Background
Healthcare in prison is unique in that incarcerated individuals are the only group of people in the United States that have a right to medical care. According to the 1976 supreme court case Estelle V Gamble, not providing medical assistance for life-threatening conditions would violate a person’s 8th Amendment—the right against cruel and unusual punishment.
Since the Supreme Court ruling in the 1970s, there have been multiple cases of people still not receiving the care they need. A 2009 nationwide survey found that only 13.1% of inmates in federal prison received medical care when 38.5% of the population was suffering from a chronic condition. In 2016, Michael Ramey was confined to a county jail awaiting trial where he complained of a terrible headache. The healthcare providers did not believe the severity of his condition which resulted in his death just a month later from meningitis. Had the medical staff delivered the quality of care that is mandated by the 8th amendment, Ramey would not have lost his life to a treatable illness.
While the supreme court ruling does guarantee medical treatment for life-threatening conditions, chronic ailments and non-threatening illnesses are often left untreated in prisons. A report from the U.S Department of Justice showed that 40% of incarcerated individuals suffered from a chronic condition while in prison. Because Estelle V Gamble does not entitle inmates to the right to preventative care, individuals have no other choice but to pay to see a healthcare professional.
The cost to receive care
Although incarcerated individuals have a right to healthcare, they are still required to pay for it themselves. Copays in prison vary by state. The average copay ranges from $2-5. Notably, people in prison make an average of 14 cents an hour. Thus, a visit to the doctor would cost a person a week’s worth of their salary. Some prisons like in Texas, Arkansas, and Florida still have unpaid labor and high copays, making it even more difficult for a person to visit a healthcare provider. In some cases, the prison will still allow a person to see a healthcare provider if they can’t afford the copay. However, debt is applied to the person’s account and could even follow them after their release.
Programs like medicare, which allows people to seek annual wellness exams at no cost, become unusable once a person is in prison. Referred to as the Inmate exclusion policy, the law states that even if a person is eligible the Medicaid funds can not be used to pay for services in prison. Without having a sufficient income, many incarcerated people are forced to forgo seeing a healthcare provider. Which could lead to worsening of conditions, and possibly death. In the discussion of prison reform, it is important to consider ways to improve healthcare.
Policy initiatives
Some states like California and Illinois have chosen to get rid of their copays. To overcome the Inmate Medicaid Exclusion policy, states have asked for exemptions and waivers for coverage. As of July 2022, only 7 states have received approval for wavering exceptions to eligibility. Of all the states, Utah and Vermont are the only ones to request to provide full coverage of their Medicaid plan for incarcerated individuals. Additionally, organizations such as the National Association of Counties (NACo) have advocated for Medicaid recipients to keep health benefits for people who are in jail awaiting trial.
Arguments for eliminating copays
Copays can make it difficult for people in prison to afford to seek medical treatment. By delaying care, illnesses can continue to progress. Avoiding medical treatment may be more expensive in the long run as diseases could become worse the longer a person chooses to seek help. Since prisons are required to provide medical care for life-threatening conditions, it may be more cost-effective to remove copays for minor illnesses rather than having a person avoid treatment, and the condition exacerbates to the point of hospitalization.
Researchers at the American Journal for Preventative Medicine suggested prisons waive copays in the wake of the COVID-19 pandemic as high fees could prevent the early detection of contagious viruses. The cramped spaces in jails and prisons make the population vulnerable to spreadable infections. According to the Center for Disease Control and Prevention, co-pays were a contributing factor to the outbreaks of MRSA in prisons in 2003. Eliminating co-pays could prevent the spread of disease in the prison population.
Challenges to eliminating Copays
Eliminating copays could force the prisons to subsidize the cost of medical visits. States like Arkansas, which have opted to continue enforcing copays, argue that 20% of prison spending comes from healthcare alone. Therefore getting rid of co-pays would increase the percentage of expenditure. In addition to the increased cost, many argue that removing the financial burden from incarcerated people could lead to moral hazard, i.e. an increase in medical visits because inmates no longer have to pay. During the peak of the COVID-19 pandemic, Arkansas waived co-pays for those who felt symptomatic or tested positive. However, the state had to reinstate copays after a month due to the overwhelming demand for medical attention that did not relate to the pandemic.
The National Commission on Correctional Healthcare (NCCHC) states that copays are not merely seen as a medical decision, but rather a fee for service. The financial strain providing healthcare puts on prison facilities could be alleviated through the copays. Moreover, the NCCHC cites fiscal responsibility for incarcerated individuals as a reason to enforce copays. If a person can afford to purchase candy from the commissary, they can use the same money to pay to see a healthcare provider.
