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."
Wake commissioners unanimously granted Harrison's request for more money, but they weren't happy about it.
"I know the answer to this question, but to state for the record, because of what is essentially a state mandate to the tune of one-point-two-eight million, that will now be at the cost of Wake County citizens, was there any sort of state funding provided to offset this cost to the county?" Commissioner Jessica Holmes asked Warren.
"There was not," Warren replied, noting that the legislation does allow the county to get a discounted hospital rate.
For the first couple of years after the law passed, Wake County carried on as usual. In 2014, the county's cost for inmate hospital care was just $141,381. But then last year, a health care provider raised the issue, pointing out that Wake wasn't meeting its obligations. Following the law will cost the county nearly ten times as much.
Julie Henry, a spokeswoman for the N.C. Hospital Association, which lobbied for the 2013 law, says the amounts of money that counties are paying show how expensive inmate care was for hospitals.
"As far as the burden on the hospitals, I don't have a number on what it was back in 2013 when it was passed," Henry says. "If the county gets the bill for it, that would be our cost." Henry and a representative of WakeMed, which performs millions of dollars in uncompensated care each year, argue that the legislation simply clarified what was already in state statute.
(State senators Thom Goolsby, Buck Newton, and Jim Davis sponsored the bill. Goolsby has left the legislature and works as a lobbyist, while Newton lost a 2016 race for attorney general. None returned calls seeking comment.)
Eddie Caldwell, general counsel to N.C. Sheriffs' Association, contends that it makes sense for the county to pay for its inmates' care because the jail is a county institution. But Wake County manager Jim Hartmann spelled it out for the board in different terms: "When the hospitals were absorbing it, when WakeMed was absorbing most of this money and nobody was paying for it, they were writing it off as indigent care. You can hang this on the state—the state clarified law to get WakeMed out of that situation. Now it's pushing the burden over to us."
In addition to taking on new costs, the county interprets the law as meaning that it must provide care for inmates with preexisting conditions, Warren told commissioners. Previously the county had denied care for such inmates, just as many insurance companies did before the Affordable Care Act prohibited that practice.
Routine treatment for medical conditions takes place in the jail's facility, which has a full-time doctor and other staff, but more complicated cases typically wind up at WakeMed or other community providers.
"A lot of the overnight stays are connected with inmates who have complications or other medical conditions associated with their substance-abuse treatment," Warren told commissioners. "We are able to detox them safely, but oftentimes they come in with other medical conditions that require further treatment."
Pregnant women require treatment before, during, and after delivery. And people on dialysis represent another big cost driver.
Commissioners asked Harrison, the typically outspoken sheriff, why inmates were spending so much more time in jail, increasing the likelihood that they'll have health problems on the county's dime.
"I'm going to tell you like it is, the lawyer hasn't gotten paid and he keeps continuing it until he gets paid," Harrison responded. "It's a cycle. You've got to remember, the court system in Wake County is really pushed. They're doing the best they can."
In North Carolina and nationally, county jail inmates tend to be older and sicker than the general population. Inmates who meet certain conditions—disability, pregnancy, or being older than sixty-five—would qualify for state or federal Medicaid assistance when not in jail. But if they are held for more than a few days, their Medicaid coverage is terminated, according to Elizabeth Scott, Wake County deputy program manager for Medicaid.
There's another catch. Federal and state inmates who have been convicted of crimes are eligible for Medicaid, but those awaiting trial—some for as long as three years—lose their eligibility. If North Carolina were to expand Medicaid under the Affordable Care Act, many more inmates could qualify under a plan being developed by the N.C. Association of County Commissioners and the state Division of Medical Assistance.
Other North Carolina counties have taken different paths to paying for inmate inpatient care, which not only costs large counties millions annually but can also throw a small county's annual budget into turmoil, given one prisoner with an unusually expensive condition.
"It's been a longstanding issue," Caldwell says. "For many inmates, they get much better care when they're in jail than when they're out. They are not entitled to unlimited medical care. They don't get cosmetic care done. But if they are having a heart attack, they are entitled to care as a constitutional right."
Mecklenburg County has been paying $1.5 million annually—up from $225,000 in 2014—since receiving a pointed letter from Carolinas HealthCare, citing the state statute.
Like several of North Carolina's other major counties—including Durham and Forsyth—Mecklenburg has adopted a different solution from Wake's. Instead of paying providers for inmate hospital care, these counties have contracted with a private company, in this case, the Tennessee-based company Correct Care Solutions. Durham County also pays CCS an annual fee of $3.17 million for jail inmates' care, including as much as $450,000 in hospital and other inpatient care.
"In the old days, we were providing the care through our health department," says Durham County Commissioner Ellen Reckhow. Under the previous arrangement, "all you need is a few huge medical expenses where people wind up in the hospital, and we pay the full retail rate."
The quality of care provided by CCS has been called into question through numerous lawsuits in states including North Carolina. Inmate Matthew McCain died in Durham County custody on January 19, 2016, and family members complained in media reports that his treatment was inadequate. A Durham Public Health Department investigation concluded that "McCain died as the result of complications from a seizure disorder. However, as a result of this investigation, it is recommended that certain changes be implemented in/by the Medical Unit to ensure the medical care provided continues to local and national standards."
The report goes on to make fourteen recommendations for improving care.
Squeezing out more taxpayer dollars, hiring private health care providers, letting inmates leave jail on their own recognizance, and delaying custody for some inmates—all are results of a law passed four years ago that's just now having its full effect.
Marc Stern, a corrections consultant who's also a faculty member at the School of Public Health at the University of Washington at Seattle, says privatization seems to be increasing, although there's no conclusive study showing that. But however care is compensated, he says, quality treatment of inmates results in a community that's healthier and safer, and in the end at lower risk.
"Inmates have more hypertension, more diabetes than the average population. Also more HIV and hepatitis B," Rice says. "We have this very sick population that in a very short time is going to come back into the community."
Wake Commissioner Erv Portman worries that Wake's cost of operation will keep rising as federal and state governments keep cutting help offered to people with low incomes and bad health.
"We need to be aware that when push comes to shove, we are the safety net," Portman says.
This article appeared in print with the headline "Bitter Pill."