Pew Charitable Trusts

Texas prison psychiatrist Pradan Nathan recalls an unsettling face-to-face session with a dissatisfied patient about a dozen years ago at a maximum security prison in East Texas. The large man, a member of a notorious prison gang, insisted Nathan prescribe him a particular medication. Nathan said he didn’t need it.

“I’m going to stab you to death the next time you come in here,” the prisoner growled.

Nathan feels a lot safer these days. He sees up to 16 patients a day from a suburban Houston office here, using an audio console, a camera and a monitor to treat inmates at two state prisons — including one with a death row — at least 30 miles from where he sits. He’s still threatened occasionally, but now it’s from a comforting distance. Needless to say, he’s a big fan of telemedicine.

He’s not the only one. Most states have turned to telemedicine to some extent for treating prisoners — often in remote areas, where many prisons are located — because it allows doctors to examine them from a safe distance. It enables corrections officers keep potentially dangerous inmates behind bars for treatment rather than bearing the cost and security risk of transporting them to hospitals. And because more doctors are willing to participate, it makes health care more available for inmates.

Though some prisons used telemedicine as early as the 1980s, its use has dramatically increased with the arrival of vastly improved technology, electronic medical records, and pressure to control ever rising medical costs.

“Telemedicine is perfectly designed for prisons,” said Marc Stern, a former assistant secretary for health services for the Washington State Department of Corrections who now consults with corrections systems on telemedicine.

How much telemedicine saves states is hard to tell because it’s difficult to calculate the costs of transportation and extra security if prisoners have to be sent outside prison walls for medical care.

But Owen Murray, vice president of correctional managed care for the University of Texas Medical Branch (UTMB), which handles health care for approximately 80 percent of the state’s prison population, is convinced telemedicine contributes to Texas’s relatively low per-capita spending on prisoner health.

Texas has the nation’s largest prison population, with about 153,000 inmates, and, according to a Pew Charitable Trusts report, spent $3,805 per prisoner on medical care in 2011, compared to a national average $6,047. (Pew also funds Stateline.)

And few states use telemedicine as much as Texas. UTMB’s prisoner health operation conducts 127,000 telemedicine visits a year with inmates in the 83 Texas correctional facilities it tends to. About three-quarters of the visits are for mental health or primary care. (All behavioral health care is handled via telemedicine, as is about 20 percent of primary care appointments, and between 5 and 10 percent of specialist visits.)

Texas lawmakers support telemedicine in prisons, Murray said, even though the financial savings are hard to pinpoint. In addition to adding to public safety, he said, telemedicine speeds inmates’ care, which in turn helps improve their health. It also helps apply the same standard of care over a wide geographic expanse.

Despite its growth, telemedicine faces the same hurdle to widespread use in prisons as it does in the general population: All states still require that doctors treating a patient in a particular state be licensed in that state, including those practicing digitally from elsewhere.

Advocates for prisoners have mixed views of the use of telemedicine in corrections. Bradley Brockman, director of the nonprofit Center for Prisoner Health and Human Rights, called it “a godsend and a real gift because prisoners are getting care from providers or specialists that they would have far less chance of getting otherwise.”

But David Fathi, director of the American Civil Liberties Union’s National Prison Project, said that while telemedicine can improve health access, too often it is used to cover over inadequate medical staffing in prisons. “Because telemedicine is less expensive, there is a tendency to use it excessively and inappropriately,” Fathi said. “It is used not as a supplement for on-site staff but as a substitute for on-site staff.”

Telemedicine in Texas Prisons

Florida was the first to experiment with telemedicine in prison, introducing it in state prisons in the late 1980s. But the technology was primitive.

When Texas started using it in prisons in the early 1990s, for example, the audiovisual equipment and slow frame speeds produced poor visuals that doctors found insufficient for diagnosis and treatment. Ear, nose and throat doctors would say, “I can’t see anything; just send the patient to the hospital,” Murray recalled.

Young doctors in the correctional system, however, saw its potential, Murray said. And since then, the equipment has improved dramatically and its price has come down.

A standard telemedicine unit — including a small audio console, a camera that can zoom in and out, and a monitor — costs less than $2,000, Murray said. The UTMB prison health operation has about 200 units, about three-quarters of which have a stethoscope and an otoscope for looking inside ears, and can transmit images and readings. That capability adds about $8,000 to a unit’s price.

During telemedicine exams, a nurse or aide is often on hand at the prisoner’s end. Sometimes there is a primary care doctor who can confer with sub-specialists and other doctors working from Galveston, site of a regional prison hospital.

Because Texas prisons have electronic medical records, doctors are able to see a patient’s record on one side of the screen and the patient on the other.

A few doors down from Murray’s UTMB office in Conroe, which is about 30 miles north of Houston, is Michelle Munch, a pharmacist. She confers with as many as 30 patients a day in prisons across the state about their medication. If they are suffering any side effects, she can modify their prescriptions.

“I can see a patient in Huntsville and then in a matter of minutes, another patient in San Antonio,” she said. Those cities are nearly a four-hour drive apart.

Nathan, the psychiatrist, is downstairs from Munch. In his sessions with patients, he routinely has to determine how inmates are handling their psychiatric medications, including antipsychotic drugs. He watches a patient’s expression, and looks for signs of involuntary motor movement or evidence that the patient is responding to stimuli that aren’t there. In the early days of Texas’s telemedicine experiment, he said, the equipment provided blurry, herky-jerky images, which were useless for his purposes.

Not anymore. The imaging is now perfect, Nathan said — better, in fact, than being in the same room because of the cameras’ zoom capability. “Plus, I don’t feel threatened at all.” He seldom sees patients face-to-face these days.

About 30 miles up Interstate 45 from Conroe is the Estelle Unit, home to about 2,600 prisoners. There, Dave Khurana works as a nephrologist, specializing in kidney care. He sees dialysis patients or those who soon will need dialysis. He has face-to-face sessions with patients at Estelle and meets remotely with inmates at distant prisons.

Sometimes Khurana uses telemedicine to see patients from his home, or when he has to be in Conroe for meetings, or even from his car. Last year, he did medical rounds while in Australia with his wife to attend a wedding.

A few months ago, Khurana said, he was in Conroe when a nurse back at Estelle spotted something suspicious on the arm of a patient about to have his dialysis treatment. From 30 miles away, Khurana was able to zoom in a camera on the patient’s bicep and identify a dime-sized ulcer. Proceeding with the dialysis, Khurana realized, could have ruptured a blood vessel.

“We could have had a bloodbath right there,” Khurana said. Instead, he ordered the patient transferred to a hospital, where an infection was discovered beneath the ulcer. He needed surgery before he could safely undergo another round of dialysis. “We avoided possible death, stroke or heart attack.”

Overcoming Distance

Without telemedicine, inmates might have to travel long distances to see doctors. Many doctors — particularly specialists and sub-specialists — often do not want to live in isolated areas; many have little interest in venturing to faraway prisons. That’s why in Texas and other states, correctional health officials often locate telemedicine facilities in or near cities, where doctors prefer to live.

