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Healthcare Study in Ne County Jails, 2005

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A Study of Healthcare in
Nebraska’s County Jails

ACLU Nebraska
Amy Miller, Legal Director
941 O Street #706
Lincoln, NE 68508
(402) 476-8091

December, 2005


“The degree of civilization in a society
can be judged by entering its prisons.”
Russian author Fyodor Dostoyevsky’s observation from the 19th century is a truth our own
country’s founders recognized when they wrote the Bill of Rights. The Eighth Amendment of the US
Constitution prohibits cruel and unusual punishment. Courts have long interpreted the amendment
to require prisons to provide basic health care for inmates in their custody.
This study began as a result of the many, many complaints ACLU Nebraska receives from
pretrial detainees, prisoners, and their families about county jail failures to provide life-sustaining
medical and mental health care. When ACLU receives such complaints, we contact county officials to
warn of impending liability. ACLU only intervenes in cases involving the most serious cases—we do
not immediately act unless we have reason to believe the medical or mental health care is so
necessary that the offender’s life could be at stake. Unfortunately, we have to intervene on such
serious cases at least a couple dozen times each year.
Our experiences lead us to believe that jail officials only rarely deliberately intend to neglect
the individuals in their care. In most instances, the problem arose due to a failure of policy or
because the jail simply did not have the training and funding to adequately deal with the situation.
However, whether the healthcare problem was created by deliberate neglect or inadvertent conduct,
we have realized the problem is widespread, and has a very high human cost.
State and county officials must work to correct the problem before another death occurs.
Under Dostoyevsky’s principle, conditions in Nebraska’s county jails are uncivilized. Under the
Constitution, these conditions cannot be ignored.

Minor Offenders Facing Major Neglect
Police book fifty to sixty
thousand people into a
Nebraska jail each year.1 Since
1 in every 33 Nebraskans could
spend a night in jail this year,
chances are each of us know
someone who has been in a
county correctional facility.
Jails are distinct from
prisons--the prison system is
under the authority of the
state, while jails are run by
local city or county
municipalities and house less
serious offenders. Although
jail sentences are less than a
year, some prisoners spend
longer than a year in jail
because they are awaiting
charges to be filed or cannot
post bond during the period

before they go to trial. Jails
accommodation of a physical
are primarily
disability, such as
facilities for
inmates who are
deaf or who use a
50,000 to 60,000 people
offenses, yet
wheelchair. Others
are booked into Nebraska
some people
require care for
have lifemore serious types
jails each year.
of illness, such as
inmates with HIV
as a result of the poor
or AIDS. This study describes
healthcare available in jail.
the problems facing people
with such physical conditions,
Healthcare gaps in county
but will particularly describe
jail range across all types of
the plight of individuals with
medical problems. ACLU
mental health needs.
Nebraska has tracked reports
of inmates facing complete
The largest number of
deprivation of care for physical
inmates facing lapsed
ailments such as diabetes,
healthcare are the mentally ill,
heart disease and asthma.
and these individuals are also
Some inmates in county jail
the most vulnerable prisoners.
face difficulty over
Nebraska has a large number


of mentally ill inmates. A
United States Department of
Justice study indicates 16.3%
of all jail prisoners in the
nation are mentally ill.2
Nebraska has a higher
percentage of mentally ill
prisoners than the national
figure: 17.5% of people in our
jails have a mental illness.3

These figures represent
national averages, as
Nebraska does not currently
track statistics in state and
county correctional facilities.

