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Updated: 13 hours 25 min ago

Judges In California Losing Sway Over Court-Ordered Drug Treatment

October 01, 2018

SANTA CRUZ, Calif. — Dressed in jailhouse orange, with hands and feet shackled, Jimi Ray Haynes stood up in a Santa Cruz County courtroom and pleaded guilty to a felony weapons charge.

Haynes, then 32, had spent the previous two weeks in jail detoxing from methamphetamine and heroin. The judge told Haynes he could serve part of his yearlong jail sentence in a drug treatment program rather than locked in county jail.

Eileen Jao, an assistant district attorney, quickly interjected: “It has to be residential, not outpatient,” she said. “It’s residential or jail.”

Jao wanted the terms to be crystal-clear. Because of a new county policy that took effect at the beginning of the year, treatment for low-income residents like Haynes, with drug-related criminal charges, must be decided by clinicians and providers — not the court. Judges can order whatever they want in terms of treatment, and prosecutors can block designated treatment they deem too risky, but essentially the type and length of treatment deemed appropriate is out of their hands.

The official record online showing that Jimi Ray Haynes can only do a residential program.

When conflicts arise between what the court orders and the providers decide, felons can languish in jail with no treatment at all.

Court-ordered rehab is increasingly falling out of fashion in California as Santa Cruz and 18 other counties begin to treat addiction like any other health condition — with the Medicaid program relying on evidence-based practices and trained personnel to make decisions on care. That has upended the status quo for judges, attorneys and defendants who often had agreed to residential treatment in lieu of jail — or at least to reduced sentences so inmates could get that treatment.

The California program appears to be unique in many respects, but other states — including Utah, Indiana, Kentucky, West Virginia, Virginia, Maryland, New Jersey and Massachusetts — also have sought federal permission to experiment with innovations in Medicaid-funded drug treatment.

In California, “these changes are a tough pill to swallow for the criminal justice system,” said Gavin O’Neill, drug court manager for the Alameda County Superior Court, which implemented the policy in July. “In the past, some judges and attorneys have been able to use residential treatment as a sanction and long-term monitoring mechanism, as well as a chance to address the underlying drug problem,” said O’Neill. “That option has been shut down.”

Proponents say that evidence-based treatment will lead to better outcomes and that residential care should be reserved for those with the most severe addictions. Under Medi-Cal, it is limited to 90 days.

“From the provider’s perspective, the judge ordering services has always been a problem,” said Katie Mayeda, a Santa Cruz County Superior Court clinician. “Judges have good intentions to put someone in treatment rather than in jail, but they don’t know the whole story. They don’t work in that realm — they’re not a clinical professional.”

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Advocates of the new approach — a Medicaid-funded pilot program that eventually is expected to be implemented in 40 California counties — say residential treatment is the most expensive and invasive option, and in many cases, outpatient treatment works as well, if not better.

If clinicians don’t approve residential treatment and prosecutors or judges won’t allow a release to outpatient treatment, the case can stall and felons become doomed to spend more time in jail.

Nearly three months into his jail stay, Haynes still was waiting for someone from a drug treatment program even to evaluate him, let alone determine his care plan. In the meantime, Haynes said, he received no drug treatment.

Because of the policy change, some prosecutors say they are less likely to accept anything but jail time.

The sign for the Santa Cruz County main jail as seen from Water Street.

“We are more inclined to just say, ‘Hey, put him in the custody of the sheriff,’ and not worry trying to treat the substance abuse problem,” said Santa Cruz County assistant district attorney Archie Webber. “If you want to do a program, you can do it on your own time.”

Webber’s rationale: He doesn’t trust the care providers, drug treatment organizations that contract with the county, to act in the interest of the state.

“We don’t want someone else to come in after us — a care provider, who hasn’t been in the process — and make those decisions for us,” Webber said.

The new policy, operating now in a third of the state’s 58 counties, stems from the expansion of Medicaid under the Affordable Care Act. That increased access to health care, including drug treatment, to the more than 13 million low-income adults in California who qualify for Medicaid.

In the past, counties had to use general funds or “block grants” to pay for court-ordered drug treatment for those who couldn’t afford it. Now, counties can pay for a range of drug treatment services — outpatient, medication-assisted, detox and residential — through Medicaid, or Medi-Cal, as it is known in California. But the new policy requires everyone seeking residential treatment to have a clinical assessment to determine whether that setting suits their diagnosis.