Overcoming distance was Wyoming’s primary motivation for adopting telemedicine in the late 2000s, particularly for mental health. “We started because we couldn’t find psychiatrists to fill our part-time jobs,” said Laura McKinnon, the Wyoming mental health director for Corizon, a private contractor that handles correctional health for the state. A lone psychiatrist often had to travel from one prison to another as far as five hours apart. During winter that often was along treacherous roads.

Today, Wyoming officials say, the state conducts about 440 telemedicine appointments with prisoners a year, with about half of them for behavioral health issues. All five state prisons are equipped with telemedicine equipment.

Louisiana officials say they conduct about 3,500 telemedicine visits a year in 9 state facilities and 14 local jails. Raman Singh, medical and mental health director of the state’s Department of Corrections, credits telemedicine with opening the pipeline to specialists once out of reach for prisons. “Telemedicine opens a whole world to you because it helps recruit specialists who don’t want to travel, let alone walk into a prison,” Singh said.

Many prisoners also appreciate telemedicine, said Liz Mestas, support services manager for clinical services in the Colorado Department of Corrections, which uses telemedicine at nine of its prisons.

“We used to have a lot of refusals because they didn’t want to lose their cells or get a different cellmate if they had to go out of the facility,” she said. “And they didn’t want to miss visits or parole appointments or work.”

Prisoners also appreciate not waiting for medical appointments, she said. The department said it doesn’t quantify the number of telemedicine appointments.

But Brockman, of the Center for Prisoner Health and Human Rights, said telemedicine doesn’t solve what he says are frequent problems in prisons of not responding to inmates’ requests for medical attention in the first place or providing adequate follow-up care. “The hope and prayer is that the savings realized from telemedicine will be spent for better diagnostic care, better access to medication, better therapeutic services,” Brockman said.

Fathi, of the ACLU, said too often, doctors practicing telemedicine on inmates don’t have their full medical histories. That was a federal court’s finding in a recent lawsuitconcerning prison health care in Arizona penitentiaries. One provision of the court-approved settlement in the case requires that mental health providers practicing telemedicine on prisoners be provided with their recent medical records, including laboratory results.

“Telemedicine does offer some positives but it is never going to be as good as having an on-site physician who can perform hands-on diagnosis and treatment,” Fathi said.

Stern, of Washington state, said it is important that doctors who use telemedicine make occasional visits to prisons — if for no other reason than to develop an appreciation for the unique world occupied by their patients.

“You have to get a flavor for how a prison operates, what is the food like, what is the noise level, how attentive is the staff, how high or low are the bunks,” Stern said. “Occasionally, you have to walk through in order to understand that peculiar environment.”

Read original article – January 21, 2016
State Prisons Turn to Telemedicine to Improve Health and Save Money

Students who applied early to the University of New Hampshire will know by the end of the month if they were accepted. Then many would-be Wildcats will start biting their nails, waiting for their financial aid letter. Four years’ tuition and fees at UNH can put families back over $67,000 — roughly what the typical New Hampshire household earns in a year.

The university’s high prices are an extreme example of rising college costs that have affected students in every state. Paying for college has become a financial strain on middle-class families across the country, and a source of anxiety for recent graduates saddled with student debt.

This election year, Democrats, in particular, want to rally voters behind their plans to make college more affordable. UNH — a flagship university in a state that votes early in the presidential primaries — has become a key stop on the campaign trail. “No student should have to borrow to pay tuition at a public college or university,” Hillary Clinton said at an event there in the fall.

But while the presidential candidates debate major new investments in public higher education, states will spend 2016 pursuing a more modest agenda. States only have limited funds to work with, even as many lawmakers say they want college to be more affordable and states aim to increase the share of residents who hold a postsecondary degree or certificate.

“The pressure on higher ed budgets is going to continue. So the question is, how do states navigate that?” said Andrew Kelly, director of the Center on Higher Education Reform at the American Enterprise Institute (AEI), a right-leaning think tank in Washington, D.C.

Rather than blockbuster new investments, expect 2016 to bring tuition freezes, tweaks to scholarship programs, and policies that push institutions to do more with existing funding. Even ambitious-sounding changes, such as eliminating tuition for community college students, likely will be targeted to limit state spending.

Boost State Spending

One way for states to bring down tuition is simply to spend more money on colleges and universities.

Public colleges are still a bargain compared to private alternatives, thanks to state subsidies. In-state tuition and fees at four-year publics averaged $9,139 in 2014, according to the nonprofit College Board. Combined tuition, fees, room and board charges were less than half the price of the average private nonprofit college. And students who receive federal, state or institution grants pay less.

But since the 1980s, states have steadily cut per-student higher education funding and institutions have steadily raised tuition to compensate. New Hampshire’s cuts have been particularly severe. In 2015, state funding comprised 9 percent of the university system’s budget, down from 16 percent in 2003, according to UNH data.

Now, few students nationwide can afford college without help from grants and loans. Eighty-three percent of full-time students at public four-year colleges received financial aid in 2012, according to the most recent data from the National Center for Education Statistics.

Washington state proved last year that tuition can go down if states spend enough money. The state increased higher education funding so much that tuition at public institutions dropped by 5 percent. As Stateline has reported, Washington’s public universities will reduce tuition even more this year.

But few other states have the money — or the inclination — to make that kind of investment.

Some members of New Hampshire’s conservative, fairly rural legislature don’t look kindly on funding higher education, said state Rep. Wayne Burton, a Democrat whose district includes UNH’s main campus. Some lawmakers see UNH as a little elitist and not very useful, he said.

“My guess is that with other compelling needs, it’s going to be hard to make the case for higher education to get more money” in 2016, Burton said, just as it was during the 2015 session.

Neighboring Massachusetts also faces a tight budget. There, Democratic state Sen. Michael Moore would like to increase higher education and scholarship funding by $137 million over five years. But, he said, “It’s going to be very difficult.” Massachusetts officials expect state tax revenue to grow by about 4 percent in the next fiscal year and Moore’s proposal will have to compete with rising health care and labor costs, he said.

States have been reinvesting in higher education since the recession ended. But states still spent less per student in 2014 than they did in 2008, according to the most recent data from the State Higher Education Executive Officers Association. That’s partly because enrollment shot up during the recession, when many people struggled to find work.

Many states committed to spending additional money in the current fiscal year, said Tom Harnisch of the American Association of State Colleges and Universities. Often, he said, the money was conditional on colleges freezing tuition or limiting tuition growth.

Wisconsin was a notable exception. There, Republican Gov. Scott Walker signed a budget that froze in-state tuition at the University of Wisconsin even as the state cut funding.

In Idaho, Republican Gov. C.L. “Butch” Otter has proposed a variation on the tuition freeze: A guarantee that students at four-year colleges and universities would pay a fixed tuition rate each year for four years. Otter has indicated that students would have to study full-time; additional qualifying criteria may emerge as lawmakers discuss the idea this session, according to Jon Hanian, Otter’s press secretary.

