 Good afternoon. On behalf of the McLean Center and the Center for Health and Social Sciences, Dr. Meltzer and I are delighted to welcome you to today's lecture in the 2018-19 series on improving value in the U.S. healthcare system. It's a pleasure to introduce Professor Harold Pollock. Harold is the Helen Ross Professor at the School of Social Service Administration. He also serves as a professor in the Biological Sciences Division and the Department of Public Health Sciences. Harold is co-director, as many of you know, of the University of Chicago Crime Lab and the University of Chicago Health Lab and a committee member of CHAS, the Center for Health Administration Studies. Harold is published widely at the interface between poverty, policy, and public health. His research appears in journals like JAMA, the American Journal of Public Health, Social Service Review, but also in popular press like The Washington Post, The Times, The Nation, The New Republic, and so on. Harold is considered one of the country's leading experts on Medicaid policy. His talk today, as you see behind me, is Medicaid policies to serve severely disadvantaged populations. Please join me in welcoming Harold Pollock. I'll try to live up to Mark's generous billing. I always wish that my mom could be here to listen to those introductions, although she would add a few things that you somehow left off about that seventh grade debate contest that I won. Yes. It's a bit of a challenge to give a talk like this, because so many of us deal with Medicaid every day and are so aware of the challenges that we face. Of course, some of you have seen me talk about Medicaid before. I want to talk a little bit about some of the characteristic challenges that we see and have a good conversation about at least some of the work that we do. Thanks so much for coming. Here's my roadmap for the next three hours or so. I want to talk a little bit about the variety of severe disadvantages that people face and severe vulnerabilities, and also how we've made actually a lot of progress in Medicaid. We've created a platform to really help people, but we don't quite know what to do with it yet. It's not quite functioning the way that it needs to to really help people the way that we all want to. I'm going to focus a little bit on SMI and the opioid epidemic and also actually on the criminal justice population where David and I have done quite a bit of work in the health lab of late. Then I'll just offer some polonious-like pompous final bromides around five o'clock today. Medicaid has been traditionally the whipping boy of American health policy. When I was trained 20 years ago as a doctoral student, Medicaid was really considered to be the stepchild. This is a cartoon from the New Yorker who says, is there a doctor who accepts Medicaid in the house? That's one of those funny but not funny things that sometimes humor is a way to say stuff that is hard to say straight up. This question about what are we really doing if we give people a Medicaid card, but the program has some defects, what are we really giving to people? In a lot of ways there was a sense that Medicaid was inadequate, it paid too little, had all sorts of problems. The concept of Medicaid as welfare medicine is a very common trope. Those of you that have seen the recent debate about work requirements in Medicaid, that is largely about, is this a health insurance program, is this a welfare program? What is the social significance of being a Medicaid recipient in America now that 70 million Americans plus are receiving Medicaid? There's always been this fear that Medicaid recipients are politically marginalized and that we're leaving poor people to the tender mercy of the states. When I talk to people about health policy and people often say, we really should leave health policy to the laboratories of democracy across America. If that person is over the age of 65, I often say, how about if we do that with your Medicare and put the full faith and credit of the state of Illinois behind your Medicare benefits? Most people say, that doesn't sound like a very good idea. There's this sense that in the American social insurance system that we have always made a distinction between the truly worthy and powerful constituencies who get what we refer to as social insurance, which is often done at the federal level, and that we leave it to the states to support groups of people that we're a little bit more ambivalent about. And certainly the way that I would have taught Medicaid 20 years ago would really emphasize that pretty highly, and I certainly today I would talk about that. The low reimbursement rate of Medicaid, the incredible bureaucratic complexity of Medicaid is a significant problem. The cross-state variation in what's covered and the quality of Medicaid, and also simply the fact that if you move across state lines, that you have to reapply for Medicaid. From this very spot, I've talked about my wife and I, our experiences taking care of her brother-in-law, who was a Medicaid recipient in New York State, and when his mom died and he had to move into our home, he was suddenly without his Medicaid because we live in Illinois at the precise moment that his mom had just died. And when you're a Medicare recipient, you don't have to worry about that. Then there's indignities such as the $2,000 countable asset test for people who qualify for Medicaid through disability. Your family home is actually to a significant extent sheltered from this requirement, but if you think about how hard it would be to live in your home if you can only have $2,000 in countable assets, what do you do during the polar vortex if your pipes burst and you got a sudden bill? And all of the mundane ways that we treat people indecently, particularly here in Illinois, where we really rank quite poorly in national rankings, we sometimes talk about the blue states and the red states. And here in Illinois, we like to consider ourselves a blue state. But if that comes with a connotation that we offer more generous and competently delivered social policy, that would be a difficult hypothesis to confirm in the data, even compared to with some of the neighboring more conservative states. Have I left anything obvious off of this list of Medicaid bad things? David? I think that point is very well taken. And so under the hood of the obvious problems are the not so obvious problems. By the another one is that is that we also pay late and Medicaid is a poor payer. I've spent a lot of time talking to people in this hospital about why how it would be nice if we were nicer to people on Medicaid in this hospital. And one of the things that people say to me back is, let's just talk about how much money right now as you're asking this question, the state of Illinois owes the University of Chicago Medical Center. And it's often a nine figure sum. And that kind of kneecaps my efforts to try to advocate within an institution where people have to worry about things like that. And so there's a whole, there's a whole variety of obstacles. Yeah, and I'll put