Even though Texas' prison population shrank this decade, the publicly funded costs to treat inmates' medical conditions continue to rise.
The state spent over $750 million on prison health care during the 2019 fiscal year, a 53% increase from seven years earlier, when that cost was less than $500 million.
The main reason, according to experts and officials: an older, sicker prison population.
While the total prison population declined by 3%, the number of inmates ages 55 and older increased by 65%, according to Texas Department of Criminal Justice data. Inmates over 55 account for about one-eighth of the population but nearly one-half of the system’s hospitalization costs, according to prison officials.
Nearly 150,000 incarcerated people rely on TDCJ to deliver their health care. Officials say the aging prison population and treatments for expensive diseases like hepatitis, HIV and cancer are driving up costs. Medical costs for the 10 most expensive inmates surpassed $3.1 million in 2019, according to a TDCJ document.
Cost-saving measures include telemedicine and access to discounted pharmaceutical drugs through a federal program. But experts say systemic change — like paroling more aging inmates and keeping people with mental illness or substance abuse out of prison — is needed to curtail expenses.
Texans shouldn't expect costs to come down if the state continues to incarcerate "the same kind of demographics you're sending to prison now," said Owen Murray, vice president for the University of Texas Medical Branch’s Correctional Managed Care.
“I think a lot of the low-hanging fruit has already been trimmed,” said Marc Levin, the vice president of criminal justice at the Texas Public Policy Foundation. “It's always good to look for other efficiency options, but I do think to some degree, if we don't address the prison population and medical parole issues, we're kind of going to be tinkering around the edges, as far as achieving either a cost reduction or even just holding the line.”
Despite ballooning costs, some say the system fails to adequately address their needs. And as lawmakers try to contain costs, some — including plaintiffs in an ongoing federal lawsuit — suggest TDCJ’s understaffed health care system does not meet constitutional standards.
“Some days, it's very questionable,” said state Sen. John Whitmire, who chairs the Senate Criminal Justice Committee.
The U.S. Supreme Court held in 1976 that prisoners have a constitutional right to health care. Since 1994, university providers with UTMB and Texas Tech University Health Sciences Center have provided medical care to Texas inmates.
But a class-action lawsuit filed in September alleges that TDCJ and UTMB have violated inmates' constitutional rights by denying them treatment with drugs considered the standard of care for Hepatitis C. The Food and Drug Administration approved the use of an antiviral drug in 2011 that has cure rates of over 90% and is now the standard of care for all Hepatitis C patients. But the complaint states that TDCJ and UTMB officials only consider such treatment for inmates who already have liver damage, which indicates the disease is posing more serious health risks.
In Texas, at least 18,000 inmates have been diagnosed with the virus, and nearly 45,000 may be infected, according to the Houston Chronicle. Prison populations across the country commonly have a higher percentage of infected people since Hepatitis C is often contracted through shared needles.
“The prisons and the jails house disproportionate number of people who are addicted to substances,” said Maria Schiff, a senior officer at Pew Charitable Trusts who researches health care in prison systems.
Dr. Melanie Roberts, a pharmacist with TDCJ, said free-world prevalence of Hepatitis C is about 1.5%. In 2018, she reported that number was 12.9% within the prison population.
HIV and Hepatitis C account for more than half of UTMB’s pharmaceutical drug costs. If plaintiffs in the ongoing lawsuit are successful, that percentage could increase.
Hepatitis C treatments have become more and more expensive in recent years, and that trend is expected to continue, Murray said. A spokesman for TDCJ said the agency cannot comment on pending litigation.
During a 2018 meeting, Roberts said the cost per patient per course of treatment was $17,308 — down from an estimate of $63,000 Murray gave lawmakers in 2014.
People with mental illness are also overrepresented in prison populations. Moreover, prisons are not healthy places, said Homer Venters, former chief medical officer for the New York City jail system.
“It’s not so simply the notion that people come to prison or jail with health problems, it’s that many of the conditions they encounter make those health problems worse and create new health problems,” he said. “And those are very, very costly.”
Solitary confinement, Venters said, can create new mental health problems — and exacerbate existing challenges inmates face. But experts also point to high incidences of chronic conditions like diabetes, high blood pressure, asthma and epilepsy. Over 40,000 inmates are diagnosed with high blood pressure, and another 9,200 have diabetes, Murray said.
