When Andre Gay went to state prison in Pennsylvania in 1972, he was just 16 years old, sentenced to life without parole for murder and aggravated robbery.
"I was a kid when I came to jail," he says, "so I was basically a blank slate."
Gay learned from the older men there, whom he called his elders. They would hold classes together every day on all kinds of topics: politics, economics, religion, law.
Then he became an elder himself. There were some telltale signs of age — stiffness and pain in the joints, sciatica, flagging stamina — but he felt relatively healthy. For years, he saw his reflection only in a scratched-up metal mirror. One day, he caught a glimpse of himself in a real mirror.
"I literally did not recognize who I was looking at. I had changed so much. It was so disconcerting that it stayed in my head all this time," Gay says. "I didn't realize I had aged that much. I didn't realize I had that much gray."
Prison is a difficult environment, and people behind bars tend to age faster than people on the outside. For that reason, "geriatric" in prison can mean someone as young as 50, though it varies by state.
Any way you define it, the U.S. prison population is getting grayer — and fast.
'You don't usually build prisons with nursing home-type housing'
The proportion of state and federal prisoners who are 55 or older is about five times what it was three decades ago. In 2022, that was more than 186,000 people.
In Oklahoma, the geriatric population has quadrupled in the past two decades. In Virginia, a quarter of the state's prisoners will be geriatric by 2030. And in Texas, geriatric inmates are the fastest-growing demographic in the entire system.
Prison systems across the U.S. have a constitutional obligation to provide adequate health care, and they're racing to figure out how to care for the elderly in their custody — and how to pay for it.
The first people to tell you this are the ones running the prisons.
"When you think about geriatric medical needs, many of the prisons across the United States are not equipped or weren't designed that way, and so the systems are grappling with how to retrofit or make do with the facilities that we have," says Nick Deml, commissioner of the Vermont Department of Corrections.
"You see it visibly, but you see it in your health care budget and in your health care needs and your housing needs," says Bryan Collier, the executive director of the Texas Department of Criminal Justice. "You don't usually build prisons with nursing home-type housing or geriatric housing or even wheelchair housing."
As that population grows, he says, prisons have to adapt in all kinds of ways: making cells wheelchair accessible, accommodating prisoners who can no longer climb to an upper bunk, providing health care and food inside units when prisoners aren't mobile, installing more outlets for CPAP machines.
"Staffing is a challenge," says Heidi Washington, director of the Michigan Department of Corrections. "What I'm more focused on going into the future is some more specialized staff that have an expertise in dealing with the aging population."
A retrofitted prison unit
Some states have opted to build entirely new facilities to house elderly or sick prisoners. Others have retrofitted existing units. At the state prison in Oak Park Heights, Minn., the Transitional Care Unit (TCU) has expanded twice in the past 20 years.
Inside the 54-bed unit, there's a clinic on one end where prisoners can get dialysis and other medical treatments. Nursing care is available 24 hours a day.
"Every patient that we have in our TCU, or just incarcerated in general, is somebody's dad, somebody's brother, somebody's sibling," says Kristin Grunewaldt, a registered nurse clinical coordinator at the facility. "We really try to do things for each patient to kind of individualize them and to make them feel more comfortable and human."
In some ways, the rooms look exactly like what they are: prison cells. The small windows have bars obscuring the view to the outside. A metal toilet sits in the corner with no option for privacy. The doors lock from the outside.
In other ways, the cells are less typical: The sinks allow space for a wheelchair to pass under, and the bed looks more like one you'd find in a hospital. There's a nurse call button, and each cell has a glass door.
"That way we can visualize what is happening with the patient as we walk by the door," says Joan Wolff, associate director of nursing for the Minnesota Department of Corrections, noting that "the doorways are substantially wider to allow for wheelchairs."
This unit is equipped to care for elderly prisoners, Wolff says. But it's small. There are just two specialized units in Minnesota's prison system that provide this level of care. Together, they can house just over 150 people. But the state's prisons have around 1,400 people over age 50, according to a department spokesperson.
Wolff acknowledges that the prison population is graying.
