People in Tarrant County’s jails get sick like everyone else. For the smaller things, they can get care from inside the jail. But when dire emergencies strike, correctional health staff call an ambulance. That’s where the problem starts.
Neither Tarrant County nor its hospital district, JPS Health Network, pay for ambulance rides for inmates coming from the county’s jails. Instead, those bills go to the incarcerated people themselves — and the majority can’t or won’t pay.
In all, MedStar is owed about $2.6 million from transports in 2022. To stop the bleeding, MedStar has been quietly lobbying Tarrant County and JPS to share the financial burden.
In the 2022 fiscal year alone, MedStar shuttled people from the Tarrant County Corrections Center to JPS Hospital an average of three to four times a day, racking up thousands of dollars in costs with each trip. Sometimes the EMS provider can bill a person’s insurance company, Medicaid or Medicare, but most of the incarcerated in need of transport are uninsured.
The average payment MedStar collected from uninsured Tarrant County Corrections Center patients last year? $2.36.
Paramedics responded to fewer calls at the county’s Green Bay Jail last year, but collection rates from services to that facility were even worse. In 2022, MedStar received $0 in payment from uninsured people at the Green Bay facility, which operates at 2500 Urban Drive.
“The reality is that we’re providing services that are not being reimbursed for, and that’s contributing to our economic challenge,” Matt Zavadsky, MedStar’s chief transformation officer, said.
Like other EMS providers across the country, MedStar is facing a sharp decline in revenues and increasing costs. MedStar began ringing the alarm in earnest earlier this summer, when its leaders informed Fort Worth City Council it would likely need a multimillion dollar subsidy to maintain current service levels through the next year.
That dire financial situation has prompted the provider to reconsider bills it previously had been letting slide, including those to the Tarrant County jails. Advocates say the situation is worsened when incarcerated people don’t receive care until it becomes a crisis, leaving an ambulance trip as the only option.
If Tarrant County or JPS stepped in to help pay for the ambulance rides, MedStar’s annual subsidy needs would decline. A Tarrant County spokesperson told the Fort Worth Report the county believes any potential responsibility for the ambulance bills lies with JPS Health Network, not the county. Under state law, counties aren’t required to pay for incarcerated people’s emergency medical care.
A portion of the law does require hospital districts to provide care for county residents who can’t pay. And in 1993 and 1996, the Texas attorney general held that hospital districts are responsible for the medical costs of indigent people in county jails.
To meet that obligation, other comparable hospital districts pay for ambulance rides from county jails as part of an agreement with their respective county governments.
Until this year, MedStar never considered invoicing JPS Health Network for jail ambulance rides. Zavadsky said they weren’t aware it was an option.
Now, he said, it’s on the table. In a statement provided to the Fort Worth Report, JPS acknowledged its responsibility to provide health care to indigent residents, including those incarcerated. But hospital officials did not state whether they felt paying for ambulance services fell under that responsibility.
“MedStar has not invoiced the hospital district for any ambulance transportation services until recently, and we are working with MedStar and the county to better understand those charges,” Jessica Virnoche, executive director of communications for JPS Health Network, said. “We cannot comment as to whether we agree with the charges until we have those conversations.”
A vulnerable population
People accused of crimes enter Tarrant County jails with empty pockets. The only money they can access is in their commissary accounts, filled by family or friends. Some lacked the resources to pay for necessities like food and shelter, let alone medical care, before they were ever incarcerated.
And across the county, nearly 20% of residents under the age of 65 live without health coverage, according to 2022 census data. While insurance coverage data isn’t available for all people inside the county’s jails, of those transported by MedStar last year, nearly 70% were uninsured.
Residents who can’t pay for care and lack health insurance are often considered indigent under the law. The Indigent Health Care and Treatment Act mandates hospital districts provide free or low-cost health care services to residents with incomes below a certain level.
JPS Health Network is one such hospital district. To join the JPS indigent care program, a county resident must fill out an application that attests to their residence, citizenship, monthly income and health insurance status.
Once accepted, residents are eligible for coverage of a variety of medical services.
But despite many incarcerated people meeting JPS Health Network’s definition of indigency, they are left on their own when it comes to paying for ambulance rides. Over the past four years, MedStar has transported people 6,257 times to JPS Hospital from the jail — and subsequently sent out bills.
