Medicaid expansion would help people incarcerated in jails and prisons — the ‘black hole of the mental health system’

Thousands of people currently cycling in and out of jails and prisons are among the roughly 600,000 who would get health coverage under Medicaid expansion, potentially transforming North Carolina’s justice system.

Dorel Clayton became unmoored after his mother died of ovarian cancer, in 2001. He went from caring for her in the hospital and at her home to self-medicating, as tried to mask his trauma and numb the pain after she passed. By the end of that year, his downward spiral would land him behind bars for a decade.

“My way of coping and grieving was to get high, get drunk, and just try not to think about it,” Clayton said recently. “And so, I found myself with the wrong group of guys. And we ended up getting these robbery charges.” 

But if Clayton’s grief led him down a path of self-destruction, it also brought him to his salvation: working for the Durham County Department of Public Health and helping people return home from prison or jail.

That kind of reentry support could go a lot further, Clayton and other advocates contend, if North Carolina would expand Medicaid — which lawmakers considered before the legislature adjourned last week. The House and Senate were divided over whether to expand Medicaid or study what expansion would look like. Neither proposal made it to the governor’s desk.

Unless state legislators vote to make North Carolina one of the 39 other states that have expanded Medicaid since the Affordable Care Act went into effect, they’ll leave a small fortune in federal money on the table. Last year’s COVID-19 relief bill, passed by Congress would give North Carolina $1.5 billion over two years to expand Medicaid, money that state Department of Health and Human Services Secretary Kody Kinsley called a “signing bonus.” 

Kinsley said expanding Medicaid would mean 600,000 North Carolinians would get health coverage. Within that number are thousands of the most vulnerable residents of the state — those with mental illnesses and addictions who cycle in and out of jail and prison.

People with mental health conditions and those who struggle with addiction are particularly affected by the state’s narrow Medicaid eligibility requirements, Kinsley said, because they don’t have access to treatment.

“They often fall into these black holes of either the local jail or into homelessness, where [it’s] really, really hard for them to get out,” he said. “By not having the federal money for Medicaid, we essentially rely on those.” 

Data kept by DHHS shows 60% of those in North Carolina jails have behavioral health conditions, four-fifths of whom are not receiving treatment. 

“Unfortunately, our jails have become the de facto mental health and behavioral health treatment facilities in our state,” Kinsley said. “Because we have so many people without insurance and the means to get access to care, when people are struggling with a mental illness, or they have a substance use disorder, often their disease leads to other behaviors that masquerade as crime.”

Kinsley suggested Medicaid expansion would allow the state to put more money into diversionary programs so people are provided with mental health treatment instead of being incarcerated. 

It’s a concept supported by the state’s sheriffs. The North Carolina Sheriffs’ Association backed expansion during the session, arguing that giving more people health insurance could reduce crime, improve public safety and save taxpayer money since fewer people would be behind bars. 

“In county jails across North Carolina, both large and small, a significant percentage of inmates are suffering from substance abuse issues, mental health issues, and physical health issues that should be treated in a medical facility rather than in a county jail. Many of these inmates cannot afford health insurance yet they do not qualify for Medicaid,” Eddie Caldwell, executive vice president and general counsel of the North Carolina Sheriffs’ Association, wrote in a letter to legislative leaders. 

Caldwell could be right: Broadened access to health care could lead to fewer people in county jails and state prisons. Recent research published in the journal PLOS ONE suggests that states that approved Medicaid expansion also reported fewer violent crime and drug arrests within the first three years of enactment. 

Greater eligibility for health insurance gives people more opportunities to seek health care and receive treatment which could make them less likely to run afoul of the law, the researchers found. 

That means Medicaid expansion could go a long way toward reducing disparities involving race and health among incarcerated people. Black people make up 23% of North Carolina’s population, but 48% of those in jail and 52% of those in prison.

To Kinsley, one of the benefits that expansion offers is in freeing up state money for reentry support. Consider the cost of treating opioid use disorder: Kinsley’s agency spends about $40 million in federal money each year to treat up to 14,000 people. 

“From a disease management perspective, getting more people into care is really hard, just because it is so costly without Medicaid expansion,” he said. “We have essentially said, ‘You have a chronic disease; we have treatments that work, and recovery is possible, but we have no way to fund it. And so inevitably, the only place for them to end up is in jail.”

But if North Carolina legislators expanded Medicaid, Kinsley said the state could pay for more treatment with the influx of federal money, then use state funds for wraparound services, like helping people find housing and access rehabilitative programs.

