Counties have no one but selves to blame for jail health costs

The Texas Association of Counties wants to portray the cost of healthcare for inmates in county jails as an "unfunded mandate," but it's hard to see the logic. Counties own their own jails. Their sheriff and muncipal police forces are hired and managed locally, and law enforcement has always been primarily a local responsibility.

That would seem to make jail health costs a local problem. Certainly litigation over the years has required counties to actually provide healthcare -- after all, if the state chooses to deprive someone of their liberty, that person's health justly becomes the government's responsibility. But there's no new mandate: indeed, there's never been a time when counties weren't liable for those costs, even if they prefer to avoid them.

The San Antonio Express News reported recently on the Medina County jail's health budget ("Counties feel ill over inmate health budgets," Oct.16), and a strident debate among county commissioners over prisoner health costs:

Presented Monday with a dental bill for $1,570 — which included $600 for "deep sedation" to extract the inmate's teeth — County Commissioner Beverly Keller said, "They don't need deep sedation. Pull them out when they're awake."

Commissioner Chris Mitchell said, "It pays to be arrested."

Commenting later, Mitchell said it's not right that the county provides better health benefits to suspected wrongdoers than it can afford to give its own employees.

One wonders who, exactly, besides the commissioners court, chooses their employees health plan? I mean, if county workers' healthcare is inadequate, who is to blame but county government?

In any event, those comments indicate a deep level of frustration, but little understanding of why these costs are being borne. No one is forcing the county to incarcerate so many people -- like most counties in the state, the majority of inmates in the Medina County Jail are there awaiting trial (see the 9-1-05 county jail population report, pdf), not serving a sentence. Where appropriate, many of those could be released on bond, and then the county wouldn't pay for their healthcare. But if counties choose to incarcerate people unnecessarily, then commissioners shouldn't complain about the costs. Maybe the commissioners court needs to have a talk with the local judges about reducing bail or releasing more defendants on personal bond.

In bigger counties, the costs escalate rapidly with the size of the jail. Reported the Express News:

Treating detainees in Bexar County cost the University Health System $9 million in fiscal year 2004-05, spokeswoman Leni Kirkman said Thursday.

The system has clinics at the 4,000-inmate county jail and at two juvenile detention centers in Bexar County, and it maintains a secure ward for inmates at its hospital.

"We do about 90,000 patient visits a year by detainees," she said.

Like Medina County, Bexar County is paying for healthcare for many more inmates than absolutely necessary. Out of a jail population of about 4,200, a whopping 2,355 were awaiting trial as of September 1st, unable to make bond (9-1-05 jail population report, pdf). That includes 572 misdemeanants, and 369 accused of low-level state jail felonies (mostly commonly possession of less than a gram of controlled substance).

As Grits noted elsewhere, a decade ago pretrial defendants made up 30.3% of the statewide Texas jail population. Today the number is nearly half, at 48.3%. Those percentages are even higher in Bexar and Medina counties -- that's a huge source of both higher medical costs and jail overcrowding pressures.

Meanwhile, in Dallas, officials are debating whether Parkland Hospital or a private prison health company should run the county jail's medical facility ("Can Parkland go it alone on jail care?, Oct. 17). The county historically spent $14 million annually on jail healthcare, but that figure jumped to $23 million in the latest budget after a series of mishaps exposed serious flaws. (The Tarrant County Jail has experienced similar problems.) Now Dallas County is considering hiring a private firm to provide jail health services, but the Morning News quoted experts who feared such care would be inadequate:

Dr. Robert Cohen, who directed care for New York City inmates through a private hospital in the 1980s, said medical staff must be able to make decisions based on patient needs, without pressure from a company concerned about shareholder profit.

"I don't think these companies represent good models," Dr. Cohen said. "They have a bad track record. Those kinds of problems wouldn't happen if Parkland were running jail care. I think Ron Anderson at Parkland knows how to provide quality medical care to an underserved population."

The UT Medical Branch currently provides healthcare at the Dallas jail, and also for Texas prisons. But they've backed out of the arrangement as of February of next year after suffering heavy losses, and Parkland has hesitated at hanging that albatross around its own neck too quickly.

Costs are even higher for the state prison system, reported the Express News:

Inmates in state prisons received more than $400 million in treatment last year, said Mike Viesca of the Texas Department of Criminal Justice.

Since 2002, the average daily cost of care per prison inmate has fluctuated between $7.92 and $7.42 last year, he said, while the inmate population rose steadily in recent years, to 151,056 now.

All this should serve as a reminder to public officials: If you're not very smart about it, and in Texas we haven't been, being tough on crime pretty quickly becomes pretty darn tough on taxpayers' pocketbooks. That's partly why state Rep. Ray Allen (R-Grand Prairie) has argued that Texas should only incarcerate those we're "afraid of," not those whom the public is merely "mad at." Texas just can't afford to continue its policy of indiscriminate incarceration, especially for low-level offenders, and inmate health costs are a big reason why.

Inmate healthcare is a huge cost driver for the criminal justice system. But if county and state politicos plan to continue Texas' high levels of incarceration, they must be prepared to pay the piper.