Months after he landed in Florida's Manatee County Jail, Jovon Frazier's pleas for treatment of the intense pain that radiated from his left shoulder to his elbow were met mostly with Tylenol.
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"It really hurts! HELP!" Frazier, then 18, wrote the second time he asked for care, in August 2009.
"I need to see a doctor!" he wrote on his eighth request form, after an X-ray came back negative. "I done put a lot of sick calls in & ya'll keep sending me back and ain't tell me nothing."
Four months later, after Frazier's 13th request resulted in hospitalization and doctors quickly diagnosed bone cancer, his arm had to be amputated, according to a lawsuit filed by his family.
But the cancer spread and Frazier died in 2011, months after his release.
As an inmate, his medical care had been managed not by the county sheriff's office that runs the jail, but by a private company under contract.
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That company, Corizon Health Inc., is under growing pressure around the country after losing five state prison contracts, downgrades by credit analysts and increased scrutiny of care of inmates held by some of its largest customers, including New York City. But Corizon, whose responsibility for 345,000 inmates at prisons and jails in 27 states makes it the country's biggest for-profit correctional health provider, is just one of many firms using a similar model to vie for the billions of dollars states and counties spend on prisoner care.
The growth of the for-profit prison care industry raises questions about how to divide expensive and complicated responsibilities between public agencies and private companies. It turns, though, on a thornier underlying issue: How do you ensure care of people that society mostly would prefer not to think about?
Inmates "are still human beings. I think some people forget that, I really do. They're somebody's child," said Shirley Jenkins, Frazier's grandmother, whose suit against Corizon was filed together with medical documentation reviewed by The Associated Press.
States spend nearly $8 billion a year on prison health care, about a fifth of their entire corrections budgets — a figure that doesn't include millions more spent in local jails, according to a July report by The Pew Charitable Trusts and the MacArthur Foundation.
The spending reflects inmates who are much more likely than the general population to have a history of drug and alcohol abuse. Many have had little regular contact with doctors or other health care providers before they're locked up, allowing chronic conditions and infectious diseases to worsen. A rising population of older inmates requires more care, even as spending taxpayer money on doctoring for the accused and convicted remains politically unpopular.
In the 1980s, when Corizon's two predecessor companies got their start, some individual counties began moving to privatize jail health care as a way to control costs. The trend has gained momentum as more states privatized care in prisons, motivated by spiraling costs and budget pressures.
Some critics say privatization, itself, is a faulty strategy, regardless of which company is hired.
"The fundamental problem is not this company or that company. ... The problem is a structure that creates incentives to cut corners and deny care to powerless people that have no other options," said David Fathi, director of the American Civil Liberties Union's National Prison Project. "Now Corizon is huge, so it gets more scrutiny."
Others say deficiencies with prison health care go beyond whether or not it is privatized.
"I don't have a great love for private health care ... but I don't think that they're the source of the problem," said Dr. Marc Stern, former health services director for Washington state's prison system. Stern, who worked for one of Corizon's predecessor firms in New York state in the early 2000s, issued a scathing report in 2012 on the company's care for inmates at an Idaho prison while serving as a court-appointed expert in a lawsuit pitting inmates and the state.
"I think the problem is how much money and effort we are willing to put into correctional health care," Stern said.
Tight budgets — whether a private company or a public agency is in charge — often lead to hiring of less-qualified nurses and doctors ill-equipped to make decisions that can put an inmate's health at risk, Stern said. If a prison runs its medical system so poorly that inmates are dying needlessly, an experienced private company can likely improve the quality of care while cutting costs, Stern said. But if care is stabilized, a prison operator that builds its own expertise in-house can provide medical services at least as well, while doing it for less because they don't have to include a profit margin, he said.
Some critics of privatization, though, say Corizon is notably problematic.
"We get letters from prisoners about medical care not being provided and the list is endless. And it's increased tremendously since Corizon took over" prison health care from the state Department of Corrections, said Randall Berg, executive director of the Florida Justice Institute, who represents inmates petitioning for care.
"I thought the Florida DOC was bad, but this is much worse."
Corizon, while acknowledging critics, says it strives to provide quality care.
"We are always troubled by any questions on the care provided to our patients and view this as an opportunity to reconfirm our commitment to operational ethics and professionalism," a company spokeswoman, Susan Morgenstern, said in a written statement. The company declined to answer questions about its recent contract losses and other difficulties.
Those struggles are widespread.
Corizon's handling of health care for the 11,000 inmates at New York City's Rikers Island jail complex is under "comprehensive review" by officials, who say they are concerned about problems including at least 16 deaths since 2009 and are looking into the possibility of replacing the firm with a teaching hospital or a city-run agency.
A year after Florida privatized medical care in its state prisons and awarded Corizon with a $1.2 billion contract, news reports point to rising inmate deaths. If the company does not address substandard care, the state's corrections commissioner wrote to Corizon's CEO in a September letter, Florida may begin withholding payment.
In Arizona, where Corizon was hired last year to replace the second largest provider, Wexford Health Sources Inc., after its management of inmate care came under fire, an advocacy group citing a rising number of deaths warned that "if anything, things have gotten worse" under the new contractor. The state recently settled a lawsuit by the ACLU that calls for stepped up monitoring of inmate medical treatment.
