Inmates Need Costly Medical Care, Too

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.

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13 responses to “Inmates Need Costly Medical Care, Too

  1. It would be interesting to know if the released inmates, following this access to care, leave prison in better health than they arrived, and if those who avail themselves of the opportunity to solve some issues have a lower recidivism rate. Long ago I wrote about the geriatric unit in Staunton, where many of the aged inmates were getting intensive or even end-of-life treatment. The DOC had a practice then of providing a “compassionate” release, meaning the state was dumping the medical costs onto the families.

    • Generally speaking, I would say they leave prison in better health. As for recidivism rates, no study had been done of the connection, if any, between recidivism and prison health care. But, you are right, that would be interesting to know.

      The state closed the prison in Staunton in the late 1990’s. I visited it once before it was closed and saw the geriatic unit. That unit is now housed at Deerfield Correctional Center in Southampton County. It is a pretty sad place to visit. With the repeal of parole, DOC no longer has “compassionate release”. It is sad, but true, that many of these inmates are better off, medically speaking, in prison. For those who are very ill or who have dementia, it is hard to find a place for them. There was at least one occasion that I was aware of in which DOC had to keep in custody an inmate beyond his legal release date (his sentence had been completed) because the agency could not find a nursing home that would take him.

  2. “I recognize that it does not have the “sex appeal” of some of the topics discussed on this blog.”

    What Dick, no cost crisis over sex change operations and trans operation reversals on inmates in prisons yet?

  3. I think this topic is interesting because it branches out to a number of other topics. For example, decriminalization of marijuana, Virginia’s incarceration rate, Oklahoma’s recent parole of non-violent offenders programs. On the medical front I’m always surprised at how many overweight prisoners there are on shows like Lockup – especially women. Is it unreasonable to control diet and demand exercise for people in prison? It seems like that would help self-esteem and lower medical bills.

    Virginia has the 16th highest incarceration rate in America. Of Atlantic Coast states only Georgia and Florida have higher incarceration rates. Maryland incarcerates 317 / 100,000, North Carolina 341 / 100,000, West Virginia 392 / 100,000, Tennessee 429 / 100,000.

    Virginia? 437 / 100,000

    The only one of our neighbors who locks up more is Kentucky at a rather astonishing 527 / 100,000.

    Why do we need to lock up so many of our citizens?

    Oklahoma locks up 702 / 100,000 but has a program of steady parole / release of non-violent offenders in response. Do we need something similar?

    https://www.sentencingproject.org/the-facts/#map?dataset-option=SIR

    • On the issue of diet and exercise, the most common chronic health conditions of inmates is diabetes and hypertension, both related to diets.

      DOC has a nutritionist in the central office who oversees the menus used in all prisons. As a result, an inmate may not like the food, but it in nutritionally healthy. The problem comes with prison commissaries, where inmates can purchase food items. The biggest seller in the commissaries is Ramen noodles. loaded with salt. Chips and soft drinks are also poplar items.

      In my conversations with DOC staff, I broached the idea of dedicating one correctional facility for inmates with hypertension and high glucose levels (pre-diabetic). At that facility, the meals would be designed for those conditions and the commissaries would have only healthy food items, e.g. fruit. In addition, as part of the program, inmates would be required to walk, run, or jog a certain distance daily. (Note: inmates cannot be required to exercise, but they can be penalized, i.e. lose “good” time, if they refuse to participate in a program.) Once the inmates got their symptoms under control, blood pressure and glucose levels down, they could be transferred to a regular prison. There are likely policy, logistical, and, perhaps, legal obstacles to such a suggestion, but I never got any response to my suggestion.

  4. Interesting, yet dated, article about obesity in prisons in Utah.

    https://archive.sltrib.com/article.php?id=3211037&itype=NGPSID

  5. Proving once again that ready and free access to medical care may have zero relationship with actually getting healthy….But take away the Coke and potato chips and double the lawsuits about unfair or cruel treatment. 🙂

  6. I was curious, does DOC buy drugs in bulk and/or negotiate price?

    • It has contracted with a prescription benefit manager. That company administers DOC’s formulary. It actually fills each prescription for each inmate and ships it to the appropriate prison. Under that arrangement, DOC does not have to have a small army of pharmacists on staff and allows the PBM to negotiate prices. Under procurement rules, the contract has to be re-bid periodically. For some specialty drugs such as those for HIV and Hep C, it is able to take advantage of VCU-MCV’s preferred status under federal statutes and get those drugs at a steep discount.

  7. Thanks Dick. it’s good to know that the State is trying to keep drug costs down. VCU/MCV can get discounted drugs also?

  8. I believe Virginia should invest in affordable, supportive housing and move as many people as reasonable out of jails and hospitals (not rely on CSB’s.) The localities can’t or won’t make these investments.

    I can speak to psychiatric detentions. Often, a judge will allow release only after a Community Service Board develops a suitable “discharge plan.” In some localities, there are zero available housing units that match the individual’s needs and budget. So instead of returning the community, the patient languishes for months on end, ultimately costing the state a/o Medicaid tens of thousands. I have witnessed this problem personally; it’s unfair and economically insane. Surely a subsidized group home with a social worker would be better and cheaper, in the long run.

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