By Rachel Crumpler
The Department of Adult Correction is constitutionally required to provide medical, mental and dental health care to the roughly 31,000 people in North Carolina’s 53 prisons. However, providing this health care comes with a growing price tag, a fiscal analyst told state lawmakers March 4 during a presentation to the Joint Appropriations Committee on Justice and Public Safety.
Health care costs totaled $429.1 million — or about one-quarter of the Department of Adult Correction’s annual budget of about $2 billion — during the fiscal year 2023-24. It’s a 36 percent increase in cost over the past five years.
Health care expenditures came in more than $48.1 million over budget — one of the widest gaps to date.
However, health care costs exceeding the budgeted amount are not unusual. Mark White, an analyst from the General Assembly’s nonpartisan Fiscal Research Division, told state lawmakers that’s been the pattern for at least a decade.
White said many factors are driving costs up.
“The aging population, the large medical need of this particular population, the constitutional obligation the department is under to attend to offender conditions, and growing industry costs in general have resulted in multiple years of cost overruns for health services,” White explained.
For example, state lawmakers allocated an additional $50 million of recurring funding to address medical budget deficiencies and $3.4 million in recurring funding for prison pharmacy operating costs in the 2021 state budget. But those funds weren’t enough to close the gap.
White said he expects health care costs to exceed the budgeted amount again this year.
The Department of Adult Correction has been able to pay for these overages through lapsed salaries — a budgeted amount of pay and benefits that remain unused because a position is vacant.
“On the one hand, the budget does not reflect the actual spending needs,” White said. “On the other hand, because of lapsed salary, the agency is able to continue operations.”
1.4 million health encounters
The Department of Adult Correction’s Comprehensive Health Services Division provides medical care to all people in custody from entry through release.
In 2024, the division recorded 1.4 million health encounters. This included just under 700,000 visits with nurses, 418,000 with medical providers, 170,000 with psychological and social workers, 88,600 with dental staff and 40,000 with psychiatrists.
About 98 percent of this medical care occurred inside prisons. Routine outpatient medical care is available at all prisons across the state, and inpatient care occurs at Central Prison and the North Carolina Correctional Institution for Women — both in Raleigh.
The remaining needed medical care — most often surgeries — was provided at community medical clinics and hospitals.
Not all of this care is provided free to incarcerated people. The Department of Adult Correction charges $5 for medical and dental services initiated by an incarcerated person and $7 for a self-declared emergency visit, according to the prison system’s copay policy. In 2023, the prison system collected $353,673 in copay fees.
NC Health News has previously reported that copays can pose a barrier for incarcerated people seeking medical care as the fees can be a financial barrier, particularly in the context of low prison wages — leading some people to delay or even avoid care.
But Brad Deen, a prison spokesman, told NC Health News that copays are intended to prevent the overuse and abuse of health care resources.
A sicker population
People behind bars are generally sicker than people in the general population; they are disproportionately likely to have chronic health problems, including diabetes, high blood pressure and HIV, as well as substance use and mental health problems.
This means there’s a large need for health care services. Changing demographics of North Carolina’s prison population are also putting increased pressure on the prison health care system to meet the demands for care.
For one, the state’s incarcerated population is aging. White told lawmakers that over the past 10 years, the number of incarcerated people older than 60 has doubled. Now, this group of more medically demanding people comprises 10 percent of the overall prison population and is expected to grow.
Research shows that incarceration has adverse effects on health and accelerates aging. One study found that an incarcerated 59-year-old has the same morbidity rate as a non-incarcerated 75-year-old. Other studies show that people face chronic and life-threatening illnesses earlier in prison than would be expected for someone outside.
“As individuals age, they have greater health care costs and needs,” White said.
More and more people in North Carolina prisons also need mental health and substance use treatment. About one-quarter of the 31,000 people incarcerated are on the prison system’s mental health caseload, and nearly 80 percent of people entering prison have a substance use disorder in need of treatment.
The Department of Adult Correction spent $45 million on mental health care last fiscal year. Most behavioral health services are provided through telehealth, with virtual clinics held on an ongoing basis at more than 30 state prison facilities. The Department of Adult Correction also offers inpatient psychiatric services, operating 144 beds for men at Central Prison and 10 beds for women at the North Carolina Correctional Institution for Women.
The department’s Alcoholism and Chemical Dependency Programs cost $16 million last fiscal year. Staff operate just over 1,300 beds for prison-based, cognitive-behavioral substance use disorder treatment programs, which range in length from 90 days to a year.
