Texas has botched its response to the opioid epidemic six ways from Sunday.
First, Gov. Greg Abbott vetoed a bill passed by the Texas Legislature in 2015 to allow people to call 911 in the event of an overdose without being charged with drug possession. As the law stands, it disincentivizes calling for emergency services because helping a friend who overdosed exposes the caller to prosecution. More people die every year because of Gov. Abbott's cruel and senseless decision on that front.
Then, the state decided to crack down on opiate prescribers, except rules the Pharmacy Board developed are a chaotic mess and exacerbating the problems they were created to solve. The Dallas News editorial board gave a good assessment of the problem.
Finally, and most damagingly, Texas remains one of a minority of states whose leaders have adamantly refused to expand Medicaid, even though every analysis of the opioid crisis has emphasized the woeful lack of resources for drug treatment as the state's biggest barrier to addressing it. More than half of Texas' drug treatment resources come through matched funds from the federal Medicaid program, while nearly all the rest is spent by the Texas Department of Criminal Justice.
As Grits has written before, there are two ways for Texas to increase drug-treatment spending without raising taxes: A) Expand Medicaid under the Affordable Care Act, or B) reduce penalties for low-level drug possession and use the savings from reduced incarceration to pay for more treatment services. There is no option C.
Showing posts with label Medicaid. Show all posts
Showing posts with label Medicaid. Show all posts
Wednesday, July 31, 2019
Monday, March 09, 2015
Sheriff: Suspend, don't terminate Medicaid benefits during local jail incarceration
Harris County Sheriff Adrian Garcia and George Masi, CEO of Harrs Health Sytems authord an op ed in the Houston Chronicle (March 6) calling for the state to suspend rather than terminate Medicaid benefits when recipients are incarcerated in the county jail for 30 days. Here's a notable excerpt:
Medicaid health-care benefits for eligible persons incarcerated in county jails are terminated after 30 days, rather than merely suspended as in many states. To further complicate its shortcomings, the policy depends on time spent in jail, not whether the inmates are acquitted or convicted.
Suspension, rather than termination, of Medicaid benefits allows eligible former inmates to more easily obtain medical care with Harris Health and other local health-care providers upon their release. Under current state practices, once an inmate's Medicaid is cancelled, they are forced to navigate a bureaucratic labyrinth in order to renew their medical benefit.
Legislation proposed in this 84th Texas legislative session would change the policy to suspension rather than termination. This could have a considerable impact on the treatment of indigent individuals in the custody of the county jail, where a quarter of the inmates receive medicine for psychiatric illness and others suffer from a myriad of additional disorders. When released, these individuals have little access to the care and medication needed to stay as healthy as they were during their time in jail.
By placing limitations on their easy access to affordable care, the state of Texas is all but ensuring a quick return to jail for individuals suffering from mental illness. Simply put, access to care reduces recidivism.
The Harris County Sheriff's Office is responsible for the medical care, custody and control of the approximately 8,500 inmates. This medical care - a constitutional obligation - is provided as part of the sheriff's budget to operate the county jail system.
The burden is further passed to the taxpayers of Harris County who pay into the Medicaid program via federal income taxes and then pay to support Harris Health's budget when otherwise uninsured patients come through their doors.
Saturday, August 23, 2014
Healthcare at reentry helps prevent recidivism
This article from Medicine@Yale makes an argument Grits has posited before, particularly as it relates to mental health services: That expanding Medicaid - in particular providing care to indigent ex-cons and covering hospital costs for prisoners - would reduce both costs and recidivism while improving public safety. Inmates leaving prison "don’t know how to find health insurance or medical care. And many
quickly wind up in emergency departments with overdoses or exacerbations
of chronic diseases that were being treated in prison."
“Obamacare is key to reducing recidivism,” [Dr. Emily] Wang says. She adds, however, that the reverse is also true. Over one-fifth of people eligible for Medicaid under the ACA expansion are incarcerated, on probation, or on parole. Many are young and healthy, making them attractive to insurance companies looking to dilute their risk pools. Far from being burdensome, then, these individuals may strengthen the health care system—much as their involvement has made the TCN more effective.Speaking of the intersection between healthcare and reentry, a story on NPR this week lauded San Antonio's proactive approach to mental health, fielding specially trained officers to deal with the mentally ill and establishing an effective diversion program to keep them out of the system. The key was for stakeholders to chip in to
“In order for the Affordable Care Act to work,” Wang says, “you have to get former prisoners involved.”
create the Restoration Center. It offers a 48-hour inpatient psychiatric unit; outpatient services for psychiatric and primary care; centers for drug or alcohol detox; a 90-day recovery program for substance abuse; plus housing for people with mental illnesses, and even job training.
More than 18,000 people pass through the Restoration Center each year, and officials say the coordinated approach has saved the city more than $10 million annually.
Sunday, June 01, 2014
By rejecting Obamacare, Texas forgoes up to $240 million in federal funds per biennium for prison health care
A few, notable items cropped up related to prison health care at a joint meeting of the Texas House Corrections Committee and a House Appropriations subcommittee on Thursday. (You can watch the video here.)
If Texas were to expand the Medicaid program under the Affordable Care Act, prison and hospital officials told a House Appropriations panel on Thursday, the state could draw down between $55 and $120 million per year in federal funds to pay for inmate hospital care, depending on whether UTMB's Galveston hospital is classified as a hospital or a prison. That comes to between $110 to $240 million per biennium compared to roughly a billion-dollar TDCJ healthcare budget. (Of course, $240 million is a drop in the bucket compared to the billions Texas forgoes by failing to expand Medicaid under the ACA.)
Without those federal funds, TDCJ expects a shortfall in its line item for inmate healthcare this year (FY 2014) of about $21.3 million, the Legislative Budget Board's John Newton told the panel. Some of it they'll be able to pay for by shifting around money from other accounts, but the agency also plans to ask LBB for authority to spend money from their FY 2015 budget, which would in turn necessitate a supplemental funding bill early in next year's session. Contributing to the shortfall: Quite a few private hospitals have been demanding payment rates higher than Medicare-allowable payments in order to treat TDCJ inmates. Eleven have been approved so far and other hospitals want the same deal.
Texas' inmate population is cared for by two medical schools - the University of Texas Medical Branch at Galveston (UTMB) and the Texas Tech Health Science Center - with UTMB's network caring for about 119,000 inmates and Tech handling about 31,000. The state authorized a 4% salary increase for prison health workers in 2014, but they received no pay hike in 2012 or 2013, nor will they get one in 2015, said UTMB vice president for offender services Dr. Owen Murray. As a result, the prison system has trouble keeping salaries competitive and struggles to maintain staffing levels.
The rising elderly population in TDCJ is the main cost driver for hospital care. A little under 10 percent of the inmate population is more than 55 years old. Those inmates are 7-8 times as expensive as other age demographics. In particular, more older inmates means more spent on chronic cardiovascular diseases as well as costs for dialysis and end-stage renal disease patients, whose numbers Murray said are increasing at a "startling" rate.
Some 15,000 TDCJ inmates have been diagnosed with Hepatitis C, but only about 100 are presently undergoing treatment. There is a new Hepatitis C drug available a called Sovaldi that's currently considered the standard of care. But it costs an astonishing $63,000 for a 12-week treatment - nearly $1,000 per pill - making it impractical for widespread use. For long-term inmates with Hep C, the state increasingly must pay for costs associated with end-stage liver disease, which is a major cost driver for hospital use. There were 488 inmates being treated for end-stage liver disease in 2013, a number which has risen to 830 in 2014, or a 70 percent one-year increase.
