Letter to Acting Secretary of Corrections Little

Re: Please eliminate the prohibitory $5 medical copay for incarcerated people in Pennsylvania

Dear Acting Secretary Little:

We write to urge you to eliminate the $5 medical copay that is required for incarcerated people to receive basic healthcare in state prisons. FAMM and the Pennsylvania Prison Society have previously outlined that this is a prohibitory barrier that unnecessarily increases the chronic disease burden for those in the commonwealth’s prisons and jails and disregards their basic humanity.

The momentum to eliminate medical copay requirements for incarcerated people continues to accelerate across the country, with Illinois recently eliminating copays after a 2019 study determined that 60% of people in the state’s prisons avoided seeking care due to the copay.

Furthermore, the value of eliminating the copay in safeguarding people’s health and safety was evident in Pennsylvania over the preceding years under the suspension of the copay at the height of the SARS-CoV-2 pandemic by former Secretary Wetzel. We firmly believe that all people deserve to have their health needs met and that the punishment of being in jail or prison should not include barriers to receiving healthcare. Thus, the copay suspension should be immediately re-implemented and steps taken to eliminate the $5 copay permanently.

Incarcerated people are the only group of individuals with a constitutional right to healthcare

As held by the Supreme Court in Estelle V. Gamble (1976), “deliberate indifference by prison personnel to a prisoner’s serious illness or injury constitutes cruel and unusual punishment contravening the Eighth Amendment.”. Therefore, this ruling established that incarcerated individuals must be provided necessary healthcare as a basic right under the U.S. Constitution.

However, incarcerated individuals in Pennsylvania must currently pay a $5 copay to receive necessary care for their chronic health conditions. Incarcerated people who are fortunate enough to have a regular job are paid a minimum wage of only 19 cents per hour and make an average wage of 42 cents per hour across the state. Thus, an individual is required to work for 12 to 26 hours to cover the cost of a single visit for routine medical care. Meanwhile, there are not enough prison jobs to provide every incarcerated person paid work and about 28% of people in Pennsylvania prisons are older adults, making a $5 copay and medical treatment even further out of reach for so many.

Additionally, incarcerated individuals carry a high chronic disease burden and are among those most in need of healthcare access. Thus, requiring a $5 medical copay for people incarcerated in Pennsylvania only functions to be prohibitive for receiving basic healthcare behind bars, which not only deprives people of their constitutional right to healthcare but also increases the severity of avoidable health problems and the subsequent financial costs of incarceration. We must eliminate the $5 copay required of incarcerated people in Pennsylvania to uphold their constitutional rights, serve their basic healthcare needs, and respect their dignity as fellow human beings.

Incarcerated individuals in the U.S. have higher rates of disease than the general population

In its 2016 special report analyzing 2011-2012 data, the Department of Justice, Bureau of Justice Statistics (DOJ-BJS) determined that 40% of people in state and federal prisons and jails had a chronic health condition and that they were significantly more likely than the general population to have some of the most common conditions, including high blood pressure, diabetes, heart disease, asthma, and even infectious diseases. Additionally, estimates of psychiatric illness range from 37% to 60%, which is also significantly higher than for the general population. Thus, the $5 copay poses a substantial obstacle to obtaining vital care for these and other chronic conditions, which is detrimental to health burden behind bars and which leads to wasted taxpayer dollars that could instead be efficiently allocated toward chronic disease management and prevention in the carceral setting to reduce overall costs of care.

Prison healthcare costs & disease mortality are higher when we deny basic care to incarcerated people

When an excessive financial barrier such as the $5 copay deters people from receiving regular care, it increases the overall costs of care for incarcerated people and exacerbates their health conditions that could have been easily managed with regular treatment. For example, it is estimated that between 48% and 64% of lifetime medical costs for a person with diabetes are for serious complications that result from poorly-managed diabetes, including heart disease and stroke.

Moreover, by barring people with psychiatric conditions from receiving regular care via the $5 copay, they are more likely to have behavioral crises resulting from their poorly-managed conditions and be punished via solitary confinement. In fact, solitary confinement is so often used punitively that both the American Medical Association and the National Commission on Correctional Health Care have condemned its use for people with mental illness.

Solitary confinement is well-documented to create devastating mental health outcomes and even increase mortality by suicide, with one study of over 200,000 people finding that those experiencing any time in solitary confinement during their imprisonment were 78% more likely to die from suicide within the first year of re-entry into the community compared to people released who did not experience solitary. Thus, the $5 copay can indirectly cause even worse public health consequences from prohibiting care.

Physicians for Criminal Justice Reform joins FAMM and the Pennsylvania Prison Society in urging you to immediately suspend and permanently eliminate the $5 medical copay for incarcerated people in Pennsylvania state prisons.

Thank you for considering our statement on this important issue. Please contact Zane Kaleem, M.D. at Zane@pfcjreform.org or 717-473-7371 with any questions or requests for assistance.

