Original Article Aged inmates' care puts stress on state May. 8, 2005 12:00 AM Arizona's prison inmates are getting older, sicker and they are staying behind bars longer, driving up health care costs that have to be shouldered by taxpayers. The state is already spending nearly $36 million a year more on health care than it did a decade ago. And the influx of aging inmates is just beginning. By 2009, more than 2,000 graying inmates, or double the number housed in 1998, will be eating up precious health care dollars in Arizona prisons. Inmates like Gene Garrett can't be denied medical care for the chronic ailments that are a natural part of growing old. Garrett is 74 years old, arthritic and on crutches. Eight months ago, he had a heart attack, and doctors put a stent in his heart. He takes 18 pills a day. The state pays all Garrett's medical bills. "All the meds and everything," he said. "I'd hate to pay for it right now with all the pills I'm taking. And that stent doesn't come cheap." Arizona, with more than 32,000 inmates, mirrors a national problem, as its prison health care allocations have increased 78 percent in the past decade. And because aging inmates, those 55 and older, can cost three times as much to care for as younger inmates, experts warn they could potentially bankrupt some of the nation's already cash-strapped prison systems. Officials blame longer sentences and truth-in-sentencing guidelines that virtually abolished parole. Greater numbers of inmates also are coming into prisons older or serving lengthy sentences for murders and sex crimes. In addition, society in general is getting older and people are living longer, a trend reflected in the prison population. All this means states across the country are scrambling to find ways to offset mounting medical expenses racked up by older inmates or grappling with adopting early-release programs for elderly inmates and those who are chronically or terminally ill. At least 16 states provide special housing units for geriatric inmates, and soon Arizona will join more than two dozen states that operate hospice facilities inside prisons to provide end-of-life care at a reduced cost. "This population is growing so fast we can't keep up with it," said Rod Norrish, facility health administrator at the Arizona State Prison Complex-Eyman in Florence. "We have to face it. It's getting to the point where it's difficult to manage from a health standpoint." 13 years to serve Just a decade ago, when Garrett first came to prison, he was running every day in the yard and lifting weights. Then the cramps started in one leg. Then in both legs. Now, the arthritis in Garrett's hip is so bad that some days he can't even walk to the chow hall, a distance of about a city block, without stopping to massage the pain. "It sneaks up and hits you right between the eyes," Garrett said from the Eyman prison, where he still has 13 years to serve for sex crimes. "You just happen to be here when it hits." Correctional officials are required to provide inmates the same level of care they would receive in the community, even if it means forking over $1,000 for an oxygen tank, hundreds of dollars for a wheelchair or $50,000 a year for kidney dialysis. Then there are hospital costs for surgeries, medications and staff costs to pay the doctors and nurses needed to care for aging and ill inmates. "You're looking at the same issues (as in the community), and now we're having to deal with them here," said Kai Jones, a correctional registered nurse at the Arizona State Prison Complex-Tucson. "We're having to look at assisted living, end-of-life and nursing homes. These people have the same needs. They're just incarcerated. We have to meet those needs." But prison inmates age even faster than people on the outside. A lifetime of poor diets, drug and alcohol abuse and violence, coupled with the stress of prison, triggers the earlier onset of chronic and geriatric ailments. Often, an inmate's physiological age is 10 years older than his chronological age. As a result, 55 is considered elderly in prison. "You just have to look at the inmates and say, 'Wow, you're only 55,' " said Warden Judy Frigo, who oversees the Arizona State Prison Complex-Florence. "They've had a pretty hard life." In the coming years, record numbers of graying inmates will struggle with typical aging maladies such as mobility issues, worsening eyesight, arthritis, seizures, respiratory problems, cancer, dementia, diabetes and heart disease. Inmates need dialysis, and two men, ages 41 and 53, are awaiting liver transplants. Some are hard of hearing. Others need daily oxygen. "It's shifting to more incapacitated people," said Gene Greeley, facility health administrator at the Florence prison complex. "It's getting older, and it's getting more acute or intense or complicated." Arizona, like many states, has mandatory sentencing laws and requires inmates to serve 85 percent of their time before release, essentially keeping more people behind bars for longer. Currently, the state houses 1,569 inmates age 55 and older, slightly less than 5 percent of the prison population. Nearly half were 55 or older at admission. More than two-thirds are serving time for violent crimes. Behind bars longer Population projections indicate the number of elderly inmates will jump to 2,035 in 2009, outpacing overall prison growth. In fiscal 2004, Arizona appropriated $20,174 per inmate regardless of age. National estimates place the annual costs for elderly inmates at about $70,000. "Most states are going to hit a wall due to this phenomenon," said Jonathan Turley, a law professor at George Washington University and founder of the Project for Older Prisoners. "The sooner you begin to deal with it, the less you'll have to spend. Arizona is not going to be an anomaly. Arizona is going to have the same problems as other states." Take David Romero, who serves his sentence in Housing Unit 8 at the Florence prison. The unit is about the closest thing Arizona has to a nursing home behind bars. Older inmates and those with chronic and terminal illnesses tend to be found in greater concentrations at the Florence and Tucson prisons because those facilities are closer to hospitals and medical specialists. The prisons also offer special housing wings for disabled inmates, where bed space is wider, there are no bunk beds and showers are modified for wheelchairs. Romero, 61, uses a wheelchair. Elephantiasis he says he contracted while serving as an Army Airborne Ranger during the Vietnam War