Voices from the Front Lines: MUM’s Linda Ketcham

Nothing to worry about here.

That might be the conclusion of attendees at the June 6 meeting about the county’s jail diversion programs. Lynn Green, director of Dane County’s Department of Health and Human Services, and her staff offered a slide presentation that seemed to depict a seamless mental health system with many opportunities for services.

Yet, the providers of those services know the reality for people who need help is often quite different. The phrase “falling through the cracks” is commonly heard. This post is the first of a series of efforts to identify gaps in the system by talking with people who deal with them every day.

Linda Ketcham of Madison Urban Ministry (MUM) has been on the front lines for many years.  She directs an agency that aims to reduce the recidivism rates of those leaving prison and jail. MUM’s offerings might seem like simple common sense: case management, job readiness, housing assistance, and peer support programs.  Their success, however, is highly unusual.  The agency’s clients have a recidivism rate of less than 10 %, compared with a statewide rate of 67%.

“We need ‘real’ pre-release programs in the jail,” said Ketcham. By “real” she means they must be funded adequately and carefully designed. Simply opening up jail space to volunteer efforts can give the illusion of help, although it might not exist. MUM has already demonstrated the effectiveness of the kind of programs that could give jail inmates a chance at a successful life in the community.

Approximately one-third of the inmates in Dane County jail are on psychotropic medications. Continued access to that medication can be the determining factor in terms of a person’s ability to maintain emotional stability and take further steps towards recovery. Upon release, however, each of them receives medication that will last only five days.

Journey Mental Health Center offers appointments on a first-come basis twice a week. Ketcham said that the “window of availability” is short and people are turned away.  She wonders if Journey collects data on the number of those who arrive and are not seen.  In addition, a recently released inmate might not be stable enough to plan a trip to the center and wait for an appointment.

Badger Care offers other obstacles. There are reports of waits of up to five weeks for an appointment with a psychiatrist through one of its HMOs. Director Green told the county board supervisors that complaints about waits for appointments are not the responsibility of her department. No agency does accept responsibility, although the wait times would appear to violate state and federal parity requirements.

Lack of affordable housing worsens many community problems said Ketcham. “The idea was that people would move from a shelter to transitional housing to permanent housing. But there is a log jam, so they get stuck in place.” If they are stuck in a shelter or on the street, people with mental illness face particularly acute challenges. They need predictability and a sense of safety in order to develop the strengths that will lead to any version of recovery.

The opioid epidemic likely will aggravate the existing problems with the mental health and substance abuse treatment system. “We have been treading water for a number of years,” said Ketcham, “but unless capacity for treatment is expanded more people will cycle in and out of jail and prison.”

What’s the solution? More money would help. But, so would some honest discussion about the budget for the Dane County Department of Health and Human Services (HHS) .

Ketcham was one of the advocates who pressured County Executive Parisi for more transparency about the annual transfer of money from HHS to the General Fund. In 2015, the county board of supervisors approved the transfer of $6.2 million. Since 2011, the cumulative figure is $25 million. Click here to read an article about the transfer.

Other budgeting practices can also be misleading to the general public, she said.  For example, many of the program allocations/expenditures in the HHS budget are not funded with taxpayer dollars.  Therefore, a total HHS budget figure gives an inaccurate picture of the contributions of county funds to health and human services programs.   Actually, on a percentage basis, those funds have declined.

Advocates are developing a campaign to educate the public about the Health and Human Services budget and to increase the contribution of county funds.  Check back for updates.



California Reforms Drug Sentencing Laws and Invests Savings in Mental Health and Substance Abuse Efforts

California has come up with a novel answer to the familiar question: “How are you going to pay for it?”

Click here to read an article from the LA Times “Prop 47 Got Thousands out of Prison.  Now $103 Million in Savings Will Go to Keeping Them Out.”

The savings came from a ballot initiative that downgraded six drug and theft crimes to misdemeanors and helped save costs of incarceration.   Twenty million dollars will go to Los Angeles County to expand housing for substance abuse treatment and social services for inmates with mental health problems.  The city of Los Angeles will receive nearly $12 million for a drug-intervention initiative and a program to help inmates find jobs.

According to grant application guidelines, government agencies will receive the grant awards, but more than 50% of the funds must go to the community-based organizations they contract with for mental health, drug abuse and other social services.  State officials expect to distribute $103 million over the next three years.











