First Person

Dental Care Was a Path to Opportunity. Then I Couldn’t Afford It Anymore.

I spent every morning as a child in the bathroom, brushing my teeth — stained yellow as if they had been dipped in melted butter — as hard as I could. My grandmother blamed the fluoride in the water that we drank. I didn’t know if she was telling the truth or not; in the end I was still ashamed of my smile. My classmates would gleefully shout “Butterteeth” whenever I crossed their paths, and the boys called me ugly. When I talked to other students, they would stare at my mouth and remark that I had something on my teeth. My face would turn hot and red, my sentence trailing off as they made a brushing motion; after realizing their mistake, they too would grow quiet and the air would be filled with shame.

I lived with that smile for 16 years. My family constantly struggled to stay afloat, and even though my single mother worked a full-time job, she couldn’t always afford health care. We went to the doctor when we were sick, not for checkups. Sometimes important issues got pushed to the back burner to make room for the day-to-day necessities, and one of those issues was dental hygiene. The appearance of my teeth felt like a declaration of my family’s lack of wealth. There are photos of me smiling brightly throughout that time, though, because even though a sense of shame followed me, I tried not to allow myself to be defined by what I looked like.

When I turned 17, my best friend’s mother started bringing me to and from the dentist’s office, a place that I hadn’t visited in almost a decade, though I don’t know how those trips came to fruition. The topic of health insurance was never brought up, and my friend’s mother never mentioned having to pay a cent. It was suddenly available to me, and I didn’t bother to ask any questions. All I knew was that I was being helped and I was so grateful. I didn’t realize just how much pain the years of neglect would cause me, though.

My mouth would fill up with blood at any opportunity, to the point where my dentist would whisper to his assistant that he wasn’t sure if he would be able to continue with that day’s work. Even a basic routine cleaning would cause my hands to shake, and soon the assistant would be packing my mouth with cotton balls in an attempt to soak up the blood. The assistant would change with every session, but the dentist and I developed a routine because he never changed. He was a kind man, always asking how my classes were and if I needed more procaine. I’d shake my head or make a noise to answer, and then he would stare back into my mouth while tears ran down the side of my face.

On the worst days, the room filled with the smell of my teeth being filed down to make room for silver caps. One evening, as I was coming home from the dentist, I coughed up blood onto a bus seat as it was pulling up to my stop. I confessed to the driver and quickly ran out the door. At home I would eat soft food, wincing when cold hit the caps, freezing them for a moment. They weren’t joking when they said beauty was pain, but “it will all be worth it,” I told myself, massaging my sore jaws.

When I listened to the voicemail from my dentist telling me my insurance was covering the cost of five porcelain veneers, I smiled to myself as I cried on the school bus. I replayed that message over and over, and the next time I climbed into the dentist’s chair, I did it with pride. It still hurt, don’t get me wrong, but when he handed me the mirror and I saw myself with my new teeth, I burst out in tears. The sounds of those children taunting me were gone; I was one of the lucky ones.

Then I grew up.

As I grew older, I fell into the same trap as my mother. Cleanings became few and far between because I was working two jobs and the dentist’s office closed too early. When I was 22, the veneer placed on my right tooth fell off in the middle of the night and I swallowed it in my sleep. That morning, I had to rush to the emergency dental clinic on my one day off. The location closest to me was a short bus ride away, and I managed to keep my mouth shut tight the entire ride there, nodding “yes” or “no” in response to questions that were thrown in my direction by the bus driver or other friendly riders.

My dental plan consists of aspirin and liquid numbing medicine.

The office receptionist told me the procedure would cost me around $2,000, and when I told them I didn’t have anywhere near that amount in my bank account, they told me to sign up for the credit card the practice offered and start a payment plan. I sat in the chair, filling out my personal information, and was approved for an even $1,000. I sobbed as I walked down to the bank, punching my PIN into the ATM to get some cash for my first payment. I got a new temporary crown, and while I knew it was important and I desperately needed it, I asked myself if the cost was worth it.

I still believe that it was. I knew that if I went backward, if I came anywhere close to having my former smile, I would be screwed. I hadn’t been able to get a job with my old grin because the boss would spend the whole interview watching my mouth move, but after my teeth were fixed, the job offers came closer and closer together. I hadn’t been able to date comfortably beforeand now, with the gift of new teeth, I was suddenly lucky and in love. These teeth had saved me from a life that I was too afraid to think about.

