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What could be one of the largest unfunded court mandates leveled against state prisons?



The answer to that question starts with the constitutional right of prisoners to health care.


What does that exactly mean and when and how did that occur? It began four decades ago with the Supreme Court case, Estelle V. Gamble in 1976. In essence Mr. Gamble was an inmate in Texas who had a back injury and sued the state department of corrections for lack of adequate medical treatment, not giving him a work excuse and punishing him for refusing to work when medically unfit.


His case ultimately went to the Supreme Court and led to the decision that the Eighth Amendment which prohibited cruel and unusual punishment now included that “deliberate indifference to serious medical needs,” would not be tolerated. Up until that point access and substandard medical care behind bars was not a concern to the courts.

Prisons and jails were originally designed for incarceration not for medical care. I learned that the hard way when I was placed as a doctor in a male medium security prison in 1987 by the NHSC when the state was under a settlement for a class action law suit regarding mental health care.


I started my career in corrections when the first HIV medication, AZT came on the market and left right in the middle of the difficult conversation of what they would ultimately do in regards to hepatitis C treatment. Who, when and how to treat is complicated on multiple levels. Having hepatitis C may or may not cause cirrhosis and it may take upwards of 20 years to develop those problems. Recently there has been an explosion in effective medications to eradicate the virus in most people who take it, but the catch is that the treatment is extremely expensive and there is not enough money in prison budgets to pay for it. Courts though do not care about expense or budgets and if prisons are mandated to give hepatitis C treatment let me give you an idea of the cost. Depending on the genotype of the virus and the type of pills that are prescribed it can cost $50,000 to $90,0000 per patient. In my institution the State Health Department screened about 500 new inmates and found that one in four had the virus. States vary in their percentages, but let’s say that is about average. There are about 2 million individuals behind bars in the US. Do the math. If one out of four are positive that’s 500,000. If the courts mandate treatment and we treated all of them for even the lowest cost that would be a price tag of $25,000,000,000. That’s 25 billion dollars.

As a physician I believe in treating patients, but what if there is no budget to do it?

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