Tag Archives: health care reform

Mental Illness – Fighting Stigma and Improving Access to Care

by Jennifer Swayne, Staff Attorney – Health Justice Program

On Friday, December 14, 2012, we once again faced unspeakable tragedy as a gunman broke into Sandy Hook Elementary School in Newtown, CT and opened fire, killing a total of 28 people—20 of whom were children. While many of the initial conversations surrounding this horrible tragedy focused on the ongoing debate about gun control, very few of those conversations focused on mental illness, the stigma surrounding it, and access to mental health care services. Some news sources have reported that the gunman faced mental illness, though it is not clear what, if any, mental health services he and his family may have sought in the past.  However, what is certain is that we need to engage in dialogue on mental illness, as there are many individuals who face significant stigma and who are not able to access critical mental health services consistently.

Mental illness knows no race, culture, ethnicity, language, socioeconomic status, age, gender, or religion, yet there is stigma and overwhelming silence surrounding its impact.  Many have probably encountered someone with mental illness without even realizing it, especially since about 1 in 4 adults age 18 and over, and about 1 in 5 children age birth to 18 suffer from a diagnosable mental illness at some point in their lives.  Because of the stigma surrounding mental illness, however, we continue to miss opportunities to help others get the support and assistance they need, especially when those who exhibit signs of mental illness are simply labeled and dismissed as “crazy.”  Instead, we are relegated to hindsight assessment when it is much too late to take action.

The mass shooting that happened in Newtown is an extreme, and there is nothing that excuses the actions of the gunman.  However, mental illness is much more complex than this extreme case of violence we have witnessed suggests. For instance, people with mental illness face greater risk of becoming the victim of crime rather than being the perpetrator.  Therefore, we must be careful not to let a single person’s actions symbolize our collective understanding of how mental illness manifests and operates.

Further, we have a health care system where mental health parity has been lacking, and sadly, quality mental health services remain a luxury reserved for those who have the ability to pay in cash for those services.  The result is that those who have no insurance, those who rely on private insurance with limited mental health benefits, and those who rely on public insurance often go without needed mental health services that can help them live full and productive lives. Untreated mental illness can result in homelessness, incarceration, victimization, high burden placed on families and caretakers, and productivity loss, not to mention the financial costs of healthcare expenditures resulting directly from failure to treat mental illness sooner rather than later.

New York State is in the process of redesigning its system of behavioral health services for some of the most vulnerable people in our society—low-income children from birth to age 21 who use public insurance.  This is a group that has suffered immensely from lack of adequate mental health services. Under Medicaid, the system of mental health care for children has been overwhelmingly underfunded and the New York State systems that serve children—Department of Health (DOH), Office of Mental Health (OMH), Office of Children and Family Services (OCFS), Office of Alcoholism and Substance Abuse Services (OASAS), Department of Education (DOE)—and other agencies at the local level, have not coordinated their efforts to serve children, leading to a disjointed system.

It is promising that New York State is engaging in a process to revamp the system of care for our children, but we have to make sure that it is a system that will actually work and result in real change or else children will continue to face dire consequences and suffer from the stigma of mental illness well into adulthood.  Children with mental health problems have lower educational achievement, greater involvement with the criminal justice system and fewer stable and long-term placements in the child welfare system than their peers.  In attempts to access mental health services, publicly insured children are also more likely to rely on restrictive or costly services such as juvenile detention, residential treatment, emergency rooms, and are more likely to be placed out of their homes in order to obtain critical services, as opposed to being able to readily access outpatient services, especially if they are children of color.

On December 14, NYLPI and the Children’s Defense Fund submitted joint comments (which you can access here) regarding the critical mental health services that children need to New York’s OMH, OASAS, and OCFS.  In our comments we:

(1) address the health disparities that impact receipt of mental health care;

(2) list the services that children should receive and who should provide those services;

(3) highlight the importance of cultural and linguistic competency;

(4) discuss the need for early identification and prevention measures such as behavioral health screening; and

(5) stress the need for training and funding so that providers are able to actually provide the appropriate services.