While Corizon's work for Florida and Arizona points to its growth, it has come even as the company has lost longstanding contracts to manage prison inmate health care in Minnesota, Maine, Maryland, Tennessee and Pennsylvania since 2012, when each job came up for bid. Auditors in three of those states documented problems including slowness to address inmates' urgent requests for off-site care and poor record-keeping that made it difficult to know whether inmates were getting prescribed medications.
"My question to you is, in light of this history, why should the state seriously be considering any proposal your company might make to get this contract back again?" a Maine state senator, Roger Katz, asked a Corizon executive during a 2012 hearing on the subject. The man who ran Maine's prisons when Corizon lost the contract is now in charge of New York's jails, where the company's care is again under the microscope.
When Corizon was created in a 2011 merger of two already large companies, it appeared well positioned for opportunities created by the overlap between the rising demand for managed health care and governments under pressure to cut spending.
But the company, which generated $1.4 billion in revenue in 2013 and is owned by a Chicago private equity management firm, is instead battling stiffening competition that has narrowed opportunity for profit, analysts say.
In recent months, credit ratings agencies Moody's and Standard & Poor's have both downgraded Corizon's holding company, citing financial underperformance in work for some of its biggest customers, contract losses, competition that has put a squeeze on profits, and pressure to make payments on heavy debt. Officials in at least one county have raised questions about the downgrades' impact on the company's ability to deliver jail services.
Corizon's contract losses are "certainly more magnified than we had anticipated," said Daniel Goncalves, the analyst who follows the company for Moody's. "We didn't anticipate this type of volatility."
The connection between Corizon's contract losses and questions about the quality of care it delivers is unclear.
But the continuing nature of the challenges facing the company are evident in Florida, where officials are "currently in the process of auditing the health care services at our institutions," state DOC spokesman McKinley Lewis said. He was unable to answer questions about whether Florida has followed through on its threats to withhold payment to Corizon or remove individual prisons from the company's contract.
In Maine, corrections officials severed a nine-year relationship with Corizon after a state audit found that "some prisoners did not receive standard medical services, such as physicals, dental services or sick call response," while also citing poor cost management and documentation.
"It was difficult to tell ... whether or not the inmates were getting all the medications prescribed to them," said Katz, a Republican legislator from Augusta who chaired the government oversight committee when it reviewed Corizon's work, in an interview.
In late 2013, Minnesota prison officials replaced Corizon after 15 years as the state's manager of inmate health care. The decision followed news reports detailing the deaths of nine inmates since 2000.
They included Xavier Scullark-Johnson, who in 2010 was serving a five-month sentence for violation of probation at the state's Rush City prison. Johnson, who at 27 had a known history of seizures, lost consciousness in his cell and was examined by a state-employed nurse before she left for the night, according to paperwork filed as part of a lawsuit by his family.
When a guard, observing seizures, contacted the doctor on call at 3:30 a.m., the contractor-employed physician suggested letting the inmate sleep. When called again, the doctor instructed the staffer to summon an ambulance. But when the ambulance arrived, a nurse just reporting for duty turned it away, citing prison protocol.
Scullark-Johnson was found without a pulse an hour later. He died the following day. The state agreed in 2013 to a reported $400,000 settlement of the suit.
A Minnesota audit of prison health care, released early last year, found that inadequate communication between staff and doctors during overnight hours "may have been a contributing factor to inmate deaths."
But in announcing Minnesota's change of contractors, the corrections commissioner said Corizon had provided "excellent" service. And in a written response to questions, the state DOC said its decision not to renew with Corizon was not related to the audit and was just the result of the normal bidding process. It would not comment on the inmate deaths. A lawyer for Scullark-Johnson's family also would not comment, citing confidentiality agreed to as part of the settlement.
Corizon's work in local jails — which hold those awaiting trial or serving short sentences — also has come under scrutiny.
At an October meeting, Volusia County, Florida, officials questioned Corizon executives about lawsuits it faces and its financial stability before voting unanimously to switch contractors, severing a relationship going back to 2005.
They did not ask about the lawsuit arguably most familiar to them — filed by the family of Tracy Veira, an inmate who choked to death in 2009 in a medical lockdown cell where she was supposed to be under watch while detoxing from painkillers.
But Deb Denys, a commissioner who quizzed Corizon, said she was mindful of the Veira case as she asked questions.
"I think everybody was," Denys said. "Sometimes you don't state the obvious."
The lawsuit stemming from Veira's death is scheduled for trial in July. A nurse who saw an ailing Veira in the jail's clinic the afternoon before she died said she told a supervisor the inmate looked like she needed hospitalization, but that Veira was instead sent back to her cell, according to an affidavit filed as part of the case and reviewed by the AP.
At the time of Veira's death, health care at the jail was contracted to one of the two firms that later merged to form Corizon. Today, the largest company in the correctional care industry pitches itself as a specialist that can bring a comprehensive and innovative approach to inmate health and safety.
But Jenkins, recalling the grandson who died after a tumor went undiagnosed, said any such expertise was of little service as months went by and he repeatedly requested treatment.
"He didn't really want us to come see him in jail," she said. "He didn't want us to see him in so much pain."
Adam Geller can be reached at firstname.lastname@example.org. Follow him on Twitter at https://twitter.com/AdGeller