It has been almost five years since I last went to the dentist. Every morning I wake up and press the tip of my tongue along the backs of my front teeth, hoping I haven’t swallowed another one in the middle of the night. I brush my teeth, ignoring the way the toothpaste turns a brownish-red color, and head off to work, where I work close to 50 hours a week between two jobs. Because I can’t afford to leave one and work full-time at the other, I don’t have health insurance, much less dental insurance. My dental plan consists of aspirin and liquid numbing medicine. It runs me an average of $12 every couple of months. I didn’t even know the pain in my tooth could be connected to the pain in my ear until I googled it. (That’s another thing that people don’t tell you about being poor: Google and WebMD are part of your health care plan.)

Now when people stare directly at my teeth, they are noticing how white the front row is. They remark that my teeth are perfect and want to know my secrets: Is it a special toothpaste? Mouthwash? Did I just get lucky? I always joke and tell them that they better be perfect because they cost me a lot, physically and emotionally.

The dentist still scares me, and I don’t know when I will be able to schedule another visit. I hope that one day, I’ll scrape together the money to have my wisdom teeth taken out. Better yet, I hope that one day, I’ll be able to work one single full-time job, a job that will offer me benefits including dental. I hope that one day, I’ll be able to have my teeth cleaned every six months instead of once every decade.

It occasionally hits me that even after all this, I’m still one of the lucky ones. People still think that I’m beautiful, and that’s enough to get me through this life. All I can really do is keep smiling.



Inside the Fight Over the Last Hospital in D.C.’s Poorest Neighborhood

Arnel Jean-Pierre has been a nurse at Washington, D.C.’s United Medical Center for seven years, and he’s seen a lot. If the D.C. city council has its way, though, the hospital will shut its doors for good in the coming years. According to Jean-Pierre, that’s going to cause a lot of avoidable pain for the residents of D.C.’s poorest neighborhoods.

“The end result is a lot of people are going to suffer,” he said.

D.C.’s council recently gave preliminary approval to a plan that would close United Medical Center, known as UMC, in January 2023, while reducing the city’s financial contributions to the capital’s only public hospital in the intervening years. Hospital officials say they need some $40 million to keep operating in this fiscal year alone, but the city’s payments going forward would be capped at $15 million annually.

The move — which will be up for a final vote on Tuesday — has activists and workers at the hospital concerned, for a whole host of reasons. It also fits into a wider recent trend of hospitals closing up shop in the neighborhoods that can least afford it.

UMC is currently the only hospital in Washington that is not in the city’s northwest quadrant — which is both its whitest and richest. The city is grappling with the effects of widespread gentrification and rapidly changing demographics. By one measure, it is the fastest gentrifying city in the country, and in the top four for most black residents displaced. The population UMC serves is majority black, the poorest in the city, and disproportionately composed of Medicaid and Medicare patients.

If the budget cap is implemented, UMC will have to cut back services before ultimately closing. Already, UMC has reduced services due to budget constraints and financial woes, including closing its cancer clinic; a notice that the hospital will lay off employees within the next 60 days was circulated recently. Meanwhile, a proposal to open a new private hospital in that part of the city is far from a done deal, meaning the current hospital has an explicit end date, but the plan for replacing it is only half-baked.

“There is a closing date in the legislation that is not tied to the opening of any other hospital and right now, the city is still only in negotiations with the new Ward 8 hospital provider, which seems to have many roadblocks. So we don’t know what a realistic timeline is to have a new hospital in that part of the city,” said Elizabeth Falcon, executive director of D.C. Jobs With Justice, which is fighting the budget cuts.

Cutting back at UMC will mean longer wait times for its patients, and according to Jean-Pierre, higher mortality rates for those who suffer from strokes, heart attacks, and gunshots, as they are the most vulnerable when delays occur.

“There’s a lot of delays now, but to even cut more is going to create a catastrophic event,” he said. “They’re paying taxes just like the folks in Georgetown, [the richest part of D.C.]. Why should they have the delay in health care when they face a stroke?” For some residents in the area, the next nearest hospital after UMC is a nearly nine-mile drive away, which can take more than an hour in rush hour traffic. And the hospitals closest to UMC already say they have more patients than they can handle.

“Too many of our debates in DC are win-lose or lose-lose. UMC is another example. The debate shouldn’t be: New hospital in Ward 8 or responsible patient care at old hospital in Ward 8. It needs to be both. Vulnerable lives are at risk,” tweeted D.C. council member Elissa Silverman.