Sincerely,

Syed Zane Kaleem
Syed Zane Kaleem, M.D.
Assistant Director, Correctional Health Care Task Force
Physicians for Criminal Justice Reform

Edjah Nduom
Edjah Nduom, M.D.
Founder and Chair, Board of Directors
Physicians for Criminal Justice Reform

Nzinga Harrison
Nzinga Harrison, M.D.
Co-Founder and Vice-Chair, Board of Directors
Physicians for Criminal Justice Reform

Kristin Huntoon
Kristin Huntoon, Ph.D., D.O.
Public Relations Committee Chair
Physicians for Criminal Justice Reform

cc:
Honorable Tom Wolf, Governor
Lieutenant Governor John Fetterman
Honorable Josh Shapiro, Attorney General
Pennsylvania Senate Officers and Leadership
Pennsylvania Senate Judiciary Committee
Pennsylvania House Officers and Leadership
Pennsylvania House of Representatives Judiciary Committee
Pennsylvania House Bill 1753 Sponsor and Co-Sponsors
Pennsylvania Department of Health
Pennsylvania Department of Aging
Pennsylvania Department of Health and Human Services

PfCJR-Statement-5-Copay-in-PA_mediaDownload

Physicians for Criminal Justice Reform calls for ending $5 medical copay in Pennsylvania state prisons

Physicians for Criminal Justice Reform (PfCJR) sent a letter today to Pennsylvania Department of Corrections Acting Secretary George Little urging that the required $5 copay for basic health care for incarcerated individuals be eliminated. PfCJR joins FAMM and the Pennsylvania Prison Society, who sent a joint letter back in March detailing why the fee creates an undue burden, in advancing this position. 

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The right to healthcare: A false promise of health in America’s prisons

Last month’s coverage of the conditions at Riker’s Island have people across the country appalled. Dr. Vernier, former physician at Riker’s Island, shared many of his experiences with patients at the prison with NPR, describing the horrific case of Carlos Mercado, who died within 15 hours of arriving at the prison due to complications of his diabetes. He had been denied insulin during the intake process.

Prisoners are the only people in the country with a constitutional right to healthcare, under the 1976 Supreme Court Estelle v. Gamble decision, which held that withholding healthcare from prisoners constituted “cruel and unusual punishment,” prohibited by the Eighth Amendment. But isn’t the case of Carlos Mercado grounds for “cruel and unusual punishment?” The right to healthcare seems to be a false promise at Riker’s, especially when we consider the facility’s history.

Riker’s is notorious for cruelty and inhumane treatment of prisoners. Earlier in de Blasio’s appointment as city mayor, a 2014 report from U.S. attorney Preet Bharara detailed graphic human rights abuses and use of violence against adolescent males placed at Riker’s Island. One such account from 2012 reads:

“…Inmate F, a mentally impaired inmate, was repeatedly punched in the face by an officer who has been involved in well over 20 other RNDC use of force incidents. Although the officer admitted that he delivered multiple blows to the inmate’s face, the Department concluded that the force used was appropriate based on the officer’s contention that he was acting in self-defense… There is no video of the incident…

…Inmate F reported that the officer challenged him to a one-on-one fight… According to DOC records, the officer was involved in a total of 24 use of force incidents… from 2007 through early 2013, including eight incidents in 2012 alone. He also has been subject to repeated disciplinary actions.”

Unfortunately, these human rights violations persist not just at Riker’s, but as an inherent part of the nation’s correctional system. Earlier this year, approximately 1,600 prisoners at the Metropolitan Detention Center in Brooklyn were left with sporadic heating and no lighting over the course of multiple days. Families were left completely in the dark about the fact that their loved ones were suffering in the facility. No generators were powered on to restore lights and heating as detainees pounded on the windows in retaliation to being left to freeze.

There are physical health consequences of being unable to read your medication labels in the dark. However, more latent are the mental health repercussions when prisoners realize they are not just trapped, but that there is nobody to even allow them their basic rights or human dignity. The right to healthcare applies to mental as well as physical health. We need to take a close look at outcomes to truly assess whether the right to healthcare is upheld in prisons or not.

The capacity for cities like New York to harm people through incarceration is vast, and there is a poor track record of tangible benefit coming from imprisonment for those detained nationwide. In 2016, the Avid Prison Project described that solitary confinement routinely exacerbates symptoms for those with mental illness. Moreover, inmates with psychiatric needs are put on waiting lists for hospital treatment much too often, even when hundreds of beds are available. It seems that the right to healthcare is a promise to take two leaps back for every small step forward.

Broken policies that keep the mentally-ill from receiving care in prisons can change. We can start by re-routing those with mental health needs from prisons to programs focused on healing and reintegration for the 42% of inmates at Riker’s Island who suffer from mental illness. Instead of reverting to punishment-based criminal justice, we can transform the lives of those in prison and reduce incarceration rates by expanding proven alternatives to incarceration.

In particular, we should expand New York’s assertive community treatment (ACT) programs for those with mental illness. Programs like Manhattan ACT bring holistic treatment and therapy to those with mental illness who face incarceration due to a felony arrest directly to them in their communities. Manhattan ACT itself has seen a 36% decrease in psychiatric hospitalizations among program participants in Northern Manhattan. In addition to their mental health benefits, ACT programs have also reduced recidivism rates. Nathaniel ACT’s graduates since 2014 have had no violent arrests within one year of graduation and its graduates since 2013 had no new felony convictions within two years. ACT programs turn lives around and are one just solution to the crisis of housing the mentally-ill in federal and state prisons.

The right to healthcare is one of prisoners’ civil rights, protected under the Eighth Amendment to the Constitution. However, if prisoners are delayed necessary treatment and placed in conditions that worsen their health problems, then this right is far from being upheld seriously. With 45% of federal prisoners having mental health or behavioral problems, we need to expand evidence-based alternatives to incarceration like ACT programs and work with our communities instead of against them.

Syed Kaleem is a medical student at Drexel University College of Medicine. He is a fellow of Physicians for Criminal Justice Reform. @ZaneKaleem on Twitter