'Some Inmates Forego Healthcare to Avoid Higher Fees'

The title of this post is a headline to a piece which ran today in the Texas Tribune revealing unintended consequences to the Legislature's decision to charge offenders who used healthcare services $100 out of their commissary account. The article opens with an anecdote of a prisoner who failed to access treatment because of the fee until his illness progressed to pneumonia, but also provides this discussion of the underlying legislation which created the situation:

As a result of HB26, which took effect last year, TDCJ prisoners who seek medical care now pay a fee of $100 once a year, whether they see a doctor once or multiple times. But if they don't see a doctor at all, they can avoid the fee altogether. Critics of the new law, though, say the fee has had unintended consequences — including situations where inmates are refusing treatment and a complicated administrative process for inmates who say they have been charged incorrectly. The fee, these critics say, hasn't even met financial expectations.

Lawmakers who supported the policy change say the goal is to take the burden off taxpayers to pay for inmate health care. “I believe it was the right thing to do at the time,” said state Rep. Jerry Madden, R-Plano, who wrote the bill. "I still think it's a reasonable thing to do."

The fee has not produced the predicted financial results. The $100 dollar copay was expected to raise $5.7 million in 2012. According to TDCJ, it generated about $2.5 million, while the $3 copay had generated roughly $500,000 each year. 

“Quite frankly, it doesn’t make much of a difference,” said Dr. Owen Murray, vice president for correctional managed care at the University of Texas Medical Branch, which along with Texas Tech University Health Sciences Center has administered health care to all TDCJ inmates since 1993. “The financial expectations for the program have not been met.”

TDCJ spokesman Jason Clark said that the medical fee is charged to the offender's commissary, or trust fund, account. “If there is not enough money in the trust fund account, the law requires that 50 percent of each deposit to the offender’s trust fund account must be applied to the amount owed until the total amount is paid,” he said. That means when inmates get commissary money from their families, half is taken out if they’ve seen a doctor and haven't paid the entire fee.

There are exceptions. Inmates with less than $5 in their commissary account are not charged. The fee does not apply to emergencies, to follow-up services on an initial treatment or to chronic care.

Remarkably, the fee hasn't even reduced the overall number of medical service calls, as legislators had hoped; it just deferred the first one. Dr. Owen "Murray said that initially the number of inmates requesting care dropped drastically, but eventually it grew back to prior rates as patients learned the system. Once they have paid the yearly fee, they 'start to put in more sick-call requests,' he said."

Let's face it: This grand microeconomics experiment has been a flop and the state prison budget cannot be balanced on the backs of inmate families. Any marginal extra income from higher copays is gobbled up by extra costs from untreated care when inmates delay visiting a doctor to avoid the $100 expense, which anyway is a pittance compared to per-inmate healthcare costs. To that extent, this post could have been titled, "On the limits of squeezing blood from a stone." This scheme was borne because the Lege wouldn't adequately fund prison healthcare costs in the state budget, shorting that line item by tens of millions. So instead of increase that line item, raise taxes, etc., the Lege short-changed prison-health care and passed this new commissary-based $100 fee hoping to reduce demand by boosting price. For the heaviest healthcare users, though, that's still a low sum, and for the others, it may defer access to healthcare that could prevent more serious illness. So demand did not go down, it only shifted somewhat from cheaper preventive care to more expensive care after patients are very sick. Because after all, TDCJ's constitutional responsibility to provide care doesn't go away just because the Legislature enacted this fee.