When a sheriff’s deputy pulled Emmanuel Pullom over on a suburban street near Birmingham, Alabama, the night of Dec. 1, 2018, he suspected that Pullom had stolen the black Ford pickup he was driving.

In Alabama, the county in which you’re arrested could be the deciding factor in who will be financially responsible for your medical bills behind bars.

In Baldwin County, known for its white-sand Gulf Coast beaches and waterfront communities, the sheriff’s office ensures that inmates in the county jail do not have to pay anything more than a $15 copayment for medical care.

“Inmates are not billed for the full cost of any medical care either inside or outside” the jail, Sheriff Hoss Mack said in an email. “Alabama Code Title 14 assigns financial responsibility of inmates’ medical treatment to the department where they are being held.”

Just across the bay in Mobile County, home to one of the busiest ports in the U.S. and the eponymous city of nearly 200,000 people built around it, Sheriff Sam Cochran takes a different tack: Some of his inmates are personally on the hook for the full cost of medically necessary care they receive from outside doctors while incarcerated, even if they are awaiting trial.

The difference between the two sheriffs’ approaches demonstrates the unique power Alabama sheriffs have to set their own rules and answer only to voters. Legal experts and civil rights advocates say sheriffs like Cochran are likely violating both state law and the Eighth Amendment of the U.S. Constitution, which prohibits cruel and unusual punishment and excessive fines.

It’s not just happening in Mobile County. In multiple instances confirmed by AL.com and ProPublica, inmates have had medical bills sent to collections while they were still behind bars, damaging their credit and putting pressure on their family members to pay up to ensure the care continued.

Brandon DeLaFosse is among them. He was arrested on domestic violence, burglary and robbery charges and booked into the Mobile County Metro Jail in November 2018, three months after he underwent surgery on his inner ear. Since then, he has received bills totaling thousands of dollars for necessary follow-up appointments and tests, some of which have gone to collections while he remains behind bars.

“He keeps getting bills in the mail,” said Alicia DeLaFosse, Brandon’s mother, who has paid hundreds of dollars for care he has received while in custody. “It’s all money he owes from going back and forth to the doctor.”

Like many inmates, DeLaFosse doesn’t have significant income or access to public or private insurance in jail.

Alabama law is clear: If an “inmate develops a medical condition which requires immediate treatment at a medical-care facility outside the county jail, the department shall be financially responsible for the cost of the treatment of the inmate.”

But Cochran said when the jail’s doctors determine inmates need care that goes beyond what in-house medical staff and contracted outpatient providers can handle, they are often taken to private medical professionals who do not have contracts with the jail. And he allows those medical providers to bill at least some of those inmates directly.

“When that person is taken out to that private medical facility or something like that, then, yeah, they’re going to bill him for that treatment,” Cochran said during an interview in his office last month. “It’s a more than reasonable thing to do.”

Asked later about the details of Brandon DeLaFosse’s case and how the practice squares with state and federal law, Cochran provided an email written by Trey Oliver, warden of the Mobile County Metro Jail.

Oliver wrote that inmates are required to pay “when they have a follow-up procedure or visit from a surgery conducted prior to being booked.”

As for DeLaFosse, Oliver wrote, “There was a follow up visit or two and his mother agreed to pay it beforehand.”

Most jails and prisons across Alabama and the U.S. either have doctors and nurses on staff or contract with outside companies to provide medical care in their lockups. It’s not uncommon for inmates to be charged low copays — typically less than $20 — for medications and medical services.

But requiring inmates to foot the bill for their health care takes that practice to another level.

That’s “like charging them for their own food,” said John Lentine, a Birmingham criminal defense attorney and adjunct law professor at Samford University’s Cumberland School of Law and the Birmingham School of Law. “To me it’s a basic human rights kind of thing.”

Michele Deitch, a senior lecturer at the University of Texas at Austin’s School of Law and Lyndon B. Johnson School of Public Affairs, said the practice is “absolutely” unconstitutional.

“There is a constitutional obligation to provide health care that meets the serious medical needs of people who are incarcerated,” said Deitch, who co-wrote the American Bar Association’s Standards on Treatment of Prisoners. “That’s not negotiable.”

The tactic is another way in which sheriffs across Alabama are avoiding financial responsibility for inmate medical care. AL.com and ProPublica reported in September that many sheriffs in Alabama and across the country are finding ways to release inmates from jail just before they incur expensive hospital bills, a tactic known as “medical bond.”

In several recent cases, incarcerated people around the country have successfully challenged policies restricting their access to free medical care in prison.

Last year, a federal court ruled that transgender inmates in Missouri’s state prisons have a right to receive hormone therapy free of charge while incarcerated, regardless of whether they were already receiving the treatments when they were taken into custody. And this year, prisoners in Minnesota reached a settlement with the state’s Department of Corrections that requires the prison system to provide prisoners who have Hepatitis C with expensive drugs that often cure the infection.

