‘Rel­a­tively large con­se­quences’

Med­i­caid, ACA un­cer­tainty threaten ex-of­fender health pro­grams

The Middletown Press (Middletown, CT) - - FRONT PAGE - By Adam Wis­nieski Conn. Health I-Team

Since 2011, Con­necti­cut has is­sued more than 39,000 new Med­i­caid cards to pris­on­ers re­turn­ing to com­mu­ni­ties, con­nect­ing them to health care ser­vices with the goal of keep­ing them healthy and out of prison.

This ini­tia­tive, which gives ex­of­fend­ers the op­por­tu­nity to see a pri­mary care physi­cian on a reg­u­lar ba­sis and ac­cess crit­i­cal men­tal health and drug-abuse treat­ment pro­grams, ex­ists be­cause of the Af­ford­able Care Act, and Med­i­caid pays most of the costs.

Re­cidi­vism data show the ini­tia­tive is work­ing, state of­fi­cials say. Yearly, the Court Sup­port Ser­vices Divi­sion refers ap­prox­i­mately 20,000 adults on pro­ba­tion to var­i­ous be­hav­ioral health pro­grams and tracks them for 12 months. In 2016, CSSD re­ported that 23.1 per­cent of adults who com­pleted their re­fer­ral pro­gram were re­ar­rested, a five-year low since CSSD started track­ing in 2012. For those who dropped out or were kicked out of the

pro­gram, 41 per­cent re-of­fended within 12 months.

But the re-en­try health care pro­grams, which rely on gen­er­ous re­im­burse­ments un­der Med­i­caid, are in jeop­ardy, as Pres­i­dent Don­ald Trump and the Repub­li­can-con­trolled Congress con­tinue to dis­cuss plans to re­place the ACA and trim Med­i­caid fund­ing. In late March, a Repub­li­can re­peal bill, which would have also con­verted Med­i­caid to a block grant pro­gram and cut state fund­ing, was pulled from con­sid­er­a­tion in the House be­cause it did not have the votes for ap­proval. The House speaker an­nounced the ACA “was the law of the land.” But now, weeks later, re­plac­ing the ACA and cut­ting Med­i­caid are back on the agenda.

State of­fi­cials are closely mon­i­tor­ing to see if the new ad­min­is­tra­tion will roll back pol­icy changes that have made it eas­ier for the state to con­nect ex-of­fend­ers to health care and drug treat­ment pro­grams.

And com­mu­nity-based or­ga­ni­za­tions that now bill Med­i­caid di­rectly for be­hav­ioral health ser­vices are also wor­ried funds will dis­ap­pear, and for­mer pris­on­ers will be left with­out health cov­er­age.

“Ac­cess to health care plays a crit­i­cal role” in pris­oner re-en­try, said Jeff Grant, ex­ec­u­tive di­rec­tor of Bridge­port non-profit Fam­ily ReEn­try. “All of these re­turn­ing ci­ti­zens who re­turn to the street with­out ad­e­quate wrap­around ser­vices are go­ing to re­turn to the be­hav­ior that got them in trou­ble in the first place.”

Na­tion­ally, stud­ies of sim­i­lar re-en­try ini­tia­tives in other states have found that pro­grams that link in­di­vid­u­als to a health care sys­tem con­trib­ute to re­duced re­cidi­vism. In Con­necti­cut, Gov. Dan­nel Mal­loy’s ad­min­is­tra­tion cred­its ac­cess to com­mu­nity health ser­vices as part of the rea­son over­all re­cidi­vism rates dropped slightly, from 32.9 per­cent in 2011 to 32.4 per­cent in 2014.

Lever­ag­ing Med­i­caid Af­ter State Cuts

A year ago, com­mu­ni­ty­based men­tal health providers took a big hit in the state bud­get, when the state ter­mi­nated $5.4 mil­lion in ser­vice con­tracts.

But fol­low­ing the lead of other states, some providers started billing Med­i­caid di­rectly for ex-of­fender treat­ment—a move they said has al­lowed them to con­tinue pro­vid­ing ser­vices to at least some of their clients. It is that backup plan that is in jeop­ardy as Congress works to cut Med­i­caid.

Non-prof­its such as Cen­tral Nau­gatuck Val­ley Help, Inc., which op­er­ates in Tor­ring­ton, Dan­bury and Water­bury, were sur­prised at the sever­ity of the state cuts. Af­ter los­ing a $1 mil­lion con­tract, Help, Inc. cut staff and em­ploy­ment pro­grams, re­duced the size of its space at each of its lo­ca­tions, and shifted be­hav­ioral health pro­gram­ming to Med­i­caid.

“We’ve been try­ing to hold on by billing Med­i­caid for the be­hav­ioral health ser­vices, and it’s chal­leng­ing.” said Roberta Murtagh, ex­ec­u­tive di­rec­tor of Help, Inc.

