In Dakota County, where medical costs at the jail were $1.3 million last year, officials say, taxpayers sometimes pay twice for the same medical visit by a sick inmate.

Many of the inmates are on public assistance, which pays health insurance premiums. Yet because of tricky privacy concerns, legal advisers have directed jail staff to not ask if people receive assistance. Instead, the jail usually is billed for the medical visit, which taxpayers wind up paying -- as well as the public assistance, said Blair Anderson, commander of the jail.

"If we're paying the bill, I should be able to extrapolate any information that's going to help me," he said. "It's irritating. And the reason it's irritating is that there are roadblocks that are put in the way of being efficient."

It's one factor adding up to big medical costs for jails in Dakota, Scott and Washington counties, and beyond. Jailers are looking for ways to cope with the surging medical costs, driven by what the director of the Minnesota Sheriff's Association calls a "perfect storm" of circumstances.

"It's well known that our mental institutions have basically closed, so by default our jails have become our mental institutions," said Jim Franklin. "It boils down to who's going to pay, out of what budget? In the end it all comes out of the taxpayer's pocket."

In Minnesota, some inmates haven't seen doctors in years, others skip from one emergency room to another, and inmates booked into jail sometimes carry contagious diseases. To avoid legal, moral and ethical dilemmas, sheriffs must find a way to treat inmates on budgets already strained by state mandates.

Dakota County's medical costs last year were up nearly 30 percent over the $1 million in 2006.

Of that, the jailers spent $325,000 on medicine for inmates. The jail also had a bill of $420,000 for nurses to administer those drugs and tend to other needs, plus other medical providers and costs.

One orthopedic operation alone can mean an inmate returning to the jail with a bill of $40,000 or $50,000, Anderson said.

Scott County Sheriff's Capt. Bonnie Case, jail administrator, said her lockup contains mentally ill inmates who need costly psychotropic medications, others with dental problems related to methamphetamine use, and on occasion, a seriously ill inmate needing a long hospital stay.

Scott County is requesting a $280,000 budget for jail medical costs, about $10,000 more than last year. But Case knows one catastrophically sick patient can jack up those costs.

"It's so difficult to budget for -- you can go by past trends, but you also will have a year of lots of catastrophic major illnesses and no way to know when you have one of those years," Case said. "That's where the difficulty lies."

Dakota County is not requesting a budget increase for 2009 for jail medical costs, said sheriff's Capt. Dave Bellows. A 1.5-percent cost-of-living increase is automatic.

"We've been very aggressive in trying to reduce health care costs," Bellows said. "The areas where we've been seeing the greatest increase is in medication costs, especially associated with treatment of mental health concerns."

Instead of turning to taxpayers for more money, the Sheriff's Office is trying to better manage the operations.

In one initiative, the Sheriff's Office, the county health department and social services are working on a coordinated approach to check databases to see if someone is insured.

"We are trying to reduce inmate medical costs by cross-checking and finding who is on medical assistance and who has private insurance coverage, or not," Anderson said, "so that the proper carrier is billed as opposed to us being a default payee."

To cut costs, the Sheriff's Office worked with mental-health providers to create a list, or formulary, of the most commonly used psychotropic medications, and tries to buy generic drugs when available.

State law says that hospitals and other providers cannot charge jails more than what they are being paid by the largest insurer, unless they have an agreement otherwise.

In Washington County, Sheriff Bill Hutton and the jail commander, Chuck Yetter, say they're forced into constant reviews of the jail budget because of unpredictable surges of illnesses ranging from chronic diseases to depression, alcoholism and drug abuse.

There, 35 percent of jail inmates are treated for mental illnesses. Another 30 percent have drug and alcohol problems, 30 percent have dental decay, 25 percent have diabetes and 25 percent have heart disease. Many inmates suffer from several inflictions at once.

Washington County plans a 10 percent increase in next year's jail medical budget, costing county taxpayers a total of nearly $800,000.

Staff writers Kevin Giles and David Peterson also contributed to this article. Joy Powell • 952-882-9017