Fatal drug overdoses had been climbing for years when Maryland health officials decided to target a particularly vulnerable group: Those leaving prison or jail.
They have high rates of addiction, but low rates of insurance for treatment. So the state sought federal permission to skip the usual paperwork to get them temporary Medicaid cards.
Advocates lauded the move as a novel way to prevent overdose deaths, since inmates going back into their communities are at high risk to use drugs again and die. But more than two years later, the state hasn’t used the authority.
“What a bummer about how this is playing out on the ground,” said Dan Mistak, general counsel for Community Oriented Correctional Health Services, a national advocacy group. “Anything that gets folks on Medicaid and gets a card in their hand is useful.”
That’s essentially what state health officials said in 2016 when they sought to sign up more people as they were released from incarceration. Now, however, officials say it wasn’t necessary to enroll people temporarily as they left jail or prison because it’s easy enough to sign them up directly in Medicaid, as long as they can prove eligibility.
“The Maryland Department of Health works to ensure Maryland Medicaid services are available to all those who qualify,” said Brittany Fowler, a spokeswoman for the agency.
Advocates say Maryland’s stubbornly persistent opioid epidemic makes clear the state’s efforts to expand access to treatment fall short.
There were 1,848 overdose deaths in the first nine months last year, the most recent figure available. That’s about four times the number of fatal overdoses during the same time period in 2010. Most fatalities are now linked to the powerful opioid fentantyl, often mixed with heroin without users’ knowledge.
Treatment providers say about two thirds of people who are arrested have a drug or alcohol problem — and they lose their tolerance when they are locked up, putting them at particular risk. Recent research in North Carolina found heroin users were 74 times more likely to overdose in the two weeks after leaving prison.
The federal provision state health officials had planned to use is called presumptive eligibility, widely used in other states to temporarily cover pregnant women and children until they can complete the paperwork to get fully enrolled in the government health plan for the poor.
Maryland health officials now say presumptive eligibility was meant only as a backup. And the backup hasn’t been needed because Medicaid applications now can be approved in as little as 24 hours — if applicants have all the proper paperwork.
But advocates note the rate of enrollment among those getting out of prison and jail hasn’t ticked up much. And many more people could be signed up temporarily while they gather needed documentation to qualify for the full Medicaid program — such as proper identification or work histories.
Two years ago, health officials reported about 150 people a month, about 11 percent of those leaving the state corrections system, had been enrolled in Medicaid at release. The number now averages 217 a month, just over 12 percent.
Fowler said staffing is an issue and the enrollment numbers should rise as more workers are dedicated to the process this year in two of the state’s facilities: the Baltimore City Correctional Center, where detainees are booked and await trial, and the Jessup Correctional Institute, where many serve prison terms.
Further, Fowler said, another change means that those who already had Medicaid coverage when they went to prison or jail no longer have to reapply when they leave the system. Previously the coverage was terminated.
Few inmates, however, come into the system with Medicaid. More are like Michael Washington, who said he didn’t have coverage, was never offered a chance to enroll in jail or prison, and wasn’t sure how to sign up on his own. That didn’t stop him from wanting drug treatment.
The Baltimore man estimated he’d spent 60 percent of his 40 years of life as an inmate for drug-related crimes, and said he wants to get clean, get a job and be part of his daughter’s life. To start, Washington said, he had been panhandling so he could buy the drug buprenorphine, which curtails withdrawal symptoms, on the street. He often found heroin was cheaper: $10 for one dose of “bupe” and $6 for a dose of heroin.
His stomach aching from withdrawal, Washington recently sought a legitimate prescription for bupe from a doctor who works from a van parked just outside the Baltimore jail complex.
“I’m here to get help,” he said upon entering. “I’ve overdosed a couple of times and you never know if the third time is the charm. … You grow up and hear only about the glitz, glamour and glory from the drug world, but no one ever tells you what it does to you physically and otherwise.”
Patients like Washington are familiar in the van, run for the last year by the nonprofit Behavioral Health Leadership Institute. Deborah Agus, the institute’s executive director, said she relies on grants to pay a pharmacy $111 per person per week for bupe.
The van’s doctors, mostly affiliated with Johns Hopkins Medicine, see about 24 people a week. More are likely to show up after the institute completes a video to show in the jail about the risks of overdose and the mobile services available just outside.
Agus said her program would be far more effective if the state would enroll people in Medicaid from the mobile facility, as it did in the past, or use its authority to sign more up temporarily from jail.
“It’s great they got this [presumptive eligibility] passed, but in order for it to be meaningful it needs to be implemented,” Agus said. “We haven’t seen the results of that.”
Gerard Shields, spokesman for the state Department of Public Safety and Correctional Services, said officials eventually plan to offer more treatment services to those in jail. Gov. Larry Hogan, who declared a state of emergency over the skyrocketing overdoses, recently announced a five-year, $378 million plan to build a therapeutic treatment center attached to the Baltimore jail.
Maryland was one of the first states to offer methadone treatment in jail to wean people off opioids, but the program remains limited to a small number who can prove they were already in treatment. A small pilot program in prison uses another injected drug to curb withdrawal and cravings.
State health officials say they still want to enroll those leaving in Medicaid. The jail remains a particular challenge because large numbers leave within hours or days.
Observers and advocates say that’s where presumptive eligibility really could work. Detainees could attest to their income and legal status and be approved for long enough to start drug treatment and get attention for other medical conditions, said Tricia Brooks, research professor at the Georgetown University Health Policy Institute.
She said there is no need to be rejected first for full Medicaid because of a lack of paperwork. Patients can deal with that before the temporary status ends in 60 days.
More states are looking at ways to connect those from the correctional system to treatment, said Samantha Artiga, director of the disparities policy project at the Kaiser Family Foundation.
That’s because most of those leaving prison and jail can now qualify for Medicaid under the Affordable Care Act. While the state and the federal government split the cost for most of the 1.2 million people covered by Maryland’s Medicaid program, the federal government picks up most of the tab for those added under the health care law, which includes low-income single adults such as many former inmates.
One corrections doctor in Rhode Island is trying to draw attention to successful efforts in that state to begin addiction treatment in jail or prison, then continue it on the outside. Upon release, those former detainees and inmates are signed up for Medicaid and treatment at a state-contracted facility, said Dr. Josiah Rich, a professor at Brown University’s medical school who also works in the Rhode Island corrections department.
Rich says the effort, begun in 2016, has cut overdoses by 61 percent among those recently incarcerated, and led to a 12 percent drop in the state’s overall fatal overdose rate.
“Throwing people back into society is trigger-central for relapse,” Rich said.
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Maryland lawmakers have introduced legislation to institute a similar program in the state, though its prospects are unclear. For now, the focus in Maryland remains largely on those who can put in the effort to get treatment.
Andrew Hill, 53, said he went to a social services office in Baltimore and enrolled in Medicaid after he was released from prison a couple of years ago. He’s been visiting the treatment van every week for a couple of months for a prescription as he awaits a treatment slot with his primary care physician.
He said officials in the correctional system, where he’s served time for drug-related crimes, tell inmates where they can seek services upon release. He’s sure most people don’t listen.
Hill didn’t blame prison officials for what he said was “up to the individual,” though he thought it would benefit them to help break the cycle of incarceration fueled by the drug culture.
He didn’t really blame the former inmates either. Reentering the outside world is daunting, especially with a years-long addiction.
“You have to get your mindset on the straight and narrow,” Hill said. “I’m still trying to get there.”