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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."