More ’aid for those who need it

Mike Saxl’s Medicaid bill could provide insurance to many of the state’s mentally ill, and relieve pressure on city services

By Noah Bruce

OXFORD STREET SHELTER: in the past ten years, it has become more of a mental health facility.

At the tail end of this year’s session, the Maine state legislature passed a bill proposed by House-speaker Mike Saxl (D-Portland) that will expand insurance coverage to some of the state’s poorest residents. Before the bill, officially known as an Act to Increase Access to Healthcare’s passage, Medicaid — state and federally funded insurance for the poor — was available only to children, parents caring for children, and the disabled. In other words, just being poor wasn’t enough to guarantee you government assistance in acquiring health care.

The bill changes this by providing access to Medicaid to the so-called “non-categoricals” — people who earn less than the federal poverty line ($8592 a year for a single person), but do not fit into one of the above categories. This is good news for the 15,905 Mainers who would benefit from the bill, but it is also good news for the mentally ill, many of whom were already eligible for Medicaid, but could not surmount the considerable barriers to entering the system as someone who was “disabled.”

Before celebration on the Medicaid victory begins, however, the state must obtain a federal Medicaid waiver from the Department of Health and Human Services. Hopefully, this will not be a problem, says Bill Brown, legislative aid to Mike Saxl, because Bush’s secretary of Health and Human Services is Tommy Thompson, former governor of Wisconsin, whose state applied for and received several similar federal waivers.

If approved, the bill will help the mentally ill who, though eligible, have not been able to enter the Medicaid system. The first barrier to the system for a mentally ill person is the recognition and acceptance that they are ill. “A lot of people are not aware that they are mentally ill,” says Palmer Peters, program manager for Portland Social Services, “and a lot of others are in denial.”

Bob Duranleau, director of the city’s social services department estimates that of the 125 people now sleeping in the Oxford Street Shelter, 25 percent fall into this category of people who are eligible for disability due to mental illness but either will not admit, or do not realize, they are ill, or are too disoriented to access the system.

Now, with the new Medicaid bill, these folks will be able to enter the system through a different avenue — low income. People previously kept off Medicaid because they have not come to terms with their illness will be able to get insurance simply by earning less than the poverty line. This should help those who are in denial who might be more willing to admit poverty than mental illness.

“Having a mental illness,” says Julie Glossock, human services counselor for the city who helps mentally ill people get on Medicaid, “carries a greater stigma in our society than having low income, and I think people would see the benefits of healthcare outweighing admitting low income.”

The bill will also help those who are poor and suffer from substance abuse problems. In the ‘90s, Congress ruled that substance abuse does not count as a disability and therefore does not make one eligible for Medicaid. Now, the Medicaid bill would allow them to apply through the poverty route as well.

Applying for Medicaid by claiming poverty instead of mental illness will circumvent several steps in the Medicaid acquisition process.

The easiest way to prove illness is with a detailed medical history says Glossock. The thing is, many people, especially the homeless, do not have medical documentation.

“If there is not current medical evidence,” says Glossock, “the individual is told to go to the doctor.” But making an appointment and then showing up, she says, can be a problem for some mentally ill people. And even though part of Glossock’s job is to schedule appointments and take people to the doctors to establish a medical history, not all of the mentally ill who attempt to get Medicaid are fortunate enough to work with Glossock — especially if they live in other Maine cities where there is no human services counselor.

Aside from applying directly for Medicaid, a common way for people with serious mental illness to get into the system is through Social Security, perhaps because they do not realize you can get Medicaid by itself. In fact, several people interviewed for this story, who work directly with the mentally ill, incorrectly believed that, for the mentally ill, Medicaid was only available through Social Security. So, if you’re going to talk about getting the mentally ill on Medicaid, you have to talk about the numerous impediments Social Security has erected.

Most people think of monthly checks for retired folks, or for people injured on the job, when they think of Social Security. However, there is a program known as Supplemental Security Income (SSI), that exists as a safety net for disabled poor adults who have not contributed money into the Social Security system. SSI is available to people disabled, either mentally or physically, who have an income under $550 per month. Along with a monthly check of $530, a person who receives SSI is automatically qualified for Medicaid.

Sounds simple.

In reality though, a trip to the Social Security office for someone who is mentally ill “can be quite intimidating,” says Gerry Cayer, director of Portland’s Health and Human Services Division. “They have a police officer right at the door. For our clients,” he says referring to the homeless, “that can be a barrier.”

Unlike Medicaid, which lets a person go to any doctor they choose, Social Security schedules a doctor’s appointment for the claimant. Glossock says this is easier for some people than having to schedule their own doctor’s visit, but no guarantee that the claimant will keep the appointment.

