Sunday, June 01, 2014

By rejecting Obamacare, Texas forgoes up to $240 million in federal funds per biennium for prison health care

A few, notable items cropped up related to prison health care at a joint meeting of the Texas House Corrections Committee and a House Appropriations subcommittee on Thursday. (You can watch the video here.)

If Texas were to expand the Medicaid program under the Affordable Care Act, prison and hospital officials told a House Appropriations panel on Thursday, the state could draw down between $55 and $120 million per year in federal funds to pay for inmate hospital care, depending on whether UTMB's Galveston hospital is classified as a hospital or a prison. That comes to between $110 to $240 million per biennium compared to roughly a billion-dollar TDCJ healthcare budget. (Of course, $240 million is a drop in the bucket compared to the billions Texas forgoes by failing to expand Medicaid under the ACA.)

Without those federal funds, TDCJ expects a shortfall in its line item for inmate healthcare this year (FY 2014) of about $21.3 million, the Legislative Budget Board's John Newton told the panel. Some of it they'll be able to pay for by shifting around money from other accounts, but the agency also plans to ask LBB for authority to spend money from their FY 2015 budget, which would in turn necessitate a supplemental funding bill early in next year's session. Contributing to the shortfall: Quite a few private hospitals have been demanding payment rates higher than Medicare-allowable payments in order to treat TDCJ inmates. Eleven have been approved so far and other hospitals want the same deal. 

Texas' inmate population is cared for by two medical schools - the University of Texas Medical Branch at Galveston (UTMB) and the Texas Tech Health Science Center - with UTMB's network caring for about 119,000 inmates and Tech handling about 31,000. The state authorized a 4% salary increase for prison health workers in 2014, but they received no pay hike in 2012 or 2013, nor will they get one in 2015, said UTMB vice president for offender services Dr. Owen Murray. As a result, the prison system has trouble keeping salaries competitive and struggles to maintain staffing levels.

The rising elderly population in TDCJ is the main cost driver for hospital care. A little under 10 percent of the inmate population is more than 55 years old. Those inmates are 7-8 times as expensive as other age demographics. In particular, more older inmates means more spent on chronic cardiovascular diseases as well as costs for dialysis and end-stage renal disease patients, whose numbers Murray said are increasing at a "startling" rate.

Some 15,000 TDCJ inmates have been diagnosed with Hepatitis C, but only about 100 are presently undergoing treatment. There is a new Hepatitis C drug available a called Sovaldi that's currently considered the standard of care. But it costs an astonishing $63,000 for a 12-week treatment - nearly $1,000 per pill - making it impractical for widespread use. For long-term inmates with Hep C, the state increasingly must pay for costs associated with end-stage liver disease, which is a major cost driver for hospital use. There were 488 inmates being treated for end-stage liver disease in 2013, a number which has risen to 830 in 2014, or a 70 percent one-year increase.

A related, remarkable statistic: TDCJ operates 483 infirmary beds, with 70 percent or more of those filled with patients who will never leave those beds until they die, said Dr. Murray. One wonders if there is any tangible benefit to public safety from incarcerating such individuals?

Vacancy rates for prison health workers are around 9.5 percent overall, but for nurses it's 13 percent; for registered nurses (RNs), the vacancy rate is 17 percent. Texas recently switched from an RN-driven model to an LVN-driven model (licensed vocational nurses) because of budget-driven layoffs. As a result, at this point Texas often staffs only one RN for every three facilities, making a 17 percent vacancy rate is a big problem. Perhaps even more pressing, "patient care technicians" have a 29.8 percent vacancy rate, and there's a 35 percent vacancy rate for dialysis patient care techs.

Texas Tech is having a particular problem finding psychiatrists willing to work at West Texas prisons; the committee was told they'd need to increase prison psychiatrists' pay 20-23 percent to be competitive with the market and fill their current vacancies. Nurses, system-wide, would need a 10-15 percent raise - more in certain rural areas where the applicant pool is small to non-existent - to be competitive with market rates and attract staff willing to work in a prison environment.

One interesting aside: Inmates take about 55-60 percent of the pills prescribed to them - a better compliance rate than in the free world (~50 percent), but still low. The state saves about $8 million per year by recycling unused medication, but Corrections Committee Chairman Tan Parker pointed out that failure to take prescribed medication could generate much higher back-end costs if and when the conditions being treated worsen.

Moreover, said Dr. Murray, there's a problem with inmates failing to comply with medication regimes after they leave TDCJ's care. He gave the example of recidivists with HIV whose condition was under control when they left TDCJ but who reenter prison a few years later with out-of-control symptoms or even a virus that's resistant to the drugs they'd been taking before.