Focus Scholarships on Need

States also can make college more affordable by targeting their spending at students, rather than institutions. States are likely to focus on need-based scholarships in 2016, said Kristin Conklin of HCM Strategists, a consulting firm that works with states on higher education issues.

By investing more in scholarships and tweaking them so they reach different kinds of students, states can further their workforce goals, Conklin said.

Take Arkansas. Last fall, Republican Gov. Asa Hutchinson announced that he wants 60 percent of state residents to hold a postsecondary credential by 2020. Officials say jobs in the state will increasingly require advanced technical training. Arkansas is one of 33 states that have partnered with Complete College America, a high-profile nonprofit that’s working with states to raise college completion rates.

To reach Hutchinson’s goal, Arkansas will have to educate more people from demographics that currently don’t enroll and finish college at high rates: working adults, low-income students, and African-American and Hispanic students. The state’s plan includes shifting scholarship money away from merit-based aid (which typically rewards middle-class students) and toward financial need.

Tennessee, which has set a similar workforce goal, has created scholarships that make community college tuition-free for recent high school grads and some adults who want to go to technical college. Both programs pay tuition not covered by other federal and state grants (some students who receive federal Pell grants can already go to community college for free).

The “free community college” idea doesn’t just encourage more people to go to college; it also helps alleviate middle-class anxiety about college costs by offering students a less expensive path to a bachelor’s degree. The cost of a bachelor’s degree can be halved if students get their first two years of credits at a community college, for free.

Oregon followed Tennessee’s lead and established a free community college scholarship for recent high school grads last year. There, Democratic state Sen. Mark Hass said he pitched the program as a way for the state to save money over the long run, because education can help young people find good jobs and escape poverty.

“I think there’s probably a dozen, at least, states that are looking at some sort of legislation to do exactly what Oregon and Tennessee are doing,” Hass said. He should know: he sits on a national advisory board President Barack Obama established last fall to spread the free community college idea.

But as existing programs show, states aren’t likely to make community college free for everybody. Both Oregon and Tennessee limited their costs by targeting certain students. Oregon’s legislators budgeted $10 million for the program’s first year and $20 million for its second, Hass said. But the funding may not be enough to meetdemand.

Moore said it would cost Massachusetts $127 million to make community college free for all students, citing a report from the nonprofit Massachusetts Budget and Policy Center.

“For us to even think about doing this, we would definitely need federal support,” Moore said. President Obama proposed creating a federally funded free community college program last January, and promoted the idea again during his 2016 State of the Union address, but the proposal hasn’t gotten much traction in Congress.

Consider Systemic Change

The third — and most difficult — way states can make college more affordable is by bringing down the cost of educating students.

AEI’s Kelly said he worries that upping state spending just shifts the cost of college from families to the government, without forcing institutions to become more efficient.

Tuition freezes, after all, don’t hold tuition down over the long term. They only tend to last for a year or two, and they don’t address the forces that push up the cost of running a university — from inflation to administration costs to labor costs to students’ demand for expensive amenities.

The California Legislative Analyst’s Office argued against a tuition freeze that Democratic Gov. Jerry Brown proposed in his 2013-14 budget by explaining that extended tuition freezes at the state’s colleges and universities have been followed by periods of steep tuition increases.

“The proposal also would have the limited near-term effect of reducing the incentive students and their families have to hold higher education institutions accountable for keeping costs low and maintaining quality,” the report said. (The University of California and California State University systems froze tuition in 2013-14, but in 2014 UC announced a plan to raise tuition).

To hold down costs and further their workforce goals, a growing number of states are changing the way they distribute higher education funding. Twenty-six states now at least partly fund colleges and universities based on performance measures, such as whether students graduated on time, and 10 more states are developing such funding formulas, according to an HCM Strategists report.

Massachusetts, Oregon and Tennessee have embraced outcomes-based funding, and Arkansas plans to implement the approach.

“I think we’re going to see more and more states define affordability as a time issue,” Conklin said. When students graduate on time, they don’t waste money.

Wisconsin’s Gov. Walker said in his State of the State address this month that he plans to talk to the University of Wisconsin system about creating three-year bachelor’s degrees, and expanding an online university degree option that lets students proceed at their own pace. He also wants to increase grant money for technical college students, and provide students with more information about the loans they’re accruing.

New Hampshire’s Burton said he hopes workforce concerns and demographic change will persuade his colleagues in the General Court to focus on the high cost of higher education.

New Hampshire announced a partnership with Complete College America last month. A business group, the New Hampshire Coalition of Business and Education, is pushing for the state to set a college completion goal. And the University of Maine has begun competing with other New England institutions on price, by announcing that it will charge area students the same tuition and fees they’d pay in their home states, rather than the higher rate usually charged to out-of-state students.

All these factors — plus the election-year spotlight — should create space for a debate about college affordability, Burton said, even in New Hampshire’s tough budget environment. “It’s going to be a much more serious discussion.”

Read original article
The High Cost of Higher Education

After two decades of “tough on crime” policies, many states are taking a hard look at the way people are charged, how much time they serve, and what happens when they are released from prison.

While bills governing the use of body cameras and other police-related measures are likely to be considered this year, many states are looking at growing prison populations, obstacles to drug treatment, and high recidivism rates as reasons to re-evaluate their criminal justice systems.

The U.S. has the highest incarceration rate in the world, and many states are at a crossroads, weighing whether to build new prisons or change how they sentence people as well as how they guide them through parole and probation.

Several states, including Alaska, Maryland and Rhode Island, are considering sweeping criminal justice changes that would ease some of the punitive policies of the 1980s and ’90s, especially when it comes to drug offenders. In some places, lawmakers will consider recommendations made by criminal justice task forces, often with the guidance of outside groups such as the Council of State Governments (CSG) and The Pew Charitable Trusts (Pew also funds Stateline).

“If there’s a theme or common denominator, it is policymakers asking what the science says will work,” said Michael Thompson, director of the CSG’s Justice Center. “The question they’re asking is, ‘Can we get a better return on our investment?’”

Sentencing Reform

States that want to decrease the number of people going to prison often turn to reducing sentences, either by scrapping mandatory minimums or reclassifying some felonies as misdemeanors. They may also divert people into treatment for drug addiction or mental illness.

Nicole Porter with the Sentencing Project, which advocates for shorter sentences, said when states do reclassify crimes, it tends to be lower level felonies, such as drug possession and property crimes like theft under a certain dollar value.

Porter said some states may be inspired by what California voters did in 2014, approving Proposition 47, which reduced some felonies, such as nonviolent property theft and drug crimes, to misdemeanors.

Not only did the state decrease the number of people going into prison, but thousands of inmates were eligible to be released early under the new law. As of September, nearly 4,500 people were released under Prop. 47. And the state’s Department of Corrections estimates 3,300 fewer people will be incarcerated each year.