Even if a person is able to complete the process, however, chances are they will be turned down for Social Security. In fact,nationally, 62 percent of the people who apply for disability are initially denied. The high rate of denial, says Jon Holder, an attorney who handles Social Security claims, stems partly from the fact that the decision is made by people who don’t meet the claimant and rarely speak with the claimant’s doctor.

In the “Kafkaesque” world of Social Security, Holder explains, the local Social Security employees who actually meet the claimant are not the ones who make the decision as to whether to grant benefits. Instead, they send the paperwork to the branch of the system called the Disability Determination Services, whose office is in Augusta. The people who work in determinations, says Holder, are not properly trained “in the law or in medicine,” and make their decisions largely based on a treatment history, which is itself often “full of holes and gaps.”

The determinations employees usually do send claimants for medical and psychological exams, but, says Holder, the doctors who are contracted by Social Security “want to keep the referrals coming” and reflect the determinations office’s “bias against granting claims.”

“The Maine office in particular has a clear bias against granting claims,” says Holder, and it’s worse for people who have a mental, rather than a physical disability.

According to Glossock, though the criteria for disability at Medicaid and at Social Security are identical, Social Security is more likely to turn someone down. Not only can this deny a seriously mentally ill person a meager income, it can keep them from insurance. Just as gaining SSI automatically enrolls a person in Medicaid, being denied SSI automatically puts a person in danger of losing Medicaid.

A person who has applied for Medicaid will usually be given a temporary Medicaid card while they are waiting to see if they will be granted permanent access to the program. However, during this time, if they are denied SSI, they then lose their temporary Medicaid card unless they can make it to the doctor’s office for another exam within 10 days. Many, of course, do not make it to the doctor’s in time. The result, says Peters, are people who are in and out of the Medicaid system and consequently on and off their medication.

After the initial SSI rejection, Holder says, 50 percent of claimants simply give up. Those who persist can file for reconsideration. Unfortunately, the reconsidering is again done by Disability Determination Services, who again fail to actually meet the claimant. Eighty four percent of reconsiderations are denied.

MIKE SAXL: his bill will help Maine’s neediest citizens — people who are poor and mentally ill.

Many people give up at this stage. If the claimant persists, they go before an administrative law judge and are finally able to tell their story to the person making the decision. Apparently, this makes a big difference, as 59 percent of those who make it this far receive social security benefits. The mentally ill, however, are far less likely than the physically disabled to persist to this point.

A year and a half often passes from the time someone makes a claim to the time the judge hands down a decision. This is a year and a half without a crucial monthly check and, perhaps even more important to the mentally ill, without insurance, which means without medication.

Unfortunately Saxl’s bill does nothing to simplify the Social Security maze, but due to the passage of the bill, people denied SSI should now be able to get Medicaid as long as they can prove that they earn less than the federal poverty level. It is important to reiterate that, though many people hope to get Medicaid by applying for SSI, Medicaid can be applied for independently of Social Security, and, thanks to this bill, people no longer have to prove a disability to be eligible.

Much of the mentally ill’s need for Medicaid stems from the 1970s, when there began a process known as deinstitutionalization from the country’s mental hospitals. Across America and here in Maine, people with serious mental illnesses, who once lived in mental hospitals, were released into the general population.

This process was initiated for three reasons: it was very expensive to keep people in the hospitals, improvements in medication allowed many patients more stability, and it was considered cruel to keep people in institutions. Though Maine began this with the rest of the country in the ’70s, the state mental hospitals in Augusta and Bangor didn’t truly desinstitutionalize until the early 1990s.

According to Robert Hayes, a Portland attorney who has served as an advocate for the homeless, deinstitutionalization was a two-part process. The first part, releasing patients, was done well by every state in the union. However, no state, he says, truly succeeded at the second part, providing the necessary community support.

Part of the problem, and the reason why the Medicaid bill is so necessary, is that seriously mentally ill people without Medicaid (or other insurance) do not have access to the health care that justified their release in the first place. Medicaid helps to pay for visits to psychologists, psychiatrists, counselors, and social workers, and to pay for medication: all of the services previously supplied in the institutional setting.

In addition to lack of access to private providers, a person without Medicaid has less access to the services provided by the non-profit mental health providers like those in Portland: Shalom House, Ingraham, and Catholic Charities, for example. If these organizations serve someone with Medicaid, they are reimbursed for their services. However, if they help someone without Medicaid, the money must come from grants, most often from the state.

“Agencies don’t want to turn folks away,” says Hayes, “but in turn they don’t want to go bankrupt. Do you close the door to someone in need or do you wreck the budget of a non-profit organization?”

According to Joe Brannigan, director of Shalom House, state grant money has remained stagnant while costs, due to inflation and the rising cost of health care, continue to rise. That means that there are less services available to people without Medicaid. Brannigan says Shalom House can provide case management; some in-home support; and sometimes peer support, which consists of help from someone who has recovered from mental illness. However, due to demand, some of these services are not always immediately available. Further, to live in Shalom House’s two group homes a person must have Medicaid.