“We had a completely different age and disease demographic makeup back 20 years ago than we do now,” he said. “We have patients who are … much older and have more comorbidities and have more medical issues than the cohort we used to take in 20 years ago.”
"You need people on site"
Staffing remains another challenge for university providers. UTMB averages about 300 vacancies among its 3,100 full-time positions, Murray said. Up to a quarter of licensed vocational nurse positions are unstaffed, he said, adding that UTMB uses nursing agencies to fill in the gaps.
University providers asked for $12.3 million last year to provide “market level adjustments” for prison medical staff. But a market level salary may not solve the shortage, according to Murray.
“Sometimes paying a market salary doesn’t really help us,” he said. “We have to pay above market to incentivize people to want to practice in probably what would be seen by the public as a less desirable environment.”
TDCJ uses telemedicine to facilitate visits between patients and doctors, mostly for primary care and mental health check-ins. Telemedicine allows doctors and patients to communicate via cameras and monitors rather than in person. Murray reported 140,000 visits via telemedicine during the past year.
Supporters say telemedicine improves access to care for inmates and safety for health care professionals while reducing the cost of providing security to accompany inmates off prison grounds for medical care. One study reported telemedicine saved Texas $780 million from 1994 to 2008. Others say telemedicine fills an important gap but shouldn't replace on-site, in-person care.
“They swear by it, and it probably is cost effective,” Whitmire said. “But I ain't so damn sure. It's not the way I'd want my family treated.”
Venters added that patients may not be able to communicate all their health needs during a virtual visit. Murray said telemedicine has helped ease staffing shortages because it allows university providers to hire health care professionals in more populous places instead of paying a premium for someone to work in more rural areas near prison facilities.
But telemedicine may not address specialized needs.
“You can't do teledentistry. You can't do telenursing,” Murray said. “You need people on site.”
Rethinking medical parole
Texas offers a form of medical release — called Medically Recommended Intensive Supervision — to inmates who are terminally ill or have serious physical or mental impairments. But inmates convicted of an aggravated offense like murder, sexual assault or a felony with a deadly weapon are not considered for release unless they are diagnosed with terminal illness or require long-term care.
Murray said UTMB refers anybody who qualifies to the Texas Correctional Office on Offenders with Medical or Mental Impairments. Over 2,100 inmates were screened in 2018, but just 63 were ultimately approved for parole. A TDCJ spokesman said inmates may be ineligible if they have already been approved for parole, don't meet clinical criteria or refuse medical parole.
"It's not like we don't have a lot of people that that meet the clinical criteria," he said. "It's that unfortunately, most of those guys have an offense that won't let them get considered."
Experts and legislators say the parole process could be more forgiving to aging offenders with significant impairments.
"Well, nobody's tougher on crime than me, but once you've incarcerated a guy past the point that he's a threat to anybody, I'd like to save that $500,000 to put him in a nursing home as a condition of parole, take that money, and spend it on either other public safety efforts or prison costs," Whitmire said.
Scott Henson, executive director of the criminal justice reform nonprofit Just Liberty, said many aging prisoners have long sentences for serious crimes but no longer pose a public safety risk.
"Most of those gray hairs, if they get out, aren’t going to take their walker and go on a crime spree,” Henson said.
More than 10,000 inmates over the age of 55 are incarcerated for serious felony offenses, according to a TDCJ spokesman.
Levin suggested reevaluating eligibility requirements — such as who qualifies as terminally ill — and including medical experts in parole board decisions.
"The bottom line is the public wants us to focus incarceration on people we're afraid of, people that are currently dangerous," he said.
Policymakers can combat costs by keeping people from entering the system in the first place, too.
State Rep. James White, a Hillister Republican who chairs the House Corrections Committee, said his committee will continue to work on diverting more people who experience mental illness and substance abuse into treatment-based services.
"The cost is cheaper, obviously," White said. "They're more effective. And also, anytime — appropriately — you can keep people from going deeper into the criminal justice system, that is a win for everyone."
Correction: A previous version of this story misstated one of the university providers that provides medical services at Texas prisons. It is Texas Tech University Health Sciences Center.
Disclosure: The University of Texas Medical Branch, the Texas Public Policy Foundation and Texas Tech University Health Sciences Center El Paso have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.