As we can see, mental illness is complex and it is not going away.  We must proactively engage in creating a better system of care rather than responding in the aftermath of tragedy. It is vital that we have honest and ongoing conversations about the state of our society, mental illness, stigma, and access to appropriate mental health care services.

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Medicaid Reform and Retrenchment: Your Voice is Needed NOW

As many of you know, Governor Cuomo has created a “Medicaid Redesign Team” to help him cut New York’s Medicaid program by $2 billion and redesign it for the long-term.  This 27-member team is made up of only one statewide community organization and has little representation from the public sector. It is primarily dominated by the hospital industry and is led by two men with ties to large, private hospitals. Given the imbalanced composition of the Redesign Team, we are concerned that the “savings” and “reforms” it will propose will also be imbalanced, resulting in cuts to Medicaid benefits, long-term and primary care services in the community, and safety net providers. In New York City, people of color are more than twice as likely to be publicly insured than whites. This means that cuts and bad decisions about reforms to the Medicaid program will have a bigger negative impact on immigrant populations and communities of color.

What can you do in response?

1. Make your voice heard! The Medicaid Redesign Team is hosting a series of public hearings across the state, including two in New York City on Thursday, January 27th. The focus of the hearings is to solicit input on how to achieve savings in the Medicaid program. Consumer advocates and allies must be out in full force at both of these hearings to provide testimony about how savings can be achieved without breaking the backs of low-income New Yorkers who depend on Medicaid for critical health benefits. Click here for more information about time & location for these hearings.

2. Join the campaign! The Save Our Safety Net-Coalition (SOS-C) is mobilizing to keep the voices of consumers and labor front-and-center during the redesign process. If you would like to get involved or simply keep informed about what is happening, please contact the Commission on the Public’s Health System at 212-246-0803 or email soscny@gmail.com.

3. Spread the word! Please tell your friends, colleagues and fellow fighters about the upcoming public hearings, encourage them to attend and provide testimony, and urge them to join SOS-C. Important public policy decisions should not be made without the active involvement of the people most impacted. Click here to download a flyer about the Medicaid Redesign Team hearings to share with your networks.

We look forward to working with all of you to ensure that New York’s Medicaid reform is humane, just and participatory.

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Leaving Undocumented Immigrants Behind

This post is by Shena Elrington, Staff Attorney and Simpson Thacher & Bartlett Public Interest Fellow in the Health Justice Program at NYLPI.

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act into law.  The legislation represents the most sweeping reform of the American health care system since the New Deal.  Although the legislation calls for nearly universal health coverage – reducing the number of the uninsured by 32 million by 2019,  it fails to extend such coverage to undocumented immigrants, creating a large coverage gap that will inevitably strain the burgeoning health care system.

The new legislation prohibits undocumented immigrants from purchasing private health insurance in newly formed state exchanges at full costs and receiving premium tax credits or cost-sharing reductions to help purchase insurance.  Notwithstanding the new legislation, undocumented immigrants may still receive emergency care under the Emergency Medical Treatment and Active Labor Act (EMTALA) and Emergency Medicaid.  Neither EMTALA nor Emergency Medicaid, however, provides undocumented immigrants with adequate care.  EMTALA, for instance, requires only that hospitals screen individuals for emergency medical conditions and stabilize (or appropriately transfer) individuals with such conditions.  Beyond screening and stabilizing individuals, EMTALA imposes no additional obligations on hospitals to provide care.  Emergency Medicaid is only available to individuals – regardless of immigration status – who are so acutely ill that the failure to receive medical attention would place their health in serious jeopardy.  Health care providers are often unfamiliar with Emergency Medicaid’s eligibility requirements and deny coverage to undocumented immigrants based on their immigration status.  Both EMTALA and Emergency Medicaid focus on providing care only when individuals are at their sickest and when the cost of treatment is at its highest.  From both a health and financial standpoint, it makes little sense for undocumented immigrants to initially engage the health care system at this point.

There are some 7 million undocumented immigrants in the United States, with an estimated 700,000 living in New York State. Sooner or later these individuals will need health care and will likely receive this care at the emergency stage.  The Affordable Care Act offers some hope for folding this population into the health care system in the form of $11 billion support for the creation of community health centers in underserved communities.  Absent federal immigration reform – an issue as divisive as health reform itself, individual states will need to ensure that undocumented immigrants are not left entirely out of the fold.  Failing to do so will only end up being more costly in the future.