Michele Deitch, director of the Prison and Jail Innovation Lab at UT Austin, said incarcerated people have a constitutional right to receive care for serious medical needs. If a medical problem requires a trip to the hospital, she said, it’s likely serious.
Research shows many people in county jails have serious underlying medical conditions; Tarrant County Sheriff Bill Waybourn has previously said this also holds true for those in Tarrant County jails.
“When the [government] incarcerates someone, it takes on the obligation to meet all of their needs, whether those are feeding them, housing them, or providing medical services,” Deitch said. “Because people who are incarcerated can’t do that for themselves.”
A question of consent
Outside of jail, residents can refuse medical care — and many do. A recent poll from Texas 2036 shows 41% of Texans have postponed or skipped care because they didn’t know what it would end up costing them.
But when it comes to emergency medical care in jail, advocates say opting out of care — and the related bills — isn’t an option.
“If people are being rushed in an ambulance to the hospital from a jail, that usually means that they were denied timely medical intervention, and it’s been allowed to become a crisis, so now you have no choice but to rush them to the hospital,” Krishnaveni Gundu, co-founder of the Texas Jail Project, said.
The top complaint Gundu’s organization gets from incarcerated people is that they didn’t receive timely medical care. The Texas Commission on Jail Standards, a regulatory body that oversees county and municipal jails, reported 30% of the complaints it received in 2022 were about medical services.
“They have no choices,” Gundu said. “They’re literally captive consumers.”
Getting emergency care while incarcerated can have long-term financial ramifications. Tarrant County has the highest concentration of medical debt out of the 20 most-populous counties in the U.S., according to a review of credit bureau data by Kaiser Health News.
For incarcerated who were already indigent, accruing medical debt is a serious issue. Ambulance rides from the jail can cost between $1,000 to $2,000, according to EMS transport data reviewed by the Fort Worth Report. Wholly uninsured patients may have their bill written off as charity care, but it isn’t guaranteed. And if there’s a gap in insurance coverage, insured patients are responsible for the remainder of the bill.
Deitch said carrying debt makes the reintegration process even more difficult for someone exiting jail. They may have difficulty paying bills or getting approved for housing.
“When you’ve got all of these bills that are hanging over your head, it can be overwhelming and doesn’t allow a person to get a footing in the community,” she said. “That actually could lead to people engaging in criminal behavior again, to try to make money to pay off some of that debt. So, it’s not smart from a public safety standpoint, either.”
When hospital districts step in
There are more than 100 hospital districts across Texas. These districts are government entities that levy property taxes to pay for medical services to the community.
Parkland Health in Dallas County, University Health in Bexar County and JPS all serve counties with between 2 million and 2.6 million residents. All three hospital districts provide inpatient medical services to people inside county jails — but they differ in how they handle coverage of ambulance rides.
April Foran, public information officer for Parkland Health, said the system has been tasked by the Dallas County Commissioners Court to provide health services to the county jail.
When ambulance transports are necessary, the hospital district absorbs those costs into its budget, Foran said.
Foran also said the Eighth Amendment, which prohibits cruel and unusual punishment, ensures incarcerated people are entitled to health services while in jail.
“In fact, they are the only group to be constitutionally guaranteed health services because to not provide health services to an incarcerated person would be considered cruel and unusual punishment or possibly, in extreme cases, an extrajudicial death sentence,” Foran said.
In Bexar County, University Health receives a bill from the city of San Antonio (which provides EMS services) when an incarcerated person is taken in an ambulance.
Shelley Kofler, senior public relations manager for University Health, said hospital staff who work at the jail then review records to make sure the person was in custody and proper protocol was followed to call for the ambulance.
Once those details are confirmed, the hospital district pays for the ambulance ride, Kofler said.
JPS is the only one out of the three hospital districts that does not have an established policy for reimbursing jail ambulance care.
Deitch, the UT Austin professor, said it’s difficult to argue under the law that incarcerated people should bear the full cost of ambulance rides. Even copays, like those required by the Texas Department of Corrections, are controversial.
“There’s nothing that says you have a constitutional right to receive medical care — and you have to pay for it at the same time,” she said.
At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here. Emily Wolf is a government accountability reporter for the Fort Worth Report. Contact her at firstname.lastname@example.org or via Twitter.