Incarcerated Individuals with Rheumatic Conditions

The January wildfires that laid waste to more than 57,000 acres in Los Angeles and killed 30 people also raised ethical questions around the use of incarcerated individuals to fight fires in California—and more broadly, highlighted issues involving the exploitation, coercion and human rights violations, such as inadequate medical care, of imprisoned people.

Although participation in California’s Fire Camp Program is voluntary, prisoners are paid categorically higher wages for fighting wildfires than for other jobs available to prisoners in correctional facilities, creating a potentially exploitive or coercive situation.^1,2 Further, incarcerated firefighters face a significantly higher risk of injury than professional firefighters. A 2018 investigation by Time revealed that incarcerated firefighters are four times more likely to sustain cuts, bruises and broken bones, and eight times more likely to suffer from inhalation injuries, than professional firefighters working the same fires.³

Given these ethical concerns, we are compelled to reflect on the broader ethical issues surrounding incarcerated individuals, particularly the ethical dilemmas related to their medical treatment.

Legalities & Ethical Guidelines

The Eighth Amendment of the U.S. Constitution prohibits cruel and unusual punishment. In Farmer v. Brennan (1994), the U.S. Supreme Court ruled that prisons are required to provide adequate medical care for inmates under the Eighth Amendment. The Court emphasized that denying prisoners medical treatment could result in “pain and suffering which no one suggests would serve any penological purpose.”⁴

In 2017, the American Medical Association (AMA) released a Code of Ethics addressing healthcare for incarcerated individuals. This document highlights the unique challenges related to informed consent, respect for autonomy and the delivery of quality healthcare in correctional settings. The policies outlined aim to improve access to comprehensive physical and behavioral healthcare services throughout the incarceration process. Additionally, the guidelines emphasize how physicians providing court-ordered care for incarcerated patients can still honor the patients’ preferences and beliefs while ensuring autonomy and obtaining informed consent.⁵

In rheumatology, physicians face ethical challenges similar to those outlined by the AMA, but also encounter a range of issues specific to the specialty. This stems largely from the nature of rheumatic diseases, which often require long-term management with high-cost medications, frequent lab and image monitoring, and access to subspecialized care, often from a multidisciplinary approach. These challenges highlight the broader systemic issues in providing adequate healthcare for incarcerated individuals, underscoring the need for policy reforms that prioritize both medical necessity and ethical responsibility.

Access to Rheumatologic Care

Access to rheumatologic care is particularly challenging for incarcerated individuals, exacerbated by the nationwide shortage of rheumatologists, especially in rural areas. A 2015 study by the Arthritis Foundation found that 21% of adult rheumatologists were based in the Northeast, while only 3.9% practiced in the Southwest.⁶

Most specialists are concentrated in urban and suburban regions, leaving rural communities severely underserved. A disproportionate number of prisons are in rural areas, where access is severely limited.⁷ This means inmates who need to see a rheumatologist will have longer wait times—or no access at all until they are relocated to a facility in an urban area with better healthcare infrastructure.

Although telemedicine, which was first introduced in Florida’s prison system in the late 1980s and was utilized in over half of state correctional facilities by 2004, has become a vital tool for delivering healthcare, it proves more challenging in rheumatology due to the need for physical examinations to diagnose and manage musculoskeletal conditions.⁸ In rheumatoid arthritis, in particular, studies have shown there is often discordance between patient and physician tender and swollen joint counts, especially in more active and early disease.⁹ As a result, incarcerated individuals may experience significant delays in diagnosis and treatment, potentially leading to worsening disease progression, increased disability and higher long-term healthcare costs.

Addressing these disparities requires systemic changes, such as expanding specialist outreach programs, improving prison healthcare policies and leveraging emerging technologies to enhance remote assessments. For example, training prison nurses to perform physical exams under the remote supervision of a rheumatologist could be a practical solution to improve access to specialist care.

Access to Medications

Another major challenge is the accessibility of medications, which are often prohibitively expensive. Conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate or mycophenolate, can cost as little as $16 per month with certain prescription-savings programs, but the overall financial burden rapidly escalates due to the need for regular lab monitoring to assess potential drug toxicity (every three to four months) and the reliance on the expertise of healthcare professionals to accurately interpret results, monitor for signs of toxicity and make appropriate changes when toxicity is seen.¹⁰

In addition, these medications are often insufficient to control disease, necessitating the use of biologic or targeted synthetic DMARDs. These therapies significantly raise costs, with annual costs through commercial insurance ranging from $43,935 to $101,402 in rheumatoid arthritis.¹¹

Although the exact costs that correctional institutions incur for medications remain unclear, many state and local jails purchase the same drugs as Medicaid agencies due to their limited negotiating power as individual entities. In contrast, larger prison systems can secure better prices through the federal 340B Drug Discount Program.¹² This program, funded by the federal government, mandates that drug manufacturers participating in the Medicaid drug rebate program also provide covered outpatient drugs to enrolled covered entities at or below a statutorily defined ceiling price.¹³

Even with such assistance, the cost of these medications remains exceptionally high, and many correctional facilities maintain strict formularies that restrict access to such costly treatments, often requiring patients to fail multiple less expensive options before qualifying for biologics or targeted synthetic DMARDs.