I'll put a pin that by the I think that also varies across states quite a bit. And you can have high quality governance with a very, a very generous Medicaid program and high quality governance with a very panerious Medicaid program. When you start to want to have a blue state policy with red state financing, that's when you run into a problem. Yes. When they are covered, they sometimes just drop out of cover. They don't seem to be aware that change in the life is so dramatic. But it's also those of us who are on the outside looking at it, in any case, that it's nearly impossible to gather data to have any way to put them accountable for any aspect of the work that is supposed to be going on or any way to check any of the claims, claims for putting the request from the person by the claims and Medicaid makes in terms of what's covered and what's not covered. And the second is the MCO system has created a whole new level of the loss of any understanding because there are so many different variations across the MCO system that started to just look at the drugs that they covered and how they became accessible. So now I can say, I'm going to acknowledge and put a pin in these points that you guys are making. We could spend an entire week outlining more of these. Some of these, by the way, also apply to private coverage as well because one of the striking things is if you ask individual patients, patient satisfaction surveys, things like that, Medicaid compares surprisingly favorably with private coverage. But there's significant issues, which I would say 10 years ago we would say are kind of decisive and relate to the deeply stigmatized position of Medicaid within the health politics of American government. By the way, one thing that hasn't come up that I do want to mention, one of the most mundane realities is just getting people access to basic services like dental care. Mark mentioned that I used to write for The Washington Post. I still write for them, but I don't have a regular column anymore. I did a piece on dental care and I just went up to the Heartland Clinic and I just met a couple of people. And this is a pretty young lady that I met who had a toothache and she was describing how every morning she had to call at 6 a.m. to try to get into a dental clinic and she was on a waiting list and the one morning when they could take her, she was taking a test for an educational thing and she ended up losing a tooth. And, you know, it wasn't the worst thing happening to her that she lost a tooth. But I remember I was talking to her and she kept smiling like this. She kept her mouth closed and she felt very stigmatized. And, you know, she lost a tooth. And, you know, it didn't have to happen. And this is another man that I met the same day who hadn't had his teeth cleaned in two years. He's a Medicaid recipient in Illinois here and he's been chewing on the left side of his mouth for two years. And the lack of imagination in our policy construct to provide basic services like this certainly makes, you know, it's a real thing. But then we get to something else that's happening which is the surprising political resilience of Medicaid and its position that turns out to be much less stigmatized than we might have thought. And in many ways, you know, a year and a half ago Republicans tried to repeal and replace the Affordable Care Act and that effort failed. And it's really striking how the popularity of Medicaid turned out to be fundamental to why that effort failed. Republican governors around the country, advocacy groups, many, many people, including people in this room who could give us a long list of why they're really angry about Medicaid, when the issue came up, should we block grant and cut Medicaid? People said, no, we're actually going to go to Washington and try to kill any politician who tries to do that. And it was really striking in a couple of different ways that Medicaid turns out to be an essential pillar for a lot of things and it has some unexpected constituencies that people didn't really understand. And I want to just lay out a few examples of that. By the way, that's true on both sides of the aisle. Is anybody familiar with Senator Sanders as an advocate for single-payer healthcare? Bernie Sanders is a senator from Vermont. He ran for president just to bring us all up to speed. That was supposed to be a joke, but the other guy says, please clap. So it turns out that Senator Sanders' single-payer bill is not a single-payer bill that he has specifically carved out the disability components of Medicaid and said, I'm not going to touch that. And I think that was a very wise decision. One reason is we've had, since 1965, 50 states have wired up a way to take care of people with disabilities. And Senator Sanders and his staff widely said, you know, if we try to rewire that, wow, we're going to scare a lot of people and we're probably going to screw a lot of things up that people have figured out how to do since 1965. And it was striking in that way. It was also striking how Republicans thought that if they specifically left alone the pieces of Medicaid that are designated as disability, that the disability community would at least be permissive about a lot of the changes they wanted to make to the ACA Medicaid expansion. And that turned out to be absolutely the opposite of what happened. Every single disability advocacy group in the United States was hotly opposed to that repeal effort. Now, part of it was that they were going to block grant Medicaid, which people understood in the long run was a way of cutting the program. But also it turned out that people, the ACA Medicaid expansion is serving a function for people, including people with significant vulnerabilities that we don't think of as the group served by the Medicaid expansion in a way that was not understood. So what's the distinction between the ACA Medicaid expansion and Medicaid that someone would get because they're on SSI? Anybody want to fill us in on that? Anybody? Those of you that are on Twitter asking about, you know, this is your moment. So one thing, every state has multiple flavors of Medicaid. And there's this saying, if you've seen one Medicaid program, you've seen one Medicaid program, that's actually itself oversimplified. If you're seen because each state has more than one Medicaid program. And so we tend to think of the idea, if you're disabled, like my brother-in-law Vincent, you would be getting a Medicaid on the basis of a disability diagnosis. And you would be getting a set of services that come with that and that come usually with an SSI, receiving SSI. Well, it turns out that disability as designated in that process is a binary thing. You're either disabled or you're not. It turns out disability in the human life world that we live in is a multi-dimensional and continuous thing. And there's lots of people who have disabilities who need Medicaid but who are not on it through the root, through that traditional root that has the word disability on it. Why would that happen? Anybody have a sense of why that? Maybe