Letter re: Access to Surgery and Health Care for Justice-Involved Individuals

We read with interest the article by Fletcher et al addressing access to health care for those incarcerated.¹ The medical care that occurs behind carceral walls is often obscured from public view and those in prison have been shown to have a 2-year decline in life expectancy for each year served.² We commend the authors for illuminating barriers to care delivery, which may help address the excess morbidity and mortality this population experiences.

When discussing individual financial barriers to patient care in carceral facilities, the authors assert that “the cost of care while incarcerated is not a concern for justice-involved individuals, given that it is covered by the state.” While it is the case that most health care costs for detained individuals are covered by the carceral budgets of jails and prisons, those imprisoned are still frequently held responsible for some measure of personal payment for treatment.

When last examined, 40 states and the federal prison system charged their detainees medical copayments. Copayments are common cost-sharing mechanisms where individuals pay a fixed amount for specific services, which theoretically helps manage health care costs and encourage responsible use of services by the consumer. In practice, however, copayments in carceral settings can lead those with fewer financial resources to delay or forgo necessary medical or surgical care.

Prison labor is compensated at an extremely low wage, often less than a US dollar per hour, which means copayments may be cost prohibitive for individuals. Copayments can also force incarcerated individuals to make difficult choices between health care and other important expenses including telephone calls with family members or necessary commissary items. Some incarcerated individuals may seek financial support from their family, extending the burden of copayments beyond prison walls and further straining disproportionately poor communities.

A recent cross-sectional analysis of a nationally representative sample of adults in state prisons revealed that 90% of individuals are held in facilities requiring copayments for at least some visits, including 63% in facilities with copayments that exceed an entire week’s prison salary.³ These high copayments were associated with individuals not receiving needed health care visits while in prison—a potentially harmful outcome for a relatively small amount of revenue generated for the carceral system.

The American Medical Association advocates for the prohibition of copayments to access health care services within correctional facilities, so that such cost-sharing mechanisms do not erect financial barriers to access for those incarcerated with limited means.⁴ In addition to the excellent recommendations made by the authors, removal of carceral copayments should be on the list of practical reforms to improve medical and surgical care for justice-involved individuals. With most people eventually released from prison, any changes we make to improve access to health care while incarcerated will ultimately benefit our communities.