By Elizabeth Thompson

At first, Tommy Green doesn’t tell his clients that he was formerly incarcerated.

As a Community Health Worker for North Carolina Formerly Incarcerated Transition Program (NC FIT) in Orange County, he connects people coming out of jails and prisons with health resources, as well as assistance with other needs, like food and transportation.

When he first meets clients, he tells them about the program, but it’s not until he says he also did time that he sees a spark in their eye.

“They look at me first like it’s just a health care worker or a health care provider or somebody in the medical field,” Green said, “but as soon as they know that I’ve been incarcerated, I’m looked at as a friend, become the big brother or uncle or father figure.”

There has been little funding directed at studying the process of reentering society after incarceration, said Evan Ashkin, professor of family medicine at the school of medicine at the University of North Carolina at Chapel Hill. However, research suggests that support from peers, people who have been through similar experiences, during reentry is beneficial for people leaving incarceration.

Ashkin, the founder of NC FIT, which connects formerly incarcerated people with health needs to health care services and other reentry resources, says employing community health workers, people with lived experience with incarceration, to help connect people to the right services is “the only reason” NC FIT works.

Reentering society after incarceration, whether it be after a week-long detainment at the local jail or over a decade in prison, can be a challenge — especially since incarcerated people are frequently sicker than the general population, with higher rates of diseases such as diabetes or hepatitis C.

Because of Green’s lived experience, he can meet clients where they are and establish a form of trust with them. They know he understands the complexities of reentry.

While some reentry specialists without a history of incarceration might immediately point clients toward the job hunt, Green said he understands that sometimes returning citizens need to decompress and get their lives together before jumping into a job.

“If you got a job and you’re not where you need to be mentally, then you’re not gonna keep that job,” Green said. “It’s not going to work.”

Mental illness and incarceration are often intertwined. A 2014 report from the National Research Council found that 64 percent of jail detainees, 54 of state prisoners and 45 of federal prisoners reported mental health concerns.

“We incarcerate people for the crime of mental illness and the crime of substance use disorder,” Ashkin said.

Despite the public health implications for people reentering society and the fact that 98 percent of people incarcerated in North Carolina will be released, many people reenter society feeling unsupported.

In a recent health policy brief in Health Affairs, Ashkin made the case for more evidence-based reentry programming for formerly incarcerated people, such as medication-assisted treatment (MAT), an evidence-based approach for treating substance use disorders, and other approaches that focus on health and well-being.

A sicker population

Incarcerated people are more likely to suffer from mental health issues. As much as 85 percent of the prison population either has a substance use disorder or was arrested for crimes related to drug use. Often, these people are using substances to “self-treat” an underlying mental health disorder.

Chronic physical health conditions, such as diabetes, and communicable diseases such as hepatitis C and HIV are also more prevalent among incarcerated people.

David Rosen, assistant professor of medicine at UNC’s medical school, said incarcerated people tend to be sicker due to a combination of things, from poverty to lack of health care.

“There is really just pervasive trauma among that population and with the trauma comes self-medication, and that’s an explanation for a lot of the substance use,” Rosen said, “And then with the substance use and with lack of access to care, people are more likely to engage in behaviors that might lead to hepatitis, HIV, STIs.”

Not to mention COVID-19’s ongoing impact on carceral facilities and that being incarcerated in and of itself can be traumatizing.

Many formerly incarcerated people are not eligible for insurance, especially in states like North Carolina where Medicaid has not been expanded. Meanwhile, the state has been slow to adopt effective strategies such as medication-assisted treatment for incarcerated people with substance use disorder.

“There’s a lot of very inefficient reentry strategies,” Ashkin said.

MAT and reentering with substance use disorder

People with substance use disorder are often forced into withdrawal when they are incarcerated, instead of being given evidence-based MAT. When people with alcohol use disorder and substance use disorder are released from incarceration, they are often pointed to other abstinence-based resources, Ashkin said.

“It’s just wrong because we have effective treatments for opiate use, MOUD, medication for opiate use disorder,” Ashkin said, “We know for the post release population, it’s like 60 to 85 percent effective at reducing overdose death, especially if we initiate people prior to release, and then continue in the community. And yet, it’s very rarely done.”

MAT is an evidence-based practice for caring for people with opioid use disorder, according to the Centers for Disease Control and Prevention, by using methadone, buprenorphine and naltrexone to treat the disorder. But whether a person on MAT will have access to their medication while incarcerated in North Carolina’s jails is hit-or-miss.

Some North Carolina jails, such as Buncombe County Detention Center, have launched effective MAT programs, while other jails force detainees with substance use disorder to go through forced withdrawal. This can be harmful, not just because withdrawal causes painful physical symptoms, but also because it can cause a person with substance use disorder to relapse, said Elisabeth Johnson, director of health services at UNC Horizons, a program that helps women recover from substance use disorder.