The irony is that state
prisons house convicted felons
who have been sentenced to a
longer time due to the
seriousness of their crimes,
Despite the fact our jails
while county jails are
have a higher percentage of
populated by pre-trial
people with a need
for mental health
The irony is that serious
care, inmates at a
offenders, and
felons receive better care in
county jail have
the least amount of
convicted of
prison than minor offenders
access to resources
less serious
do in county jails.
for their illness of
crimes and
any other type of
prisoner. This is because state
Yet the Nebraskans who will
and federal prisons have onbe quickly returned to our
site medical and mental health
communities are the ones who
staff to diagnose, treat, and
face serious disruptions and
monitor prisoners. In contrast,
setbacks to their mental health
most county jails in Nebraska
do not have any on-site health
People who are released
from jail after incarceration
Compare the situation for
disrupting their mental health
someone in a state prison and
care are often returning to very
someone in a county jail:
dire circumstances which are
Nationwide, only 41% of the
aggravated by the jail's failure
mentally ill receive some form
to provide care. Prior to being
of treatment while in a county
arrested, almost a third of
jail.4 Of those who do receive
mentally ill people were
treatment, the majority are
homeless.7 47% were
simply receiving some
unemployed prior to their
maintenance by being given
arrest, 38% have a history of
their prescribed medication.
alcoholism, and 65% were
Only 16% of those treated
using drugs and/or alcohol at
received actual counseling with
the time of their arrest.8 These
people often were victimized by
a mental health professional.
sexual or physical abuse in
In other words, the majority of
their earlier lives, as well: 31%
jail inmates who are mentally
of the men and 73% of the
ill receive no care.5 In state
prison, not all prisoners with
women are survivors of abuse.9
mental illness are being
Finally, an individual with
treated, but 60% of them are
illness who enters the
receiving some treatment.6
criminal justice system is very

likely to be re-incarcerated:
approximately 8 out of 10
mentally ill prisoners currently
in jail have prior convictions,
and are statistically likely to
be in jail again.10 All of these
figures reflecting the obstacles
that mentally ill prisoners face
are significantly lower for
prisoners without mental
ACLU Nebraska intends
this study to raise awareness
of the problems faced by
prisoners in our county jail
system and suggest some
initial steps to bring about
1. Jail Profile Report 1995-2003.
Nebraska Crime Commission
Statistical Analysis Center.
March 29, 2005.
2. Ditton, Paula M. Mental
Health and Treatment of Inmates
and Probationers. US Dept of
Justice, Bureau of Justice Special
Report NJS 174453, July 1999.
Online at:
3. Neb.Leg.Res. 191, 99th Leg.
1st Reg.Sess. May 18, 2005.
4. Ditton at 174463.
5. Id.
6. Id.
7. Id.
8. Id.
9. Id.
10. Id.


Stories of Neglect from Nebraska County Jails
These stories are just a
fraction of the cases reported
to ACLU Nebraska each year.
Most people affected by jail
healthcare problems want to
stay anonymous due to fear of
retaliation or stigma. The
counties described are not
alone in their failure to provide
care. Rather, ACLU has
identified a systemic problem
in all county facilities.

Un-medicated Inmate
Commits Suicide
Prior to going to jail, Robert
Pantona was under doctor
orders to take medication for
his anxiety disorder. While
held in the Sarpy County
Correctional Center, news
reports indicate Robert did not
get his prescription at all,
despite his repeated requests
for help. On July 15, 2002,
Robert Pantona hung himself
in his jail cell. (Omaha World
Herald, July 19, 2002.)

Deaf Inmate Denied Sign
A pre-trial detainee in a large
urban county was deaf and
communicated solely through
sign language. He asked the
jail for an interpreter to allow
him to participate in the
services offered to other
inmates, including AA
meetings, church services and
mental health counseling. The
jail refused to provide
interpreters, even though the
detainee's ability to
communicate in writing was
very limited. The man spent a

year almost entirely isolated
from contact with others.
After ACLU intervened, the
jail agreed to provide sign
interpreters for rehabilitation

asked him no questions about
his medical or mental health
condition upon his intake, and
that there was no process to
apply for his prescriptions to
be transferred to the jail. This
jail was small and there was
Three Months Without
no medical or mental health
Heart Medication
staff at all. Despite requests
from the man and his wife, he
In a southeastern county jail in
spent 4 weeks without any
Nebraska, a man was
medication. He began
sentenced to a short sentence
hallucinating and hearing
for non-violent offenses. He
voices that told him to commit
was over 50 years old and had
suicide. ACLU intervention
a history of heart problems.
resulted in the man being
He needed daily cardiac
taken to a doctor in the
medications as well as
community, who recognized
immediate access to
the serious need for treatment.
nitroglycerin in
The man was
case of a heart
attack, but the jail
The stories of neglect are not
transferred to
refused to provide
limited to a few counties.
another, larger
him any of his
facility where
We have a statewide
prescriptions at
his medications
all. For three
were provided.
months, the man
was on a waiting
list to see a doctor--during this
time, his only medication was
an aspirin each day. After
ACLU intervened, the man
was immediately evaluated by
a doctor and appropriate
medications were restored.

