$100 Co-Payment, In Prison?

Most people know little to nothing about if and how prisoners receive healthcare.

Some might question whether prisoners even deserve healthcare.

So thankfully we have the rule of law to inform our decisions. In 1976 the Supreme Court ruled (Estelle v. Gamble) that not providing adequate medical care to prisoners was a violation of the Constitution’s 8th Amendment against cruel and unusual punishment.

But case law is just that; we still lack accreditation requirements and oversight monitoring to ensure prisoners receive healthcare at all. According to the American Journal of Public Health, 68% of local jail inmates, 20% of state prison inmates, and 14% of federal prison inmates did not receive a medical exam while incarcerated.

Inmates have high rates of chronic medical conditions. In addition, substance use disorders and mental illness are also common; an estimated 50% of the prison population has a mental illness.

Inmates may be pre-disposed to health problems because of their higher than average rates of poverty (80% of prisoners are poor). Most prisoners are not covered by any form of health insurance (even those who were Medicaid eligible) when they are incarcerated.

Passage of the ACA marked a turning point. The ACA made it possible for jails and counties to enroll prisoners on Medicaid (under Medicaid expansion). While Medicaid does not cover standard health care for inmates, it can pay for their hospital stays beyond 24 hours.

Standard health care in prison is administered in a variety of ways. In some states, inmates pay for it. NPR recently reported 35 states authorize copayments and other fees for medical services at state prisons or county jails (based on data from the Brennan Center for Criminal Justice at New York University School of Law).

Inmates pay for it out of commissary accounts (accounts funded by their families or through employment in prison jobs).

How does this translate into healthcare received?

Not surprisingly, prisoners skimp and delay receiving healthcare when they have to pay for it. Most come from families that are too poor to raise funds for bail or defense, so a $100 co-payment for medical care is out-of-the question.

That said, for many prisoners and jail inmates, prison is the first time they have received a routine physical exam and health assessment. It is also an opportunity to enroll them in Medicaid before they are released. With coverage, they can continue receiving preventive healthcare when they return to their communities. Many in law enforcement and corrections believe healthcare will keep those who have been to jail or prison from returning, especially those who suffer from mental illness.

San Francisco’s Sheriff, Ross Mirkarimi, is heading an initiative where every inmate is enrolled in a health insurance policy under the ACA, whether they want it or not. “You have a captive audience,” Mirkarimi said. He says he wants to make sure the 30,000 prisoners who come through the jail system every year are covered on the day they’re released.

CNN recently reported on what happens to the 13 million who return from correctional facilities without having access to adequate health services. They reported “being released from a correctional facility puts a person at high risk for being hospitalized or dying.” Yet most health care practitioners know nothing about how healthcare works in correctional facilities, or the unique stressors common to prison life, such as solitary confinement, abuse at the hands of inmates and guards, social isolation.

While the formerly incarcerated have a wide range of healthcare needs, they are often discriminated against by healthcare providers. A 2014 study published in Health & Justice found 42% of individuals released from prison felt discriminated against by individuals working in the health field, based on their criminal record.

One solution to this problem is to connect healthcare from the jail to the community. This way, after their release, former inmates can receive healthcare at a clinic where staff are sensitive to their incarceration experience. With the opportunities presented by ACA, correctional healthcare and community providers are trying to make this connection in a few different ways. The Transitions Clinic model offers community-based care to former prisoners, and hires some to work as health workers with their peers. Federal programs encourage jails and prisons to adopt electronic health records in correctional healthcare, to coordinate inmates’ healthcare inside with the care they receive before and after their incarceration.

As ACA implementation takes hold, we can expect to see more interest and innovations in healthcare delivered on the inside.