By Elizabeth Thompson
Seated on lush forest land in the far west of the state, Graham County, the third-least populous county in North Carolina, is just one major medical emergency in its county jail from completely depleting its budget.
Much of the county’s land is United States Forest Service land, so its tax base is small, and it’s not growing, said Becky Garland, Graham’s finance officer. It has only two ambulances, so if they’re being used, the only option is to send sick detainees from the county jail two hours away to the nearest hospital — in a helicopter.
“One helicopter ride can cause our jail inmate medical budget to just be decimated in about 15 minutes,” Garland said.
Garland hovers on the precipice of an inevitable budget crisis. A COVID outbreak spread throughout the county jail earlier this year — thankfully, no one was hospitalized — then, another inmate needed gallbladder surgery. Any one medical emergency could mean deleterious outcomes for the county.
Jails in North Carolina bear the medical responsibility for people who are in their care, meaning any necessary medical procedures come out of taxpayer funds. Even if people in jail were on Medicaid before intake, they are no longer covered.
Some counties, especially rural counties in the western part of the state, are calling for Medicaid to be expanded to help cover these costs and reduce recidivism.
“Our health care out here is more precarious anyway,” Garland said. “We don’t have the hospital capacity and if we had the Medicaid expansion and we knew we’ve got an inmate with a chronic illness, we could be taking that inmate to … getting preventive care, so that we’re not in an emergent care situation all the time.”
The problem isn’t new, Garland said.
“I’ve been here 12 years,” she said, “and I’ve had this problem for 12 years.”
But it could be a problem with a solution.
How Medicaid expansion works
Medicaid expansion allows households with an income below 133 percent of the federal poverty level to qualify for coverage under the Affordable Care Act (ACA). Ninety percent of the expansion would be covered by the federal government, and the state would cover the remaining 10 percent. Most people who currently qualify for Medicaid are low-income workers, people with disabilities and pregnant people, so expansion would mostly benefit low-income adults without children.
There are 38 states, plus the District of Columbia, which have expanded Medicaid, according to the Kaiser Family Foundation. North Carolina is one of 12 which have not yet.
Opponents to expanding Medicaid, many of which are Republicans, say they’re skeptical that the federal government would continue funding in perpetuity, leaving the state to foot the bill. Still, some states have passed Medicaid legislation that would allow them to back out of Medicaid expansion if that were the case.
Other Republicans are leading the push for expansion, such as state Sen. Kevin Corbin (R-Franklin), who has been a vocal supporter of expanding Medicaid.
Related story: What happens when a state expands Medicaid?
If Medicaid were expanded in North Carolina, it wouldn’t cover every single medical cost for detainees, since the ACA did not change a long-standing interpretation that people cannot receive Medicaid benefits if they are in jail. However, the statute does allow detainees treated as an inpatient in a medical facility, such as a hospital, nursing home, juvenile psychiatric facility or intermediate care facility for 24 hours or more outside of the state correctional system, to be covered if they are eligible, according to the National Association of Counties.
Medicaid expansion would allow more people to be covered, thus allowing more otherwise-uninsured people to be covered by Medicaid under this exception.
Medicaid expansion would not just help some counties pay medical costs, some advocates say, it could help reduce recidivism by helping currently uninsured people address behavioral health issues, such as substance use disorder or other mental illnesses which could land them in jail. As it stands now, detainees with these issues may be incarcerated and then released, with their problems unaddressed, then find themselves right back behind bars within weeks or even days.
Case study: Ohio
Ohio, a state similar to North Carolina in terms of size and population makeup, expanded Medicaid in 2014, under Republican Gov. John Kasich.
Greg Moody, an executive-in-residence at the John Glenn College of Public Affairs, was part of the Ohio Governor’s Office of Health Transformation which was instrumental in making this expansion possible. At the time, he said, one of the most powerful groups coming out in support of expanding Medicaid was seemingly unlikely — sheriffs.
“Individuals with mental health needs, untreated behavioral health needs, were ending up in their jails because there was no alternative available to them that could be paid for,” Moody said.
Ohio’s expanded Medicaid program also enrolled incarcerated people in Medicaid prior to their release, to ease reentry to society. In a 2018 study, the state found that two thirds of people in the pre-release program having Medicaid made them less likely to be incarcerated again.
“That stability is critical,” Moody said, “particularly if you need something related to addiction or related to medication, related to behavioral health. It’s just critical that you don’t lose your meds, and so we’re able to line that up before people leave. We were trying to do that ourselves prior to expansion, but it was 100 percent state funded.
“Now, it’s covered by Medicaid.”
A push for Medicaid expansion
In North Carolina, some sheriffs have similarly come out in support of expansion, including conservative stalwart Alamance County Sheriff Terry Johnson, who has advocated that jails do not have the ability to treat the mental health problems sent to them.
“Our staff has saved eight people trying to commit suicide in our detention facility and if you will go back and do the history on some of these people, you will find that issue started in childhood and continued to escalate all the way up until they violated the law,” Johnson said at a press conference last year.
Jails and hospital emergency rooms have become the safety net for mental health crises, said Robin Huffman, executive director of the North Carolina Psychiatric Association. Huffman has worked with Alamance County on its Stepping Up Initiative to fight mental illness with treatment instead of incarceration.
“We’re meeting regularly, acknowledging that this is a problem, and working on solutions to fix it,” Huffman said. “… We have law enforcement officers who are saying, ‘Oh, these aren’t just bad people. I get it, there’s something wrong with them, and, and there’s a better way.’”
The North Carolina House budget allocates $500,000 to a diversion center in Alamance County where people who are arrested with mental illness can receive medical services as part of Johnson’s Stepping Up Initiative. It’s unclear if the initiative will make the final budget and get that funding, since it is not in the Senate budget and the two chambers now need to work out their differences in conference.
Even though some 98 percent of incarcerated people in North Carolina will eventually be released, according to the North Carolina Department of Public Safety, people reentering society from the state’s jails and prisons are often not linked to substance use treatment or mental health services. And the COVID-19 pandemic has exacerbated the struggles that come with reentry, North Carolina Health News has previously reported.
The state has programs such as the North Carolina Formerly Incarcerated Transition Program (NC FIT), which helps connect people to health resources upon their release, but the program still can’t come close to meeting the need, the program’s director Evan Ashkin, who is also a professor at the UNC Chapel Hill School of Medicine, said.
Paying for it is also challenging.
NC FIT has limited resources to meet staggering needs, Ashkin said, but it is still unable to help people cover specialty care for chronic medical problems, like diabetes, hypertension and communicable diseases like hepatitis C and HIV.
“It’s a huge problem for our clients,” Ashkin said. “We’re able to, because of this fundraising which is not terribly sustainable, get them into primary care but we can’t get them into specialty care and a lot of people have serious medical problems and they need to see specialists for routine screening procedures… all this stuff which we can’t help them with.”
On the western side of the state, Ronnie Beale, a Macon county commissioner, said failing to provide mental health treatment for justice-involved people does no one any favors, at a town hall about Medicaid Expansion held by Care4Carolina and the NC Rural Center at Southwestern Community College.
The Macon County Board of Commissioners voted last week to support Medicaid expansion, according to the Southern Scoop, a local news outlet. They joined the Graham, Swain and Jackson county boards in supporting the policy.
“Jails have become everything,” Beale said. “That’s where you go. You got to remember, when these people get out of jail, or they get out of wherever, they don’t disappear. They don’t just go away, you’re going to see them again, they will come back. They’re going to be homeless, they’re going to end up in your ER. They will be back.”