Corrections Committee Chairman Tan Parker wondered why inmates weren't forced to take medication since the state must pay for more expensive health services in the long term if their conditions worsen. Forcing them to take medication would amount to a "cost containment" strategy, he said. He was told that prisoners have the same rights to refuse health care as free world patients and, with the exception of mental health patients, can refuse medication if they choose.

Toward the end of the hearing, advocates from the Texas Civil Rights Project, the Texas Criminal Justice Coalition (see their written testimony), and the Texas Inmate Family Association addressed the meeting. Watch their presentations on the video beginning at the 2:11:50 mark.

MORE (June 2): From Terri Langford at the Texas Tribune.


Anonymous said...

Obamacare=Crack for state legislatures.

sunray's wench said...

It's fascinating, and the answers are staring them in the face for some instances/inmates, yet the Lege still wont do anything about it all.

Paroling the over 55s, or at least giving them more favourable odds (points system?) for parole would help TDCJ, but in the long term TDCJ and the Lege would need to make more effort to keep the support network in place outside of prison for those inmates while they serve their time.

Building a dedicated hospice unit may be an idea for the terminally ill inmates currently taking up those 400+ medical beds. That might make the TDCJ Officer's union happy (more jobs?) and could equally help other inmates in training in end of life care (other states manage this, such as Oregon).

But if more effort was put into rehab (social, substance and employment), and inmates' progress tracked more thoroughly and encouraged from the day they enter TDCJ, then better/smarter parole decisions could be made across the whole inmate population.

They need to get the media on side, because they are the ones in general whipping up the hysteria about paroling unsuitable inmates.

Anonymous said...

Part of being a republican is the firm requirement of being pound smart and penny foolish. That, and not being able to see the forest because of the trees...

Anonymous said...

Reduce the number of crimes: drugs, prostitution, possession of child pornography and thereby reduce the number of prisoners.

rodsmith said...


"Some 15,000 TDCJ inmates have been diagnosed with Hepatitis C, but only about 100 are presently undergoing treatment."

Could be a hell of a payday for a nice class action lawsuit by a good lawyer.

or course the article does not state how much of that 15k got it INSIDE the prison.

Skifool said...

On the refusal of the State to take the Medicaid $$$, one word fits: "Shameful."

Anonymous said...

States should reject the urge to jump on federal dollars as the go-2-solution. States should take care of their own problems. Just look a t what a great job fed. dollars have done for quality of education across the nation. NO THANKS

school marm said...

"Just look a t what a great job fed. dollars have done for quality of education across the nation"

7:38, you seem ignorant about how schools are funded. Ask your local school board rep what percent of district funds comes from the feds - 90% is state and local.

Anonymous said...

school marm - and you my friend seem ignorant of the grant requirements that are attached to federal grant funds that regulate the operations of the education system. Doesn't matter the percentage, as soon as there is acceptance of federal education money you must abide by the federal guidelines, administrative law, etc. etc. not just with federal dollars but with the local and state money as well.

Anonymous said...

Federal Funds, it is still my money. So who is going to raise my taxes, Texas or the Feds?

Gritsforbreakfast said...

Hmmmm ... @8:57, perhaps you're unaware that prison health care already must comply with minimum constitutional standards set by federal courts. In California, failure to comply with court-created standards recently resulted in a federal court order to reduce their prison population by about 25%. Texas' system for years was under a special master for similar reasons (see Ruiz vs. Estelle).

The feds are in our business on prison health care either way. The issue is whether Texas would like their money as well as their mandates. $240 million out of a billion-dollar-per-biennium prison health care budget is a substantial chunk, and it wouldn't come with any strings that aren't already in place.

@9:14, as it stands your federal taxes pay for Medicaid in other states and Texas gets nothing out of the deal (at least, in Medicaid funds). Why would you prefer your taxes to pay for indigent health care in California, New York, etc., but not Texas?

The Homeless Cowboy said...

