August 26, 2020
Health Care for Federal Prisoners
This In Focus provides a brief overview of how the Bureau
Care Level 4: Prisoners are severely physically
of Prisons (BOP) provides medical care to prisoners in its
impaired, and may require daily nursing care. This
custody. BOP operates 122 prisons across the country, and
includes prisoners who are receiving treatment for
at of the end of FY2019 there were approximately 177,000
cancer, prisoners who are quadriplegic, and prisoners
prisoners under BOP’s jurisdiction, making BOP one of the
who need dialysis.
largest correctional systems in the country. Under 18 U.S.C.
Section 4042(a), BOP is required to “provide for the
In addition to their security level, BOP institutions are
safekeeping, care, and subsistence of all persons charged
classified based on the medical care level that they provide.
with or convicted of offenses against the United States, or
BOP designates an institution’s care level based on the
held as witnesses or otherwise.” 18 U.S.C. Section 4048
medical resources available to meet the needs of each
governs fees for health care services provided to prisoners.
institution’s population. Generally, institutions at each care
However, the manner in which BOP provides health care
level are designed to house mostly prisoners at that
services to prisoners is largely dictated by regulations and
designated medical care level. However, no institution has a
policy statements rather than statutory law. The relevant
prisoner population completely composed of a given care
regulations can be found in Title 28, Part 549 of the Code of
level (e.g., a Care Level 2 institution might house prisoners
Federal Regulations, and the relevant BOP policy
who have a designation of Care Level 1 or Care Level 2).
statements are PS 6010.05, Health Services Administration,
and PS 6031.04, Patient Care.
Health Services Units
Each BOP facility has a Health Services Unit (HSU), which
Medical Care Levels
is responsible for providing health care services to prisoners
BOP uses a four-tiered system to classify the level of
of that facility. The primary administrators of the HSU are
medical care delivered to prisoners. The purpose of this
the Clinical Director (CD) and the Health Services
system is to assign prisoners with greater medical needs to
Administrator (HSA). The CD is responsible for oversight
those facilities with more comprehensive on-site medical
of medical care provided at the institution. The CD’s
resources. Prisoners classified as Care Level 1 are generally
responsibilities include reviewing applications and
healthy, and the intensity of care increases with each
credentials for members of the medical staff, ensuring that
corresponding level. Each prisoner in BOP’s custody is
new health care providers are properly trained prior to
assigned a medical care level as a part of BOP’s process of
being allowed to work independently, and implementing
determining where a prisoner will serve his or her sentence
and monitoring in-house, continuing professional education
(i.e., designation). The medical care level is based on each
training. The HSA plans, implements, and directs the
prisoner’s medical history and other available information.
administration of the HSU. The HSA’s responsibilities
include procuring medical supplies and equipment,
Care Level 1: Prisoners are generally healthy, under 70
overseeing maintenance and sanitation at the HSU, and
years of age, and may have limited medical needs
ensuring that staff is properly licensed, registered, or
requiring clinical evaluation and monitoring (e.g., mild
certified. BOP policy also requires each HSU to have a
asthma or diet-controlled diabetes).
written comprehensive preventive maintenance plan for all
HSU equipment that follows manufacturers’
Care Level 2: Prisoners are stable outpatients, requiring recommendations, which includes a procedure for reporting
at least quarterly clinical evaluations (e.g., medication-
and documenting equipment failure.
controlled diabetes or epilepsy).
Prison Health Clinics
Care Level 3: Prisoners are fragile outpatients who
BOP provides medically necessary health care treatment to
require frequent clinical visits , and/or who may require
all prisoners housed in BOP-operated facilities. The
some assistance with activities of daily living, but do not
treatment provided is consistent with the standards of care
require daily nursing supervision. This care level may
for non-incarcerated individuals. Most medical treatment is
include stabilization of medical or mental health
provided through health care clinics that are operated in
conditions that require periodic hospitalization.
each BOP facility. Most clinics have examination rooms,
Examples of prisoners in this care level include
treatment rooms, dental clinics, radiology and laboratory
prisoners with cancer in remission less than one year,
areas, a pharmacy, and administrative offices. The
prisoners with advanced human immunodeficiency virus
following services are offered at prison clinics across all
(HIV) infections, and prisoners with severe congestive
medical levels:
heart failure.
