United for No Injustice, Oppression or Neglect

Copayment requirement is Fiscally and Ethically Unsound

By John Stanly, M.D.

Legislation passed in 1993 (Assembly Bill 113, Andal) authorized the California Department of Corrections to charge inmates a five dollar fee for each self-initiated visit to a medical care provider in prison. Other components of the bill allowed for the Court to collect costs of incarceration. At face value, this doesn’t seem like a significant concern; in this age of HMO’s we all have co-payments to make. As well, with swelling prisons and soaring costs, defraying expenses to the inmate seemed appropriate. 

In general terms, however, prisoners do not have significant assets. There are few "deep pockets" amongst criminals. The drug kingpins and crime bosses are the rare exception and are highly publicized. Prisoners also tend not to have wealthy families, if they did then they’d have had good attorneys to keep them out of prison and rehabilitation centers to keep them off drugs. Many have no family that care and receive no money from the outside. Legislation that tries to recuperate prosecution and incarceration costs from the economically challenged felon population is simply window dressing for a political future. In practice, the co-payment system costs more than it collects and challenges an inmate’s right to access medical care.

State auditors released a report in January of this year that estimated the inmate co-payment system was losing $2.5 million dollars per year and should be abandoned. About $650,000 in average collections per year do not come close to offsetting administrative costs at the 33 facilities across the state. The audit was further critical of the Department of Corrections inability to document a reduction in operating costs – numbers of visits per inmate per year are not available. 

Besides the fiscal irresponsibility of the co-pay system, there are medical ethics questions, as well. Five dollars is a lot of money to an inmate. Salaries for prison work are approximately 18 cents an hour or about three and a half days of work, more if restitution is deducted from their paychecks. This is not a trivial expense compared to a typical co-payment in the public sector. Would you go to the doctor if you had to pay $150 out of pocket as a co-payment? This is what five dollars translates to at a minimum wage salary. While medical care is not denied if the inmate doesn’t have funds, I believe any disincentive that limits the pursuit of health care is inappropriate. 

We have chosen to punish our criminals by taking away freedom. Our humanitarian society would not condone torture or ill treatment through medical neglect as part of punishment, but this is the case. The prison health care system is overburdened and inmates have limited access to help. Policy changes have been primarily influenced by Federal Court decisions that react to suits from mistreated prisoners. There are no patient advocates, no quality controls and no other choice. Working prisoners are not given sick days; unexcused absences add time to their sentences. Health care delivery statistics are either not kept or hidden. Media access is restricted by order of the Governor. Keep in mind that the public is free to choose providers or even treat themselves. Prisoners cannot go to the drug store for an aspirin or antacids. Without meticulous custodial care, our prisons risk committing neglect by simply limiting freedom. To knowingly permit continuing medical neglect with the pain, suffering and permanent physical damage that follows is punishment: nothing less than torture in my mind.

Doctors and nurses have a social duty to remedy the situation. The state government wants to cover up the problem and deny it exists. Doctors have been fired for whistle-blowing - trying to improve inmate health conditions. Nurses are hired as correctional officers to fulfill a dual role in violation of ethics defined in the Code of Nursing. There isn’t enough money to adequately care for the inmate population. Scores of positions are advertised for psychiatrists, doctors, dentists and nurses. The prison health care leaders admit there is a crisis and are doing their best just to handle the most urgent life and death issues. But this is not the way. Prevention is the key. Early intervention while problems are small and easily treatable is crucial to holding down costs. Inmates should not be dissuaded from seeking care rather they should be encouraged. 

We need to spend more money on prison health care in a proactive manner. But there are also easy solutions that can save money. Inmates should be able to access over the counter medicines without a health care visit. Something that we take for granted. Imagine being told to wait a week for a simple cold remedy. A swallow of cough syrup, antacid or a sore throat lozenge may be all that is needed to make the difference between a good night’s sleep and hours of agony. Most public dental plans provide free checkups and cleaning twice a year because this is cost effective. Inmates joke that a typical dental exam in prison amounts to just counting teeth to keep track of how many will be pulled. There are not enough dental hygienists to provide basic care, which is fine from the state budget perspective, since extracting rotten teeth is inexpensive. Of course, that doesn’t happen until an emergency visit for a dental abscess requires something be done. Pain and agony is inconsequential, part of the punishment. 

Elimination of the inmate co-payment is a step toward reversing this philosophy of care. There will be some who abuse the system, as is true anywhere. But these cases are truly uncommon and can be handled professionally, not punitively. I believe prison doctors would rather not have to charge; the co-payment was forced upon them also. There is much to be done to improve the system, cutting this foolish program is one that makes ethical and fiscal sense. Opening the system for a review would help. Prison facilities have not all been licensed and only one is accredited by the Joint Commission of Hospitals. As a society we must re-examine our need for a cruel prison system and either re-evaluate who should be in prison or spend more to properly care for our prisoners. The $2.5 million dollars saved would be better spent providing desperately needed medical care. 


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