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James Vogel knew he had it coming in 2009 when an Aitkin County judge sentenced him to five years in prison for his sixth drunken-driving conviction. What gave him pause was the mysterious lump in his gut -- a bulge the size of a football -- and who was going to take care of it.
The lump turned out to be a rare form of non-Hodgkins lymphoma. Terminal. Five years average life expectancy.
Yet, at the direction of the Minnesota Department of Corrections, Vogel soon started receiving the best medical care in America: a year of intensive chemotherapy, then a trip to the Mayo Clinic for nearly a month to receive a sophisticated bone-marrow transplant.
By the time he left Mayo in August 2010 and headed back to prison in Oak Park Heights, Vogel, now 52, was on his way to being what state corrections officials describe as a "million-dollar prisoner."
Vogel's treatment epitomizes a pair of forces bearing down on Minnesota's corrections system: Soaring medical costs and a rapidly aging prison population. More than one in 10 Minnesota inmates is now over age 50 -- a share that has doubled in the past decade -- and increasingly many of them need specialized treatment for costly illnesses such as cancer, diabetes and heart disease. More than 550 offenders are serving life sentences; at an average age of 40, most face at least 30 more years in prison before they have any chance of parole.
With a medical budget that has tripled in the past decade, to $68 million last year, the Corrections Department faces politically sensitive questions -- among them the matter of providing expensive, sophisticated medical care to offenders who have committed heinous crimes, at a time when many Minnesotans are struggling to afford basic care and health insurance.
"The aging curve in prison is crushing when it comes to costs, just like the one for the general public, and it won't get any better," said Sen. Tony Lourey, DFL-Kerrick, whose district includes a correctional facility and the secured treatment center for the state's sex offenders.
Nan Larsen, the Corrections Department's medical director, is often asked by legislators why prisoners are afforded care that those on the outside would find difficult to obtain. A direct, tough-minded administrator, she has an answer:
"Their punishment is that they are separated from us, from society and from their families -- but not from our care."
Besides, Larsen notes, inmates like Vogel have unique status. As a prisoner in the United States, he is a member of the only class of Americans with a constitutionally guaranteed right to health care, as determined by the U.S. Supreme Court.
Vogel, a construction worker from Grand Rapids, Minn., understands the paradox.
"I probably would not have gone to see a physician, or had the cancer found as soon as it was, if I hadn't been arrested," he said in an interview at Stillwater prison. "I'll admit that. So there's a level of gratitude over the treatment I've received."
Prisoners elderly at 50
When Vogel became a million-dollar inmate, he joined a select group of convicts who need highly specialized care -- at cost of more than $14 million just last year.
They've lived hard lives and pushed their bodies to the breaking point. In Minnesota, a prisoner at 50 is considered elderly, with the medical problems of someone 60 or older.
A snapshot of inmate health is sobering:
More than 80 percent are considered chemically dependent, and nearly 20 percent are estimated to be hepatitis C-positive. Decades of smoking, boozing and drug use have pushed their hearts, livers and kidneys to the edge of failure.
Obesity, hypertension and diabetes are common.
More than 20 percent of the men and nearly 70 percent of the women are on psychotropic medications.
Just to treat prisoners with cancer, the department has spent more than $14.4 million over the past five years. Four prisoners now await stem-cell transplants.
Cardiac care -- ranging from heart bypass grafts and stents to pacemakers -- has cost nearly $2 million over the past four years.
On a recent morning deep inside the maximum-security Oak Park Heights prison, 16 prisoners were laid out in a semi-circle with tubes needled into their arms. Some of the most violent men in the state were hooked up for thrice-weekly, three-hour dialysis sessions to cleanse their failed kidneys.
Although they're a comparatively small number of prisoners, their care costs have doubled in the past four years and will only go higher. Currently, the dialysis program costs more than $560,000 a year. The number of dialysis patients is expected to double by 2020 and cost $1.8 million.
Currently, nine prisoners with hepatitis-C are deemed candidates for a special drug that has shown remarkable success over a 12-week regimen. The Corrections Department says it would cost $40,000 per treatment, a total of $360,000 if each prisoner is given the drug.
And finally, when prisoners are considered so ill that they must be hospitalized, the daily rate for a room and routine care is $5,000.
Price tag: $49 billion
Across the country, many states are struggling with the same burden. The nation's prison population has almost tripled in the past two decades, to nearly 1.6 million inmates, due mainly to tougher sentencing guidelines; overall corrections spending has grown fivefold, to $49 billion in 2008, according to the Pew Center on the States.
Nationally, the number of prisoners over age 65 nearly doubled in the past decade, reaching more than 26,000 in 2010, according to a recent study by Human Rights Watch. Medical costs for older inmates range from $8,500 to $11,000 per person per year, the report found.
"Prisons were never designed to be geriatric facilities," said Jamie Fellner, the report's author. "Yet, U.S. corrections officials now operate old age homes behind bars."
To control costs in Minnesota, the Department of Corrections contracts its prison care to a national, for-profit health provider called Corizon, formerly Correctional Medical Services. This year, DOC will pay Corizon $28 million to provide basic care to prison inmates, up $9 million from 2006.
Corrections officials say the relationship is saving taxpayers tens of millions of dollars; while public health care spending in Minnesota has increased an average of 8 percent annually over the past six years, the department says it has been able to keep its cost growth to about 5.5 percent using privatized care for prisoners. But inmates complain of long delays between the time their illnesses are diagnosed and when they get treatment.
Larsen notes that, while some inmates get the finest care available in Minnesota, others are denied services that are routinely covered by the health insurance of people on the outside.
By her count, there are more than 65 health insurance mandates for which the average citizen on private health insurance can receive coverage. They include certain kinds of cosmetic surgery, breast reconstructive surgery, wigs for hair loss and removal of port wine birth marks.
"The DOC does not provide this level of coverage," Larsen said.
Offenders, she added, receive a "community standard'' of care consistent with standards established by the state Board of Medical Practice.
"If an offender can live safely and participate in [prison] programming with a hernia, and it is not causing pain and not interfering with daily living, the [prison] doctor may not authorize treatment," Larsen said.
On borrowed time
A prisoner living out a sentence doesn't watch a clock. He measures it by watching his body change. To Vogel, each day is borrowed time, thanks to the all-expense-paid chemotherapy and his care at the Mayo Clinic.
Larsen has declined to free Vogel on a conditional medical release to participate in clinical trials that could advance his cancer treatment, saying it would set a precedent. "Your condition is presently neither grave nor terminal by any medical standard," she wrote in a letter to him. "While it may be true that the lymphoma will someday claim your life, you are currently well-managed within our system."
Vogel acknowledges that he's been an imperfect inmate -- acting out behaviorally and sneaking medications that landed him in segregation.
But he still points to his release date in November and notes that the lump in his body is gone.
"I'd like to have Thanksgiving with my family," he said. "I don't want to die in prison."
Paul McEnroe • 612-673-1745