But the closing of UMC is about more than just one hospital in one part of one city. It is also emblematic of larger trends in which hospitals are closing, consolidating, and moving out of low-income urban neighborhoods in favor of neighborhoods with richer residents.

In 2014, a Pittsburgh Post-Gazette/Milwaukee Journal Sentinel analysis found that the number of hospitals in major U.S. cities fell by nearly half between 1970 and 2010, and most of those that closed were public hospitals or hospitals located in low-income neighborhoods. Meanwhile, two-thirds of hospital openings during the same time period were in more affluent neighborhoods.

D.C.'s poorest residents are saddled with its least-functional hospital.

That tracks with D.C.’s experience. The city lost Providence Hospital, in its northeast quadrant, earlier this year, and now UMC has been put on life support, while its four other major hospitals are in wealthier or rapidly gentrifying parts of the northwest.

Not surprisingly, hospital closures lead to worse health outcomes, particularly for those who suffer from heart attacks or injuries that require immediate medical attention. Areas that lose hospitals also tend to lose other medical services as well, as doctors and other practitioners move away or decide to open new practices elsewhere. This turns low-income areas into health care deserts.

Plus, those same areas tend to be the least served by public transit, and have the most residents who don’t own their own modes of transportation, putting ever-higher barriers between patients and the care they need.

“Localities are getting out of the business of running hospitals. That doesn’t mean people are out of the business of getting sick in every neighborhood,” said Falcon. “We are at a moment in history where governments don’t like paying for government services.” Available data on hospital closures is not great, but between 1996 and 2002, per one study, at least 13 public hospitals closed; another study found that public hospitals that closed between 1990 and 2010 were in neighborhoods with significantly higher percentages of black residents than public hospitals that remained open.

On the private side, meanwhile, powerful, multi-facility health systems are responsible for much of the hospital consolidation cities have experienced. Between 2005 and 2017, there were 1,000 hospital merger and acquisition deals announced. 40 percent of hospital stays now occur in markets in which there is only one hospital owner. Such consolidation, in addition to making hospitals fewer and farther between, drives up prices and drives down management quality.

UMC has had its struggles, of course. A slew of errors led regulators to shut down its obstetrics ward in 2017. The only reason the city has been running the hospital at all is that its financial misadventures necessitated a 2010 rescue from bankruptcy. But few think that the city would let it collapse completely. Organizers are moderately confident that, if a new hospital is not completed in the neighborhood by January 2023, the council would at least continue to keep UMC’s emergency room open.

But none of that stops the slow bleeding already occurring there, or makes up for the preventable illnesses, injuries, and deaths that will happen in the intervening years due to the cap on funding; it says nothing good about the city that its poorest residents are saddled with its least-functional hospital. None of UMC’s problems change the fundamental fact that the bulk of D.C.’s available health care services are in the parts of the city where the residents are the wealthiest.

“We are trained to do no harm,” said Jean-Pierre, the UMC nurse. “But the D.C. council does not live by the same code of ethics. Based on the cutting, they’re doing a lot of harm.”



Trump’s New Union-Busting Rule Will Wallop Home Health Workers

Earlier this month, the Department of Health and Human Services finalized an obscure rule that could have huge implications for an estimated 800,000 independent home health providers paid directly by the state for Medicaid-funded services. Under the rule, these workers will no longer be able to assign deductions from their paychecks to cover things like insurance premiums, retirement contributions, and union dues. The rule singles out the most isolated home health workers who are not employed or paid via agencies; those who are can assign deductions at will.

Advocates argue the rule is designed to suppress unions by making it more difficult to collect dues. And there’s more than union dues at stake: Home care providers could, for example, experience lapses in health coverage by failing to keep up with premiums.

Many home care workers are family members providing home and community-based care to loved ones. Their work can include assistance with activities of daily living like bathing, dressing, and toileting, along with light housekeeping, help with errands, and other services designed to help disabled people and older adults stay in their communities. Home care is one of the fastest growing professions in the United States, with a projected growth rate of 41 percent for those working at agencies.

The median wage for home care workers is $10.49; a 2017 National Employment Law Project survey found unionized employees made $2 more per hour when examining the difference between weighted average wages. The majority are women of color, reflecting the gendered and racialized history of the field, and 28 percent are themselves on Medicaid.

In some ways, Medicaid-funded home care can act as an anti-poverty program and compensate people for care work that is normally considered unworthy of pay. “When I found out about In-Home Support Services [the California implementation of the program],” said Andrea Dudley, who cares for her son, “it was like a godsend…it’s not a lot of money, but it’s helped me.”