The counties that have begun providing drug treatment services under the so-called Drug Medi-Cal Organized Delivery System represent nearly 75 percent of the state’s more than 13 million Medi-Cal enrollees, according to the California Health Care Foundation. (California Healthline is an editorially independent publication of the California Health Care Foundation.) The rules on clinical decisions apply to everyone, not just inmates.

Santa Cruz County Superior Court on May 18.

Proponents hope all 58 California counties will come on board eventually, although the pilot Medi-Cal program is approved only through 2020, after which the federal government would have to reapprove the experiment.

Los Angeles County implemented the new Medi-Cal program just over a year ago and indicates it is running relatively smoothly.

“L.A. County got in front of it early on,” said Albert Senella, president and CEO of Tarzana Treatment Centers. “Treatment is now driven by medical necessity.”

But educating the courts on the new procedures can be a time-consuming process, and experts say it may take months or longer in some counties before the new rules sink in.

Because of a new county policy that took effect at the beginning of the year, treatment for low-income residents like Jimi Ray Haynes, with drug-related criminal charges, must be decided by clinicians and providers. (Courtesy of Santa Cruz County Sheriff’s Office)

In addition, counties and drug treatment providers say they have been weighed down by an administrative and staffing burden unlike anything they’ve seen before.

“It has been a tremendous amount of work,” said Senella. “A huge sea change in the way things are done.”

Some offenders say delays in receiving care are tough.

Haynes said he just wanted treatment, ideally in a residential setting.

“I’ve tried the whole white-knuckling sobriety thing,” said Haynes, who has a 10-year history with methamphetamine and heroin addiction. “The only measure of success I’ve had being clean and sober was in a residential drug treatment program.”

He would like to be able to visit with his wife and three children in a setting more pleasant than jail. Haynes wasn’t much older than his school-age kids are now when he visited his own father, then behind bars. He shook his head as if to erase the image.

“I don’t want my kids to see me in jail,” he said.

Haynes was released from jail this summer. Court records say his probation was revoked on July 17 after he was discharged from a drug treatment program for defiance and non-compliance.

He was re-arrested and, as of late last month, jailed in Fresno County.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

5 Things To Know About Trump’s New ‘Public Charge’ Immigration Proposal

September 25, 2018

A proposed rule from the White House would make it harder for legal immigrants to get green cards if they have received certain kinds of public assistance — including Medicaid, food stamps and housing subsidies. Green cards allow them to live and work permanently in the United States.

“Those seeking to immigrate to the United States must show they can support themselves financially,” Homeland Security Secretary Kirstjen Nielsen said in a statement.

The proposal, announced Saturday night, marks a new frontier in the administration’s long-term effort to curb immigration, both legal and illegal. It already has spurred intense criticism from Democrats, anti-poverty activists, health care organizations and immigrants’ rights advocates, who call its restrictions unprecedented.

“We are operating in an overall climate of tremendous fear and anxiety as a result of the administration’s overall approach to immigration enforcement and immigration policy,” said Mark Greenberg, a senior fellow at the Migration Policy Institute, which studies migration and refugee policies at local, national and international levels. He is also a former Obama administration official.

But what effect would this proposal have?

It’s a complicated question, touching upon vast government programs, with billions of dollars at stake. While the implications aren’t all immediately clear, Kaiser Health News breaks down some of the key elements.

1. First Thing First: What Is The White House Proposing?

The Trump administration wants to redefine a status known as “public charge” — a category used to determine whether someone seeking permanent resident status is “likely to become primarily dependent on the government for subsistence.”

In the past, people have been at risk of being defined a “public charge” if they took cash welfare — known as Temporary Assistance for Needy Families, or Supplemental Security Income — or federal help paying for long-term care. (Immigrants must be in the country legally for five years before being eligible for TANF or SSI.)

And that “public charge” designation could undermine their applications for permanent residence.

The new rule would expand the list to include some health insurance, food and housing programs. Specifically, it would penalize green-card applicants for using Medicaid, a federal-state health plan for low-income people. (Penalties would not apply for using Medicaid in certain emergencies or for some Medicaid services provided through schools and disability programs.)

