The Affordable Care Act and Drug-Mental Health Treatment for Offenders-Pew Charitable Trusts-Stateline-DC Public Safety

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[Audio Begins]

Len Sipes: From the nation’s capital, this is DC Public Safety. I’m your host, Leonard Sipes. Ladies and gentlemen, at our microphones, is Michael Ollove, he’s a staff writer for Pew Charitable Trust–Stateline and he’s here as a health policy writer, talking about an extraordinarily important article to those of us in corrections, especially those of us in community corrections and parole and probations. An article that came out back in April, in 2013 – Ex-felons About to Get Healthcare Coverage, Michael Ollove from Pew, welcome to DC Public Safety.

Michael Ollove: Thanks Len. Good to be here.

Len Sipes: I’m really impressed with this article, Michael, because so many people I’ve talked to find this topic to be the most important topic criminologically speaking, that they’ve encountered in the last five, maybe ten years. The overwhelming majority of us in parole and probation do not possess a dime for drug treatment; do not possess a dime for mental health treatment. So you know, let alone vocational and educational training, and let alone cognitive behavioral therapy. The overwhelming majority of parole and probation organizations, if the judge or somebody comes along and signs that “this person needs mental health treatment” that “this person needs substance abuse treatment” they simply refer them to the local health clinic, where they ordinarily wait in line for months at a time until an opening comes up and it’s questionable whether or not the treatment modality for mental health for drug treatment is designed around that particular person. Oftentimes it’s just described as a cookie cutter approach. What people in community corrections are really excited about is the possibility of real funding for mental health treatment, real funding for substance abuse treatment. In terms of the article that you wrote, there seems to be that possibility, correct?

Michael Ollove: Well, at least for the people that are coming out of prisons.

Len Sipes: Right. And we’re talking about the seven million people in corrections, five million are under community corrections, five million are in parole and probation, so the overwhelming majority of adjudicated individuals who are caught up in the correctional system would be eligible for this?

Michael Ollove: Yes. And for all years previous – all ex-offenders.

Len Sipes: Right, so what we’re talking about is Medicaid. We’re not talking about Medicare, we’re talking about Medicaid and we’re talking about not necessarily the Affordable Care Act, as it stands now. What we’re saying, according to this article, is that this went into effect back in January?

Michael Ollove: No, no, it goes into effect this January.

Len Sipes: Oh, it goes into effect this January? Okay.

Michael Ollove: It is part of the, it is part of the Affordable Care Act.

Len Sipes: Affordable Care Act – okay. Because – help me understand this. Part of the Affordable Care Act is that the individual comes out and is at that point eligible, if he wants to or she wants to purchase their own medical healthcare plan. So that’s one part of it, correct?

Michael Ollove: That’s one part of it.

Len Sipes: Starting this January, under Medicaid, there is the possibility for enhanced funding for medical treatment if you’re below a certain income level, correct?

Michael Ollove: That’s right. None of this was directed specifically toward ex offenders. It was generally for the, a poorer population and the change made in the Affordable Care Act is it’s widening the eligibility for Medicaid to – this simplifies it, but it’s mainly going to offer Medicaid for the first time to single people. All single people under a certain income will be eligible for Medicaid for the first time.

Len Sipes: What income level will that be?

Michael Ollove: It’s up to – States have to – would have to make someone eligible for Medicaid up to 133% of the poverty level. But this is with a big caveat. Because of a Supreme Court ruling, originally all the states were going to have to do this, but the Supreme Court said this is now optional. So 20 – I think it’s 27 states, I might have that off by one or two, 27 states have opted out at this moment from the Medicaid expansion. So in those states, this single individual under a certain income is not going to get Medicaid.

Len Sipes: Well, then, that leaves a lot of states, though, where there is a possibility of people getting or having access to Medicaid if they’re under a certain income limit, if they’re on community corrections – if they’re on parole and probation.

Michael Ollove: That’s right. And for that population, I mean, that population is largely male and largely single and largely poor.

Len Sipes: And filled with a lot of health problems.

Michael Ollove: And filled with terrible health problems.

