health care

How America’s Health-Care System Makes Mass Incarceration Worse

The jail in Perry County, Alabama.
The jail in Perry County, Alabama. Photo: W. Steve Shepard Jr./Getty Images

The prohibitive costs of America’s for-profit health-care system are well documented. Even in 2016, after the major provisions of the Affordable Care Act had taken effect and the national uninsured rate was down to 8.8 percent, a historical low, nearly 30 million people still lacked coverage, a disproportionate share of them black or Latino. More than half of Americans have delayed or foregone medical treatment because they were worried they wouldn’t be able to afford it. It was a prudent calculation: January 2016 saw 26 percent of adults report that they or someone in their household either had trouble paying or could not pay their medical bills.

Twenty percent of this cohort had insurance, demonstrating that even coverage didn’t guarantee affordability, though it was better than the alternative. The fallout is as evident in big-picture trends, like medical debt plaguing one in six Americans for a dizzying total of $81 billion, as in how individuals manage them, including diabetics who’ve died because they were forced to ration insulin. None of these shortcomings stem from a lack of spending: The United States dedicates 18 percent of its GDP to health care. Yet Canada spends just 11 percent, insures everybody, and provides higher-quality care. As my colleague Eric Levitz notes:

The source of these divergent outcomes isn’t hard to discern: Canada has a single-payer system that enables it to save money on redundant administration, and to dictate reimbursement rates to medical providers. America, by contrast, subsidizes the private insurance industry (and its wasteful administrative bureaucracies), while allowing physicians’ cartels and hospital monopolies to dictate their own pay rates to private providers.

But among the less-appreciated features of America’s system is how it supplements our more explicitly punitive institutions. Nowhere is this more evident than in Alabama, where an investigation from ProPublica and published on Monday found that sheriffs in 15 of its 67 counties had issued so-called “medical bonds” to jail inmates — meaning they’d released sick detainees from custody when they needed medical treatment in order to avoid paying their medical bills, often saddling them with debt that, by law, the county would’ve been responsible for.

The earliest case explored in the report is from 1996, but the majority documented have occurred since 2013. The practice is especially pronounced in Alabama’s poor rural counties, according to the report, where money concerns and the relative absence of on-site medical professionals at county jails have transformed inmate health care into a dystopian budgeting consideration.

The examples are harrowing. From ProPublica:

In September 2018 … a 38-year-old inmate at the Lauderdale County Jail was taken to a nearby hospital after he suffered a stroke that left him partially paralyzed and unable to communicate verbally, stand or perform daily tasks, state court records show. The inmate, Scottie Davis, was released from sheriff’s office custody on bond the following day, though he couldn’t sign the release document.

(When medical circumstances leave a prisoner unable to sign a release form, a judge usually determines whether they can be let go; sometimes, they authorize whether bond can be lowered to make this financially feasible.)

Davis was responsible for all medical debts incurred after he was bonded out. In other examples, people get rearrested soon after their release, once they’ve received treatment or — as with one inmate who couldn’t immediately get the surgery he required — when care isn’t available. “[The] law demands that we take care of people that are incarcerated in the jail,” Randolph County Commissioner Lathonia Wright told ProPublica of the logic behind this practice. “If we get a bill, we pay for our medical bills. They come straight from the hospital.”

In another case, Michael Tidwell, a 42-year-old diabetic arrested in 2013 for violating the terms of his probation, experienced a life-threatening blood sugar spike in custody after employees at the Washington County Jail failed to follow his sister’s instructions about how to medicate him:

On his fourth day in the aging jailhouse, Tidwell became ill and vomited off and on for the ensuing 48 hours. He was unconscious for most of his final two days there, according to court and medical records.

Before he was taken to Washington County Hospital, Tidwell’s blood sugar reading was 1,500 mg/dl; a normal reading for him is 80 to 100 mg/dl. Over the less than seven full days he was incarcerated, he had lost at least 17 pounds, records show.

None of this stopped deputies from propping up Tidwell’s limp body, placing a pen in his hand, and having him sign a form certifying his release before they transported him to a hospital in Mobile for treatment.

Some Alabama counties, wary of the possibility that arrestees might commit new crimes while out on medical bond, have developed more innovative solutions to avoid paying for their prisoners’ treatment. Lauderdale County, in 2017, authorized the use of ankle monitors to keep tabs on detainees after they leave jail to get expensive care. In practice, this allows jailers to surveil recently released prisoners and reincarcerate them swiftly but without having to cover their health care. “It’s accomplished what we wanted to accomplish,” Rick Singleton, the Lauderdale County sheriff, told ProPublica. “It’s saved us some money.”

The U.S. imprisons more of its citizens per capita than any other country in the world. Alabama has the fifth-highest incarceration rate in the U.S., locking up 946 people for every 100,000, far outstripping the national rate. It’s a system that ruptures families, destabilizes communities, ensures chronic unemployment, and prohibits vast swathes of the citizenry from participating in the political process. Conditions in jails and prisons are torturous; Alabama in particular has drawn national attention for the violence and degradation that mark its correctional facilities.

A lack of interest in prisoners’ rehabilitation and reintegration into society confirms revenge as the system’s primary function. In this light, there’s a clear logic to compounding the wages of being jailed in Alabama by refusing to cover prisoners’ medical costs — which often derive from ailments exacerbated, if not caused in the first place, by conditions in those very jails. But it’s also a cruel practice that, on top of abdicating legal responsibility for inmate care, calls into question whether these people needed to be locked up at all, considering how swiftly they were released once it became clear they’d cost their jailers money. This is not merely an indictment of Alabama’s jails and the barely checked power of county sheriffs. It’s an indictment of a health-care system that lends itself so seamlessly to immiserating the lives of the miserable.

How America’s Health-Care System Worsens Mass Incarceration