The Department of Corrections has seen its medical costs for staff, treatment, and medications increase so much, it projected a $6.5 million shortfall in its medical budget this fiscal year. (Courtesy)
Over the last several months, the Department of Corrections has needed an additional $6.5 million to keep up with inmate medical costs, including a 176 percent increase in ambulance costs since 2022. It’s not alone among correctional facilities.
The superintendent of the Cheshire County jail has seen some medical costs jump 25 percent since last year. Merrimack County jail is looking at a 15 percent increase in its next budget. Unable to recruit medical staff to work in its jail, Rockingham County increased wages by $162,000.
The causes are many, from huge increases in the costs of some medications and a new approach to treating substance use disorder behind bars, to sicker patients with expensive medical needs. The costs fall to taxpayers even for the many inmates who had Medicaid insurance because they lose that coverage while they are incarcerated. And while state law allows prisons to parole people for medical reasons, the cost of their care is not among them.
Congresswoman Annie Kuster has introduced federal legislation several times that would allow inmates to keep Medicaid while incarcerated. She reintroduced similar legislation in May, saying it’s good both for inmates who can maintain their health care and counties and states that are picking up the costs. So far, she’s been without success.
Doug Iosue, superintendent at the Cheshire County jail, has a $50,000 budget for medical care provided outside the jail for his approximately 100 inmates and one inmate who needs dialysis at a cost of $6,000 a month.
“The thing that goes to the larger issues for me is that health care costs are resting with corrections in a way that I don’t think serves the best interest,” Iosue said. “(People) end up in the system incarcerated and … jails and prisons were not designed to be hospitals, health care providers, detox centers, and mental health providers.”
While counties and the state are seeing costs spike, the drivers are not identical.
Medical treatment isn’t optional
Within the state’s prisons, a few things are driving the projected $6.5 million shortfalls in the medical budget this fiscal year: higher costs for medical staff and care, and significant price increases for certain medications.
In February, Corrections Commissioner Helen Hanks told lawmakers and the Executive Council she needed an additional $5.69 million for staffing and medical care alone.
The health care workforce shortage plaguing all providers has not spared the department, especially when it comes to registered nurses, Hanks wrote in a request for additional funding, which was approved.
The vacancy rate for nurses was 17 percent across all prisons when Hanks made her request in February and 27 percent at the men’s prison in Concord.
The double challenge of competing with higher-paying private employers and treating convicted felons in a dangerous setting has been so hard to overcome that the department went eight weeks with no response to job ads for a single nursing position, Hanks wrote.
That’s forced the department to rely more heavily on pricier temporary staffing agencies, which it has always needed but to a lesser extent. That cost went from $358,000 last year to $1.7 million this year, Hanks said.
The cost of medical care has jumped since last year, too, with anesthesia costs up nearly 48 percent and eye care up almost 55 percent. And, the department has been scheduling more procedures this year after having to postpone care during the pandemic when providers prioritized treating COVID-19 patients.
Meanwhile, the department signed a new medical care contract with Wexford, a Pennsylvania company that provides staffing and services in correctional settings. It’s a 23 percent increase over its prior contract with another company, Hanks wrote, but it adds necessary medical providers, including an oral surgeon, podiatrist, psychologist, and two more licensed alcohol and drug counselors.
“While the cost of providing medical care to residents has increased this year, (the) cost pales in comparison to the litigation costs faced by not providing these legally required medical services,” Hanks warned lawmakers and executive councilors. “The New Hampshire Department of Corrections takes our constitutional obligation to provide adequate medical care to residents very seriously, and we are confident we are fulfilling this obligation.”
Meanwhile, the department projects a $765,000 shortfall in its medication budget. Hanks covered some of that jump by transferring nearly $286,000 in unspent department funds. She received an additional $479,000 from lawmakers and councilors for the rest.
An increase in inmates with Hepatitis C has driven up expenses for those medications, for a cost of $873,500 for the 61 inmates the department expects to treat this year, according to Hanks. That’s with discounted prices provided by the federal government.
Other drug prices are also up.
The cost for long-acting antipsychotic medication has climbed by nearly $107,000 over last year, to nearly $280,000 this fiscal year. The cost to treat a single inmate with the drug Jakafi, used for certain bone marrow disorders, is nearly $196,300 a year.