Len Sipes: The thing that’s astounding to me is that I cannot – because every survey I read, every piece of research I read in terms of mental health is, ranges from anywhere from a certain diagnosis mental health problem – a formal diagnosis, which runs anywhere from say, 10 to 15% to individuals claiming problems with mental health issues which ranges to 50% and up. So what we’re talking about is if 5 million people under community supervision – if we’re going to say conservatively that 50% are self-identifying with mental health problems, 10 to 15% have a specific diagnosis for mental health problems. We’re talking about literally 100s of 1000s, if not millions of people.

Michael Ollove: Right, who before would have almost no access to mental health services.

Len Sipes: Right, and the research basically says that there is a correlation between mental health issues and people going back into the prison system, so if we can stabilize these individuals through mental health interventions then we literally save the states hundreds of millions of dollars by deferring people going back and we save lots of victims of crime, if they get mental health treatment. But at the moment, the bottom line is, from my perspective, is that in most states they’re not getting it or they’re not getting it in sufficient doses.

Michael Ollove: Not at all, not at all. And you’re absolutely right about recidivism. In places that have had mental health in place for prisoners, there’s been a sharp reduction in their re-

Len Sipes: Their going back into the system.

Michael Ollove: Their going back to prison. Yeah.

Len Sipes: Let me read from your article because I find it’s really intriguing. “Newly freed prisoners traditionally walk away from the penitentiary with a bus ticket and a few dollars in their pockets. Starting in January, many of the 650,000 inmates released from prison each year will be eligible for something else: Healthcare by way of Medicaid, thanks to the Affordable Care Act. A sizeable portion of the nearly 5 million ex offenders who are on parole and probation on any given day will also be covered. The expansion of Medicaid, a key provision of the Healthcare Reform Law, is the main vehicle for delivering health insurance to former prisoners. Researchers and those who advocate on behalf of ex-convicts hail the change as monumental, saying that it will help address the generally poor health of ex-offenders, reduce medical costs, and possibly keep them from sliding back into crime. And we haven’t even talked about substance abuse because substance abuse is a medical problem, as defined by virtually everybody – the AMA and everybody else. Our population here, in the District of Columbia, self-identify 85% of them as having substance abuse histories. I can’t think of one study out there that puts the figure below 70%. So the overwhelming majority of the individuals caught up in the criminal justice system have drug problems, and have alcohol problems. The – let’s just say conservatively, 50% self-identify as having mental health problems. So we’re talking about out of the five million individuals coming out of prison, or currently on parole and probation supervision on any given year, there’s 650,000, there’s 700,000 released on any given year. We’re talking about literally millions of people in need of mental health treatment and substance abuse treatment who are not getting it.

Michael Ollove: That’s right. And the consequences are shocking. I came across a statistic when I was doing the story that really blew me away, which is that prisoners in the first two weeks after their release from prison have 12, more than 12 times the chances of dying in the first two weeks than people in the normal population. And the two leading causes of death for the newly released inmates are drug overdose and cardiovascular disease.

Len Sipes: Right, because they’re in prison and we all know that prisons are not completely drug free, but ordinarily they are.

Michael Ollove: Right.

Len Sipes: And so they come out and they immediately start doing it once again and their systems cannot take it and the risk for death is rather high.

Michael Ollove: And they have nowhere to go, realistically very few options for drug treatment in those first days.

Len Sipes: They really have a sense when they come out that there really is nothing for them.

Michael Ollove: Yeah.

Len Sipes: And I think that’s what states are beginning to do. States are beginning to try to channel them into the Medicaid provisions of the Affordable Care Act and to try to get them to understand that they do have access to, if they’re under a certain income level, they do have access to mental health treatment and substance abuse treatment.

Michael Ollove: Yes.

Len Sipes: Okay. Now, let’s talk a little bit about Stateline. And it’s one of the things that I do want to compliment Pew about. I read Stateline every single day, and you can segment Stateline in a variety of different topics. I, needless to say, I look at the Crime and Justice segment. But people really do need to understand that Stateline, under Pew – if you just go ahead and use the search engine of your choice – I was reminded one time that I should not use the word “Google”. Use the search engine of your choice and do, and put in Pew and put in Stateline and you will get an amazing amount of daily coverage from all over the United States and original content written by writers there at Pew, correct?

Michael Ollove: That’s right.

Len Sipes: Why did Pew decide to take this on? I mean, this topic on? I mean, you have Reuters, you have the Associated Press, you have all sorts of other news distribution services. Why did Pew decide to take this on?