No Meds Result in
Hallucinations and
Suicidal Impulses
In a northeastern county jail
in Nebraska, a man was
serving 6 months for a nonviolent offense. He had a
history of mental illness and
managed his condition through
an anti-psychotic prescription.
The inmate reported the jail

HIV Test Denied
A pre-trial detainee in a
central Nebraska county jail
noticed symptoms that
concerned him. He believed he
had a sexually transmitted
disease or HIV, so he asked for
a screening test from the jail.
This jail did have on-site
medical staff, but they refused
to test him. The man
contacted the Nebraska AIDS
Project, a non-profit agency
that provides free medical
screening. Nebraska AIDS
Project agreed to come and do
the test at no charge to the
man or the jail, but the jail


continued to refuse the test.
The man alleges the staff said
they did not want to know
whether the man had a
medical condition, because
that would oblige them to
provide treatment.

Prison-Ordered Meds Cut
Off by County Jail
A state inmate with anxiety
disorder had been evaluated by
the state prison psychiatrist
and prescribed anti-anxiety
medication. Without the
medication, this woman could
not sleep or function normally.
During her incarceration, the
inmate was sexually assaulted,
which required her to be
briefly transferred to a large
urban county jail to testify
against her assailant. The
county jail medical staff
immediately discontinued her
medication--they asserted it
was their policy with any new
prisoner. While that policy
might make sense for someone
coming in off the street, this
inmate had already been
evaluated by a professional
from a correctional center. The
strain of confronting her
perpetrator in court while
deprived of her medication
caused the inmate’s anxiety
disorder to re-occur. ACLU
intervened with the help of the
prosecutor's office to have her
returned to the York for
treatment. The prosecutor
agreed to work with the jail so
future court appearances
would not interrupt her
(“Stories of Neglect from
Nebraska County Jails”
continued on page 10)

Nebraska county jails have five primary areas that can
contribute to the personal tragedies described above: inadequate
funding, loss of Medicaid eligibility, the need for improved
mandated standards, inadequate other facilities, and the need for
a watchdog.
◘ Funding Needs: Most funding for county jails comes
from the county in which the jail is housed. Although most
Nebraska jails provide sufficient basic care of inmates, medical
and mental health care is very expensive. Some jails may be
attempting to reduce expenses by limiting the care provided to
inmates, but many jails appear to simply not have the funding to
provide the care needed by inmates with physical or mental
health problems.
One example of the problem faced by jail administrators is
the high cost of prescription medications. Any prisoner who was
receiving medication at the time of their arrest is entitled to have
that medication continued if it is actually necessary for a serious
medical or mental health condition. Many prisoners may have
been receiving their prescriptions through state or federal social
assistance programs prior to incarceration, but most of those
programs cut off eligibility upon incarceration. (This issue is
discussed in detail below.) Given the obvious security concerns,
the jail cannot just ask the inmate's family to bring in their
prescription for fear of contraband being passed into the jail. This
unfortunately creates an incentive for county jails to not inquire
about prescription medication needs and to delay medical
evaluation requests: if officials don't know about the problem,
then they don't have to buy the prescription.
The gap between urban and rural jails is also a funding
problem. In the larger urban areas, county jails often have onsite medical staff to do some screening and care of inmates. In
smaller rural jails or in impoverished counties, the jail staff does
not usually include a medical professional. Instead, the county
must pay to have the inmate transported to a medical provider in
the community and then pay the costs for care. This inequity
between counties can mean two inmates with identical medical
needs can have very different experiences in jail: one may be seen
by a doctor upon intake and be given their prescription
medication, while the other inmate will remain in a jail cell
without ever being seen by a medical professional or receiving
any medical attention.
Increasing funding to county jails is an essential
component so the jail administrators no longer have to wonder
where they will find the funding to prevent a death in their jail.