you have patients for whom this is true. Why would that happen? This is the pop quiz part of the talk. What is the definition of disability? So we'll make that a little more granular if you could. Well, over time, HIV evolved, expanded. So one thing is there's people who are marginal. Like, suppose I'm a 50-year-old man. I've been laid off from my job in an unskilled... I used to be a coal miner and I got laid off. And I have a sore back and I'm kind of depressed. And I'm having trouble finding work. But it's not exactly clear what's going to happen to me through that disability process. And maybe part of the reason why I got some problems is I have some issues with OxyContin that are kind of part of it too because my back hurt and I started taking prescription opioids. And what is true about addiction in terms of the disability designation in Medicaid? Anybody know? Not only is it not a disability, it's a contributing factor in the determination of disability. So anybody who's affected by the opioid epidemic, they cannot be on Medicaid SSI because of an opioid disorder, even if it's an obvious, properly diagnosed disorder that is disabling. You could be homeless living in a homeless shelter because you have a drug addiction and alcohol problem that's very severe. You're not eligible through that route to get Medicaid. So that's one issue. By the way, there's some other reasons why somebody might be on Medicaid in another way. So Albert mentioned one issue. What's another issue? Somebody go, yes? And there's all sorts of interesting normative questions about what counts as a disability. And if I use a wheelchair but I'm a graduate of the University of Chicago Law School, maybe I'm more competitive in the labor market than someone who does not need to use a wheelchair but has no marketable skill in the labor market where they live. But also I could also have problems like I could have $10,000 in the bank and I'm not going to meet the asset requirement. But I have very low income and there's all kinds of reasons. So it turns out that a lot of people were using the ACA Medicaid expansion who had genuine disabilities. And that was something that Washington was late to get that memo in terms of reaching out to constituencies. The other interesting thing is that the consumer experience in Medicaid turns out to be better than the experiences many people have on the Affordable Care Act state marketplaces. By the way, this has had an ambiguous impact on American politics. Many people who supported President Trump in 2016 in places like West Virginia, Kentucky, one of the sources of great resentment was I'm on this crappy insurance, whatever you call it, through Obamacare and if I go to the emergency room it's going to cost me $600. And my cousin, who everybody understands is a total screw-up, he's on Medicaid and he can get all this stuff for free. But you can imagine that that has some very interesting long-term implications for the future of American healthcare if people think that Medicaid is better than what they have. And many of the under-the-hood issues that David mentioned from a patient perspective, that's not necessarily what they see. And it was also interesting, I'm going to come back to this, when you talk to Republican politicians around the country, there was some interesting developments around that as well and I'll come back to that. There's also some other things that turn out to be valuable about Medicaid and this is the part of the talk that many of my progressive friends find a little bit less comfortable. You know, I teach at SSA where I'm actually the right flank of the school, I think, which is... you know, I'm the house arch-conservative because I'm a liberal Democrat but that's the... So, you know, Medicaid gives voice to local values and experiments, the waiver process, there's a number of aspects of Medicaid that allow different policy choices to be made and different political compromises to be made. And, you know, I often don't like what these compromises are. For example, Arkansas has put in a work requirement that in many ways is poorly designed and I consider to be cruel to people who end up discovering that they're kicked off a program because they failed to meet a bureaucratic requirement and there's a lot about the work requirement that I personally would not do. But what those things do is they... I also, though, in the larger picture, I say, well, there's Arkansas where they have a work requirement I don't like and there's Texas where they just did not expand ACA Medicaid at all and if you have a stroke in Texas and you are a poor person and uninsured, you're out of luck in a lot of ways. Which do you like better? The work requirement that's not ideal but that allows you to take care of people or nothing. And there's a sense that states can find a dignified political path to create bipartisan compromises through Medicaid that you can't do in Washington. You know, governors, if you remember the House of Representatives in the United States, you really don't run anything. You can basically babble like I'm doing right now with no consequence. And if you're the governor of Ohio or Wyoming, you can't do that. You've got a rural hospital that might close. You've got a bunch of real problems that you have to deal with. And Medicaid... there's a supple T to allowing Medicaid to be the vehicle where these compromises are made. That's a real thing. And, you know, many of my progressive colleagues are like I have a two-step process for bringing about universal coverage. Step one, we achieve permanent political dominance at every level of American government. And then step two, here's what we do. Can we just kind of go back to step one for a second on that? Medicaid allows for compromise in a real way. Medicaid is also the safety net for the safety net. And that's also something that's very important. Anybody familiar with the Oregon Health Insurance Experiment? How many of you have seen at least 52 talks and blog posts about the Oregon Health Insurance Experiment? So the Oregon Health Insurance Experiment found that the physical health benefits of giving someone Medicaid were real but modest. And the benefit was mental health, reduced anxiety over finances and so on. But the benefits weren't as great as one might have expected. And one reason why was that the Oregon Health Insurance Experiment, giving someone Medicaid partially substituted for free care they were getting anyway. A very large fraction of people in the control group were getting more than 60% of the medical care of the people in the treatment group, as I recall. And so to a great extent, what the Medicaid expansion is doing is it's subsidizing the care, it's stabilizing that network that provides the care. And that is just as important as what the human beings see who get the care. And particularly cities and counties, Medicaid is a critical thing. One of the late intentions in American politics when it comes to taking care of really severely disadvantaged populations is what is the distribution of burdens between states