A related, remarkable statistic: TDCJ operates 483 infirmary beds, with 70 percent or more of those filled with patients who will never leave those beds until they die, said Dr. Murray. One wonders if there is any tangible benefit to public safety from incarcerating such individuals?
Vacancy rates for prison health workers are around 9.5 percent overall, but for nurses it's 13 percent; for registered nurses (RNs), the vacancy rate is 17 percent. Texas recently switched from an RN-driven model to an LVN-driven model (licensed vocational nurses) because of budget-driven layoffs. As a result, at this point Texas often staffs only one RN for every three facilities, making a 17 percent vacancy rate is a big problem. Perhaps even more pressing, "patient care technicians" have a 29.8 percent vacancy rate, and there's a 35 percent vacancy rate for dialysis patient care techs.
Texas Tech is having a particular problem finding psychiatrists willing to work at West Texas prisons; the committee was told they'd need to increase prison psychiatrists' pay 20-23 percent to be competitive with the market and fill their current vacancies. Nurses, system-wide, would need a 10-15 percent raise - more in certain rural areas where the applicant pool is small to non-existent - to be competitive with market rates and attract staff willing to work in a prison environment.
One interesting aside: Inmates take about 55-60 percent of the pills prescribed to them - a better compliance rate than in the free world (~50 percent), but still low. The state saves about $8 million per year by recycling unused medication, but Corrections Committee Chairman Tan Parker pointed out that failure to take prescribed medication could generate much higher back-end costs if and when the conditions being treated worsen.
Moreover, said Dr. Murray, there's a problem with inmates failing to comply with medication regimes after they leave TDCJ's care. He gave the example of recidivists with HIV whose condition was under control when they left TDCJ but who reenter prison a few years later with out-of-control symptoms or even a virus that's resistant to the drugs they'd been taking before.
Corrections Committee Chairman Tan Parker wondered why inmates weren't forced to take medication since the state must pay for more expensive health services in the long term if their conditions worsen. Forcing them to take medication would amount to a "cost containment" strategy, he said. He was told that prisoners have the same rights to refuse health care as free world patients and, with the exception of mental health patients, can refuse medication if they choose.
Toward the end of the hearing, advocates from the Texas Civil Rights Project, the Texas Criminal Justice Coalition (see their written testimony), and the Texas Inmate Family Association addressed the meeting. Watch their presentations on the video beginning at the 2:11:50 mark.
MORE (June 2): From Terri Langford at the Texas Tribune.
If Texas were to expand the Medicaid program under the Affordable Care Act, prison and hospital officials told a House Appropriations panel on Thursday, the state could draw down between $55 and $120 million per year in federal funds to pay for inmate hospital care, depending on whether UTMB's Galveston hospital is classified as a hospital or a prison. That comes to between $110 to $240 million per biennium compared to roughly a billion-dollar TDCJ healthcare budget. (Of course, $240 million is a drop in the bucket compared to the billions Texas forgoes by failing to expand Medicaid under the ACA.)
Without those federal funds, TDCJ expects a shortfall in its line item for inmate healthcare this year (FY 2014) of about $21.3 million, the Legislative Budget Board's John Newton told the panel. Some of it they'll be able to pay for by shifting around money from other accounts, but the agency also plans to ask LBB for authority to spend money from their FY 2015 budget, which would in turn necessitate a supplemental funding bill early in next year's session. Contributing to the shortfall: Quite a few private hospitals have been demanding payment rates higher than Medicare-allowable payments in order to treat TDCJ inmates. Eleven have been approved so far and other hospitals want the same deal.
Texas' inmate population is cared for by two medical schools - the University of Texas Medical Branch at Galveston (UTMB) and the Texas Tech Health Science Center - with UTMB's network caring for about 119,000 inmates and Tech handling about 31,000. The state authorized a 4% salary increase for prison health workers in 2014, but they received no pay hike in 2012 or 2013, nor will they get one in 2015, said UTMB vice president for offender services Dr. Owen Murray. As a result, the prison system has trouble keeping salaries competitive and struggles to maintain staffing levels.
The rising elderly population in TDCJ is the main cost driver for hospital care. A little under 10 percent of the inmate population is more than 55 years old. Those inmates are 7-8 times as expensive as other age demographics. In particular, more older inmates means more spent on chronic cardiovascular diseases as well as costs for dialysis and end-stage renal disease patients, whose numbers Murray said are increasing at a "startling" rate.
Some 15,000 TDCJ inmates have been diagnosed with Hepatitis C, but only about 100 are presently undergoing treatment. There is a new Hepatitis C drug available a called Sovaldi that's currently considered the standard of care. But it costs an astonishing $63,000 for a 12-week treatment - nearly $1,000 per pill - making it impractical for widespread use. For long-term inmates with Hep C, the state increasingly must pay for costs associated with end-stage liver disease, which is a major cost driver for hospital use. There were 488 inmates being treated for end-stage liver disease in 2013, a number which has risen to 830 in 2014, or a 70 percent one-year increase.
A related, remarkable statistic: TDCJ operates 483 infirmary beds, with 70 percent or more of those filled with patients who will never leave those beds until they die, said Dr. Murray. One wonders if there is any tangible benefit to public safety from incarcerating such individuals?
Vacancy rates for prison health workers are around 9.5 percent overall, but for nurses it's 13 percent; for registered nurses (RNs), the vacancy rate is 17 percent. Texas recently switched from an RN-driven model to an LVN-driven model (licensed vocational nurses) because of budget-driven layoffs. As a result, at this point Texas often staffs only one RN for every three facilities, making a 17 percent vacancy rate is a big problem. Perhaps even more pressing, "patient care technicians" have a 29.8 percent vacancy rate, and there's a 35 percent vacancy rate for dialysis patient care techs.
Texas Tech is having a particular problem finding psychiatrists willing to work at West Texas prisons; the committee was told they'd need to increase prison psychiatrists' pay 20-23 percent to be competitive with the market and fill their current vacancies. Nurses, system-wide, would need a 10-15 percent raise - more in certain rural areas where the applicant pool is small to non-existent - to be competitive with market rates and attract staff willing to work in a prison environment.
One interesting aside: Inmates take about 55-60 percent of the pills prescribed to them - a better compliance rate than in the free world (~50 percent), but still low. The state saves about $8 million per year by recycling unused medication, but Corrections Committee Chairman Tan Parker pointed out that failure to take prescribed medication could generate much higher back-end costs if and when the conditions being treated worsen.
Moreover, said Dr. Murray, there's a problem with inmates failing to comply with medication regimes after they leave TDCJ's care. He gave the example of recidivists with HIV whose condition was under control when they left TDCJ but who reenter prison a few years later with out-of-control symptoms or even a virus that's resistant to the drugs they'd been taking before.
Corrections Committee Chairman Tan Parker wondered why inmates weren't forced to take medication since the state must pay for more expensive health services in the long term if their conditions worsen. Forcing them to take medication would amount to a "cost containment" strategy, he said. He was told that prisoners have the same rights to refuse health care as free world patients and, with the exception of mental health patients, can refuse medication if they choose.
