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Rural Hospital CEOs Call for Medicaid Expansion in N.C.



In this Wednesday, Dec. 19, 2018 file photo, North Carolina Gov. Roy Cooper speaks to the Associated Press during an interview at the Governor's mansion in Raleigh, N.C. In a roundtable discussion with rural hospital executives, Cooper increased pressure on Republican state senators to support legislation that would expand Medicaid coverage to uninsured adults who don't meet current requirements. A similar bill was proposed in 2017, but failed after GOP opposition. Photo: AP Photo/Gerry Broome, File

A group detailed to Gov. Roy Cooper the problems they have keeping their doors open and bills paid.

At a roundtable meeting April 24, CEOs of rural North Carolina hospitals explained to Gov. Roy Cooper and state Health and Human Services Sec. Mandy Cohen that expanding Medicaid would help their institutions keep the doors open.

There were some common elements to all their stories. For starters, all of their hospitals are operating on thin margins.

The group nodded in agreement as each talked about excessive use of their emergency departments and the uncompensated care resulting from ED patients who were uninsured or unable to pay.

Adding to their problems, many said they have a difficult time recruiting medical professionals, and that their counties are turning into “doctor deserts.”

The consensus was that Medicaid expansion wouldn’t solve all their problems overnight, but they agreed it would go a long way to relieving pressure on their emergency departments and create a healthier patient population.

“We can talk about the present, but we really need to talk about where we are going to be in three to five years,” Chris Lumsden, CEO of Northern Hospital of Surry County, told the group. “This issue is monumental to us. [Medicaid expansion] is something we can do today that will impact patient care and economic development down the road.”

In North Carolina, there have been six rural hospital closures since 2010. Across the U.S., there have been 104 closures during that same time, according to data compiled by the UNC Sheps Center for Health Services Research.

Cohen said that 80 percent of the hospital closures nationwide occurred in states that didn’t expand Medicaid.

Big employers

The CEOs’ pleas have some backing from the research. Greg Tung, a health economist from the University of Colorado, found in his research that Medicaid expansion has had a positive impact on hospitals’ financial situations and that they were less likely to close their doors.

Rural hospitals are most at risk for closure in states that did not expand, he said.

“Rural hospitals tend to be in a more financially precarious situation compared to urban hospitals,” Tung told NC Health News.

He said this has a trickle-down effect to the rural economy surrounding each institution.

“Rural hospitals are anchor institutions in their communities. They are kind of a pillar of the local community and the local economy, they provide a lot of skilled, well-paying jobs for that area,” he said. “So when a rural hospital closes, it has a disproportionately large impact on that community, especially in comparison to an urban hospital closure.”

Lumsden said the financial stability of his hospital is vital to the health of the surrounding economy.

Northern Hospital employs 900 people, not including physicians, and it’s one of the largest employers in the area.

“The issue of Medicaid expansion needs to be dealt with quickly,” Lumsden said.

Uncompensated care

Lumsden also brought up the large amount of uncompensated mental health care his emergency department provides. Currently, Northern Hospital averages 50 to 60 involuntary commitments a month.

“They are sequestered in the ER department for sometimes days,” he said. “They are complex, difficult patients. Very tough on staff. And we don’t get paid. We provide at least a million dollars of free care to [involuntary commitment] patients and that just adds to the dynamics.”

Michael Nagowski, CEO of Cape Fear Valley Health System, said he has one of the busiest emergency departments in the state with 140,000 visits a year to one ED. More than 20 percent of Cape Fear’s ED visits are uncompensated.

“We see the things that should be handled in the urgent care or primary care, but they won’t accept those patients,” he said. “If you don’t have a payer source, some people just don’t go until it’s a real emergency. Now we have a cost of care issue at another level.”

“And think about the human impact,” he said. “Let’s catch you before you’re diabetic. Let’s catch you before you have heart disease.”

Cohen echoed Nagowski’s remarks, pointing out that conditions such as high blood pressure are manageable with the right medications.

“What happens when you don’t take your blood pressure medicine is you end up in the emergency room with a stroke,” Cohen said. “And caring for a stroke is not only enormously expensive, but that person is not going back to work, certainly not right away.”

“Now we’ve not only lost a worker for one of our businesses, but someone who is the breadwinner for their family, and now they are in medical bankruptcy,” she said. “And you have uncompensated care.”

Cohen said she often finds herself explaining to people with health insurance how Medicaid expansion will benefit them.

“It’s actually keeping the hospital doors open for them,” Cohen said. “But also keeping prices down for everyone who is lucky enough to get insurance through their employers.”

‘All of it is negotiable’

Nash UNC Health Care CEO Lee Isley said he’s in favor of Medicaid expansion because “it’s the right thing for the community,” but he had a concern.

According to his calculations, closing the coverage gap would bring Nash UNC about $10 million, but under some Medicaid expansion proposals, the state’s hospitals would take on 10 percent the cost in the form of an assessment. For Nash, that would come to about $7.5 million. He added that moving to Medicaid managed care will likely cost his institution about $1.7 million, bringing his hospital right back to breaking even.

Isley told the governor that hospitals should take on part of that assessment, but he asked if it would be possible to share the cost with other health care entities.

Cooper said he was looking into putting some of that cost on insurance companies.

But does Medicaid expansion have a chance in North Carolina?

Cooper said there are enough votes to pass a GOP-backed version of expansion in the state House right now if the Republican leadership would bring it to the floor for a vote.

He expressed less confidence about prospects in the state Senate.

“Obviously the leadership of the Senate has some concerns about this, but we hope that all of it is negotiable,” he said. “It’s so important for us to take this step here in North Carolina.”