AL.com and ProPublica attempted to contact the sheriffs of all 67 counties in Alabama via email or phone to ask whether they allow inmates to be billed for care they receive while incarcerated. Of those, 13 sheriffs and one chief deputy responded. The sheriff of Mobile County and chief deputy of Jackson County each said they allow providers to bill inmates for necessary care in certain situations. Ten sheriffs said they do not allow inmates to be billed. Two others declined to comment.

“I’m Still Getting Bills”

Days after Thanksgiving last year, Brandon DeLaFosse was arrested in Mississippi on outstanding warrants stemming from an incident earlier that month in Mobile County, Alabama.

The then-28-year-old was driven back to Mobile, where he stayed in the county jail until Feb. 28, when he was sentenced to three years in prison.

DeLaFosse’s health problems continued behind bars. Since his ear surgery last year, he has suffered from persistent ear infections and severe hearing loss.

And his bills are piling up.

In between Marlboro Lights and peanut butter-and-syrup sandwiches at her Irvington home last month, DeLaFosse’s mother, Alicia, said she spends many hours each week making calls, sending emails and conducting research to advocate on behalf of her son.

She said a steady stream of medical bills addressed to her son has arrived at her house since his arrest. Billing records show that she has spent more than $600 on his care since his arrest, and more than $1,000 in outstanding bills have gone to debt collection.

On Dec. 6, 2018, while he was in the Mobile County Metro Jail, Brandon DeLaFosse was taken to see an ear, nose and throat specialist at Providence Hospital in Mobile for a surgery follow-up visit recommended by the doctor. But first, his mother said, jail staff required her to make a payment to the doctor’s office. After the appointment, the hospital’s billing department sent a bill for $729 for tests he underwent that day to Alicia DeLaFosse’s house.

“The way the nurse at the jail explained it to me is because it was something that didn’t happen at the jail, it’s preexisting. ... I had to go pay for it myself,” she said. “For the jail to allow him to go see the doctor, I had to go to the doctor’s office and pay $125 first.”

A registered nurse at the jail in Mobile noted in Brandon DeLaFosse’s medical record that his mother made a payment and that the nurse had scheduled a follow-up visit for later that month. In January 2019, a nurse practitioner at the jail wrote a note in his file stating she would request another follow-up appointment with his doctor “with the expectation that it is handled in the usual fashion with his mother arranging for payment.”

"I don’t think it’s fair. They're responsible for my medical care, so why should it be coming out of my pockets or my family's pockets?" Brandon DeLaFosse said in a jailhouse phone call.

Cochran, the Mobile County sheriff, said via email that he views the situation as a “legal dispute between [Brandon DeLaFosse], us and our contracted provider. I know of no complaint or claim made against us.”

“The mom agreed to pay [the] bill. Looks like she reneged,” Cochran wrote. “Otherwise if it would have been medically necessary our contracted folks would have handled.”

Alicia DeLaFosse said she “didn’t renege” and paid for all of the medical costs she knew about in advance.

Brandon DeLaFosse continued to be billed for outside medical care after he was moved to state prison. On July 23, nearly five months after his sentence began, he saw a doctor and underwent tests at Providence Hospital. He was sent a bill for $224.70 for outpatient diagnostics administered that day, plus $71.98 for the doctor visit.

That shouldn’t have happened, a spokeswoman for the Alabama Department of Corrections said in a statement.

“By ADOC’S policy, all inmates in the care, custody, and control of any ADOC correctional facility are not charged or responsible for community-based medical care or mental health services,” the spokeswoman, Samantha Banks, said.

Any state prisoners “incorrectly” billed for outpatient medical care should notify the provider that they were incarcerated at the time, the statement explained. “The medical provider should submit to the Department the appropriate paperwork and any outstanding inmate medical bills will be directed to the appropriate payer.”

State prisoners in Arizona have reported similar issues with providers billing them directly for medical care they received while incarcerated, as KJZZ radio reported this year. Like in Alabama, the Arizona Department of Corrections has said the bills were sent out in error and that the department or its medical contractor would pay the inmates’ bills.

But that’s a vastly different situation than the one facing inmates in some Alabama counties, where sheriff’s offices are not chalking up such bills to error and are in fact deliberately choosing to avoid paying medical bills for inmates in their charge.

Constitutional Question

Though the public often has little sympathy for inmates, incarcerated people do have clear rights, particularly when it comes to health care behind bars.

Alabama law states that “necessary clothing and bedding must be furnished by the sheriff or jailer, at the expense of the county, to those prisoners who are unable to provide them for themselves, and also necessary medicines and medical attention to those who are sick or injured, when they are unable to provide them for themselves.”

In another section of the state code, a definition of a county inmate includes an explicit reference to their health care being provided for: “any person being held in a public institution under the administrative control and responsibility of the county sheriff and for whom the county is responsible for the provision of medical care.”

Brandon Blankenship, an assistant professor of law and ethics at the University of Alabama at Birmingham, said that allowing inmates to be billed for care that they receive while incarcerated amounts to cruel and unusual punishment and that the bills are excessive fines.