Toward the end of the hearing, advocates from the Texas Civil Rights Project, the Texas Criminal Justice Coalition (see their written testimony), and the Texas Inmate Family Association addressed the meeting. Watch their presentations on the video beginning at the 2:11:50 mark.
MORE (June 2): From Terri Langford at the Texas Tribune.
Wednesday, February 19, 2014
'Dallas Buyers Club' concept metastasizes
Though it may sound like a spin-off of the Oscar-nominated movie Dallas Buyers Club, this PBS News Hour report about the black market in prescription drugs out of Mexico really has more to do with inflated pharmaceutical prices and the failure of states like Texas to expand Medicaid under Obamacare. The story opens:
When black markets occur for legal commodities - especially ones that don't get you high - it's an indictment of government-sanctioned oligopolies controlling distribution and price. Drug companies on the US side are making a fortune from this over-charging, subsidized by friendly government regulators and now gun wielding law enforcement officers. Don't police have anything better to do than arrest folks for getting legal, prescribed drugs to sick people who need them at a cost they can actually afford?
In borderland Texas, a widespread lack of health insurance is linked to poverty and high rates of diseases such as diabetes, obesity and high blood pressure.In the movie Dallas Buyers Club, Matthew McConaughey's character sought out AIDS drugs from Mexico because of approval delays at the FDA. These days, the practice has become more common and generalized, with folks bringing everyday medications into the country illegally because of inflated prices barring access to medication by the uninsured.
Cheaper prescription drugs to treat these conditions are available across the border in Mexico. But physicians and law enforcement are tracking a relatively new trend — the smuggling of medicine in bulk from Mexico to U.S. patients who no longer feel safe shopping for them in Mexico.
Mexican Pharmacist Jorge Sandoval says people who buy his medicines these days often buy for people they don’t even know.
“There’s a trade in legal prescription medication,” he said in Spanish from his shop in Chihuahua, Mexico, about an hour south of the border. “The trade is generated by people (in both countries) who want to buy medicine at a lower price. People are bringing in ice chests to fill with medicines that they sell to friends and relatives.”
About 24 percent of Texans have no medical insurance, the highest percentage of uninsured in the nation. And although Texas has some of the highest enrollments in the new health care marketplaces created under the Affordable Care Act, the numbers represent a small fraction of the overall uninsured.
That’s one reason why, for years, people have crossed the border for cheaper medicine. The diabetes medicine Metformin is $35 a month here and $15 in Mexico. The blood thinner Coumadin is $60 a month here, $15 there.
But what’s new here is a cottage industry of smugglers buying medicines in bulk to bring back to the U.S.
When black markets occur for legal commodities - especially ones that don't get you high - it's an indictment of government-sanctioned oligopolies controlling distribution and price. Drug companies on the US side are making a fortune from this over-charging, subsidized by friendly government regulators and now gun wielding law enforcement officers. Don't police have anything better to do than arrest folks for getting legal, prescribed drugs to sick people who need them at a cost they can actually afford?
Tuesday, November 13, 2012
Criminal justice action on bill filing day at Texas Lege
Bill filing at the Texas Lege began yesterday for the 83rd session and the Texas Tribune listed these criminal-justice related bills filed on the first day:
Ellis' innocence commission bill IMO is a bit of an anachronism and efforts in Texas to exonerate innocent folk from prison have arguably moved beyond it. Grits would rather see the state boost funding to innocence clinics at the state's largest law schools if it's going to invest in the task of investigating old innocence cases. (In the interest of full disclosure, my day job is with the Innocence Project of Texas, whose policy stance happily coincides with my own.) The innocence commission was a suggested tactic from the past, but where they were created they never did much and Texas has developed its own mechanisms - somewhat organically, though spurred and partially funded by the Legislature - for pursuing cold innocence cases through the law schools and a network of private attorneys. The investigation into old arson cases currently underway shows more promise as a model for how to vet old innocence claims than any "innocence commission" created anywhere in the country. At this historical juncture, the state should build on its own successes on this score rather than seek to copy what somebody else has done.
These weren't the only criminal justice related bills. On the House side (see all filed bills), Martinez-Fischer has a bill to create "an executive commissioner for the prevention of driving while intoxicated." His HB 27 would make cell phone use while driving illegal except for law enforcement and emergency vehicles. Allen Fletcher has an enhancement for leaving the scene of an auto accident that results in death. He also filed a bill exempting drivers' contact information on traffic tickets from the Public Information Act, a suggestion with all sorts of unintended consequences which IMO make it a very bad idea. (More later.) Rep. Menendez has a prostitution enhancement and another one for graffiti. And he's filed an interesting little bill requiring suspension of Medicaid eligibility for jail inmates bur also mandating their reinstatement upon release. (I'd need to know more about what problem this aims to solve to form an opinion.) Senfronia Thompson has a bill related to diversion programs for juveniles accused of prostitution. Lois Kolkhorst has a bill banning the use of RFID tags to track kids in school. David Simpson has refiled his bill to limit intrusive searches in airports. Richard Raymond filed a manslaughter enhancement for DWI, and a perhaps quixotic bill to abolish the Court of Criminal Appeals.
On the Senate side (see the full list of filed bills), I like state Sen. Dan Patrick's idea to eliminate straight ticket voting in judicial races. I'd personally like to make them entirely nonpartisan, like city council seats. And Sen. Ellis has a bill expanding access to probation for low-level drug offenders, including a court-fee based funding source for treatment programming. Though not exactly a criminal justice bill (the drug war prosecuted by other means), SB 11 would require welfare recipients to pass a drug test to receive support.
For betting purposes, Grits would put the over-under on new crimes and penalty enhancements the Lege will pass at 53. As an added prediction: Despite having just more than a third of House seats, most enhancements that pass will be filed by Democrats and most of them will originate in the House. I don't know why, but judging from years past that seems to be the trend.
Obviously, these are only filed bills listed above, and as my father likes to say, there's many a slip twixt the cup and the lip. Likely there will be some 7,000 or so pieces of legislation filed before the session is through, with perhaps 1,000 of them in some way shape or form (often quite different from how they began) eventually becoming law. I've only provided cursory summaries here, so please check out the bills that particularly interest you and provide your own analyses in the comments.
- Sen. Leticia Van de Putte, D-San Antonio, and Rep. Senfronia Thompson, D-Houston, filed three bills that would focus on helping victims of human trafficking.
- HB 21, by Rep. Trey Martinez Fischer, would create a database of individuals with multiple family violence crimes.
- HB 23, by Martinez Fischer, would require sex offenders to list their offenses on social media sites.
- HB 104, by Rep. Larry Gonzales, would repeal the Driver Responsibility Act, which requires drivers to pay expensive annual surcharges for certain traffic violations. Failing to pay results in suspension of a driver's license.
- SB 88, by Ellis, would allow the governor to grant more than one 30-day reprieve for a death row inmate.
- SB 89, by Ellis, would create a commission to investigate and prevent wrongful convictions
- SB 91, also by Ellis, would require prosecutors and defense lawyers to share evidence in criminal cases
Ellis' innocence commission bill IMO is a bit of an anachronism and efforts in Texas to exonerate innocent folk from prison have arguably moved beyond it. Grits would rather see the state boost funding to innocence clinics at the state's largest law schools if it's going to invest in the task of investigating old innocence cases. (In the interest of full disclosure, my day job is with the Innocence Project of Texas, whose policy stance happily coincides with my own.) The innocence commission was a suggested tactic from the past, but where they were created they never did much and Texas has developed its own mechanisms - somewhat organically, though spurred and partially funded by the Legislature - for pursuing cold innocence cases through the law schools and a network of private attorneys. The investigation into old arson cases currently underway shows more promise as a model for how to vet old innocence claims than any "innocence commission" created anywhere in the country. At this historical juncture, the state should build on its own successes on this score rather than seek to copy what somebody else has done.