Holly Harris with U.S. Justice Action Network, a coalition of liberal and conservative groups pushing for criminal justice changes, said reducing felonies to misdemeanors could have a big impact on women. Though they are the fastest growing segment of prison population, many women are nonviolent offenders or are serving time for drug crimes that might be reclassified.

In Alaska, the state’s Criminal Justice Commission in December called for limiting prison beds to serious and violent offenders, reclassifying many of the lowest level misdemeanors as violations punishable by a fine, and shortening jail time for more serious misdemeanors to no more than 30 days. The panel also called for changing simple possession of heroin, methamphetamine and cocaine to a misdemeanor.

But states that are adjusting sentences aren’t just shortening them. Last year, Maine legislators reduced sentences for some drug possession crimes, but increased themfor cocaine and fentanyl powder, one of the opioids that have concerned state leaders as they battle heroin addiction.

“The dichotomy feels like legislators have a split personality,” said Alison Holcomb, director of the American Civil Liberties Union’s Campaign for Smart Justice, which lobbied against the increased sentences in Maine. Holcomb said while attitudes around some drugs have relaxed, some states that are trying to crack down on the abuse of opiates have imposed harsher sentences.

But reducing sentences could have unintended consequences. In Utah, state Rep. Eric Hutchings, a Republican, said the reclassification of some crimes as misdemeanors blocked some people from drug courts and treatment programs meant only for felons — something he said the state will fix this year.

Many states may also consider ending some mandatory minimum sentences, which have helped to swell prison populations in several states. Iowa Attorney General Tom Miller, a Democrat, said he wants the Legislature to eliminate mandatory minimums for less serious crimes, which under current law can land someone behind bars for decades.

Bills in several states, including Florida, Massachusetts and Virginia, would either scrap mandatory minimums or give judges more power to depart from them when issuing sentences. Last year, Maryland, North Dakota and Oklahoma gave judges more discretion to exempt some people from mandatory minimums, according to Alison Lawrence with the National Conference of State Legislatures.

Changes to Parole and Probation

States are also looking to get people who are already in the criminal justice system out faster and to help them transition back into society while on parole.

One option is “presumptive parole,” which means presuming that inmates are eligible for parole, rather than requiring them to convince the parole board they should be released, an approach Mississippi adopted in 2015. Michigan’s House is currently weighing the policy, something the state’s Department of Correctionsestimates will free up enough beds to save the state $82 million a year.

“It puts the burden on the state to show a compelling reason why you should not be released on parole,” Harris said.

States may also consider scaling back the amount of time prisoners must serve before they become eligible for parole. Mississippi used to require convicted felons to complete 85 percent of their sentence before they were eligible, but changed the law in 2014. Now nonviolent offenders must serve 25 percent of their time, while violent offenders must serve 50 percent, before they can be considered for parole.

Some states are trying to make their parole process more responsive to parolees’ behavior.

Several states, including Alabama and Utah, have adopted “swift, certain, fair” approaches, which aim to provide an immediate response to parolees’ behavior, whether it’s jail time after a failed drug test or a reduced parole term if someone has been following the rules and  making a lot of progress in post-prison life.

Hutchings said Utah legislators passed such a measure last year after examining the recidivism rates of parolees. One-third were back in prison because they had committed new crimes, but two-thirds were there for parole violations.

People need a quick, clear response when they do something wrong in order to change their behavior, Hutchings said, but the state was taking too long to get people in front of a judge when they violated parole — and they were often sent back to prison for too long.

“These are not people we’re afraid of. They’re just people who are not doing what they said they were going to do,” he said. “It’s kind of like the game Chutes and Ladders. You get your stuff together but then one slip-up and you’re back at the beginning. Even if you just get sent back to jail for 60 days, you don’t show up for work so you lose your job. You can’t make your car payments so it gets repo’ed. You go all the way back to zero.”

The state adapted one of its facilities to include a special section for parolees and probationers, giving them access to drug treatment, therapy, and their parole or probation officer. Officers can also order parolees and probationers to sleep at the center for a few nights, to make sure they stay out of trouble, or to be locked up for up to five days — or even longer with a judge’s approval.

Michigan state Sen. John Proos, a Republican, said he wants to expand his state’s “swift and certain” program, which now operates only in some counties. He’d also like the state to open it up to probationers.

But he also wants to understand why prison doesn’t better prepare inmates for parole. “Do we need more education? Do we need more resources?” he asked.

Several states already provide some resources, including substance abuse and mental health treatment, before people even go to prison.

Maryland’s working group on criminal justice reform found the state spends about $26 a day to incarcerate one person, versus $4.55 per person for probation and parole. To reduce the number of people entering prison, the group proposed starting a grant program to cover the county costs of specialty courts and re-entry programs.

Collateral Consequences

Some states are likely to consider ways to remove some of the barriers that make it difficult for people to make a life for themselves once they get out of prison.

Each year, several states take up “ban the box” legislation, which blocks employers from asking on job applications whether someone has served time. The idea is that if employers have a chance to get to know applicants before finding out about a criminal past, they are more likely to give them a second chance.

While 19 states have some sort of ban the box policy, sometimes it only applies to the state or its contractors, but not private employers. Arkansas state Sen. Jeremy Hutchinson, a Republican and the chairman of the Senate Judiciary Committee, said he expects the state to consider such a policy this year, but he’s not sure how far he wants to go.

“There’s a lot of hesitancy, even on my part, to dictate to employers what should be on their job application, but the state can be a model,” he said.

States are also likely to consider laws that allow for the expungement or sealing of records, or certificates of rehabilitation, which allow a state to vouch for the good reputation of people who have been convicted of crimes and served their time.

This month, the Kentucky House voted to let people convicted of most Class D felonies — the lowest level of felony, punishable by one to five years in prison — erase their criminal records and get a second chance at jobs, housing and other opportunities sometimes denied felons.

Juvenile Justice

Some states are also reevaluating their juvenile justice systems and trying to open them to an older population, prompted in part by new brain science which suggests cognitive abilities are not fully formed until age 25.

In New York, after failing to change the state’s status as one of the few where 16- and 17-year-olds are automatically tried as adults, Democratic Gov. Andrew Cuomo issued an executive order in December requiring that young prisoners be housed separately from older inmates — an idea that has been talked about in other states as well.

Read original article
States at a Crossroads on Criminal Justice Reform

A week before 22-year-old Joe White was slated for release from the Barnstable County Correctional Facility, 26 law enforcement officials and social workers huddled around a table to discuss his prospects on the outside.

For substance abusers like White, they aren’t good.

In the first two weeks after a drug user is released from jail, the risk of a fatal overdose is much higher than at any other time in his addiction. After months or years in confinement, theoretically without access to illicit drugs, an addict’s tolerance for drugs is low but his craving to get high can be as strong as ever.

Most inmates start using drugs again immediately upon release. If they don’t die of an overdose, they often end up getting arrested again for drug-related crimes. Without help, very few are able to put their lives back together while battling obsessive drug cravings.

