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Mentally Ill, Chemically Addicted - And Stuck In Jail


When Prisoners Come Home, Gotham Gazette's Social Services topic page update for January, painted a disturbing picture of how much support released prison and jail inmates need to have a chance at productive lives on the outside, and how little New York City and New York State tend to give them.

Now, several legal advocacy groups, including the New York-based Urban Justice Center and the Legal Aid Society of New York, are pointing out how the state fails one of its most vulnerable and fragile groups of newly released prisoners - those with both serious mental illness and a substance abuse problem. On October 21, the groups filed a federal lawsuit on behalf of the hundreds of seriously mentally ill New York City parolees who their advocates say are unfairly denied community-based mental health and substance abuse services each year, often remaining in jail for many additional months for no more reason than a lack of community treatment slots that they can be referred to.

The suit charges that the state is illegally discriminating against these "dual-diagnosis" parolees -- who are mentally ill as well as having substance abuse problems -- because there are many more residential treatment programs available for parolees with substance abuse problems only; and these parolees are typically released days, not many months, after state officials agree they need treatment and not more jail time.

Dually-diagnosed parolees are generally only eligible for so-called MICA (Mentally Ill, Chemically Addicted) programs, of which there are far fewer in the city. Empty beds in these programs are a rarity. One of the key aims of the lawsuit is to force the state to increase the number of, and parolees' access to, these programs.

Currently, the filers of the suit say, a typical scenario involves a mentally ill parolee returned to jail - and then warehoused there -- for minor parole violations, such as missing appointments with their parole officers. The complaint claims that these violations are typically related to, if not directly caused by, the parolees' mental illnesses and co-existing substance-abuse problems. Even when, as frequently happens, their state parole officials decide that release and treatment for these parolees' illnesses would be more appropriate and effective, as well as better serving the interests of justice, than additional jail time, the re-imprisoned parolees tend to languish in jail for months waiting, often in vain, for one of the handful of state-funded treatment beds in the community that they might qualify for.

"I've met people who've had to wait a year to get out of jail again, even after their parole officers have determined that they need community treatment, not more jail. Six to nine months' wait is typical," said Heather Barr, an attorney with the Urban Justice Center. "And often in the end they don't even get the community beds they were waiting for - they're just released - eventually -- because no beds have come open. And then they end up back in jail for more parole violations that probably would have been avoidable if they'd gotten some help out there.

"And I've seen people who actually have to be kicked out of jail in the end, because they might be getting some kind of treatment in there, maybe psychiatric medications and some observation, which is better than nothing. Have you ever been to Rikers Island? It's a horrible, horrible place, but people have so few options, and such bad options, that even a cell in Rikers seems like something. They know they need continuing and/or better treatment and support to function outside in society, and there just is no treatment for them out there. There's no bed; there's no hope of a bed."

Barr said that there are probably a couple of hundred Mentally Ill Chemically Addicted beds in the city, but almost all are full at any given time. And parolees are discriminated against for admission, either deliberately or by default, she said.

"For instance, on one day this past September, there were 18 MICA beds open," Barr said. "Now, twelve of those beds were at places that won't accept parolees - they demand on-site interviews for admission and won't allow telephone interviews, and people in jail can't get to the places to be interviewed. That leaves six beds total for all the homeless people with mental illness and substance abuse problems, people with addiction problems just discharged from the psych wards, and so on, in New York City. And there's a big focus on providing treatment beds for the homeless, which is great, except parolees usually can't qualify on those grounds -- the rules say that if you weren't homeless before going to jail, you're not considered homeless for treatment-eligibility purposes -- even though many if not most of them have no place to live anymore when they get out of jail, which is pretty typical."

As for how these extra beds are to be paid for, Barr notes that it costs $70,000 a year to keep someone locked up at Rikers Island, but only about $12,000 to provide them with a year of residential treatment at a Mentally Ill Chemically Addicted program.