Using food stamps, Section 8 rental assistance and federal housing vouchers would also count against applicants. Enrollment in a Medicare Part D program subsidy to help low-income people buy prescription drugs would work against them, too.

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The proposal “is definitely a dramatic change from how public charge works today,” said Kelly Whitener, an associate professor at Georgetown University’s Center for Children and Families who specializes in pediatric health benefits and managed-care systems.

A leaked version of the rule from March suggested officials then were also considering penalizing those who receive subsidies to buy health insurance on the Affordable Care Act marketplaces. But that idea was not in the proposal published this weekend. The marketplace subsidies are aimed at people at a generally higher income bracket than the beneficiaries targeted in the Trump plan, Whitener noted.

“They’re really homing in on low-income immigrants,” she added.

Nielsen said the proposed rule is “intended to promote immigrant self-sufficiency and protect finite resources.”

2. Is This As Unprecedented As Critics Say?

Yes.

Public charge is an old idea. In the 1990s, lawmakers expanded it to consider explicitly whether people had received cash-based welfare.

But including programs like Medicaid and food stamps, which are much wider in scope, is a significant change. It would more likely hit working people — the majority of people on Medicaid are themselves employed, and almost 80 percent live in families with at least one working member, according to data compiled by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Children who are American citizens but whose parents are immigrants could be more likely to suffer repercussions, said some experts. When parents opt out of public assistance for fear of their own legal status, their kids are less likely to be enrolled in programs such as the Children’s Health Insurance Program, or CHIP, for which they would qualify.

To be clear, receiving public aid wouldn’t necessarily stop people from getting a green card. But it would tilt the odds against them.

“Another piece is the enormous discretion the administration will have under its proposal in making judgments about who gets admitted to the country and who gets a green card,” said the Migration Policy Institute’s Greenberg.

3. When Will The Policy Shift Take Effect?

This is an early step in the complex federal rule-making process. And a lot could still change.

Once the proposed rule appears in the Federal Register, a 60-day countdown starts, during which anyone can weigh in with comments.

A final rule likely wouldn’t take effect until 2019.

And DHS is still seeking input on some details. For instance, it hasn’t decided whether CHIP would be counted as one of the “public charge” eligible programs.

In the interim, people who had received public benefits before the rule took effect would not be penalized for doing so.

4. Already, Though, The Proposal Is Having Effects.

DHS estimates that 2.5 percent of eligible immigrants would drop out of public benefits programs because of this change — which would tally about $1.5 billion worth of federal money per year. But others expect a much larger impact.

“The chilling effects will be vastly greater than the individuals directly affected,” Greenberg said. “There’s considerable reason to believe that [the White House estimate] may be a significant understatement.”

In the proposed rule, DHS notes that the changes could result in “worse health outcomes,” “increased use of emergency rooms,” “increased prevalence of communicable diseases,” “increased rates of poverty” and other concerns.

Given the complexity of these programs and the proposed rule — and the high stakes at play — low-income immigrants would be much more likely to avoid public benefits altogether, immigration experts said. Millions of immigrants are likely to be affected directly or indirectly, according to the Center for Law and Social Policy, a D.C.-based nonprofit organization.

That could have stark health implications.

Take free vaccines, for which children are often eligible and which would not be subject to the public charge rule. Families afraid of jeopardizing a green card could still be more likely to opt out of that service, Whitener said.

Already, she added, there are reports of people declining federal assistance — even though nothing has yet happened.

“The fear factor cannot be underestimated,” she said.

5. Will People Sue?

Legal action is likely.

Officials such as California Attorney General Xavier Becerra, who has frequently clashed with the White House, are weighing challenges to the rule.

“The Trump Administration’s proposal punishes hard-working immigrant families — even targeting children who are citizens — for utilizing programs that provide basic nutrition and healthcare. This is an assault on our families and our communities,” Becerra said in a statement.

But these actions depend on the final shape of the regulation, which could change through the rule-making process.

“They are likely to receive a very large number of sharply critical comments, and there is no way to know what changes they might make as a result,” Greenberg said.

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

From Syria To Southern California: Refugees Seek Care For Wounds Of War

September 19, 2018

EL CAJON, Calif. — In his native Syria, Mahmoud spent months in captivity in a crowded room three floors underground, never seeing the sun. Disease spread quickly among the prisoners, he said. Food was scarce, often spoiled.