“Even if you have someone who’s stable on buprenorphine and then gets arrested, depending on the county they’re in, I’ve known women who have gone through detox while they’re pregnant because they’re in jail,” Johnson said.

After leaving a prison or jail, people were 40 times more likely to die of an opioid overdose within two weeks after their release, according to a study conducted by the University of North Carolina at Chapel Hill.

“These people get incarcerated. And while they’re there, their tolerance goes down, and then they get out and think they can use the same amount of drugs that they used before they went in,” and they accidentally overdose, Green said.

One of Green’s clients, who was forced into withdrawal in jail, died of an opioid overdose after she was released.”

This problem has been exacerbated as opioid overdoses have soared throughout the COVID-19 pandemic, and fentanyl, an opiate that is more addictive, has been introduced into North Carolina’s drug supply.

In response, NC FIT has partnered up with North Carolina’s prison system to introduce MAT while people are still incarcerated. COVID stalled the prisons’ pilot project to expand its MAT program at N.C. Correctional Institution for Women (where the program is already in place for pregnant prisoners), Wake Correctional Center and Orange Correctional Center.

“Staff training is underway at those facilities, and the expectation is to implement those initiatives at the end of this year or the beginning of next year,” said John Bull, spokesperson for the North Carolina Department of Public Safety.

The COVID-19 pandemic has made reentry more complicated in other ways as well.

COVID complications

It’s no secret that COVID-19 pandemic ravaged carceral institutions, most of which don’t have the physical space to allow safety measures like physical distancing, Ashkin said. North Carolina’s prisons and jails continue to report COVID-19 cases, even as the state’s most recent wave is receding.

The COVID-19 pandemic caused logistical problems for people reentering, from not being able to get a Social Security card to be able to work, or not being able to use technology to access telehealth services because they were incarcerated for a long time.

Medically vulnerable people were being released from prison due to the pandemic, but they often weren’t connected with the medical resources they needed, Green said.

“That was almost a pandemic in itself,” Green said. “You had guys coming home scared to death because they didn’t know what was going on. They didn’t understand what a pandemic was. I think everybody understood how deadly it could be and that created more fear as well. And then also again, add on the factor of not being technology savvy.”

NC FIT established FIT Connect, which helped get medical records from people released early to connect them to federally qualified health centers to get the help they needed

People are continuing to come home from incarceration with COVID or having had COVID.

As we look forward to what life post-COVID could look like for people incarcerated and those reentering, Ashkin said there is still much we don’t know about this disease, especially when it comes to the impacts of long COVID, a condition in which people continue to experience health problems four or more weeks after being infected with COVID-19.

“Because there are higher rates of COVID because of exposure, we’re gonna see continued high rates of people post-release suffering complications, just like everybody does who gets COVID,” Ashkin said.

“But the caveat is poor access to care and uninsured, and exacerbating that problem in the poor communities of color that are most impacted by incarceration, where people return to, where we know there are more limited resources and harder to access medical care.”

Insurance after incarceration

Because Medicaid has not been expanded in North Carolina, many people reentering society after incarceration are either uninsured or uninsurable. Expansion would allow people up to 138 percent of the federal poverty guidelines to be eligible for Medicaid.

“There are many people who don’t qualify,” UNC’s Rosen said. “Even many people in the FIT program, who have chronic health conditions won’t necessarily qualify for Medicaid because they don’t have a disability.”

NC FIT has been able to help cover its clients’ costs with grant money, but it doesn’t have the funds for specialists, Ashkin said. Even then, the program is not at the scale to care for every formerly incarcerated person returning to the community.

“We have 10 community health workers that can have 30 to 50 patients each,” Ashkin said. “If you do the math, it doesn’t even come close to serving the needs of the state.”

Even if NC FIT were able to scale itself to meet the greater need, the price of more expensive medical care for peoples’ chronic needs is “insurmountable,” Ashkin said.

Medicaid expansion is not off the table yet in budget negotiations at the legislature. In addition, President Joe Biden’s Build Back Better legislation includes a provision that would attempt to bridge the Medicaid “coverage gap” in states that have not expanded Medicaid, such as North Carolina, by making those people eligible for tax credits to purchase a Marketplace insurance plan.

Ashkin said that even if that falls through, formerly incarcerated people need some kind of Medicaid funding for at least 12 months after incarceration.

“People do get out, they get their diagnosis in the hospital of heart failure or prostate cancer or any disease, and they need to see a specialist, and again NC FIT cannot do that,” Ashkin said. “So people are going without specialty care. Which is going to result in bad outcomes and again, drive up emergency room utilization and other avoidable costs.”