ON APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA
(D.C. Civil No. 94-06663)
Before: GREENBERG, ALITO, and ROSENN, Circuit Judges
Opinion Filed: October 22, 1997
Several years ago, the Berks County Prison instituted a "fee-for-service" policy under which it began charging inmates a small fee when they sought health care. Under this policy, indigent inmates are guaranteed care, but their prison accounts are debited for the relevant charges. In this appeal, we consider constitutional challenges to this policy.
A. The following facts are uncontested or were found by the district court. See Reynolds v. Wagner, 936 F. Supp. 1216, 1219-23 (E.D. Pa. 1996). The Berks County Prison houses both pre-trial detainees and sentenced prisoners. Of the institution's average daily population of approximately 775, between 100 and 120 are federal inmates housed under contract with the federal government. The remaining 550 inmates are held under state law. Approximately 35% of the inmate population is Hispanic, and approximately 10% of the population speaks only Spanish.
The Berks County Prison styles itself as a "new generation prison" based on the philosophy of providing inmates with more choices in their daily lives so that they can learn to act more responsibly. In accordance with this approach, the prison, in 1993, adopted a program under which the inmates held under state law are generally charged small fees when they seek health care. The purpose of the fee program is not to generate revenue but to "instill inmate responsibility and discourage abuse of sick call." Reynolds, 936 F. Supp. at 1219.
Under the program, inmates are charged a $3 fee for a medical evaluation by a nurse. (This is referred to as "sick call.") If a nurse refers an inmate to the doctor after the initial sick call, there is no charge to see the doctor. However, if the inmate chooses to see the doctor without a referral, there is a $5 charge. If the doctor decides that the inmate should have been referred at the initial screening, the $5 charge is waived. Inmates are not charged for follow-up visits ordered by a doctor or nurse and are not charged for legitimate return visits for a condition for which they have already been treated. Inmates are not charged for prescription medicine, and over-the-counter medication is issued by the medical department if deemed necessary for an inmate's treatment. Over-the-counter medication is also available for purchase from the commissary.
The Inmate Handbook sets forth certain exceptions to the fee requirement. Initial commitment screenings, psychiatric services, and emergency services *fn1 are free. Similarly, there is no fee for the treatment of chronic illnesses, including such treatment as changes of dressings, colostomy changes, and treatment for conditions such as diabetes, hypertension, or AIDS related syndrome. The determination of whether a condition at sick call is a chronic illness or emergency is made by a member of the nursing staff. The assessment of an inmate's condition is made independently and regardless of his financial status.
Whenever medical service is provided, an inmate is required to sign a "Medical Service Fee Form." Id. at 1220. If the inmate refuses to sign the form, a member of the medical staff initials the form, and the fee is deducted from the inmate's account. No inmate is ever refused treatment because he lacks funds in his account, but the account of an inmate who lacks funds is nevertheless debited, and a negative balance is thus created.
If an inmate's account has a negative balance, 50% of his incoming funds are used to satisfy the negative account, and the the remainder can be used for personal purchases. This 50% deduction continues until the negative balance is eliminated. At discharge, any available funds are credited towards the inmate's negative balance and the remainder, if any, is paid to the inmate. Negative balances that remain on an inmate's account after discharge are maintained on the inmate's permanent record. If the inmate is recommitted, the negative balance is imposed again. In addition, if an inmate departs the prison with a negative balance, a collection agency may be employed to collect the debt.
The nurse who makes the initial assessment of an inmate's condition informs the prisoner about the channels through which a fee assessment can be challenged. An inmate who disagrees with a fee assessment mustfirst file an "inmate communication form," which is reviewed by the medical department. Id. at 1221. An inmate who receives an unfavorable response to his inmate communication may submit a grievance to a prison committee *fn2 consisting of the warden, the assistant warden, the deputy warden for treatment services, the deputy warden for custody services, and the director of administrative services. Grievances are decided by a majority vote of the committee whose decisions may be appealed to the Berks County Prison Board.
Details on the workings of the program are contained in the Inmate Handbook. Copies of the Inmate Handbook are provided in each housing unit, in the library, and in every department of the prison. During orientation, a prison officer and a counselor review the contents of the Inmate Handbook with the inmates and answer questions. Although there is no copy of the Inmate Handbook in Spanish, Spanish-speaking officers and counselors explain the Handbook to all Spanish-speaking inmates during orientation. Moreover, the medical department employs "at least three nurses" who are fluent in Spanish. Id. at 1222.
B. In November 1994, individual inmates filed this action under 42 U.S.C. Section(s) 1983, challenging the constitutionality of the program. The original complaint was subsequently amended, and the case was certified as a class action in February 1995. Named as defendants were the Berks County Prison and its warden. *fn3
In August 1995, the district court issued an order bifurcating trial on the issues of liability and damages. In May 1996, the court held a one-day trial on the issue of liability. At the conclusion of the trial, the district court rejected the inmates' constitutional claims. See Reynolds v. Wagner, supra. This appeal followed.
C. On appeal, the inmates challenge three of the district court's holdings: (i) that the fee-for-service policy did not constitute deliberate indifference to the inmates' serious medical needs and therefore did not violate their Eighth Amendment or Fourteenth Amendment rights; (ii) that the fee-for-service program did not result in the taking of inmate property without due process; and (iii) that the program did not impermissibly infringe on the inmates' First Amendment right of access to the courts.
The Supreme Court has rejected strict scrutiny as the appropriate standard of review for the constitutionality of prison regulations. Turner v. Safley, 482 U.S. 78 (1987); see also Monmouth County Corr. Inst. Inmates v. Lanzaro, 834 F.2d 326, 332 (3d Cir. 1987). Instead, the question is whether the regulation is reasonably related to a legitimate penological interest. Lanzaro, 834 F.2d at 332. In determining the reasonableness of a challenged regulation, we consider:
(1) the rational relationship between the regulation and the governmental interest put forward to justify it;
(2) the existence of alternative means to exercise the asserted right;
(3) the impact on prison resources of accommodating the asserted right; and
(4) the existence of "ready alternatives" to accommodate the asserted right at "de minimis" cost to valid penological interests.
Id. (citation and footnote omitted).
The inmates' central claim concerns the validity of regulations relating to the prison's provision of health care. The specific standard applicable to an Eighth Amendment claim concerning the denial of health care to inmates is the two-pronged standard enunciated in Estelle v. Gamble, 429 U.S. 97, 104 (1976). This standard requires a showing (1) that the prison officials were deliberately indifferent to the inmates' medical needs and (2) that those needs were serious. Id. We apply the Estelle standard in the context of the level of scrutiny set out by Turner.
A. The inmates make two separate sets of arguments as to why the Berks County Prison program constitutes "deliberate indifference" to their "serious medical needs." First, they contend that charging inmates for health care is per se unconstitutional because the Constitution bars a state from conditioning inmates' access to health care on their "ability or willingness to pay." (Appellants' Br. at 13). Second, the inmates maintain that even if a fee-for-service program is not per se unconstitutional, the Berks County Prison program is unconstitutional "as implemented."
B. Before addressing the merits of these arguments, however, we must consider the defendants' contention that the inmates lack standing because they "have demonstrated no actual harm." (Appellees' Br. at 23). The defendants contend that the inmates "offered no evidence to support a finding that serious medical conditions were ...