Asthma care faces unique challenges in incarcerated populations
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Key takeaways:
- Funding and staffing shortages make adequate asthma care challenging in jails and prisons.
- Inmates are not permitted to carry inhalers while they are incarcerated due to security issues.
Individuals with asthma and other chronic illnesses who are incarcerated do not receive the same levels of treatment as individuals outside of the correctional system, according to a study published in JAMA Health Forum.
Yet these individuals have a constitutional right to health care, and much can be done to improve the treatment they receive, Jeffrey E. Keller, MD, president-elect of the American College of Correctional Physicians, told Healio.
State of care
“The people who provide medical care in jails and prisons are good, competent medical professionals who are doing a thankless job,” Keller told Healio. “It is a problem that there are not enough of them.”
Keller, who worked in the penal system for more than 25 years before recently retiring, agreed with the authors of the study that correctional health care was “chronically underfunded” in addition to understaffed.
“Inmates are not eligible for government insurance. If you have Medicaid, you can’t use it,” Keller said, adding that veterans who are incarcerated are not able to use their Veterans Administration benefits either.
Correctional health care is funded entirely by the taxpayers who support those institutions, whether they are local, state or federal facilities, and not by insurance companies, Keller clarified.
But legislators would face backlash for increasing funding to take care of inmates when people in their own communities go without health care, Keller explained.
“It’s hard to do politically, so almost all prisons are underfunded,” Keller said.
“Almost all prisons don’t have enough nurses. They don’t have enough doctors. They don’t have enough mental health people. So, the ones that are there are laboring at a huge disadvantage because it is hard to keep up,” Keller continued.
Shortages in security impact treatment as well, Keller said.
“Oftentimes, the security people say, ‘Well, we can’t bring the people who are scheduled for medical today because we don’t have the guards to guard them,’” Keller said. “That sort of thing happens all the time.”
Even space for equipment and treatment is an issue.
“A lot of times, prisons really don’t have a place to put it,” Keller said. “Where are we going to put it? What room will we use? That sort of thing.”
Asthma care
In their study, Curran et al reported that incarcerated patients account for 0.85% of the total population with asthma, but they only receive 0.15% of distributed asthma prescriptions, indicating a 5.45-fold relative difference between diagnosis and care.
Other disparities included a 1.87-fold difference for hepatitis B or C, a 2.4-fold difference for hypertension, a 2.86-fold difference for diabetes, a 3.01-fold difference for HIV, a 4.08-fold difference for depression and a 4.11-fold difference for severe mental illness.
Keller noted the difference between jails, where inmates are usually held temporarily for up to 14 days, and prisons, where sentences can be a year and far beyond.
Jails typically focus on acute and emergency care, such as withdrawal for inmates with addiction
“Prisons tend to focus more on chronic care,” Keller said.
When inmates enter the correctional system, providers aim to keep them on whatever medications they may be taking. But sometimes in jail, Keller said, inmates do not bring medications with them.
“So, you’ve got to work to get them their medications,” Keller said. “That’s something that we prioritize highly.”
Providers can order prescriptions such as steroids from their pharmacy. But even when prisons provide inhalers, Keller said, those inmates are not allowed to carry them because they are made out of metal and could be used as a weapon.
“We have to have the inhalers with the security near where the person is housed, but they have to ask to use it. It’s not on their person,” Keller said. “That’s not ideal medically, but that’s the hand we’re dealt. We can’t change that.”
Keller said that inmates should be allowed to carry their own inhalers, and while such policies may be possible in minimum security prisons, he doubted it would happen in medium or maximum security facilities.
“Anything that can be done to make asthma care more secure so patients can have their rescue medications on hand, that would be nice,” he said.
Spacers, made of plastic, present similar problems and often are banned as well.
“I’m a big believer in spacers, but the plastic is hard enough that you could make a shank out of it and actually stab somebody and hurt them,” Keller said.
Instead, Keller used spacers that were made from cardboard and were less costly too.
“The plastic spacers were like 30 bucks. Unbelievably expensive,” Keller said. “But these cardboard ones were security-safe and worked just as well, and we handed them out to our asthma patients.”
Also, biologics may be more commonly used to treat asthma elsewhere, but not in prisons.
“They are more expensive,” Keller said. “In a prison that’s underfunded and laboring to meet a budget, there’s not anything that’s banned, but there’s pressure to use less expensive medications.”
Plus, Keller said, he would want any inmate whose asthma was severe enough to warrant treatment with a biologic to be seen by a pulmonologist.
“Some or many community pulmonologists don’t really want to see prison inmates,” Keller said. “A lot of state legislatures mandate that we only pay Medicaid rates. Physicians are not willing to take Medicaid rates, so they will not see prison inmates. So, that is a burden.”
