by Dick Hall-Sizemore
In the most recently completed fiscal year, the general fund cost to provide medical care to Virginia prison inmates was $221.6 million.
That is a lot of money by any measure; it exceeds the entire budget of all but a few state agencies. However, despite its size, it does not get much public attention.
Like the state budget, medical costs threaten to consume the DOC budget. The FY 2019 expenditures constituted more than 18% of the agency’s general fund budget. Each year, the budget request for additional funding for medical services is at the top of DOC’s list. Its FY 2019 appropriation for medical services exceeded its FY 2017 appropriation by $34.8 million. For the upcoming biennium, the agency has requested an additional $21.8 million in the first year and $28.3 million in the second year.
Beginning with the current fiscal year, DOC’s reported inmate medical services expenditures will understate the costs of treating this population. Inmates are partially eligible for Medicaid and some of the state’s costs of providing medical care for inmates will be shifted to Medicaid. Otherwise, the requests for the upcoming biennium would have been greater.
The eligibility of inmates for Medicaid coverage is a fascinating story. The federal statute establishing Medicaid plainly states that incarcerated persons are not eligible for coverage. However, federal staff at the Centers for Medicare and Medicaid Services several years ago interpreted “incarcerated” as not including persons who had been admitted as inpatients to a hospital. How an inmate confined to a secure, locked ward at MCV supervised by correctional officers is not “incarcerated” has always baffled me. Nevertheless, if an inmate is taken to an MCV outpatient clinic, DOC is responsible for the total cost, but if that inmate is admitted as an inpatient, Medicaid will reimburse the state for most of the costs.
In previous years, only inmates who were elderly or disabled were eligible for Medicaid coverage. With Medicaid expansion, almost all inmates are likely to be eligible, with the federal government paying 90% of the costs. In 2017, it was estimated that Medicaid expansion would save DOC approximately $27 million annually. The state’s share of those costs would be covered with the Medicaid appropriation to the Department of Medical Assistance Services.
DOC is under constant pressure from the Governor’s budget office and the General Assembly to reduce its medical costs, or, at least, to reduce the annual increases. While there are actions that the agency can take, and has taken, on its own, there are some major factors over which it has little control:
Courts. In the 1960’s, the U.S. Supreme Court ruled that prisoners were entitled to medical care under the provisions of the Eighth Amendment. This right has been subsequently defined as care consistent with “community standards.”
The judicial enforcement of this right has had significant consequences recently. DOC entered into a settlement in 2016 following a federal lawsuit over inmate medical care at Fluvanna Correctional Center for Women. Early this year, the federal court issued an injunction against the department for violating portions of that settlement. Additional court actions are ongoing. Complying with the provisions of the settlement has cost DOC millions of dollars.
Nature of population. In general, people who enter prison do not have a history of taking care of their health. Many have a history of substance abuse, with all of the attendant health effects associated with that behavior. Many have never seen a dentist.
In addition to their generally poor health, the Virginia prison population is getting older. In 2010, there were 5,152 inmates over 50 years old, which was 16.1% of the total prison population. In 2018, the number of inmates over 50 had increased to 7,028, 23.5% of the population. As with the population at large, older inmates have more health issues and their problems tend to be more serious. DOC now operates a facility for inmates who need assisted living, intensive nursing, and dementia care.
Medical costs. Although DOC has its own doctors and nurses who provide a lot of medical care in-house, it is still subject to the general rise in medical costs. Prescription drugs are expensive, for example ($22.7 million in FY 2019). While DOC will no longer be responsible for inpatient costs (Medicaid), many inmates still need to see specialists and be treated at outpatient facilities offsite, such as MCV. At any major prison, it is not unusual for there to be several medical runs on any day.
The whole issue of inmate medical services is a complex one and this post is just a broad overview. I recognize that it does not have the “sex appeal” of some of the topics discussed on this blog. But it is a major public policy and budget issue with which the GA grapples each year. If there is interest, I can discuss some more of the underlying issues in future posts, as well as analyze some of the efforts to curb costs.