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Combine and Conquer: The Day Immigration Met Health Reform in Our Nation’s Capitol

By, Nisha Agarwal, Director of the NYLPI Health Justice Program.

Right now, five hundred thousand immigrants and their allies are rallying in Washington, DC, having traveled from across the country in caravans of buses to demand humane and just immigration reform.  Also right now, the votes are being tallied and negotiated on the most comprehensive health reform package in two decades.  For those of us who aren’t in DC ourselves, Twitter tracks the movement on the ground for the immigration march:

From @thenyic: ‘Senator Schumer on conference call with 220 buses (11000 people!) heading from NY to DC for the March for… http://fb.me/vlRfj4w5

From @nakasec: We are here!!!!! Can you hear the sounds of drumming??? Yes we can! Hal soo it dah!! Si se puede!! #immigration #m4a #dreamact

Meanwhile, email lists and blogs are active, urging last minute phone calls and petition signatures to get Democrats to vote with their hearts on health care reform, and not from their fear.

Every day I work at this meeting point between immigrant rights and health equity, but it is not every day that I can see these issues reverberate on a national scale.  Today, however, they echo and re-echo, and I listen in awe and gratitude to my fellow activists and allies.  This is a progressive moment, and it is because we have made it one.  In all the bickering about the details of the legislative packages and the concern about the eventual outcome of HCR and CIR—important arguments and worries to have—we shouldn’t forget what has already been accomplished: Both the push for health care reform, which is nearing its end, and the fight for immigration reform, which is just beginning, are strong, durable movements that progressives have built, with massive ground operations and multiple, coordinated perspectives tightly networked through cyber-space.  We have shown that power can be built from the ground up, even in the wake of decades of reactionary national government and the collapse of the global economy, and in the face of a deep blue hate.  I am optimistic that we will win health care and immigration reform, and I am proud of the structures we have created to do so.  We here at NYLPI’s Health Justice Program are in full solidarity with all of our friends in DC right now.  Si se puede.  Hal soo it dah.  Yes we can.

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Immigrants Are Largely Left Out of Health Reform

From our friends at the New York Immigration Coalition, a new report on immigrants in health reform and the barriers that immigrants face to getting insurance in general.

Immigrants, both those residing lawfully in the United States and those who are undocumented, will continue to face major barriers to health coverage even if federal health care reform is enacted, according to a new study released today by New Yorkers for Accessible Health Coverage (NYFAHC) and the New York Immigration Coalition (NYIC).  Currently, noncitizens comprise 12 percent of New York State’s population but 29% of its uninsured population.

“Two million New Yorkers are noncitizens, and they lack health insurance to a much greater extent than citizens,” said Jenny Rejeske, study co-author. “The substantial majority of these noncitizens are here legally, and they pay the same taxes as citizens do.  There is no justification for impeding their access to insurance and the care that they and their families need. It is time for policy makers to remove the barriers that prevent immigrants from getting the health care they need.”

The New York State Health Foundation-funded report, Health Insurance and Immigrants: Obstacles to Enrollment and Recommendations, documents numerous factors contributing to high uninsurance rates among noncitizens:

  • Immigrants work in lower paying jobs and for smaller firms that tend not to provide health insurance;
  • Undocumented immigrants are barred from public health insurance programs like Medicaid and Medicare that are available to citizens;
  • Even lawful permanent residents are barred from Medicaid and Medicare for five years,
  • Legal immigrants fear that enrolling in public coverage will classify them as “public charges” who may be denied permanent residence status;
  • Legal immigrants fear that receiving public coverage will expose their sponsors to claims for reimbursement;
  • Immigrants face cultural and language barriers; and
  • Immigrants are sometimes arbitrarily denied benefits even when they are entitled to them.

“The health reform bills currently being debated in Congress fail to address most of these barriers. Even more ominous, some proposals, such as one to exclude undocumented immigrants from using their own money to purchase full-price coverage in health insurance exchanges, would make it even harder for immigrants to enroll in coverage,” said study co-author Mark Scherzer.