These limitations require correctional providers to be creative in their solutions, Keller said.
“If you have somebody in the community who you can get to see your patients, then that is a great blessing. But it is not always the case,” he said.
Telemedicine offers promise in connecting inmates who need specialist care with those providers, Keller said, and many facilities are now exploring how they can use technology to improve care. But this equipment requires financing and space, which again are in short supply.
However, there are some advantages to asthma care in correctional facilities, Keller said. For example, Keller noted that smoking often is cited as the most common asthma trigger.
“Inmates are not allowed to smoke, so the incidence of asthma in a correctional setting is going to be less,” he said. “People who had asthma problems due to smoking in the community, when they come, they would improve.”
Inmates also are less exposed to common allergens that can trigger asthma as well, Keller continued.
“They have no dogs. They have no cats. They don’t get outside,” Keller said.
Further, Keller said that he did not have a lot of problems with bad asthma during his career in correctional medicine, but that does not mean that these problems never happen.
“You’re more likely to have problems with asthma in a jail than in a prison, because in jail they’re only there for a couple of weeks,” he said.
Areas to improve
Looking ahead, Keller said that asthma screenings would improve asthma care in the correctional system, if the funding and space issues could be overcome.
“Most prisons that I know of, and jails especially, don’t have the capability to do pulmonary testing functions. And most prisons are reluctant to send incarcerated patients out for pulmonary function testing, so a lot of times, physicians and practitioners in prison can wing it rather than do formal pulmonary function testing,” Keller said.
Greater access to experts for difficult cases would benefit inmates with asthma as well, Keller continued.
Keller also expressed concern about patients continuing their care once they leave the correctional system. For example, former inmates often have difficulties applying for jobs that would provide health insurance so they could get the care they need.
“A lot of employment forms ask if you’ve ever been convicted of a felony. If you write ‘yes,’ then your application goes in the garbage,” Keller said.
Public insurance sometimes plays a role.
“Most prisons work really hard to try to get people who are going to be released on Medicaid,” Keller said. “In some states, inmates upon release are automatically eligible for Medicaid, and in other states, they’re not.”
The Affordable Care Act paved the way for many of these inmates to get Medicaid once they were released, Keller said.
“The Affordable Care Act is a blessing, a super blessing, for incarcerated patients, because you could sign people up for Medicaid before they left prison,” Keller said.
Frequently, inmates do not have any insurance before they enter the correctional system, and they remain without insurance after they leave it.
“When people went to jail, that was oftentimes the first time that they had easy access to medical care. In the community, they had no health insurance. No doctors. They were basically disenfranchised for medical care,” Keller said.
“I kept seeing people say, ‘Hey, I haven’t seen a doctor in years. Would you check me out?’ So, I would, and say, ‘You’ve got diabetes and high blood pressure. We better get you on some medications,’” Keller continued.
Keller also said that government insurance such as Medicaid and Medicare should be used for incarcerated patients.
“If you’re a 65-year-old and you go to jail, why do you have to lose your Medicare benefits? Why can’t we just keep them? If we could, that would go a long way to providing needed funding for the shortage for incarcerated inmates,” Keller said.
It also would provide continuity, he continued, preventing inmates from needing to apply all over again if their eligibility lapses while they are incarcerated.
“Those sorts of benefits should follow you wherever you go,” Keller said. “It shouldn’t stop at the doors of a jail or a prison.”
Keller’s career
Treating patients with no insurance at all was quite a change for Keller when he began his career in correctional medicine after 25 years practicing in a high-volume emergency department.
“I felt like I was doing more good in the jail,” he said.
Keller made the career move after county commissioners could not find anyone to provide care in their local jail and asked him to apply for the position.
“I told them I would do it for a year until they could find someone else,” Keller said. “What I found was I liked it, and I didn’t see that coming.”
Keller also said he was drawn to the population’s constitutional right to health care.
“They’re the only residents in the United States that have a constitutional right to health care,” he said.
Soon, he joined the American College of Correctional Physicians.
“The American College of Correctional Physicians was established as a way for those physicians who work in jails and prisons to get together and interact, talk, create policies, and create educational policies to do what we can to improve the quality of medical care given to incarcerated people,” Keller said.
Keller commended similar work from the National Commission on Correctional Health Care and the Correctional Nurse Association, comprising professionals who could be making more money in private practice, he said.
“We all have the idea of improving medical care for incarcerated people,” he said, adding that they are committed to helping this underprivileged population.
“There are lots of problems in the correctional medical system,” Keller said. “The competence of the medical professionals who are there is not one of them.”
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For more information:
Jeffrey E. Keller, MD, can be reached at jeffk2996@gmail.com.