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As part of its mission, the BOP is (on paper) required to deliver timely, medically necessary health care to adults in custody, balancing generally accepted standards of care with public safety concerns. (See the clinical guidance for particular medical conditions used by the BOP, as well as the bureau’s overall policy on patient care, which is a core medical policy that was recently revised and includes the standards of care. It includes the standards of care including the scope of services offered and a definition of the care level assigned to each prison. For example, care level 1 facilities house adults who are generally healthy, while prisoners at level 4 institutions require extensive medical and nursing care.)
However, both the quality and timeliness of health care are among the most common complaints from prisoners.
BOP’s Health Services Division (HSD) is responsible for providing medical, dental and mental health care to all persons in its custody. However, HSD lacks the line authority required to manage health care as an agency-wide system, as well as to directly address specific issues at individual institutions. As documented by a 2019 report by the National Academy of Public Administration, this results in both highly inconsistent quality and timeliness of actual care:
“In the absence of line authority, the HSD must rely on the cooperation of wardens and staff to ensure that appropriate medical care is provided to inmates. [The division] must spend time reaching agreement on issues and marshaling support for action among wardens and staff in the correctional line of authority. Ultimately, action is contingent on the voluntary support of wardens and staff, who change over time.”
As mentioned above, the BOP developed a classification system to describe prisons’ capability to care for varying degrees of illness.
Each institution in the BOP is assigned a care level that is commensurate with the treatment available in the local community. Level 1 is the most basic and four is the most advanced – both for medical and mental health care. Medical and mental health each have their own criteria that determine their respective care levels.
Staffing for health services is determined in part by the care level of the facility. A care level 1 facility houses AICS who are healthy overall or have medical conditions that are easily managed. A care level 2 facility houses AICs with chronic, but stable, conditions that require few visits to medical specialists or outside hospitals. AICs in care level 3 institutions have more complex medical conditions. And finally, care level 4 prisons (also called medical referral centers) are basically hospitals.
Note that the facilities also vary within levels. For example, one care level 2 institution may have a dietician while another does not. To accommodate a special need or a specific security classification, an AIC designated as needing care level 3 may be placed outside of the region in which he or she came from prior to incarceration. The same applies to medical referral centers. Each has a limited number of inpatient beds and thus has a unique mission. For example, FMC Devens cares for the majority of dialysis patients.
AIC care levels are fluid and change with their health status. AICs who are new to the BOP are reviewed by the Office of Medical Designation (OMDT). Thus, it is essential that their pre-sentence reports are as accurate and current as possible, and that AICs include their medical records (including a list of their prescriptions, dosages, and pharmacies/providers used, with phone numbers) in their legal paperwork when they first arrive.
A BOP document issued in February 2024 shows the care level for each BOP facility, by region. Note that there are few care level 3 facilities.
A medical intake is completed upon arrival. Like all insurance companies and hospitals, the BOP has a drug formulary. It may be necessary upon admission to a facility for one drug to be substituted with a therapeutic equivalent. Medications fall into classes of drugs and therapeutic substitutions can easily be made. If a substitution cannot be made and the necessary medication is not on the formulary, a request for a can be requested by the provider. Temporary approvals may be granted to allow time to gather the necessary justification.
AICs who are already on medication-assisted treatment (MAT) for drug addiction when they arrive int the BOP must bring documentation of the drug and dose as well as the provider.. This information must be verified prior to continuation of the medication.
If a medical procedure was planned prior to incarceration, it is best that it be completed before the individual enters prison, if at all possible. (Such an arrangement would need to be negotiated by the attorney, is less likely for violent crimes) Since a procedure cannot be scheduled without consultation by a BOP specialist, the entire process would have to start over again if it is not completed prior to incarceration. And there is no guarantee that two specialists will recommend the same procedure.
Care plans developed based on medical consultations once individuals are incarcerated must comply with the facility’s utilization-review process, similar to the system imposed by insurance companies and hospitals across the country. If an AIC is sent to see an outside specialist, the resulting treatment recommendation still must be reviewed and approved by BOP medical staff.
Note as well that attention for potentially serious medical conditions is given priority over elective or non-urgent care.
Some AICs report difficulties in obtaining their medical records. BOP policy mandates the release of such records (generally for the previous two years) upon submission of a simple “cop out” request.
We suggest the request be submitted electronically, then followed up politely and professionally, adhering to the chain of command. The chain of command (aside from the unit team) on a medical issue is the health services administrator (who should be available on mainline, when key officials are available for questions), the associate warden of operations and, finally, the warden.
It is important to conduct this inquiry in the most non-adversarial way, despite any unprofessional behavior on the part of staff.
While we rarely encourage filing remedies (official complaints), it’s necessary going up the chain of command with polite requests is not productive. Since access to medical records is required by BOP policy, no more than a BP-8 should be necessary.
Note that external individuals, such as attorneys, may gain access to an AIC’s medical records by having the incarcerated person complete a “certification of identity” form and then filing a FOIA request.