Exorbitant medical costs are a familiar burden to most people in the United States—but for those incarcerated in the country’s jails and prisons, these fees present a particular hardship. With little, if any, access to income, many incarcerated people struggle to afford the bills; when they can’t pay, they can accrue insurmountable debt. As detailed in the National Consumer Law Center’s (NCLC) report Medical Debt Behind Bars: The Punishing Impact of Copays, Fees, and Other Carceral Medical Debt, carceral medical debt—which takes a variety of forms—can negatively impact health outcomes, hinder successful reentry, and jeopardize financial security across generations.
Medical copays are one of the most common (and commonly known) ways individuals accrue carceral medical debt, but carceral medical debt can stem from a wide array of other sources. Whether it is everyday expenses, such as purchasing over-the-counter medications from the commissary, or emergency response charges (often referred to as “man-down” fees), incarcerated people are saddled with expenses in every facet of health care. Medical billing errors are common, as is the failure by prisons and jails to pay third-party medical providers. And the costs persist beyond release: both people whose sentences have ended and those who are on medical release bond must pay medical bills for any health issues incurred (or exacerbated) while incarcerated.
Recent policy developments aimed at addressing this country’s broader problem with medical debt offer some promising avenues for relief, but more work is needed to stop carceral medical debt from spiraling out of control. Advocates working to address carceral medical debt should look to models that successfully provide for low-income people’s health-care needs without contributing to their debt burdens, while also remaining wary of solutions that could worsen financial and health outcomes.
Compounding the high cost of medical care is the fact that most incarcerated people cannot access public or private health insurance. Most health insurance is terminated or suspended shortly after a person becomes incarcerated. Medicaid and Medicare, the main public health insurance programs in the United States, have not historically covered treatment within the carceral system, although there is some effort to change this, at least as release nears. Furthermore, people who are incarcerated cannot shop around for medical services or cheaper providers; they are forced to rely entirely on the correctional facility to provide care. And while people who are incarcerated have a constitutional right to health care, the courts have not prohibited prisons and jails from charging for these services. As a result, many facilities leave incarcerated patients with copays and other fees.
Despite how expensive it is, the care provided by correctional facilities is inadequate at best, and these facilities are ill-equipped to respond to the significant and growing health-care needs of a disproportionately unwell, rapidly aging incarcerated population. A 2021 report from the Department of Justice revealed that 40 percent of individuals incarcerated in state prisons, and 33 percent of those in federal prisons, have chronic health conditions such as cancer, diabetes, hypertension, and asthma. The level of medical care required to treat such conditions is complex and costly. Additionally, an alarming number of people in the carceral system also suffer from untreated trauma, substance abuse disorders, and mental health conditions; the three largest mental health providers in the country, in fact, are New York’s Rikers Island, L.A. County’s Twin Towers Jail, and Chicago’s Cook County Jail.
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Given the rising costs and increased demands on the carceral health-care system, many jails and prisons have looked for ways to actively disincentivize care and shift the financial burden to incarcerated people and their families. Copays and other fees are regularly assessed for all aspects of medical treatment, from routine preventative screenings to in-hospital surgical care. Today, all federal prisons and 38 states charge copays for carceral medical visits, ranging from $2 to $13.55 per standard visit. Emergency responses or “man-down” calls may result in significantly higher fees. Local jail systems also regularly charge copays and other medical service fees, although data on the amounts charged is limited.
In theory, these fees are meant to offset costs and reduce alleged abuse of the carceral medical system. In reality, these fees rarely reduce health-care costs for prisons or jails. They may, in fact, do the opposite, increasing costs for the facility, particularly if people delay seeking treatment for manageable conditions for so long that they escalate into expensive medical emergencies.
While copays and other similar fees may in some cases seem nominal, people who are incarcerated are disproportionately low income and often earn less than a dollar a day—if they earn anything—for their work while incarcerated. That means a copay of $5 could require someone to pay a week or more of prison wages. In short, having a job while incarcerated does not necessarily alleviate the burden of these fees.
When, predictably, people who are incarcerated cannot afford a medical copay, they accrue carceral medical debt. People are often forced to ask their families to deposit funds into their accounts to cover these expenses. In many cases, these family members are already stretched thin financially. Still, these family members, who are disproportionately women of color, contribute funds to help their loved ones get the care they need, resulting in an added financial burden on already vulnerable families.
For all of these reasons, many people report avoiding seeking necessary medical care due to an inability to afford the costs and an unwillingness to accrue debt. This terrible choice can ultimately come at the expense of their health, and delaying or avoiding treatment can result in more expensive emergency services and preventable outbreaks of infectious diseases. Disease outbreaks not only strain resources and increase costs, but also jeopardize the health of additional incarcerated people and correctional staff, which can lead to community spread in the public at large.