Some have expressed fear that the federal money to expand Medicaid might disappear, but Cooper said he doesn’t think it will. People in Washington D.C. have been trying to do away with these policies for the past two years and have not succeeded, he said.

“They couldn’t kill it,” he said. “One, because people need health care. Two, because Republican and Democrat governors in states that have expanded came to Washington and said, ‘This is working. Don’t take this away.’

“Plus you can write safeguards into the legislation that can stop coverage if the federal money dries up,” Cooper said. “But I don’t see this happening. If it didn’t happen in the last two years, it’s certainly not going to happen any time soon in a divided Congress.”

This article was originally published at North Carolina Health News.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at

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How Death Doulas Ease the Final Transition



Vivette Jeffries-Logan, left, and Omisade Burney-Scott are death doulas. They perform sacraments of soothing and release drawn from their West African and Indigenous spiritual traditions. Photo: Madeline Gray/YES! Magazine

End-of-life caregiving is an ancient practice that’s now re-emerging in the death positivity movement, which urges a shift in thinking about death as natural and not traumatic.

Vivette Jeffries-Logan and Omisade Burney-Scott are friends for life—and collaborators in death.

Three years ago, when a mutual friend realized she wouldn’t survive pancreatic cancer, the two central North Carolina women were within the circle of friends she summoned.

Over the course of about three months, the women stayed at Cynthia Brown’s side as the community activist and one-time Durham City Council member went about the process of dying.

They rubbed her head, kept a watchful eye on her pain, and helped her decipher doctorspeak. And when her spirits appeared to lag, they’d tell her jokes and sing at her bedside.

This, Jeffries-Logan says, was a good death: “If I can help someone at the end of life heal and be clear, I will. There are some things we are required to do alone, but we are not isolated. We are community people. What happens to my nation happens to me. What happens to me happens to my nation.”

Jeffries-Logan and Burney-Scott are death doulas; their form of caregiving is both old and new. The ancient Greek word “doula,” meaning “woman servant” or “slave,” was repurposed in the 1960s to describe birth workers who offer encouragement, back rubs and other assistance during childbirth.

These days, end-of-life doulas, sometimes called death midwives, are an emerging profession in the growing death positivity movement, which urges a paradigm shift for thinking and talking about death as natural and not inherently traumatic.

They provide nonmedical support to help ease the final transition for the terminally ill. But it’s not merely about that culminating moment, “The End.” They help the dying and their loved ones navigate death with all its “before and afters”—including sickness, acceptance, finding resources for all the legal housekeeping, funeral planning, and bereavement.

For Burney-Scott and Jeffries-Logan, it’s the highest calling.

Sisters in ritual, they performed sacraments of soothing and release drawn from their West African and Indigenous spiritual traditions. Burney-Scott is African American and was initiated in the West African Ife religious practice, and Jeffries-Logan is a member of the Occaneechi Band of the Saponi Nation, a tribe rooted in the North Carolina Piedmont region.

Being a death doula “is not fun. But it’s an honor,” says Burney-Scott, a healer and longtime advocate who most recently worked as a reproductive justice organizer in North Carolina.

She stumbled into the practice when her mother’s dear friend, a hospice nurse, showed Burney-Scott what to do at her mother’s passing. “I didn’t want to do it,” she says. “The thing I feared most, from when I was a little girl and even when my mom was healthy, was losing my mother. She was that mom that all my friends would talk to, the mom who could let you know [you] were the most special person in the world even when she was yelling at you to do your laundry.”

Near the end, her mother made her retrieve a manila envelope containing her will, insurance information, deeds—the bureaucracy of death. But without ever using the word “doula,” her friend guided Burney-Scott in ushering out of this world the woman who had brought her into it.

“Aunt Cora” encouraged Burney-Scott to whisper her love in her mother’s ear, to hold her hand, play music, and to be present in “an organic practice.” One day, when her mother struggled to breathe, Cora assured Burney-Scott that she didn’t need to fetch doctors—that nothing was wrong. “She’s leaving,” Cora told her, a simple statement that’s also a tenet of end-of-life care: Death can’t be controlled, but you can prepare for some aspects of it.

Because there is no universal or official training, no licensing and no regulation, there is no official estimate of how many death doulas operate in this country.

But death and dying are constant. And beyond the eulogies and coffins, there’s a clear and growing need for death-related services. The number of Medicare-approved home- and hospital-based hospices, for example, rose from barely 30 to slightly more than 3,400 between 1984 and 2009. A decade later, more than 4,500 exist, according to the Centers for Medicare & Medicaid Services.

Groups such as the International End-of-Life Doula Association and others train and certify doulas, providing hands-on experience, like a practicum. Still, many death doulas enter the field as Burney-Scott did, pressed into duty by a family member’s passing. Few can make it into a full-time, paying job. Others have a background in the clergy or are people of faith, are volunteers involved in work with the sick and shut-in, or are shamans or healers.

Still others become end-of-life doulas because they are nurses, midwives or health care professionals who, through experience, have come to know that the end of life is more than just what happens to your body.

Merilynne Rush, a nurse and home-birth midwife, co-founded Lifespan Doulas, an organization that trains and certifies end-of-life doulas. In three years, she says, the group has trained 200 people. She sees the need to educate and vet death doulas even while she thinks that community-trained doulas are valuable and necessary.

Vivette Jeffries-Logan, a citizen of the Occaneechi Band of the Saponi Nation, stands at the re-creation of her ancestors’ village site in Hillsborough, North Carolina. She spent eight years studying with elders. Photo: Madeline Gray/YES! Magazine

“There are so many people who are called in their communities [to do this] that no one should tell them they can’t,” Rush says. “I’d never be able to go into every community. That’s one reason for never having any kind of regulation that imposes a state-sanctioned structure that says you are in or out.