Murtagh said the agency didn’t see a big change in the num­ber of clients in Tor­ring­ton and Dan­bury, but in Water­bury num­bers plum­meted from 200 clients a year ago to about 70.

Those who get treat­ment say it is work­ing. Ryan Puzin­ski, 29, of Tor­ring­ton, said drug abuse treat­ment at Help, Inc.’s Watkins Cen­ter has helped him stay clean af­ter serv­ing 18 months for sell­ing heroin.

Med­i­caid pays for Puzin­ski’s drug-abuse coun­sel­ing ses­sions, as well as methadone, urine test­ing and Lo­gis­tiCare trans­porta­tion so he can get to med­i­cal ap­point­ments.

“I get a lot out of it,” he said. “It’s def­i­nitely helped me with iden­ti­fy­ing my trig­gers and my is­sues. Talk­ing to peo­ple, hear­ing peo­ples’ sto­ries, talk­ing about my is­sues, get­ting feed­back, stuff like that helps.”

Christina Brague, 42, of Tor­ring­ton, said the dru­gabuse treat­ment she gets at Help, Inc. through HUSKY D has been a “life saver.”

“It’s been a hard road, but I did it,” said Brague, who is on pro­ba­tion and has been en­rolled in the pro­gram since Septem­ber.

Not all non-prof­its had the re­sources to switch to Med­i­caid. Fam­ily ReEn­try, which op­er­ates in Bridge­port, New Haven and Nor­walk, lost its $1.9 mil­lion be­hav­ioral health state­funded con­tract. They cut their be­hav­ioral health pro­grams but kept em­ploy­ment, hous­ing and men­tor­ing pro­grams.

“A lot of eggs were in the De­part­ment of Cor­rec­tion bud­get bas­ket. We didn’t want to … put all those eggs in a Med­i­caid bas­ket only to find out that bas­ket will be empty as well,” Grant said.

Ac­cess To Pri­mary Care

Com­mu­nity work­ers say tak­ing care of gen­eral health is part of a suc­cess­ful re-en­try.

The Yale New Haven Hos­pi­tal - Pri­mary Care Cen­ter op­er­ates Tran­si­tions, part of a net­work of 17 clin­ics na­tion­wide pro­vid­ing pri­mary care “to pro­mote healthy rein­te­gra­tion, im­prove health care uti­liza­tion, and de­crease prison re­cidi­vism.” The clinic, which has 700 pa­tient vis­its each year across its two lo­ca­tions in New Haven, is partly funded through grants from the Cen­ters for Medicare & Med­i­caid Ser­vices, a pro­gram cre­ated un­der the ACA that Trump’s Health Sec­re­tary Tom Price has vowed to elim­i­nate.

“As a so­ci­ety, we tend to put health care on the back burner, but most of these guys never had a pri­mary care physi­cian,” said Jerry Smart, a com­mu­nity health worker for Tran­si­tions Clinic in New Haven. “If you get an ill­ness that pre­vents you from work­ing, how are you sup­posed to sur­vive? Re­lapse is just around the cor­ner.

“We are deal­ing with a pop­u­la­tion that is com­ing from an en­vi­ron­ment that’s plagued with vi­o­lence, trauma, drugs,” Smart added. “There’s a lot of stress. I tell ev­ery­body who comes home, you may look good on the out­side but you don’t know what’s go­ing on the in­side. Get some blood work, get a phys­i­cal.”

Robert Nixon, 40, of New Haven, re­ceives care at Tran­si­tions af­ter serv­ing 15 years in prison.

“Be­hind bars, it’s like a Motrin for ev­ery­thing,” he said. “When you come home, you start think­ing where do I get the things that I need?”

Af­ter spend­ing most of his adult life be­hind bars, Nixon said, he strug­gled in the out­side world with sim­ple things like cross­ing busy in­ter­sec­tions in New Haven.

“It’s great you can go to a place where they know what you’re go­ing through,” he said.

“Tran­si­tions is a com­mu­nity. They un­der­stand you. They ex­plain ev­ery­thing to you. You walk out with a clearer head about how bet­ter to take care of your­self.”

Heidi Lu­betkin, vice pres­i­dent of clin­i­cal and sup­port ser­vices at Com­mu­nity Re­newal Team, Inc., in Hartford, said many ex-of­fend­ers re­ferred to the agency for men­tal health and drug abuse treat­ment were also in need of pri­mary care. The agency con­nected with the Univer­sity of Hartford’s Project Hori­zon to get its clients pri­mary care help from vol­un­teer reg­is­tered nurses.

“I think it’s im­por­tant to take care of the com­plete per­son,” she said. “You can’t take care of just one thing. Yes, take care of their sub­stance abuse and men­tal health, but you can’t do that if they feel like crud.”