These weren't the only criminal justice related bills. On the House side (see all filed bills), Martinez-Fischer has a bill to create "an executive commissioner for the prevention of driving while intoxicated." His HB 27 would make cell phone use while driving illegal except for law enforcement and emergency vehicles. Allen Fletcher has an enhancement for leaving the scene of an auto accident that results in death. He also filed a bill exempting drivers' contact information on traffic tickets from the Public Information Act, a suggestion with all sorts of unintended consequences which IMO make it a very bad idea. (More later.) Rep. Menendez has a prostitution enhancement and another one for graffiti. And he's filed an interesting little bill requiring suspension of Medicaid eligibility for jail inmates bur also mandating their reinstatement upon release. (I'd need to know more about what problem this aims to solve to form an opinion.) Senfronia Thompson has a bill related to diversion programs for juveniles accused of prostitution. Lois Kolkhorst has a bill banning the use of RFID tags to track kids in school. David Simpson has refiled his bill to limit intrusive searches in airports. Richard Raymond filed a manslaughter enhancement for DWI, and a perhaps quixotic bill to abolish the Court of Criminal Appeals.
On the Senate side (see the full list of filed bills), I like state Sen. Dan Patrick's idea to eliminate straight ticket voting in judicial races. I'd personally like to make them entirely nonpartisan, like city council seats. And Sen. Ellis has a bill expanding access to probation for low-level drug offenders, including a court-fee based funding source for treatment programming. Though not exactly a criminal justice bill (the drug war prosecuted by other means), SB 11 would require welfare recipients to pass a drug test to receive support.
For betting purposes, Grits would put the over-under on new crimes and penalty enhancements the Lege will pass at 53. As an added prediction: Despite having just more than a third of House seats, most enhancements that pass will be filed by Democrats and most of them will originate in the House. I don't know why, but judging from years past that seems to be the trend.
Obviously, these are only filed bills listed above, and as my father likes to say, there's many a slip twixt the cup and the lip. Likely there will be some 7,000 or so pieces of legislation filed before the session is through, with perhaps 1,000 of them in some way shape or form (often quite different from how they began) eventually becoming law. I've only provided cursory summaries here, so please check out the bills that particularly interest you and provide your own analyses in the comments.
Monday, October 22, 2012
Oklahoma eyeing Medicaid funds for prison hospital costs
A staff editorial in the Tulsa World cited Medicaid funding for prison hospital services as a compelling argument as to why the state should accept federal money for Medicaid expansion in 2014, urging lawmakers to wait past election season to make up their minds. The editorial closes:
With more than 25,000 inmates behind bars, and one of the highest per-capita incarceration rates in the nation, Oklahoma spends a lot on prisons and has for the past 40 years. Inmates aren't always in the best health. With its tough 85-percent rule requiring certain offenders to serve most of their sentence before being eligible for release, inmates are staying in prison longer and therefore growing old there. The geriatric-age prison population is growing rapidly and with aging, coupled with a poor health history, come health problems.See related Grits posts:
Already, some older, blind and disabled inmates qualify for Medicaid-funded hospitalization. The change would make the eligibility almost universal in the prison system. ...
Inmate care is an expensive proposition. If most of that cost could be shifted to the federal government, Oklahoma tax dollars might be freed up for other programs such as education and infrastructure. DOC is wise to take a wait-and-see approach and not to refuse the money quickly like Texas apparently has done.
Wednesday, October 10, 2012
Underfunded veterans mental-health care channels them into justice system
The Texas Tribune reported on a hearing of the House Defense and Veterans Affairs committee related to mental health challenges facing veterans. Notably:
Grits also finds it curious that the Tribune account made no mention of how this subject - as with many corrections-related health matters heading into next year - plays into the debate over the proposed Medicaid expansion under the Affordable Care Act to include adults with incomes up to 133% of federal poverty levels, a matter which Texas must decide in the coming legislative session and which may be informed, one might guess, by the outcome of the national Presidential election.
It's fine to say veterans, the homeless and other special populations should receive mental-health care before they enter the criminal justice system, but the harsh reality of operating those systems doesn't allow for "should bes" but must deal with what actually is. Who will pay for preventive mental health care for the indigent if not Medicaid? Counties? I wouldn't hold my breath. And the state's not likely to pony up. Plus outside the largest cities, there's a stark shortage of behavioral healthcare providers, even if there was money available to pay them. Medicaid would create a market for those services and the hope is providers would follow the dollars.
My own view is that, if Texas would participate in the mostly federally funded (90/10, when it rolls out completely) Medicaid expansion under the Affordable Care Act, it would have an enormous palliative benefit for the justice system, particularly as it regards creating a funding mechanism to pay for preventive mental health care for at-risk populations, including but not limited to veterans. It would also make much simpler an array of reentry concerns about continuity of care to have a ready insurance plan available for the 70,000+ people released from Texas prisons each year, not to mention the hundreds of thousands more on the probation rolls.
Right now, the state's approach is mostly to ignore mental health issues until they fall into government's lap via the criminal justice system. Part of the reason the Harris County Jail has become one of the largest mental wards in the nation is that front-end care has been under-valued by legislative budget writers while funding for jails and prisons until very recently was considered sacrosanct. Now the budget crisis has become so severe that even sacred cows like prison and jail funding are on the table for potential reductions, which is a marked change in the terms of debate even from just a few years ago. In that context though, it's also difficult for the state to come up with extra money for up-front care.
Though Governor Perry has already announced his opposition to Medicaid expansion, Grits doesn't for a long shot consider that a fait accompli because of the billions of dollars the state's medical industry would be leaving on the table in the wake of such a decision. Economist Ray Perryman has a column making the rounds in several Texas papers declaring that, from an economic perspective, Texas only has "one rational choice" available, which is taking the money under Obamacare and expanding Medicaid. That's certainly been my view and I suspect once the partisan winds of election season have passed, more than a few Texas legislators struggling with issues like veterans mental health care and recidivism reduction will see the same thing and press to accept the much-needed federal dollars for that purpose.
See prior, related Grits posts:
Studies by the U.S. military have shown an 80 percent increase in suicides since the start of the war in Iraq in 2003. According to testimony by Lt. Col. Alba Villanueva, the director of joint family support services for the Texas Military Forces, which includes the Texas National Guard, there have been 15 suicides among Texas soldiers in the last three years, and two in the last 30 days.Further,
Suicides and the mental health problems that lead to them are often a matter of untreated post-traumatic stress disorder and the lingering effects of military training.
the mental health problems that persist, others said, are serious even if returning soldiers are far from thoughts of suicide. "Sometimes the problems aren't surfacing for three or four months, whether it’s drugs or the criminal justice system,” said Rep. Dan Flynn, R-Canton, explaining that returning soldiers do not want to seek mental health treatment because they just want to get on with their lives.