“At the same time, when you are working within a medical organization, they need to know you are OK and there are some standards,” she adds. “Training should never be mandatory, but optional.”

A diversity consultant who focuses on Native communities and trauma, Jeffries-Logan distrusts what she believes is a move toward professionalization.

Her death doula work is grounded in Indigenous customs, and communicating with the ancestors does not happen through curricula. Heeding a call from her ancestors, she did a traveling ceremony, designed to pave a deceased person’s road to the afterlife, for an infant relative who died before he turned a year old. As part of a common tribal custom, she won’t speak the name of the deceased aloud for a year; to do so could keep the spirit tied to its temporal life—now a thing of the past—and distract it from the arduous journey to the ancestors.

Neither she nor Burney-Scott takes money for what they do. Rather, they extend their services to family and friends based on existing connections and an understanding that death is cultural and clinical. “It’s not like I was going to roll up and do this with just anyone. I don’t do shallow-ass relationships,” Jeffries-Logan says.

She questions what happens when the training moves out of informal community pedagogy and into a classroom.

“Who’s the certifying body? Who has the funds to pay for services?” she asks. She thinks of formalizing death doula work in the same vein as yoga, an Indian spiritual system that has been co-opted from communities of color and networks of caring to be dominated by white instructors who teach a fraction—the poses, the breathing—of the whole for pay.

Both women know that communities of color lag in accessing end-of-life care—whether because of cultural beliefs, experience and well-founded fear of racism in medical settings, lack of insurance or financial resources, or misconceptions about what’s available.

For example, Black people represented 8 percent of those receiving Medicare-funded hospice benefits in 2017, compared to 82 percent for white people.

In many Southern Black communities, people won’t talk about death, Burney-Scott says. “There is truth in our mouth. You can manifest things with your word. Don’t talk about death [lest] you invite it in.”

That goes for other communities, as well. A 2010 study comparing Latino immigrants to white cancer caregivers found that the Latinos were surprised and even disturbed by transparent talk about death in hospice pamphlets and consultations.

Furthermore, Rush says that generally when death is imminent, “most people are overwhelmed and don’t know where to turn. They don’t even know that they can get hospice earlier. And even then, they may have a nurse come in for a few hours or an aide, but they aren’t there all the time. People have to rely on their community and network.”

And that’s just what Cynthia Brown did once she accepted that she wasn’t going to beat cancer, calling on the women her family members sometimes referred to as “Cynthia’s girls.”

“She invited us into the process from the very beginning. We swung into action on the logistical things: running errands, taking her to appointments, making meals,” Burney-Scott says.

“And then she said, ‘I want to cut my hair.’ She had 12 braids left. Each one of us cut two braids. Then, she called and said, ‘Hey, will you come over and help me write my memorial?”

She summoned Jeffries-Logan and another friend to help her assemble and bless her ancestors’ altar. With trademark precision and humor, she even planned who would cook at her funeral repast or meal: not her many loving white friends; she didn’t trust their chops in the kitchen.

Offerings to the Orisa Osun sit on the floor of Omisade Burney-Scott’s home in Durham, North Carolina. Omisade is an initiated priest of the Orisa Osun and Egungun in the Ifa/Yoruba spiritual tradition. She was initiated into the tradition in Nigeria six years ago, but has been practicing for the past 21 years. Photo: Madeline Gray/YES! Magazine

Her death doulas and friends, in turn, called on each other, their own histories of loss, and their ancestors to help guide Brown through her own departure.

And when the end came, the friends all rolled to the hospital one last time. Burney-Scott donned her trademark white head wrap and packed a bag with crystals and Florida water, a citrusy blend believed to have calming properties.

Jeffries-Logan carried tobacco as an offering; red cedar to represent blood and life force; water from the Eno River, which courses through her tribal nation’s territory; and a ceremonial turtle rattle, used by tribes in special ceremonies.

“Cynthia fed me, I laid up on her couch, we carpooled to anti-racism trainings around the state,” Jeffries-Logan says, her eyes moist and a catch in her voice. “And when we did a ritual for my mother [who died from Alzheimer’s disease] in the ocean, Cynthia told me, since she had lost her parents at a young age and had to be like a mother to her younger siblings, she knew what it was like to be a motherless child. I was going to do whatever I could for her.”

She didn’t want her beloved sister-friend “scratching and clawing to stay here.” So she stroked the soles of Brown’s feet—which got cooler and cooler as death approached—not to bring back sensation, but to help untether her from this earth.

When Brown took her last breath, Burney-Scott’s and Jeffries-Logan’s hands were among those resting on her body. It was a fitting end: a social death for a community advocate who told her friends, “You continue to fight the good fight, and you have to promise me that you won’t leave anyone behind.”

This article was originally published by YES! Magazine.

Cynthia Greenlee, Ph.D., wrote this article for the Death Issue, the Fall 2019 edition of YES! Magazine. Cynthia is a writer, editor, and historian based in North Carolina. Follow her on Twitter @CynthiaGreenlee.

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Rural Hospital Closings Reach Crisis Stage, Leaving Millions Without Nearby Health Care



A welcome sign to Bristol, a small town that sits in Virginia and Tennessee, June 26, 2019. Bristol is trying to recruit doctors because the rural town is facing many of the same health care shortages of other rural towns. Photo: Sudhin Thanawala/AP Photo

Presidential candidates and other politicians have talked about the rural health crisis in the U.S., but they are not telling rural Americans anything new. Rural Americans know all too well what it feels like to have no hospital and emergency care when they break a leg, go into early labor or have progressive chronic diseases, such as diabetes and congestive heart failure.