Medicaid expansion could bolster diversionary programs and treatment options for those struggling with addiction, sparing them from spending time in a cell. It could also help people like Clayton — those coming home from prison or jail, who might have chronic illnesses like diabetes or diseases like addiction or alcoholism. 

 “Health is wealth”

Clayton had been a certified nursing assistant at the time of his mother’s passing. Her death, and the neglect of the elderly and infirm that he witnessed while looking after her in the hospital, renewed his commitment to working in the medical field. Clayton became a peer counselor while he was in prison, mentoring incarcerated young people and leading group therapy sessions. There, he saw how mental illness and substance abuse can lead to a person’s incarceration. 

In 2010, Clayton started working at Freedom House, a halfway house and detox center. For about 18 months he commuted to work and then headed home to sleep in a prison cell. Finally, in 2011, he went home for good. 

Once he became a health care counselor following his incarceration, he glimpsed the revolving door between jail or prison, substance abuse and detox centers — and recognized the similarities to his own story.

“A lot of these people are actually doing the same thing I did, they’re self-medicating,” Clayton said. “They’re trying to escape the different hardships and different tragic things that have happened in their life.”

Now, Clayton is a community health worker with the Formerly Incarcerated Transition Program, which connects men and women coming home from prison or jail — and who have chronic illnesses — to health care services. 

“One of the huge barriers we face in North Carolina doing this is the fact that people are uninsured,” said Dr. Evan Ashkin, director of the FIT program. “It’s hard enough in states where people have insurance to get them connected to care, because of all the chaos post-release.”

That “chaos” can include a litany of more pressing issues, like finding a job or a landlord willing to rent to someone with a criminal record. 

“A lot of times when you have all those barriers coming home, you will put your chronic illness on the back burner,” Clayton said. “So, because you have asthma or high blood pressure, ‘I don’t have anything to eat or anywhere to stay, I’m not really worried about that right now.’”

Clayton and the other community health workers — all of whom have also done time behind bars — help those coming home to understand why it’s important to see a doctor. Clayton tells the recently incarcerated that “health is wealth” — if they are sick then they can’t work. He tells them about his own experience. He tells them how he too, initially resisted seeking mental health care because of the stigma.

Clayton gives his clients vouchers to cover the cost of their co-pays and medications. He teaches them what a primary care doctor is. He tells them why it’s important to refill their medications and take them as prescribed. He even helps them come up with a comprehensive reentry plan, aiding their transition to life outside the confines of a cell. 

Because North Carolina hasn’t expanded Medicaid, FIT works almost exclusively with federally qualified health centers, which receive federal grants to offer services to uninsured patients. Patients pay according to a sliding scale — if they can afford it.

“Most of our clients can’t even afford that sliding scale fee, and they certainly can’t afford their meds,” Ashkin said, requiring FIT to raise additional money to cover at least part of those costs.

If there is a limitation of FIT’s work, it’s that the program can help only with primary care services. 

“So, if people have other specialty needs, that is not covered. We do not have the money for that,” Ashkin said. “If somebody may have been in the prison system or in the jail and they were diagnosed with kidney failure or some kind of cancer, or other issue, and they have specialty appointments at a medical center, there’s no way to pay for those upon release.”

Clayton said even those with a criminal record who do get jobs probably won’t earn a living wage or get health insurance. “And so again, when you’re trying to have food, trying to have a roof over your head, it’s just difficult to try to pay for health care also,” he said.

That leaves the formerly incarcerated at risk of falling yet again into North Carolina’s Medicaid “chasm,” in Askhin’s words.

“In our state, you only get Medicaid if you’re aged, blind or disabled, or a kid, or pregnant woman,” he said. “Over 90% of our folks do not fit into that category.”

Worse yet, those FIT clients cannot get subsidies for an Affordable Care Act plan, Ashkin said. When the law was written, Congress assumed that people below 100% of the federal poverty line would qualify for Medicaid, assuming every state would be in favor of expansion.

“There are no subsidies in the Affordable Care Act, if you’re that poor,” Ashkin said. “So, our patients are both uninsured and uninsurable.” 

These issues vanish if North Carolina expands Medicaid. Access to health care would be dramatically widened, specialty services would be covered, chronic care medications would be more affordable.

“It would help so much it’s hard for me to even believe that it could happen,” Ashkin said, summarizing what expansion would mean for the people the FIT program serves: “An enormous impact on the well-being, life expectancy and health outcomes for people in our state.”