Last month, a local man pleaded guilty to writing a bad check and ended up in the Calhoun County Jail – sending Calhoun County officials into alert mode as they made phone calls, sent e-mails to and visited jail officials about this new inmate.

What was the problem?

According to Calhoun County Administrator Ken Joiner and Sheriff Larry Amerson, the man suffered from end-stage renal disease, and keeping him at the jail meant the county would have to pay $2,000 per dialysis treatment just to keep him alive.

“We can’t say to the inmate, ‘you’re going to cost us too much,’” said Amerson, referring to the fact that the county is mandated by law to cover inmate health care costs. “We have a real lack of control of medical problems.”


Cutting costs

But judging by the taxpayer money spent on inmate healthcare over the past decade, county and jail officials have better control over jail medical expenses than one might think.

For the last three years, taxpayers have shelled out fewer dollars than ever to keep Calhoun County Jail inmates healthy.

And local officials say the cost of inmate health care will continue to decrease. The Calhoun County Commission has lowered the jail medical budget by another 30 percent to $397,359 for fiscal 2011, down from $560,050 despite continued growth in the number of inmates.

“We have continued to look at what we can do so the taxpayers don’t have to pick up such a large tab,” Joiner said.

He, Amerson and Brent Cobb, the newly licensed nurse practitioner who oversees medical operations at the jail, all agree that a number of long-term and recent changes to jail health care management have helped cut costs without cutting corners.

“We have an obligation to take care of them (the inmates),” Amerson said. “But there are ways … of looking at … reducing the burden to taxpayers.”

County and jail officials point to the steadily decreasing health care budget as a sign of cost-cutting success.

Joiner attributes that success to two things.

One: Cobb’s December promotion to nurse practitioner from nurse means he can now perform most of the activities the commission used to pay doctors to do.

Two: Policies implemented in the last half-decade – like allowing non-violent, non-repeat offenders with high medical costs out of jail early, asking all inmates who require medical services to pay a $10 fee, and seeking reduced-cost contracts with local pharmacies, doctors and Anniston’s Regional Medical Center – continue to relieve the day-to-day and case-by-case expenses associated with medical care.

That’s a one-two punch that is “absolutely working,” according to Joiner and others on the Calhoun County Commission.

“Our actual expenditures are way below what we’ve budgeted (for jail health care this year),” said Faye Robertson, assistant administrator.


Actual versus planned expenses

Although the commission budgeted $560,050 for jail health care in fiscal 2010, actual expenses have been much less, records show.

Calhoun County taxpayers have spent $318,889 so far this year to provide the 450 to 480 inmates who live in the jail at any given time with a range of medical services – from routine check-ups to prescription allergy medications to more expensive care, like dialysis for diabetes patients and chemotherapy for inmates with cancer. That price tag may seem large, but it’s really not, according to jail and county officials. Broken down, taxpayers have spent, on average, $708 in medical costs per inmate this year.

The price per inmate doubles, though, if one takes into consideration that about half of all inmates need medical treatment on a consistent basis, said Lt. Eric Starr, the jail’s administrator.

That’s much less than the $2,976 an average American spends on health care each year, according to the U.S. Bureau of Labor Statistics.

And next year’s $397,359 proposed budget, thanks to Cobb’s new nurse practitioner role, means costs per inmate will be that low or lower, Joiner said.

Until last December, the commission paid $6,666 per week to four doctors from Anniston Family Practice who made rounds at the jail. But when Joiner saw that other county jails with in-house physicians and larger, on-site medical staffs were able to cut back on contract costs, he and the Calhoun County Commission decided to pay for Cobb to get his nurse practitioner’s license from the University of Alabama at Birmingham.

Cobb said the license allows him the freedom to perform a larger range of medical tasks – from diagnosing illnesses to giving shots – as long as he has a doctor supervising him. He passed the exam Monday and now the commission will only have to pay $3,333 per week – half of what it used to pay – to have two doctors as on-site supervisors, Robertson said.

Cobb said he feels fortunate to have the opportunity to serve as a nurse practitioner at the jail and thinks it will be a great benefit to local taxpayers.

“Our goal is to provide proper medical treatment for inmates, while doing so at the least expense for the Calhoun County taxpayers,” he said.