Barnstable, on Cape Cod about 70 miles from Boston, has broken that cycle with the help of a relatively new addiction medication, Vivitrol, which blocks the euphoric effects of opioids and reduces cravings. Such medications have been shown to be far more effective at helping people quit drugs than counseling and group therapy programs that do not include medication.

But even as the nation grapples with an epidemic of opioid overdoses, the use of medication to treat opioid addiction has faced stiff resistance: Only about a fifth of the people who would benefit from the medications are getting them.

The opposition is especially strong in prisons and jails. About two-thirds of the nation’s 2.3 million inmates are addicted to drugs or alcohol, compared to 9 percent of the general population, according to a study by the National Center on Addiction and Substance Abuse at Columbia University. Yet only 11 percent of addicted inmates receive any treatment.

White, whose story was relayed by Barnstable officials and who asked that his real name not be used, was a homeless substance abuser when he began a yearlong stint for stealing credit cards. He was set to receive a Vivitrol injection two days before he walked out — improving his chances of surviving long enough to get a second 30-day injection and some counseling.

Barnstable has been offering the medication to departing inmates for nearly four years. During that period, the recidivism rate among Vivitrol recipients has been 9 percent. That’s compared to a national re-arrest rate for drug offenders of 77 percent within five years of release, according to the Bureau of Justice Statistics. (Like many jails, Barnstable does not track its own recidivism rate.)

Beyond Barnstable

Since 2014, nine Massachusetts prisons and 10 jails have added Vivitrol to their drug treatment arsenals. About 50 state prisons in Colorado, Kentucky, Missouri, Pennsylvania, Tennessee, Utah and West Virginia now dispense the medication. And at least 30 jails in California, Illinois, Indiana, Kentucky, Maryland, Michigan, Missouri, New York, Ohio, Utah, Wisconsin and Wyoming also are offering it to departing inmates, according to the drug’s manufacturer, Alkermes.

The nation’s nearly 200,000 federal prisoners have not been offered any addiction medicines, though the Federal Bureau of Prisons is considering changing that policy this year.

Addiction experts argue medication-assisted drug treatment is not spreading fast enough in U.S. prisons and jails.

One of three medications approved for opioid treatment, Vivitrol is not a narcotic and therefore not a controlled substance. The other two medications, buprenorphine and methadone, are narcotics, which are anathema to most criminal justice systems.

The downside to Vivitrol is that patients must be off of all opioids for at least seven days before receiving an injection, a painful and sometimes costly proposition. Being behind bars obviates that problem, since most addicts do not have access to drugs while incarcerated.

Addiction specialist Dr. Kevin Fiscella said the failure to offer medication to more incarcerated addicts is “a missed opportunity” to treat inmates, many of whom are motivated to beat the disease that put them in prison, in a controlled environment. “There is no better place to intervene in an individual’s addiction than in corrections,” he said.

For one inmate at a Massachusetts prison, opting for Vivitrol was easy. In a video provided by corrections officials, he said he injured his shoulder playing lacrosse in high school and was prescribed Percocet, an opioid painkiller. He said he fell in love with the way it made him feel and quickly moved to heroin, a cheaper, more available alternative. Right after he graduated, he was arrested for breaking and entering and theft, and was sent to prison.

“I have friends that have sworn up and down about Vivitrol and how good it is and how it takes away the urge. They all have jobs now. They’ve been out of trouble forever. So when I got offered it, I said, ‘Don’t even finish the sentence, I’ll sign up right now,’ ” the inmate said.

Not a ‘Magic Cape’

Vivitrol is an injectable form of naltrexone, an oral medication that has been used to treat opioid addiction since 1984. It is similar to naloxone or Narcan, which reverse the effects of an opioid overdose.

Vivitrol and related medications, called antagonists, block the brain’s opioid receptors, making it nearly impossible to get high from opioids. Although scientists are not exactly sure how, antagonists reduce the addicted brain’s obsessive cravings for drugs.

Approved for opioid treatment by the U.S. Food and Drug Administration in 2010, Vivitrol was added to Barnstable’s longstanding re-entry drug treatment program in 2012.

Inmates who enter the program are told about the potential benefits of the medication and given the option of receiving their first injection a few days before being released.

“No matter how long they’ve been drug-free, inmates tell us they start actively dreaming about getting high in the last few weeks before they’re released,” Barnstable Sheriff James Cummings said.

Of the nearly 200 inmates who have chosen to receive the injection, about half have remained sober. Only one has died of an overdose.

“It’s not a magic cape,” said Andrew Klein, a corrections expert who is working with prisons and jails — including Barnstable — on medication-assisted treatment programs.

The biggest challenge, Klein said, is getting inmates to continue taking the medication once they leave the facility. “The physical symptoms of their addiction clear up pretty quickly and they feel like they’ve licked it, so they stop showing up for the monthly injections,” Klein said. “That’s when they tend to relapse.”

Experts agree that medications should be combined with behavioral counseling.

But the precise amount and type of counseling hasn’t been established. “At the very least, they need to be reminded to keep taking the medicine,” said Klein, a consultant withAdvocates for Human Potential, which specializes in behavioral health.

Although Vivitrol’s efficacy at dampening drug cravings has been shown, the drug is relatively new and no definitive study has proven its long-term effectiveness at preventing relapse.

Dosing and Counseling

At Barnstable, only 34 of the inmates who took Vivitrol completed an intensive six-month rehabilitation program before release. Despite agreement on the effectiveness of combining counseling and other types of therapy with the medicine, Barnstable does not require it.

“We’re seeing Vivitrol as a lifesaving medication,” said Jessica Burgess, the jail’s health services director. “We’re not going to deny it to anyone.”

Inmates interested in receiving it are given a physical exam. They also receive a short-acting oral form of the drug to check for potentially severe adverse reactions such as gastrointestinal disorders or dizziness. Inmates are also warned that once they are released, the long-acting medication will prevent them from getting high on opioids or alcohol.

On average, participants in the Barnstable program received five shots, including the injection they received before being released. Some stopped taking the injections after two or three months and relapsed. But according to Cummings, the sheriff, most were eager to get back on the medication.

Most ex-prisoners can’t afford to continue on the medication — which costs $1,000 per injection — without insurance coverage of some kind. In Massachusetts, prisons and jails enroll departing inmates in the state’s Medicaid program, which covers the cost.

Word of Mouth

Nearly half of the inmates in Barnstable’s 588-bed facility are addicted to opioids when they arrive. But in the nearly four years Vivitrol has been offered, fewer than 200 have opted to take it.

Their reasons for declining it vary. Most are in denial that they have an addiction. Many are unwilling to give up drugs and alcohol. Some don’t want to make the monthlong commitment that comes with receiving the injection.

But officials here say resistance is starting to diminish.

“The number of requests we’re receiving from inmates asking for Vivitrol has been steadily increasing since the start of the program,” Burgess said. “We attribute this to word of mouth and increased awareness.”

In the first year of the program, 37 inmates received the shot, followed by 51 the second year and 53 the third year. Since May 2015, 50 have signed up.