Well we have some lively opinions today.I do not believe Obamacare is Crack for the State Lege, It is however Crack for Obama and the Insurance industry. Ms. Sunray you are always good to hear from and I see no problem in paroling terminally ill inmates, but you must realize they just go on someone's budget. They cannot work and their healthcare must be addressed, at least until the Obama death camps are in full swing. At present we all know the State provides the minimum of legally required healthcare to inmates. They would as soon let them die as waste money on them, this is Texas, it's been that way for over a hundred years and aint gonna change. You may force their leaders to provide lip service to lofty morals and ideals but the reality is they could care less and we all are grown ups and we know it. i am all for rehab Social and substance, and most assuredly in regard to employment. Lets explore this; Social and substance abuse rehab are addressable issues and to a certain extent so is employment, we do however need to realize that it is the norm now for companies to hire people at 30 hours a week to negate the need to offer benefits so if we don't change employment laws no future hires will have insurance or any type of benefits as corporation lobbyists have helped them legalize their scrooge like countenance. 11:51 That was really helpful (Gee Wally!) 12:12 Really? No kidding? That's your shot? Hey rodsmith, How are you? I know I can always count on you for some biting social commentary. To skifool I would say, I think that is the reason we are not Obama drones, we have people who care about the strings that come with that Manna people keep touting, and telling them they MUST accept. We are Americans, we have brains we are not now or ever going to be Washington's Lackey's. 7:38 I agree we should be very cautious there are some things we lose by choosing to live as Texans but the freedom of choice is not one of them, we cannot accept their money if it curtails our right to govern and make decisions that are good for our State. Grits, I love this blog, thanks for allowing us to blow off our steam and opinions

sunray's wench said...

Mr Cowboy ~ I was advocating paroling more over 55s so that they could work and contribute to their own health insurance, and building a hospice for the termially ill so that resources could be better managed for their care :)

One thing also struck me as odd. If America is so hot on self-made wealth, why do parolees have to be employed by someone else? Why can't they run their own businesses, like lawn cutting, fence building, etc? As long as they pay their taxes and parole fees, why should it matter if they are self-employed or employed?

Anonymous said...

There's no jobs out here for the crime-free people,let alone convicts.

Paul-UK said...

Sovaldi at $1000 a pill! The cost on this side of the pond is under $700 a pill

Unknown said...

A lively discussion today indeed. I'll contribute my 2 cents too.

My understanding as a Grits reader is that UTMB & TX Tech have continued to treat prisoners by mandate for years in spite of the fact that the state remains millions of dollars in arrears for prior years' bills (perhaps Grits could tell us the amount or correct me if I'm wrong). HOW they continue to operate under a deficit baffles me, but I'm certain that patient care suffers in the resulting negative work environment. I know because my father is one of those sick & elderly inmates, and for him getting "treatment" is downright dangerous.

So for the Texas Lege to proudly & stubbornly refuse that $240 million feels like an arrogant spit in face to the prisoners, their families who suffer alongside them, AND the overworked & underpaid healthcare providers at TDCJ, UTMB, & TX Tech.

And please don't assume that every sick & elderly prisoner would be a drain on the state for health care upon release. My dad probably isn't the only inmate who earned full health care benefits from his 25 year military career prior to his (wrongful) conviction & incarceration. Yes, federal tax dollars would fund his care upon release, but he earned it serving his country. Furthermore it would cost far less to care for him in the somewhat functional VA system than in the completely dysfunctional TDCJ system.

Nigel Jones Solicitor said...

I have to admit, when i was growing up in the UK, we always thought of the US as a place with limited regulation, low taxes and freedom from people arbitrarily breaking down your door, whereas we were stuck with EU regulations on the straightness of bananas and the metric system, high taxes and the local Plod being able to beat the cr*p out of you if you were the wrong colour/ From the North or Ireland/ looked at them funny.

Seems while the UK has rolled back a lot of of that rubbish, the US has gone other other way. Shame.

"Red" Merriweather Coast said...

It's really a shame that Texas didn't expand Medicaid. It's literally a life-or-death situation for sick people at the income cut-off for ACA plans. Besides, Texas is going to pay for their care anyway when they wind up in the emergency room. I mean, what Rick Perry did is turn down free money because he'd rather pay more for a worse system. 'Murica!

But in the meantime, compassionate release for eligible inmates could help relieve some of the pressure on prisoner health care systems. I don't think you're supposed to keep people who haven't been sentenced to life in prison if they have a fatal illness anyway, right? Obviously, letting people out of prison isn't very popular, but maybe if we calmly explain the situation to the public ... okay, I can see how that's not going to work.

sunray's wench said...

Red ~ given the low numbers of the public who actually vote, I don't think having to explain things to them is the issue. Needing to pull the Lege politicians out of the last century, and convincing the media that sensible (not even "early", given that many inmates are not paroled when they are legally eligible for parole) parole practices is a good thing, is the real task here.

Peter Marana said...

There appeared to be a lack of life-cycle costing of disease at this hearing. Most of the testimony and discussion was only reacting to the current budget and disease rates. To keep this short, diabetes is a major driver of downstream care costs. Yet no one addressed this issue. Also the New Hep-C drug, at $63K per course, must be viewed in the context of avoiding other expensive medications and the costs of end of life liver disease care. Also factored in is that the new HEP-C standard of care saves someone's life.