Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his “true calling” of correctional medicine. In a piece for MedPage Today earlier this week, Dr. Keller said one of the more frequent questions he gets from people curious about jail medicine is “Who pays for this? And how do you yourself get paid?”
Firstly, correctional medicine has an entirely different payment and reimbursement system than for the rest of American medicine. In fact, inmates have a medical system that has more in common with Canada’s single-payer model than the US.
Keller asserts that the central fact upon which correctional medical care hinges is this one: Inmates are the only residents of the US with a constitutional guarantee of medical care. He says “residents” rather than “citizens” because the guarantee of healthcare while imprisoned applies to illegal immigrants as well as US citizens.
There is no such guarantee for the rest, residing freely in the US. If free US citizens want medical care, they have to figure out some method of paying for it. Most do this by obtaining some type of medical insurance, usually through an employer or from the government.
Keller goes on to note that inmates, however, aren’t working and so it is rare for an inmate to have private insurance. Also, inmates also lose the right to use any federal insurance plan when they are incarcerated.
By law, Medicaid and Medicare benefits (with few exceptions) cannot be used while incarcerated. Incarcerated inmates also lose VA benefits and even active duty military insurance. That means a jailed veteran, for example, can’t be taken to his/her next VA clinic appointment. He/she is no longer eligible to use the VA system, even to get medications refilled.
Instead, every correctional facility has to set up its own independent medical program that is paid for by whatever entity is in charge of the jail. Counties pay directly for the medical care of the inmates in their county jails. Each state pays for this medical care of their state prisoners out of the general fund. And the federal government funds medical care for inmates in federal prisons. Any way you view it. Keller says, “This is your tax dollars at work!”
This unique (for the US) system of providing medical care to incarcerated inmates makes correctional medicine different in many important ways from medical care in the free world.
What this system means for inmates is that they all have equal access to medical services. There are no “haves” and “have-nots” like there are outside the walls, where uninsured people do not have equal access to medical care. Inmates don’t have to do anything to be eligible for medical benefits, other than be incarcerated. In this way, correctional medicine is similar to socialized medicine, like in Canada, Keller argues.
The only time that inmates re-enter the world of fee-for-service medicine is when they need specialty care that cannot be provided in the jail or prison medical clinic. The specialist would submit a bill to the county for payment like she would bill the insurer of any other patient. Most states have legislation that such services are reimbursed at Medicaid rates, even though Medicaid itself is not used.
The US has two very different medical systems, says Keller–one for free citizens and the other for incarcerated residents.
Compared with the rest of the world, “The way we fund medical care for incarcerated inmates is less peculiar than the rest of the US medical system.”
So, prison health care in the United States is equal access, no bills…and is far less complex and draconian than healthcare on the outside? Oh, and although the food isn’t Le Coucou, it and cable TV are also free? Hmmmm. Something’s out of whack here.
Back in March, Anna Gorman wrote an excellent piece for Kaiser Health News about the ongoing process of revamping health care at LA County jails. Much of the following constitutes excerpts from her investigation.
In Ms. Gorman’s excellent article, she talks about meeting one Michael Callahan, an outgoing 43-year-old carpenter, who landed in a LA County jail last September because of what he terms “bad decisions and selling drugs.” He had uncontrolled diabetes and high blood pressure when he arrived, but his health was the last thing on his mind. Consumed by a meth addiction, he hadn’t taken his medications for months.
“When I got here, I was a wreck,” said Callahan, who is stocky and covered with tattoos. “My legs were so swollen that if I bumped them they would break open.”
By January, however, Callahan’s diabetes was improving, and his blood pressure had dropped. Now, he takes his medications daily and sees a doctor every other month. Even as he counts the days until his release this summer, Callahan knows he is getting much-needed medical care.
“I’m where I need to be, not where I want to be,” he said.
Callahan’s situation is contrary to common sense expectations: He may actually wind up leaving jail healthier than when he arrived.
Officials at the Los Angeles County Department of Health Services hope to see more cases like his as they embark on an ambitious effort to improve health care for jail inmates. Their project follows decades of complaints, lawsuits and reports of poor medical and mental health care at the Los Angeles County jails, which together house about 18,000 inmates on any given day.
The county’s overhaul is designed to raise the quality of health care behind bars and better equip inmates to manage their health after they are released. But the challenges are enormous–the population is disproportionately sick, and the jails weren’t designed to be medical facilities.
The innovative effort at one of the nation’s biggest jail systems is based on a logical premise: Inmates don’t stay in jail for long–the average stay is just 60 days–so it’s a crucial opportunity to diagnose and begin treating their diseases.
“People are there for just a blip in time, days, weeks, months … and they’re returning back to the community,” said Mark Ghaly, director of community health for the county Department of Health Services. “What happens in the jail matters.”
The main health clinic at the Men’s Central Jail in downtown Los Angeles is located just inside a large metal gate. Inmates there and at all the county’s jails can get a wide variety of medical and behavioral care.
“It’s a giant health system and it’s complex,” said Margarita Pereyda, chief medical officer of correctional health services for LA County. “We are a hybrid between a hospital and an ER and an outpatient kind of environment.”
Part of the plan is to make clinics inside the jails more like ones on the outside. That means assigning inmates to primary-care doctors to manage their chronic diseases and getting them appointments and medications quickly. It also means expanding treatment for mental health and substance abuse and referring those who need advanced medical or behavioral care to specialists who work for the county.
To improve inmates’ access to care, county officials launched a physician recruitment effort in March month. They released a series of online videos featuring medical providers with the slogan “Mission Possible.” As an incentive, they are offering to pay up to $120,000 in medical school debt for each of the new hires who need it. That strategy has been used to lure doctors to low-income communities around the US.
Among some prisoners, attitudes about their own health are already beginning to shift. Ms. Gorman notes that inmate Callahan said he’s determined to stay sober and continue monitoring his health when he gets out. “I’m 43 years old and that’s not the age to be screwing around with diabetes,” he said. His words are more characteristic of a patient on the outside than an inmate on the other.Steve's Take: Our dysfunctional #medical system could learn a thing or two from our prison #healthcare system Click To Tweet
Compared with the rest of the world, the way we fund medical care for incarcerated inmates is less bizarre than the rest of the US medical system. But with our colossal litigious machinery, cranking inexorably toward incarceration for some fairly high-profile persons in Washington, I find it interesting that the entirely different correctional medical system might just get some long-overdue needed attention.
(Ref: Kaiser Health News)