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United States: should prisoners have to pay for medical care during a pandemic?

Some states stop charging copays to encourage COVID-19 care.

As COVID-19 threatened jails and prisons in March, the Connecticut Department of Corrections decided to waive the $3 fee it charged prisoners for a medical visit.

“We didn’t want the lack of funds to be a reason offenders were denied medical treatment, especially during the pandemic,” said Andrius Banevicius, public information officer for the prison system. “We wanted as many offenders as possible to have access to medical care.”

As prisons throughout the country have become hotspots for the coronavirus—and as prisons’ medical capabilities have been the focus of scrutiny—states have been divided over whether to continue to charge for medical treatment.

All but 12 states and the District of Columbia charge fees to prisoners who ask to see a doctor; officials say they want to discourage prisoners from abusing the medical system or stretching staff too thin. Rates are set by each state, ranging from $2 to $8 each time a prisoner seeks a visit, according to the Prison Policy Initiative, a national think tank. But low wages in prisons mean this fee could be equivalent to a week’s work, and the cost can discourage prisoners from seeking care.

While Connecticut and 10 other states’ corrections departments have waived all copays because of COVID-19, others have suspended fees only for those exhibiting coronavirus symptoms, and one state has made no changes at all, according to the Prison Policy Initiative. Some states made the changes preemptively, while others were compelled by courts to eliminate the fees.

In Arizona, corrections department officials removed the costs after a federal judge found that their response to the pandemic was inadequate.

Nevada charges prisoners $8 per visit. It opted not to make any changes to its medical fee policy during the pandemic, but Scott Kelley, a department spokesman, said medical officials within the prison are refraining from charging “when there is clear evidence the medical service is directly COVID-19 related.” Kelley said the department charges copays to defray the cost of inmate health care.

Waiving copays only for symptomatic prisoners can create problems; in a staggering number of positive cases in the U.S., the infected individuals have no symptoms. The Centers for Disease Control and Prevention estimates that around 40 percent of people who have COVID-19 are asymptomatic, but in correctional facilities, where social distancing and sanitation measures are not always enforced, that percentage can be far higher. At Marion Correctional Institution in Ohio, where one of the first large prison outbreaks in the country took place, 95 percent of positive prisoners showed no symptoms, officials reported.

This is not the first time copays have been called into question during an infectious-disease outbreak. Between 2001 and 2003, MRSA—a bacterial infection that is resistant to antibiotics—tore through jails and prisons. Prisoners in Georgia, California and Texas were contracting infections at such a high rate that the CDC stepped in.

Researchers found problems including improper laundry procedures, limited access to soap and high turnover among medical staff. Prisoners were failing to recognize the severity of their own symptoms. But researchers also found that prisoners lacked “proper access to medical care,” citing copays as a substantial barrier and aggravating factor in the outbreak.

A recent study from the American Journal of Preventive Medicine came to the same conclusion about copays and COVID-19, finding that high fees can “prevent the timely identification, isolation, treatment, and referral of cases.” The paper recommended eliminating copays to help address the pandemic.

Still, some states are struggling with the practicality of eliminating copays. In Arkansas, officials waived them for a month and then reinstated copays; they said they were overwhelmed with medical requests that had nothing to do with the pandemic. Now prisoners who show symptoms of the virus are exempt, though all indigent prisoners can get medical treatment regardless of whether they can pay, said Cindy Murphy, the communications director for the Arkansas Department of Corrections.

Arkansas earmarks its copays to fund contracts with independent agencies that review the quality of medical services inside the prisons.

Lawyers representing prisoners in Arkansas have sued over conditions including copays, saying there should not be financial barriers to medical care. In May, a judge denied the emergency injunction, but the class-action suit will go to trial next year.

“There are things we don’t know about this virus still, and things we didn’t know when we filed suit,” said Omavi Shukur, one of the lawyers involved in the case. “Even medical complaints that aren’t necessarily flu-like symptoms can still actually indicate that somebody might be positive for COVID-19.

Kaleem Nazeem, who was imprisoned in Arkansas for more than two decades, has been advocating for prisoners since his release in 2018. At the beginning of his sentence, the copay policy wasn’t yet in effect, and after it was implemented he said it became harder to see a doctor.

Sometimes prisoners would have to visit the infirmary several times—paying each time—before staff determined they were sick enough to see a doctor, he said.

“When guys have ailments that aren’t life-threatening from a self-diagnostic perspective, they don’t want to go to the infirmary, because they don’t want a lien on their account or to waste $3 to be told they need ibuprofen,” Nazeem said. “You can have a serious problem, and if it’s not diagnosed it could get worse.”

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