“I don’t think it’s ever been challenged in court in Alabama, but from where I’m sitting, the answer to me is that, no, it’s certainly not constitutional under the Eighth Amendment.”

The tactics of some Alabama sheriffs stand in sharp contrast to what’s going on elsewhere in the country. This year, California and Illinois banned the practice of charging inmates copays, and a number of other states have taken, or are considering, steps to rein in the practice.

“They usually cannot afford even a $5 copay, so the idea that they could pay thousands of dollars for these services is laughable from a practical perspective and it’s downright evil on many different levels,” said Deitch, the University of Texas at Austin professor.

In 1983, the U.S. Supreme Court decided a seminal case, City of Revere v. Massachusetts General Hospital, involving a person who was hurt during an arrest and taken to a hospital. The court ruled that “as long as the governmental entity ensures that the medical care needed is in fact provided, the Constitution does not dictate how the cost of that care should be allocated as between the entity and the provider of the care. That is a matter of state law.”

But that ruling did not answer the question of whether inmates can be stuck with the bill.

“We don’t have any clear Supreme Court ruling,” said Fred Cohen, a professor emeritus at the University at Albany’s School of Criminal Justice who has decades of experience in corrections law and serves as executive editor of Correctional Law Reporter.

Cohen said he believes there is a good case to be made that the practice of allowing inmates to be billed for medical care violates their constitutional rights.

“I don’t think it’s an open policy question in that inmates should not be required to pay,” he said. “I think it could be held unconstitutional by the right court.”

Different Systems

Several days after Charles Tillman was booked into the Washington County Jail in March 2018, his left testicle became severely inflamed. He told a guard, and on March 22, Tillman was taken to Washington County Hospital for treatment and an ultrasound.

The 40-year-old, who has a long rap sheet, was driven back to the jail following the appointment and was released from the facility the following day. (The Washington County Sheriff’s Office confirmed the dates of his incarceration. But the nature of his offense was not clear based on court records, and the sheriff’s office would not discuss his charges during a phone call with Tillman and a reporter.)

It wasn’t until weeks later that Tillman learned that he had been billed directly for that visit and that the debt had been sent to a collector, upending his credit. He showed AL.com and ProPublica a copy of his credit report showing it had been negatively affected by unpaid medical bills.

“They tried to get me to sign paperwork but I refused to sign it, the hospital bill saying I was responsible for it.”

As of this month, Tillman still owed $1,856.42 for medical care he received at Washington County Hospital. The hospital confirmed that it treated him during each of his brief incarcerations in the jail in February 2017, March 2018 and September 2018.

“I got the bills at my [home] address,” said Tillman, who has since been released. “They’re on my credit report now as negative marks — that’s what’s keeping me from getting a car right now.”

Washington County Sheriff Richard Stringer was unable to explain Tillman’s situation, saying the county’s policy is to pay for all medical costs for inmates who aren’t covered by insurance.

“That’s not standard procedure,” Stringer said. “It would have to be an unusual case for that to happen, and I don’t keep up with every case that comes in. But no, that’s not our policy.“

Hundreds of miles northeast, Rocky Harnen, chief deputy of the Jackson County Sheriff’s Office, said preexisting conditions should be inmates’ responsibility.

“If it’s something preexisting, say diabetes or something, and you’ve got to go to the doctor every now and then, then that’s their responsibility to pay for that,” he said.

“If it’s going to your own doctor, they would be responsible for that. I guess they would bill them at their house. The taxpayers shouldn’t be responsible for ongoing issues that are preexisting.”

Harnen referred subsequent questions about the legality of the practice to County Attorney John Porter, who did not cite any laws that allowed it.

“I can’t say that there’s not any medical care that they have to pay for,” Porter said.

Asked if inmates sometimes have to pay for outpatient care for preexisting conditions, he said, “I wouldn’t say that that’s incorrect. … I can’t give you a blanket answer to that but it would be depending on the circumstances.”

That’s not the way inmate health care works in many county jails across Alabama. In Etowah County, northeast of Birmingham, inmates are never billed for care they receive while incarcerated, according to Sheriff Jonathon Horton.

“We provide medical services for inmates in our care so they should not receive any bills,” Horton said. “They shouldn’t be billed. That’s my understanding.”

Lauderdale County Sheriff Rick Singleton said that he would love to have inmates in his jail in northwest Alabama foot the bill for certain types of medical care, but that he is not legally able to do so. For instance, he said he would like to have avoided the $300,000 the county once had to pay for open heart surgery for “the town drunk” arrested on a public intoxication charge.

“If they’re in jail on public intoxication and they’ve got preexisting health conditions, I don’t think the taxpayer should have to foot the bill to pay for it,” Singleton said. “If they get injured inside the jail or they get sick inside the jail, we of course pay for it. But my issue is with having to pay for preexisting conditions. But we have to do it.”

Help Us Investigate

ProPublica and AL.com will be investigating the extraordinary power of Alabama sheriffs all year. Are you from Alabama? Do you have reason to believe we should be looking into your sheriff or sheriff’s office? Get in touch.