"We know that it's coming, and we want to be prepared on our end," she says, adding, "There's been a lot of discussion about what resources we can provide for individuals to ensure that their needs are being met even in a general population."
'What happens is fellow inmates are their nurses'
Dan Pfarr, CEO of a reentry nonprofit in Minnesota called 180 Degrees, says the older men he sees come out of prison are in rough shape.
"They've gone so long with substandard health care or not the right types of health care," says Pfarr, whose organization has contracts with the state. "For men coming out of prison, 40 is the new 60, 60 is the new 80."
He says he doesn't see how prisons could suddenly become prepared for an aging population.
"What is it — a new set of cells over on the left side of the facility that offer what? That offer better nursing care, better nutrition, better sunlight, better access to health and wellness? Well, if that's not happening along the way, how is that going to happen as guys turn 70, 80?"
In Pennsylvania, Andre Gay avoided a future where he grew sick and died in prison. He became eligible for parole after the U.S. Supreme Court ruled that juveniles could not be sentenced to mandatory life without parole and that this applied retroactively. He was released in July 2022, after more than 50 years in prison.
He's 68 now and spends his time helping get other prisoners released. He does it partly because he believes prisoners, particularly the elderly, aren't getting the care they need.
"The prison administration, their culture, I wouldn't even call it benign neglect. It was just indifference," Gay says. "Prison is not good for anybody. A lot of times, the elderly have it the worst."
Gay, who also goes by Shabaka, says people in prison end up helping each other. He recalled how one young man would care for an elderly man who was blind: "He used to always come to his cell and take him to the yard, to the kitchen, wherever he needed to go."
Other people tell similar stories.
"They're not set up to take care of elderly people that are now full-time patients," says Joan Sehl, whose partner, Terry Dreibelbis, is a Pennsylvania prisoner in his 70s. "So what happens is fellow inmates are their nurses."
Representatives for the Minnesota and Pennsylvania departments of corrections maintain that they're providing adequate health care to those in their custody.
'It's really a story of how we choose to punish people'
More elderly people in prison is largely a sentencing problem, says Marta Nelson, the director of sentencing reform at the Vera Institute of Justice, a criminal justice research organization.
"It all stems from the longer sentences and the longer length of time that people have had to spend serving sentences in the United States, really starting from the '70s and '80s, but which became quite well known in the '90s," Nelson says. "People who went in as young people then are now aging. So it's really a story of how we choose to punish people."
For instance, the Violent Crime Control and Law Enforcement Act of 1994, commonly known as the 1994 crime bill, incentivized states to build more prisons and keep people in those prisons for a longer percentage of their sentences. Other tough-on-crime policies — like mandatory minimum sentences and "three strikes" laws, in which the punishments for repeat offenders severely ratchet up — also contributed to why many people who went to prison decades ago are still there.
Today, there are more people serving a life sentence in prison than there were people in prison at all in 1970, according to a 2021 report from the Sentencing Project, an advocacy organization.
Caring for aging prisoners is expensive, but the data on just how expensive is murky. A 2013 study estimated it could be anywhere from three to nine times more expensive than for younger prisoners. And a 2015 report from the Justice Department's Office of the Inspector General found that federal prisons with the highest percentage of elderly prisoners spent five times more per person on medical care than those with the lowest percentage of aging prisoners.
Partly because of this cost, Nelson says, state lawmakers need to think more seriously about releasing elderly prisoners. But she acknowledges that this is complicated.
"You have somebody who is in prison for, say, murder. Well, OK, this person literally couldn't hurt a fly. And yet at one point in time, they created a great deal of harm," she says. "So how can we release them? I think they're afraid of the narrative about what it means to revisit what this person did."
The idea of releasing elderly prisoners is "a hot potato," says Kevin Kempf, executive director of the Correctional Leaders Association. "Not too many people are clamoring to get that responsibility for all the reasons that you can imagine."
But, he adds, "we just have to be really careful about who we incarcerate. That's the bottom line, because sometimes prisons don't make people better. We make people worse."
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