ihsa water polo How the Obamacare wars hurt the mentally ill
ATLANTA Every day he without his meds, Scott Patrick demons return: the urge to get high to forget that he dying of AIDS; the anxiety, paranoia, and phantom noises spurred on by his bipolar disorder and PTSD.
Patrick, a former male prostitute and recovering drug addict, was released from a Georgia jail last month without any of his medications on hand. “I could die dirty or die clean,” he said. “I want to die clean.”
So like many struggling Atlantans with nowhere else to go, Patrick sought treatment at Grady Memorial, the state’s largest safety net hospital. He carried all his worldly possessions with him: a change of clothes, a Bible, and some vitamin C drops.
The partisan war over Obamacare is now threatening the mental health services that Patrick and countless others are seeking. The president health care law cuts federal subsidies to safety net hospitals that were expected to have more paying patients under the law’s Medicaid expansion and insurance exchanges. But Republican controlled states like Georgia have refused to go along with the expansion. That turned safety net providers like Grady into unintended casualties and mental health services for Georgia most troubled residents are first on the chopping block.
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It was never meant to happen this way. States like Georgia, which has the nation sixth highest uninsured rate, were supposed to be the biggest beneficiaries of the new Medicaid dollars. But in 2012, the Supreme Court unexpectedly ruled that the federal government couldn force states to accept the expansion.
Along with22 otherstates with Republican governors or statehouses, Georgia Gov. Nathan Deal has refused to go along with the Medicaid expansion, saying the cost to the state would be untenable. Democrats counter that it a cruel political stunt, since the cost of new coverage is overwhelmingly paid for by the federal government.
So safety net hospitals like Grady are now caught in the middle: they aren getting new Medicaid funding, yet they see a cumulative $18 billion reduction in federal payments by 2020.
Grady alone expects to lose $45 million in annual federal subsidies by 2018 because of Obamacare. At the same time, it losing the opportunity to gain $25 million a year in new revenue because of Georgia decision to opt out of the Medicaid expansion, which the hospital says would cover 30,000 of its patients. Grady is also facing immediate reductions from the county government, which helps foot the bill for its uncompensated care. Fulton County has proposed to reduce its funding to Grady from $50 to $25 million, and it expected to come to a final decision on Friday.
As the fiscal pressures mount, mental health services for low income residents are especially vulnerable to cutbacks. On an annual basis, “the mental health department leaves us $8 million in the hole,” says John Haupert, Grady Hospital CEO. “As a business decision, that lands it on the list.”
Scott Patrick on his way to the Basilica of the Sacred Heart of Jesus in Atlanta where Reverand Marino Gonzalez the Director of Parish Outreach, looks after him and helps him get food. All standard issue for released convicts in the area, marking him as a man who had done time.
He then headed to an overnight shelter, avoiding the part of town where everyone knew him as “Peanut” the slight guy with light brown hair who was often strung out on drugs and always slept in Piedmont Park.
But there was one thing Patrick missed from his year behind bars: the medication he was given for mental illness. “I want to feel like I did when I was in jail a level mood,” said Patrick, who was locked up most recently for entering a car with the intention of stealing it.
When he showed up at Grady in late December, it was the first time Patrick had ever sought mental health care on his own. He now one of thousands of new patients to flood the hospital just as major budget cuts are looming.
Mental health visits to Grady emergency room spiked 20% in 2013 on top of a 20% rise in 2012, Haupert says. If a hospital or other major provider closes in the state, chances are that Grady will get at least some of the overflow.
Georgia prison system is still the state single biggest provider of mental health care, but Grady is number two, logging more than 68,000 visits in 2013. The police drop off so many mental health patients there every day, “you almost think they were another ambulance service,” said hospital spokesperson Denise Simpson.
Patients pack the emergency room at all hours, some of their ailments visible, others not: the short elderly woman talking and gesturing angrily to herself for hours; the young man weeping uncontrollably,
unable to walk unassisted from the triage area to a chair. “They gonna call you,” a hospital attendant told him as he curled into a ball. “You gonna have to do the best you can.”
Some will wait as long as 36 hours to get treatment, like Eric, 48, who suffered from uncontrollable panic attacks after a stranger threatened to kill him, holding a gun to his head while shouting racial epithets. In the hallways, psychiatric patients may wait days to be transferred to a bed, lying on gurneys without treatment. Security guards make the rounds to usher out the homeless just looking for somewhere to wait out the cold. Nearly everyone in the room is African American.
Donn Smith, makes his way up a hill to the CNN Center in Atlanta to get a coffee. and a Vietnamese women. He is wheelchair bound from Polio. He says if there are budget cuts “There will be more suicides. People need their medications to keep them from hurting themselves or other people.”
Like other hospitals, Grady is trying to reduce the burden on its overloaded ER and cut back on costly psychiatric beds. Haupert says one likely target for cutbacks is inpatient care, which has been falling out of favor for decades as hospitals have scaled back their old fashioned psych wards. In Georgia, the state run mental hospitals were so abusive and poorly run that the US Attorney filed suit, forcing the state to close them after a 2010 settlement.
Grady itself hasn been immune to serious management problems. The hospital nearly closed in 2007, when it was facing a $55 million budget gap and reports of subpar care. It since turned itself around and returned to solvency after being privatized, even turning a $27 million profit in 2012 and raising $680 million in operating revenue last year. But about 32% of the patients Grady treats are still uninsured, leaving the hospital heavily dependent on outside funding.
Grady currently receives $90 million a year from the federal government for serving a high number of low income, uninsured, and Medicaid patients a subsidy that Obamacare will eventually cut in half. In addition to $50 million from Fulton County, the hospital got $11 million from DeKalb County, which recently threatened to cut its funding as well. Other safety net providers have faced an even bigger crunch: budget shortfalls forced three of Georgia public hospitals to close last year, forcing patients to travel long distances to get medical care.
Georgia providers aren alone: public hospitals have also closed in North Carolina and Virginia, both of which declined the Medicaid expansion, and cutbacks are on the horizon for others. “Our concern especially in the absence of a Medicaid expansion will be more pressure on psychiatric beds,” says Joseph Parks, medical director of the Mental Health Department in Missouri, another GOP controlled state refusing to expand the program. Elsewhere, hospitals warn that cancer treatment and infant care are at risk of being scaled back, and some are already laying off employees.
In Atlanta, the looming cuts are particularly worrying to advocates for the city poorest. They stress that access to mental health care at Grady is critical to keeping troubled residents off the streets and out of prison. “If you trying to end a person homelessness, and you don address their mental illness, you lose the battle,” said Protip Biswas of United Way Atlanta.
Homeless men line up in the courtyard of The Shepherd’s Inn men’s shelter in Atlanta, Georgia, waiting to get assigned a bed for the night.
There is already a cautionary tale an hour north of the city, in Rome, Georgia. After the state shuttered its mental hospital there, community based services were supposed to fill in the gap. But the number of inmates with mental health issues at the local Floyd County jail has skyrocketed from 20 to 115 in the past year, which the sheriff attributes to the rocky transition.
Back in Atlanta, Patrick is terrified he’ll backslide without receiving proper treatment. He says he feels hopeless, anxious, and sometimes hears voices without his meds feelings that have previously led him to commit crimes and abuse crack, cocaine, and meth.
During one bout of paranoia, he violently carjacked a man. “I busted his head open,” he said. “I thought he was out to get me.”