Eliminating Financial Assessments for Health Care Services During Incarceration

Position Statement

The National Commission on Correctional Health Care is opposed to charging or causing assessment of fees, copays, or any other monetary assessments or creating or causing other disincentives that may restrict people’s access to health care. NCCHC further encourages correctional health leadership to advocate against local mandates, internal policies, and informal culture that restrict access to care.

Discussion

NCCHC supports unobstructed access to health care for people who are incarcerated. Access to health care among incarcerated people is a constitutional right1. Access to health care facilitates health and supports reentry and community integration after incarceration2. It is well-documented that fee-for-service and co-payment programs restrict people’s access to care3-8. Fees for care compel individuals to make care-seeking decisions regarding their symptoms that they are not qualified to make (for example, does my chest pain, fever, or cough warrant me paying a fee?).

NCCHC recognizes that lack of access to health care remains among the most significant characteristics of jail, prison, and juvenile correctional systems in the United States. People who have been incarcerated have higher morbidity and mortality9,10 from treatable serious medical and mental health conditions in large part because of social determinants of health, including lifelong inequities in access to health care and services. Black, indigenous, and other people of color (BIPOC) are overrepresented in carceral settings, and people with incarceration histories primarily come from and return to the communities with the greatest health and socioeconomic disparities. Consequently, health care fees have disparate impact on the BIPOC community and foster health and socioeconomic inequities for individuals and their families11-20.

Contrary to NCCHC’s position, and contrary to sound medical practice as stated by the American Medical Association, some jurisdictions mandate financial assessments such as fees for service or co-payments19. Evidence suggests that such mandates discourage both essential and less critical health care, with adverse effects on people’s health20-23. A randomized study showed that removal of court fees reduced recidivism24. Similar effects are likely with correctional health care fees. Where such practices still exist in correctional facilities, aggregate data regarding health care utilization should be shared publicly to demonstrate that such practices do not impact utilization. Such data should include, at minimum, utilization by service type (primary care, specialty services, mental health services including substance use treatment, hospital transfers, and telehealth visits) and by age, race, ethnicity, and zip code. The purpose of the utilization review is to document any disproportionate impact and prevent harms that may be caused to people with the greatest socioeconomic disparities and overrepresentation in the correctional population.

Guidelines

NCCHC’s mission is to improve the quality of health care in jails, prisons, and juvenile confinement facilities. Given the potential adverse impact on care, NCCHC is opposed to charging fees for health care. However, we recognize that such practices exist and offer guidance to mitigate barriers that fees impose. To ensure health services are available to all regardless of ability to pay and to promote health equity, the following guidelines are strongly recommended:

