In the U.S., correctional facilities are required by law to provide inmates with access to medical care. As health care costs have spiraled out of control everywhere, jails and prisons have attempted to develop innovative ways of reducing this hefty financial burden while simultaneously meeting their legal obligation to provide care.

One approach that has gained significant popularity in recent years is to require inmates to pay a small fee, usually less than $10, to gain access to medical care in certain situations. There are arguments both for and against these co-pays. I’ll list just the main points.

Proponents argue that co-pays reduce the abuse of urgent appointments as well as the over-use of routine medical visits for frivolous complaints. They believe that requiring inmates to invest financially in their own care encourages personal responsibility–outside of prison, required co-pays are the norm for most people. Since inmates spend money on toiletries, candy, and chips, co-pay supporters therefore believe that inmates should be able to contribute something toward their medical care.

Those opposed to co-pays point out that most inmates are already indigent, and taking money away from them that they would have used to buy toiletries, postage stamps, and other similar items would be unreasonable. They express concern that requiring payment reduces access to care (and access to care still is very poor in some correctional systems). Inmates may put off seemingly minor health problems that could worsen and ultimately result in an increase in morbidity, mortality, and cost. From an institutional public health standpoint, inmates with infectious diseases may be more likely to go untreated, resulting in the unnecessary spread of illness to staff and to other prisoners.

I have personally observed inmate behavior in systems both with and without co-pays, and I have seen both sides of the issue in action.

In my opinion, some inmates with no personal investment in their own care may tend to behave in an entitled manner, may be less likely to follow treatment recommendations, and may have unrealistic expectations of the medical team. On the other hand, I have seen inmates who are required to pay something for their care put off much needed medical attention simply because they could not afford it.

How have the courts reacted to inmates who have challenged co-pays as being unconstitutional?

According to attorney, Robert P. Vogt:

The general rule appears to be that it is not unconstitutional to charge inmates a co-pay fee for the provision of medical services provided that needed medical services are not denied simply because the inmate cannot pay. This general rule attempts to strike a balance between correctional facility obligations and inmate responsibilities.

Courts have recognized that the constitution ‘guarantees only that inmates receive necessary medical care; it does not guarantee free medical care.’

For jails and prisons considering starting a medical co-pay program, the National Commission on Correctional Health Care (NCCHC) has published a position statement on the issue. In principle, the NCCHC is opposed to co-pays on the grounds that already-scarce correctional health care resources may become less accessible. However, they do list guidelines that should be followed for those wishing to implement a co-pay program.

While on the surface the concept of whether inmates should be charged co-pays for medical care may seem straightforward, the practical aspects of implementing such programs without reducing access to needed care are quite complicated and fraught with numerous ethical and legal issues.

Jeffrey Knuppel is a psychiatrist who blogs at Lockup Doc.

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