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Report says some Iowa jails unlawfully charge inmates for health care

The Iowa Supreme Court heard oral arguments Wednesday in a lawsuit brought by a former public health department employee against the governor and other state officials.
Madeleine C King
A new report says Iowa jails are charging inmates for medical care and not following Iowa law as they do it.

A state investigation into jail health care fees found several county jails fail to follow Iowa Code.

At least nine Iowa jails are breaking the law when charging jail inmates for health care, according to a report from the state ombudsman’s office.

While investigating complaints from inmates, the ombudsman found some county jails take money directly out of inmate commissary accounts to pay for medical expenses, violating Iowa law.

“We’re calling for the Department of Corrections to make a change. We had a constructive dialogue with the department and they understand what the problem is so we want to encourage them to take the step of amending the rule that is causing the confusion," said State Ombudsman Bernardo Granwehr.

Jails can charge adult inmates for medical services, but only if they are convicted of a crime or sentenced for contempt of court for violating a domestic abuse order. Even if the inmate qualifies to pay, a jail must seek payment through the courts. It cannot be removed directly from a commissary account.

These rules date back to 2006 when state law clarified the circumstances under which a jail may charge an inmate for medical costs and how collection may be executed. After receiving complaints in 2017 about the practice in jails, the ombudsman found that part of the problem was an out-of-date section in the Iowa Administrative Code, the document that interprets and implements Iowa law. The ombudsman asked the Iowa Department of Corrections to lead the update of administrative rules to reflect Iowa Code. But the department declined to consider the rule change.

“(After the letter,) We assumed – incorrectly as it turned out – that jails were now aware of our position and would change their reimbursement practices to be consistent with Iowa law,” the report said. “To date, inmate complaints to our office about medical charges have continued.”

In response to the report, Department of Corrections Director Beth Skinner acknowledged the issue and agreed to bring it to the attention of the Iowa Sheriffs & Deputies Association.
“I clearly see what needs to be done and will take appropriate steps,” one unnamed jail administrator quoted in the report, adding, “I have read (applicable Iowa Code) hundreds of times for Room and Board, but NEVER put 2 and 2 together on the medical piece.”

Nine counties “inconsistent” in collection of inmate medical fees

Copays or copayments are commonly charged for health care in the United States. They’re fixed fees a patient pays to a medical service provider to receive services like a doctor’s visit, treatment or medication.

Since 2006, it has been legal for Iowa jails to charge inmates for costs related to medical treatment. But there is a process, and it isn’t always followed by county jails. The report details instances in Scott, Wapello, O’Brien and Mills counties in which inmates were charged for medical care and had their due process rights violated.

Iowa law requires county jails to provide medical care even though reimbursement for those services is not generally available.

“Nevertheless, an inmate’s due process rights cannot be ignored,” the report said.

In a 2022 complaint, a Scott County inmate served two separate stints in the jail. The jail billed his account for $118.50 for medical services, with $98 taken before his conviction. The remaining $20.50 came out of his account during his time in jail post-conviction. The jail never sought reimbursement through the courts.

To get reimbursed for medical expenses, Iowa Code requires a sheriff to file a claim with the clerk of the court with information on the incarcerated person and the charges they wish to have reimbursed. The process gives inmates a chance to object to the legal basis of taking the fund and to identify human errors in fee calculations. This is also important because a jail directly charging an inmate’s commissary account could jump the priority of an inmate's other potential creditors, for example, a child support payment.

In another complaint from 2022, a Scott County Jail inmate was charged $129 for medical services. He was arrested on three warrants, only one of which was a criminal charge. The other two were for contempt of court for not paying child support. The criminal charge was dismissed — meaning he wasn’t convicted of a criminal offense. While he was there for contempt-of-court charges, they involved child support, not a domestic abuse order. The ombudsman’s report says this doesn’t comply with Iowa Code.

In Wapello County, the jail deducted $130 from an inmate’s account for medical services. The inmate had not been convicted and did not qualify to be charged for medical services. When the ombudsman’s office asked the jail administrator if they would refund the $130, the administrator declined.

“As for returning money back to (the inmate)," the administrator wrote, "it would create accounting discrepancies and to be fair we would have to do the same for others.”

Rather than following state law, Wapello County Jail has its own process laid out in a form titled “Inmate Medical Policy and Fees.” It advises inmates that the jail will take money out of their accounts for medical services. The report points out that nowhere in Wapello's form does the county explain deductions will occur only after a person has been convicted.

The O’Brien County jail charged another inmate $197.54 for medical service. The jail told the ombudsman that the inmate signed a waiver making her responsible for paying those costs.

Most of the counties investigated by the ombudsman’s office declined to alter their process. But in Mills County, after the ombudsman intervened, the county corrected its process to comply with Iowa law.

“Among the 12 county jails that we contacted, Mills County is the only one that we found to be in general compliance with (Iowa Code), having changed its practice after our investigation,” the report said.

Jail copay a 'drop in the bucket' for health care costs.

While charging copays for medical treatment is a widespread practice in Iowa jails, they don’t recoup costs. In 2022, Scott County spent $370,000 on medical aid for inmates. Inmate accounts were charged $7,440, and the jail collected less than $3,000.

If the amount collected is so small — less than 1% of the cost to provide service — the report says it begs the question: "why the jail charges a co-pay?”

“It is not so much about financial impact as it is evaluating real medical needs versus fictitious demands,” said one Scott County assistant jail administrator quoted but not named in the report.

Groups like the National Commission on Correction Health Care oppose fee-for-service and copayment programs for inmate health care. They argue that inmates are disproportionately in poverty with a higher incidence of drug use. They are less likely to seek treatment in the first place for a serious medical problem. Using co-pays as a hoop to jump through, they argued, only makes patients less likely to get the care they need.

“This is not a money maker for jails. It's really a drop in the bucket compared to the services provided," Granwehr said.

An unnamed former jail administrator in Mills County was quoted in the report saying she believed inmates with medical needs should not be allowed to buy commissary products as they would “spend their last dollar on a candy bar” and the county would receive nothing.

Iowa has considered dropping copays. In 2020, the state stopped charging prison inmates copays for medical services for flu, respiratory or COVID-19 symptoms. But according to a 2022 Prison Policy Initiative report, it has since resumed the practice.

Zachary Oren Smith is a reporter covering Eastern Iowa