More than 20 percent of our nation’s rural hospitals, or 430 hospitals across 43 states, are near collapse. This is despite the fact that rural hospitals are not only crucial for health care but also survival of their small rural communities. Since 2010, 113 rural hospitals across the country have closed, with 18 percent being in Texas, where we live.

About 41 percent of rural hospitals nationally operate at a negative margin, meaning they lose more money than they earn from operations. Texas and Mississippi had the highest number of economically vulnerable facilities, according to a national health care finance report in 2016.

As rural health researchers, we’re well aware of the scope of rural hospitals woes’, which span the entire country. Struggling rural hospitals reflect some of the problems with the U.S. health care system overall, in that the poor often struggle to have access to care and there are few obvious solutions to controlling rising costs.

If 20 percent of America lives in a rural county, why is the nation so slow to address rural health disparities?

There goes the hospital, and the town

Mississippi Attorney General Jim Hood, who is running for governor on a plan to expand Medicaid, which he says would help rural hospitals in his state. Hood was campaigning in Jackson on Aug. 28, 2019. Photo: Emily Wagster Pettus/AP Photo

Each time a rural hospital closes, there are tragic consequences for the local community and surrounding counties. While the medical consequences are the most obvious, there is also loss of sales tax revenue, reduction in supporting businesses such as pharmacies and clinics. There are also fewer professionals, including doctors, nurses and pharmacists, and fewer students in local schools.

The closing of a rural hospital often signals the beginning of progressive decline and deterioration of small rural towns and counties. Hospitals often serve as financial and professional anchors as well as source of pride for its small rural community. It also often means loss of other employers or inability to recruit new employers due to lack of nearby health care. When a rural hospital closes its doors, unemployment often rises, and average income drops.

There are no nurses, doctors, pharmacists or ERs for local farmers, ranchers, growers and assorted men, women and children who love living and working in America’s vast rural regions. Rural communities and rural citizens are often left with no options for routine primary care, maternity care or emergency care. Even basic medical supplies are often hard to find.

Residents in these communities have had to take their chances living in America’s heartland, finding alternative options for basic health care services.

A compound fracturing

Those rural hospitals that have remained open are facing increasing legislative, regulatory and fiscal challenges. Some policy analysts have noted that the states with the most closings have been in states that did not expand Medicaid.

And, many of the towns in which they are located suffer from an apparent leadership vacuum. There are typically few experts within small towns who are prepared to address ways to avoid the loss of rural health care services and rural hospitals.

Small, rural communities are also less likely to have conducted formal comprehensive health needs assessments or invested in strategic planning to strengthen the ability of the community to adapt more quickly to changes in the local economy as well as changes in financing health care at the federal level. Health care services planning is often limited to input from the rural community leaders and “power brokers” rather than a cross-section of the greater community.

For example, community leaders may want to have an orthopedic surgery option, but if they had input from the community, they would know that prenatal/maternity care was more of a priority and these patients don’t have transportation so they also need a bus or van to pick up for appointments.

There are also cross-cutting rural community challenges such as:

  • Declining reimbursement levels
  • Shrinking rural populations
  • Health professionals moving to bigger cities for higher compensation
  • Increasing percentage of uninsured leading to rising uncompensated care
  • Increasing operating costs
  • Older and sicker rural dwellers with complex multi-system chronic diseases.

The result is that rural hospitals often lack a dependable economic base to operate. In addition, changing processes, payment strategies and regulations coming from state and federal regulators place the small rural facility at particular risk because keeping up with changing payment or reporting rules often requires a full time person.

The continuing closures have accelerated the urgency to understand and address the problems faced by rural Americans seeking access to care. Each rural region of the country has its own industry, economy, cultures and belief systems. Therefore, rural solutions will be unique and not an urban solution downsized to a smaller population.

Replacing the hospital with … what?

People who choose to live in rural America often love the lifestyle but are increasingly facing challenges because of the closure of hospitals. Photo: LightField Studios/

At Texas A&M Health Science Center, we are among several researchers focused on rural disparities by researching causes of socio-economic inequities and by working within those rural communities to “give a leg up” to distressed rural communities and counties nationally, and in Texas.

We’ve come to see that providing health care services in rural counties may not include maintaining a full-service hospital, but rather “right-sizing” care to match the resources, demographics, geography and availability of providers in the community.

For example, the ARCHI Center for Optimizing Rural Health is currently working with hospitals and their communities to determine feasible health care options that will be supported by the community, meet community needs, and most importantly, offer local, high-quality care. Using tools like ARCHI’s DASH – a quarterly dashboard that shows performance of the hospital in financial, quality and patient satisfaction arenas – may help hospital boards, communities and local leaders better understand their status and need for change from business as usual.

While it may be that the changing health care delivery systems are altering what health care delivery looks like, change can almost never be instant. Communities may need to envision alternatives to hospitals.

In some communities, urgent care with radiology and lab services may be able to service the majority of health care needs. In other communities, a “micro-hospital” with an ER and swing bed options – which allow rural hospitals to continue to treat patients who need long-term care or rehabilitation – may be the better fit. Telehealth, or providing care through televideo virtual face-to-face from remote sites to rural residents, can also be an option.

Challenges specific to the dilemma of rural hospital closure will take a national, state and local effort focused on the plight of rural communities struggling to maintain availability of essential health care services. Our nation’s vulnerable rural communities deserve a focused, coordinated effort to address this compelling problem before any more rural hospitals close their doors.