According to the 2022-23 annual programs report,12 prisons offered a total of 657 beds for intermediate treatment programs lasting 90 days. Another 10 prisons offered a total of 650 beds for long-term treatment programs ranging in length from 120 to 365 days.
But as NC Health News has previously reported, demand for this treatment significantly outpaces treatment availability. On average, the yearly treatment need is double the yearly treatment slots, according to a March 2024 report on the prison system’s substance use disorder treatment programs.
Rising pharmacy costs
About $76 million, or nearly 20 percent of the Department of Adult Correction’s health expenses, are pharmacy-related. White said pharmacy costs have ticked up in recent years, driven partly by an aging prison population that requires more medications.
White provided another driver of cost increase: hepatitis C treatment.
Hepatitis C is a highly contagious disease — spread through contact with infected blood, often through intravenous drug use — that targets the liver and is curable thanks to newer medication that can eliminate the virus.
In 2021, the prison system settled a lawsuit brought by three incarcerated men who sued for access to hepatitis C treatment and, as a result, more incarcerated people are now screened and treated for this disease. However, this treatment comes with a steep price tag that strains the budget.
White said that before the court settlement in 2019, the prison system spent about $4.6 million on hepatitis C treatment — a price tag that ballooned to $25.4 million in 2024, despite falling prices for the treatment. Last year, 1,725 people were treated at a cost of about $14,700 per person.
Prolonged vacancies
Persistent staff vacancies also make providing health care more challenging.
Overall, the Department of Adult Correction — an agency with more than 18,000 full-time employees — has a vacancy rate of 24 percent. Health care positions have an even higher vacancy rate of 28 percent. Nurse positions are particularly tough to fill, with a vacancy rate of 37 percent.
“When we have prolonged vacancies, the requirement [for health care] doesn’t go away,” said Arthur Campbell, chief medical officer at the Department of Adult Correction. “We’re still obligated to provide the care that’s needed.”
In response, the department has had to turn to contract or travel nurses, who are more expensive on a per capita basis. Campbell said that about 55 percent to 60 percent of the prison system’s nursing and provider staff who perform in-house health services are now contract workers.
Correctional officers, who supervise and transport incarcerated people, account for the largest number of vacancies. Over one-third of about 8,000 positions are unfilled.
A shortage of correctional officers is hitting some prisons harder than others. Craggy Correctional in Asheville, Granville Correctional in Butner and Pender Correctional in Burgaw have the highest vacancy rates — all above 60 percent. In comparison, the best-staffed prisons have correctional officer vacancy rates as low as 3 percent.
In response to staffing challenges, the Department of Adult Correction has closed beds at some prisons.
They’ve also relied heavily on overtime, requiring staff to pick up extra shifts to keep operations going. In fiscal year 2023-24, the department spent $67.7 million on overtime — over 11 times the budgeted $5.8 million.
Brandeshawn Harris, chief deputy secretary for operations at the Department of Adult Correction, told lawmakers the department wants overtime numbers to drop. She acknowledged that employees working such long hours puts facilities at risk and takes a toll on staff.
“We do try to get individuals to volunteer for it, but that doesn’t always work,” Harris said. “It’s a difficult balance, and we try to do as much as we can to keep the overtime numbers down.”
Harris said two of the top reasons people leave the Department of Adult Correction are because of overtime and low pay. The starting salary for a new correctional officer is just over $37,600, with pay rising based on years of experience and the custody level of the prison.
Filling these tough front-line jobs will take better pay, said Anthony Vann, interim chief deputy secretary for administration at the Department of Adult Correction. He told lawmakers that correctional officer starting pay in Tennessee is about $51,000, and county jails are similarly paying around $50,000 — places people are opting to work instead.
“Do we know a magical number?” Vann asked. “No, we don’t. They’re still having problems recruiting — even at those particular numbers — but it’s not as bad as ours.”
Other facts about the Department of Adult Correction:
- The Department of Adult Correction supervises more than 107,000 people — more than 31,000 people inside prison and another nearly 76,000 people in the community on probation, parole and post-release supervision. In context, this supervised population would be North Carolina’s 11th largest city — between High Point and Asheville.
- The average daily cost to incarcerate someone in prison in fiscal year 2023-24 was $151, more than $55,000 per year.
- The Department of Adult Correction’s Division of Community Supervision team of probation/parole officers supervises twice the number of offenders in the community on probation, parole and post-release supervision with fewer personnel and resources — only accounting for about 12 percent of the department’s overall budget.
Source: Data from Fiscal Research Division presentation to lawmakers on March 4.
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