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.