CLEVELAND, MISSISSIPPI - APRIL 28: A prisoner at the Bolivar County Correctional Facility receives a COVID-19 vaccination administered by medical workers with Delta Health Center on April 28, 2021, in Cleveland, Mississippi. (Photo by Spencer Platt/Getty Images)

CW: mentions of death by suicide, trauma from incarceration, and medical neglect.

When Ronald Marshall would hear about someone who was sick, he’d gather several days’ worth of food from his prison locker box and bring it to the sick person to encourage them to get care. Incarcerated people often face having to choose between purchasing hygienic supplies or food at the commissary or visiting the infirmary and incurring copay costs. 

“We know the brother doesn’t have the $3 to pay for the medical copay,” Marshall explained. “But he’s sick, and the dormitory is six-to-eight people [full]. It’s a cluster, [and] germs spread fast.”

Despite how quickly health issues can compound and spread within prison walls, like many in the U.S., incarcerated people often avoid seeking care because out-of-pocket copays can strain families with limited financial resources and saddle them with medical debt. For many incarcerated people, that financial risk—on top of the risk of mistreatment and verbal abuse that often accompanies an infirmary visit—is more than enough to deter them from making a sick call.

“People struggle with not affording the copay,” said Cynthia Alvarado, who served 12 years in State Correctional Institution at Muncy in Pennsylvania after being wrongfully convicted of murder. “That creates mental health issues ’cause now you’re depressed, now you’re sad, now you have more problems over not being able to afford something that should just be free while you’re in the custody of their care.”

In 1976, the U.S. Supreme Court ruled in Estelle v. Gamble that denying health care to an incarcerated individual is a violation of the Eighth Amendment, but that ruling says nothing about prohibiting copays for medical care. Prison health care isn’t insurance-based, so any associated expenditures come out of the jurisdiction’s budget. Unless initiated or authorized by the Department of Corrections, any time an incarcerated person seeks medical care, their commissary account is charged a fee, or a copay. 

Depending on the state or commonwealth, some services are excluded. As of May 2022 in Massachusetts, a $3 copay cannot be collected for diagnosis and treatment of contagious diseases and all mental health care. Exclusions vary, however, and it assumes that an incarcerated individual knows that those exclusions exist. Ultimately, advocates point to the copays levied against incarcerated people as a significant barrier that prevents them from accessing the care they need until it is too late. 

The hidden costs of “low copays”

As of February 2022, all federal prisons and 40 states charge incarcerated people a copay when they initiate medical care. The average cost falls around $2, a deceptively low price tag that obscures the financial scarcity that many incarcerated people and their families live with. Average prison wages tend to be low—according to a report by the American Civil Liberties Union, incarcerated people earn between 13 cents and 52 cents per hour and in seven states aren’t paid at all for most work assignments. Additionally, incarcerated people are taxed up to 80% of those wages for “room and board,” court costs, restitution, and other fees like building and sustaining prisons.” Also, in some states, not everything is covered by copays—medications and additional treatment may incur other fees, all of which can quickly pile up, especially for conditions that require regular visits. 

This means that incarcerated people often require an entire month’s pay to afford covering a single copay. And then, in addition to medical care, they might have to choose between using their hard-earned money to seek care or pay for supplies and privileges, such as pens, paper, and postage to send letters to loved ones, or paying for a phone call to speak with their children. Incarcerated people aren’t allowed to keep basic over-the-counter resources like NSAIDs or cold medication, so even something as simple as needing aspirin for a headache means incurring a copay for visiting the doctor. 

Alvarado explained that to deal with her acid reflux or other ailments while she was incarcerated, it was $5 to make a sick call and then $5 for each medication needed to treat it. She could buy some medication at the commissary, like antihistamines, but it was often extremely expensive. The costs to treat any chronic conditions would quickly pile up. Eventually, she just learned to deal with the impacts on her health rather than risk a large amount of outstanding debt to be paid upon her release. 

