Abstract
COVID-19 created acute demands on health resources in jails and prisons, burdening health care providers and straining capacity. However, little is known about how carceral decision-makers balanced the allocation of scarce resources to optimize access to and quality of care for incarcerated individuals. This study analyzes a national sample of semi-structured interviews with health care and custody officials (n = 32) with decision-making authority in 1 or more carceral facilities during the COVID-19 pandemic. Interviews took place between May and October 2021. We coded transcripts using a directed content analysis approach and analyzed data for emergent themes. Participants reported that facilities distributed personal protective equipment to staff before incarcerated populations due to staff's unique role as potential vectors of COVID-19. The use of testing reflected not only an initial imperative to preserve limited supplies but also more complex decision-making about the value of test results to facility operations. Participants also emphasized the difficulties caused by limited physical space, insufficient staff, and stress from modifying job roles. The rapid onset of COVID-19 confronted decision-makers with unprecedented resource allocation decisions, often with life-or-death consequences. Planning for future resource allocation decisions now may promote more equitable decisions when confronted with a future pandemic event.