Gatekeeping Wellbeing: Healthcare Copayments While Incarcerated as a Barrier to Good Health

Abstract Introduction Healthcare copayment policies in US prisons create financial barriers to accessing care, particularly for individuals with little or no income. During the COVID-19 pandemic, some state Departments of Corrections temporarily suspended copayments, offering a unique opportunity to evaluate the impact of these policies on health outcomes. Methods Using data from the COVID Prison Project (April 2020–June 2021), we analyzed COVID-19 testing and policy data from 40 state prison systems and Immigration and Customs Enforcement (ICE). Facilities were grouped by copayment policy: never charged, suspended all copayments, suspended only COVID-19-related copayments, or maintained copayments. We used generalized estimating equation log-binomial regression models to estimate the risk of high COVID-19 transmission (≥10% positivity), adjusting for masking and social distancing policies. Results Facilities that suspended all copayments had a 42% lower risk of high transmission compared to those that never charged copayments. In contrast, facilities that suspended only COVID-19-related copayments or maintained copayments had a 60% and 87% higher risk of COVID-19 transmission. Conclusion These findings suggest that copayment policies may deter timely healthcare access and contribute to disease spread. Policymakers should consider eliminating copayments in correctional settings to improve health outcomes and reduce public health risks.