In many states, care is provided even if the person has inadequate funding, but that amount gets charged to an incarcerated person’s account, even if it leaves them in the negative. This means that incarcerated individuals must rely on an outside network, such as family members, to provide them the necessary funds, go into debt (which can follow them upon release), or completely forgo care. And while some incarcerated people have outside support systems and can keep money in their accounts, it’s not an option available for everyone. 

Maria Goellner, the Pennsylvania state policy director for Families Against Mandatory Minimums, says that this is not only a financial burden but an emotional one for both incarcerated people and the families who support them.

“Most people in prison do not come from wealthy backgrounds, so we are compounding a socioeconomic issue,” Goellner said. “[Their] families are subsidizing this. They also have the added stress of worrying about the lack of proper care [and] whether they can afford to subsidize it. It’s money that they need.” 

A literature review from 2020 details different types of debt that a formerly incarcerated person holds and what impacts it might have, including medical debt, which one study found formerly incarcerated women are particularly impacted by. But the harsh reality is that many people, especially those serving a life sentence, will not be released from prison alive. 

Reports of COVID-19 incidence suggest that the risk of contracting the disease was higher in prisons than the rest of the U.S. population—research points to the COVID-19 death rate being 2.3 times higher for incarcerated people compared to the general public. Early in the pandemic, many states suspended the collection of copays to curb the spread of disease, although the practice has since resumed in many states. With the rise of long COVID and complications worldwide, it remains to be seen how this might impact the short- and long-term health of those who are incarcerated. 

Even before the COVID-19 pandemic, one report surveying incarcerated people in 2016 suggests that 17.5% of people in state prisons report ever having had an infectious disease, and 51% report ever having had a chronic condition. Particularly for those with chronic conditions, both the cost of seeking care and the cost of not being able to seek care can add up to devastating results.

These risks become even higher for marginalized people in carceral facilities, who tend to be Black, Latinx, and other people of color, often in poorer health than the general population, and part of a rapidly aging population that needs more specialized care. For many advocates, the removal of medical copays in prison is about more than affected individuals—it’s also about moving toward equity and justice within the carceral system. 

Ongoing efforts to permanently end copays

Officials claim that prison medical care copays are meant to discourage people from seeking what they call unnecessary and wasteful health care, as well as teach them how to budget, but the ultimate impact of this condescending assumption is that incarcerated people are discouraged from seeking care. Some states have recognized these challenges, and advocates are doing what they can to abolish copays.

Illinois eliminated its $5 medical copay in 2019, which became effective right before the start of the COVID-19 pandemic. The overlap of the pandemic’s onset and the elimination of copays somewhat obscures the true impact on the Illinois prison population, but 2018 surveys conducted by the John Howard Association of Illinois, a prison oversight organization that helped with the effort to abolish copays, found that over 60% of people who were incarcerated avoided seeking care because of the copay.

“Not having a copay definitely makes a difference in people’s willingness to seek medical care,” said Jennifer Vollen-Katz, John Howard Association of Illinois’s executive director. 

While Pennsylvania paused the collection of copays during the early stages of the pandemic for anyone with flu-like symptoms, staffing problems caused medical lines to increase, and the state reinstituted the copay to help reduce them. But this reduction in staffing lines comes at a human cost, according to Anton Andrew, who works with the Pennsylvania Prison Society as their Education and Advocacy Fellow.

“People are getting sick and have injuries that are going without treatment that are getting more severe until they’re in a critical situation and ultimately are taken [to the infirmary] by the department, or just cave in and cough up the copay,” Andrew said. 

Copay collection in Pennsylvania was indefinitely paused at the end of May 2021. But there are two problems: unless legislation passes to rescind them permanently, it could mean future harm if they resume, and inconsistency over whether there are copays can cause extreme confusion.

