COVID looks like it may stay. That means prison medical copays must go.

Forty states and the federal prison system continue to charge incarcerated people unaffordable copays for medical care.

by Tiana Herring

In 2017, our analysis of medical copays in prisons across the country brought to light the common but utterly backwards practice of charging incarcerated people unaffordable fees for their health care. At that time, only eight states did not charge medical copays: Missouri, Montana, Nebraska, New Mexico, New York, Oregon, Vermont, and Wyoming. While several other states have since added themselves to this list, the vast majority have still not eliminated medical copays. With a new legislative session starting in many states, we reviewed each state's policy — and any temporary changes they've made in response to the COVID-19 crisis — to identify places where repealing these fees should be on the agenda. (Looking for your state's policies? See the appendices in the full, online version of this briefing.)

40 states & the federal prison system still need to eliminate medical copays

Since 2017, two additional prison systems — California and Illinois — have eliminated medical copays, and, for the last two years, Virginia has suspended medical copays as part of a pilot program. Texas reduced its exorbitant $100 yearly health care fee to a less atrocious, but still out-of-reach, $13.55 per-visit fee. Idaho also reduced its medical copays in prison from $5 to $3 in 2018.

Even a $3 copay, though, is unaffordable for most incarcerated people, given the obscenely low wages that incarcerated people earn. For people earning 14 to 63 cents an hour in prison (and many earning nothing at all for their work), a typical $2-5 copay is the equivalent of charging a free-world worker $200 or $500 for a medical visit.

Unaffordable copays in prisons and jails have two inevitable and dangerous consequences. First, when sick people avoid the doctor, disease is more likely to spread to others in the facility and into the community, when people are released before being treated or when diseases are carried by correctional staff back to their homes. Second, illnesses are likely to worsen as long as people avoid the doctor, which means more aggressive (and expensive) treatment when they can no longer go without it. Medical copays encourage a dangerous waiting game for incarcerated people, correctional agencies, and the public, with little payoff in terms of offsetting medical costs and reducing "unnecessary" office visits. In fact, when evaluating the costs versus benefits of charging copays, the Oregon Department of Corrections concluded, "copay systems do not seem to lower overall health care costs," and "triage on a case-by-case basis is more cost effective than implementing system-wide copayment plans."

Policy changes made during the pandemic are already being rolled back

In the face of COVID-19, we've found that many prison systems relaxed their medical copay policies to avoid disincentivizing people in prison from seeking necessary medical care. Before these changes, medical copays in prisons typically ranged from $2 to $5. Twenty-eight states modified their policies during the first few months of the pandemic, and, ultimately, all but one state — Nevada — temporarily changed their policies. Of the states that do charge medical copays as a matter of policy, only 10 completely suspended these fees at some point in the pandemic. The federal Bureau of Prisons, on the other hand, did not modify their copay policy until March 2021, and only suspended copays for COVID-19 related care for three months before the waiver expired.

Most states that have modified their copay policies during the pandemic only suspended copays for respiratory, flu-related, or COVID-19 symptoms. But these limitations ignore the facts that not all COVID-19 symptoms fall within these vague categories, and many people don't display symptoms at all.

Our survey of all 50 state prison systems found that a handful of states have already returned to their pre-COVID-19 medical copay policies, disincentivizing people from seeking early and frequent medical care behind bars, despite the continued pandemic.

As states stop publishing data about COVID-19 in prisons and start rolling back basic policies that do the bare minimum to protect incarcerated people, it's important to remember that the pandemic is still ongoing and cases, hospitalizations, and deaths continue to rise. Five states — Alabama, Arkansas, Idaho, Minnesota, and Texas — rolled back their COVID-19 copay modifications at some point during the pandemic. Alabama went from suspending all copays to reinstating them for all cases in December 2020. Similarly, Minnesota and Texas had modified copays to accommodate people with COVID-19 symptoms, but reinstated all copays in December 2020 and September 2021, respectively. We confirmed that 22 states continue to operate with their COVID-19 copay policy changes in place, but in 15 states we were unable to confirm whether these modified policies remain in place.

Copays never make sense behind bars, particularly during a highly contagious viral pandemic. They are cruel, counterintuitive, and disincentivize people from seeking medical care when they need it. As our nation enters the third year of dealing with a virus that has ravaged prisons and jails — and increasingly looks endemic — it is urgent that lawmakers take action to permanently eliminate copays for incarcerated people.

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For more information, including detailed data on state copay policies and changes to those policies in response to COVID-19, see the full, online version of this briefing.