This article is part of a collaborative project, Seeking a Cure: The quest to save rural hospitals, led by IowaWatch and the Institute for Nonprofit News, with additional support from the Solutions Journalism Network.

Jane Bolin, Professor of Health Policy + Management, Deputy Director of the Southwest Rural Health Research Center; Associate dean of research, College of Nursing, Texas A&M University ; Bree Watzak, Clinical assistant professor, pharmacy, Texas A&M University , and Nancy Dickey, Professor, Executive Director, Texas A&M Rural and Community Health Initiative, Texas A&M University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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These Sheriffs Release Sick Inmates to Avoid Paying Their Hospital Bills



Empty pre-op beds at the new Boone Memorial Hospital. Photo: Kara Lofton / West Virginia Public Broadcasting

Inmates suffering heart attacks, on the verge of diabetic comas and brutalized in jail beatings have been released so sheriffs wouldn’t have to pay for their medical care. Some were rearrested once they had recovered.

Michael Tidwell’s blood sugar reading was at least 15 times his normal level when sheriff’s deputies took him to the hospital. But before they loaded the inmate into the back of a car, deputies propped up his slumping body and handed him a pen so he could sign a release from the Washington County Jail.

“I could barely stand up or keep my eyes open,” he recalled.

Tidwell said that he didn’t know what he was signing at the time, and that he lost consciousness a short time later. The consequences of his signature only became clear in the weeks that followed the 2013 medical emergency.

By signing the document, which freed him on bond from the small jail in south Alabama, Tidwell had, in essence, agreed that the Washington County Sheriff’s Office would not be responsible for his medical costs, which included the two days he spent in a diabetic coma in intensive care at Springhill Medical Center in Mobile.

It’s unclear whether Tidwell, who was uninsured at the time and in poor health afterward, was billed for his care or if the medical providers wrote it off. Neither Tidwell’s attorneys nor the hospital was able to say, and Tidwell was unable to get answers when he and a reporter called the hospital’s billing department.

What is clear is that the sheriff’s office avoided paying Tidwell’s hospital bills.

Tidwell had been on the receiving end of a practice referred to by many in law enforcement as a “medical bond.” Sheriffs across Alabama are increasingly deploying the tactic to avoid having to pay when inmates face medical emergencies or require expensive procedures — even ones that are necessary only because an inmate received inadequate care while incarcerated.

What’s more, once they recover, some inmates are quickly rearrested and booked back into the jail from which they were released.

Local jails across the country have long been faulted for providing substandard medical care. In Alabama, for instance, a mentally ill man died from flesh-eating bacteria 15 days after being booked into the Mobile County Metro Jail in 2000. And in 2013, a 19-year-old man died of gangrene less than a month after he was booked into the Madison County Jail. In both cases, officials denied wrongdoing and surviving relatives settled lawsuits alleging that poor jail health care contributed to their loved ones’ deaths.

But the use of medical bonds isn’t about inferior care. It’s about who pays for care.

While medical bonds have been a last resort in many states for more than 20 years, experts say they are employed in Alabama more often than elsewhere. Their use in some counties but not in others illustrates the vast power and latitude that sheriffs have in Alabama, which is the subject of a yearlong examination by and ProPublica.

Several Alabama sheriffs, including Washington County Sheriff Richard Stringer, said in interviews that they often find ways to release inmates with sudden health problems to avoid responsibility for their medical costs. Stringer denied any wrongdoing in his office’s handling of Tidwell’s emergency.

“We had a guy a couple of weeks ago with congestive heart failure. … The judge let him make bond so the county didn’t get stuck with that bill,” Lamar County Sheriff Hal Allred said in a March telephone interview. “We don’t have any medical staff in the jail. I wish we did, that would be great, but the way the county finances are, I won’t live long enough to see it.”

Typically the process works like this: When an inmate awaiting trial is in a medical crisis, a sheriff or jail staffer requests that a judge allow him or her to be released on bond just before, or shortly after, the inmate is taken to a hospital. If the request is granted, the inmate typically signs the document granting the release.

Michael Jackson, district attorney for Alabama’s 4th Judicial Circuit, said he is aware of multiple recent cases in which sheriffs released inmates on bond without first obtaining a judge’s approval. Jackson said he also worries about the risk of inmates reoffending after they receive medical treatment.

“I’m not saying there should be no situation where an inmate can get released early, but it shouldn’t be about money,” Jackson said in a phone interview this month. “No one’s watching them when they get out, and people might get robbed or their houses might get broken into.”

While judges usually sign off on bonds, lawyers who represent inmates and other experts say sheriffs are often the key decision-makers and can be held legally responsible for what happens after they release inmates via such methods.

If an inmate is already sick or injured when he or she is released, sheriffs are “not going to be able to avoid the liability just by opening the trap door and letting them go,” said Henry Brewster, one of Tidwell’s attorneys.

“They Have to Do Something”

Shortly after Tidwell was locked up for a probation violation in 2013, his sister Michelle Alford, a nurse at a Mobile hospital, said she brought his diabetes medications to the Washington County Jail and gave them to the guard on duty.

She says she explained to the staff that her brother is a “brittle” diabetic, meaning he needs frequent monitoring. She provided the jail with a two-page document that explained how often his blood sugar needed to be checked, what symptoms to watch for and the purpose of each medication.

The jail’s employees, none of whom had any formal medical training, did not follow those instructions, according to Tidwell’s jailhouse medical records, a copy of which Alford provided to and ProPublica.

