Each year that someone spends in prison cuts their life expectancy by two years. Mass incarceration multiplies that impact on a societal level: if not for incarceration, the U.S. life expectancy would be five years higher.

The abysmal state of health care behind bars bears much of the blame for those figures. Medical neglect kills hundreds of incarcerated people every year despite the 1976 Supreme Court ruling that deliberate indifference to medical needs amounts to cruel and unusual punishment. The COVID-19 pandemic compounded the impact of this inadequate care, with nearly 3,000 incarcerated people dying due to the virus since March 2020.

Routine care is denied

Last month, the New York Supreme Court held the New York City Department of Correction in contempt for failing to comply with an earlier order to provide people in its custody with access to basic medical services. A lawsuit filed by public defenders and pro bono associates noted more than 1,000 instances in December 2021 alone in which someone did not make a scheduled medical appointment because a corrections officer did not escort them. Corrections officers often record incarcerated people as declining treatment that they were in fact never offered. This April, people held on Rikers missed 11,789 medical appointments.

The New York ruling highlights the denial of basic care that plagues jails and prisons nationwide. In state facilities, more than 20 percent of incarcerated people with a persistent medical condition go without care. That number jumps to more than 68 percent in local jails. Among a population more likely to suffer from chronic health conditions like heart disease and diabetes, that inadequate care can be deadly.

Denial of medical care stretched to COVID-19 vaccine distribution, too. When vaccine eligibility was introduced, people living in congregate settings such as nursing homes or homeless shelters were given priority access due to their increased vulnerability. However, some states arbitrarily excluded people living in jails and prisons, defying the recommendation of public health experts. New York was one of those states, before the state’s Supreme Court ruled that excluding incarcerated people was dangerous and discriminatory.

Incarcerated people are similarly excluded from Medicaid coverage, which greatly diminishes access to critical care.

Physicians who work in jails also describe conflicts that arise due to the structure of the carceral system, which leaves patients’ health in tension with the corrosive toll of incarceration. “One of the practices that's ongoing today is having health staff clear people for punishment and solitary confinement,” Dr. Homer Venters, former chief medical officer of the New York City jail system, told Gothamist. “It's unethical but it happens in almost every jail in the country and it really degrades our ability to care for patients and [their] ability to trust us.”

No federal standards leave reproductive health on the chopping block

Organizations like the National Commission on Correctional Health Care (NCCHC) set standards and offer accreditation to jails and prisons for health care services. Yet participation is optional, and just 17 percent of facilities (500 of 3,000) are accredited. That leaves significant ambiguity as to what constitutes the legal minimum standard of “reasonably adequate” care.

Similarly, there are no federal standards governing reproductive health for incarcerated people, and abortion access in jails and prisons is dependent on jurisdiction. Three state prison systems deny abortions altogether, and access is murky in other states deemed hostile to abortion rights. An estimated 58,000 pregnant people enter jails and prisons every year, and the Dobbs Supreme Court decision overturning Roe v. Wade means that even more people could now be forced to give birth while incarcerated.

Moreover, access to contraception—often used to treat medical conditions, not just prevent pregnancy—is limited. One study of 22 state prison systems found that 27 percent of states did not offer contraception at all, and six prison systems allowed access to permanent sterilization but no other contraception.

The cost of care is prohibitive

People held in jails and prisons are required to pay copays of $2–$5, even though they typically make between $0.14 to $0.63 per hour. That’s equivalent to a copay of hundreds of dollars for people making minimum wage. Expensive copays often prove prohibitive, giving incarcerated people pause before seeking treatment. The NCCHC says that copays may jeopardize health for incarcerated people, staff, and the public alike, and that fee collection may actually cost more than the revenue copays generate.

Oversight and decarceration are necessary

To ensure better health outcomes, officials should look at two solutions: reducing jail and prison populations and improving oversight.

Overcrowding drives many of the most significant health threats in jails and prisons. Dangerous overcrowding in the California state prison system led the U.S. Supreme Court to rule the conditions unconstitutional in 2012 and order the state to reduce the number of people incarcerated by 46,000. A lower jail and prison population will lead to better health outcomes and place less stress on inadequate health care systems.

Improved oversight can improve those systems, too. New York provides a case study: a 2009 law created health department oversight of jail and prison practices regarding HIV and hepatitis C, markedly improving care while still falling short of what is needed. Dr. Venters called for the creation of an Office of Correctional Health, which would track the health risks of incarceration while providing evidence-based care.

Oversight must be expanded. Last year, former Governor Andrew Cuomo stymied a bill that would give the state Department of Health more power over the prison health care system. Legislators in New York should press for passage of that bill next legislative session, and lawmakers nationwide should pursue similar tactics to protect public health.