“When they come home, they want to go home, they don't want to be involved with the system,” he said.I reference this discussion to point out how disconnected it seems from the reality facing veterans and others suffering from mental illness: An extremely limited base of providers and little public funding for the levels of mental health services needed to play a preventive rather than a reactive role. In the real world, as opposed to some legislative flow-chart, the criminal justice system is the main location where the system proactively provides services to treat serious mental illnesses. So those who most need treatment too often wait until their behavior deteriorates to the point that they wind up in the county jail or a state penitentiary, where mental health care has also been reduced thanks to budget cuts.
“We're going to have to figure out some way to close that gap.”
Mental health problems often stem from the process of reintegrating into civilian life, [Military Veteran Peer Network statewide coordinator [Sean] Hanna said, adding that "it's not until they begin to enact their plan for what their life will look like that they start to face these struggles."
Hanna said the problem can be addressed by “more boots on the ground” — more funding for hired professionals to coordinate peer networks of veterans, because he says many returning soldiers will only seek help if they get advice from other veterans, and in rural areas of the state other veterans may not be nearby.
Grits also finds it curious that the Tribune account made no mention of how this subject - as with many corrections-related health matters heading into next year - plays into the debate over the proposed Medicaid expansion under the Affordable Care Act to include adults with incomes up to 133% of federal poverty levels, a matter which Texas must decide in the coming legislative session and which may be informed, one might guess, by the outcome of the national Presidential election.
It's fine to say veterans, the homeless and other special populations should receive mental-health care before they enter the criminal justice system, but the harsh reality of operating those systems doesn't allow for "should bes" but must deal with what actually is. Who will pay for preventive mental health care for the indigent if not Medicaid? Counties? I wouldn't hold my breath. And the state's not likely to pony up. Plus outside the largest cities, there's a stark shortage of behavioral healthcare providers, even if there was money available to pay them. Medicaid would create a market for those services and the hope is providers would follow the dollars.
My own view is that, if Texas would participate in the mostly federally funded (90/10, when it rolls out completely) Medicaid expansion under the Affordable Care Act, it would have an enormous palliative benefit for the justice system, particularly as it regards creating a funding mechanism to pay for preventive mental health care for at-risk populations, including but not limited to veterans. It would also make much simpler an array of reentry concerns about continuity of care to have a ready insurance plan available for the 70,000+ people released from Texas prisons each year, not to mention the hundreds of thousands more on the probation rolls.
Right now, the state's approach is mostly to ignore mental health issues until they fall into government's lap via the criminal justice system. Part of the reason the Harris County Jail has become one of the largest mental wards in the nation is that front-end care has been under-valued by legislative budget writers while funding for jails and prisons until very recently was considered sacrosanct. Now the budget crisis has become so severe that even sacred cows like prison and jail funding are on the table for potential reductions, which is a marked change in the terms of debate even from just a few years ago. In that context though, it's also difficult for the state to come up with extra money for up-front care.
Though Governor Perry has already announced his opposition to Medicaid expansion, Grits doesn't for a long shot consider that a fait accompli because of the billions of dollars the state's medical industry would be leaving on the table in the wake of such a decision. Economist Ray Perryman has a column making the rounds in several Texas papers declaring that, from an economic perspective, Texas only has "one rational choice" available, which is taking the money under Obamacare and expanding Medicaid. That's certainly been my view and I suspect once the partisan winds of election season have passed, more than a few Texas legislators struggling with issues like veterans mental health care and recidivism reduction will see the same thing and press to accept the much-needed federal dollars for that purpose.
See prior, related Grits posts:
- Medicaid expansion and addressing severe mental illness through the justice system
- Texas decision to reject Medicaid expansion would hasten trend toward using justice system as mental health substitute
- Obamacare provision a boon to budget writers on state prison health costs but complicates UTMB negotiations
- Banking on Obamacare for future prisoner hospital costs
- Will Texas expand Medicaid coverage under Obamacare to include prisoner hospital costs?
Tuesday, September 18, 2012
Medicaid expansion and addresing severe mental illness through the justice system
A friend forwarded me a handout being circulated at the Harris County Criminal Justice Coordinating Council detailing a pair of studies of "Kendra's Law" out of New York, which provides court-ordered outpatient mental health treatment to a small subset of probationers in the "most desperate need for psychiatric treatment."
According to the handout, "Taken together, the two reports establish that assisted outpatient treatment (“AOT”) drastically reduces hospitalization, homelessness, arrest, and incarceration among people with severe psychiatric disorders, while increasing adherence to treatment and overall quality of life. The independent evaluation further indicates that the effectiveness of Kendra’s Law is not simply a product of systemic service enhancements, but is in part attributable to the value of AOT court orders in motivating treatment compliance." In particular:
Who knows if these outcomes would be replicable in Texas, but these data - particularly the bit about outcomes sustained beyond the probation period - made me think once again about the proposed Medicaid expansion under the federal Affordable Care Act. And since we're on the subject, I should reference a recent report referenced at Sentencing Law and Policy titled, The Affordable Care Act: Implications for Public Safety and Corrections Populations. That analysis noted that "About half of all people in jails and prisons have mental health problems and about 65 percent meet medical criteria for alcohol or other drug abuse and addiction," so clearly Medicaid expansion would impact many people who cycle through the justice system. What's more, "Pre-release and reentry programs might also be better able to connect people who are leaving jail or prison with community-based intervention services," which would definitely have implications for folks mandated to receive intensive services under some version of Kendra's Law (not to mention folks receiving psychiatric meds leaving prisons and jails). The report concluded that:
And yes, I know Gov. Perry has said he opposes Texas expanding Medicaid eligibility, so maybe such musings are just a pipe dream. But these are recurring dilemmas and it's rare that an opportunity such as the ACA presents itself to plug such gaping holes in the system. In any event, it's worth a discussion.
According to the handout, "Taken together, the two reports establish that assisted outpatient treatment (“AOT”) drastically reduces hospitalization, homelessness, arrest, and incarceration among people with severe psychiatric disorders, while increasing adherence to treatment and overall quality of life. The independent evaluation further indicates that the effectiveness of Kendra’s Law is not simply a product of systemic service enhancements, but is in part attributable to the value of AOT court orders in motivating treatment compliance." In particular:
During the course of court-ordered treatment, when compared to the three years prior to participation in the program, AOT recipients experienced far fewer negative outcomes. Specifically, the OMH study found that for those in the AOT program:What's more:
• 74 percent fewer experienced homelessness;The related findings of the independent evaluation were also impressive. AOT was found to cut both the likelihood of being arrested over a one-month period and the likelihood of hospital admission over a six-month period by about half (from 3.7 percent to 1.9 percent for arrest, and from 74 percent to 36 percent for hospitalization).
• 77 percent fewer experienced psychiatric hospitalization;
• 83 percent fewer experienced arrest; and
• 87 percent fewer experienced incarceration.
Kendra’s Law also resulted in dramatic reductions in the incidence of harmful behaviors. Comparing the experience of AOT recipients over the first six months of AOT to the same period immediately prior to AOT, the OMH study found:Even more encouraging, such improvements were to some extent sustainable beyond the time participants received intensive services. For those who spent more than six months in assisted outpatient treatment, increases in use of medications and reductions in hospitalization "were sustained in the post-AOT period, whether or not intensive services were continued."