◘ Medicaid Eligibility: Incarceration immediately results in termination of Medicaid,
making the jail solely responsible for paying for the prisoner's health care. This shifts cost from the
state to local county budgets while simultaneously endangering the health of those in jail.
Different counties are paying different amounts for Medicaid-eligible prisoners: some jails
have contracts with local health providers that allow the jail to pay the Medicaid rate, some jails
actually pay up to 10% below the Medicaid rate, and still other counties are paying the full rate
without any discount. In other words, there is no standard rate of pay for health services between
county jails and some counties who lack negotiation power are being charged more than the state
would be charged for caring for the same individual.
The cessation of Medicaid during incarceration presents problems for
the individual upon release as well, since benefits are not
There is no standardized rate
automatically reinstated upon the inmate's return to freedom.
for health care services: some
Instead, the person must re-apply for Medicaid and the approval
process can take many months--the shortest period for approval is
counties are paying more
one month, and most cases take longer for final decision.1 During
than the Medicaid rate.
this waiting period, the former inmate must attempt to find housing
and employment while rebuilding their life. When facing these
obstacles without medication for a physical ailment or mental health condition and with no
counseling or other services, former inmates face difficult or even impossible circumstances.
Problems quickly compound, and it is very difficult for many of these individuals to avoid a quick
return to jail for another offense.
A recent study from the University of North Carolina-Chapel Hill concluded that inmates who
were allowed to remain on Medicaid had quicker access to services upon release which assisted them
to connect back to the community.2 This is particularly important for inmates with mental illness,
because those who are on Medicaid are more likely to remain stable, while those without services are
more likely to re-offend with even more serious crimes in the future.3
Changing Medicaid eligibility requirements would both aid individuals with serious medical
needs and assist economically distressed counties.
◘ Mandated Standards Change: The Jail Standards Board is the state agency that creates
the requirements by which all county jails must abide. The Board has 11 members: the State Fire
Marshal, the Director of the Department of Correctional Services, and 9 members appointed by the
Governor for three-year terms. The work is supported by staff employed under the Crime
Commission's Jail Standards Division.4 The standards currently in place can be found at Title 81 of
the Nebraska Rules and Regulations.5 These standards are currently inadequate because they fail to
address any mental health issues. Nebraska has not revised the medical sections of Title 81 in over a
decade, even though amendments have been recommended by the Jail Standards Board. The Board
submitted revisions in 2001 to change seriously needed medical and mental health provisions, but the
state has never approved the provisions as required by the Administrative Procedures Act. The
amendments remain in limbo. The Jail Standards Board is currently working on revising the
standards again and resubmitting them.6
The suggested changes from 2001 included requiring a complete medical and mental health
screening upon admission into any jail. Such screening would allow jail officials to identify health
care needs of new inmates promptly. The revisions also would have required that any person
presenting a serious risk to themselves or others (as defined by the Nebraska Mental Health
Commitment Act) would be taken to a different facility rather than being put in a jail. Only
individuals who appeared to be a serious risk but who had been cleared by a licensed medical or


