She said the American Civil Liberties Union receives far more complaints about jails than prisons, where workers have more time to address medical problems. But both immediate and long-term care are important for the public as well as the inmates, as only one in 11 prisoners is serving a life sentence, Alexander said: "The state has taken away a person's ability to get medical care on his or her own. And it's certainly in the public's interest to provide care in jails and prisons."
She and others at the ACLU note that correctional heath care has improved generally across the country with the advent of national standards. There still are major lapses, however, such as in California, where the U.S. Supreme Court recently ordered the release of 40,000 inmates to ease overcrowding that contributed to inadequate health care.
A legislative audit released last year suggests there have been improvements in Maryland, but shortcomings still exist. About 9,320 chronically ill inmates in 2009 were logged into a database that is supposed to ensure quarterly medical visits, but the audit said that probably doesn't represent the true total. Specifically, a sampling of 70 inmates found 15 of them uncounted. Auditors said the situation hadn't improved much since the previous evaluation in 2007.
The audit also found the state's own review of HIV patients showed that of 82 prisoners with the virus, 27 percent were not seen on schedule.
Baucom, the state's medical director, said the audit focused on record-keeping, rather than outcomes, which show chronic care was improved. She also said records have improved since the report.
Baucom argues the new efforts make the system more efficient, though she and financial officials couldn't say exactly how many dollars have been saved. They believe money was saved on reduced trips to the emergency room and hospital stays, for example.
In general across the country, there isn't evidence that prevention and early intervention efforts save money, said Mark Barnes, a Harvard lecturer in law and public health who formerly worked for the New York State correctional system.
Hurdles inside and outside
In the United States, HIV infection was long undertreated because good medications hadn't been developed in the 1980s, and they were too expensive in the 1990s, Barnes said. And while HIV drug costs have dropped, others have not. For example, the newest hepatitis-C drug costs $48,000 annually.
"In prison health care, whatever the budget is, that's the budget," he said. "People who supervise the systems have difficult choices to make."
And there are certainly problems to choose from. Diseases spread more readily in an incarcerated population through sex, drug needles and crude tattoo implements, observers say. And those who are in the system tend to be far sicker than the general public.
For example, about 41 per 10,000 prison inmates were estimated to have AIDS in 2007, compared to 17 per 10,000 persons in the general population, according to the Justice Department. Most large prisons have an HIV infection rate of about 3 percent to 6 percent, officials estimate.
A study published in 2005 using unidentified blood samples collected from every Maryland prisoner showed the prevalence of HIV was 6.6 percent and the prevalence of hepatitis-C was almost 30 percent. Those rates are among the highest in the nation, said Liza Solomon, former director of the Maryland State AIDS Administration and now a principal associate at the research and consulting firm Abt Associates. The tests were anonymous, and many inmates didn't know they were infected.
And Solomon said traditional prevention methods can't always be used. Few corrections systems hand out condoms because they can be used to smuggle drugs, and none provides clean needles because they can be used as weapons.
Officials instead try to educate prisoners about lifestyle choices and risky behaviors, said Richard Rosenblatt, a former assistant secretary for treatment services in Maryland's public safety department. He said inmates are treated "like they are any other patient, and that may have an impact on health, but it really has an impact on the safety of the facility because they feel respected."
But Rosenblatt knows no matter the successes inside, few prisoners will continue to see a doctor once they are released. He said federal Medicaid dollars can't be spent on inmates so prison workers can't sign them up for care upon release unless it is HIV treatment, which has a separate pot of federal money. But most ex-offenders have chaotic new lives and typically don't make or keep appointments on their own.
Rosenblatt said there is little political will at the state level to fund any kind of program for ex-offenders when so many others go without health care.