Michael Ollove: Well, Pew does a lot of research related to states and state governance and Stateline provides coverage of state [PH 00:11:26] houses and state issues so Pew thought that that was a natural, there was a natural relationship between what they were doing and what this journalism was doing.

Len Sipes: It’s a great idea, because every day I get the summation of the most powerful news stories from throughout the country state by state by state. So within a 10 minute glance, I have a pretty good sense of what’s going on in the criminal justice system throughout the country or another person could look at the healthcare issues or another person could segment it another way. It allows you within 10, 15 minutes to have a good sense as to what’s going on through the rest of the country. But regarding your particular issue, so I think Pew should be really congratulated for that, and also Pew is very involved in the issue of looking at sentences, sentencing reform, looking at parole and probation practices as well. I’m not quite sure that’s under your particular section, but Adam Gelb is going to be before these microphones in about a month’s time, and he is also with Pew. So Pew is really dedicated to this concept of getting news out and at the same time looking at the possibility of reform in the criminal justice system. Now, what about this – getting back to this. So many people have said, “When are you interviewing this guy from Pew? Because I’ve been talking to my counterparts throughout the country and everybody’s excited about this interview today because this is such an ungodly, important topic. But 27 states have opted out. That’s discouraging.

Michael Ollove: Yes, it’s, I mean, this is not going to be any secret to your audience, but it’s a political fight. The Republican governors and legislatures have not, in many states, signed on. Even though the Medicaid expansion in the first three years, the federal government is going to pay 100% of the costs of that expansion –

Len Sipes: Wow.

Michael Ollove: And in 10 years, it will eventually go down to, it will be 90%, but that still means that the states that have refused to come along are turning aside millions, 10s of millions of dollars, each of those states. And there’s a lot of thinking that even though they’ve said no to the first year, there’s opportunity to sign on, successive year, even in the middle of a year. And I think a lot of people believe that that money’s going to be impossible for them to continue to turn away. Especially since they’re denying – they’d be denying their poor populations medical care.

Len Sipes: I desperately want to stay away from politics, but the Affordable Care Act, it’s almost impossible to stay away from politics entirely. I do note that there’s a lot of folks within the conservative wing, there’s something called “Right on Crime” that is headed up by some of the leading conservatives in the country who are advocating very strongly for programs like this, because they’re sick and tired of the states spending billions upon billions of dollars that they’re spending now for correctional care. So we do know that these programs have an impact – not an overwhelming impact. I interviewed Joan Petersilia from Stanford Law, one of the leading criminologists in the country, who warned the rest of us not to overpromise in terms of these programs and the impact of these programs, but if you have a 10, 15, 20% reduction in the return to states, that is a savings of billions of dollars and that’s a savings of my God, hundreds of thousands, if not millions of crimes. So providing these services, mental health, specifically, and substance abuse – if they’re so strongly correlated with criminal activities, so strongly correlated with the people out there, seems to have great sense in terms of lowering the rate of return to prison systems, lowering the rate of return of crime, and that seems to be becoming increasingly a bi-partisan issue.

Michael Ollove: It is, it definitely is. I did a story about a year ago in an unexpected place about a program where prisoners that were identified as seriously, mentally ill – before they left prison they were set up with support services on the outside. Housing, job training, education, mental health. And the surprising place that was doing this was Oklahoma. They realized that there was a – the exact correlation that you mentioned. That if you can prevent these people from using again, and returning to crime, and therefore returning to prison, you are saving your state dollars.

Len Sipes: Enormous amounts of money –

Michael Ollove: Yeah.

Len Sipes: Enormous amounts of money. And the states are strapped. They’re cash strapped. I mean, it’s one of the things that Pew has covered through Stateline over and over again and it may be the principle story of the last five years as to the budget difficulties that states have had to face. So this is one – it’s one way of tackling those budget difficulties.

Michael Ollove: Right.

Len Sipes: Right, I want to reintroduce our guest, ladies and gentlemen. Michael Ollove, who I used to know, who worked at one time as a writer for the Baltimore Sun and Mike and I go way back and he is now with Pew Charitable Trust, writing for Stateline. He is a staff writer. We’re look gin at health policy. So Mike – and Michael, just this article, I, again, I have passed it out to my peers, we’ve discussed it within parole and probation organizations throughout the country and this is one of the most anticipated radio shows as far as my peers are concerned because this is, they see this as an opportunity to really provide services and really lower rates of recidivism. Ex-felons Are About to Get Healthcare Coverage again, April 5th, 2013, by Michael Ollove from Pew Charitable Trust. You say within the article that states are trying to make sure that inmates, upon release from the prison system are aware of the possibility of this coming up and trying to channel them into Medicaid related programs, if they’re eligible in terms of their financial means?