• 55 percent fewer recipients engaged in suicide attempts or physical harm to self;
• 49 percent fewer abused alcohol;
• 48 percent fewer abused drugs;
• 47 percent fewer physically harmed others;
• 46 percent fewer damaged or destroyed property; and
• 43 percent fewer threatened physical harm to others.
Who knows if these outcomes would be replicable in Texas, but these data - particularly the bit about outcomes sustained beyond the probation period - made me think once again about the proposed Medicaid expansion under the federal Affordable Care Act. And since we're on the subject, I should reference a recent report referenced at Sentencing Law and Policy titled, The Affordable Care Act: Implications for Public Safety and Corrections Populations. That analysis noted that "About half of all people in jails and prisons have mental health problems and about 65 percent meet medical criteria for alcohol or other drug abuse and addiction," so clearly Medicaid expansion would impact many people who cycle through the justice system. What's more, "Pre-release and reentry programs might also be better able to connect people who are leaving jail or prison with community-based intervention services," which would definitely have implications for folks mandated to receive intensive services under some version of Kendra's Law (not to mention folks receiving psychiatric meds leaving prisons and jails). The report concluded that:
The ACA is not a panacea – it will not eradicate the societal factors that contribute to excessive poor health among African Americans and other minorities, nor will it eradicate other biases within the criminal justice system that contribute to disparate rates of incarceration. It does, however, pose an opportunity to level at least one dimension of the playing field – access to treatment for mental illness and addiction – two problems that increase the likelihood of arrest and recidivism. In doing so, it may help reduce racial/ethnic disparities in incarceration.Mandating mental health services for folks with the most severe psychiatric problems could reduce the frequency with which they cycle through the criminal justice system, as is depressingly common, and if the NY results are any indication, could also prevent a good deal of crime and substance abuse among those with the most severe mental health needs. And if Texas were to expand Medicaid eligibility in 2014, it would present an opportunity for financing such services that at the moment seem fiscally out of reach.
And yes, I know Gov. Perry has said he opposes Texas expanding Medicaid eligibility, so maybe such musings are just a pipe dream. But these are recurring dilemmas and it's rare that an opportunity such as the ACA presents itself to plug such gaping holes in the system. In any event, it's worth a discussion.
Thursday, July 19, 2012
Texas' decision to reject Medicaid expansion quickens trend toward using justice system as mental health substitute
Grits has been further pondering the implications of recent national health care politics on the criminal justice system, now that Gov. Rick Perry and Lt. Governor David Dewhurst have both said they'll oppose expansion of the state Medicaid program to cover Texans with incomes up to 133% of federal poverty levels, even though the feds would pay 100% of costs for the first three years, and 90% of costs after 2019.
Obviously this means the Texas prison system won't be taking advantage of possible state-budget savings from pawning off prisoner hospital costs on the feds. But the more I consider it, the implications for the justice system from this ill-considered political stance are profound and much more far reaching, particularly as it regards the use of jails and prisons as a substitute for funding a more robust community-based mental health system.
At Monday's House County Affairs hearing, Chairman Garnet Coleman noted the irony in response to testimony by witnesses regarding the effectiveness of Veterans Courts, which are essentially mental-health courts aimed at current and former military members. Citing the example of a mentally ill veteran coming back from Afghanistan who, as a civilian, earned less than 133% of the poverty rate, Coleman noted such a person could essentially gain access to mental health services only by committing a crime. (The Department of Veterans Affairs provides some services, he noted, but nothing like those needed for someone with a chronic, serious mental illness.) By rejecting Medicaid funds, said Coleman, the state would strip away options for indigent veterans and everybody else below the 133% threshold to access treatment services outside the justice system.
His comments got me thinking: The biggest implication for the criminal justice system from rejecting Medicaid funds really stems from the missed opportunity to attract billions (with a "b") in new funding for mental health services that would be delivered outside the criminal justice system.
This would be huge. When discussing the problems posed by the criminalization of mental illness, there's bipartisan acknowledgement that the justice system isn't the best vehicle for providing mental health services. But it's all we've got for now, the fatalists lament, and if one wants to suggest expanding community-based mental-health services, the first response is always "show me the money." Heck, last session legislators even cut mental-health budgets in prison, much less community-based services. With the opportunity to expand Medicaid services on the table - and the feds paying for ALL of it for the first several years, 90% after 2019 - the money to pay for indigent mental services is now officially available. State leaders only need say "yes."
Without such an influx of community-based mental health funds, indigent mental-health care costs will continue to plague county jails and local emergency rooms. Other testimony at Monday's House County Affairs hearing mentioned that, while the overall Bexar County jail populations is declining (as is happening to various degrees across the state), demand for mental-health beds is the one category that continues to increase, straining capacity. And their experience is a microcosm of what's happening statewide.
The reasons are obvious. Texas has under-invested in mental-health care to the point that the state faces a court order declaring long wait times for forensic hospital beds unconstitutional. Mentally ill inmates in jails cost much more than the per-inmate average and pose unique procedural challenges resulting from the justice system's inability to constructively deal with them. The decision to reject billions in community-based mental health funds for the indigent only exacerbates the problem.
Obviously this means the Texas prison system won't be taking advantage of possible state-budget savings from pawning off prisoner hospital costs on the feds. But the more I consider it, the implications for the justice system from this ill-considered political stance are profound and much more far reaching, particularly as it regards the use of jails and prisons as a substitute for funding a more robust community-based mental health system.
At Monday's House County Affairs hearing, Chairman Garnet Coleman noted the irony in response to testimony by witnesses regarding the effectiveness of Veterans Courts, which are essentially mental-health courts aimed at current and former military members. Citing the example of a mentally ill veteran coming back from Afghanistan who, as a civilian, earned less than 133% of the poverty rate, Coleman noted such a person could essentially gain access to mental health services only by committing a crime. (The Department of Veterans Affairs provides some services, he noted, but nothing like those needed for someone with a chronic, serious mental illness.) By rejecting Medicaid funds, said Coleman, the state would strip away options for indigent veterans and everybody else below the 133% threshold to access treatment services outside the justice system.
His comments got me thinking: The biggest implication for the criminal justice system from rejecting Medicaid funds really stems from the missed opportunity to attract billions (with a "b") in new funding for mental health services that would be delivered outside the criminal justice system.
This would be huge. When discussing the problems posed by the criminalization of mental illness, there's bipartisan acknowledgement that the justice system isn't the best vehicle for providing mental health services. But it's all we've got for now, the fatalists lament, and if one wants to suggest expanding community-based mental-health services, the first response is always "show me the money." Heck, last session legislators even cut mental-health budgets in prison, much less community-based services. With the opportunity to expand Medicaid services on the table - and the feds paying for ALL of it for the first several years, 90% after 2019 - the money to pay for indigent mental services is now officially available. State leaders only need say "yes."
Without such an influx of community-based mental health funds, indigent mental-health care costs will continue to plague county jails and local emergency rooms. Other testimony at Monday's House County Affairs hearing mentioned that, while the overall Bexar County jail populations is declining (as is happening to various degrees across the state), demand for mental-health beds is the one category that continues to increase, straining capacity. And their experience is a microcosm of what's happening statewide.
The reasons are obvious. Texas has under-invested in mental-health care to the point that the state faces a court order declaring long wait times for forensic hospital beds unconstitutional. Mentally ill inmates in jails cost much more than the per-inmate average and pose unique procedural challenges resulting from the justice system's inability to constructively deal with them. The decision to reject billions in community-based mental health funds for the indigent only exacerbates the problem.