Copays are not the only source of carceral medical debt. In places where local and state laws do not require jails and prisons to cover the cost of medical care, incarcerated people are often billed for the full cost of their medical care. This can leave them with substantial, unaffordable medical debt from ambulance bills and hospital stays if they become seriously sick or injured while incarcerated.
Another source of carceral medical debt arises through the use of “medical bond” or “medical furloughs.” In some jails and prisons, when someone experiences a serious medical issue, the facility may choose to release the person on “medical bond” or “furlough” before transporting them to a hospital for treatment. Because the person has technically been “released,” the facility is not required to pay for their medical care, leaving them with potentially tens of thousands of dollars in hospital bills. As Pro Publica found in an investigation into this practice in Alabama, once the person released on “medical bond” has recovered, the carceral facility will then take steps to rearrest them immediately.
In addition to copays and other direct fees for medical care, people in jails and prisons are regularly charged for basic medical items from the commissary, such as over-the-counter medications and hygiene products. These items are often subject to excessive markups imposed by the private equity–backed contractors in charge of commissary supply. Medically necessary devices, such as wheelchairs, inhalers, and prosthetic limbs, can come with impossibly high costs for incarcerated people. It is not uncommon for these devices to cost tens of thousands of dollars, leading to debt and a lower quality of life for people with disabilities.
Carceral medical debt can also stem from billing errors and mistakes. In some cases, these errors are due to medical fees that the prison has improperly assessed. Disputing medical bills is hard for anyone, and it’s exponentially more difficult for people who are incarcerated and have limited access to communications. Billing errors may also arise due to prison health-care contractors failing to pay outside medical provider claims, resulting in the provider improperly seeking to collect the bill from the incarcerated person who received the care. Holding exploitative for-profit contractors accountable for these mistakes, and for inadequate care at large, has become more difficult in light of recent attempts by these companies to use the bankruptcy process to protect them from liability, as was the case with Corizon Health.
As with contesting medical bills, the process of fighting debt collection is terrifying for anyone. Carceral medical debts, such as copays and facility-assessed fees, are typically collected directly through “inmate trust” accounts or commissary funds while the person is incarcerated. After a person is released, prison and jail systems may hire third-party debt collection companies to collect outstanding medical debts. Hospitals and other outside medical providers may also use collection agencies to recoup medical debt billed directly to the incarcerated person.
There is no consistent data on how collections proceed, but people may be subject to abusive and unfair medical collection actions that result in real financial harm if third-party debt collection agencies are involved. Debt collectors may file lawsuits to seek court judgments against the person who allegedly owes the debt. If a judgment is entered, the collector can then garnish the person’s wages, seize money from their bank accounts, and place liens on their homes. In worst-case scenarios, people can also be arrested for failure to appear in court or failure to respond to information subpoenas related to the collection lawsuits, even if they cannot afford to pay the debt. Carceral medical debts may also appear on credit reports, impacting a person’s ability to get a job, bank account, or loan to help resolve the debt.
While we don’t know the full extent to which people have medical debt as a result of incarceration, available data suggests that the numbers are substantial. The Fines and Fees Justice Center reports that people leave the Nevada state prison system with an average of $4,500 in medical debt stemming from copays and other medical fees. In one case, the state attempted to collect over $100,000 in medical debt from one man after he was released from prison. Absent increased transparency by correctional facilities, we may never know the scale and impact of this problem.
Carceral medical debt negatively impacts health outcomes, makes reentry more challenging, and takes a toll on families, who often help pay their loved one’s expenses while they are incarcerated. And fiscal arguments for levying these fees on incarcerated people may not hold water. For example, in 2024, Nevada state prisons assessed over $2 million in carceral medical debt, but the state only collected around $6,000—a drop in the bucket for the state’s correctional budget, but with devastating long-term consequences for those who owe the debt.
Nevada is one of several states that have recently taken positive steps to address the heavy burden of carceral medical debt by eliminating copays and fees for routine or emergency medical care and preventing commissary markups on hygiene items. This June, Nevada once again made significant strides in this space by enacting SB88, which discharges medical debt upon release, ensuring that medical debts do not hinder successful reentry.
Carceral medical debt is just one of the ways the U.S. carceral apparatus perpetuates the suffering of individuals and communities impacted by the criminal legal system—yet because of that, the issue offers an avenue for significant socioeconomic relief. To that end, NCLC urges policymakers and prison and jail administrators to enact the following changes:
- Eliminate medical fees and require governments to provide free, adequate medical care to people in prisons and jails.
- Stop collection of carceral medical debt and discharge outstanding carceral medical debt.
- Prevent private contractors from profiting off incarcerated individuals seeking medical services and devices.
- Increase access to Medicaid and Medicare in prisons and jails.
These reforms won’t solve all the harms experienced by people who are and have been incarcerated, but without them, these individuals will continue to be left with insurmountable debts that harm them financially and physically. Such a burden can have devastating ripple effects for families and communities across the country—and with the problem only poised to grow, taking immediate action is imperative.
Image: The New York Public Library (public domain)