and more local units of government, which are often the ones that are really left holding the bag to do homeless services, to do addiction treatment, and so on. And Medicaid is often stabilizing that. And Cook County Health System, Medicaid expansion has been very, very important to the financing of that. So we built this costly platform, and let me talk a little bit about what's working and what's not working in these three critical populations. Criminal justice population, people who use drugs or otherwise have substance use disorders, people with serious mental illness. And at least I'll tell you a little bit about the world that I see. And I think a lot of us in the room see different aspects of this. But that's what I see. So let's start with what we're doing right in criminal justice. First, in a place like Cook County, David and I are doing a big trial called the Supportive Release Center of people leaving Cook County Jail to make sure they have a place to go if they're leaving at 10.30 at night. And one of the really amazing things about Cook County Jail is almost everybody that's going through there is insured on Medicaid. And they do a great job there. They enroll them on jail entry, which is a lot easier to do than doing it when people are leaving, when it's sort of a chaotic process and people just want to get the heck out of there. You know, we do see some people who are undocumented, who are not Medicaid eligible, but very small number. And that's quite something. And it's also striking that there's a very broad bipartisan consensus that this is a good thing. And I was an advocate for the Affordable Care Act when it passed. And this is really striking to me. And I'll come back to this one or two times again. But when ACA was passed, many of us were very worried that there was going to be a Willie Horton-like politics around expanding Medicaid. You know, what the ACA Medicaid expansion does is it provides health coverage to basically low-income adults who are not vets, who are not moms, who are not disabled, who are not eligible for public insurance any other way. And if you start thinking about who are the large populations of people who fit that description, you very quickly realize, wow, the criminal justice population is one obvious place where you're going to find a lot of people. And there was a tremendous fear that we were going to have Willie Horton leaves Cook County jail, gets enrolled in Medicaid, and butchers a nun and ends up on the front page of the Tribune. That was a very real anxiety. One of the interesting things is that that has... Republicans have not done that at all. There have been a couple of Republican politicians around the country who've dipped their toe in trying to say that Medicaid expansion is subsidizing criminals, things like that. That has not been where Republicans want to go with this. They don't feel it's a politically effective message and it's not a message that they feel good about that they want to do in terms of their values. When we talk to Republican politicians around the country, most people that I've talked to say, I think it's really important that we give health insurance to people leaving the criminal justice system who have profound problems that we have to take care of. That's interesting. And actually it turns out that David Dagan and Steve Tellis have a wonderful book on criminal justice reform called Prison Break, where they talk about how within the deepest red states in America there's a real groundswell of support for criminal justice reform. That's a real thing. It comes from Christian conservatives who are very motivated by their redemptive possibilities of people who are moving through the criminal justice system, who they want to assist. And it comes from libertarians who are very unhappy with the idea of mass incarceration. In fact, the rhetoric of this movement has things like prison guards are bureaucrats with guns. They actually have talking points that they distribute to conservative politicians in places like Texas, South Carolina, Alabama, where they're trying to deal with some of these mass incarceration issues. Very, very important. This is not a liberal thing. They do not bring liberal policy experts in to talk to people. This is not at all the identity vouching that they want to be doing. But it's a real thing. And there's been a very strong support across the board that we have to help people going through the criminal justice system, that it speaks well of American politics. Yes. Mark. Is it done for financial reasons or to improve the care of the incarcerated? It's funny. A little bit of both. So one of the things that's happened in a place like Texas, where basically conservative Republicans have, maybe they're a little nervous now with the veto thing, but they basically own the state politically and they're saying we could build a new prison and do a tax cut. What's interesting, by the way, is Republican politicians in the purple states are more resistant to this, because they still need the criminal justice issue as a partisan tool as they fight with Democrats. In places that are solidly Republican, they really do start saying, well, how do we want to spend our money? And is this just too expensive? And we don't need the issue from a partisan perspective. But I think it's a very genuine thing. I think to a great extent people are motivated in a very genuine way by a sense of values that something has gone badly wrong with the criminal justice system. Now there's some things we're not doing right. And some of them are obvious. We do a very poor job of making sure that people actually have practical access to services. This is particularly true in jails. So there's prisons and there's jails. And basically if you're convicted of a serious felony, you go to prison and jail is much more the place where people go while their charges are being adjudicated, if they have a less serious charge, they've just been arrested. The jail is a much more fluid place, often includes people who have significant life challenges going on. And at 26th and California, we have people who might be leaving at 10.30 at night who are at this moment a maximum personal vulnerability and you say, who's paying attention to those people? And the answer comes back with nobody. And what we're trying to do with the supportive release center trial with TASC and Heartland is to say, can we at least give people a place to go so that we can take care of that? And I'll come back to that in a minute. Very poor attention to social determinants in Medicaid. Come back to that. And all of the ways that we don't really give people access to services even when they're nominally eligible for them. And of course, in the deepest red states where there's no Medicaid expansion, people leaving the criminal justice system are by and large uninsured. And that's a particular challenge. By the way, when people who are in the criminal justice system are injured, we did a study of gun offenders. Anybody know the percentage of gun offenders that we interviewed who have