People outside of corrections who seek treatment for opioid and heroin addiction also have reservations about Vivitrol. Abstaining from opioids for seven days can be painful and dangerous. If patients relapse, they are at high risk for an overdose.

At Gosnold, a treatment center in nearby Falmouth, CEO Raymond Tamasi said the most common objection is fear of using drugs while on the medication and overdosing. That’s despite clear evidence that people who try to abstain from drugs without the help of medications are far more likely to die from an overdose, he said.

“Advances are coming in pharmacology,” Tamasi said. “Someday soon I expect we’ll view Vivitrol like the early days of penicillin.”

Read original story – Published January 13, 2016
Helping Drug-Addicted Inmates Break the Cycle

Dr. Marvin Seppala wrote a book on conquering drug addiction with counseling and group therapy.

The spiritual, abstinence-based strategy pioneered by Alcoholics Anonymous helped him overcome his own alcohol and cocaine addiction when he was 19. As medical director of Minnesota’s fabled Hazelden clinic, he watched it work for patients.

He believed in it — and then he changed his mind.

In 2007, Seppala began working at Beyond Addictions, a now defunct treatment center in Beaverton, Oregon. Instead of relying solely on counseling, the center gave its patients a relatively new medication, buprenorphine, to relieve their drug cravings.

Back in Minnesota, his patients had been bailing out of treatment to use illicit drugs again. In Oregon his patients on buprenorphine weren’t relapsing or overdosing — they reported feeling “normal” again.

Nearly a decade later, doctors and brain researchers agree that medications such as buprenorphine, methadone and naltrexone are the most effective anti-addiction weapons available. Nevertheless, more than two-thirds of U.S. clinics and treatment centers still do not offer the medicines. Many refuse to admit people who are taking them.

The result is that hundreds, perhaps thousands, of Americans are dying unnecessarily, victims of an epidemic that killed more than 28,000 people in 2014 — more than homicides and almost as many as auto accidents.

The research is unassailable: Staying in recovery and avoiding relapse for at least a year is more than twice as likely with medications as without them. Medications also lower the risk of a fatal overdose.

Addicts who quit drugs under an abstinence-based program are at a high risk of fatally overdosing if they relapse. Within days, the abstinent body’s tolerance for opioids plummets and even a small dose of the drugs can shut down the lungs.

And yet as the country’s opioid epidemic worsens — every day, more than 70 Americans die from overdoses, and the numbers are climbing — only about a fifth of the people who would benefit from the medications are getting them, according to a new study by the Johns Hopkins Bloomberg School of Public Health.

“When we discovered medications that worked for AIDS, deaths immediately plummeted. It became a chronic disease instead of a terminal disease,” said Dr. Andrew Kolodny, chief medical officer of the Phoenix House treatment centers, based in New York.

“This epidemic could be the same,” he said. “We have medications for addiction now. But unfortunately, we’re not making them available enough.”

People who could benefit from the medications are not getting them for numerous reasons. Among them:

• Too few health care professionals have specialized training in addiction medicine. Although some primary care doctors have stepped in to fill the void, most are unwilling to treat patients with addictions and say they are often recalcitrant and disturbing to others in their waiting rooms.
• Insurance coverage is limited. Few private insurers and state Medicaid programs cover all of the medications approved by the Food and Drug Administration. When they do, they typically limit the dosage or how long patients can take the medication or require them to first try group therapy, which is cheaper.
• Many leaders of traditional drug treatment centers, such as national detox chains and residential rehab programs, are recovering addicts who conquered their own addictions without medication. They reject the notion that an addict can truly recover from a drug problem by becoming dependent on a different drug.
• Greater use of medication could cut into the centers’ revenue, by reducing the number of people who opt for expensive residential stays. And smaller clinics that might want to add medication services would have to hire a physician to do so, which many of them could not afford.

Dr. Kelly Clark, an addiction specialist in Kentucky and president-elect of the American Society of Addiction Medicine, said some of the resistance is cultural, rooted in a widespread belief “that drug addiction is a moral failing, and that people should just get over it.”

“There is no other disease where approved medications are not provided to everyone who needs them,” Clark said. “We used to consider people with mental illness inferior, even possessed. Scientific advances have combatted stigma around a wide variety of brain diseases, but not addiction.”

Hazelden was one of the many treatment centers that resisted the use of medication — until Seppala returned from his stint in Oregon in 2009 and began pushing the board to shift course. Hazelden started offering the medications shortly thereafter.

“It’s hard to argue when you have patients dying of overdoses,” Seppala said. “We said this is truly a crisis, we can’t just base our service on philosophy, we have to look at the data and base our treatment on the best way to save lives.”

Freedom from Drugs

Opponents say addiction medications such as buprenorphine reduce drug cravings, but they don’t attack the underlying psychological problems that often go with addiction. Nor do they address shame, guilt and self-loathing — as counseling does.

Dr. Robert Mooney’s belief in abstinence has never wavered. As medical director at Vista Taos, a treatment center in New Mexico, he refers his patients elsewhere if they want to take medication. “What we do here is abstinence-based, because there are some people that nothing else will work on,” he said.

Mooney, a psychiatrist and board-certified addiction specialist, beat his own addiction to alcohol and cocaine with an abstinence-based approach, and he grew up in an abstinence-based treatment business. His parents, Dr. John and Dot Mooney, a surgeon and a nurse, overcame their own drug and alcohol addictions through abstinence and opened a treatment center, in Statesboro, Georgia, in 1971, to help others tread the same path.

“I tell patients, ‘We’re going to take you off all medications and give your brain a chance to land, and it’s going to be a long road.’ You need to prepare people for that.”

Mooney said he isn’t interested in arguing with those who believe in addiction medications, because in his view there has not been adequate research on the long-term effectiveness of either approach. “But let’s at least hang on to an abstinence-based philosophy, because we absolutely need it as part of the solution,” he said.

Seppala’s 2001 book, Clinician’s Guide to the Twelve Step Principles, embraces the approach first laid out in 1935 by Alcoholics Anonymous, “a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem.”

He still says addicts who want abstinence-based treatment should get it. But, he said, medication should be offered. Like other addiction doctors, Seppala stresses that medication should be combined with counseling and group therapy whenever possible. Given the horrific toll of the drug epidemic, “We ought to put everyone on some sort of medication and give them all the psychosocial counseling we can,” he said.

The scope of the epidemic is staggering. Since 2008, more than 115,000 Americans have died from overdoses of prescription opioid painkillers and nearly 39,000 have died from heroin overdoses — reaching an overall death rate of 9 per 100,000 in 2014. That’s six times the drug overdose death rate of the 1970s, according to data from the U.S. Centers for Disease Control and Prevention.

New data from the CDC indicate the death toll from this epidemic has not yet peaked. Prescription opioid overdose deaths rose 16 percent from 2013 to 2014, to nearly 19,000. Heroin overdose deaths rose 28 percent and deaths from relatively new illicit opioids, such as fentanyl and tramadol, spiked 79 percent.