On his fourth day in the aging jailhouse, Tidwell became ill and vomited off and on for the ensuing 48 hours. He was unconscious for most of his final two days there, according to court and medical records.

Before he was taken to Washington County Hospital, Tidwell’s blood sugar reading was 1,500 mg/dl; a normal reading for him is 80 to 100 mg/dl. Over the less than seven full days he was incarcerated, he had lost at least 17 pounds, records show.

Tidwell’s release form bears his signature scrawled incomprehensibly outside the signature box, overlapping the typed prompt for “Signature of Defendant.” It does not match other examples of his signature on court documents reviewed by and ProPublica.

“If you’re in there and you get sick, they have to do something and get some medical attention,” he said. “But if you’re in so bad of shape that they’re trying to hold you up and get you to sign something, that’s wrong.”

Tidwell, who was 42 at the time, was assessed at the local hospital and taken to Springhill, a larger and better-equipped hospital, where he lay in a coma in the intensive care unit. He was suffering from renal failure and other complications related to his diabetes, according to the records.

During a conversation in his office in downtown Chatom, Stringer, the Washington County sheriff, said that he and his jail staffers are not medically trained. Instead, they “listen to what [inmates are] complaining about and examine them to determine if they need medical bond, because people will do anything to get out of jail.”

If they decide an inmate has a serious and potentially costly medical issue — and doesn’t pose a threat to the public — Stringer said he or the jail’s administrator will call a judge and request that the inmate be released.

Asked last week whether he believes Tidwell was legally able to provide consent to being bonded out, Stringer said: “They’ve got to be physically able to sign the bond. I’m sure he was [conscious] or he wouldn’t have been able to be bonded out. … It’s been so long ago it’s hard to remember all these things. I’m sure we did what needed to be done.”

But in an earlier interview, the sheriff provided an alternate explanation for Tidwell’s hospitalization.

“When someone comes in and says he’s a diabetic, we try to prepare a meal that will accommodate his diabetes,” Stringer said. “But now on commissary, they’re on their own there. I mean, you know you’re diabetic. Don’t order — he actually ordered 12 honey buns.”

Tidwell, who denies eating a dozen honey buns in the jail, recovered and was sent home from the hospital.

He filed a lawsuit against Stringer and several sheriff’s office employees in 2014; it was settled the following year. Stringer said he believes he and his employees would have been exonerated had the suit gone to trial, but because he said the settlement was for “something like $20,000 … it’s not worth fighting it.”

But Tidwell’s problems didn’t end there. Exactly three months after Tidwell was released on bond, a judge issued a bench warrant for his arrest on another probation violation.

“They’ll Lower the Bond” and ProPublica have reviewed the cases or media reports of inmates in 15 of Alabama’s 67 counties who were issued last-minute bonds or released on their own recognizance just before they were hospitalized for emergencies.

In September 2018, for instance, a 38-year-old inmate at the Lauderdale County Jail was taken to a nearby hospital after he suffered a stroke that left him partially paralyzed and unable to communicate verbally, stand or perform daily tasks, state court records show. The inmate, Scottie Davis, was released from sheriff’s office custody on bond the following day, though he couldn’t sign the release document. Someone instead wrote the words “Unable to sign due to medical cond.” in the space for the inmate’s signature. Davis was responsible for the medical costs after he was bonded out.

Lauderdale County Sheriff Rick Singleton said when inmates are too ill to sign their names, sheriff’s officials notify a judge who decides whether to allow them to be released on bond.

And earlier last year, in Randolph County, an inmate was released on a medical bond before going to the hospital for surgery, according to The Randolph Leader, a local newspaper. When he wasn’t able to immediately get the procedure, he was rearrested on a new misdemeanor charge and booked back into the Randolph County Jail.

The county ended up on the hook for over $10,000 the procedure was expected to cost. Some county officials view the turn of events as an unfortunate financial setback.

Randolph County Commissioner Lathonia Wright said in a phone interview this month that paying inmates’ hospital bills is “really rough” on the county’s budget, but it sometimes can’t be avoided.

“I hate that we have to pay for it out of taxpayer money, but the law demands that we take care of people that are incarcerated in the jail,” he said. “If we get a bill, we pay for our medical bills. They come straight from the hospital.”

In urban counties with larger populations, the majority of inmates’ medical problems are dealt with in the jails, usually by private companies that provide infirmaries, round-the-clock nurses and doctors who make regular visits.

But in some rural counties, sheriffs do not have any staff members with medical training or the budget to absorb significant hospital costs.

Jim Underwood, who was sheriff of Walker County from 2015 until January, said the county budgeted about $350,000 per year for jail health care while he was in office. The sheriff’s office did everything it could to keep costs down, Underwood said, adding that before he was sheriff, one inmate’s medical care cost about $300,000.

“I think that a lot of it does depend on what they’re charged with … but there are people released because of medical bills,” he said. “You have to go through the judge; they’ll lower the bond.”

Underwood said he believes the practice “happens everywhere” in Alabama, though it takes different forms in different counties. One sheriff’s office has paid for inmates to wear ankle monitors while out on bond for unexpected medical care; another waited for an inmate’s relatives to secure a private bond before allowing him to be taken to a hospital, records show.

Sheriff’s officials in Washington County, where Tidwell was in custody, have faced other lawsuits alleging improper use of medical bonds, including in the case of a woman who died of a stroke one day after being released from the county’s jail in 2016. In that case, which was settled this year, an audio recording captured a top sheriff’s office official asking jail staff to ensure the woman was released on a medical furlough, a method of release similar to a medical bond, before taking her to the hospital.