Mahmoud said his captors, foot soldiers of Syrian President Bashar Assad, tortured him and shot him in the leg.

“I was in jail for seven months. They let me go, but I was physically sick, and tired,” the 29-year-old refugee said, speaking inside a cheerful, modern medical clinic here with signs posted in English and Arabic. “I had infections, inflammation. I’m still trying to get treated for it all.”

Mahmoud, tall and friendly, agreed to be interviewed on the condition that only his first name be used for fear of retaliation against family back home. He settled in one of the largest Syrian refugee communities in the United States — a midsize California town near San Diego.

And by virtue of this influx of refugees, it has become a health care hub for a traumatized and physically ailing population.

On an old-fashioned Main Street, among Western-themed murals, thrift shops and halal markets, sits the bustling El Cajon Family Health Center, serving Mahmoud and other victims of the devastating civil war in Syria.

Halal markets in El Cajon cater to the Iraqi immigrants who have been coming to the area for more than 30 years. Today, the markets are also frequented by the growing Syrian refugee community.(Heidi de Marco/KHN)

The El Cajon Family Health Center is a community clinic that treats many Syrian refugees.(Heidi de Marco/KHN)

Syrian refugees struggle disproportionately with post-traumatic stress disorder, anxiety and depression because of their exposure to extreme violence and anxiety about relatives still in Syria, clinic staff and community volunteers say. Most who have fled spent years holed up in camps or apartments, with little access to routine medical care for war wounds or chronic conditions such as diabetes or heart disease.

Virtually all of the people who enter this country as part of the federal government’s refugee resettlement program qualify by income for Medicaid, the government-run health insurance program for low-income people (known as Medi-Cal in California).

Physicians and others who work with Syrian patients say that the refugees experience long waits and must often travel long distances to see specialists — challenges shared by many other low-income groups.

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But access to medical interpreters is woefully insufficient, and refugees are often stymied by the paperwork and bureaucracy so unlike what they had back home. There, they were accustomed to walking in and seeing a doctor without having to wait, said Suzanne Akhras Sahloul, founder of the Syrian Community Network, a Chicago-based nonprofit that aids refugees.

Patients are often confused by Medicaid and the managed-care plans that provide it. They sometimes switch health plans inadvertently, which can lead to delays in care, El Cajon Family Health Center physicians and caseworkers said.

Of the 5.6 million people who have fled Syria since its civil conflict broke out in 2011, only a tiny fraction — around 21,000 — resettled in the U.S.

More Syrian refugees came to San Diego County than any other U.S. metro area — over 1,000 as of the first quarter of 2017, according to the State Department. And more than 80 percent of them live in El Cajon, where county service providers and resettlement agency offices abound, said Chris Williams, executive director of the Syrian Community Network-San Diego, a local branch of the aid organization.

Medical assistant Lagham Katola speaks Arabic during a checkup with a Syrian patient. Health care facilities are required to provide medical interpretation services, but they often do so over the phone.(Heidi de Marco/KHN)

Resettlement agencies, which work with the State Department to smooth entry into the U.S., generally help refugees sign up for Medicaid and get the care they need for their first three months in this country. After that, they are largely on their own to maintain coverage and get care.

“They will say, ‘Why do I need to visit the family doctor? Why can’t I go to the specialist?’” said Aileen Dehnel, a case manager at the El Cajon Family Health Center.

“Everywhere we go, people are helpful,” said Mahmoud, who now lives in Anaheim, Calif. “But the No. 1 challenge is the language.”

Relatively few trained interpreters in the area speak Arabic, and they are in high demand. In a communication vacuum, Mahmoud said, information gets passed from neighbor to neighbor, changing slightly with each telling, as in a game of telephone.

“We don’t know what’s going on,” he said.

Translators don’t always help, Mahmoud said. One time, he had to rush to the emergency room after a gallbladder attack, and an interpreter on the phone kept asking everyone to repeat themselves, blaming the difficulty on bad audio equipment. Mahmoud and his wife, Noura, became so frustrated that she used Google Translate to figure out what the nurses and doctors were saying. (Noura also spoke on the condition her last name not be used.)