been shot in their adult life? Let's just give you an idea of one aspect of this. The people we interviewed, 40%. Not shot at, shot. Before ACA Medicaid expansion, those people were almost always uninsured when they were shot. And some of those people were walking with colostomy bags because they got emergency care when they got shot in the abdomen, but they couldn't get surgery to get that fixed afterwards. People who were wearing helmets because they had missing pieces of skull and they were trying to find a physician who would close up the... We don't see that after Medicaid expansion in Chicago, Detroit, the way that we did 10 years ago. But we do see that in Houston, Miami, places where they don't do the Medicaid expansion. Another challenge we have is just bureaucratic siloing. We decouple correctional healthcare from Medicaid. So when you come into the correctional healthcare system, you are disenrolled in Medicaid. And the services that you get in that setting are paid for in a totally different way. And then you have to be reconnected to Medicaid when you leave. And guess what? There's all kinds of problems with that process in terms of continuity of care and so on. And so we've created a real transitional nightmare with that. And many people are trying to improve that process. But it's... Arizona actually has a Medicaid waiver where they're trying to do all their correctional care through Medicaid, which would be a much better system. The federal government doesn't like that because basically it would have to pay the federal match for the correctional care. Just one of the predictable issues that we have, when people leave prison, they have an incredibly high risk of death. The risk... The adjusted mortality rate in the first two weeks leaving correctional setting is about 12 times that of the general population. The two most common causes of excess mortality are homicide and opioid overdose. And I'll come back to that. But there's a famous study by Ben Zwanger and colleagues. So people are precisely at the moment when they're between systems. They're at the maximum vulnerability. So let me say some things about addiction. Again, there's some surprising things that we're doing right. So I mentioned the Willie Horton anxiety around the criminal justice process. There was the same anxiety that advocates for the Affordable Care Act had about addiction and mental health parity. And in fact, the addiction community while the Affordable Care Act was being formulated developed a whole political strategy about how to present addiction in the political process as ACA was being debated. And they go to the Senate Finance Committee and every Republican votes for all of the addiction and mental health measures in the Affordable Care Act, including the ones... These are all people who voted against the Affordable Care Act in its final bill, but they all voted for the substance use and mental health parity components that never became a controversial issue in ACA in a really striking way. Part of it was that President George W. Bush had made important contributions to mental health parity. It turns out that substance use and mental health parity is kind of a core principle in American politics right now. Whether it's actually implemented is another question. But we assume that many of us were overly pessimistic about what the values were in the American political process. It seems like everyone that you talk to has a cousin or a spouse or themselves have had issues like this, and the conversation in American politics is much more humane than it was, for example, during the crack epidemic 25 years ago. Part of the issue is that we also do not have a large amount of drug-related crime in America right now. It certainly exists, but there's no fear of massive crime, and that has a big impact on the way people think and talk about these issues. People think about people involved in the opioid epidemic as people who need help. Not people who are going to punch me in the face to try to steal my backpack. And that matters. One of the things that I'll get to in a minute, I've been talking to policymakers around the country, and it's really striking how when states were debating should we expand Medicaid after the ACA, the addiction component became a feature, not a bug, from the point of view of many Republican politicians around the country. We should expand Medicaid because it will help us with the addiction issues we're facing as a state. That was very important. That was totally the opposite of what many of us expected in how this conversation was going to go. There's some evidence that Medicaid expansion promotes more integrated care. Tom Diano and I published some papers where we found that there were more integrated care arrangements that involved specialty addiction providers in states that expanded Medicaid than in other states. There's also a lot of evidence that states that didn't expand Medicaid that just people with addiction disorders have a much harder time getting treatment. Things that we're not doing so well now, getting to David's point, the under-the-hood aspects of Medicaid really strongly influence access and quality and are not done very well in many states. Very few states cover the full range of evidence-based care. If you look, for example, at the American Society of Addiction Medicine and the continuum of care that they identify, very few states cover the full gamut the way that it would be nice if they did. The other aspect I don't think has gotten nearly enough attention, but I'm worried about for the future, which is where we have this, everything that everybody is doing right now with Medicaid and addiction is being framed by the opioid epidemic. If you talk to anyone within five minutes, they will start talking about the number of people who have died of opioid overdose in their state and how they're on fire to try to reduce that number. And the Trump administration, Congress, every state, every interest group is saying we've got to do something to stop people from dying. We have 72,000 people died last year of drug overdose. That's way worse than HIV at its peak. It's way worse than gun homicide. If you add it onto AIDS at its peak, it's unbelievably bad. But there's a problem that that's framing everything. And, you know, there's a lot of different kinds of addiction issues that people have. And if we start rewiring how we do residential addiction treatment based on the needs of people with opioid disorders, for example, it's not at all clear that that is the right way to do it when people have alcohol disorders or serious mental illnesses that require residential care who just have different needs. And I think we're going to discover that we're making some big policy mistakes because of that coincidence. In a way, it's been generative that people are so... There's a humane conversation about the opioid epidemic. That's good. But I think a lot of the details we're going to get wrong for other kinds of addiction disorders because we're so focused on that. And the opioid epidemic, I