This In Focus provides a brief overview of how the Bureau of Prisons (BOP) provides medical care to prisoners in its custody. BOP operates 122 prisons across the country, and at of the end of FY2019 there were approximately 177,000 prisoners under BOP's jurisdiction, making BOP one of the largest correctional systems in the country. Under 18 U.S.C. Section 4042(a), BOP is required to "provide for the safekeeping, care, and subsistence of all persons charged with or convicted of offenses against the United States, or held as witnesses or otherwise." 18 U.S.C. Section 4048 governs fees for health care services provided to prisoners. However, the manner in which BOP provides health care services to prisoners is largely dictated by regulations and policy statements rather than statutory law. The relevant regulations can be found in Title 28, Part 549 of the Code of Federal Regulations, and the relevant BOP policy statements are PS 6010.05, Health Services Administration, and PS 6031.04, Patient Care.
Medical Care Levels
BOP uses a four-tiered system to classify the level of medical care delivered to prisoners. The purpose of this system is to assign prisoners with greater medical needs to those facilities with more comprehensive on-site medical resources. Prisoners classified as Care Level 1 are generally healthy, and the intensity of care increases with each corresponding level. Each prisoner in BOP's custody is assigned a medical care level as a part of BOP's process of determining where a prisoner will serve his or her sentence (i.e., designation). The medical care level is based on each prisoner's medical history and other available information.
In addition to their security level, BOP institutions are classified based on the medical care level that they provide. BOP designates an institution's care level based on the medical resources available to meet the needs of each institution's population. Generally, institutions at each care level are designed to house mostly prisoners at that designated medical care level. However, no institution has a prisoner population completely composed of a given care level (e.g., a Care Level 2 institution might house prisoners who have a designation of Care Level 1 or Care Level 2).
Health Services Units
Each BOP facility has a Health Services Unit (HSU), which is responsible for providing health care services to prisoners of that facility. The primary administrators of the HSU are the Clinical Director (CD) and the Health Services Administrator (HSA). The CD is responsible for oversight of medical care provided at the institution. The CD's responsibilities include reviewing applications and credentials for members of the medical staff, ensuring that new health care providers are properly trained prior to being allowed to work independently, and implementing and monitoring in-house, continuing professional education training. The HSA plans, implements, and directs the administration of the HSU. The HSA's responsibilities include procuring medical supplies and equipment, overseeing maintenance and sanitation at the HSU, and ensuring that staff is properly licensed, registered, or certified. BOP policy also requires each HSU to have a written comprehensive preventive maintenance plan for all HSU equipment that follows manufacturers' recommendations, which includes a procedure for reporting and documenting equipment failure.
Prison Health Clinics
BOP provides medically necessary health care treatment to all prisoners housed in BOP-operated facilities. The treatment provided is consistent with the standards of care for non-incarcerated individuals. Most medical treatment is provided through health care clinics that are operated in each BOP facility. Most clinics have examination rooms, treatment rooms, dental clinics, radiology and laboratory areas, a pharmacy, and administrative offices. The following services are offered at prison clinics across all medical levels:
BOP, through its Programs Review Division, conducts internal reviews of its health services programs. BOP policy states that each program or operation at each facility is to be reviewed at least once every three years, but reviews can be performed more frequently depending on the results of prior reviews. In addition to these internal reviews, BOP requires all institutions to be accredited by the American Correctional Association (http://www.aca.org), which includes standards on the provision of health care to prisoners. BOP also requires all institutions with a designation of Care Level 2 or 3 to be accredited by the Accreditation Association for Ambulatory Health Care (http://www.aaahc.org).
Federal Medical Centers
BOP operates seven Federal Medical Centers (FMCs) that provide health care services to prisoners with more serious chronic or acute medical conditions. FMCs provide medical treatment to prisoners who are designated Care Level 4. BOP provides the following services at FMCs:
FMCs are accredited by the Joint Commission (http://www.jointcommission.org).
Health Care Outside Prison
BOP will transport a prisoner to a community health care facility or provider (e.g., a hospital) when it cannot provide medical services to prisoners through an in-prison clinic. BOP maintains contracts with community health care facilities or providers to provide necessary services. Generally, each BOP facility maintains its own contract with health care facilities or providers in the community. The contract sets the rate to be paid for providing health care services to prisoners.
BOP maintains national contracts for purchasing some goods and services, such as X-ray equipment, pharmaceuticals, and medical/surgical supplies. Other than that, each facility procures its own medical goods and services. Goods and services acquired by each facility can vary, and include contracted health care professionals, medical imaging service (such as ultrasound and magnetic resonance imaging), medical equipment, and medical waste disposal.
In June 2017, the Government Accountability Office (GAO) published a report on BOP health care costs (GAO-17-379) that found federal prisons in rural areas rely on outside medical care for prisoners to a greater extent than non-rural facilities because BOP faces difficulties with recruiting a sufficient number of medical personnel to staff in-prison clinics in rural areas. According to GAO, this challenge is in part because medical professionals may not want to relocate to rural areas and the salaries offered by BOP are not competitive with the private sector.
The 2017 GAO report examined health care service delivery at 98 BOP institutions. GAO found that 64 of BOP facilities had one to five hospitals within a 20-mile radius and 9 had no hospitals within a 20-mile radius. Nearby hospitals are not required to contract with BOP. Some hospitals decline to do so because of concerns about having prisoners in their facilities. GAO reported that BOP developed its care level system so that prisoners' health care needs are matched to facilities with sufficient community health care resources (e.g., prisoners with significant health issues are not housed in prisons where there are few hospitals nearby).
BOP Health Care Personnel
The majority of personnel who provide health services are employees of BOP. However, some BOP health care providers are Commissioned Corps Officers in the U.S. Public Health Service (USPHS) detailed to BOP per an interagency agreement. According to BOP, all employees and contractors meet Office of Personnel Management standards for qualifying education and experience as well as continuing education requirements.
Health Care for Female Prisoners
Approximately 7% of federal prisoners are female. Many imprisoned women enter prison with chronic health conditions that are untreated or undertreated. All prisoners receive a medical examination upon intake to a prison. BOP offers additional screenings to female prisoners, including pregnancy tests for females of childbearing age and other tests as clinically indicated, breast and pelvic examinations, and an offer to provide a Pap smear. BOP also requires facilities to provide female prisoners with age-specific preventive health examinations (e.g., breast or cervical).