The delivery of prison health care ranges from that delivered by prison service employees to care delivered by on-site nurses or doctors. The differences in the quality of care are substantial and, globally, health promotion as well as illness prevention are almost nonexistent. The focus tends to be on immediate curative care.

Regardless of the mode of delivery, providing health care to the prison population is expensive and, as the above indicates, many medical problems among inmates are not being addressed well. Poorly trained correctional officers and poor quality of health care are just a few of the problems the correctional system must address. Furthermore, the cost of delivering health care to prisoners is increasing rapidly. The annual median cost of incarcerating a prisoner in 2003-2004 was $28,000 per state prisoner in the United States, $45,000 in Australia, and $53,000 in Great Britain.[37] States spend 10 percent of their corrections budgets on average to cover the cost of inmate health care-a total of more than $3 billion annually. One could argue that prison health care services are expensive primarily because the focus is on curative care rather than on preventing disease and disease surveillance.

Clearly something needs to be done as the costs of providing health care are substantial and many governments (federal and state) are having a difficult time keeping a lid on prison health service budgets. California now spends about two and a half times as much per prison inmate as it does per student in the University of California system. Texas has the highest rate of incarceration in the country, and, as such, has particular reason to worry about increasing health costs. The state pays nearly $270 million for inmate health care per year, which translates to approximately $2,150 per inmate.[38]

The need for governments to contain prison health care costs has economic as well as ethical implications. A nationwide public debate erupted in the United States when in 2002 a twice-convicted felon received a $1 million heart transplant. In another case, $5.1 million was spent in five months to treat a 49-year-old hemophiliac and diabetic who was serving a 15-month jail sentence.[39] How then should care be provided? What are prisons obligated to provide? Who should pay for the services? How can quality be assured?

The notion of universal access to health care for those incarcerated has its roots in the 1929 Geneva Convention, and more recently through the efforts of Amnesty International and the International Red Cross. The Council of Europe in 1989 issued a directive stating that prisoners should have the same access to health care as the nonincarcerated population, and that the health care provided to prisoners should be equivalent to that provided to the nonincarcerated population. In the United States, prison inmates are the only citizens with a constitutional right to health care. A prisoner’s constitutional right to health care dates back to a 1976 U.S. Supreme Court decision in the Texas case, Estelle v. Gamble. In this case, judges ruled that deliberate indifference to a prisoner’s serious illness or injury constitutes cruel and unusual punishment under the Eighth Amendment. (A precursor to this dates from the English Bill of Rights of 1689 in which Parliament stipulated among other things that cruel and unusual punishment ought not to be inflicted). Regardless of the country, the big issue in providing medical care for prisoners is cost and availability of trained personnel.

At the moment, more than half of the U.S. states are trying to recoup money by collecting a copayment from prisoners. All federal prisons and 70 percent of state prisons require inmates to pay a copayment for their medical care.[40] Chronically elderly prisoners, a group that generally has greater health care needs, are least able to afford a copayment and generally suffer more as a result. In some states, the copayment is waived for indigent prisoners. In an effort to reduce prison health care costs, eight states-Connecticut, Louisiana, Michigan, Montana, New York, South Carolina, Tennessee, and Texas-have established medical parole laws to get aging and seriously ill prisoners who no longer pose a risk to society out of prison.

In the United States, most jail and prison systems pay for and maintain an inhouse infirmary. Since the 1970s, however, many states have started contracting with privately run groups to manage the health of their inmates. The extent to which the private sector should be involved in prison health care delivery is being hotly debated in the United States and in Europe. Some individuals view privatization of prison health care as a better means of managing health care costs and improving quality of health care delivered. Opponents of prison privatization posit that cost savings from privatization are usually the result of cuts in services. Although prison health care remains largely in the public sector, movement toward privatization has been seen in both the United States and in Europe. The United Kingdom has the most privatized prison system in Europe with 10 percent of prisoners housed in 11 private prisons, many of which have not been performing well with regard to providing health care to the inmates.[41]

Thirty-four U.S. states have some privatized health care, and in 24 states, inmate health care systems were run completely by private contractors. In the United States, the largest correctional health care firm, St. Louis-based Correctional Medical Services, Inc. (CMS), insures one out of every seven inmates nationally.