Nora Demleitner, a law professor at Washington and Lee University in Virginia who specializes in criminal sentencing, said medical bonds may violate inmates’ rights and the way some sheriffs use them is “totally flawed.”

“It’s a stunning problem,” she said. “When [inmates] file lawsuits, and rightly so, they should get civil compensation.”

Demleitner added via email that the phenomenon is prevalent in a number of counties and entirely absent in others. and ProPublica have reviewed media reports of sheriffs pursuing medical bonds for inmates with medical crises in 25 states.

Alan Lasseter, a Birmingham-based attorney who has filed lawsuits over alleged police misconduct and jail health care issues, said sheriffs’ reliance on medical bonds appears to be on the rise.

“It’s only something I’ve been hearing about for about two years, maybe longer, but it’s becoming more common and it’s really starting to resonate with me that it’s been happening more and more in Alabama,” Lasseter said.

“They Are Responsible”

Marcus Echols said his daughter was 9 years old when he first learned that she was his child. Until then, the girl’s mother had been collecting child support from another man who was eventually determined not to be her father, according to court records and Echols.

In 1998, a judge in Morgan County ordered Echols to pay more than $9,000 worth of back child support and interest in monthly payments of $500.

Over the ensuing years, Echols, who pays support on other children and has had trouble keeping a job, repeatedly failed to make the required payments. By November 2015, when he was arrested for contempt of court for failure to make child support payments, his debt totaled more than $50,000. He was booked into the Morgan County Jail in Decatur, a city in north Alabama.

Two months later, on Jan. 16, 2016, Echols suffered a heart attack inside his painted cinder-block cell.

For over half an hour, guards argued over whether he needed to be taken to the hospital, Echols, now 49, said.

They eventually took him to Huntsville Hospital. Several hours later, Echols said, he awoke from a procedure and was told by a doctor that he had needed three stents inserted because his heart had suffered extensive damage over the extended period of time between when he went into cardiac arrest and his arrival at the hospital. Medical records reviewed by and ProPublica confirm Echols’ account of his condition and treatment.

The doctor also informed him that he had been officially released from Morgan County Sheriff’s Office custody, Echols said.

Echols said he was glad to find out that he would be allowed to go home instead of back to jail, but when he received a bill less than two weeks later from Huntsville Hospital for the costs of his medical care, he learned that he was personally responsible for more than $80,000.

“I didn’t get the bill until about a week after I got out of the hospital,” Echols said. “It just showed up in the mail.”

Echols said he never learned what mechanism the sheriff’s office had used to release him from its custody, and none of the court records associated with his lawsuit provide any clarity.

“I didn’t sign nothing. … When I woke up,” he said, “the doctor told me that the sheriff’s office had told him to tell me that I had been released from jail.”

A local charitable foundation ultimately paid Echols’ bills. But he still feels that he was taken advantage of.

“It seems like a scam that they’re running. They’re running the jail at the lowest possible cost at the expense of everyone else.”

Ana Franklin, who was sheriff at the time of Echols’ incarceration and hospitalization, declined to comment on Echols’ experience. But she said her “first consideration in whether or not to release someone on a medical release was never the budget.” She said the primary factors that drove such determinations when she was sheriff included criminal history, risk of reoffense and whether the jail was equipped to provide adequate medical care.

“It’s great to just say the sheriffs cut them loose because it saves them money on their medical,” said Franklin, who pleaded guilty last year to a federal charge of failing to file an income tax return. “But it’s just as big a liability issue that an inmate is going to say that we didn’t provide adequate treatment for them in the jail as it is that he’s going to sue us and say we cut him loose and they had to pay their medical bills.”

In March 2016, just a few weeks after Echols’ heart attack, the sheriff’s office attempted to obtain a new warrant to arrest him for contempt of court for his continued failure to pay the thousands of dollars worth of back child support he still owed.

Morgan County District Judge Charles B. Langham issued an order stating that Echols “is still under medical care” — he was attending cardiac rehab sessions at the time — and denied the sheriff’s office’s request. A year later, Langham issued an order for a new warrant for Echols’ arrest. At the time, Echols was unable to work, had applied for federal disability and was living with relatives.

Echols’ sister, Lashundra Craig, said she takes issue with the sheriff’s office’s persistent attempts to arrest her brother despite his continuing health issues.

“They are responsible for whatever happens to the inmates. … If they don’t want to be responsible for the medical costs but they want to put you back in jail to face your responsibility, to me it’s showing they just still want their money,” she said.

“They Said They Would Release Me”

It has historically been difficult for inmates to prevail in lawsuits alleging that sheriffs violated their rights by releasing them while they required medical attention.

On July 3, 1996, four inmates beat Leroy Owens with a metal pipe; stabbed him with a screwdriver; kicked, stomped and punched him; and left him in a pool of blood in a common room on the second floor of the Butler County Jail in Alabama’s Black Belt.

Owens described the events of that evening in a recent interview, and they are laid out in detail in the records of the federal court case he and a fellow inmate who was also beaten would later file against then-sheriff Diane Harris, the county and the county commission in Alabama’s Middle District in Montgomery.

For nearly an hour, no one answered Owens’ cries for help or those of other inmates who banged on the jail’s walls, one of whom yelled, “They’re killing him up here,” according to the court records.

Finally, Harris’ chief deputy, Phillip Hartley, was called to the jail. Twenty minutes after the attack ended, Owens was taken downstairs and then driven to a nearby hospital, where he was treated for his injuries.

The hospital released Owens into the custody of two sheriff’s deputies, who were given a discharge document detailing “specific procedures to care for Owens’s head wounds and other injuries. It instructed them to monitor his level of consciousness, pupils, vision, and coordination, and to call the hospital immediately if any change occurred,” according to a summary of Owens’ allegations included in the U.S. Court of Appeals for the 11th Circuit’s ruling on the appeal of his federal case.

