By Rachel Crumpler
The Central Prison Healthcare Complex bustles with activity. Inside the 600,000-square-foot Raleigh facility, incarcerated men from across North Carolina shuffle through the five-story building for medical care, ranging from dental procedures, imaging, specialty care or even surgery in one of two on-site operating rooms. Some arrive for routine appointments. Others stay for months for extensive treatment.
On a morning tour earlier this month, the urgent care unit — seven open, bay-style gurneys with handcuffs attached to the bedframes, plus other observation cells — was unusually quiet.
Hospital director Chad Lovett, who has been at the helm since 2019, said the lull wouldn’t last long.
In another unit, 10 incarcerated men sat connected to dialysis machines for hourslong treatments to manage their kidney disease. Down the hall, oral procedures were underway in the dental clinic. On another floor, psychiatrists and nurses worked to stabilize patients on psychiatric medications — many occupying the inpatient mental health beds for weeks and months at a time. Other medically fragile men occupy the facility’s 60-bed long-term care unit for skilled nursing care.
The medical complex, tucked within the perimeter of Central Prison in Raleigh, serves as the main hub of medical and mental health care for incarcerated men from across the state. Opened in 2011 at a cost of roughly $154 million, it has 398 beds — 216 dedicated to inpatient mental health.
A similar medical complex operates inside the state’s largest women’s prison: North Carolina Correctional Institution for Women, also in Raleigh. Other prisons across the state have more limited medical capabilities, though some maintain infirmaries or chronic disease housing units. For care that cannot be provided inside any prison, the department relies on community hospitals and providers — something that is even more expensive.
As North Carolina’s prison population grows and ages, medical demands are rising — and so are costs.
“Our health care budget continues to escalate significantly,” Arthur Campbell, the N.C. Department of Adult Correction’s chief medical officer, told NC Health News. “As the population is aging, our health care costs are also increasing. Some of it’s just the nature of the market for health care, but a lot of it is the fact that these folks are getting older and need more care.”
The Department of Adult Correction is constitutionally required to provide medical, mental and dental health care to the more than 32,000 people in its custody. However, the price tag is surging.
Growing price tag for prison health care
Prison medical costs swelled to $444.7 million in fiscal year 2024-25 — a 65 percent increase over the last decade, when expenditures totaled $269.5 million in fiscal year 2015-16.
Health care costs have routinely exceeded the department’s budget, which is set by state lawmakers, and the gap is growing wider.
“We can’t suspend health care services,” Department of Adult Correction Secretary Leslie Cooley Dismukes told lawmakers in January during a presentation to the Joint Legislative Oversight Committee on Justice and Public Safety. “It’s not like uniforms or food that we might be able to change.”
The department’s health services budget for fiscal year 2024-25 was $362.2 million, but costs exceeded that by $82.5 million, Dismukes said.
The department entered the current fiscal year with $52.5 million in unpaid medical bills, Dismukes said, and she projects a similar — if not larger — shortfall this year.
“The medical situation hasn’t changed,” Dismukes told lawmakers in January. “In fact, it’s gotten worse. … It’s compounding.”
Aging, high-needs population
A growing share of the state’s incarcerated population is older and sicker — a demographic shift that’s driving rising costs.
Research shows that incarceration has adverse effects on health and accelerates aging, and people develop chronic and life-threatening illnesses earlier than those outside prison.
A 2018 report by the now-defunded Program Evaluation Division at the N.C. General Assembly found that average health care spending for an incarcerated person age 50 and older is typically four to five times higher than for younger prisoners — costing the prison system an estimated $27,748 more per person each year.
“We have had a 300 percent increase in our inmate population age 70 and over in the last 10 years, which is huge,” Dismukes said. “It’s increased our need for long-term care, which is very, very expensive.”
For example, due to insufficient capacity, the department pays about $150,000 per patient per month to house a handful of people in a private long-term care facility in Greensboro for around-the-clock care. In 2025, the cost totaled more than $6 million for just 16 patients.
At the same time, prison admissions outnumbered releases each month in 2025, increasing the state’s prison population by nearly 700 people by year’s end. Incarcerated populations tend to have more medical needs than the general public, including higher rates of mental illness and substance use disorders.
“They arrive with pre-existing conditions that, because they have not received health care previous to coming to DAC, have worsened over time,” Dismukes said. “When we get them, they’re in pretty bad shape, and we are constitutionally obligated to treat their illness.”
Campbell said that the majority of people in custody — about 26,000 people — have a chronic condition, such as diabetes, hypertension, HIV or cancer.
Single patient costs can be “astronomical,” Dismukes explained.
For example, one person with hemophilia — a disorder marked by low levels of blood clotting factors that can lead to excessive bleeding — requires a prescription that costs $900,000 per year. A prescription for a person with multiple sclerosis costs $476,000 annually.
In the past, when prison officials have not treated diseases, they’ve faced lawsuits that they invariably lose, such as one in 2018 that compelled the state to provide pricey hepatitis C medications.
Such pharmaceutical costs continue to climb, consuming an increasing portion of the system’s health care budget.
