These are the bills no one wants to pay. When taxpayers name their priorities, paying millions of dollars for hospital treatment for county jail inmates usually isn't at the top of the list. But it has to be done, and the bills add up—a jail's population often includes a high percentage of people with mental illness and substance-abuse problems. Inadequate care can lead to serious health damage or death, which in turn can lead to civil suits or federal civil rights investigations.
In North Carolina, the cost of those inmates' care is increasingly falling on the shoulders of county taxpayers. And in Wake County, that's becoming an expensive problem.
"If someone comes into our care that is getting cancer treatment and they are now incarcerated, we are responsible for paying those treatment bills and ensuring that they continue their treatment," Sara Warren, a budget and management analyst for the Wake County Sheriff's Office, recently explained to county commissioners.
Myriad factors are at work. Hospitals with already-large charity responsibilities are reluctant to take on more patients for whom they will not be fully compensated. Several county jails, including Durham's, are contracting with private companies—some with controversial histories—to provide medical care for inmates while saving money. There are also quirks in health care laws, such as inmates' loss of Medicaid once they are put in jail. Even the legislature's decision not to expand Medicaid under the Affordable Care Act plays a role.
Perhaps most important was a state law passed in 2013 that made counties pay more for their inmates' hospital care. That law contained an odd collection of provisions, one on the naming of district court judges and another concerning notaries public. But a third section said that any hospital or other inpatient treatment will be paid for by the county that runs the detention center. Before the law passed, counties were supposed to absorb the costs but often only paid a small fraction of the total amount to the hospitals; the hospitals had to write off the losses. They complained, and the legislature listened.
Coupled with North Carolina's practice of stripping inmates of Medicaid coverage after a few days in jail, the law amounts to a multimillion-dollar invoice to the state's counties, likely $10 million over three years in Wake and Mecklenburg alone.
Wake County commissioners believe it's an example of the cost-shifting that's taking place as the legislature seeks more room in its budget to offset another billion-dollar tax cut. They grumbled before agreeing to pay $1.28 million just to catch up with the estimated $1.7 million cost of inmates' off-site medical care in this year's budget. And commissioners anticipate another million-dollar-plus fee in the fiscal year that starts July 1.
How much larger remains unclear—and that's a problem, too. Wake County Sheriff Donnie Harrison told commissioners last month that unpredictability is the killer. With any arrest, bank-busting services such as cancer treatment, inpatient substance-abuse treatment, pregnancy care, or dialysis could suddenly become the county's responsibility.
"We can't anticipate that when we do the budget in July," Harrison said.
The exigencies of the system can even determine who stays in jail and who's let out. Some inmates being treated at WakeMed are released on their own recognizance, Harrison told commissioners, which "saves us a ton of money." One suspect with broken legs and other injuries, on the other hand, was transferred to the care of the state Department of Corrections to lower his tab.
The majority of inmates in Wake's two detention centers, which can hold as many as 1,580 people combined, have not been convicted and thus are presumed innocent. And because of an overwhelmed Wake court system, their average time behind bars has nearly doubled in the past fifteen years, from about fifteen days around the turn of the century to about twenty-five now, which means medical costs to taxpayers are escalating as well.
As Wake County grows beyond one million residents, the millions of dollars dedicated to inmate care take a bite out of money available for schools, affordable housing, transportation, and other law enforcement needs. That's the reason, veteran legislative players say, that legislators should take the long view when adjusting the details of fiscal matters.
"You have to be careful any time you pass legislation that impacts who pays for what, because there can be some untended consequences on down the road," says Mary Bethel, president of the statewide Coalition on Aging, speaking generally and not about any specific situation. "You have to look at all the long-term ramifications."