According to the U.S. Department of Health and Human Services (HHS), nationwide medication-assisted treatment capacity has increased somewhat in the past decade, but not enough to keep pace with the worsening opioid epidemic.

Many of the nation’s hardest-hit areas are rural and suburban. Rates of addiction are much higher in those areas and the shortage of providers is even worse.

“There are entire communities that are devastated by this epidemic,” Clark said. “If you have an opioid addiction, the odds are good that many, many in your world have the same disease. I’ve treated adolescents and their parents and grandparents.”

Nationwide, nearly 22 million people have some kind of substance use disorder, but only one in 10 goes to a treatment center, according to the most recent survey by the U.S. Substance Abuse and Mental Health Services Administration. In contrast, the treatment rate is as high as 80 percent for other chronic diseases such as diabetes, asthma, heart disease and high blood pressure.

Difficult Terrain

Addiction to opioids, including heroin and prescription pain pills, is difficult to treat. Not everyone recovers. Among those who do, most relapse at least once before entering a period of sustained recovery. For the millions of opioid addicts who are uninsured, homeless or recently incarcerated, getting on medication — and staying on — is a struggle.

But the affluent and the well-educated are also victims of this new epidemic. Their search for effective treatment can be frustrating and dangerous, their relapses frequent.

Kevin Flattery seemed to be in an ideal position to beat his addiction to OxyContin, a widely abused opioid painkiller.

After graduating from the University of Virginia, in 2010, Flattery moved to Hollywood to pursue his passion for filmmaking. Opioid painkillers were cheap and easy to acquire on the street there. Kevin tried them and liked them, in part because they relieved some of the stress he was experiencing as he pursued his high-pressure career.

Two years later, he realized he had an addiction that was taking over his life. Kevin decided to move back to his parents’ home in Mount Vernon, Virginia, an upper-middle-class suburb of Washington, D.C., to find help.

He had family support, financial means and no shortage of local treatment providers. But he got conflicting signals from the counselors he saw.

He checked himself into Inova Fairfax Hospital for detox, and the experts there suggested he start taking buprenorphine, one of the FDA-approved drugs.

The medication worked well for Kevin — at first. But he veered off course a couple of times, stopping the daily medication and buying OxyContin to get high. Each time, he got himself back on buprenorphine within a few days.

Experts say that’s a typical path for people who take such medicines. It often takes several tries before they stabilize and enter a period of sustained recovery.

But after a few months, Kevin wasn’t sure he wanted to stay on the medication for the long term. He attended local 12-step programs where he was criticized for taking it.

Kevin’s father, Don Flattery, said his son was confronted with judgment and pressure about it. “He was made to feel that he was not in recovery, not serious about his sobriety, and substituting one addiction for another — all utterly false but damaging to him nonetheless.”

Conflicted about how to proceed, Kevin stopped taking buprenorphine. Ten days later, he relapsed and suffered a fatal overdose, at age 26.

Three Medications

Buprenorphine and methadone are regulated as controlled substances by the U.S. Drug Enforcement Administration (DEA). Like the opioid painkillers that cause the addictions they are meant to relieve, both are commonly sold on the street.

But their euphoric properties are limited, making them poor options for getting high. The illicit use of methadone can cause a fatal overdose, particularly when combined with other drugs. But buprenorphine is relatively safe, even when used illicitly.

Methadone can cost less than $5 per day; buprenorphine costs about $10 per day. Although medical research has yet to establish standard lengths of time for using either, many have maintained recovery for decades on methadone. Buprenorphine has been used successfully for years by some, and only months by others.

A 2000 federal law requires doctors to seek a special waiver from the DEA to prescribe buprenorphine and limits their number of patients to 30 in the first year and to 100 in subsequent years. HHS may loosen the patient limit this year.

Methadone can only be dispensed by about 1,400 licensed clinics nationwide, both stand-alone and in prisons or hospitals. Most of them are in major cities, meaning the medication is unavailable to most in rural areas. Patients must show up every day to receive their dose under the supervision of a licensed professional.

Vivitrol, an injectable form of naltrexone, is not a narcotic and therefore not regulated. Instead of fulfilling the addicted brain’s perceived need for opioids, it blocks the effect of the drugs and thereby reduces cravings.

Any doctor can prescribe and administer Vivitrol. But it has a major drawback: To avoid severe and dangerous withdrawal symptoms, patients must completely detox from all opioids for at least seven days before receiving the first shot. For many, that means residential treatment, which can be costly. The drug itself is also expensive, at $1,000 per month.

Research on Vivitrol’s long-term effectiveness is still to come, but its use is spreading, particularly in jails and prisons. Patients are also increasingly opting for Vivitrol because the shots are effective for 30 days, tempering the temptation of stopping daily doses to get high.

Addiction doctors agree that all three medications should be available to patients, because one may be more effective than another, depending in part on the person’s age, length of time as an addict, home and work environment and underlying mental health issues. The American Medical Association, the American Academy of Addiction Psychiatry and the American Society of Addiction Medicine unequivocally support their use.

Patients should have a say in the kind of medication they want to receive, said Dr. David Gastfriend, scientific adviser to the Treatment Research Institute, in Philadelphia, which analyzes the effectiveness of addiction treatments. “They’ve heard about certain drugs from their friends or they’ve had past experiences and they often have ideas about what they want,” he said. “Treatment works much better with patient buy-in.”

Gastfriend and other addiction experts emphasize that medication should be accompanied by at least some counseling or group therapy. How long patients must stay on the medications remains unknown.

A Turning Point?

For advocates of medication-based treatment, recent policy changes are cause for optimism. The Affordable Care Act allows states to expand health insurance coverage to low-income adults and, for the first time, makes Medicaid and private insurance coverage of substance abuse treatment mandatory.

In the past, Medicaid only covered low-income pregnant women, children and disabled adults. Any drug or alcohol coverage was limited to those three populations. A severe drug or alcohol addiction, while debilitating and life-crushing, did not qualify on its own as a disability.

Under the ACA, 30 states plus D.C. have opted to expand Medicaid to low-income, able-bodied adults, giving millions of poor Americans coverage for addiction treatment. The health law also requires all state Medicaid programs and all insurance companies to cover the gamut of recommended treatments for addiction.

In addition, the federal Mental Health Parity and Addiction Equity Act, although not enforced everywhere, requires insurers to pay for proven addiction treatments at the same dollar level as medical and surgical treatment for purely physical diseases such as cancer.

“There has never been a better time to confront the addiction problem we have in this country,” said Michael Botticelli, director of the U.S. Office of National Drug Control Policy.

“We know so much more about addiction from years of scientific research. We know that substance use disorders are diseases of the brain, that they can be chronic and relapsing,” Botticelli said. “But we also know that like other diseases, they can be prevented, treated and people can recover.”

Read original article – Published January 11, 2016
In Drug Epidemic, Resistance to Medication Costs Lives

When Milwaukee resident Linda Hopgood found out last summer she was about to lose her food stamp benefits, she immediately started looking for work. But she said she quickly became discouraged by employers telling her she did not have the skills they were looking for.

