Stop the Revolving Jail Door

Split sentencing, in which a felon serves a portion of his time in jail and another portion in the community but under supervision, shows promise.

By The Times editorial board

June 29, 2013, 5:00 p.m.

Criminal defendants convicted of felonies in California used to be sentenced to state prison. Most, after serving 50% of their terms, were released on parole and returned to their communities. And of them, most ended up back in prison, either because they committed new crimes or because they were caught violating parole. California was good at running felons through a revolving door and very bad at guiding their safe return to society: getting the addicted off drugs, getting treatment for the mentally ill, getting those with antisocial and criminal mind-sets into structured, supervised programs with reliable records of reforming those former inmates who were amenable to reform.

The state had a Department of Corrections and Rehabilitation, but in most cases it neither corrected nor rehabilitated. It kept criminals incapacitated, but when they returned to their neighborhoods, they were at least as dangerous as when they were sent away.

Today, defendants convicted of felonies defined by law as violent, serious or sexual continue to go to state prison; and despite widespread public misunderstanding and assertions to the contrary by officials who ought to know better, defendants convicted of lesser felonies also go to state prison if they have rap sheets that include past violent, serious or sexual offenses.
But since October 2011, newly convicted "non-non-non" felons — those whose offenses are not violent, serious or sexual — with no current or previous record of serious convictions go to county jail. Just like their counterparts in state prison, they will serve their time, get out and return to their communities.

And then what? The addicted and the mentally ill will most likely remain untreated; they and other inmates badly in need of life skills, anger management counseling or similar programs will leave jail at complete liberty, with an unstructured reentry into society. Their prospects for success — shunning trouble, getting work, leading productive, crime-free lives, leaving their neighbors safe — will be about the same as those of felons returning from state prison: not good.

Evidence has shown, time and again, that the outcomes are better for inmates who begin programs in jail — and who then return to society under supervision while continuing mandatory treatment and education. There are three choices for dealing with inmates, and three well-documented outcomes: no treatment or education in or out of jail, and a poor chance at success; compelled treatment and education in jail, and slightly better chances; and mandatory treatment in jail followed by mandatory treatment and monitoring, for a period of time, on return to society, with much improved prospects of breaking the cycle of offending, being locked up, returning to the streets and offending again. And keep in mind: The beneficiaries of these programs are not just the offenders but also those who are victimized by them.

AB 109, the criminal justice realignment laws adopted in 2011 that gave counties new responsibilities over low-level felons, also proposed a reinvention of the reentry process to deal with criminal recidivism. Defendants could receive what is known as a "split sentence," with a portion of the time to be served in jail and another portion to be served in the community, under supervision by probation officers who would monitor mandatory participation in rehabilitation and other programs. The period served under supervision in the community, after release from jail, is known as a "tail."

In keeping with the spirit of realignment, which gives counties maximum flexibility to experiment, compile data, compare notes and adjust as necessary, AB 109 doesn't mandate split sentencing. Nor does it compel counties to abide by any formula or guideline in determining how much it can spend on programming, or what kind of programs to offer. Counties can decide whether to spend more of their realignment funding on incarceration or reentry.

Some counties — especially those already geared toward community-based corrections for their misdemeanor defendants — have embraced split sentencing. In Contra Costa County, for example, 90% of the AB 109 felony sentences are split. Other counties and their trial courts are also turning to split sentencing, pairing the post-incarceration tail with innovative and proven programs that reintroduce felons to their neighborhoods with carefully tailored treatment and scrutiny. Because more time is served under community supervision, jail cells are freed up for the most dangerous offenders.

So how tightly is the state's largest jurisdiction, Los Angeles County, embracing the opportunities presented by split sentencing? This county is bottom of the barrel, with a supervised tail in only 4% of sentences.

The reasons for the failure to use this proven tool are unimpressive. Defense lawyers and prosecutors are used to bargaining over custody time, not negotiating for tails. Defendants would rather do their time and return to the streets at full liberty. Prosecutors would rather maximize custody time than require post-custody programming. Judges defer to the lawyers' plea bargains when sentencing. The focus is shortsighted, aimed at efficient processing, not structured reentry or breaking the cycle of recidivism. The leader of a committee made up of local law enforcement officers, judges and county service providers told the Board of Supervisors last week that he expects no change in the number of split sentences here.

Lawmakers this year considered a bill that would have required courts to include at least a six-month tail on AB 109 sentences, helping sluggish counties to begin solving the recidivism problem even when they don't want to. Under heavy lobbying from prosecutors, the measure died in committee.

That's a shame. Los Angeles County and its courts are squandering the opportunity presented by AB 109 to return corrections and rehabilitation to the criminal justice system. If they can't make use of split sentencing on their own — and so far they have demonstrated that they can't — they will need to be pushed.