Paula Mattis, the department’s director of medical and forensic services, said in an interview that the department is continually looking for less expensive treatment alternatives and ways to lower drug prices, which includes a rebate program being offered by the vendor that manages the department’s pharmacy program. Mattis said a grant from the Department of Health and Human Services helps with the cost of opioid treatment, a significant expense.
‘It’s the right thing to do’
Treatment expenses in jails are different from those in prisons in part because jails carry an inmate’s medical costs for much shorter periods of time. Where prison sentences can be years long, the jail may house someone from a few days to a year.
Several jail superintendents said they are not treating people with non-symptomatic Hepatitis C, for example, as their 84-day course of treatment can run longer than a sentence. But treatment for opioid use disorder makes up a significant portion of county jail budgets, as does mental health care.
“If I had to talk all day about something, it would be the mental health we are dealing with every day,” said Travis Cushman, superintendent of the Merrimack County jail, where the average daily census is 136. “Mental health is the No. 1 thing to talk about.”
State court and county officials have launched a new effort to divert that population and those with substance use disorders to treatment and out of jail and prison. It will be months or longer, however, before those initiatives produce results.
Before Cushman hired a private company to provide medical staff and care, he went six months without an in-house mental health provider. The Lakes Region Mental Health Center in Laconia is helping provide those services, but Cushman said the new contract will take over that staffing soon.
Temporary staffing agencies were not a good option, he said, because they are expensive and unreliable.
“I personally always want to keep county positions and county jobs,” Cushman said. “I personally only want to contract out when it’s absolutely necessary, and we had reached a point where it was absolutely necessary.”
Like the Department of Corrections, jails are seeing increases in the number of inmates who need medication-assisted treatment for opioid use disorder. Cushman said 28 percent of his jail population is on MAT.
County jails have been required by law to provide that treatment for opioid addiction since 2021.
Cushman, like other jail superintendents, is hoping to recover some of those costs with funding from the New Hampshire Opioid Abatement Trust Fund. The county has requested $1.1 million to cover its costs for the last three years.
“It would be really nice to get some of that,” he said. “When it came out that we had to offer (medication-assisted treatment) and we adopted the program, it was essentially an unfunded mandate.”
Jason Henry, superintendent of the Rockingham County jail, said the medication is only part of the cost carried by taxpayers. Henry must also assign staff to monitor inmates while they take the medication and afterward in case they have a reaction.
Henry opposed the legislation mandating medication-assisted treatment without state money to pay for it. “We screamed to the high heavens,” he said.
But Rockingham County has chosen to house a methadone clinic inside the jail since 2020, unique among the state’s 10 counties. Inmates begin treatment early into their stay, and the jail arranges continuing treatment after their release. The cost combined with an aging inmate population, a prevalence of mental illness, and even dental care is straining his budget.
“People think community jails can do more than (jails) think we can do,” Henry said.
Henry has also submitted a funding request to the opioid trust fund.
Iosue, in Cheshire County, said referrals to outside medical providers are increasing at a significant cost. He’s fit the $6,000 a month dialysis treatment for one inmate for now, but that will become harder if the inmate is with the jail for an extended time. But he knew he couldn’t also afford the chemotherapy for another patient, at a cost of $127,000 per treatment.
With the support of the prosecutor and defense attorney who handled the man’s case, Iosue was able to release him with an electronic ankle monitor. On the outside, Medicaid will cover the cost. It was possible, Iosue said, only because the man was not a violent offender.
The mandated medication-assisted treatment is not a cost the county can avoid. Iosue said the percentage of inmates receiving suboxone or methadone in Cheshire County has gone from 20 to 50 percent in the last several years. In addition, the county has expanded its use of medication-assisted treatment significantly in the last several years.
Initially, it was available only for pregnant inmates whose babies were at risk during the inmate’s withdrawal. Now the county provides the treatment for all inmates with opioid use disorder at least three to four weeks before their release, hoping it will encourage them to remain in treatment after release, even if they were not on it when they were incarcerated.
The jail is also providing inmates with mental health treatment within 10 days of arrival.
“It’s the right thing to do based on best practices,” Iosue said. It’s also become necessary, he said.
“We are certainly the default medical provider in the community,” Iosue said. “We are certainly the biggest detox center.”
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