Wisconsin’s Medicaid Waiver Can Be Stopped

Wisconsin earned national headlines when state officials announced plans to request a waiver from the federal government allowing it to restrict access to Medicaid benefits in new and devilish ways.

Those officials want Wisconsin to become the first state in the country to require applicants who are childless adults to submit to a drug test and undergo treatment if results are positive.  The request would also add time limits on coverage and require co-pays and work requirements.

The severity of the proposals galvanized local advocates.  Newspaper articles throughout the state pointed out that the waiver would result in loss of access to health care for many of the state’s most vulnerable citizens.

More than 1,000 comments were received by the state’s Medicaid director during the 30-day comment period required by the federal government.   The Department of Health Services, which had planned to submit the waiver on May 26, announced a delay in order to review them.  The legislature’s Joint Finance Committee passed a resolution stipulating that the waiver could not be implemented without its approval.

The federal government offers other methods of challenging the waiver request.  The application must show that comments have been reviewed and concerns acknowledged in the request.   After the submission is accepted as complete, the federal government requires a 30-day comment period during which advocates can register opposition.

They have many sources of information from which to draw.  One of the most comprehensive is a comment letter from Mike Bare of Milwaukee’s Public Policy Institute.  He makes points rarely included in the most common critiques.  Click here to read the full letter.

Bare wrote that such waivers by law are to be “demonstrations of innovative ways to expand eligibility and Medicaid services to improve access to care and reduce costs.”  Officials claim their first objective is  “ensuring that every Wisconsin resident has access to affordable health insurance to reduce the state’s uninsured rate.” Instead, writes Bare, the health care system has large affordability gaps and the waiver would make them worse.

The second stated objective is creating “a medical assistance program that is sustainable so a health care safety net is available to those who need it most.”  Bare points out that  charging fees and premiums to low-income participants reduces enrollment.  In addition, Wisconsin is requesting permission to disenroll a participant for non-payment of those premiums.  It would be the only state to charge a premium to enrollees below 100% of the poverty line and disenroll them if they are unable to pay.

The proposal would impose a 48 month time limit on benefits if the individual is working less than 80 hours a month and is not participating in job training.  Full-time students and people who have been determined to have a disability or a mental illness would be exempt.

Bare questions the use of “job training” and “employment training” interchangeably and  points out that neither term is defined.   He argues that the exemptions from the work requirement should be expanded to include individuals with two or more chronic conditions and those who are homeless.  Bare also makes the point that access to health care enhances the capability of an individual to find work and  poor health impedes that effort.

The most notorious aspect of the waiver is the request that applicants be screened by questions about illegal drug use and tested if deemed necessary.  Refusing or failing the test and then rejecting treatment would mean the applicants go at least six months without Medicaid coverage.

That request has been challenged on many grounds.  It would unfairly target minorities, identify few people with drug abuse problems, and cause further and unnecessary stress to people who are struggling  to get by, according to a story in the Boston Globe.   Click here to read the full article.

Wisconsin Assembly member Jimmy Anderson pointed out that states that had tested recipients of other welfare benefits programs found only 200 positives out of the thousands of people who received benefits.  He wrote that the effort likely would be challenged as unconstitutional because people have a “right to be secure in their persons against unnecessary searches and seizures.”   Click here to read his op ed.

For a more academic analysis of these problems, read Proposed Medicaid Section 1115 Waivers in Maine and Wisconsin by Kaiser Health Network.  KHN cites Wisconsin’s own figures that project a decline in the number of those covered.   “Wisconsin projects that enrollment will decrease from 150,050 beneficiaries in CY 2016 to 146,407 in CY 2018, while costs will increase from $825 million in CY 2016 to over $1 billion in CY 2018.”

UPDATE:  Click here to read an article on 6/8 about Walker’s submission of the waiver.  Drug testing requirements were modified slightly.

UPDATE:  Click here to read a more comprehensive analysis of changes Walker made as a result of submitted comments.

UPDATE:  Click here to read the summary of comments and responses DHS posted on its website.  As of receipt of the application, the federal government has 15 days to determine if it is complete and to notify the state government if it is not.  A 30-day comment period begins upon a ruling that the application is complete.

UPDATE:  Click here to read an AP story reporting that less than 10 of the comments submitted supported the waiver.