Copyright © 2013, Los Angeles Times

HHS issues final rule on insurance exchanges

March 12, 2012 | Mary Mosquera, Contributing Editor


WASHINGTON – The Department of Health and Human Services has released its final rule on the establishment of health insurance exchanges - online marketplaces. The rule also includes provisions for qualified health plans and exchange functions in the individual market.


The final rule, which combines what originally had been separate proposed rules published in July and August 2011, encompasses the key functions of exchanges related to eligibility, enrollment and plan participation and management. The department received more than 24,781 comments on the proposed rules.


HHS seeks further comments from the public on several sections, which are issued as interim final rules, related to options for conducting eligibility determinations, the ability of a state to permit agents and brokers to assist qualified individuals, and Medicaid and Children’s Health Insurance Program.


The 644-page rule appeared March 12 in a preview section of the Federal Register. HHS will officially publish the rule on March 27.


The policies incorporated in the rule give states more flexibility to design and create their exchanges - websites - where individuals and small businesses will be able to shop for and compare health coverage. Exchanges are scheduled to go live in 2014 under the health reform law. “Exchanges will offer Americans, competition, choice and clout,” the final rule said.


The rule offers guidance about the options on how to structure exchanges in setting standards for establishing exchanges, setting up a small business health options program (SHOP), performing the basic functions of an exchange, and certifying health plans for participation in the exchange.


The rule also provides guidance for establishing a streamlined, web-based system for consumers to apply for and enroll in qualified health plans and insurance affordability programs.


Boosting competition


Insurers will have to compete for their customers’ business, said Health and Human Services Secretary Kathleen Sebelius. “More competition will drive down costs and exchanges will give individuals and small businesses the same purchasing power big businesses have today,” she said in a statement.


The final rule makes sure that exchanges will coordinate with Medicaid, CHIP, and the Basic Health Program so that an applicant experiences a seamless eligibility and enrollment process regardless of where he or she submits an application.


In response to comments, the final rule provides two ways for exchanges to interact with Medicaid agencies when making eligibility determinations. Exchanges can conduct eligibility determinations for Medicaid and for advance payment of premium tax credits, or the exchange will make a preliminary eligibility assessment and then turn it over to the state Medicaid agency for final determination.


Also, a state-based exchange may determine eligibility for advance payments of the premium tax credit and cost-sharing reductions, or it could be approved ifHHS makes determinations for these functions.


HHS previously provided a total of $50 million to all states except Alaska, which refused it, to begin to plan the exchanges. Recently, 33 States and the District of Columbia have received more than $667 million in establishment grants to begin building exchanges.


The federal government will put in place an exchange for states that choose not to establish one or will not have one operational by 2014.


The health reform law also provides for a premium tax credit for eligible individuals who enroll in a qualified health plan through an exchange to reduce the cost-sharing obligation of eligible individuals.


HHS said it has worked with states, small businesses, consumers, and health insurance plans and sought public comments to come up with the rule’s provisions.




http://www.healthcareitnews.com/news/hhs-issues-final-rule-insurance-exchanges 

To stay fiscally healthy, state's hospitals want fewer patients

http://www.latimes.com/health/la-me-hospital-changes-20120305,0,5184223.story

By Anna Gorman, Los Angeles Times

March 4, 2012, 5:15 p.m.

To survive the unprecedented challenges coming with federal healthcare reform, California hospitals are upending their bedrock financial model: They are trying to keep some patients out of their beds.

Hospital executives must adapt rapidly to a new way of doing business that will link finances to maintaining patients' health and impose penalties for less efficient and lower-quality care.

It's too soon to know precisely how the changes will affect patients. But experts say more will be treated in clinics and doctors' offices than in hospitals. And when they are admitted, their hospital stays could be shorter.

"How can we change our mind-set from how many patients we have in the beds to how many patients we are keeping healthy and out of the hospital?" asked Michael Rembis, president and chief executive of Hollywood Presbyterian Medical Center. "We haven't figured out how to do that yet."

The federal reform law changes the way hospitals and doctors will be paid. Going forward, fees will be based on patient outcome rather than on how long patients stay in the hospital or how many services they receive. And hospitals will be penalized for preventable readmissions and hospital-acquired infections.

Promoting higher-quality hospital treatment is long overdue, said Anthony Wright, executive director for the consumer group Health Access. "We were inadvertently subsidizing bad care," he said.

Wright said he hopes the new incentives will lead to more coordinated treatment for patients.

In preparation for the healthcare overhaul, many hospitals are replacing paperwork with electronic record systems and working more closely with physicians to improve care and reduce the number of unnecessary tests.

