Nassau's and other county jails' inmate health care not routinely monitored or accredited, despite higher illness rates

No organization or government agency nationally or statewide routinely monitors or accredits all jails to ensure they are providing satisfactory health care to inmates, who are often sicker than the general population and unhappy with their medical care.

In New York, state oversight of medical care in jails -- unlike hospitals and nursing homes -- generally takes place after a death or complaint.

There's little incentive to change that to ensure that inmates get quality health care, largely because communities don't want to pay much for inmates, who aren't a sympathetic or powerful group, advocates and experts said.

"There's always an incentive not to provide care, to keep costs down," said Jack Beck, director of the Prison Visiting Project at the nonprofit advocacy group Correctional Association of New York.

Jails in New York, as in the rest of the country, are run by cities or counties, which also are responsible for the medical care.

In New York, the Commission of Correction is the state agency tasked with overseeing 54 state Department of Corrections and Community Supervision facilities, 14 New York City Department of Correction facilities and 63 county jails with about 77,500 inmates and prisoners. This includes 1,170 inmates in Nassau and 1,407 in Suffolk.

The commission, which has an annual budget of $2.9 million and a staff budgeted for 32 but down to 31, does annual inspections of the jails, but "they don't frequently encompass medical care," said commission spokesman Justin Mason.

Instead, its five-person forensic medical unit investigates deaths and allegations of poor care or systemic problems.

How oversight works

Their findings are presented to the seven-person Medical Review Board, which meets four times a year and issues a report. If violations are found, the commission monitors the jail to see that it implements the required reforms.

The commission can be scathing in its findings. It recently declared the company that Nassau County hired in 2011 to provide medical care at its jail, Armor Correctional Health Services of Miami, "incompetent" in the July 14, 2014, death of inmate John Gleeson, 40, of Oceanside. The commission also said that the for-profit company "has engaged in a pattern of inadequate and neglectful care."

It came to a similar conclusion in the Feb. 10, 2014, death of Kevin Brown, 47, of Far Rockaway, in the Nassau jail, saying that his death of heart failure "may have been prevented."

"By law, the Commission of Correction and its Medical Review Board can -- and vigorously does -- investigate the quality of care provided by medical personnel or contracted medical providers," said commission spokeswoman Janine Kava. The commission also has regulations that detail how health services must be provided in county jails, and it conducts minimum standard evaluations of jails annually -- although the evaluation does not have to include health care, she said.

This is unlike hospitals and nursing homes, which undergo routine, extensive, surprise surveys by the state and/or the nonprofit Joint Commission and must be accredited to get federal Medicare or Medicaid reimbursements.

Michael Mushlin, a law professor at Pace University and vice chairman of the Correctional Association of New York, who has written extensively on prisoners' rights, said the difference is part of the larger problem of the closed nature of prisons and jails to regular outside scrutiny. "If you have a closed institution, bad things are likely to happen; if you have oversight, you will lessen the likelihood of that," he said. "The lack of oversight is appalling, not just for medical care but for everything."

Jason Starr, director of the New York Civil Liberties Union's Nassau County chapter, agreed.

"It's the Wild West. No one knows what's happening," he said. "There isn't that architecture of centralized oversight and accountability." And, he said, there's little will to ensure that health care -- or any care -- is meeting quality standards.

"This isn't a hard thing," he said. "Folks just don't want to do it."

Dr. Robert Cohen, physician member of the New York City Board of Correction, which oversees health and mental health care in all of the city's correctional facilities, said there is an "essential contradiction" between providing medical care and keeping potentially dangerous people locked up.

"Providing health care for prisoners that meets minimal constitutional standards is possible, but not simple," said Cohen, who has also served as an independent monitor for the federal courts overseeing medical care for prisoners in several states. "Medical care requires compassion and respect for a person's medical needs and autonomy, while jails are closed violent institutions which seek to maximize control and limit prisoner choice. Effective oversight of medical care in jails is necessary because of this essential contradiction, and requires both inside and outside monitoring according to medical, not correctional standards."

Dr. Marc Stern, who was once medical director of the Albany county jail and now serves as a consultant for the U.S. Department of Justice to jails and prisons under investigation for their health care, said the issue is by no means limited to New York. "There's no national requirement for uniform monitoring and accreditation of health care delivery within correctional facilities," he said.

He said that those places where the warden or superintendent is involved in the oversight of medical care tend to do better.

In New York, health services have topped the list of formal grievances filed by inmates in county jails for the past six years, according to the state commission's annual reports. Last year, they represented 22 percent of all grievances.

The state is not alone. Nationwide, 49 percent of county jail inmates, in a report published in February by the federal Department of Justice's Bureau of Justice Statistics, said they were "not at all satisfied" with their medical care -- a higher percentage than state and federal prisoners.