Tuesday, July 10, 2012
Health clinic hours reduced 50% at some Texas prison units because of budget cuts; Ogden says prison health budget underfunded 15%
Clinic hours at some Texas prison units were cut by up to 50% in the wake of recent budget cuts, Texas Tech officials told state senators on Monday.
The Texas Senate Finance Committee met yesterday to address correctional managed health care. Go here to watch the hearing online. The only MSM coverage appears to be from Chris Tomlinson at AP. The money quote from that story: "Dr. Denise Deshields, the health director of Texas Tech University's prison health care system, said the new cut could lead to an unconstitutionally low level of care. 'I don't know how we would possibly handle an additional 10 percent reduction in appropriations. We are really cut down to the bone as it is,' she said."
Further, "The vice president for offender health services at the University of Texas Medical Branch, Dr. Owen Murray, said that because of staffing cuts guards are now expected to help make medical decisions that nurses and doctors once made."
Grits listened to much of the hearing this morning. Here are a few tidbits the abbreviated AP story didn't pick up:
The Texas Senate Finance Committee met yesterday to address correctional managed health care. Go here to watch the hearing online. The only MSM coverage appears to be from Chris Tomlinson at AP. The money quote from that story: "Dr. Denise Deshields, the health director of Texas Tech University's prison health care system, said the new cut could lead to an unconstitutionally low level of care. 'I don't know how we would possibly handle an additional 10 percent reduction in appropriations. We are really cut down to the bone as it is,' she said."
Further, "The vice president for offender health services at the University of Texas Medical Branch, Dr. Owen Murray, said that because of staffing cuts guards are now expected to help make medical decisions that nurses and doctors once made."
Grits listened to much of the hearing this morning. Here are a few tidbits the abbreviated AP story didn't pick up:
Thursday, June 28, 2012
Will Texas expand Medicaid coverage under Obamacare to include prisoners' hospital costs?
The Internet today, naturally, is abuzz with commentary about the US Supreme Court's ruling upholding most of "Obamacare" but giving states the right to opt out of the Medicaid-expansion piece without losing federal funds they already receive. Now that the court has ruled, Grits thought it worthwhile to iterate the questions raised implicating Texas criminal justice spending. Specifically, will the now-optional state Medicaid expansion happen in the Lone Star state, and will it include hospital care for Texas prison inmates?
The answers could determine whether the Texas Lege can reduce the line item for prison health spending in the next biennium, or if they must increase it by a nine-figure sum. Here's how Stateline.org described the new option to cover state prisoners' hospital bills under the federal Affordable Care Act:
Though the feds will substantially up their subsidies in 2014, covering inmate hospital care through Medicaid is something some states are already doing. Reported Stateline.org, "Dr. Gloria Perry, the chief medical officer for the Mississippi prison system, says her agency heard about the cost-cutting measure from a health care vendor looking for business in the state. The agency then verified the legality of the procedure with the state Medicaid office and quickly created a reimbursement program. No state laws or appropriations were required."
Given the US Senate's filibuster rule, where 60 out of 100 votes are needed to pass legislation, I don't see the federal healthcare law being repealed even if Mitt Romney is elected President and Republicans reclaim the US Senate, despite a great deal of chest pounding to the contrary on the campaign trail. The battle over implementing federal healthcare legislation has now shifted inexorably to the states.
Whether Texas will accept billions in federal subsidies to expand Medicaid as envisioned under Obamacare will be one of the biggest political debates of the 83rd Texas Legislature. And at the end of the day, Grits wonders whether the deciding factor won't be the new law's effect on prisoner health care costs.
RELATED (6/29): In the Fort Worth Star-Telegram, columnist Bud Kennedy had some kind words to say about this item. "Of all the blog posts and blather Thursday on both sides of the Supreme Court case, one of the most incisive comments came from Austin criminal justice blogger Scott Henson," he wrote, concluding, "I give him credit for thinking before shouting."
Regrettably, though, there was an error in Kennedy's recitation of the effect of Medicaid expansion on state prison healthcare costs. He declared that "the federal government would pick up 90 percent of the state's nearly $500-million-per-year prisoner healthcare costs." In fact, as Grits understands it, the Medicaid expansion would only cover hospital costs for prisoners, not in-prison clinics or other health services delivered on-site. That would still be a quite-large sum, but Medicaid would not cover all prisoner health costs.
According to a state auditor's report (pdf) published in 2011, hospital services account for about $16% of Texas prison health costs - roughly $150 million per biennium. Also, Texas runs its prison pharmacy through UTMB-Galveston's hospital system, but Grits can't tell without more research whether pharmacy costs would be covered by Medicaid under that scenario: It's possible. Notably, Texas underfunded prison healthcare in the current biennium by more than $100 million, so while Medicaid wouldn't pay for all prison health costs, it would plug the state's short term prison health deficit. Otherwise, the only way to reduce prison health costs in the state budget is to reduce the number of people Texas incarcerates.
See prior, related Grits posts:
The answers could determine whether the Texas Lege can reduce the line item for prison health spending in the next biennium, or if they must increase it by a nine-figure sum. Here's how Stateline.org described the new option to cover state prisoners' hospital bills under the federal Affordable Care Act:
most state prisoners (currently) do not qualify for Medicaid. That's because all but a few states limit Medicaid to low-income juveniles, pregnant women, adults with disabilities and frail elders. The majority of people in lock-ups are able-bodied adults who do not qualify, even on the outside. In 2014, however, when Medicaid is slated to cover some 16 million more Americans, anyone with an income below 133 percent of the federal poverty line will become eligible. Since most people have little or no income once they are incarcerated, virtually all of the nation’s 1.4 million state inmates would qualify for Medicaid.So the question arises: Will the Texas Legislature expand Medicaid in 2014, or will the state thumb its nose at the new law and abstain from accepting additional federal healthcare money? Given that the feds would pay 100% of the costs until 2019, not to mention the fact that expanding Medicaid would allow the state to pawn off a great deal of prisoner healthcare costs on the feds, there will be terrific fiscal temptation to accept the subsidies. OTOH, Governor Rick Perry, Attorney General Greg Abbott, and many Republican legislators have staked out extremist positions against Obamacare, and the state could choose to reject the money on principle. That's a bit like cutting off one's nose to spite one's face, since Texas taxpayers would then be in the position of subsidizing healthcare in other states while failing to receive any of the benefits, not just in expanded coverage for free-world Texans but in reduced state prison health costs.
As a bonus to state corrections agencies, most inmates would be considered new to Medicaid, making them eligible for 100 percent coverage by the federal government between 2014 and 2019. After that, states would be responsible for only 10 percent of their coverage. In addition, state health insurance exchanges—which are required to be functioning by 2014—would make it easier for corrections departments to sign inmates up for the program.
Though the feds will substantially up their subsidies in 2014, covering inmate hospital care through Medicaid is something some states are already doing. Reported Stateline.org, "Dr. Gloria Perry, the chief medical officer for the Mississippi prison system, says her agency heard about the cost-cutting measure from a health care vendor looking for business in the state. The agency then verified the legality of the procedure with the state Medicaid office and quickly created a reimbursement program. No state laws or appropriations were required."
