I have to admit, at first I was a little intimidated by John Kelly’s article in the April issue of Youth Today (subscription only). For starters, it’s about Medicaid, a knotty subject I’ve never been able to untangle. Kelly is a clear writer, though, and I know from chatting with him that he’s got a sharp eye on important juvenile justice issues, so I waded in.
The article highlights the Bernalillo County Juvenile Detention Center in New Mexico, which has tapped state and matching federal Medicaid funds to help establish and support a mental health clinic on campus. The clinic’s comprehensive services, according to juvenile justice reform expert Bart Lubow, are second to none. But wait a second: I thought juvenile offenders aren’t eligible for Medicaid.
That’s the widespread misperception–shared, Kelly reports, by officials in charge of juvenile justice or Medicaid administration in thirty-four states–that the article effectively dispels. Why do so many people share this misperception? I called Kelly on the phone yesterday afternoon to ask him for myself, and also to talk about the issues his smart piece raises. “The initial reading of the clause in the Medicaid rules would lead to that conclusion,” he told me. “It would be safe to assume that those kids would not be eligible. It’s funny: in some states people were surprised that they were eligible, but other people, like people I talked to in Pennsylvania, they’ve been doing this for twenty years. The reality is, you can pull it off.”
What it comes down to, Kelly explained, is the difference between an offender who is in detention after he has been adjudicated (serving a sentence or awaiting placement elsewhere) and a youth being detained before adjudication. The kids who are being treated in the Bernanillo clinic haven’t yet had their court hearing, so they don’t qualify as “inmates.” Bernalillo director Tom Swisstack, Kelly reported, “made the case to the state Medicaid office that the federal definition of inmates excludes anyone ‘in a public institution for a temporary period pending other arrangements appropriate to his needs.'” The Medical Assistance Division of New Mexico’s Human Services Department eventually agreed, stipulating that the youths in Swisstack’s care would be eligible for Medicaid for 60 days. (This is a state-by-state determination; in Pennsylvania, for example, the threshold is closer to one month.)
With the funding Swisstack secured, the majority of which came from tapping the “Medicaid pipeline,” he was able to construct two buildings on site, hire behavioral health therapists and get some of his staff trained to address specialized mental health needs. The result, as of 2001, is a fully functioning, fully funded mental health program that is helping to lower recidivism rates among Bernalillo’s offenders–the rate dropped from 88 percent to 33 percent–and reducing residential care costs. And it’s helping to streamline the adjudication process, too: by the time an offender from Bernalillo arrives in court, he or she is on a treatment regimen and the judge is presented with a set of recommendations developed by a caseworker and mental health professionals who understand the teen’s particular needs.
The trick to getting a program like this up and running, Kelly said, is to demonstrate cost savings not only to the state but also to the healthcare providers. “It seemed like a big deal for Bernalillo to get Medicaid funders on their side, to say, ‘We promise you this will save you money. We will bill you less.’ That’s a good idea, it seems to me. To say to Aetna or whoever, You guys are overspending.”
How does it save money, precisely? What was Bernalillo’s pitch? Basically, Kelly said, it goes like this: “You’ve got this kid who gets into detention, and he’s got a behavioral disorder. He’s destined for a residential treatment center, where they’re going to diagnose him, provide treatment, and he’ll stay for thirty days, maybe longer. Then he’ll get sent out with prescriptions he may or may not be able to pay for. And if he stops taking his meds, he may very well wind up back at the beginning. So you’re paying for a strategy that [Bernalillo is] showing has not had success. This is a system that quickly provides a treatment option that more often than not will be outpatient. And [Bernalillo can] do it in a way that will allow the kid to afford medication, and be more likely to stay out of jail.”
Kelly concedes that the program further blurs an already blurry line between the role of the juvenile justice system and that of mental health providers. Ideally, he argues, “you want these systems separate, but the reality is they’re intertwined right now.” At Bernalillo, “There is a concerted effort to say, ‘Let’s get the kid as far out of the juvenile justice system as possible when he’s in treatment…. They have drawn a clear line between line staff and clinic staff, and there is a liaison between them, so it’s as austere as possible.”
The upshot, complications and challenges notwithstanding, is a more inclusive approach to dealing with troubled teens. “If you start from the premise that juvenile justice tends to be underfunded, and that this is a stream of money that is to some extent is available everywhere, then it’s at least worth looking into. That’s all we were trying to say.”
That, alone, is a lot.