The 48-year-old former nursing aide has been out of work for four years. She lives in her son’s house and spends her days watching her daughter’s three children. Without the $187 in food stamps she had received each month for the last seven years, she’s now walking to church every day for free meals.

Hopgood lost her benefits when Wisconsin reinstated work requirements for food stamps. With 22 new states reinstating the requirements as of Jan. 1, another 500,000 or more people could find themselves in her situation by spring.

The reinstated requirements are only for able-bodied adults between the ages of 18 and 49 who have no young children living with them. If they do not work 80 hours per month, or take part in 80 hours of a qualified job-training or educational program, they can only receive food stamp benefits for three months out of every three years.

The federal government suspended the work requirements on those food stamp recipients nationwide in 2009, when jobs disappeared and unemployment rates shot up during the Great Recession. Over time, as their economies have improved, states have had to reinstate the work requirements.

Now, all but seven states — California, Illinois, Louisiana, Michigan, Nevada, Rhode Island and South Carolina — and the District of Columbia have work requirements for able-bodied adults without dependents in at least part of the state. For work requirements to be waived, unemployment must be higher than 10 percent, or states must prove a lack of jobs.

Some governors have not sought permission to forgo the requirements, despite high unemployment rates. For instance, this year, Mississippi (6.6 percent), New Mexico (6.2 percent) and West Virginia (7 percent) could have applied but didn’t, said Ed Bolen, senior policy analyst at the left-leaning Center on Budget and Policy Priorities (CBPP).

And South Carolina (6.7 percent) only sought permission to forgo the requirements until March.

States also can seek federal permission to waive the requirements only in areas that continue to lack jobs. But many of them haven’t.

Wisconsin, for instance, could have sought to forgo work requirements in Milwaukee, where jobs are harder to come by. But Republican Gov. Scott Walker chose not to, saying that the requirements would boost the workforce.

“We aren’t making it harder to get benefits — we are making it easier to get a job,” said Laurel Patrick, Walker’s press secretary.

Others, however, say reinstating the requirements makes life harder for people like Hopgood who already face barriers to employment. And, they say, few states have taken the time or money to set up programs that would help people find jobs or get trained.

“If the state doesn’t provide any of these [programs], you’re out of luck,” Bolen said. “And that model doesn’t lead people to get jobs — it makes them desperate.”

Poor and Uneducated

About one in 10 food stamp recipients, or about 4.7 million, fall into the category of being able to work and having no dependent children, according to new data from the U.S. Department of Agriculture, which oversees the Supplemental Nutrition Assistance Program, or SNAP, better known as food stamps. On average, their households receive about $191 a month in food stamp benefits.

They are poor, with an average household income of about $3,768 a year. And they are uneducated — one in four didn’t graduate high school, and two in four only earned a high school diploma, according to a January report by the CBPP.

The federal government offers more than $90 million a year for employment and training programs, and requires states to offer them to this population.

But the programs can be as basic or comprehensive as the state wants — from offering advice on resumes and job searching, to providing individualized case management that matches a person with a relevant job skills training program. USDA strongly encourages states to move toward the latter.

If any state offers a model for providing education and job skills to this population, it may be Washington.

The state’s program started small in 2005, in one community center serving just its immediate area, and now serves the entire state in all community colleges and 29 community-based organizations, said David Kaz, director of policy and communications at the nonprofit Seattle Jobs Initiative.

With work requirements back in place in Seattle and surrounding areas starting this month, Kaz said the programs — which include job search instruction, job training, GED prep, English language classes, vocational education and job retention services — should have the capacity to serve anyone who needs it.

Washington is one of a few states that make use of federal matching funds available for establishing programs in community colleges or in contracting with nonprofits to provide job skills and training.

One nonprofit, FareStart, offers a 16-week, hands-on culinary and life skills training program that prepares students to work in the food services industry. The program has more than doubled with the state funding, now serving about 300 people each year, according to Molly Hancock, vice president of programs.

Of the people who enroll, 55 percent graduate, and of those who graduate, 93 percent find jobs within three months, Hancock said.

State data show that, overall, about 70 percent of people who use the state’s programs become employed, Kaz said.

Washington is also one of 10 states that received grants from the federal government in 2014 to test different kinds of employment and training strategies, which could serve as models in the future. The others were California, Delaware, Georgia, Illinois, Kansas, Kentucky, Mississippi, Vermont and Virginia.

Measuring success

While there is evidence in Washington that education and training programs help people rejoin the workforce, there is little data or research that has shown that cutting food stamps motivates people to work.

When the CBPP, for example, looked at food stamp data in 2013, it concluded that receiving food stamps does not create disincentives to work. Yet when looking at public benefits offered during the recession, including additional food stamp benefits, Casey Mulligan, a professor of economics at the University of Chicago, came to the opposite conclusion.

New data available from Kansas, which restored work requirements in 2013, show that work requirements do get people working, said Jonathan Ingram, vice president of research at the conservative Foundation for Government Accountability. The state tracked employment and earnings of adults subject to the requirement, and the foundation is planning on releasing a report with details this winter.

The data show that of the 25,913 who faced the work requirement, 12,807 left the program, Ingram said. Of those, about half found employment within three months. Among those who continued to be enrolled in food stamps, the work participation rate rose from 13 to 35 percent and average income more than doubled, from $1,867 to $4,346 annually.

“That’s the whole point of the work requirement is you want to get these able-bodied adults working,” he said. “What they really need is a good-paying job, not more welfare.”

Differing views

After Walker reinstated the work requirement in Wisconsin, in April, about 15,000 adults like Hopgood lost their benefits between July and September when they didn’t meet the requirements. In that same period, about 3,200 people who were enrolled in the state’s employment and training program found new employment.

Some look at those numbers and see success, while others see failure. Milwaukee Hunger Task Force Director Sherrie Tussler said she doesn’t think the state is providing adequate support.

With all the need in the community, Tussler said she fears her organization — which is also the area’s food bank — will run out of food.

But Patrick, Walker’s press secretary, said the state is committed to helping people re-enter the workforce, and has spent $50 million on comprehensive employment and training programs.

The state is one of five this year, along with Colorado, Delaware, South Dakota and Texas, that have pledged to provide employment and training programs to anyone who wants them.

Republican state Rep. Mark Born, chairman of Wisconsin’s Public Benefit Reform Committee, said the number of people who found work is impressive. And, he said, the fact that thousands chose not to participate in the state’s program was their own decision.

“If you are an able-bodied adult and you choose not do anything to help yourself, you shouldn’t expect the state government or federal government to provide benefits for you,” he said.

Yet sometimes, states have trouble simply finding people to let them know their benefits are expiring.

Hopgood, in Milwaukee, said it took the state two months to track her down, as she is technically considered homeless. That means she had 30 days to meet the requirement.

“I would think that before they just give you a three-month notice about your life they could explain everything,” she said. “And give people a chance to see if they could find work, or not.”

Read original article – January 19, 2016
New Work Requirements Put Food Stamps at Risk