Prisoners have a fundamental right to receive health care while incarcerated, a right that is mandated by the US Supreme Court. However, negligent care in prisons persists and is often an issue of limited access due to cost mitigating policies. Since the 1990’s, prison systems have integrated managed care strategies, like co-payments, to mitigate increasing health care costs. As of 2017, 84% of states issue co-payments in their prisons and all federal prisons issue co-payments, per the Federal Prisoner Healthcare Co-Payment Act [pdf]. Like standard insurance plans, co-payments are meant to decrease sick calls and reduce “frivolous” medical utilization and costs. Proponents argue co-payments promote inmate responsibility and lower overall medical costs; however, critics argue they create barriers to accessing care for impoverished prisoners and may increase costs in the long run. Despite the existence of co-payment programs in prisons, there is inconclusive evidence on its effectiveness in mitigating costs while maintaining prisoner health.
Though the exact policies vary from state to state, co-payment systems are administered by charging inmates when they receive medical care and prescription drugs. Co-payments range from $2 to $10 per visit or drug supply [pdf]. For example, if an inmate requests a sick call and is given an antibiotic for their illness, there would be two separate co-payments – one for a visit and one for the prescription. These payments are withdrawn from individuals’ commissary accounts (internal accounts) where money can be deposited by family members or earned through prison jobs. If no money is available, a hold is placed on the account, and future deposits go toward medical debt until paid. Outside of medical care, the primary purpose of these accounts is to pay for daily items: toiletries (shampoo, soap, lotion), tampons and pads, phone call cards, over-the-counter medications, stamps, and paper.
While $6 may not seem expensive at face value, it takes on another meaning when we consider the average state prison wage: $0.14 per hour. Scaling up to the federal minimum wage, a $6 copay is the equivalent of about $311, meaning treatment for something as simple as a sinus infection could cost the equivalent of over $600. This steep price makes it clear how seeking prison medical care can become cost-prohibitive and places an unfair burden on the families of poor prisoners.
Prison’s Gender Gap
Prescription drug co-payments are particularly burdensome to incarcerated women, the fastest growing segment of the US prison population. Research indicates that female prisoners use more healthcare services and prescriptions than male prisoners, as is true with women in the general population, making access to care one of the most pressing issues facing female prisoners. Moreover, co-payments have an amplified effect on incarcerated women and negatively impact their physical, financial, and social well-being.
Upon entering prison, the average woman faces a drug-related charge and is a single mother of two with a history of physical and sexual abuse, drug use, and prostitution. She often comes to jail with serious health concerns, including human immunodeficiency virus (HIV) infection, hepatitis C, tuberculosis (TB), methicillin-resistant Staphylococcus aureus, sexually transmitted infections, and mental illness. Though many states have chronic disease management programs that replace the copayment requirements for conditions, many women are ineligible unless they are consistently symptomatic, so their conditions go untreated. Prisoners’ untreated health problems expose other prisoners, prison staff, and the public to infectious diseases, increasing the burden of local health care services.
Incarcerated women face unique obstacles in acquiring everyday necessities with their scare financial resources. For instance, prisons systematically provide inconsistent access to menstrual hygiene products (some allotting just 1-2 pads per day), so women often must resort to buying pads, tampons, and other toiletries through their commissary accounts. Additionally, since approximately 60% of incarcerated women have children, many mothers must choose between seeking medical care and communication with their children. Calling cards, prepaid cards that allow women to use the phone, start at $25 and calls cost about $0.22 per minute. While a cheaper option, materials for letters (pens, paper, stamps, etc.) must also be bought through commissary accounts. Requesting outside family for financial assistance is often not an option for women because these family members are taking on the responsibilities and costs of caring for their children while in prison.
Lacking Continuity of Care
A lack of continuity of care in prescription drugs is one of the more obvious long-term effects of co-payments. Continuity can be broken both when a woman enters a correctional facility and in the months following her release. This lack of continuity most notably impacts the management of family planning and mental health conditions.
Upon entering prison, most women who are on birth control stop receiving the prescription, unless it is necessary to treat a chronic condition. Birth control is often viewed as unnecessary for female prisoners since female inmates are held in single-sex facilities. However, conjugal visits with spouses are allowed in some prisons, and sexual relationships/rapes occur between guards and inmates within the prison. Moreover, these women are at higher risk of unplanned pregnancies after release, when they have no prescription or birth control supply and become sexually active again.
Co-payment policies also severely impact inmates with mental health conditions, particularly those that are less noticeable (e.g., depression). Studies indicate that approximately 25% to 50% of inmates require mental health treatment. A small proportion of these individuals, about 20%, were taking medication for their conditions upon admission to prison. However, more than 50% of those who were previously medicated stopped receiving pharmacotherapy once in prison. Prisoners who experience inconsistent or less overtly symptomatic mental illnesses are often not considered for chronic behavioral health medication in their initial screening and are thus subject to co-payment policies if they seek treatment at a later time.
The Bottom Line
Incarcerated women who are subject to co-payment systems experience increased financial stressors and a lack of continuity in pharmaceutical care. While the co-payment structure reduces short-term healthcare costs in prison, the long-term financial effects are unknown, and inmate health outcomes are negatively impacted. These negative impacts are most evident in women’s mental health and family planning. Ultimately, these policies disproportionately burden incarcerated women and contribute to systemic health inequities in their communities after release.
Morgan Craven