Mentally ill offenders face mistreatment and neglect in many U.S. prisons, according to a new report by Human Rights Watch, an independent nongovernmental organization that investigates human rights violations around the world. The 215-page report, Ill-Equipped: U.S. Prisons and Offenders With Mental Illness, describes the ways in which prisons are dangerous and damaging places for persons with mental illness.

A deficiency in mental health services in many prisons leaves prisoners undertreated or not treated at all, according to the report. Prisoners cannot get appropriate care because of a shortage of qualified staff, lack of facilities, and prison rules that interfere with treatment. The report attributes the high rate of incarceration of mentally ill persons to underfunded, disorganized, and fragmented community mental health services and to punitive sentencing laws that mandate imprisonment for low-level nonviolent offenses.

The Human Rights Watch report is based on more than two years of research that included visits to numerous facilities in 13 states and interviews with more than 300 prisoners, corrections officials, mental health experts, and attorneys. It describes how prisoners with mental illness are likely to be bullied, physically and sexually abused, and manipulated by other inmates, who call them "bugs." It describes prisoners who, because of their illness, rant and rave, babble incoherently, or huddle silently in their cells. They talk to invisible companions, lash out without provocation, beat their heads against cell walls, cover themselves with feces, mutilate themselves, and attempt suicide. Unable to conform their behavior to the rigid expectations of prison life, they often fall into self-defeating patterns of irrational opposition to the demands placed on them. The report notes that corrections staff, most of whom lack training in mental illness, often interpret such behavior as failure to comply with rules. Prison management is predicated on obedience to rules, and rule breaking is subject to discipline and punishment. Mentally ill prisoners have higher than average rates of disciplinary infractions.

The report describes specific cases in which mentally ill prisoners have been punished for self-mutilating ("destroying state property"—the property in question being the prisoner's own body), for attempting suicide by swallowing a piece of a broken mirror and by hanging with a torn sheet ("destroying state property"), for yelling and kicking cell doors because of auditory hallucinations ("creating a disturbance"), for throwing papers at a guard because of delusions ("battery"), and for smearing feces on a cell door ("being untidy"). One delusional prisoner told a clinical psychologist in a confidential counseling session that his skin was poisonous and that if a correctional officer touched him, the officer would die. The psychologist, who was also a case manager, wrote a disciplinary ticket saying that the prisoner was threatening to kill an officer. The prison was eventually forced to drop this charge.

According to the report, prison mental health services in the United States have improved over the past two decades because of lawsuits on behalf of prisoners. However, the report also describes how the system has been overwhelmed by the growing number of inmates with mental illness. The report urges Congress to enact legislation to provide federal grants to divert mentally ill offenders into treatment programs rather than prison and to improve the quality of mental health services for inmates. It also recommends using independent mental health experts to assess mental health services in each prison system, urges elected officials and the heads of correctional agencies to ensure that mentally ill prisoners receive services that are consistent with community standards of care, and calls for rules to prevent placing prisoners with mental illness in isolated confinement or in super-maximum security prisons.

The report, along with material collected but not included in the document because of space limitations, is available on the Human Rights Watch Web site at www.hrw.org. The additional material includes expert reports produced during litigation that are not readily available to the public and that document problems in specific prisons.

Growth in Medicaid spending has declined for the first time since 1996, according to a new survey conducted for the Kaiser Commission on Medicaid and the Uninsured. Spending grew at a rate of 9.3 percent in 2003, down from 12.8 percent in 2002. In the past three years, two-thirds of states tightened eligibility and reduced health care benefits for low-income families and elderly persons. The survey also found that all 50 states and the District of Columbia have planned or implemented additional Medicaid cost containment actions for fiscal year 2004. The survey report, States Respond to Fiscal Pressure: State Medicaid Growth and Cost Containment, notes that the reductions in expenditures are occurring at a time when Medicaid enrollment is increasing because of sluggish economic conditions.

According to the report, most states adopted the familiar strategies of curbing payments to providers and controlling the costs of prescription drugs, particularly by imposing new or higher copayments. Other strategies include restricting or eliminating dental coverage and vision and eyeglass coverage as well as coverage for home health care in 20 states. The survey also found that the $20 billion that Congress provided in fiscal relief to the states in June 2003 was critical in preventing more far-reaching cost-containment actions and helped some states avoid significant reductions in eligibility.

In addition to the survey report, the commission released the results of two studies of states' fiscal situations and of factors contributing to the growth in Medicaid spending. Data from the first study are presented in The Current Fiscal Crisis and Its Aftermath. The report shows that the primary cause of the fiscal crisis in the states has been a sudden and dramatic falloff in state tax revenues and that growth in Medicaid expenditures has played a much smaller role. In fiscal year 2002, states lost $62 billion in tax revenues, whereas Medicaid spending increased by about $7 billion. Measured as a share of the economy, the decline in state revenues—7.4 percent—is twice as steep as the declines that occurred in the 1990-1991 recession (3.5 percent) and the 1980-1982 recession (3 percent). The report concludes that the states are likely to face fiscal difficulties for the next several years.

The second report, Medicaid Spending Growth: 2000-2002, presents data indicating that health care expenditures for persons with disabilities and for elderly persons has accounted for nearly 60 percent of the increase in Medicaid spending since fiscal year 2000, even though the rates of growth in enrollment for these two groups were far lower than those for children and nondisabled adults. Spending increases have also been driven by higher costs of hospitalization and prescription drugs. Medicaid spending per enrollee increased by 8.6 percent between 2000 and 2002. The report notes that this rate is lower than the per-person rate of increase in health care spending for individuals with private insurance and considerably lower than the rise in health insurance premiums, which increased by about 12 percent per year during the two-year period.

All three reports are available for downloading on the Web site of the Kaiser Family Foundation at www. kff.org.