She says she's optimistic the coalition will win the suit - eventually. "Some of these cases can drag on for years," she said. "But it's so clear, in this case, that the state is denying people with specific disabilities the same care as others, like people with just substance-abuse problems, that we pretty much have to win. That's illegal. It violates the Americans with Disabilities Act, among other things."

The full text of the complaint (in PDF format)is available on the Web site of the Washington, D.C.-based Bazelon Center for Mental Health Law, another of the groups that filed the suit against Governor George Pataki and other New York officials.

The complaint is being brought specifically on behalf of two incarcerated parolees, William G. and Walter W., and the class that they represent of mentally ill parolees in New York City jails waiting for community treatment. The parole officers of both the two recommended MICA treatment for their serious, long-term mental illnesses (schizophrenia and major depression, respectively) with accompanying substance abuse problems. But the two have remained at Rikers respectively for seven and nine months to date, while they wait for the elusive MICA beds to open up. For Walter W., indeed, the wait could well be too long - the state's parole hearing officer in charge of Walter's case, while he agreed back in May that such treatment is the most appropriate option for Walter, has also said that if no such bed opens up, Walter will be sentenced instead to time in a state prison.

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF.

 

 

 

 

 

 

 

 

 

 

 

 

 

A Push For A National Health Service?


Since this health column last reported on the plight of the millions of uninsured and under-insured people in New York and across America, the situation has, unfortunately, gotten worse.

Health care costs are soaring once again; insurance premiums are rising at double-digit rates; the economy, despite all the current administration's talk of a recovery, seemingly remains stalled in the doldrums; states are in fiscal crisis; and continuing layoffs have yanked from millions more Americans the employer-provided health insurance they once took for granted. A September 30 report from the U.S. Census Bureau revealed that, between 2001 and 2002, the number of uninsured Americans rose sharply (by 2.4 million) for the third year in a row. That means 43.6 million Americans, or more than 15 percent of the population, now lack even basic health coverage. Millions more are underinsured. In New York State, the percentage of uninsured is higher than the national average and the total well over three million people, most of them in New York City. According to the Institute of Medicine, already 18,000 Americans die every year because of inadequate insurance; as more lose their coverage, the numbers will rise.

But advocates of a universal national health system – at least, the optimists among them -- see promise amidst the general catastrophe. They are allowing themselves to hope that the erosion of health coverage among Americans who until recently considered themselves comfortably middle-class – and thought the lack of health insurance the problem mostly of a limited subclass of the impoverished, the disadvantaged, and the marginal -- will have real political repercussions in the forthcoming presidential elections and in the halls of Congress.

Voices ranging from liberal politicians to middle-class consumer groups to physicians can now be heard saying the same thing: that after decades of misfires – most famously Bill Clinton's messy failure ten years ago to achieve his campaign promise of universal health care – America, the last holdout, may finally join all the other countries of the industrialized world in adopting some form of national health insurance.

An NBC News/Wall Street Journal poll done in July did indeed find that health care costs ranked as Americans' top economic concern, cited by 24 percent of respondents. By contrast, only 16 percent cited high taxes as their main concern. The incumbent and the other would-be candidates in the next presidential election clearly feel pressure to respond. President George W. Bush and most of the major Democratic presidential contenders have each proposed health care reforms, ranging from Bush's plan for tax credits to help the uninsured buy insurance to the Democrats' various proposals to expand health coverage by rolling back Bush's tax cuts.

But all of these plans retain the basic forms of our current health insurance system -- for-profit hospitals and HMOs; private insurance companies that reap high profits and also spend considerable amounts (subsidized by the premiums of the insured) for marketing, overhead, executive salaries, and profit-sharing with investors; and great influence wielded by the hugely powerful and profitable pharmaceutical industry.

But a group of doctors has come up with a far more sweeping and radical plan, one which calls for a true one-payer, nationalized health service that would cover everybody, and that would (theoretically at least) redirect our vast health care expenditures from corporate coffers and back into health care services.

