A report published by the National Consumer Law Center (NCLC) on September 6, 2024, found an inverse relationship between medical copays imposed on prisoners and their access to healthcare. That is, those incarcerated in lockups charging higher copays were less likely to seek treatment for medical issues, while those with lower copays were more so.

Most prison systems require copays when prisoners sign up for sick call to see a nurse, doctor, dentist, optometrist or other medical provider. In 38 state prison systems and the federal Bureau of Prisons, some form of copay is required. The same is true in many county jails.

These fees are generally small, ranging from $2 to $13, according to a 2017 report by the nonprofit Prison Policy Initiative (PPI). The amounts are disproportionately pricy for those behind bars, however, because prisoners typically receive very low wages or no wages at all. For most, a copay may represent income for several days or even a week of prison labor.

In Tennessee, for example, a standard copay is $3.00, while for an emergency medical request it is $5.00. Yet most state prisoners earn just $1.00 to $3.00 per day, so the copay may represent a week’s work. In states where prisoners receive no pay, the financial burden of medical copays falls on family members and friends who fund their prison trust accounts.

According to the NCLC report, the disproportionately high costs of medical copays disincentivize prisoners from seeking healthcare—even for serious medical conditions. Those findings were mirrored in a report published in the Journal of the American Medical Association (JAMA) on August 5, 2024; using prisoner wage data compiled by PPI, that study found “that prison systems with more expensive copays (relative to prison wages) limit access to necessary healthcare for incarcerated pregnant people and those with chronic conditions more than prisons with no copays or copays equivalent to or less than one week’s prison wages,” PPI reported.

At least 25 state prison systems and the BOP do not require copays for certain types of medical treatment, such as chronic conditions, pregnancy care, job-related injuries or mental health care. Still the negative impact of such fees on prisoner access to healthcare is widespread. Prisoners are less likely to submit sick call requests if they think a copay may apply. As a result, their conditions worsen until they need more extensive (and expensive) medical treatment. Further, when prisoners contract contagious diseases, such as COVID-19 or MRSA, the chilling effect of copays makes it more likely that they will infect others before seeking care. And in the close confines of prisons and jails, contagions can spread quickly if not treated promptly.

A 2023 survey of former prisoners in Nevada found that over 80% reported not seeking healthcare due to the cost of the prison system’s copay. As one put it simply, “I avoid medical as much as possible because I cannot afford it.”

Ironically, prison officials justify copays by claiming they reduce costs when prisoners are discouraged from seeking unnecessary medical care. In reality, though, copays deter prisoners from seeking needed and necessary care, too. On top of that, the cost of collecting copay fees often exceeds the amount collected.

Medical copays, and the chilling effect they have on access to healthcare, are especially egregious given the poor health of many prisoners. “In 2021, the Dept. of Justice found that 40% of incarcerated people in state prisons and 33 % of incarcerated people in federal prisons reported having a chronic health condition,” NCLC reported. The incidence of “chronic health issues and disabilities” is more than twice as high behind bars as not. That is partly due to prison conditions such as violence, overcrowding, inadequate nutrition and lack of preventive care, as well as an aging population of prisoners serving longer sentences. The NCLC also noted that the provision of carceral medical treatment by for-profit companies is a contributing factor to inadequate healthcare.

The NCLC report offered four recommendations to improve access to medical care in prisons and jails: 1) end the practice of charging copays; 2) stop the collection of carceral medical debt, including post-release; 3) prevent private contractors from profiting by providing carceral healthcare; and 4) increase access to Medicaid and Medicare in correctional facilities.

Several state prison systems—including those in California, Illinois, New York and Virginia—have eliminated copays, recognizing their counterproductive impact. The Nevada Department of Corrections also abolished copays in June 2023.

“Addressing carceral medical debt is crucial to ensuring fair and equitable access to healthcare for incarcerated individuals and to reducing the overall burden of medical debt,” the NLCL report concluded. “Without additional reforms, individuals in jails and prisons will continue to suffer significant financial and health consequences.” See: Medical Debt Behind Bars, NCLC (Sept. 2024).  

Additional source: Prison Policy Initiative

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