"As hospitals and physicians think about how they are going to care for populations, they recognize they have to collaborate," said David O'Neill, senior program officer at the California HealthCare Foundation.

Some hospitals are going a step further and partnering with physicians to form accountable care organizations, groups that agree to offer coordinated care for Medicare patients. Under the reform law, the organizations will share the savings from lowering costs and improving care.

The California Medical Assn., a leading doctor alliance, says the new accountable care groups will succeed only if physicians still have the autonomy to make medical decisions on behalf of their patients.

"If they are dominated by the hospitals, they will fail," said Francisco Silva, the association's general counsel. "They will not reduce costs or improve efficiency.... It has to be a true partnership."

Hospitals that don't adapt may have to eliminate services or close their doors, according to the California Hospital Assn. Already, the state has fewer hospital beds per capita and shorter hospital stays than the national average.

"Everyone is scrambling on the hospital side to prepare for fewer patients," said Jim Lott, executive vice president of the Hospital Assn. of Southern California. "It does change the paradigm."

The shifts — which will occur along with ongoing cuts in Medicare and Medi-Cal — don't take effect until 2014, but already they are prompting hospitals to cut costs and stop duplicating services wherever possible.

Hollywood Presbyterian is working with nearby hospitals to identify the best and most cost-effective treatments. In addition, the hospital is trimming expenses and entering new partnerships with outpatient clinics to keep discharged patients from returning to the hospital unnecessarily.

Providence Health & Services, Southern California, which operates five hospitals, has offered voluntary buyouts and streamlined supply purchases. The hospital group also is trying to reduce the chances of medical complications and is standardizing treatment of some illnesses to improve efficiency.

The Providence hospitals couldn't afford to wait until healthcare reform takes effect in two years, said senior vice president and chief executive Michael Hunn. "The numbers are not sustainable," he said. "We have got to get our arms around waste."

The most significant moves are driven by cuts to Medicare and Medi-Cal, which in California make up more than half of hospitals' gross revenues. California also has some of the lowest Medi-Cal reimbursement rates in the country.

Because government insurance programs don't cover costs, hospitals have traditionally relied on private payers to make up their deficits. But that is becoming more difficult because insurers are under pressure to reduce rates as part of healthcare reform.

Hospitals are launching their transformation when revenue growth at some facilities is running at 20-year lows, according to Moody's Investors Service.

"They are being hit on both fronts — fewer patients and getting paid less for each patient," said Brad Spielman, vice president of healthcare ratings for Moody's.

Michael Blaszyk, chief financial officer of Dignity Health, which operates more than 40 hospitals in California, Nevada and Arizona, said healthcare reform has placed hospitals at a "fundamental crossroads."

"All hospitals have had to make choices about what services are appropriate and what services are not," he said. "You cannot continue to operate at a financial loss."

Smaller hospitals will be among the hardest hit because they are on their own in paying for administrative costs and negotiating rates with insurance companies, said Richard Scheffler, a UC Berkeley health economics professor. The ones that join larger health systems are more likely to survive, he said. "Mom-and-pop hospitals have two choices: disappear or join the party," he said.

Long Beach's Community Hospital executives knew their bottom line wasn't improving. So last year, the hospital decided to join MemorialCare Health System, which runs several hospitals in Southern California. Now the hospital is in the black and can focus on care rather than finances, said former board chairwoman Nancy Myers. "If we had not merged ... we probably would not have been able to make it," she said.

Even as hospitals rush to revamp their care, there is still uncertainty about what lies ahead, saidAllen Miller, an L.A.-based healthcare consultant. An increasing number of aging baby boomers may require more hospitalization in the years ahead, complicating efforts to reduce costly admissions.

"No matter how much we think we can decrease hospital admissions, we are still going to need the beds," he said.

Many Returning Home from Prison, War: More Services Needed

By Carla María Guerrero

After leaving prison, Stacy Johnson (left) and Lori Hogg found the services they needed at A New Way of Life to stay off the streets and reintegrate into the community. (Photo by Joshua H. Busch)

Stacy Johnson had no idea what to expect when she was dropped off last August in front of a well-kept home in a quiet neighborhood in South Los Angeles. The 45-year-old had just been released early from serving her third prison sentence. She arrived at A New Way of Life Reentry Project hoping to make a fresh beginning after what had been a tumultuous twenty years.

Every year thousands of men and women like Johnson leave California prisons and return to South L.A. in need of jobs, housing and other supportive services. Their numbers could grow even higher under the state’s new prison “realignment” law, which transfers responsibility for “nonviolent, nonsexual, nonserious” felony offenders from state to county authorities.

According to Los Angeles County’s Criminal Justice Committee, an estimated 9,000 men and women who have served their prison sentences will be released to the county’s supervision by midyear and nearly 15,000 by mid-2013.