Michael Ollove: Yeah. Some states have taken steps, they’re not waiting for the prisoners to get out and they’re not taking the attitude of “prisoners are just going to have to find their way once they’re on the outside. They’re trying to ease their transition to Medicaid to make sure that they have coverage from the moment or nearly the moment that they leave.

Len Sipes: And a sicker population, I’m not – I can’t imagine a sicker population.

Michael Ollove: No.

Len Sipes: People have a view of people caught up in the criminal justice system, and I’m not quite sure exactly what that view is, but in reality, that view is one of hundreds of thousands, if not millions of very sick people. Not necessarily limited to mental health, not limited to substance abuse but limited in terms of sheer, day to day physical ailments and this is a very sick population.

Michael Ollove: It’s a very sick population. Higher rates of chronic and infectious diseases, particularly asthma, hypertension, tuberculosis, diabetes, hepatitis, HIV Aids, they are all higher than the general population. They come out, they are sick people.

Len Sipes: Much higher.

Michael Ollove: Much, much higher.

Len Sipes: And as you walk into this building in downtown DC, where we’re broadcasting from now, there are about 800 people who come into this building every single day for parole and probation or pretrial services. Many are in wheelchairs, many are on crutches, many – you can tell that many are struggling with their physical ailments. So I would imagine the whole idea of the health writer is that if you get to this population fairly early, let’s forget substance abuse, let’s forget mental health. If we focus on their physical ailments for the early and give them ways of dealing with them and ways of contributing to their health, that’s also eventually the potential for a huge savings down the road.

Michael Ollove: It is, and with this population, it was pointed out to me by people that work with this population – you know, they have so many, I mean, leaving aside what the reason was that they were in prison in the first place, when they come out, they have so many deficits, you know, in terms of making it on the outside, getting jobs with a record, their education deficits, just figuring out how to open up a bank account, that sort of thing. So the point was made to me that health – caring for themselves is something that can stand in the way of their success on the outside. If they are not healthy or it might prevent them from getting employment, from getting a stable life, and possibly returning to crime if they can’t make it.

Len Sipes: Yeah. And I would invite you at a certain point to sit in on one of our women’s groups. Because there, and I’ve sat in four or five times, and I’ve interviewed maybe 20, 25 women on supervision and formerly under supervision on this radio show. Their ailments are endless. I mean, it is – they come from histories of abuse, neglect, child abuse is just an amazing part of their lives, sexual violence, directed towards them as a child is a major part of their lives. They all have children – 80%, 70, 80% have children. The majority of males are fathers. So in this case, they’re coming out of the prison system, they’re trying to deal with mental health, they’re trying to deal with substance abuse, which I would imagine is applicable to probably 70 to 80% of the women that I’ve talked to caught up in the criminal justice system. They’re trying to deal with these issues and they’re trying to stabilize their lives and they’re trying to find employment and they’re trying to reunite with their kids. And there comes a point where I’ve oftentimes said that the odds are stacked so heavily against them that it’s almost impossible for them to succeed. So just for the sake of their own children, getting off of substance abuse or dealing with their substance abuse issue, dealing with their mental health issues, which are enormous, especially considering their backgrounds – if there’s no funding for that, then the possibility of them returning to the prison system and the possibility of the state picking up for the care of their children is just unbelievably high.

Michael Ollove: Yeah, you’re right, it’s completely stacked against them. No matter how earnest they are about making it.

Len Sipes: Right. Because I have sat down – and I’ve sat where you’re sitting right now, of women who are in the middle of all this, and they will tell you bluntly that it’s impossible. It’s almost impossible, and we have, within the District of Columbia, some fairly decent systems are in place in DC. Other sorts of organizations that will take women in, that will provide all these different services – but there’s, you know, these are donated services on the part of physicians. Now we, through this program, through Medicaid, through the expansion of the Affordable Care Act, there’s the possibility of them actually getting funding for dealing with these issues.

Michael Ollove: Yes.