According to one of the proposal's authors, Chicago physician Dr. Quentin Young, American doctors have traditionally been conservatives when it comes to health care reforms, and they almost reflexively tend to oppose anything that smacks of government-administered health insurance. "But now even doctors are realizing that there's something worse than the government, and that's corporations," Dr. Young said. "Even people who have insurance, so-called 'good' insurance, are now finding their charges and coverage being questioned, because the insurance companies have discovered that simply not paying out claims is the best way to maximize their profits. Doctors can't provide their patients with the care they know is needed, and they're being harassed to death to justify what they do provide."

The plan was developed by Physicians for a National Health Service (PNHP), an organization of 11,000 doctors, many of them prominent. Two former Surgeons General and a former editor of the New England Journal of Medicine lead the group, which went public with its so-called "Proposal of the Physicians' Working Group for Single-Payer National Health Insurance" at a press conference in New York in August. The next day, the proposal appeared in the Journal of the American Medical Association (JAMA 8/13/03), which some in the group see as a victory in and of itself, although a spokesman for the (generally conservative) American Medical Association said that the AMA itself still opposes a single-payer health care system. (The AMA has a long history of battling government-administered health insurance; for example, it opposed the creation of Medicaid in 1965.)

The plan, which has now been endorsed by more than 10,000 physicians, calls for a government-financed national health insurance system that would cover every American for all necessary medical care from infancy to death. (In essence, it would be like an improved, expanded version of Medicare, but available to all, not just the elderly and disabled.) Prescription drugs, mental health care, and long-term care would be covered. The government would administer the plan, but most doctors and hospitals would remain private, and patients would be free to choose any physician or hospital they wished. Health professionals would decide what services should be covered, based on the latest medical evidence. Private insurance companies would still exist, but could only provide insurance for services such as elective surgeries that would not be covered by the government plan.

The full text of the proposal, which contains further details and cost-savings analyses, can be read online here (In PDF format).

The proposal criticizes the incremental, piecemeal health reform plans offered by Bush and the main Democratic presidential hopefuls.

"Proposals that call for tax credits or that push seniors into private HMOs all retain the role of private insurers. They are doomed to failure, because they perpetuate administrative waste, and make universal coverage unaffordable," said Dr. Oliver Fein, chairman of the New York Metro Chapter of PNHP, who presented the proposal at the New York press conference.

The plan's authors claim that single-payer national health insurance, far from increasing health care costs, would save at least $200 billion each year by eliminating the high overhead, marketing, profits, and administrative costs that private, for-profit insurers divert money to (rather than spending it on actual health care services).

"We spend $1.6 trillion on health care each year, which is one-seventh of our Gross National Product. That would be a very high cost for an excellent health care system; and what we have is a rather poor one," Dr. Young said. "Compared to countries that spend far less than we do, America scores very poorly on the standard, accepted indices of public health."

But is America, the sole holdout among industrialized countries in terms of adopting a national health plan, ready for such sweeping change?

"Well, I'm old enough to remember the civil rights movement, and anybody who predicted that before it happened would have been laughed at as some utopian dreamer," said Young. "I would say that the conditions for mass social change are ripening. There's a vast discontent out there with the current system, whose weaknesses are being starkly exposed right now. It will take a monumental effort, and a change of administration, for this to happen, but I think in the end it will."

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

World Trade Center Health Registry


The city's health department has announced plans for what could become the largest public-health investigation ever: a comprehensive survey to follow the health of those people most directly exposed to 9/11's World Trade Center collapse and the subsequent clean-up efforts.

The launching of the World Trade Center Health Registry was announced at a September 5 press conference by the city's Health and Mental Hygiene Commissioner, Thomas R. Frieden, MD, and Dr. Henry Falk, Associate Administrator for the Agency for Toxic Substances and Disease Registry and the director of the federal Centers for Disease Control's National Center for Environmental Health.