It was like a godsend…it’s not a lot of money, but it’s helped me.

Home health work, like other labor that takes place in the intimate setting of the home, has been historically undervalued. When the Fair Labor Standards Act (FLSA) passed in 1938, domestic workers were explicitly excluded from wage and hour protections, in part at the behest of Southern Democrats. In the years since, domestic workers, including those offering home health services, have fought to organize. In the 1970s, Congress amended the FLSA to cover some domestic workers, but home health aides were still left out by a provision excluding “babysitters” and “companionship services.” But recently, they’ve started making gains. They won wage and overtime protections under FLSA in 2015 and have grown home care worker union participation. In 2010 they pushed for the passage of a Domestic Worker Bill of Rights in New York, and a similar national bill to extend these protections nationwide has been introduced by Sen. Kamala Harris (D-CA) and Rep. Pramila Jayapal (D-WA).

Now anti-union proponents, pushed by groups such as the National Right to Work Committee, are on the offensive. In 2014, they won a significant victory with Harris v. Quinn, which ruled that home health care workers are not public sector employees. Therefore, those who choose not to join the union may not be required to pay service fees, enjoying the benefits of collective bargaining without the costs.

In this instance, the government argues Medicaid monies should only be paid out to providers, with exceptions for tax deductions but not for third-party payees. In response to concerned comments about the implications of this rule, the government insisted that “it in no way prevents” home health workers from paying union dues, insurance premiums, and other costs via other means. To prove their point, HHS staffers even calculated the cost of envelopes and stamps for mailing payments.

While HHS staffers dismissed concerns, worker advocates argue this rule change could make things extremely difficult for home health workers, and not just when it comes to sending in union dues. Some are unbanked, making it challenging to mail a check. Others deal with significant demands on their time and schedules that could make it hard to keep track of due dates and mail things on time. Issues like these could potentially lead to lapses in health coverage and other problems that could be easily resolved with automatic deductions. More to the point, home health workers themselves have repeatedly stated they want the option to make assignments.

The extremely targeted nature of this rule has big implications. Independent providers are difficult to organize because of their far-flung nature. They don’t have a shared office, meeting place, or workspace to network, because they labor entirely in private homes, out of the public eye. They are underpaid and vulnerable to exploitation. Union membership can change that. Dudley commented that the union helps her “stay informed” and connected with other workers.

The rule is “a blatant attack on us,” she added, asking what should make care workers in particular subject to a bar on withholdings. It’s a question shared by other worker-advocates and their allies. Unions such as the SEIU and AFSCME are organizing against it, and at least five states are suing.

“It’s our choice to take our deductions out of our checks,” said Dudley.



Opioid Crackdowns Punish Chronic Pain Patients Without Fixing the Crisis

When Emma Stern’s private insurance changed two years ago, so did her pain management plan. The Oregon resident has insomnia and a painful chronic kidney condition that require careful medication. Stern’s new internist said the Drug Enforcement Agency (DEA) stripped her license for “overprescribing” opioids, so she could not provide Stern with necessary prescriptions. Instead, she referred Stern to a pain management clinic.

During a recent visit to her pain clinic, Stern’s pain management doctor informed her that her treatment plan was going to need to change again: Now, she would have to choose between taking Xanax and taking hydrocodone (also known as Vicodin). The doctor was not concerned that she was misusing her medications, but that law enforcement would come after him if “something happened to [her].” So, Stern had two options: medicate her pain, or get enough sleep. She chose the latter.

While Stern’s story may seem extreme, her experience is representative of many chronic pain patients who have come up against various barriers that have been set by state governments, the medical field, and corporate pharmacies. According to recent CDC findings, 50 million Americans have chronic pain; although chronic pain affects people from all economic backgrounds, it tends to hit those in poverty the hardest. People in chronic pain tend to experience greater poverty, and struggle with the cost of medications and frequent pharmacy or doctor’s visits. The treatment of chronic pain also has major disparities when it comes to race, and black women in particular have suffered the consequences of those disparities.

Many of these access issues stem from a response to the opioid addiction and overdose crisis, declared a public health emergency by the Department of Health and Human Services in 2017. However, early response efforts have increased chronic pain and its consequences, leading to worse outcomes for chronic pain patients that should be addressed as a new public health crisis.

This crisis accelerated when the Centers for Disease Control (CDC) released their set of guidelines on opioid prescribing, intended for use by primary care providers, in 2016. The CDC has since clarified that the guidelines were recommendations, not strict policy, but the harm to many chronic pain patients like Stern has been done.