Aileen Dehnel, a case manager at the El Cajon Family Health Center, helps a Syrian mother and daughter check in. Dehnel says refugees become confused by the paperwork and sometimes change their health plans without realizing it. Dehnel writes detailed instructions in Arabic for the patients she works with, but many of them can't read in any language, she says.(Heidi de Marco/KHN)

The signs in the El Cajon Family Health Center lobby are written in English, Spanish and Arabic.(Heidi de Marco/KHN)

Another refugee, 34-year-old Nisreen Tlaas, recalled having fainting spells after her arrival from Homs, Syria, in 2016. Two emergency rooms misdiagnosed her illness before the staff at a third hospital performed an MRI and saw an aneurysm in her brain.

She finally received lifesaving surgery — but only after a caseworker from the Syrian Community Network smoothed communications between a surgeon and a medical interpreter.

Dehnel, of the El Cajon Family Health Center, writes detailed instructions in Arabic for the patients she works with, and many pharmacies in El Cajon now print prescription labels in Arabic as well. But that’s not enough to make sure a diabetic patient gets his insulin or a pregnant woman takes her prenatal vitamins correctly, because many of the patients can’t read in any language, she said.

Language frustrations aside, the main challenge facing many Syrian refugees is psychological distress.

PTSD among Syrian refugees contributes to physical symptoms such as chronic pain, said Dr. Mai Duong, a family doctor at the El Cajon Family Health Center.

Some patients have seen relatives hurt or killed in fighting. Others don’t know if their friends and family are safe. Syria is among the countries affected by the Trump administration’s “travel ban,” and the administration also recently cracked down on refugee admissions in general.

Adjusting to life in the U.S. also can cause enormous anxiety. But many Syrian refugees resist asking for help for fear that authorities will swoop in.

“People always downplay their distress,” Duong said. “They worry that their kids will be taken from them.”

Mahmoud has tried talking to psychologists. But they haven’t been able to help him escape his dark thoughts.

“Our families are in a war zone right now,” he said. “I’m always in fear that my family will be killed.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Medicaid Covers Foster Kids, But Daunting Health Needs Still Slip Through The Cracks

August 24, 2018

“We would not be able to foster without Medicaid,” says Sherri Croom of Tallahassee, Fla. Croom and her husband, Thomas, have fostered 27 children in the past decade. They’re pictured here with four adopted children, two 18-year-old former foster daughters and those daughters’ sons. (Courtesy of the Croom family)

Sherri and Thomas Croom have been foster parents to 27 children — from newborns to teenagers — during the past decade.

That has meant visits to dozens of doctors and dentists for issues ranging from a tonsillectomy to depression.

While foster parenting has innumerable challenges, health care coverage for the children isn’t one of them. Medicaid, the federal-state health insurance program for the poor, picks up the tab for nearly all children in foster care and often continues to cover them if they are adopted, regardless of their parents’ income. And as a result of the 2010 Affordable Care Act, foster children who have Medicaid at 18 can retain the coverage until they turn 26.

This KHN special series examines the reach and the role of Medicaid, the federal-state program that began as a medical program for the poor but now provides a wide variety of services for a large swath of America.

More Stories

“We would not be able to foster without Medicaid,” said Sherri Croom, 41, of Tallahassee, Fla. “It pays for everything.”

Yet, Croom and other foster parents say that even with the coverage they struggle to meet the extraordinary health needs of their children. Part of the trouble is too few doctors accept Medicaid, most notably mental health specialists.

Families also face the challenge of coordinating treatment decisions between government welfare agencies and foster kids’ biological parents.

Treating The Effects Of Abuse And Neglect

Although foster care children make up only a tiny portion of the 74 million Americans who receive Medicaid, this population faces significantly more health needs than most enrollees. These children often have experienced abuse, neglect, violence and parental substance abuse. About half of them have been diagnosed with mental health disorders, according to the Medicaid and CHIP Payment and Access Commission.

Medicaid is the nation’s largest health program, yet its broad reach beyond traditional populations of low-income children and parents and people with disabilities is less known. Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly.

A 2016 study in the journal Pediatrics found that children in foster care were twice as likely as others to have learning disabilities and developmental delays, five times as likely to have anxiety, six times as likely to have behavioral problems and seven times as likely to have depression.

And the number of these enrollees has increased in recent years, largely as the opioid epidemic has devastated many families. Between 2012 and 2016, children in foster care nationally rose from roughly 397,000 to 437,500, according to federal data.