For particularly vulnerable populations like women and those with a uterus, delaying care because they cannot afford it can be extremely harmful. Despite a predominantly male prison population, the number of women who are incarcerated has risen over 740% between 1980 and 2019. Regular mammograms or pap smears can detect cancer with enough time to prevent it from becoming a chronic issue or even fatal. Still, as time between regular gynecological screenings grows longer, a lack of money only serves as a deterrent to seeking timely care. Alvarado explained that women might experience something abnormal, such as bleeding, but it is ultimately ignored until it’s too late. All too often, along with the trauma of a forced hysterectomy, patients must take hormone pills for the rest of their lives. 

“If they would have got the screening sooner, or had they not had the $5 copay, we would have treated that cancer or even known or found that there was cancer there,” Alvarado said. “And then the end result is the hysterectomy that women are getting so often in prison that nobody is talking about.”

Marshall, who was released in October 2021 after serving 23 years of a robbery sentence in different Louisiana prisons, is involved in the writing and advocacy of a bill that directly addresses copays. Louisiana, notably, has the highest percentage of incarcerated individuals in the U.S., so reform cannot come soon enough. Despite support from those in power to completely abolish copays in Louisiana prisons, the bill stalled in committee in March. The main area of concern is the same one repeatedly heard: without a copay, people would abuse the health care system and seek wasteful care.

Instead of full elimination, what’s proposed now is that for anyone with more than $200 in their account, copays are reduced from $3 to $2. For anyone with an account balance below $200, the copay is completely removed. While this policy may reduce the chances of going into medical debt while incarcerated, advocates say this isn’t nearly enough, especially as the Louisiana prison population ages. 

“The longer you’re in prison, [the more] you begin to lose your support system,” Marshall said. “Family dies off. Loved ones die off. You’re there alone. You have men who have been incarcerated for 30-40 years [who] don’t have anyone sending them anything.”

Health care should be a matter of humanity, not money 

The consequences of completely foregoing or receiving inadequate care is only magnified when a person is incarcerated. Individuals can develop complicated, chronic issues that could otherwise have been prevented and that affect their quality of life, and transmissible diseases and viruses like tuberculosis and HIV are known to spread quickly in prisons. Both Marshall and Alvarado have seen people permanently affected by the poor medical care they received. Alvarado recalls a woman who is now paralyzed because of a botched hysterectomy. Marshall remembers a man who repeatedly sought relief for chronic headaches and ultimately suffered a burst aneurysm. While he survived, Marshall said he’s different now.

“These guys are still walking on earth, but their quality of life is not the same as a result of the medical care that they received while incarcerated,” Marshall said.

Alvarado was released in March 2020 but still has health issues from being incarcerated: physically, stomach issues she could not afford to treat persist to this day, and emotionally, the women who died because of untreated medical conditions or by suicide have also stayed with her.

“[I] see girls alive at 5 o’clock and then by six, they hang themselves because of mental health issues,” Alvarado said. “Or seeing the comrades die because of [denied] medical treatment. I have to live with all that stuff.”

Medical copays in prison are only one problem in the prison health care system, but advocates say they speak to the larger issue of how incarcerated people need to be treated as people. Sometimes health care may be the only human attention a person has received in an unfathomable amount of time. This is why Alvarado says she did janitorial work in the infirmary while incarcerated—receiving health care is much more than just treating physical or mental ailments. 

“I wanted to work in [the infirmary] because I knew that there were a lot of aging lifers in that area,” Alvarado said. “They were already being neglected, so I figured I could offer them some type of relief while I was cleaning their rooms or assisting them in ways that I could—just being another human.”

And despite everything she witnessed and what prison stripped her of—both literally and figuratively—Alvarado refused to give up completely. It’s why she’s so willing to speak about these issues today.

“Don’t say ‘I hope,’” Alvarado said, “Say ‘I will,” because that makes you stronger, and they will not win.”

Cecille Joan Avila (she/her), MPH, is a former photojournalist who now writes about domestic health policy issues. Her areas of interest are in ethics, getting people to care about historically excluded...