Aside from the service organizations, luckily, a mentally ill person without insurance can receive substantial help from the city of Portland. While it’s not nearly the same as having your own apartment or even your own room in a halfway house, the Oxford Street Shelter does keep 125 people a night from sleeping on the sidewalk.

In addition, the city operates the India Street Free Clinic, which serves people for a small fee, and the free Healthcare for the Homeless clinic out of the Preble Street Resource Center. However, according to Nate Nickerson, director of Portland’s public health and human services division, out of the 1600 to 1700 patients Healthcare for the Homeless serves every year, 30 to 40 percent have mental illness and there are only a few staff members to work these clients.

Though they are valuable, these services provided by the city were not designed specifically to serve the mentally ill. In fact, those who run the Oxford Street shelter — Peter Murdoch, Gerry Cayer, and Bob Duranleau — report that the shelter has drastically changed its mission in the ten years since desinstitutionalization took hold in Maine. Where once it existed mainly to serve the transient population, the shelter’s directors now find themselves devoting much of their efforts to serving the needs of many of Portland’s mentally ill. Therefore, the Medicaid bill should take some of the burden off these city services and offer people who are both homeless and mentally ill far greater treatment options.

Though the city does their best to help them, when the mentally ill do not receive the healthcare they need, often because they do not have insurance, they can be at risk of having a breakdown, sometimes a public one. When this happens, the person will most likely be taken into custody by the police.

“If you are a depressed suicidal,” says Carol Carothers, director of the Maine chapter of the National Association for the Mentally Ill, “and the police pick you up because the neighborhood is concerned and you are scaring people, it’s the same as letting diabetes go until a person is really ill.”

Like someone who is sick due to diabetes, a person who is mentally ill and is out of control will be taken to the hospital, but only if they are a danger to themselves or others. If they are not, unfortunately, they will be taken to jail, what Carothers calls, “the largest mental health provider.”

“A lot of citizens are not conscious of the fact that upwards of 40 percent of my jail population require medication to manage their [mental] illnesses,” says Cumberland County sheriff Mark Dion. Dion believes that “we’re right back to the ’50s again” in the sense that large numbers of the mentally ill are institutionalized. Now, however, they find themselves not in hospitals but in jails and prisons.

“We say we’re a state that has deinstitutionalized,” he says. “I think we have repositioned from a therapeutic requirement to a corrective requirement.”

In addition to the obvious stressor of being behind bars, it’s unlikely a mentally ill person will receive the best of services once in jail. At the Cumberland County jail, for instance, there is only one social worker for the entire population. Ingraham sends a medical team to the jail to deal with crisis situations, but Dion has been unable to convince any local psychiatrists to sign a contract to provide services. As a result, Dion may have to make use of “tele-psychiatry,” a service that, much like tele-conferencing in a business’s boardroom, would allow inmates to see and speak with a psychiatrist based in another state. Not the most intimate of healthcare settings, but it would get inmates the prescription medication they need.

Hopefully, the Medicaid bill will allow some mentally ill people to enter the system and receive the healthcare they need to avoid depression, crisis, and potentially jail. “It’s a couple steps in the right direction,” says Cayer.

However, many mental health issues still exist. Housing, says Cayer is a big one. While Medicaid should help some mentally ill people gain access to group homes like those run by Shalom House, the simple fact is there is more demand than supply, and, in Portland, there are waiting lists for such services.

Another large consideration is the income threshold — $8592 dollars per year for a single person. Anyone who makes over this amount will be barred from Medicaid.

While the bill will help those who will admit poverty but not mental illness, it will do nothing for those who are so disoriented they can’t make it to the Medicaid office. For these people, attorney Robert Hayes believes the state should enact what is known as “presumptive eligibility” — the concept that an approved provider, say a case manager at Shalom House, should be able to presume eligibility and sign someone up for Medicaid who is obviously mentally ill and poor.

“The best way to prevent help to the poor is to bureaucratize,” says Hayes. “The best thing the state could do would be to liberalize the concept of presumptive eligibility as far as federal law allows.”

Then there is the sticky issue of large numbers of the mentally ill in jail. Dion believes public money should be used to create a low-threshold, acute care clinic — another option where police could take people experiencing a mental health crisis. “There’s something unsettling about trying to fit jail into a mental health care slipper,” he says.

For the meantime though, the Medicaid bill will provide health care for some of Maine’s neediest citizens — people who are both poor and mentally ill. “Saxl’s bill is a good thing for the mentally ill” says Carothers. Hopefully, the federal government will agree.

Noah Bruce can be reached at nbruce@phx.com.