Given the US Senate's filibuster rule, where 60 out of 100 votes are needed to pass legislation, I don't see the federal healthcare law being repealed even if Mitt Romney is elected President and Republicans reclaim the US Senate, despite a great deal of chest pounding to the contrary on the campaign trail. The battle over implementing federal healthcare legislation has now shifted inexorably to the states.
Whether Texas will accept billions in federal subsidies to expand Medicaid as envisioned under Obamacare will be one of the biggest political debates of the 83rd Texas Legislature. And at the end of the day, Grits wonders whether the deciding factor won't be the new law's effect on prisoner health care costs.
RELATED (6/29): In the Fort Worth Star-Telegram, columnist Bud Kennedy had some kind words to say about this item. "Of all the blog posts and blather Thursday on both sides of the Supreme Court case, one of the most incisive comments came from Austin criminal justice blogger Scott Henson," he wrote, concluding, "I give him credit for thinking before shouting."
Regrettably, though, there was an error in Kennedy's recitation of the effect of Medicaid expansion on state prison healthcare costs. He declared that "the federal government would pick up 90 percent of the state's nearly $500-million-per-year prisoner healthcare costs." In fact, as Grits understands it, the Medicaid expansion would only cover hospital costs for prisoners, not in-prison clinics or other health services delivered on-site. That would still be a quite-large sum, but Medicaid would not cover all prisoner health costs.
According to a state auditor's report (pdf) published in 2011, hospital services account for about $16% of Texas prison health costs - roughly $150 million per biennium. Also, Texas runs its prison pharmacy through UTMB-Galveston's hospital system, but Grits can't tell without more research whether pharmacy costs would be covered by Medicaid under that scenario: It's possible. Notably, Texas underfunded prison healthcare in the current biennium by more than $100 million, so while Medicaid wouldn't pay for all prison health costs, it would plug the state's short term prison health deficit. Otherwise, the only way to reduce prison health costs in the state budget is to reduce the number of people Texas incarcerates.
See prior, related Grits posts:
Friday, October 21, 2011
Obamacare provision a boon to budget writers on state prison health costs but complicates UTMB negotiations
Via Sentencing Law and Policy, I was fascinated to see an article from Stateline.org about how "Obamacare" may soon actually provide hospital coverage for state-level prisoners, which is an aspect of federal healthcare reform I was definitely unaware of. Reported Stateline.org:
This news, though - while welcome from the perspective of Texas taxpayers who will see state costs for inmate healthcare decline - seemingly throws a monkey wrench into everyone's plans. Presently, UTMB charges more than Medicaid rates for hospital care, so once inmates are covered by Medicaid, that part of the contract would cease to be the "plum" they consider it now. Similarly, local hospitals may be less likely to seek out contracts with the prison system if they must accept Medicaid rates, and it's a virtual certainty that private prison health contractors won't want the job at the low rates Medicaid pays.
At the same time, the state would be foolish NOT to sign inmates up for Medicaid, where the feds would pay 100% of hospital costs between 2014 and 2019 and 90% after that. Given recent cuts to Texas' prison healthcare budgets, the state has virtually no choice but to go that route. Right now, 100% of hospital costs come from the state budget.
I've no idea whether the parties to negotiations are aware of these changes to federal law, but signing up prisoners for Medicaid would alter the incentives for everyone involved, making hospital care less lucrative and attractive for UTMB, local hospitals, and private prison health providers alike. Indeed, finding providers willing to take Medicaid rates is already a challenge in the free world, so it remains to be seen how all this will play out.
In any event, this is good news in the medium term for Texas budget writers, even if it's an especially complicating factor for TDCJ's ability to contract for hospital care, with UTMB or anybody else, in the short run.
The federal health law’s controversial Medicaid expansion is expected to add billions to states’ already overburdened Medicaid budgets. But it also offers a rarely discussed cost-cutting opportunity for state corrections agencies. Starting in 2014, virtually all state prison inmates could be eligible for Medicaid coverage of hospital stays—at the expense of the federal government.I find this report fascinating in the context of the ongoing negotiations between university health systems in Texas and the state prison system over provision of inmate care. Hospital care is considered the "plum" of Texas inmate healthcare, while the money losing part is the frontline clinics inside prison facilities. So UTMB has been pushing to keep the hospital care and dump in-prison healthcare, while the Department of Criminal Justice has threatened to farm out inmate healthcare to local hospitals if UTMB won't agree to continue operating the prison clinics.
In most states, Medicaid is not an option for prison inmates. But a little known federal rule allows coverage for Medicaid-eligible inmates who leave a prison and check into a private or community hospital. Technically, those who stay in the hospital for 24 hours or more are no longer considered prison inmates for the duration of their stay.
Here’s how it works:
Under the 1965 law that created Medicaid, anyone entering a state prison lost Medicaid eligibility. The same went for people who entered local jails, juvenile lock-ups and state mental institutions. The reasoning was that states and local governments had historically taken responsibility for inmate health care so the federal-state Medicaid plan was not needed.
But an exception to that general rule opened up in 1997 when the U.S. Department of Health and Human Services wrote to state Medicaid directors saying inmates who leave state or local facilities for treatment in local hospitals can get their bills paid by Medicaid, if they are otherwise eligible. In addition to the incarcerated, those on probation or parole or under house arrest were among those who could participate.
Still, most state prisoners do not qualify for Medicaid. That's because all but a few states limit Medicaid to low-income juveniles, pregnant women, adults with disabilities and frail elders. The majority of people in lock-ups are able-bodied adults who do not qualify, even on the outside. In 2014, however, when Medicaid is slated to cover some 16 million more Americans, anyone with an income below 133 percent of the federal poverty line will become eligible. Since most people have little or no income once they are incarcerated, virtually all of the nation’s 1.4 million state inmates would qualify for Medicaid.
As a bonus to state corrections agencies, most inmates would be considered new to Medicaid, making them eligible for 100 percent coverage by the federal government between 2014 and 2019. After that, states would be responsible for only 10 percent of their coverage. In addition, state health insurance exchanges—which are required to be functioning by 2014—would make it easier for corrections departments to sign inmates up for the program.
This news, though - while welcome from the perspective of Texas taxpayers who will see state costs for inmate healthcare decline - seemingly throws a monkey wrench into everyone's plans. Presently, UTMB charges more than Medicaid rates for hospital care, so once inmates are covered by Medicaid, that part of the contract would cease to be the "plum" they consider it now. Similarly, local hospitals may be less likely to seek out contracts with the prison system if they must accept Medicaid rates, and it's a virtual certainty that private prison health contractors won't want the job at the low rates Medicaid pays.
At the same time, the state would be foolish NOT to sign inmates up for Medicaid, where the feds would pay 100% of hospital costs between 2014 and 2019 and 90% after that. Given recent cuts to Texas' prison healthcare budgets, the state has virtually no choice but to go that route. Right now, 100% of hospital costs come from the state budget.
I've no idea whether the parties to negotiations are aware of these changes to federal law, but signing up prisoners for Medicaid would alter the incentives for everyone involved, making hospital care less lucrative and attractive for UTMB, local hospitals, and private prison health providers alike. Indeed, finding providers willing to take Medicaid rates is already a challenge in the free world, so it remains to be seen how all this will play out.
In any event, this is good news in the medium term for Texas budget writers, even if it's an especially complicating factor for TDCJ's ability to contract for hospital care, with UTMB or anybody else, in the short run.
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