has left his right leg so swollen and shapeless he can't put a sock on his foot. Nearly eight years ago, when Romero first came to prison for selling drugs, his leg was already oozing, but he could still walk on it then. He has been in and out of the hospital, and now his kidneys are failing. Three days a week, Romero goes to dialysis. He figures his condition is so chronic that if he was free, he would be in a hospital. "My health just keeps going downhill," Romero said. "Guys like me . . . we're costing people a lot of money." High need, demand Arizona prison officials say aging inmates, like older adults who are not imprisoned, utilize a disproportionate amount of the costliest health care services. Last year, nearly 800 inmates age 55 and older were enrolled in chronic care clinics; 213 were hospitalized for a total of 1,901 days. "We've got more people who have more kinds of debilitating conditions than does the general public," Corrections Director Dora Schriro said. "In general, our population is high-need, high-demand. It's an expensive group to manage. If you narrow the focus to people whose mobility begins to be impacted, whose health care costs go up, whose security needs may start to change, it starts earlier, so it's a bigger group with potentially larger costs." That reality has fueled debate about whether states should continue to lock up elderly inmates or structure sentences to allow certain non-violent offenders to be released on home arrest, a move that could alleviate runaway health care costs. It also would eliminate state costs to feed, house and guard aging and ill inmates. Some states have begun offering medical parole for non-violent elderly inmates who are suffering chronic illnesses. Arizona does not. And although this state does allow "compassionate release" for inmates near death, they are rare. Since 1992, Arizona's Board of Executive Clemency has heard 12 such requests; nine were granted. "There are some inmates, no matter how sick they are, that still provide real risks to the public," Schriro said. Officials caution that the cost-saving benefits of releasing aging or ill inmates have to be carefully weighed against public-safety risks and the need to make sure justice is served. Although recidivism studies indicate inmates 55 and older are far less likely than younger inmates to continue to commit crimes, releasing them is still not a popular option. States that do allow early releases generally stipulate inmates must be physically incapacitated or suffering from an illness so debilitating that they are incapable of presenting a danger to society. "Being tough is very popular. Everybody wants to be tougher than the next guy. For me, it's a cheap trick. They don't look ahead," said Herb Hoelter, director of the National Center on Institutions and Alternatives. "This is really a sleeping giant. And it's going to wake up one day, and people are going to say, 'Oh, no. What did we do here?' " Arizona's system is already struggling. Prison health officials say they've largely hit their maximum bed capacity for aging and ill inmates. Some inmates already stay longer than they need in costlier hospital units, guarded by corrections officers, because there aren't enough beds to care for them inside prison. Inmates who need 24-hour nursing care can go to "inpatient care" units, but the bed space is limited. At the state's only nursing-home-type facility, Housing Unit 8 in Florence, "we are approaching a waiting-list concept," Greeley said. "We've had days when I can't get you in a bed." Getting costs down From 1998 to 2003, health care allocations made up an increasingly larger part of the state's overall prison budget. By 2003, health care costs accounted for nearly 14 percent of the budget. However, in the past two years, health care appropriations have dropped as Arizona officials expanded their telemedicine program, which allows for videoconferencing between inmates and doctors, and consolidated its pharmacies. The state also has formed an interagency agreement with the Arizona Health Care Cost Containment System to help negotiate lower hospital rates. Inmates are being reclassified, and when the process is complete at the end of the year, officials will have a better idea of the custody needs of specialty groups like the aging and chronically or terminally ill. It's too soon to tell if the efforts will be enough to compensate for the expected growth in the elderly prison population. In the meantime, prison officials are becoming more aggressive about inmate health education, and inmates now eat a high-fiber, low-fat, low-salt diet designed to promote health. Officials also are looking at training inmates as aids for the sick and elderly to ease costs. At the Tucson prison, six new "inpatient care" beds are being added, and a former group-therapy room is being remodeled into a four-bed hospice facility. An adjacent room will provide two more hospice beds. Officials say the hospice program will provide tremendous cost savings for the state. Inmates who just need comfort in their last days no longer will rack up thousands of dollars a day in hospital costs. "With tougher parole throughout the U.S. and different sentencing guidelines, I figure that we're going to have more people dying in prison," said Jim Clenney, facility health administrator at the Tucson prison. "We're trying to follow the same offerings that the private world has as far as allowing people to die with dignity. It's the right thing to do." Bill Gause, who has spent half his lifetime behind bars, expects to die in prison. Now 72, Gause came to prison in 1969 for killing his estranged wife. Years ago, he was a prison trusty who even managed a bus garage for a school district. Now, he picks up cigarette butts. Gause's left leg, ravaged by arthritis, doesn't hold him anymore, so he is in a wheelchair. The arthritis also is in his elbows where the pain is so intense it burns. He has kidney stones that double him over and three stents in his heart after two heart attacks. His bifocals changed almost constantly as his eyesight worsened. He pops 10 pills twice a day and uses an inhaler for his emphysema. "I think they brought me here to die," Gause said from his dormitory-style housing unit for disabled inmates at the Tucson prison. "I'm not too far from it." Gause spends his days reading Westerns and drawing. "I'm not a threat to nobody. That's practically impossible. What am I going to do? I'm an old man," Gause said. "It only goes downhill from here."