NYAPRS Note: This article elucidates that need for a form of presumptive eligibility in New York, to allow people leaving jail or prison to immediately access a Medicaid ID with a full array of integrated benefits. The practice of suspending people who are incarcerated from Medicaid eligibility is, while permitted by Federal law, not necessary in order to keep from paying for their care. The “fix” to this situation is multi-faceted, and involves a tangled system between the Medicaid agency but also criminal justice entities, as well as a vast technological system that must be changed to make easy access to Medicaid possible. NYAPRS continues to work with MHANYS and across this system in this legislative season to understand a path forward to immediate coverage for persons discharged from forensic settings.
Ex-Inmates Navigate Access to Healthcare as Many Remain in Medicaid Limbo
The Guardian; Aparna Alluri, 5/17/2015
Yusef Ali started “seeing things” in 1987. He believed the FBI was after him. He was homeless and he didn’t have insurance. He went to a hospital, but “they would tell me that I was faking it”, said Ali. “It kept getting worse.”
Soon after that, Ali, now 61, broke into a building that he thought the FBI was using and set fire to it. That landed him in jail and then, after he was diagnosed with paranoid schizophrenia and dual personality disorder, in a state mental hospital.
When he was released in 1998, he was linked to a mental health clinic for medication. “I would only half go,” Ali said. “I kind of got back into gang banging.” The clinic was in a rival gang’s territory so he stopped going. Within weeks, he stopped taking his medication. Within months, he was homeless again.
He was living in Chicago’s Lincoln Park when, in 2004, he met a caseworker from Thresholds, an Illinois-based care provider for people with mental illnesses. Eventually he was coaxed into enrolling in Thresholds’ program. He moved into assisted-housing and enrolled in Medicaid, the federal program that covers health costs for poor families and people with disabilities.
Until 2010, when the Affordable Care Act expanded coverage to all low-income adults, most men in the correctional system were not eligible for Medicaid. It was restricted to children, poor pregnant women, parents with young children, the elderly and people with disabilities. Ali, however, had been eligible for Medicaid throughout because of his disability. But he didn’t enroll until six years after his release.
This gap in care is a huge concern as Medicaid adds 15.1 million new beneficiaries – 35% of whom have interacted with the criminal justice system, according to early estimates.
Jails and prisons are enrolling people in the hope that access to care will cut recidivism and costs in the long run. Several studies argue that without healthcare, former prisoners, and especially those struggling with substance abuse or mental illness, are likely to break the law again.
But enrollment by itself may not be enough because it’s just the first step in a long, often difficult, process of delivering care.
“It’s not just medication,” said Peggy Flaherty, Thresholds’ associate director. “They also need housing. They need jobs.” Thresholds, like many organizations working with people living in extreme poverty, provides “wraparound” services, which includes helping them get housing and employment.
Thresholds also hires and trains formerly homeless people to staff their teams. That helps, according to Flaherty, so the people they are trying to help can “feel this is somebody who’s walked in similar shoes”.
Trust a hard thing to come by
The caseworker who befriended Ali had himself been homeless. “I seen that he really cared about me,” Ali said. Eleven years later, Ali is still on his medication. He now shares his apartment with Patty, his three-legged cat.
“We try to offer something they want, something they need,” said Flaherty. “Like a cup of coffee or a bite to eat. We try to develop a relationship. Who are we for somebody to trust?”
Most providers will tell you trust is a hard thing to gain among the formerly incarcerated.
Ali started using drugs when he was 13 years old. He was first arrested when he was 17. Since then he has spent more than 16 years behind bars. Like Ali, most prisoners in the US are poor, uninsured and overwhelmingly African American. They often alternate between incarceration and homelessness. Many of them have been arrested, detained and incarcerated more than once, given the high rates of recidivism in the US.
They are also sicker than the average American – they have a higher incidence of hypertension, asthma, arthritis, HIV, hepatitis C and substance abuse. There are10 times more people with mental illnesses in prisons and jails than there are in state hospitals. But most of them, like Ali, were probably diagnosed in prison because they have never been to a doctor, not counting visits to the emergency room. This makes them both vulnerable and challenging to work with.
“When you’re inside, you have all these dreams, goals, and then reality hits,” said Mary Johnson, a tall 48-year-old with blond hair who spent 15 years in New York state prisons. “People get discouraged. Nobody comes home wanting to go back to prison. It’s really hard to put in the work.”
Johnson is now the director of the Coming Home program, which provides wraparound services to former prisoners, at the Mount Sinai St Luke’s hospital in Manhattan. She joined the program after meeting Kathy Boudin, its co-founder. Boudin, now an adjunct professor at Columbia and New York universities, spent 22 years in prison. Johnson and her colleagues insist this is what gives programs like theirs an edge: having been in prison, they know what makes the formerly incarcerated a particularly challenging group.
And it all circles back to healthcare. If they’re sick or if they aren’t taking medication, they are less likely to find a job. Without a job, it’s harder to find a place to live. Shelters aren’t always ideal because many of Johnson’s patients, especially those who have spent time in solitary confinement, suffer from post-traumatic stress disorder. “You put him in a room with three people … it’s easier for him to go out on to the street than stay inside,” she said.
But enrolling in Medicaid isn’t easy either. For one, people have to provide a permanent address. Enrollees then have to wait 45-90 days as it’s processed. To complicate matters more, there’s a federal law that prohibits Medicaid payments during incarceration, and allows states to either suspend or terminate an inmate’s benefits while they are behind bars.
A sprawling bureaucracy
As of December 2014, only 13 states opted for suspension while the rest terminate coverage. So inmates in at least 20 states will have to reapply for Medicaid if they end up in prison a second time and lose coverage. Why? Because until recently Medicaid’s enrollees didn’t include this many former prisoners. So states are still entangled in a web of processes that are transitioning from old to new, from pre- to post-Obamacare.
“It’s not like we are going to the back room and fixing something,” said Matt Salo, executive director, National Association of Medicaid Directors. “Even seemingly simple changes can involve complicated negotiations across multiple layers of state, local and federal government agencies.”
That, in a nutshell, is Medicaid. A sprawling bureaucracy that disburses hundreds of billions of dollars in payments each year. And it’s only getting bigger.
Meanwhile, people returning home from prison often when they are running out of medication and have no immediate access to a doctor find themselves without access to healthcare at a time when they need it the most.
http://www.theguardian.com/us-news/2015/may/17/medicaid-prisoners-healthcare-access