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Health Care for Federal Prisoners
intake health screening to identify infectious diseases,
Health Care Outside Prison
urgent medical and mental health needs, and
BOP will transport a prisoner to a community health care
medications for ongoing conditions;
facility or provider (e.g., a hospital) when it cannot provide
medical services to prisoners through an in-prison clinic.
comprehensive medical history and physical exams;
BOP maintains contracts with community health care
facilities or providers to provide necessary services.
sick call triage and episodic visits to assess, diagnose,
Generally, each BOP facility maintains its own contract
and treat short-term health problems;
with health care facilities or providers in the community.
The contract sets the rate to be paid for providing health
chronic care to manage long-term diseases (e.g.,
care services to prisoners.
diabetes, asthma, and congestive heart failure);
BOP maintains national contracts for purchasing some
preventive health visits;
goods and services, such as X-ray equipment,
pharmaceuticals, and medical/surgical supplies. Other than
long-term nursing care to manage seriously ill offenders that, each facility procures its own medical goods and
who need help performing daily activities;
services. Goods and services acquired by each facility can
vary, and include contracted health care professionals,
rehabilitative care; and
medical imaging service (such as ultrasound and magnetic
resonance imaging), medical equipment, and medical waste
oral health care.
disposal.
BOP, through its Programs Review Division, conducts
In June 2017, the Government Accountability Office
internal reviews of its health services programs. BOP policy
(GAO) published a report on BOP health care costs (GAO-
states that each program or operation at each facility is to be
17-379) that found federal prisons in rural areas rely on
reviewed at least once every three years, but reviews can be
outside medical care for prisoners to a greater extent than
performed more frequently depending on the results of prior
non-rural facilities because BOP faces difficulties with
reviews. In addition to these internal reviews, BOP requires
recruiting a sufficient number of medical personnel to s taff
all institutions to be accredited by the American
in-prison clinics in rural areas. According to GAO, this
Correctional Association (http://www.aca.org), which
challenge is in part because medical professionals may not
includes standards on the provision of health care to
want to relocate to rural areas and the salaries offered by
prisoners. BOP also requires all institutions with a
BOP are not competitive with the private sector.
designation of Care Level 2 or 3 to be accredited by the
Accreditation Association for Ambulatory Health Care
The 2017 GAO report examined health care service
(http://www.aaahc.org).
delivery at 98 BOP institutions. GAO found that 64 of BOP
facilities had one to five hospitals within a 20-mile radius
Federal Medical Centers
and 9 had no hospitals within a 20-mile radius. Nearby
BOP operates seven Federal Medical Centers (FMCs) that
hospitals are not required to contract with BOP. Some
provide health care services to prisoners with more serious
hospitals decline to do so because of concerns about having
chronic or acute medical conditions. FMCs provide medical
prisoners in their facilities . GAO reported that BOP
treatment to prisoners who are designated Care Level 4.
developed its care level system so that prisoners’ health
BOP provides the following services at FMCs:
care needs are matched to facilities with sufficient
community health care resources (e.g., prisoners with
dialysis for prisoners with chronic renal failure,
significant health issues are not housed in prisons where
there are few hospitals nearby).
oncology treatment (chemotherapy and radiation
therapy),
BOP Health Care Personnel
The majority of personnel who provide health services are
inpatient and forensic mental health,
employees of BOP. However, some BOP health care
surgery (i.e., limited orthopedic and general surgery
providers are Commissioned Corps Officers in the U.S.
procedures),
Public Health Service (USPHS) detailed to BOP per an
interagency agreement. According to BOP, all employees
prosthetics and orthotics,
and contractors meet Office of Personnel Management
standards for qualifying education and experience as wel as
long-term ventilator-dependent management,
continuing education requirements.
dementia care, and
Health Care for Female Prisoners
end-of-life care.
Approximately 7% of federal prisoners are female. Many
imprisoned women enter prison with chronic health
FMCs are accredited by the Joint Commission
conditions that are untreated or undertreated. All prisoners
(http://www.jointcommission.org).
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,
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Health Care for Federal Prisoners
and an offer to provide a Pap smear. BOP also requires
Nathan James, Analyst in Crime Policy
facilities to provide female prisoners with age-specific
preventive health examinations (e.g., breast or cervical).
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