Vanderbilt Law Review

Article Title

HMOs Behind Bars: Constitutional Implications of Managed Health Care in the Prison System


Richard Siever


In 1991, the Correctional Corporation of America (CCA) entered into a contract with the State of Tennessee to house and treat state prisoners at CCA facilities. In response to increased costs, CCA negotiated a contract with a physician to be the exclusive provider of medical services for one of its facilities. Essentially, this contract formed a managed health care system: the doctor's payment structure included a base salary, but it also incorporated financial incentives that could increase his overall compensation if he were to provide less care to inmates.

Later, Anthony Bowman, a prison inmate with sickle cell anemia, died when prison health officials failed to transfer him for medical treatment. Bowman's mother sued CCA, asserting that the contract between the doctor and CCA violated CCA's Eighth Amendment obligation to provide adequate medical care. Furthermore, Ms. Bowman claimed that the financial incentive provisions of the contract motivated the doctor to delay transfer of the inmate to an outside hospital-the proximate cause of his death.

The Bowman case, recently decided by the Sixth Circuit Court of Appeals on jurisdictional grounds, left unanswered an important question regarding the scope of the Eighth Amendment and application of the Cruel and Unusual Punishment Clause. The United States Supreme Court recently readdressed the Clause's scope and the Constitutional standard, again affirming an ambiguous duty on the part of government. Problems concerning health care in the prison context, and the nature of this "duty" imposed upon the prison system remain unsolved given the subsequent advent of managed health care. How should the Court's standard apply to Bowman and future cases, given the managed care organization that allegedly failed to properly care for an inmate?

Part I of this Note describes the history and evolution of the Eighth Amendment prohibition of cruel and unusual punishment and its development within the context of prison health care. Part I also briefly discusses the current state of prison health care as it relates to the current problem. Because courts have never applied the Eighth Amendment to managed health care, Part II analyzes the most recent interpretations of the Court's Eighth Amendment jurisprudence, the nature of its obligation on the government, and applications of the right in circumstances analogous to managed health care. This Note also examines Bowman v. CCA, a contemporary case implicating the potential constitutional problem presented by managed care in prisons. Part III concludes that given the current case law surrounding the Eighth Amendment, and the nature of the prison's duty, an inmate could raise a valid constitutional claim. Finally, this Note proposes an analysis for courts to use in such circumstances, applicable to various forms of managed health care.