Prisons and jails have scarcely ever supported healthy living, and their medical care systems have had an infamous reputation of uncertain availability, low quality, and high cost. In some states, medical expenses incurred while incarcerated individuals have had consequences beyond release.

For many returned citizens, such medical bills have resulted in debt that has followed them into collection. 

Anna Anderson, a staff attorney at the National Consumer Law Center, wrote about this phenomenon in the report “Medical Debt Behind Bars: The Punishing Impact of Copays, Fees, and Other Carceral Medical Debt.” 

In her report, Anderson examined how persons in prison generally do not have access to private or public health insurance coverage that could pay for various fees or cover their medical care. 

 “Many people who are incarcerated are low income and from low income families, making it impossible in most cases to afford any medical fees they are charged,” wrote Anderson. “Overcrowding, poor nutrition, family disconnection, and violence are all common elements of carceral life, leading to adverse physical and mental health outcomes,” she added.

Citing an absence of comprehensive data, Anderson acknowledged that she did not know the full extent of the problem, but said she felt confident the data suggested the numbers as “substantial,” and especially relative to the limited financial resources most incarcerated and formerly incarcerated people have.

Anderson’s report blamed high cost having prevented incarcerated persons from seeking care, which had worsened their health. In Nevada, “more than 82% of respondents reported avoiding getting medical help because of how much the fees cost,” she wrote.

Much of Anderson’s research for the report in fact came from Nevada. She referenced a study by the Fines and Fees Justice Center that revealed an audit of the Nevada Department of Corrections. Her largely anecdotal evidence revealed the state attempting to collect “over $100,000 from one man after he was released from prison for outstanding carceral medical debt.”

Anderson discussed some states practicing elaborate cost-shifting schemes to game the system. Texas and at least 24 other states routinely shifted medical care costs for incarcerated persons by releasing on “medical bonds” or “medical furloughs” any incarcerated persons in need of medical care “so that the jail will not have to pay the medical bill,” Anderson reported. “Once the person receives treatment and recovers, the sheriffs then often quickly move to rearrest and book the person back into jail.”

Another cost-avoidance scheme involved transfers, Anderson wrote. Some prisons “transfer the patient to outside hospitals or other third-party medical providers. These providers then submit claims to the facility or the facility’s healthcare contractor for payment. If the claims go unpaid, the hospitals and providers sometimes take steps to collect directly from the patient, even if they are still in the custody of the jail or prison system.”

Health care issues during incarceration have affected women more than they have affected men, the report stated. “Women are more likely than men to enter incarceration with health problems, and two-thirds of women lack health insurance before they are incarcerated. Incarcerated women also have additional medical needs related to pregnancy, menopause, cervical cancer, breast cancer, and more, and they tend to utilize medical services within prisons more than men.”

Anderson’s report made the key point that after release, many states have not canceled the medical charges incurred during incarceration. Anderson wrote she found “no consistent data as to how collections proceed, but some prison and jail systems may hire third-party debt collection companies to collect outstanding medical debts.”

Anderson’s investigation revealed that in Iowa “at least nine jails failed to follow state law and improperly charged and collected medical fees from incarcerated people.” Sheriffs charged and collected medical fees from incarcerated persons awaiting trial, a violation of Iowa’s due process code. “The jails were offsetting an incarcerated person’s financial accounts to collect medical fees without court orders,” a further violation of Iowa law. Even worse, “jails refused to make any changes even after being told they were not in compliance.”

Anderson’s report also listed some progress. Until 2023, incarcerated persons in Nevada incurred charges of $50 every time they went “man-down,” meaning a call for an emergency response by officers and medical staff, Anderson wrote. Nevada has since ended the practice.

More progress resulted from a lawsuit in Oregon that ended high fees for medical devices, the report declared. After an Oregon prison had denied an incarcerated person a necessary repair for a prosthetic limb, the device failed — causing a fall resulting in severe injury and surgery which led to almost $50,000 in medical expenses.

In worst-case scenarios, unpaid medical debt could lead to “collection calls, lawsuits, wage garnishments, license suspensions, and ruined credit. In some states, a missed court appearance for a debt collection case could even land a person back in prison.”

Anderson offered broad recommendations to eliminate medical fees and to provide free medical care in prisons and jails. Many of her ideas focused on procedural changes that would not necessarily require legislation.

“Saddling incarcerated people with medical debt leads to worse health and financial outcomes. This practice may also ultimately cost the public more money and damage public health. Addressing carceral medical debt is crucial to ensuring fair and equitable access to healthcare … and to reducing the overall burden of medical debt. Without additional reforms, individuals in jails and prisons will continue to suffer significant financial and health consequences,” Anderson concluded.