Len Sipes: And that to me is just enormous. I mean, in terms of dealing with all the different things that we’re talking about, suicide, cancer, liver disease, HIV, overdoses – I mean, if you don’t have the money, what are you going to do? I mean, what traditionally have they done in the past?

Michael Ollove: Well, I think the recidivism rate has been very high. Homeless – this contributes to the homeless rate. A lot of them have psychiatric – are acting out because of psychiatric problems, on the street. They’re going back to jail or prison. You know, there is no good result without this kind of care.

Len Sipes: The article, reading again from the article, “New York, Oklahoma, Florida, Illinois, and California are among the states that already have pre-release programs aimed at connecting at least some outgoing prisoners with Medicaid. Some states, including New York are also investigating ways of connecting ex-prisoners with full service medical homes that coordinate healthcare services to manage patient’s care. The states that get ahead of this are going to have fewer people incarcerated and healthier societies, according to one individual at Brown University that you interviewed. So again, the different people that I’ve talked to in community corrections, in parole and probation organizations throughout the country see this as the green light, see this as maybe one of the most important issues within the last five or ten years for people coming out of the prison system.

Michael Ollove: Absolutely. It’s a game changer for that population.

Len Sipes: Yeah, and a game change means basically no substance abuse treatment, to getting substance abuse treatment. Now, I don’t know if it’s going to be the sort of designed substance abuse treatment and designed mental health treatment that is advocated by professionals, but at least it’s going to be something that was there, that was not there before.

Michael Ollove: Yeah, and you do raise a good point that is, that affects more than this population. The ACA, when the number of uninsured goes down, that is, people get insurance for the first time, we already have a primary care, a shortage of primary care doctors and we have a shortage of mental health professionals. The ACA is going to bring tens of millions of people, new patients, into the system. And there’s a real question about whether there are enough providers. I mean, we know there won’t be enough providers for all of those people. It’s been a problem, even aside from the ACA, having enough primary care doctors and psychiatrists. So you know, whether there’s – that community is big enough to handle this population is a big question.

Len Sipes: Yeah, and you know, it’s interesting. I was at my doctor’s office the other day at Hopkins, at Hopkins Community Healthcare, and that’s exactly what they were saying. They said that, because we were talking about how busy it was and how difficult it was to get in to deal with my rather minor medical ailment and he said, “Well, wait till the Affordable Care Act kicks in.” And so that applies – so it’s going to have to be sorted out over the course of years in terms of, okay, now that we have the money, do we have the wherewithal to provide these enhanced services to people coming out of the prison system?

Michael Ollove: Exactly. That’s the next big dilemma.

Len Sipes: But once again, I don’t know where else to take this. This is a start. You know, somewhere in the next five years we’ll figure it out. Somewhere in the next five years we’ll have the opportunity to provide meaningful, hopefully meaningful medical care, mental health treatment and substance abuse treatment to literally millions of people who at the moment currently aren’t getting it.

Michael Ollove: And it may have the biggest impact on public safety of anything that has been tried previously.

Len Sipes: You know, and that is the interesting thing. That’s what some people are suggesting. Some people are suggesting that this may have a major impact that was totally unanticipated. That nobody really thought about this in terms of its application to people on community supervision, but this may have the most significant impact both fiscally and criminologically of anything that we’ve done in the last 10 years.

Michael Ollove: Yeah, and the irony is, my guess is that as Congress was voting for the ACA, voting for or against it, it hadn’t occurred to anybody that prisoners, ex-prisoners, were going to be eligible.

Len Sipes: Well, that’s why when the article came out I became so excited. Because I have a group of fellow spokes people for both correctional systems and parole and probation systems and I immediately sent this out to them and everybody was going, “Wow, this is the greatest thing since nickel beer. This could be a game changer.”

Michael Ollove: Yeah.

Len Sipes: All right. So I really appreciate Michael Ollove coming in today from Pew Charitable Trust-Stateline. He is a health policy writer, staff writer for, again, Pew and I really appreciate the job that Pew does in terms of keeping the rest of us informed on criminal justice issues and healthcare issues and all the other issues throughout the country. I think Pew does a wonderful job. And ladies and gentlemen, we appreciate you listening. This is DC Public Safety. We appreciate your comments, we even appreciate your criticisms and we want everybody to have themselves a very, very pleasant day.

[Audio Ends]

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