should also say it's just really hard. I think if we had absolutely excellent policies and interventions that were everything that everyone asked for, we would still have tens of thousands of Americans dropping dead every year from this thing. And that's just a reality. It's just a really, really hard problem. And it's not one that if you put me in charge of it that I feel I could just solve it. I was actually on an NIH study section two weeks ago called something called the HEAL Intervention where states were asked to submit huge grants. Each grant was maybe $120 million level. And you had to promise that you would reduce opioid mortality by 40% in three years. And when I was reading these applications, my thought was zero of these applications are going to... They're excellent applications, but zero of them are going to reduce opioid mortality by 40%. That's just... I just don't see that we know how to do that. Some things that I just want to mention in the two hours that I've left, so one of the real challenges we have with addiction is the way that we separate personal health services from public health. And this is really a big problem in addiction in a couple of different ways. One is that we need to do a lot of harm reduction in the context of HIV prevention. That would be syringe support programs, giving out sterile syringes, things like that. Medicaid typically does not pay for that. Case finding, distributing naloxone to prevent overdose. Those things tend to be quite separate from Medicaid and therefore quite separate from the health services that Medicaid pays for. So if you go into addiction treatment, they really need to be giving you an extensive package of overdose prevention supports, partly giving you naloxone in case you relapse when you're... We have some continued level of use, partly to connect you with a local service provider who can help you with the issues that you might have. That's not really happening. There are ways that addiction is stigmatized. It's harder to get transportation supports, for example. If you only get to addiction treatment, then it is. If you have other kinds of health problems where you might need transportation to a health care provider. And also uncertainty about Medicaid's future. When we talk to addiction programs, one of the things that we hear is we're afraid to take full advantage of what Medicaid offers right now because it's such a politically volatile issue. And so we are worried that if we expand services that what will happen is we will end up putting down a lot of fixed costs and then Congress will cut Medicaid and we will be stuck. And that's a big challenge that people... where political polarization makes it hard to on the ground do the things that people would like to do. What we've seen so far with the Medicaid expansion is programs are... there's less of an expansion of overall capacity than there is an expansion in just programs being paid for things they're already doing. And they're waiting for the dust to settle politically. Just some work that we... this is actually Brenda and Salana and Colleen Berry and Ken Stowler looked across states and found states vary dramatically in what their Medicaid programs cover. And amazingly enough, the states that generously cover methadone maintenance, a much higher percentage of people with opioid disorders are actually enrolled in medication-assisted treatment, which is the evidence-based treatment. Many states do not cover methadone or do not cover methadone properly in a generous way. And you see many more people are outside of the treatment system in those places. One in 20 justice-referred adults in specialty treatment for opioid use receive methadone or buprenorphine. This is terrible. This is the standard of care. And almost no one who is getting justice-referred treatment is getting the proper treatment right now through these vehicles. And when we looked across states, this is from a health affairs article that Colleen Grogan is the first author on from our INDATS group. We found basically the blue states cover a lot. The red states cover less. Notice, by the way, blue and red does not match the political blue and red Texas. You see they cover quite a bit. Whereas some of the states that are hardest hit, like Kentucky, are really lagging behind in just covering what people need. So it's not enough to just cover addiction treatment. You have to cover the treatment that works for the person's condition. So some more on the INDATS. We did find the major story is the differences between the expansion and non-expansion states. The biggest thing that we found under the hood when you mentioned managed care is the places that required prior authorization for buprenorphine treatment. Units were much less likely to offer that kind of treatment. They just did not want to deal with Medicaid to get the prior authorization. A patient would call up and say, I really think I should be on Suboxone, which is buprenorphine. And the units would be like, it's just too much hassle to deal with Medicaid around that issue and they're just not doing it. So we did find an expansion of services, but an incomplete expansion. So I'm getting down there. Hang in there with me. We also found that it mattered quite a bit whether there were physicians who were equipped to prescribe the treatments that people need, the places that had a good supply of physician. This is actually a paper that I did with Huffay Nguyen and Jason Hockenberry. We found that when there's buprenorphine-wavered physicians, it's a lot easier to get Medicaid services for people than otherwise. And we did find many, many restrictions on Medicaid that percolated through to patients. And I think that the bottom line is really that prior authorization of services is the key constraint that we found in Medicaid. This is Christina Andrews, the first author on a lot of these papers. It was quite striking how important that aspect of Medicaid was. In fact, if you show up in your cash-paying patient, they might be more willing to deal with you. Did you have a question, Mark? So let me get on to serious mental illness just in case you're not depressed enough with everything else I've been telling you. Many of the same issues come up with SMI and many people with SMI are in different types of Medicaid. And that was some of the people protesting. This is a protest during the ACA repeal. People with serious mental illness kind of were in the background compared to the people using wheelchairs from the optics point of view. But a lot of people with facing mental illness issues were very concerned about the repeal. This was a group that was called Not Dead Yet, which is one of the greatest advocacy names ever. So some things that we're not doing so well. Housing is a big one. A lot of people with serious mental illness need help with housing. And they need to have integrated care within the medical care system, but also between the medical care system and other sectors. And I'm going to spend the last 10 minutes of my talk laying out some of that. So a lot of us