Re­duc­tion In Fed­eral Funds

Since be­com­ing the first state to ex­pand Med­i­caid, Con­necti­cut has re­lied more and more on fed­eral dol­lars to pay for re-en­try ser­vices and other pro­grams.

In fis­cal year 2017, $3.5 bil­lion in fed­eral Med­i­caid funds flowed into Con­necti­cut, an in­crease of nearly $1 bil­lion since the ACA was passed. Much of that in­crease is due to ex­pand­ing Med­i­caid cov­er­age to child­less adults, aged 19 to 65, earn­ing up to 138 per­cent of the fed­eral poverty level, which Con­necti­cut calls Husky D. Cur­rently, 208,113 low-in­come res­i­dents are cov­ered un­der HUSKY D, up from just 75,000 five years ago.

A sig­nif­i­cant num­ber of those newly cov­ered in­di­vid­u­als are re­leased pris­on­ers. Num­bers from the state De­part­ment of So­cial Ser­vices show that 87.8 per­cent of new Med­i­caid sign-ups from Jan­uary to Novem­ber last year were HUSKY D.

Un­til now, the fed­eral gov­ern­ment picked up 100 per­cent of costs un­der HUSKY D, which gave Con­necti­cut a great in­cen­tive to sign up re­leased pris­on­ers for Med­i­caid. The fed­eral share drops to 95 per­cent this year and notches down ev­ery year un­til it hits 90 per­cent in 2020. Still, that means Con­necti­cut will pay just $32.1 mil­lion in fis­cal year 2017 to make sure more than 200,000 low-in­come res­i­dents have health in­sur­ance, ac­cord­ing to an es­ti­mate in the gov­er­nor’s bud­get re­leased in Fe­bru­ary.

Ac­cord­ing to the gov­er­nor’s bud­get, the HUSKY D pro­gram will cost an es­ti­mated $1.46 bil­lion in 2018. Un­der cur­rent law, the fed­eral gov­ern­ment will pick up 94 per­cent of that ($1.37 bil­lion), while the state will pick up 6 per­cent ($87.5 mil­lion).

But if Repub­li­cans suc­ceed in chang­ing Med­i­caid fund­ing to a block grant pro­gram, states would get a lump sum and less than what is given now. Ac­cord­ing to es­ti­mates from the state’s Of­fice of Pol­icy and Man­age­ment, the GOP’s pro­posal from March would cut as much as $450 mil­lion in fis­cal year 2020. This would force the state to make up the dif­fer­ence in fund­ing or cut pro­grams and re­duce the num­ber of peo­ple served.

A change in Med­i­caid fund­ing “would shift money back to the state gen­eral fund and would likely mean re­duc­tion in ser­vices,” said Brian Hill, di­rec­tor of re­search, pro­gram anal­y­sis, and qual­ity im­prove­ment at CSSD. If the state “con­tin­ues to trim money [for those ser­vices] over the years, we don’t have that money sit­ting in a sep­a­rate pot ready to sup­plant the Med­i­caid funds as they get cut,” Hill said.

“We’re talk­ing about thou­sands of of­fend­ers who wouldn’t be get­ting the ser­vices they need,” Hill said.

Michael Lawlor, the state’s un­der­sec­re­tary for crim­i­nal jus­tice pol­icy and plan­ning, said re­peal­ing Oba­macare would lead to more crime and re­cidi­vism.

“Our goal is less crime. All the things we are do­ing, we be­lieve, have the ef­fect of re­duc­ing crime, and all the data we have show that it’s work­ing,” Lawlor said.

Even af­ter the Repub­li­can bill failed in March, Lawlor said, they were still con­cerned about changes to Med­i­caid — big and small.

“We have to be on guard with what­ever pro­pos­als are be­ing made,” he said.

In 2004, the De­part­ment of Health & Hu­man Ser­vices en­cour­aged states to sus­pend rather than ter­mi­nate peo­ple on Med­i­caid when they are im­pris­oned, some­thing Con­necti­cut does. Lawlor said even with­out Congress, the new ad­min­is­tra­tion could roll back changes like this and add an ob­sta­cle for re­leased pris­on­ers get­ting help they need.

“Right now we’re con­cerned about the un­in­tended con­se­quences of even rel­a­tively mi­nor changes that they could make that would have rel­a­tively large con­se­quences,” Lawlor said.

“You could eas­ily re­verse all the progress that’s been made with a cou­ple of mi­nor changes to fed­eral law.”


Dr. Lisa Puglisi checks the blood pres­sure of Adrian Heg­gie at the Yale New Haven Hos­pi­tal - Pri­mary Care Cen­ter Tran­si­tions Clinic, a pro­gram that pro­vides health care to those re­leased from prison.

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