“Immigrants make up a large proportion of the uninsured but are conspicuously absent from plans to expand coverage,” said David Sandman, Senior Vice President of the New York State Health Foundation. “If immigrants are left behind, we must ensure a strong safety net of health care services is in place to address their needs and fulfill the promise of opportunities to lead healthy and productive lives.”

The report’s key recommendations include:

  • Develop subsidy systems that allow low-income workers to enroll in affordable health insurance through their employers or independently;
  • Repeal the federal government’s “five-year bar” on Medicare and Medicaid enrollment;
  • Make public coverage available to all New York State residents, regardless of immigration status;
  • Develop a public education campaign to eradicate the notion that enrolling in public coverage would endanger immigration status;
  • Carefully monitor and control immigration officers who improperly exclude immigrants from adjusting their legal status;
  • Change federal and state laws to remove covered health expenses from the categories that can be recovered from immigrant sponsors;
  • Address cultural, linguistic and navigational barriers confronting immigrants by enforcing existing language access rules and improving support of community-based outreach, education, and navigation programs; and
  • Ensure the preservation and strengthening of robust hospitals and community health clinics, where the majority of low-income uninsured residents seek care.

Health Insurance and Immigrants: Obstacles to Enrollment and Recommendations is the third in a series of reports that analyze how health coverage among immigrants can be increased. The complete report is available upon request or at www.NYShealth.org; www.thenyic.org or www.cidny.org.

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Squeaky Wheels: Community Advocacy and Healthcare in Southeast Queens

This post is by Equal Justice Works Fellow Seth Cohen, an attorney at New York Lawyers for the Public Interest (NYLPI). Seth’s EJW Fellowship is sponsored by Johnson & Johnson and Patterson Belknap Webb & Tyler LLP.

As we have written about in previous posts, Southeast Queens is a low-income community of color that has long experienced some of the worst health outcomes in New York City across a variety of measures. Despite this, and despite the fact that this community—long designated a Medically Underserved Area—has experienced a continuing trend of healthcare disinvestment. Consider this: over the past year, three hospitals that served Southeast Queens have closed; there are only 48 full-time primary care doctors per 100,000 people in Southeast Queens, almost 2/3 less than in whiter neighborhoods in Queens. All the while, Southeast Queens has the unenviable distinction of having abysmal health outcomes, including some of highest rates of infant mortality, low birth weight, and diabetes in the City.

One might think that the New York State Department of Health (DOH), the state government entity that handles all things health, would move quickly to shore up health services in a community with such a critical shortage of services and such a critical need for them. To its credit, DOH awarded $30 million in HEAL NY grants to spur healthcare services development borough-wide. Southeast Queens United in Support of Healthcare (SQUISH), a community-led coalition, advocated for allocating part of those funds toward fundamental healthcare services that Southeast Queens needs most: primary care; emergency care; and inpatient beds. The DOH grant disbursements signaled a first step—over $5 million was awarded to two community health centers that serve Southeast Queens.

Nevertheless, the grants did little to directly address the community’s most critical needs. For an area that has seen a disproportionate share of hospital and clinic closures in the borough, Southeast Queens simply did not receive funding proportionate to the critical need and unacceptable health outcomes the community faces. Indeed, it ultimately received the least amount of HEAL funding as compared to other areas in Queens.

Part of the difficulty for Southeast Queens—or any low-income community of color in New York, for that matter—is the fact that New York lacks any meaningful, structured way for people who live in the community and who use healthcare services there to provide ground-level input to DOH as to what they see as the most pressing health concerns, and how to best address those concerns. As it currently stands, DOH seems to turn a blind eye to the very individuals who actually utilize healthcare services. This perspective, though, is questionable at best, and will certainly not lead to a reduction of health inequities any time soon.