“The only treatment available [for my condition] at this point is treating the pain and the chief of urology at OHSU instructed my primary care doctor to allow me to have a monthly supply of opioid pain medication,” Stern said, but the results of opioid scaremongering have left her in agonizing pain instead. Part of the CDC’s 2016 guidelines, under the heading “Assessing Risk and Addressing Harms of Opioid Use,” stated that “[c]linicians should avoid prescribing opioid pain medication and benzodiazepines concurrently.” For someone with complex medical issues like Stern, this guideline is not useful.

Some government agencies are starting to recognize the consequences of cracking down on pain patients’ opioid prescriptions; the Food and Drug Administration (FDA) recently released a safety alert on the negative effects of sudden discontinuation or abrupt tapering of opioids, which can include “serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”  The authors of the 2016 CDC guidelines for opioid prescribing also recently clarified how its guidelines are meant to be used as a response to widespread misapplication of those guidelines.

Very few opioid addictions begin with a patient who has a doctor’s prescription.

The misconception that opioid prescriptions lead to opiate addiction has been widespread, and overarching state and federal measures to combat the opioid overdose crisis are reaching a fever pitch. There’s the Oregon Health Authority’s (OHA) now-tabled proposal to force-taper all Medicaid patients on opioids for certain chronic pain conditions; Senators Kirsten Gillibrand and Cory Gardner’s controversial proposal to limit all acute pain medication prescriptions to a seven day fill, which sparked massive pushback from the chronic pain and disability communities; and Ohio Senator Rob Portman, who favors a three-day fill limit. In contrast, the American Medical Association (AMA) has come out against arbitrary pill limits, as has a group called Health Professionals for Patients in Pain (HP3).

Very few opioid addictions begin with a patient who has a doctor’s prescription: Up to 80 percent of people with an opioid addiction illegally obtained pills from another source like a friend or relative first. While the opioid overdose epidemic from illegal heroin and fentanyl is a serious problem, federal and state actions to decrease the number of opioid prescriptions and/or pills in circulation overall will have — and are already having — a hugely negative impact on chronic pain patients who take opioid medications. While the number of pain prescriptions has declined since 2010, the number of deaths due to overdoses involving heroin and synthetic fentanyl has increased.

According to Thomas Kline, MD, a physician in North Carolina who maintains a list of chronic pain patients who committed suicide after being forced off of their medications, the anti-opioid hysteria that has taken root in the medical field and the federal government has resulted in “people [being] killed.”

Senators and state representatives are not medical doctors, and overarching government intervention of the kind that we are witnessing in private medical treatment can and does have consequences that are bad for chronic pain patients.

A one-size-fits-all policy, whether at the state or federal level, when it comes to chronic pain and opioids may have unintended consequences for chronic pain patients. Dr. Kline puts it more starkly: “Limiting the number of pills [that patients can get] is not going to work. All it’s going to do is screw people.”



2.2 Million Americans Are Behind Bars. That’s More Than The Prison System Can Handle.

Sam was no stranger to arrest. Since becoming addicted to methamphetamine after moving to Hawaii for a chef position, he spent years bouncing between jails, rehabs, and the streets. But when his module caught fire during a riot at the Maui Community Correctional Facility, he found himself faced with an impossible choice: Go back inside the burning building, or extend his sentence.

The conditions that led to the riot were nothing new. MCCC was designed to hold 301 people, but at the time was packed with over 400. The jail has a history of chronic overcrowding; in 2016 the American Civil Liberties Union of Hawaii filed a complaint that named MCCC as the most “egregiously overcrowded” on the islands, to the point that it was unsafe. Among other issues, the report notes that it was common for three, four, or sometimes five people to be placed into cells designed for two, forcing them to sleep on the floor among roaches and rats, sometimes with their heads beneath the toilet.

Tempers were strained by other issues, as well. Anonymous whistleblowers told The Maui News about undersized, nutritionally insufficient meals, and last year, the facility was fined more than $16,000 for failing to maintain a functioning fire alarm system. The phones — which often serve as the sole connection to incarcerated people’s children, partners, and other family — were chronically broken. “And mail,” Sam said, “we’d get [letters] that were weeks and weeks and weeks postdated, or never, ever get them; they’d just get sent back.”