Monitoring inmates, seeking jail alternatives

While Cobb’s new position certainly helps lower jail medical costs, Joiner said the commission also owes much of its cost reduction to an inmate monitoring program it started seven years ago.

In 2003, the commission created a court liaison position to monitor every individual inmate’s charge, incarceration time, bond requirements and, most importantly, medical expenses. The idea was to work with Calhoun County judges to find alternatives to incarceration for nonviolent, non-repeat offenders who had expensive health care needs.

For example, if a young woman convicted of receiving stolen property was pregnant, she could be a candidate for probationary release so taxpayers wouldn’t have to shoulder her pre-natal care costs, Joiner said.

But until the court liaison position was created in 2003, there were plenty of inmates just like that hypothetical woman who got “lost in the system,” left sitting in jail until a judge picked up her case file, Amerson said.

And all the while, county taxpayers were paying hundreds of dollars for her health care.

“To us, the most important cases may be the least important charges or crimes but the people with the most expensive medical bills,” Joiner said.

Records show that before the court liaison position began, from fiscal 1999 to fiscal 2003, jail health care expenses – including medical services and prescription drug and medical supplies – steadily increased by nearly $100,000 each year. Then, the year after the commission created the position, health care expenses dropped nearly $200,000 and leveled off or only rose slightly until they began dropping steadily again two years ago, in fiscal 2008.

Both county and jail officials attribute the more manageable health care costs to the court liaison position.

But not everyone is excited at the prospect of judges allowing convicted criminals – whatever their charges – out of jail early based on medical costs, even if it means they have to wear a GPS tracking device on their ankles or attend drug abuse clinics.

Lt. Chris Roberson, commander of the Calhoun-Cleburne Drug and Violent Crime Task Force, said that kind of negotiation can make his job of keeping drug addicts off the streets a lot harder.

“Because people get right back out there and start using again,” he said. “It ticks you off to see all the good work you do to make a hard case go that way, especially because the ones (inmates) that know nobody will keep them (in jail) are selling as soon as they get out.”

But Judge Brian Howell said he and other county judges are more than aware of the problem that releasing certain nonviolent offenders, like those charged with drug crimes, can pose for local law enforcement.

“So we make sure drug offenses get extra conditions (before letting them out of jail based on cost of medical care),” Howell said.

Some of those extra conditions include electronic anklets combined with heavy probationary regulations – something Roberson said helps his officers keep tabs on drug offenders who don’t stay incarcerated.

And Joiner said it’s important to keep some of these people out of jail, because it’s too expensive for taxpayers to keep them behind bars.

“And we would never ask the judges to release someone who would be a threat to society,” he said.


A snapshot of inmate health

It’s nearly impossible to pinpoint the most common illness or health problem at the Calhoun County Jail because the types of diseases, illnesses and health afflictions are as varied as the inmates who are held there, Cobb said.

What is consistent, according Starr and Cobb, is the number of inmates who need care – usually about 50 percent or a little higher.

Starr said the drug- and alcohol-filled lives many of the inmates lead before incarceration is the main reason so many need medical assistance once they arrive at the jail. Amerson and Cobb agreed, but also pointed out there are plenty of inmates who have legitimate health conditions such as high blood pressure but never care about treating them until they get in jail.

“We have people who never take medication for their heart conditions until they get here,” Amerson said. “And then they want the prescriptions, because they know … if they get too expensive, they could maybe get out.”

Stanley Hickey, president of Selma-based inmate advocacy group Fairhope Inc., agreed that inmates’ pre-incarceration lifestyles make them more likely to have health issues but said most start treatment only once in jail, because they can’t afford to when on their own.

“And it’s simple, jails have a responsibility to let them have treatment,” Hickey said.

Cobb and the two nurses on his staff are required to treat any and every inmate who requests medical care, whether they simply need aspirin for a headache or an emergency appendix removal.

Although the $10 co-pay for all inmates who need health care is technically mandatory, Cobb said only about 70 percent of inmates can afford to pay. And those who can’t still get health care, he said.

And that means county officials like Joiner will continue to search for ways to provide care at the best bargain for taxpayers – which is just what they did for the man who needed those $2,000 dialysis treatments.

The County Commission struck up a bargain with a local Oxford medical clinic to provide the man with the same treatments but at a lower cost than a Medicare patient would pay – $350.

“(Inmate healthcare) requires constant attention and revisiting,” Joiner said. “But it’s worth it.”