Instead, after they arrived at the jail, Hartley insisted that the bloodied inmate sign a bond granting his release, according to Owens and the court records.

“I signed out of the jail. All I know is it was a piece of paper I signed. I was bleeding and I was coming in and out of consciousness,” Owens, who is now 56, said last month. “They said they would release me if I signed it.”

After Owens signed the bond, Hartley drove him almost to the county line and dropped him off at about 3:30 a.m. on July 4, 1996, on the side of a desolate stretch of highway, without shoes, according to Owens and the court records.

“When he released me from the jail, he took me to the edge of the county and he said, ‘Your best bet is to leave town,’” Owens recalled.

After spending the night in a hotel, Owens awoke “in terrible pain” and was taken by ambulance back to the emergency room, according to the court records. He returned to the hospital again on July 8 for further treatment, the court records show.

Medicaid ultimately paid the hospital bills Owens incurred after he was bonded out from the jail.

Danny Bond, the current sheriff of Butler County, did not respond to repeated requests for comment.

In 2001, the 11th Circuit reinstated Owens’ case against the county, the sheriff and others after a lower court had dismissed it. The court ruled that though Owens and the other inmate did not prove that Harris or the county were deliberately indifferent to their medical needs, they “sufficiently stated a claim against the County and the Sheriff for the conditions at the Butler County Jail.” The court, however, also found that Harris was “entitled to immunity for her policy of releasing sick and injured inmates.”

Judge Rosemary Barkett, writing for a four-judge minority, disagreed, saying that the allegations of deliberate indifference against Harris should not be dismissed. Barkett wrote that Harris and her staff should have known that releasing Owens and leaving him on the side of the road after 3 a.m. could be a constitutional violation.

Harris and the county denied wrongdoing; Owens and the other inmate plaintiff ultimately settled the suit.

Meanwhile, legal experts who reviewed relevant portions of Alabama’s state code said they were able to find only two vague references to the issue: a statement that certain fees shall not be assessed “if a person is released on judicial public bail or on personal recognizance for a documented medical reason” and a stipulation that “the sheriff or jailer, at the expense of the county,” must provide “necessary medicines and medical attention to those who are sick and injured, when they are unable to provide them for themselves.”

Despite that, some lawyers and experts say inmates often have a hard time winning cases against sheriffs on those grounds.

“If a county sheriff threw someone out of the jail who’s unconscious and said ‘good luck,’ you could possibly make a civil rights violation or negligence claim,” said Paul Saputo, a Dallas-based criminal defense attorney who has represented multiple clients who have been bonded out of jail for medical reasons.

“If you have a heart attack and are taken to a hospital, and the question at the end of the day is who’s gonna pay for it, that’s a little bit closer of a call.”

“They’re Technically Still in Custody”

Lauderdale County, in Alabama’s northwest corner, has taken official action to expand the use of medical bonds.

During its April 25, 2017, meeting, the Lauderdale County Commission agreed to enter into a contract with a Tennessee company to provide ankle monitors and monitoring services for inmates who are permitted to leave the county’s jail to obtain expensive medical treatments.

Lauderdale County District Attorney Chris Connolly explained the concept during a discussion of the ankle monitor plan earlier that month, as Florence’s Times Daily newspaper reported at the time.

“Putting them on an ankle monitor and then releasing them on medical furlough or a recognizance bond would still allow us to have control of them, but also it would make them responsible for any medical treatment or expense,” Connolly said.

The new approach to reducing the jail’s medical costs has been used 12 to 15 times since the contract was signed, Singleton, the Lauderdale County sheriff, said in a telephone interview last month.

“I guess you’d consider it like house arrest,” he said. “They’re technically still in custody” and must immediately return to the jail once they are deemed healthy enough to do so. But instead of adding to the $500,000 of medical care the jail averaged annually as of 2017, the inmates must pay the bill. That means the program has been a success, according to Singleton.

“It’s accomplished what we wanted to accomplish,” he said. “It’s saved us some money.”

Singleton also emphasized that the program does not affect public safety because ankle monitors are only used in cases involving nonviolent inmates who are not considered threats to the community.

Lauderdale County District Judge Carole Medley, who rules on small-time criminal cases nearly every day in her courtroom, said she often grants bonds so inmates can obtain medical care, which they must then pay for themselves. She said that she is “very pro-ankle monitor,” and that she considers the program “a win-win” for inmates and for the jail and the county’s finances.

“I release people on [own recognizance] bonds every other week for medical issues. Do I take into consideration the charge? Of course. And there are times where we release them on an ankle monitor to get their medical needs addressed, and then some of them do return to jail.”

Critics of the practice say it raises important questions about the very purpose of incarceration. For instance, if sheriffs and other officials claim that these inmates must be jailed to prevent them from harming others, punish them for wrongdoing and deter would-be criminals, why are those officials so quick to abandon those goals in order to avoid paying their medical bills?

Jasmine Heiss, a campaign director at the Vera Institute of Justice in New York, said if such inmates can in fact be safely released when doing so saves tax dollars, perhaps they shouldn’t have been incarcerated in the first place.

“Broadly, what we would like to see is people who can be safely released on their own recognizance being released earlier in the process rather than waiting until people have these severe medical crises,” Heiss said.

Research reporter Claire Perlman contributed to this report.

This article was originally published by ProPublica.

This article was produced in partnership with, which is a member of the ProPublica Local Reporting Network. It was originally published by ProPublica.

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