who cover Medicaid a long time have always been wondering, can't we find housing? Wouldn't that be so much more cost effective for so many people who keep showing up in the emergency room, for example? And David and I are involved in some interventions around that. Yeah, this one? It's interesting, because once you're on SSI, you're suddenly insured by Medicare, right? Well, SSDI would get you the Medicare. So SSDI, I guess that's one. So insured, as things go, everything's paying better, full payments, then we have the Medicaid. It's really not valid. And so I'm wondering, is part of this problem that we're not managing the transition to SSDI well? And what part of it is? And then occasionally also, you will honestly meet people, not so much in the hospital, I find, but in the clinic who are on disability. And you kind of wonder why they're there and how they got there. My experience with a few of them is that they're actually pretty high-functioning people just have to figure out a way to get this system to work pretty well for them. So, you know, there are problems on both sides. Well, you identified, oh, I'm sorry. I said there are problems on both sides of this, but I just wonder how much, you know, when we think about what's wrong or right about Medicaid, which leads to this population, the issue isn't maybe only just or even so much Medicaid, but the other programs that Medicaid surround. Well, I think that last point is so on target, because Medicaid is basically the safety net for every other program. And in the context of SSDI, the major way that it is is when you qualify for SSDI, once you get on the program, there's a two-year waiting period to get Medicare. During that time, that's when many people suffer the most punishing financial consequences of disability. And that two-year waiting period made some sense in the pre-ACA era when there was a sort of hazard issue around disability insurance and a desire for private disability insurance to pick up some of these costs. But very often, people, when they first get on SSDI, they have to wait two years to get Medicare. It's complicated. SSDI is a very complicated program, but that's a big challenge. And there certainly are people who are ambiguous cases in SSDI. And so that's no question. So there's a real set of issues there. And to the extent we can decouple the health insurance question from the financial assistance question also, that would, of course, be better. So I did some work in Chicago here, where I, again, I did some... By the way, those of you that know that I'm interested in personal finance would love that I've got this annuities ad up on the corner, which I take no responsibility for. So the people that are sort of the friendly faces who keep showing up. So I went up to Uptown, and I talked to some folks who live in supportive housing. This is a man named Haywood, who has had a whole series of medical challenges, and his entire life was stabilized when he was put into an apartment that costs, like, $800 a month. And he's now... His grandchildren come and visit him. He's got a refrigerator to hold his medicine. His life was transformed. That's his caseworker from Heartland there, who's a wonderful person. Here's another lady, Antonia, who had some similar issues. And supportive housing was just fantastic for her in many ways stabilizing her condition. And ended up being much cheaper because she was... Her health care utilization really stabilized when her life stabilized. The ability to have your own private space to be if you have a serious mental illness and you might be dysregulated every now and then is incredibly important. You just have a private space to be so that no one's... You're not freaking out other people or getting into conflicts, whatever. You can retreat, have some privacy. So Steve Brown, many of you know, over at UIC is doing a lot of work to try to house what are sometimes called the superutilizers. They're various names for folk. And it's a wonderful program in a lot of ways. Where you say, basically, you keep showing up at our emergency department. We're spending a fortune. Why don't we just find you an apartment? And maybe that's cheaper. And we're doing some work with some of the high-flyers type people who get involved with police a lot. And so there's nothing more beautiful than a galley proof. This came yesterday. Is there anything more beautiful? The thing actually comes out and the planet continues to rotate. You get so excited when you see the galley proof, you expect that this is going to be transformational. But we were tracking people who had repeated 9-1-1 calls where police were involved and ambulance. And we actually tried to identify people's risks that they had. And there were risks that they had because of their person-level risks. Or event type of risks that people had, like on check-day somebody's calling because there's a dispute between an SSDI recipient and their payee. Or this place-based risks. There's hotspots, like the train stations, where there's a lot of calls. And we also found there are things that are, we call them harm spots after Larry Sherman or risk spots. Maybe there's a private home where there's someone who lives there where there's significant challenges that might be 9-1-1 calls. There are frequent customers, our Medicaid recipients. And we're trying to help improve policies to help that group in a lot of ways. One of the striking things is how the healthcare system and the emergency first response system don't really inter-digitate. Inter-digitate. I can say that word. So here, Ruth Tenner, I just asked her if she would map up all the group homes in Chicago where there had been that type of 9-1-1 call. And we just made this map. As far as I know, no one else has ever made this map. So if you are a first responder in Chicago, you get a call, come to this address. Something's happening at this address. You're very often coming cold to that. You don't know that there's a person who lives in that home who's deaf. And I've exhausted everybody. Hey, Harold, thanks for your talk. I wanted to ask you, you talked about the bipartisanship support of Medicaid, especially at the state level with governors. I was wondering if you could share your opinion on what's going on in Utah and the political aspect there. Many states, by the way, have many experience with it on validation. The state legislature has been managing to explain that in a couple of two ways. One is to think of work requirements and the second is the ACA Medicaid expansion is supposed to go up to 138% for the property line and we want to do that with the other one, the Medicaid. And in Utah, one is only going up to 100%. So the good thing about that is that over 100% you can get into the ACA market. It saves the states a lot of money. If you look at 100% of the data to help get Medicaid out of the state exchange, there's two bad things about it. The story about an issue in the past it makes the risk pool in the state market to those governors. And I think one of the long-term consequences of that will be added