According to the National Partnership for Action to End Health Disparities, an initiative launched by the United States Department of Health and Human Services, such ground-level input is essential to eradicate health disparities. Three of the primary actions the Partnership calls for include:

  • Create opportunities to engage stakeholders from all sectors in discussions and actions to ensure community responsiveness and accountability toward ending existing health disparities;
  • Create mechanisms for individuals (e.g., residents, advocates) who have been affected by, or concerned with, health disparities to share their stories with the public and decision makers at all levels
  • Develop or support efforts to educate legislators and elected officials about health disparities and the determinants of health

Notwithstanding these recommendations, DOH has continued to take a hands-off stance, maintaining that it is merely a “neutral” government entity unable to actively engage in or commit to correcting the systemic health inequities that persist in the community. As dispassionate and impervious as this may sound, DOH has indicated, however, that it was up to community residents to work with elected officials and other stakeholders to locate and negotiate with healthcare providers who would be willing to serve the community. Only then might DOH get involved.

So, this is exactly what SQUISH has started to do.

SQUISH has initiated conversations with Addabbo Family Health Care to prepare for leveraging any future federal dollars from healthcare reform to bring additional Federally Qualified Health Clinics (that serve predominantly Medically Underserved Areas like Southeast Queens) to the neighborhood.

SQUISH also recently met with elected officials—including Assembly Members William Scarborough, Michelle Titus, Barbara Clark, and New York City Council Member Leroy Comrie—to begin to hammer out a plan to effectively address healthcare needs in the near-term and also to craft a long-term plan to ensure quality healthcare delivery in Southeast Queens.

There is also the matter of figuring out how to influence next steps at the site of Mary Immaculate Hospital, the now-defunct hospital in Jamaica that went bankrupt and shuttered its doors approximately one year ago. The current owners of the site have indicated they “envision[] several options for redeveloping the Mary Immaculate site, including an educational facility, nonprofit organization use, government operations or a religious facility.” No doubt you can see what redevelopment option is curiously absent from this list: reusing the site to provide health services to the community. While reopening a hospital may prove a challenging enterprise, it is not unheard of. The communities of Watts and Willowbrook, low-income communities of color in Los Angeles, California that are similarly medically underserved, were recently successful in forging a pact with various stakeholders to reopen their community hospital, the King/Drew Medical Center, using federal stimulus funds. As put by one community resident affected by the lack of local healthcare services put it,

“The fact that we are in the richest and most affluent society in the world yet don’t have health and medical infrastructures in key urban cities to take care of potentially life-threatening situations is the reason we should have hospitals in communities, particularly underserved communities with large populations of uninsured.”

Three thousand miles from Watts, this sentiment is equally applicable  in Southeast Queens as SQUISH continues to advocate for healthcare for its community.

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Update: Immigrants and Health Reform

This update comes to us courtesy of our friends at the New York Immigration Coalition.

Congressional leaders and President Obama are back after taking a break for the holidays and passage on Christmas Eve of the Senate’s health reform bill, H.R. 3590, the “Patient Protection and Affordable Care Act.”  Now that both the House and the Senate have passed their respective bills, they must come together to negotiate a final bill.  Congressional leaders have decided to bypass the Conference Committee process for a more abbreviated negotiation process among Democratic leadership and committee chairs, including Senate Majority Leader Harry Reid; House Speaker Nancy Pelosi; House Majority Leader Steny Hoyer; Senate Majority Whip Dick Durbin; House Committee Chairs George Miller, Charles Rangel, and Henry Waxman; Senate Committee Chairs Max Baucus and Tom Harkin; as well as NY Senator Charles Schumer, Vice Chair of the Democratic Conference.

This negotiation process is the last chance to make the improvements that are of vital importance to immigrant workers and families.

By and large, the House bill better exemplifies the general goals of health reform – making health insurance more affordable for millions of people (including immigrants who are naturalized citizens and lawful residents), helping to contain the skyrocketing costs of the health care system in the United States, and including many provisions to reduce health disparities and improve health outcomes.  However, there are still grave inequities for immigrant community members, both lawfully residing and undocumented, that must be addressed in this final negotiation process.    While naturalized citizens and many lawfully residing immigrants would gain access to more affordable health insurance, the five-year waiting period in federal Medicaid for lawfully residing immigrants remains and undocumented immigrants are excluded from reforms.  Most appalling is a provision in the Senate bill, which will be used as the basis for negotiations, which prohibits undocumented immigrants from buying full-price insurance with their own money in the new Exchange insurance marketplace.  Below is a discussion of the major provisions in the bills and the impact on immigrants.

