By Beth Schwartzapfel
The Marshall Project, May 30, 2018
For those in the outside world accustomed to paying $25 or more at every doctor’s visit, the idea of prisoners paying $2 to $8 to see a doctor seems nominal. Forty-two states plus the federal Bureau of Prisons charge a co-pay, according to the Prison Policy Initiative, a criminal justice think tank.
When you’re making pennies an hour, or nothing at all, a small co-pay can be the equivalent of hundreds of dollars.
Prisons charge co-pays for similar reasons as free-world health insurers: to cut down on unnecessary medical visits by requiring patients to share in the cost of their care. U.S. prisons spend between $3,000 and $10,000 per inmate per year on medical care — about 20 percent of total prison spending—according to a 2014 analysis by the Pew Charitable Trusts.
“We want a real-world environment for the prisoners because in the real world you and I would be required to have a copay,” Mark Myers, spokesman for the Oklahoma Department of Corrections, told the news site the Frontier. Prisoners in Oklahoma earn 5 cents per hour at the bottom of the wage scale, so the state’s $4 co-pay is roughly equivalent to $580 for a minimum wage worker on the outside, the Frontier reported.
Most states charge a fee for each visit, with a $3.47 national average, according to the Prison Policy Initiative’s 2017 analysis. At $8 per visit, Nevada’s prison co-pay is the highest in the nation. “Charging a co-pay encourages the inmates to develop personal responsibility for their health care, it helps manage the volume of unnecessary doctor appointments in the clinics and assists with a small portion of the medical costs,” said Brooke Santina, spokeswoman for the Nevada Department of Corrections.
Despite their toll on inmates’ individual finances, the fees don’t add up to much on prisons’ balance sheets. In Illinois, the $5 co-pay brings in about $400,000 per year — not enough to recoup the administrative costs of running the program, according to Department of Corrections spokeswoman Lindsey Hess.
Illinois lawmakers want to change that in their state. They voted last week to eliminate the $5 co-pay the state’s prisons have been charging for years. “When you’re denied your liberty, medical care is part of the deal. If you need it, you should get it,” said Jennifer Vollen-Katz, executive director of the John Howard Association, a state prison watchdog group that pushed the legislation. In letters and surveys, co-pays consistently emerged as one of prisoners’ biggest concerns, Vollen-Katz said, with more than half saying they avoid health care to avoid the co-pay.
By Don McCanne, M.D.
The insistence on charging prisoners who have essentially no income a co-pay for health care services is an example of how fixated our policymakers are on designing health care financing systems based on existing policies, no matter how flawed.
Who in their right mind really believes that a prisoner earning maybe a nickel an hour is developing “personal responsibility” for health care by paying a four dollar co-pay for a medical visit? Yet this personal responsibility meme has permeated nearly our entire health care financing system resulting in adverse outcomes because of the financial disincentives to obtaining appropriate health care.
Although co-pays for prisoners are ridiculous on the face of it and should be eliminated, as you go up the scale of income and levels of cost sharing, the negative impact might lessen, but it is not eliminated except perhaps for the very wealthy. Numerous studies have confirmed that cost sharing for working families with good incomes can still result in financial insecurity and impaired access to care.
Our personal responsibility should be to obtain care for our family members or ourselves when it seems appropriate for preventive or therapeutic purposes. The burden of cost sharing conflicts with such personal responsibility – the opposite of what our policy goals should be.
A well designed, single payer improved Medicare for all gets the personal responsibility concept right so that everyone can receive appropriate health care when needed.
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