mental health authority would be allowed into a jail.
Some jails in Nebraska have already adopted their own mental health policies, but there is no
uniformity across the state. Approval of the recommended amendments would provide uniformity
and minimum protections for new detainees in jails, and would be a necessary step to reformation of
our county jail system.
In addition to the amendments which the Jail Standards
Board has already developed that await approval, ACLU Nebraska
believes additional changes to the minimum jail standards are
Model healthcare standards
needed. Our state already has a complete model ready for adoption:
already exist. Adult facilities
the standards for juvenile detention facilities offer a comprehensive
model that ought to be adopted for adult facilities as well.7 Juvenile
should adopt the Nebraska
detention facilities have a very thorough screening process to
juvenile facilities standards.
identify all current illnesses or health problems, medications,
special health needs, and current or past mental illness. The
juvenile standards include ongoing observation of the inmate's
condition, a protocol for emergency treatment, and management of prescription needs.
◘ Inadequate Facilities for Mental Health Care: The Nebraska Behavioral Health
Services Act of 2004 authorized the closure of the regional mental health centers in favor of opening
community-based services. Community services would of course be a tremendous benefit--if they
existed in every community. Unfortunately, many cities lack any community based mental health
services. The transition away from the regional center system is merely shifting people who are
mentally ill to jails and the criminal justice system.
Jails are trained to not accept seriously mentally ill people if they are a hazard to themselves
or others. These people are to be placed in emergency protective custody and then taken to a hospital
or other facility. Yet most Nebraska communities do not have a psychiatric ward even in their
hospitals, and are unable to properly care for individuals who have had contact with law enforcement.
Recent news reports indicate some hospitals are filled to capacity with people with medical problems,
leaving no beds available for psychiatric patients.8
County jails currently do no discharge planning--they are not required to do so by the jail
standards. Individuals who are discharged from jail do not receive any information about social
services, community-based mental health care, or how to apply (or reapply) for Medicaid for medical
needs. This disrupts their care and can result in re-offending. More crime in the community and
more incarceration harms both the public and the individual. We need to expand community based
services AND provide information about same to released inmates.
Until true community-based services are available statewide, the closing of the regional
centers is compounding problems for local hospitals and county jails who are left to care for prisoners
with mental illness.
◘ Watchdog for Jail Complaints: Each county jail has an internal grievance process for
inmates to express concerns or request additional services. Although each jail can create its own
process, most consist of a written form for inmates to submit with a description of the complaint.
There are no statewide standards about how the complaints are then handled. Some jails have onduty staff address the complaint. Some jails submit the complaint to one administrator, which can
delay review and response based on individual schedules. An inmate may not receive a reply for
days, weeks or even months. If the complaint is not satisfactorily dealt with, jails usually have an
appeal process to take the matter to a higher-ranking jail official, but this takes significant time.
Obviously, this complaint process is not satisfactory for emergency medical and mental health needs.


An inmate who needs his heart medication could be forced to wait weeks.
The Jail Standards Board is the state agency that creates the minimum standards for county
jails. In addition to creating the standards, the Board reviews complaints about county jails. The
Board accepts complaints on an emergency basis, but ACLU Nebraska's experience is that few
individuals who are experiencing a healthcare problem have ever heard of the Board and are
unaware of its ability to intervene with jail staff. Further, the Board is extremely limited in its
ability to effectuate change: the staff may contact a jail about an emergency problem, but has no
immediate enforcement ability if the jail refuses to correct the problem. The only power the Board
has is to find a jail out of compliance with the standards. This remedy is rarely used, and offers cold
comfort to someone experiencing serious health problems.
Increasing public awareness about the Jail Standards Board as a resource and increasing the
ability of the Board or another entity to have stronger enforcement powers would assist regulating
those few county jails that are willfully not providing appropriate care to prisoners.
1. Interview with Ann Schultz of Nebraska Health and Human Services, July 20, 2005.
2. Gary S. Cuddeback et al, Preventing Jail Detentions: The Role of Health Insurance, Seriousness
of Offense, and Use of Community Mental Health Services. APHA Conference, Washington DC.
3. Id.
4. Nebraska Crime Commission, Jail Standards Board Overview. Online at:
5. Adult standards are found at Title 81 of the Nebraska Rules and Regulations. Online at:
6. Interview with Denny Macomber, Jail Standards Division Executive Director, July 7, 2005.
7. Juvenile standards are found at Title 83, Chapter 11 of the Nebraska Rules and Regulations.
Online at:

It is in the best interest of all to properly care for Nebraskans who are briefly incarcerated in a
county jail. Preventing a health condition from disintegrating with medication, offering ADA
accommodations to people with physical disabilities, and providing a system of care for the mentally
ill are the right thing to do, but also benefit our communities as a whole by preventing wrongful
death, litigation and recidivism. This is particularly true for the mentally ill who need a continuity of
services both in jail and upon release. The recommendations the ACLU has include the following
1. Increase funding and reform Medicaid eligibility. At minimum, county jails should
not be paying more than the rates charged for Medicaid patients. Increased funding as well as
Medicaid reform will insure all Nebraskans can receive needed medication and will remove the