Foster children’s health problems frequently demand specialized and consistent care, yet these children’s often unstable lives make it difficult for doctors or other health specialists to care for them, said Dr. Moira Szilagyi, a pediatrician based in Los Angeles. The kids often move between foster homes or from foster homes back and forth to their families.

“Every time they change providers, some information is lost and leads to some duplication of services or children fall out of treatment,” she said.

Melanie Stimmell, a foster parent currently to a dozen children in Winter Garden, Fla., said nearly all the children she and her husband have taken in have had some mental health issues. She recalled it took months to find a nearby, Medicaid-friendly therapist for an 11-year-old who was bipolar and had been hospitalized before coming to her home.

Delays in getting these kids care has lasting consequences, she said.

“The issues snowball into other issues,” she said. “It affects their performance in school, which hurts their ability to make friends, which hurts their self-esteem and then they fall behind in classes and get held back and it affects everything in their life.”

In addition, some experts warn that children who have aged out of foster care at age 18 may delay care because they don’t know that they still have access to Medicaid until they turn 26.

“We are concerned that there are thousands of kids who should be getting Medicaid but aren’t because they are not plugged in to the system,” said Irene Clements, executive director of the National Foster Parent Association.

State performance varies widely on signing up former foster kids through age 25. For example, according to state officials, Florida has signed up about 7,900 of them; Iowa, about 700; Colorado, more than 21,000; and Indiana, 1,685.

Ali Caliendo says Medicaid coverage has been invaluable since she and her husband, Terry, became Anthony’s foster parents over four years ago. The child had bronchitis and pneumonia in his first year and struggled with some social and emotional problems early on. The Caliendos have adopted Anthony, who is now 5 and on a “good trajectory” as he prepares for kindergarten this fall, his mom says.(Courtesy of Ali Caliendo)

An Experiment In Care Coordination

A few states, including Florida, Georgia and Texas, have started to test an idea that might improve foster children’s access to care.

They are placing foster children in their own Medicaid health plan — separate from the coverage offered to most Medicaid families.

These plans are typically run by private, mostly for-profit Medicaid managed care companies, including Centene, Amerigroup and United Healthcare.

Supporters say these plans can be designed to meet the higher health needs — particularly for mental health services — of foster children.

For instance, Florida’s child welfare plan is required to have more primary care doctors and mental health specialists available than traditional Medicaid health plans. It also offers extra benefits such as nutrition counseling, art therapy and a $25 monthly allowance for over-the-counter items such as cough syrup and vitamins. About 34,000 foster kids are in the plan managed by Centene Corp.

“This is a promising model,” said Roxann McNeish, a research assistant professor of child and family studies at the University of South Florida.

She said having health plans with administrators and physicians trained to address the unique needs of foster kids has helped better coordinate care to them. But more study is needed to see if children’s health has improved care compared to traditional health plans, she cautioned.

These plans can also allow children to remain under the same coverage if they move to different parts of the same state.

Szilagyi says getting care to foster children is often difficult because responsibilities vary between state agencies, birth parents and guardians. “Obtaining consent from parents to provide health to the child can be challenging,” she said.

The foster-care only plans try to improve this because they are trained to work with state foster care caseworkers to speed care to children.

But a 2016 study conducted by researchers at the University of South Florida for the state Agency for Health Care gave the plan mixed results. It found that parents often complained about lack of access to doctors. On the other hand, child welfare agencies reported having more input in health decisions for children. This is important because those agencies are responsible for recruiting and supporting foster parents and coordinating health services for the children.

The report did not examine whether the children in the plan had better outcomes.

Glen Casel, chief executive of Community Based Care of Central Florida, a foster care agency that contracts with the state to provide child welfare services, said these specialized plans have limited benefit. “I don’t think a foster-care-only plan is a silver bullet,” he said.

His nonprofit has worked with Centene to get more mental health providers in the network, particularly in communities that typically don’t have large numbers of Medicaid enrollees but have foster parents.

“It’s a daily fight for us,” he said.

Despite the challenges, foster parents do recount success stories.

Ali and Terry Caliendo, of Las Vegas, said Medicaid has been invaluable since they became foster parents to 7-month-old Anthony in 2013. He had bronchitis and pneumonia his first year and later was repeatedly sent home from day care for being too aggressive toward other children.

“He was so sick as a baby, and then socially and emotionally he really struggled with violent rages and attachment issues,” Ali Caliendo said.