On March 11, 2019, some of the people detained at MCCC began complaining to the guards. It started as a typical, minor confrontation, but this time they’d had enough of being ignored. When a guard ordered everybody back to their cells, several detainees refused. And then they did more than refuse. They began by throwing chairs at windows, smashing computers, and stacking together toilet paper rolls and other flammable items. Overbooked and understaffed, the situation quickly became more than the guards could control. Soon, there was a fire. Detainees report being locked in cells while the module burned, their guards nowhere to be seen. Fire sprinklers worked only sporadically. Smoke filled the cells, blindingly thick. Sam said he was able to escape to an outdoor recreational area, but when he and several others arrived, police negotiators yelled at them to go back inside and leave through the emergency exit, or face escape charges. But according to Sam, those emergency exit doors were jammed.

Eventually the fire was doused, but detainees then had to contend with police in riot gear, who were beating people, sometimes after zip-tying them, according to the reports given to The Maui News. Once the riot was settled, people jailed in the facility were sent back to the same cells that had just been trashed. Many had no access to working toilets. Sam’s mattress was gone. Eventually he passed out on the concrete floor, succumbing to sheer exhaustion.

In the month after the riot, two inmates escaped from the facility through a broken door. MCCC has not stopped housing people, not even for repairs, which include fixes for smoke-stained walls and replacement beds, chairs, tables, and kitchen equipment. One module had to be decommissioned due to the damage; the people housed inside were relocated to other areas of the facility, which are now even more crowded than they were prior to the riot.

When asked for comment, a prison official told TalkPoverty “The disturbance at the Maui Community Correctional Center (MCCC) is under investigation and internal review by the Department of Public Safety. There is nothing further we will be discussing about the on-going investigation at this time.”

The damages are expected to cost 5.3 million dollars, much more than it would have cost to fix the phones or provide sufficient meals to the people housed in the facility. National estimates place the cost of feeding incarcerated people at around $2.62 per person per day; raising that figure by a full dollar would not bring MCCC’s food budget, at capacity, to even half a million dollars. And phone calls, which cost money to detainees and their families, are a highly profitable industry in the corrections world, which means those phones essentially pay for their own repairs. What happened at MCCC is an extreme, dramatic example of the deleterious effects of overcrowding within correctional facilities, but the core issue is one that quietly affects pretrial jails and prison facilities across the nation.

Last April, guards were so overwhelmed by a riot in a South Carolina maximum-security prison that they waited more than four hours to enter the building, leading to the deaths of seven inmates. A 2017 riot in Delaware that led to the death of a corrections officer has also been attributed to overcrowding and understaffing. And earlier this year, the U.S. Department of Justice deemed Alabama state prisons for men were in violation of the Constitution due to severe overcrowding that led to physically and emotionally dangerous conditions. Some evidence suggests overcrowding may even be linked to a rise in the use of solitary confinement.

What took place in Maui is only one example of a nationwide issue.

Overcrowding can manifest in everyday deprivations, like the denial of visitation, vocational and rehabilitation programs, and appropriate medical care. And it stems from laws and policies that target vulnerable populations. There are laws targeting transient and low-income people, such as panhandling, loitering, and public camping ordinances. Then there are those which could theoretically affect anyone, but somehow tend to target the poor anyway. Drug laws, for example, disproportionately affect people like Sam; addicted, cash strapped and in need of medical treatment. Sometimes people can be incarcerated for months simply for carrying a used syringe or a baggie with stray powder.

Those laws are paired with the cash bail system allows wealthier people to pay their way out of jail pending trial, and leaves those with less economic means — about 460,000 people, or one-quarter of all incarcerated people —  behind bars. People who face pretrial detention are more likely to be convicted, usually through a guilty plea.

When people are picked up on allegations that are essentially the result of deprivation — whether of food, housing, or appropriate medical care — and can’t make bail, they languish in correctional facilities until those facilities become stretched beyond capacity. Because these laws essentially target people for activities of necessity — for example, sitting on a sidewalk — they lead to overzealous arrests of people who don’t have the money to bond out. Too often, the crimes that land people in jail stem from an acute need for mental health or substance use services —the exact type of care that these facilities are unable to adequately provide.

What took place in Maui is only one example of a nationwide issue. Across the country, cash bail practices along with anti-drug user and anti-loitering laws continue to funnel people through an already overloaded system, increasing the cost demand on facilities to provide for the basic needs of the people housed inside. The result is hundreds of thousands of people crammed into jails and prisons that are unsafe, unhealthy, and, quite possibly, unconstitutional.

Editor’s note: When requested, names have been changed to allow people to talk more freely about their experiences behind bars.