Not a healthy group

According to the same report, 40 percent of jail inmates have at least one chronic condition, compared with 27 percent of the general population. Almost twice as many suffer from high blood pressure than the general population. They are three times more likely to have had an infectious disease such as hepatitis C and four times more likely to have HIV.

Among those with a chronic condition, about 40 percent said they were not taking their medication because they hadn't seen a doctor. And 36 percent said either the doctor thought medicine was unnecessary or the jail would not provide it.

Mental health problems also are rife in jails. Another Bureau of Justice Statistics' report published in 2006 -- the latest available -- found that 64 percent of jail inmates had a mental health problem. More than three-quarters of those who did also suffered from substance dependence or abuse. But, the report said, only 1 in 6, or about 17 percent, of jail inmates with mental health problems had received treatment since admission.

All of this takes its toll. Nationwide, the death rate in jails has been rising for the last three years even as the jail population decreased 4 percent, according to a third Bureau of Justice Statistics' report published in August. Suicide has been the leading cause of death in jails since 2000. In 2013, it accounted for 34 percent of jail inmate deaths. By contrast, in state prisons, suicide accounted for 5.5 percent of deaths and cancer is the leading killer, followed by heart disease.

New York had the sixth-highest number of jail deaths nationwide in 2013, the latest national statistics available. State commission statistics show that deaths in county jails alone jumped from 20 in 2013 to 35 in 2014. Of those, 16 in 2014 were suicides, compared with six the previous year.

Experts and advocates like Cohen said that the way to improve medical care is to have it monitored based on medical standards, not correctional standards. And jails, if they choose, can become accredited in health care by several not-for-profit organizations.

A leader in its field

The National Commission on Correctional Health Care is considered a leader in improving medical care in jails and prisons, but its reach is limited and its impact hard for an outsider to gauge.

Formed in the 1970s to advance health care in correctional facilities after an American Medical Association study of jails found inadequate health services and a lack of national standards, it offers a voluntary health services accreditation program for prisons, jails and juvenile detention facilities.

But only a small number of facilities have chosen to become accredited: about 500, about half of which are jails, according to commission spokesman Brent Gibson. The last official census in 2006 puts the number of state and federal prisons at 1,821 and the number of jails at 3,283.

Gibson said a list of commission-accredited facilities is not publicly available nor, he said, was the commission aware of any studies comparing the quality of health care at accredited facilities with those that are not.

The nonprofit American Correctional Association also offers voluntary accreditation that includes health care. Repeated attempts to contact someone at the organization were unsuccessful.

Of the 159 facilities listed by the association as accredited in New York, only two are county facilities, one a juvenile detention center in Erie County and the other, Westchester County's Norwood E. Jackson Correctional Center. The rest are state or federal facilities.

The nonprofit Joint Commission, which accredits hospitals and other health care facilities nationwide every three years following rigorous on-site visits, also accredits 65 federal prisons, according to Lon Berkeley, project director for community health center accreditation for the commission. But it has accredited "less than a dozen" jails and none in New York, he said.

The relative lack of accreditation and the growth of for-profit companies like Armor has fueled worries about the quality of medical care in jails among some advocates, who fear the for-profit companies have a strong financial incentive to deny care. No one appears to have a good idea of how many correctional facilities have outsourced health care nationally but Stern estimated that it is about half of local jails and state prisons. In New York, about a third of county jails' health units are run by for-profit companies.

"If it's cheaper to outsource health services, the quality of the health services that are going to be provided are not going to match the quality of publicly provided health services," said John Brickman, a lawyer in Great Neck and member of the board of directors of the Correctional Association of New York. "You see it over and over again because somewhere there's a bean counter saying you're spending too much time with that patient, ordering too many tests and specialists."

Nassau County hired Armor to administer medical care at an annual cost of $11 million, lowering the county's previous costs by $7 million a year.

An Armor spokeswoman has said that the company applies nationally recognized guidelines and "has a proven record of delivering quality health care to more than 40,000 patient-inmates in eight states."

Suffolk doesn't outsource

In Suffolk, county employees provide health care at the jails. This year, that care will cost about $12 million, including a $2.1 million contract with Peconic Bay Medical Center in Riverhead to cover hospitalizations, according to the county legislature's Budget Review Office.

Stern, who once worked for the precursor of Corizon Health, the largest for-profit correctional health care company in the country, said that for-profit companies don't necessarily provide worse care.

"It's tempting to put a finger on private companies because they are a little more visible," he said. "I'm not a big fan of private companies but that is focusing on the wrong issue."

Asked what the issue is, he said: "It's mostly money. The second part to it is it's [health care] not something society wants to see local government put a lot of money into. It's, 'Let them rot; they did something bad. We don't want them to get good things easily.' "