–56, http://www.ncbi.nlm.nih.gov/pubmed/8340896.

197

Joshua D. Lee et al., “Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders,” The New England Journalof Medicine 374 (2016): 1232-42.

198

Michael S. Gordon et al., “A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Findings at 6 Months Post-Release,”
Addiction 103, no. 8 (2008): 1333-1342.

199

Michael S. Gordon et al., “Buprenorphine Treatment for Probationers and Parolees,” Substance Abuse 36, no. 2 (2014): 217-225.

200

Because of federal prescribing regulations, prisons are not permitted to provide a supply of methadone. Therefore, all states facilitating
access to this treatment do so via a referral to a methadone clinic.

201

Carla K. Johnson, “Prisons Fight Opioids with Vivitrol Injection,” Journal of Emergency Medical Services (Nov. 14, 2016), http://www.
jems.com/articles/news/2016/11/prisons-fight-opioids-with-vivitrol-injection.html.

202

Louisiana Department of Public Safety and Corrections—Corrections Services, “Strategic Plan: FY 2017-2018 to 2021-2022” (July
2016), http://www.doc.la.gov/media/1/final.strategic.plan.fy.2017-2018.to.2021-2022.pdf.

203

Raman Singh (medical health director, Louisiana Department of Public Safety and Corrections), interview with The Pew Charitable
Trusts, May 2, 2017.

204“Mental Health Services,” Oklahoma Department of Corrections, accessed May 9, 2017, http://doc.ok.gov/mental-health-services.

205

2015 New York Laws, Correction, Article 16 § 404, http://law.justia.com/codes/new-york/2015/cor/article-16/404.

206“Program Profile: Mental Health Services Continuum Program,” National Institute of Justice, last modified Jan. 26, 2016, https://www.
crimesolutions.gov/ProgramDetails.aspx?ID=445.

207

Janeen Mongar (quality management program administrator, Colorado Department of Corrections), interview with The Pew Charitable
Trusts, Aug. 25, 2016.

208

Terri Catlett (deputy director, health services, North Carolina Department of Public Safety), interview with The Pew Charitable Trusts,
Aug. 23, 2016.

209

Laura Brooks (director, Health & Rehabilitation Services, Alaska Department of Corrections), interview with The Pew Charitable Trusts,
Oct. 19, 2016.

135

pewtrusts.org

Philadelphia

Washington