A landmark 1976 U.S. Supreme Court ruling (Estelle v. Gamble) makes incarcerated people the only group in the United States with a protected constitutional right to health care.

But the exact nature of that health care is open to interpretation.

For example, in the late 1970s, Jorge Renaud was serving 27 years in a Texas state prison when he somehow caught his head in the mechanical door to his cell. The incident almost severed his ear from his head. Renaud, now national criminal justice director of Latino Justice, a civil rights group, recalls that when he got to the infirmary, “an inmate literally stapled my ear together.”

Not exactly state-of-the-art care, by any measure.

Today, multiple medical organizations and correctional associations, including the National Commission on Correctional Health Care and the American Diabetes Association, have issued standards for health care for the more than 2 million people in federal, state, and local correctional settings.

But those standards are entirely voluntary.

The predictable result is that the level of care varies widely from state to state, county to county, and facility to facility.

Here are some realities of correctional health care in the U.S.

Jail care is acute care

One of the most dramatic differences in correctional health care exists between jails and prisons. Jails are by definition temporary facilities, with an average stay of 26 days. (Prisons typically house people who are serving sentences of more than 1 year.)

That means that in jails, providers often only have time to address acute conditions, says Warren J. Ferguson, MD, a professor of family medicine and community health at the University of Massachusetts Chan Medical School and head of the Academic Consortium on Criminal Justice Health.

Bigger facilities usually offer more care

Larger facilities – both jails and prisons – are more likely to have a clinic with staff on site. They may even have their own pharmacies, says Ferguson.

Smaller facilities with only a licensed practical nurse on staff might need to call 911 for emergencies. More and more facilities, large and small, now rely on telemedicine.

Accredited institutions have higher standards

Institutions accredited by the National Commission on Correctional Health Care or the American Correctional Association also tend to have better care, Ferguson says. These institutions typically screen a prisoner for a variety of illnesses within 24 hours of their arrival, though different organizations may require different screenings.

They may also do more to protect the privacy and dignity of inmates. For example, new commission standards require that pelvic, rectal, breast, and genital-area exams be done in private areas, such as behind a screen or curtain.

You can often find accreditation and other information on the website of specific facilities. The Texas Department of Criminal Justice webpage for the state’s Ramsey Unit, for example, shows that it houses over 1,500 inmates and has an on-site infirmary with 21 medical staff and accreditation from the Correctional Association.

You can also search for accredited facilities on the association’s website.

Inmates may have to pay for health care
The law mandates that incarcerated people receive health care, but that doesn’t mean it’s free. Most facilities require copays.

In Texas, for instance, the cost of a prison sick visit is $13, and experts say that in some cases, people in jails and prisons forgo care because of the cost.

It’s not always clear who gets to make this decision, and that can be a real problem, says Marc F. Stern, MD, a consultant in correctional health care and senior medical adviser to the National Sheriff’s Association.

That’s why, he says, “there are some jails and prisons that provide excellent care, then jails and prisons that don’t.”

“There’s no book, no manual that says you have to do this and can’t do that. It’s all been based on case law.” And that case law can vary from state to state.

To have case law, you have to have a case. And if the case has merit, that means something has already gone wrong for someone’s health care, says Aaron Fischer, JD, chair of the American Diabetes Association’s Legal Advocacy Subcommittee.

“A very significant part of my work is representing people who are in jails and prisons, either in individual cases where they were grievously harmed or in larger class-action lawsuits which are trying to change the system moving forward,” he says.

What Are Insulin Pumps?“There are so many extra barriers,” says Kathryn Godley, a registered nurse and family nurse practitioner who co-led a diabetes support group for men at Great Meadow Correctional Facility in Comstock, NY, for 10 years.

For instance, incarcerated people with diabetes may have to make multiple trips to the infirmary to get regular blood sugar testing. They may not have access to snacks when blood sugar plummets. They may not be allowed to have insulin pumps or continuous glucose monitors. Exercise may be limited.

The members of the support group at Great Meadow wrote a guide to managing diabetes while incarcerated that includes, among other things, exercises that can be done in a cell.

Larger facilities may try to provide specialized diets for diabetes or another condition, but it’s uncommon, says Leslie Soble, senior program associate at Impact Justice’s Food in Prison Project.

Diabetes, which affects about 9% of incarcerated people (vs. 6.5% of the general population), may be one of the hardest conditions to manage behind bars, as it requires healthy food, exercise, and regular blood sugar monitoring to keep in check.

Prison and jail diets “are extremely high in refined carbohydrates, sodium, and sugar and low in fruits and vegetables and quality protein,” Soble says, adding that there are exceptions. Impact Justice, a prison reform nonprofit, works closely with the Maine Department of Corrections to use fresh fruit and vegetables from on-site gardens.

Even prescribed treatments and medicines can be a problem. Prison and jail health care systems often follow strict protocols that can limit the types of treatment and care available. The result is that sometimes, important medicines or treatments may simply not be allowed.

“Prisons and jails are stagnant places when it comes to information,” says Daniel Rowan, program manager of the New Mexico Peer Education Project, who trains incarcerated people to be peer health educators in the areas of hepatitis C, diabetes, sexually transmitted diseases, and more.

Most correctional facilities don’t allow internet access, but families, friends, and advocates can “snail-mail” educational materials from credible sources like the CDC or National Institutes of Health.

Other incarcerated people may also be a source of information, if not actual care. “Typically there was one person in every [peer education] class who had so much personal experience that they were an expert,” says Rowan.

In New Mexico, half of people who are incarcerated have been exposed to the hepatitis C virus. Project ECHO’s New Mexico Peer Education Project trains people held in state prisons to educate their peers about hep C as well as other infectious diseases and addiction.

There are similar programs in Indiana and Texas. Research suggests these programs can reduce risky behavior. And there are other benefits. For example, Rowan was trained as a Project ECHO peer educator midway through a 5-year prison sentence in Roswell, NM.

“When people are trained as peer educators, it’s pretty common to have an increase of confidence,” says Rowan, who is now employed full time with Project ECHO. “The ability to speak and communicate, shaking hands and making eye contact, are transferable skills.”

Some prison systems have medical grievance procedures. That’s your opportunity to ask for what you’re not getting.

“In Texas, they have patient liaisons on each unit,” says Savannah Eldridge, a registered nurse and founder of Be Frank 4 Justice, a nonprofit that advocates for the rights of incarcerated people.

When Eldridge gets requests for help from incarcerated people, she often gets resolution by going straight to the Texas Corrections Department’s Office of Professional Standards.

When that fails, there are often local nonprofit organizations that can help you advocate for your needs through official or legal channels.

One thing that can help your care is to keep protected health information (PHI) forms. This allows friends, family, and advocates to have access to an incarcerated person’s medical information. Eldridge advocated for the Texas PHI form to be valid for 2 years, up from just 6 months previously.

In the long run, health care on the inside cannot be separated from health care on the outside. In fact, more than 95% of people in prisons will eventually make their way back to the community.

Any health care provided inside a prison or jail stops as soon as the incarcerated person steps back into the community. There are other options, like Medicaid, but they may not always be available.

“There’s a major disconnect between health care in the correctional setting and health care in the community,” says Rodlescia Sneed, PhD, an assistant professor of public health at Michigan State University.

But, she says, there are ways to plan ahead. A person looking toward release from prison can connect with friends, loved ones, and outside aid organizations about setting up health care as they transition back into the community.

And many prison systems have caseworkers and re-entry programs to connect you with housing, employment, and health care resources after release from prison.