Medicaid paid for him to see psychiatrists, psychologists and physical and occupational therapists.

“Having the support through Medicaid made it an easier decision to be foster parents,” Caliendo said.

The Caliendos adopted Anthony at 18 months and were able to keep his Medicaid coverage. This fall, he begins kindergarten.

“Because we were able to intervene early, he is on a good trajectory, and we are really pleased,” she said.

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

Readers And Tweeters: On Seniors Packing Heat And When They Should Pack It In

July 30, 2018

Straight outta the “accidents waiting to happen” file: An estimated 9 percent of Americans 65 and older are diagnosed with dementia, marked by mental decline and personality changes. And about 45 percent of folks 65 and older have guns at home.

Over four months, Kaiser Health News, in partnership with “PBS NewsHour,” investigated the intersection of gun ownership and dementia, uncovering dozens of alarming cases of gun-related deaths and injuries (“Unlocked And Loaded: Families Confront Dementia And Guns,” June 25). The feature and accompanying video triggered a huge response, with many readers sharing personal experiences. KHN plans to follow some of those leads for follow-up stories.

Social media exploded with shares on this hot-button topic. A clinical psychologist in Woodland Hills, Calif., compared the struggle of taking away a dementia patient’s car keys to keeping firearms out of reach:

Families have difficulty restricting their #dementia symptomatic family members from driving. Possession/Access to #firearms is JUST as important when dealing #aging/#mentalhealth. Unlocked And Loaded: Families Confront Dementia And #Guns https://t.co/jM2Y3Imxhm via @khnews #NRA

— Harry Stark, Ph.D. (@HarryStarkPhD) July 3, 2018

— Harry Stark, Woodland Hills, Calif.

Gerry Hills of Phoenix advocated for red-flag laws, which allow law enforcement or other state officials, and sometimes family members, to seek a court order to temporarily seize guns from people who pose a threat to themselves or others.

Need Red Flag laws. As Boomers age this and suicide will get worse

— Gerry Hills (@gahills14) June 26, 2018

— Gerry Hills, Phoenix

On Facebook, Bettina Camcigil of Alexandria, Va.,  took a hard-line stand on gun possession:

— Bettina Camcigil, Alexandria, Va.

And the South Sound Alzheimer’s Council in Olympia, Wash., issued a reminder that guns and dementia do not mix:

Be on the lookout for further coverage on guns and aging from Kaiser Health News.

A Plug For The VA

Great article on integrated health care (“Texas Clinics Busting Traditional Silos Of Mental And Physical Health Care,” July 5). Please consider sharing with your audience the history of the Department of Veterans Affairs health care system and its long-term commitment to this very issue, dating to the 1990s at least. Thank you.

— Dr. David A. Nardone, retired clinical director of primary care at VA Medical Center, Portland, Ore.

The Feedback Loop: More On That Doggone Pain

Editor’s note: We previously shared letters on this topic, but readers continue to react.

I was very disappointed with the tone of Julie Appleby’s article on painkillers (“Doling Out Pain Pills Post-Surgery: An Ingrown Toenail Not The Same As A Bypass,” June 22), which suggests vast numbers of the American public are at risk of becoming dependent on analgesics if they are prescribed after surgery or for other painful conditions. This is just wrong; millions of people undergo surgeries every day and do not end up dependent on painkillers.

For example, I had a total hip replacement a few years ago and was prescribed OxyContin after surgery. I stopped taking them after I recovered and had no desire to continue taking them.

Now when patients present to the ER with a painful condition, they are offered Tylenol because of the erroneous fear by doctors and the organizations they work for that they are going to make an addict out of a patient. Relieving pain and suffering should be the No. 1 motivation for health care organizations, not trying to size up how likely someone might abuse pain pills.

There are probably people whose chemical makeup makes them more susceptible to becoming addicted to opioids, as with alcohol; however, that is not the majority of people. It is disgusting to me that physicians are sitting around scheming about how few analgesics they can give someone after surgery.

I am a retired registered nurse. When I started working over 40 years ago, there was never any question about giving patients adequate pain relief. Now they are more likely to let patients suffer in pain. Honestly, my dog’s pain is better treated by his vet than mine is at my doctor’s office.

— Suzanne Bolwell, Bellevue, Wash.