dis-incentive for jails to ignore serious medical needs. While prescription medications for
medical and mental health needs appear to be the primary gap in county jail healthcare, we
also need to explore providing better mental health counseling in county jails.
2. Create stronger minimum jail standard policies. The recommended changes to the
Jail Standards--and the upcoming recommendations being developed by the Jail Standards
Board--must be passed to strengthen a statewide uniformity of policies. Ideally, though, we
must bring our adult facilities up to the standards in place for juvenile facilities. Our out of
date current policies must be revised and approved to guarantee every Nebraskan, regardless
of the county of incarceration, is receiving appropriate care.
3. Mandated intake screening and follow-up care. Each county jail should be required
to do detailed screening of each person booked into custody in order to identify medical
conditions, mental health history, and prescription needs. Beyond identifying needs of each
new inmate, the jails should do further follow-up contact with the individual’s community
health providers before making any decisions about changing or cutting off medications.
4. Develop appropriate facilities for people who are mentally ill. Community-based
mental health facilities must be in place before we completely close the regional centers.
Otherwise, jails and hospitals will become the new housing for people with serious mental
illnesses. Anecdotal reports from county jails already indicate their populations have
increased with people who should be in a facility trained to deal with their illnesses. We also
need to make discharge planning a mandate for jails so people who are released are given
information about community based services to prevent recidivism.
5. Improve watchdogs for inmate grievances. The minimum jail standards should
improve the internal grievance process so serious medical issues can be addressed without
delay. Improving public awareness of the Jail Standards Board as a resource--or developing a
new watchdog entity--would ensure meritorious complaints result in action against jails who
are not complying with the law.

The problem is a palpably serious one: we know there are many people with medical and
mental health needs in our county jails, and we know the counties cannot meet all those needs under
the current system. Ironically, the people in county jail are the least serious offenders but are also the
most neglected prisoners. The proposals outlined above will begin to ensure we have fewer deaths,
fewer serious health problems, and fewer re-offending criminals in our communities. If we don’t
address the local needs, our already overcrowded state prison population will continue to grow as we
create more criminals.
People who are injured or killed while in jail due to negligence have the ability to bring a civil
rights lawsuit. This sort of after-the-fact remedy is not the solution for Nebraska, though. A large
damages award entered against a small county could bankrupt the system, and it will never make the
grieving family whole. Instead, we need to avoid tragedy by taking appropriate steps to improve our
county jail system. The issue must be studied and then dealt with both by local county officials and
by state legislators.


Stories of Neglect (continued): A Letter from Jail
A typical letter received from county jail inmates includes this one written to ACLU
in September, 2004: “I am under the care of a psychiatrist at the Community Mental
Health Center. I take four different medications: an anti-depressant I am supposed to take
every day, an anti-anxiety drug, a sleep aid and a prescription for migraines to take as
needed. But I am unable to get these medications so far in jail, even though I have been
here for many weeks. At first I was told that the jail staff would have to contact my
psychiatrist. Then I was told my doctor hadn’t faxed the information yet. When I continued
to ask for my meds, I finally was told that yes, the doctor faxed the information, but that I
would have to wait another week until the jail hired a doctor to see me and THAT doctor
would decide whether I would receive any medication. All these decisions are being made by
the county Sheriff who runs this jail. How can a non-medical person like the Sheriff control
medication that a licensed physician already decided was medically necessary for me?!? I
have been suffering bouts of serious depression and anxiety...what would happen if someone
became suicidal after a Sheriff decided to stop their medication?”
(ACLU intervention resulted in this inmate being given all his medications within 24 hours
of receiving his letter, but not every inmate knows how to contact the ACLU, and not every
jail is willing to respond to complaints so promptly. The inmate’s question about nonmedical personnel having the authority to ignore medically-ordered care will continue to be a
problem for every person with a medical or mental health problem in Nebraska jails unless
we mandate new standards and change our existing jail systems.)

ACLU Nebraska is a non-profit, non-partisan organization incorporated under the laws of the state of Nebraska.
We are affiliated with the national American Civil Liberties Union. ACLU Nebraska was established in 1966. We
are entirely funded by private donations of members and contributors and receive no governmental funding. Our
sole mission is to protect the freedoms described in the US and Nebraska Constitutions. We work to protect the
fundamental constitutional rights through legislative lobbying, litigation and public education. Copies of this report
are available for download from our website.
941 O Street #706
Lincoln, NE 68508
(402) 476-8091
Grateful appreciation is extended to Sarah Pruett, student researcher from Grinnell College, for
her substantial work in researching and writing this report.