Another pressure point is the number of people entering the prison system as “safekeepers” — those awaiting trial who are transferred from county jails because they pose security risks or require a higher level of medical or mental health care than counties can manage.
The department houses about 200 safekeepers at a time and has experienced an influx with medical needs. These folks stay on average more than 100 days — straining already limited resources. Campbell told lawmakers that roughly two-thirds of safekeeper admissions in 2025 were for medical or mental health reasons.
“The impact of that is significant because we very often have to admit our sentenced offenders to community hospitals because we don’t have a bed for them,” Campbell said. “Otherwise we could have kept them within one of our facilities.”
Internal constraints
High medical staff vacancy rates at correctional facilities also drive up costs, forcing the department to rely more on contract and community providers who are more expensive.
About 74 percent of registered nurse positions are vacant as of March 19, Campbell told NC Health News. The majority of filled positions are contractors, who cost roughly 30 percent more to employ.
North Carolina’s starting salary for correctional nurses — $58,898 — is the lowest among neighboring states and well below the regional average of $75,446 among Southeastern states, according to a N.C. Department of Adult Correction analysis.
The salary isn’t competitive with other North Carolina employers, either, posing a major challenge to recruitment and retention, Campbell said.
“It becomes very difficult when they can go right down the road and make a lot more money at UNC, for example, and not be in this kind of environment,” Campbell said.
Medical and custody staff shortages have also closed beds throughout the prison system, pushing more patients to more expensive community hospitals.
“We have an entire unit at Central Prison closed down that we could use for medical offenders, but we can’t because of staffing,” Dismukes told lawmakers.
In 2025, correctional officers spent more than 280,000 hours taking incarcerated people to 46,700 community medical appointments, according to Department of Adult Correction data.
Equipment failures also add costs. For example, the CT scanner at the Central Prison Healthcare Complex has been out of service for several months, Campbell said, which means people are sent elsewhere for imaging.
Lovett, the CEO of the health care complex, said the average cost for a CT scan in the community is about $2,800, compared with roughly $500 internally.
“There’s a significant difference, and that does not include the custody staff involved in the movement and transport,” Lovett said.
At least two officers are required to go on each external medical trip, which removes them from shifts inside prisons — at a time when custody staffing is already close to bare-bones.
The department has requested $3.2 million in nonrecurring funding from state lawmakers in the upcoming short session to replace unserviceable medical equipment across the entire prison system, including laboratory equipment, EKG systems, IV pumps and vital signs machines.
Bringing more care inside
To help contain costs, the department is working to deliver more care inside prisons.
In 2025, the Department of Adult Correction’s Comprehensive Health Services Division recorded 2.7 million clinical encounters, including primary care, nursing evaluations, diagnostic studies, speciality medical appointments and procedures. About 88 percent of the medical care took place inside prisons across the state, including nearly 15,000 telehealth appointments.
Central Prison Healthcare Complex performed 459 operations last year — a 48 percent increase from 2024 — helping avoid community hospital visits and admissions.
The department is also focused on expanding specialty medical services, Campbell said. Last year, the department hired a full-time endocrinology specialist who treated about 3,800 offenders, reducing external endocrinology appointments by 75 percent.
Optometry and ophthalmology have been among the greatest outside medical expenses, so the department targeted internal expansion. Now, 22 prisons offer optometry on site, and 7,500 eye exams were performed last year.
“The community hospital system is providing health care to make profit,” Lovett said. “Every year they’re expanding their markup because they can, so that price naturally increases year over year over year, whereas our entire business [in prison medical] is about saving that cost. Everything we’re trying to do every single day is try to provide a service at the cheaper cost that’s not marked up so that we’re being good stewards of the fiscal dollars of our taxpayers.”
Part of that effort is emphasizing prevention.
“Let’s not let these folks get so sick that they need to be in the hospital,” Campbell said.
Medical expansion rests on staffing
Internal health care expansion depends heavily on staffing, Campbell and Lovett emphasized.
“It’s one of the biggest linchpins,” Lovett said.
“Prior to COVID, the capacity within our system was better because we had more facilities open, more available beds,” he said. “We were staffed at a custody level much better. For us at [the Central Prison Healthcare Complex], we were able to move patients through our system much more effectively. But since that’s all compressed down, it’s put us in a very tight space.”
Campbell said the department has identified at least two other prisons where it would like to establish infirmaries, but that can’t happen until the facilities hire more correctional officers. System-wide correctional officer vacancy rates by facility range from a low of about 5 percent to as high as nearly 69 percent, according to December 2025 staffing data from the Department of Adult Correction provided to NC Health News.
The department has identified in its strategic plan a need for another medical complex — likely in the western part of the state — to keep up with growing medical needs, reduce travel and ease pressure on the Central Prison Healthcare Complex.
But that’s a long way off and will once again depend on staff, which has been a chronic problem.
“All of it is going to be resource-driven,” Campbell told NC Health News. “All of it is going to be dependent on being able to get the staff. … The last thing we want to do is have to rely, increasingly, on the community.”
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