  1. Health care professionals have no role associated with any fee from patients.
  2. No charges should be assessed for the following:
    • Receiving screening (medical, dental, and mental health) or any required follow-up to the screening
    • The health assessments required by facility policy
    • Chronic care or other staff-initiated care, including follow-up and referral visits
    • Acute care, including any costs related to emergency care and trauma care
    • Infirmary care or hospitalization
    • Pregnancy and postpartum care
    • Laboratory and diagnostic services
    • Prescription medications to maintain health
    • Diagnosis and treatment of contagious disease
    • Mental health care, including substance use disorder treatment
    • Preventive health care
  3. No one should be denied care because of a record of nonpayment or current inability to pay.
  4. Before initiating a financial assessment protocol and at least annually thereafter, administrators should:
    • Conduct a cost–benefit analysis to determine the financial need for the financial assessment and the expenses resulting from its administration. Such an analysis should consider not only operational costs, including the administrative burden of collecting and tracking fees, but also costs incurred by the community, such as health care costs associated with gaps in care and the long-term consequences of failure to provide preventive measures and timely health care to avoid more significant, life-threatening, and costly outcomes.
    • Weigh factors related to adverse outcomes on the individual, the institution, and the community when access to care is limited.
    • Examine its management of systems for sick call and triage, use of emergency services, and other aspects of the health care system for efficiency and efficacy to establish baseline usage and be prepared to document the impact of the financial assessment protocols.
  5. Before and after the implementation of financial assessments, administrators should track facility-specific utilization by diagnosis, the incidence of disease, and all other health problems.
    • Population health indicators should be maintained and regularly reviewed as part of ongoing quality assurance, including disease prevalence, adverse events, time from admission to diagnosis, onset of serious medical issues, and frequency of encounters appropriate to the patient’s presenting issues.
    • Any indication that infection levels or other adverse outcome indicators, as well as incidents of delayed diagnosis and treatment of serious medical problems, are either on par with or lower than the levels before implementation should be treated as indicators that the program is hindering access to needed care.
  6. Details of the financial assessment protocols should be communicated to all people upon admission, as well as to staff, and all written and oral communications should clearly state that access to care will not be denied regardless of ability to pay.
    • Only certain nonessential services initiated by the patient should be considered for a financial assessment (fee, other charges, or administrative action).
    • All facility staff should have working knowledge of the situations that will or will not be subject to a financial assessment as well as administrative procedures necessary to request a visit with a health care professional.
    • Facilities should frequently conduct anonymous surveys of people who are incarcerated to assess access to and quality of health care services.
  7. All financial assessments should be made after health care services are rendered.
  8. Financial assessments should be small and not compounded when a patient is seen by more than one health care professional for the same circumstance.
  9. No one should be denied care because of a record of nonpayment or current inability to pay.
  10. Financial assessments should not encroach on access to necessary hygiene items (e.g., shampoo, shaving accessories, menstrual supplies) and over-the-counter medications and should allow for a minimum balance in a commissary account or other means for such essentials of daily living.
  11. The facility should have a grievance system that accurately tracks complaints about financial assessments.

August 2022 – Reaffirmed with revision by the National Commission on Correctional Health Care Governance Board