Undocumented Immigrants & the Exchange. The Senate bill contains a dangerous provision prohibiting undocumented immigrants from buying health insurance with their own money at full price in the Exchange, while the House bill does not.  The exclusion must not make it into the final bill.  This provision is completely counterproductive to the goals of health reform.  Health reform should allow opportunities for more people to pay into the health care system, not less.  It is costlier to the health care system and to tax payers to exclude people – without insurance people avoid care until it becomes more serious, and more costly.  Also, verifying the citizenship or immigration status of each person who wants to pay their own money in the Exchange would be very costly to do and to an inhuman end – to keep people who just want to keep themselves and their families healthy from buying insurance with their own money.  It is unfathomable to think that a provision of health reform would actually cause some people to lose the coverage they currently have.  Finally, creating an immigration status requirement for the purchase of private goods sets a dangerous and unacceptable precedent.

Undocumented Immigrants, Medicaid & Subsidies. Undocumented immigrants are already restricted from most public health insurance programs, including Medicaid and Family Health Plus in New York, and neither bill changes that policy.  Also, neither bill allows undocumented immigrants to be eligible for the affordability/tax credits or subsidies that would make insurance more affordable.

Lawfully Residing Immigrants & Medicaid. Tragically, neither bill restores federal Medicaid eligibility for lawful permanent residents within their first five years.   This means that the most recent, lowest income legal residents will still not have access to a critical safety net benefit that their own tax money supports.  Yet these same people will be required to buy insurance.  Importantly, as a result of a lawsuit in 2001, New York extends Medicaid and Family Health Plus coverage to all lawfully residing immigrants who meet the income guidelines regardless of how long they have been lawful residents, and must continue to do so with state-only money.

The NYIC acknowledges New York Senators Schumer and Gillibrand for cosponsoring an amendment filed by Senator Menendez giving states the option to restore Medicaid to lawfully residing immigrants within their first five years.  Although the amendment did not come to a vote before the Senate bill was passed, Senate Majority Leader Reid made a commitment to the Democratic caucus that this provision would be included in the Senate Conference Report.  We must hold him and Congress to that commitment.

Lawfully Residing Immigrants & Subsidies. Hundreds of thousands of lawfully residing immigrants in New York who currently make too much money for Medicaid or Family Health Plus, do not receive insurance through an employer, and cannot afford to buy insurance on their own are eligible in both bills for the affordability/tax credits that will make insurance more affordable.

The Politics of Reform. The Obama administration will be especially influential in this final bill negotiation process.  The President must hear from you that the exclusion of undocumented immigrants in the Exchange is unacceptable and that the five-year waiting period in Medicaid for legal immigrants must be removed.  Allowing undocumented immigrants to use their own money to buy unsubsidized insurance in the Exchange is consistent with the goal of achieving just and humane immigration reform this year, and not a bargaining point.

As we look to the Senate/House negotiations, we have these priorities:

1) Everyone, regardless of immigration status, should be able to buy insurance with their own money in the Exchange.   Adopt the House policy.

2) Lawfully residing immigrants must be treated fairly.

a. Include Senate amendment 2991 enabling states to restore Medicaid to legal immigrants in their first five years.

b. For legal immigrants who live in states that retain the five-year waiting period, make sure that subsidies for those lowest income legal immigrants are fair.

c. Allow all lawful residents, including non-immigrant visa holders to be eligible for subsidies.

3) Adopt House provisions for verification of citizenship and immigration status, which are more established, streamlined, and protective of individual rights.

4) Protect the safety net health care system so that the millions of people who remain uninsured after reform passes still have access to health care.

Contact:  Jenny Rejeske, Health Advocacy Coordinator, 212-627-2227 x223, jrejeske@thenyic.org.

For more information and talking points, please visit the website of the New York Immigration Coalition www.thenyic.org or the website of the National Immigration Law Center:  www.nilc.org.

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