By Kimberly Tsoukalas, LHC Program Coordinator 

Photo Courtesy of Getty Images 

Written in 2013, Administration Regulation Number (ARN) 703 dictates the current co-pay system that allows inmates in the Alabama Department of Correction (ADoC) facilities to seek medical care. Constitutionally, inmates have a right to medical care while incarcerated as the Supreme Court referenced the Eighth Amendment’s prohibition against cruel and unusual punishment as a precedent for providing healthcare access to inmates. ARN 703 states that “all inmates have access to healthcare regardless of their ability to pay. No inmate shall be denied care because of a record of non-payment or current inability to pay for health services.” However, the prison co-pay system establishes that ADoC is not responsible for providing care free of charge when an inmate has the means to pay the designated amount for health services. 

According to the Prison Policy Initiative, a think tank dedicated to prison reform, the average inmate in an Alabama correctional facility makes between $0.25 and $0.75 per hour making license plates, building furniture, and creating chemicals for use in state agencies. At $4 per visit, it would take almost one weeks’ wage to see a medical professional. 

ARN 703 and similar legislations state that utilizing a co-pay method for healthcare prevents inmates from misusing healthcare services as well as “instilling inmate responsibility by having them make resource allocation decisions.” Forty-two states, along with the Federal Bureau of Prisons, utilize a copay system. Some states operate on a method more closely associated with a deductible, such as the state of Texas which charges $100 per calendar year for unlimited visits with a medical provider. 

Recent research completed by the John Howard Association, an independent prison monitoring association advocating for prison reform and improving conditions for incarcerated persons, found that prison co-pays were the top source of stress for inmates, and over half of all inmates stating that they avoid healthcare due to the cost of the co-pay. According to Fisher and Hatton (2012), “co-payments contributed to delays in treatment, avoidance of health care professionals, unnecessary suffering, and poor health outcomes. …  [and] place an unfair burden on prisoners who are poor, limit access to health care, and contribute to needless suffering and potentially to preventable deaths.” 

While legislation dictates that co-pays should be waived in cases of chronic illness or mandated care, a qualitative research study found that oftentimes those exceptions aren’t equally granted or sometimes ignored entirely. Even in specific scenarios where a medical condition is covered without a copay, such as MRSA, the Center for Disease Control and Prevention identified the perceived costs as one of the leading factors in infectious disease outbreaks within prison systems. According to the Marshall Project, “with prisoners living in close quarters, any policy that deters people from going to the doctor also increases the risk of contagion.” 

Healthcare for inmates takes up approximately 20% of prison spending, a key point when arguing for co-pays in the Alabama prison system. However, research conducted in other states such as Illinois shows that the funds collected from the co-pay system in inmates don’t even cover the administrative costs associated with operating it. Additionally, since the state is required to cover the costs associated with chronic conditions, some health researchers state that it may be cost-defective to charge co-pays as minor, treatable conditions can blossom into extensive hospital stays when medical treatment is delayed. 

According to the National Commission on Correctional Healthcare, the leading arguments for a co-pay system are: 

• The cost of medical care is an increasingly heavy burden on the financial resources of the facility, state, or county. The cost needs to be controlled legally without affecting needed care.
• Sick call can be and is abused by some inmates. This abuse of sick call places a strain on available resources, making it more difficult to provide adequate care for inmates who really need the attention.
• Inmates who can spend money on a candy bar or a bottle of shampoo should be able to pay for medical care with the same funds—it is a matter of priorities.
• It will do away with frivolous requests for medical attention.
• It cuts down on security problems in transporting inmates to and from sick call by reducing utilization.
• It instills a sense of fiscal responsibility and forces the inmate to make mature choices on how to spend money.

Arguments against charging inmates a fee for health care services include the following:

• Access is impeded. A fee-for-service program ignores the significance of full and unimpeded access to sick call and the importance of preventive care.
• Inmates are almost always in an “indigent” mode. They seldom have outside resources and most have no source of income while incarcerated. They most often rely on a spouse, mother, or other family member to provide funds they can use for toiletries, over-the-counter medications like analgesics and antacids, telephone calls, writing paper and pens, sanitary napkins, candy, etc. These “extras” become extremely important to one who is locked up 24 hours per day. The inmate may well choose to forgo treatment of a medical problem in order to be able to buy the shampoo or toothpaste.
• The program sets up two tiers of inmates: those who have funds to get medical care and commissary privileges, and those who have to choose between the two.
• Avoiding medical care for “minor” situations can lead to serious consequences for the inmate or inmate population, since the minor situation can deteriorate to serious status or lead to the infection of others.
• Crowded conditions increase the risk of spreading infections, and effective measures need to be taken to reduce this risk. Daily sick call should be encouraged rather than discouraged. Co-pay has been identified as a contributing factor for outbreaks of methicillin-resistant Staph aureus (Centers for Disease Control and Prevention, 2003).
• A properly administered sick-call program keeps costs down through a good triage system, which has a lower level of qualified staff see the complaining inmate first, with referral to higher levels of staff only as medically indicated.
• Charging health service fees as a management tool does not recoup costs; rather, when looking at the increased administrative work involved or the long-term effect of the program, charging health service fees can cost more to implement than what is recovered.
• Inmates frequently have low health literacy and may not understand the difference between medically significant and medically insignificant symptoms nor when it is important to seek medical services. Thus, it may be ineffective to expect inmates to determine when to pay for medical services.

Several organizations, including the NCCHC, advocate for the removal of a co-pay system. During the pandemic, many states eliminated co-pays for inmates to reduce the impact of the virus on the prison system. Additionally, states like California have voted to eliminate co-pays entirely. Alabama recently passed two pieces of legislation related to prison reform – a bill allocating nearly $800 billion to construct two new prison facilities in the state and an amendment to a previous bill that mandates supervised probation for non-violent offenders. Should the prison co-pay system be examined or overturned as well? 

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