that it makes how much more expensive for a lot of people. The Medicaid population of each of these states back what is the best health and population in the state market. So it turns out that in the states that didn't expand Medicaid how much more expensive something like 8% to 11% higher than they would get in the state expanded. So they're damaging the risk pool. I think the fact that Utah most Republican states in the country is expanding is still a good thing. And so it's one of those things where I would have preferred that they don't do that. But I'll take that over to Texas any day after me. I do think that the fact that the states that perform on these veterans have 90% of the people shut out of Medicaid expansion. If you actually look at the U.S. map it looks like there's a bunch of states all over the country. There should be a human being effect all thousands of them. The fact that Montana and Wyoming are doing their best doing it is just good like how they're not. I do think the next time we're on Democrats we're just going to say we've always been in Medicaid facing health insurance because we don't trust the government in the south. So in states that did expand Medicaid and where people can now get into Medicaid without an assets test but those same states didn't actually do anything to remove the asset test from their disability provisions. How does that actually get implemented? It's crazy. The Medicaid accountable asset limit is $2,000. If you just imagine how you're supposed to live with that constraint, it's crazy. By the way, did anyone know when that $2,000 was set at $2,000? 1989. It was $1,500 more than 40 years ago. So that is a huge, huge problem because people with serious disabilities very often the ACA to Medicaid expansion is not common with long-term services. And so there's a punishing asset requirement that causes tremendous hardship in people. And Andrea Kanwas who wrote a book about her sister along with her family and her sister-in-law came out of a wheelchair and was just what you bring in the Louis State in America and ultimately ACA will convince law officers to take over the real asset that's supposed to help with that and they could have raised the asset upon the WSCC I'm waiting for one thing. But I mean, if you get into Medicaid without the assets in a state where there's no asset test because they expanded Medicaid and you then use the Medicaid provisions that help pay for nursing home care or whatever right now the states still have the right to come after you for I forget the word isn't reimbursement but it's yeah so does this actually happen? Blue State's red state approach to Medicaid is there really a solution in the offing? We've got a changing governor who certainly talks a good talk but what's it going to take to actually move us off of what we do with Medicaid in the state of Illinois? I think we have to be I think we have to be open about some of the issues that David mentioned that things actually have to work and there is, we accept a mediocre quality of governance around a lot of issues and it's bipartisan issue and it goes and all of us who rely on this system see them every day I think that when the people actually disability space our current ranking is 44 or 47 and I think that we have as a state that we have to be a much longer conversation but I think that probably it's around Medicaid and the markets around the Illinois before and I think every fiscal everything in the state constitution has a fiscal policy problem or in some way works it out we need significantly more revenue we need more revenue on two percentage points that states annually increase the finance our current population and when you basically have a progressive income tax on the pension issue in the state constitution obviously a challenge the I think the disability has to be has to be pressured in the state in the long run I think I'm optimistic that one good thing is that our services are so bad that we have such a course of vision that's preventing all the problems and no budget for two years so that even all the functions didn't matter what the government state should be doing which is good I think when I look at people there it was really strange when I talk to people I am you know we have to give people that we know what we serve by each program that desperately cut through both quality of government and key leaders in both parties I don't even think this was how am I to politically think that I have my constituency and that's why I've been more receptive even though I'm totally against the world of government things like that are sometimes essential because they create a dignified path and I don't know why we may need some things like something so that a broad range of stakeholders in Ohio they pro-life and very important in Medicaid expansion we want people to know that it's a pregnant that they will have access to health coverage and that they do not need to train in the pregnancy because they are afraid that they will not their child quality will not be met their health quality will not be met I thought that was great for you to create that kind of human coalition where you evaluate disagreements but also you evaluate monies at least at the state level you have some hope of being able to do that and you've got a lot of history going on in regards to the housing issue do you happen to know if there have been any further efforts to incentivize either at the federal or state level private property owners to participate in the section 8 program or any other program in order to offer low cost housing to the homeless your person is in a very innovative space before trying to do social impact bombs for example to try to incentivize that it's a very complicated space because there are so many flavors of housing from section 8 and it's a quarter of the amount of money that we have it is one asset that goes first here at least it's not going to be a big expense the main policy value of the big development of new cities is that they just don't really have housing it's just super expensive here in Chicago we can't physically provide housing it's not it's not ridiculously expensive if you go to a place and you go all the way it's an 8 foundation it's worth the housing it's a physical housing but I think we're going to have to really experiment a lot I don't think it's going to be money since we're spending a lot of money on the niches I think many people play a big role in that because the niches are going to have to pay for housing they have to be much easier to do than just here somebody who's working in section 8 and in section 8 the value of the section 8 is much more for example and a company that's that's where you're going to make serious money and there people's sense of worthy or something worthy of 4 companies on the niches too it is a sense that people who need housing because there's a special need for it has a much easier way to do that than people who don't have to do that I wish we could give them I'm happy he came to mind those of you that have to go first okay