"The effects of 9/11 are still being felt today by all New Yorkers, and all Americans. Hundreds of thousands of people from all walks of life were in the vicinity of the twin towers when they collapsed, and were exposed to a combination of smoke, dust, and debris.  We need to study the health of these people in order to understand the possible health consequences related to 9/11," said Dr. Frieden. "If you were there on 9/11, you are strongly encouraged to sign up for the WTC Health Registry."

Dr. Falk said, "The World Trade Center Health Registry will do what no other health survey is doing. It will record and measure the health impact of 9/11 in the broadest possible terms.  The Registry is a tool for giving us health data that could guide how we respond to this kind of disaster for generations to come.  The more people enroll - even if they feel perfectly healthy - the better our chances will be of understanding any health effects from this tragic event."

People in any one or more of the following categories are eligible to enroll in the registry, regardless of whether they have experienced any health problems:  

· People who were in a building, on the street, or on the subway south of Chambers Street on 9/11/01;
· Workers involved in the rescue attempts, recovery, or clean-up work at the World Trade Center site, and/or the associated recovery operations on Staten Island, at any time between 9/11/01 and 6/30/02;
· Students and staff at schools (pre-K to 12) or daycare centers south of Canal Street on 9/11/01; and
· People living south of Canal Street on 9/11/01.

If enough people enroll, city and federal health officials said, the registry could result in an investigation as much as five times the size of the one following the 1979 Three-Mile Island nuclear accident in Pennsylvania. That study tracked 38,000 people. Falk noted that the report based on the Three-Mile Island registry, which was issued last year and stated that people who lived near the nuclear plant showed no significant increase in cancer deaths, probably served to calm a population nervous about the unknown long-term health effects of the accident.

"I plan to enroll in the World Trade Center Health Registry, and I encourage all Battery Park City residents and workers who were here on 9/11 to step forward and enroll too," said Timothy S. Carey, CEO and president of the Battery Park City Authority, who was also present at the press conference.

To advertise the registry, which is being funded with $20 million in federal funds, the city health department says it will put posters in subways and commuter trains that read, "I was there September 11th." It will also use billboards, direct-mail solicitations, Internet ads, and brochures to urge people to step forward and enroll.

Officials stressed that all medical information collected from individuals will be kept strictly private and confidential, and that no medical examinations or tests will be required for participation.  People can drop out of the registry at any time.

Those who enroll in the registry will be asked to answer a 30-minute telephone survey of where they were on 9/11, how long they were in areas afflicted by smoke and fumes, and whether they have had any health problems since.  Registrants will be periodically contacted to report any health changes.  This information will then be compared with that of the general population, in order to identify any health problems possibly linked to 9/11.  Ultimately, findings drawn from the health registry should be able to allow researchers to observe patterns that may be invisible to individual physicians.

The announcement of the survey follows closely on recent revelations that the Environmental Protection Agency gave New Yorkers false assurances about air quality in the days after the terrorist attack.  But city health officials say that the registry was not launched in response to the recent accusations. Plans for the registry were first announced last year. The health registry's goal is to follow up with hundreds of thousands of people who were directly exposed to the aftermath of the twin towers' collapse, which produced choking clouds of dust, asbestos, smoke, and fire. It will re-contact registrants periodically over the next 20 years to track any changes in their physical or mental health. People exposed to the WTC aftermath have already reported symptoms of asthma, persistent cough, burning eyes, and other ailments presumably caused by the airborne contaminants that so thickly pervaded the downtown area in the days following 9/11/2001.

Officials said the registry will issue quarterly reports to inform the public about what it learns from the project. The reports will be posted online  www.wtcregistry.org. The first report is expected this fall.

The registry is a jointly funded effort of the New York City Department of Health and Mental Hygiene, the Agency for Toxic Substances and Disease Registry, and the Federal Emergency Management Agency (FEMA).  RTI International, a nonprofit research firm, will conduct the interviews. 

To find out more about the WTC Health Registry and the enrollment process, you can visit www.wtcregistry.org or call 311 or toll-free to 1-866-NYC-WTCR (1-866-692-9827).

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF.



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