In addition to the direct costs of medications, additional costs are tied to medication use, such as lab monitoring, specialized storage requirements, and the administrative burden of obtaining prior authorizations and managing appeals. For infusion medications, further costs arise from the need to transfer patients to specialized facilities, which adds travel expenses and requires additional personnel.

Access to medications is not an issue exclusive to incarcerated populations—the high cost of medications can be a significant barrier for both insured and uninsured Americans—but it remains crucial to explore solutions for alleviating this burden on incarcerated patients. By implementing policies that enable correctional facilities to purchase DMARDs at reduced costs, whether through ways similar to other systems providing care to low-income individuals or by improving the purchasing power of 340B programs, we can improve access to essential medications. This, in turn, could lead to better health outcomes and reduced disabilities for this population.

Environmental Challenges

It is well-documented that as the general population ages, so does the incarcerated population. Current estimates in the U.S. indicate that 12% of incarcerated individuals are older than 55, reflecting a 300% increase in this demographic over the past two decades.¹⁴ Studies also reveal that 15% of inmates in both state and federal prisons have arthritis or other rheumatic diseases.¹⁴ This presents a unique challenge because exercise is a key component in managing and alleviating symptoms of arthritis and rheumatic diseases.

Within the prison system, inmates often lead sedentary lifestyles due to limited mobility within their cells, restricted access to exercise facilities and insufficient opportunities for physical therapy, which is crucial for teaching proper techniques to reduce symptoms. Even when facilities offer exercise training programs, their effectiveness is maximized when tailored to the individual and their specific rheumatic disease. Unfortunately, the majority of studies examining prison-based exercise programs focus on healthy individuals without chronic conditions, leaving a gap in knowledge regarding the needs of those with such diseases.¹⁵

Additionally, it is well-established that psychosocial stressors can exacerbate rheumatic diseases, and prisons are inherently high-stress environments, with conditions that promote social isolation, limited autonomy, overcrowding, fear of violence and harm, and poor sleep. Depression, which is known to have a negative impact on rheumatic disease and contributes to flares, is common among prisoners, with one systematic review reporting a prevalence of up to 29%.^16,17

These issues are compounded by frequent transfers between facilities, which can disrupt continuity of care and put patients at risk of lapses in medication adherence and follow-up care.

Perhaps most concerning, given the immunocompromised state of many patients undergoing treatment for rheumatic conditions, is their heightened risk of infectious diseases, such as tuberculosis, due to overcrowding, poor ventilation, inadequate sanitation and substandard disease surveillance, which further jeopardizes their health.¹⁸

What Can We Do?

Addressing these issues requires a comprehensive, multidisciplinary approach that prioritizes policy reform, improved healthcare coordination and greater advocacy for incarcerated individuals with rheumatic conditions. Under the Eighth Amendment, incarcerated individuals are entitled to adequate medical treatment, including care for chronic rheumatologic conditions, yet structural barriers often prevent access to necessary treatment.

Solutions must include:

• Expanding telemedicine while ensuring in-person specialist access when needed;
• Implementing standardized treatment protocols; and
• Providing specialized training for prison healthcare staff.

Efforts must focus on improving healthcare access, continuity and coordination within correctional facilities, while also raising awareness about the unique needs of incarcerated individuals with rheumatologic conditions.

Policymakers should advocate for expanded medication formularies, improved oversight of prison healthcare systems and the integration of electronic health records across facilities to maintain continuity of care.

Researchers and advocacy organizations must work to highlight the unique challenges this population faces, pushing for evidence-based policy changes that ensure equitable healthcare access.

By fostering collaboration among healthcare providers, policymakers and correctional institution staff, we can create meaningful reforms that improve the management of chronic rheumatic diseases in correctional settings.

Katherine Terracina, MD, is an assistant professor at UT Health Houston, McGovern Medical School, where she is an active clinician specializing in general rheumatology, as well as a clinician educator deeply committed to training the next generation of physicians. She is a member of the ACR’s Committee on Ethics and Conflict of Interest.

Prajakta P. Masurkar, PhD, MPharm, is a health economics and outcomes research associate director at UCB Inc., specializing in evidence generation for payers in rheumatology and dermatology diseases, including psoriasis, psoriatic arthritis, hidradenitis suppurativa and more. She is a member of the ACR’s Committee on Ethics and Conflict of Interest.

References

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