References

  1. Estelle v. Gamble, 429 U.S. 97 (1976).
  2. Jordan, A. O., Lincoln, T., & Miles, J. R. (2022). Correctional health is public health is community health: Collaboration is essential. In R. B. Greifinger (Ed.), Public health behind bars (2nd ed, chapter 33). Springer Nature.
  3. American Public Health Association. (2021). The impacts of individual and household debt on health and well-being (Policy No. 20216). https://www.apha.org/Policies-and-Advocacy/Public-Health-Policy-Statements/Policy-Database/2022/01/07/The-Impacts-of-Individual-and-Household-Debt-on-Health-and-Well-Being
  4. Cherkin, D. C., Grothaus, L., & Wagner, E. H. (1990). The effect of office visit copayments on preventive care services in an HMO. Inquiry, 27, 24-38
  5. Freeman, J. D., Kadiyala, S., Bell, J. F., & Martin, D. P. (2008). The causal effect of health insurance on utilization and outcomes in adults: A systematic review of US studies. Medical care, 46, 1023-1032. https://doi.org/10.1097/MLR.0b013e318185c913
  6. Kiil, A., & Houlberg, K. (2014). How does copayment for health care services affect demand, health and redistribution? A systematic review of the empirical evidence from 1990 to 2011. European Journal of Health Economics, 15, 813-828. https://doi.org/10.1007/s10198-013-0526-8
  7. Selby, J. V. (1997). Cost sharing in the emergency department—is it safe? Is it needed? New England Journal of Medicine, 336, 1750-1751. https://doi.org/10.1056/NEJM199706123362411
  8. Fees for Health Care Services for Prisoners, 18 U.S. Code § 4048 (2018). https://www.govinfo.gov/content/pkg/USCODE-2020-title18/html/USCODE-2020-title18-partIII-chap303-sec4048.htm
  9. Fernandez, L., Ennis, S., Porter, S. R., & Carson, E. (2022). Mortality in a multi-state cohort of former state prisoners, 2010-2015 (Working paper no. CES-22-06). U.S. Census Bureau. https://www.census.gov/library/working-papers/2022/adrm/CES-WP-22-06.html
  10. Zlodre, J., & Fazel, S. (2012). All-cause and external mortality in released prisoners: systematic review and meta-analysis. American Journal of Public Health, 102(12), e67-e75. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.300764
  11. Anno, B. J. (2001). Correctional health care: Guidelines for the management of an adequate delivery system. U.S. Department of Justice, National Institute of Corrections. https://www.ncchc.org/wp-content/uploads/CHC-Guidelines-2.pdf
  12. Floyd, A. (2019, March 8). Interdisciplinary call to action addresses correctional healthcare and the community. University of Central Florida. https://ccie.ucf.edu/2019/03/08/interdisciplinary-call-to-action-addresses-correctional-healthcare-and-the-community
  13. Flynn, A., Warren, D., Wong, F., & Holmberg, S. (2016, June 6). Rewrite the racial rules: Building an inclusive American economy. Roosevelt Institute. https://rooseveltinstitute.org/publications/rewrite-the-racial-rules-building-an-inclusive-american-economy
  14. Brennan Center. (2019, September 9). Is charging inmates to stay in prison smart policy? https://www.brennancenter.org/our-work/research-reports/charging-inmates-stay-prison-smart-policy
  15. Kuhlik, L., & Sufrin, C. (2020). Pregnancy, systematic disregard and degradation, and carceral institutions. Harvard Law and Policy Review, 14, 417-466. https://harvardlpr.com/wp-content/uploads/sites/20/2020/11/Kuhlik-Sufrin.pdf
  16. Lewis, N., & Lockwood, B. (2019, December 17). The hidden cost of incarceration. The Marshall Project. https://www.themarshallproject.org/2019/12/17/the-hidden-cost-of-incarceration
  17. Muhammad, K. G. (2010). The condemnation of blackness: Race, crime; and the making of modern urban America. Harvard University Press.
  18. Ollove, M. (2015, July 22). No escaping medical copayments, even in prison. Pew Charitable Trusts. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/07/22/no-escaping-medical-copayments-even-in-prison
  19. Pew Charitable Trusts. (2010, September 28). Collateral costs: Incarceration’s effect on economic mobility. https://www.pewtrusts.org/-/media/legacy/uploadedfiles/pcs_assets/2010/collateralcosts1pdf.pdf
  20. Maruschak, L. M., & Berzofsky, M. (2016). Medical problems of state and federal prisoners and jail inmates, 2011-12 (NCJ 248491). U.S. Department of Justice. https://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf
  21. American Medical Association. (2021). Health care while incarcerated H-430.986 (policy). H-430.986 Health Care While Incarcerated
  22. Fisher, A. A., & Hatton, D. C. (2010). A study of women prisoners’ use of co-payments for health care: Issues of access. Women’s Health Issues, 20, 185-192. https://doi.org/ 1016/j.whi.2010.01.005
  23. Glick, A. L., Ehret, M., Banfi, V., & Shelton, D. (2017). Effectiveness of co-payment policies in the correctional healthcare setting: A review of literature. Journal for Evidence-based Practice in Correctional Health, 1, 2. https://opencommons.uconn.edu/jepch/vol1/iss2/2
  24. Wyant, B. R., & Harner, H. M. (2018). Financial barriers and utilization of medical services in prison: An examination of co-payments, personal assets, and individual characteristics. Journal for Evidence-based Practice in Correctional Health, 2, 4. https://opencommons.uconn.edu/jepch/vol2/iss1/4
  25. Wyant, B. R., Harner, H. & Lockwood, B. (2021). Gender differences and the effect of copayments on the utilization of health care in prison. Journal of Correctional Health Care, 27, 30-35. https://doi.org/10.1089/jchc.19.06.0052
  26. Pager, D., Goldstein, R., Ho, H., & Western, B. (2022). Criminalizing poverty: The consequences of court fees in a randomized experiment. American Sociological Review, 87, 529-553. https://doi.org/10.1177/00031224221075783