At the same time, the end of the Iraq War means the return of a significant number of veterans to the community. They share many of the same critical needs for jobs, housing and health services as those exiting prison. For both populations, locating these services in a community affected by deep budget cuts and the economic recession can be difficult.
But once found, these services can make a huge difference in whether an individual coming back from war or prison successfully reintegrates into the community.

Crucial Help
For Johnson, connecting with A New Way of Life and its founder, Susan Burton, has already changed her life immeasurably. She is in school full time and has been sober for almost three years. Eventually she would like to find a full time job and get her own place.
“I owe [Burton] everything. I came out of prison with nothing. I would’ve been back on the streets, probably using [drugs] again and staying in motels,” said Johnson, who knows firsthand how easy it is to fall prey to addiction.

At 22, Johnson started using crack cocaine and her life started unraveling. That same year, she was convicted of voluntary manslaughter after she picked up a knife to protect herself from being raped. Her assailant died and Johnson got twelve years in prison. After leaving prison she tried to rebuild her life around a new job and a new boyfriend. But he was abusive. She turned to drugs again, lost her job and her freedom, and gained one strike.
After serving two years, she lived in motels or on the streets and took drugs to numb the desolation. “When you are on drugs, you are weak. You are so vulnerable,” Johnson said. She went to jail a third time after being arrested for crack cocaine possession.

According to the California Department of Corrections and Rehabilitation, the state has one of the highest recidivism rates in the country. Nearly seven in ten former inmates will return to prison within three years.

Realign Priorities
For Cpl. Lauren Johnson, a 28-year-old African-American veteran of the Iraq War, knowing about the services and support available is key to successfully reintegrating back into communities.

“My experience was different from most veterans returning home because I was knowledgeable about the resources and services available to me,” she said. Originally from a Texas community with a strong military presence and culture, Lauren Johnson knew what benefits to tap into to help pay for school after her tour in Iraq.

Now working for Congresswoman Karen Bass, Lauren Johnson connects veterans with resources and services in South L.A., including referrals to Veterans Affairs and local organizations that provide housing, employment training and other services.

“It is imperative for us to mobilize for veterans once they come home. They’re used to unit cohesion and sometimes it can be a bit scary when you no longer have that camaraderie and that network you’ve been used to,” she said.

Social service advocates fear additional budget cuts will further erode the safety net in South L.A. at one of the most crucial moments.

“There needs to be an investment in housing, prevention, intervention and education … instead of systems of supervision and further incarceration,” A New Way of Life founder Burton said. “There needs to be a realignment of investment into people and communities so that crime won’t rise but opportunities for jobs and training programs will.”

Carla María Guerrero is the communications assistant at Community Coalition

State convicts arrive in L.A. County with costly mental illnesses

Via latimes.com

Newly released state prisoners are arriving in Los Angeles and other counties with incomplete medical records and mental illnesses that have officials struggling to provide treatment.

As California begins shifting supervision of thousands of newly released state prisoners to local probation agencies, ex-convicts are arriving with incomplete medical records and more serious mental illnesses than anticipated. And mental health officials are scrambling to provide appropriate — and often costly — treatment.

"At the start, every day ... there was a crisis," said Dr. Marvin Southard, director of the Los Angeles County Department of Mental Health. "There was somebody we didn't know what to do with."

In some cases, he said, released inmates have had to be immediately transferred to hospitals or residential centers for psychiatric care.

A new state law designed to reduce prison crowding and cut costs requires that certain nonviolent convicts serve their time in county lockups rather than state prisons. It also makes counties — rather than the state parole agency — responsible for supervising such inmates after their release.

The transition, called "realignment" by Gov. Jerry Brown, has raised well-publicized concerns among law enforcement officers across the state, as they try to accommodate more inmates in already crowded local jails. But realignment also presents less-visible challenges for local probation and mental health officials dealing with an influx of patients with drug and alcohol addictions, schizophrenia, bipolar disorder and depression.

Mental illness and drug addiction are common in California prisons, where more than half of inmates report a recent mental health problem and two-thirds report having a drug abuse problem, according to a Rand Corp. study. Many don't receive the treatment they need while incarcerated and may skip care once released, said the study's author, Lois Davis.

"If you have individuals struggling with depression and anxiety ... they are going to have a much harder time linking to services," she said. "It limits their ability to find a job and reunite with their family, and they will be at greater risk for recidivism."

Roughly 3,300 people have been released to Los Angeles County so far. The probation department is expecting about 6,000 more. County mental health officials estimated that about 30% will require mental health services and about 60% will have drug addictions.

Continuing treatment after inmates are freed is essential to preventing them from relapsing, having mental breakdowns, ending up in hospitals or landing back behind bars, officials said.

"We took it very seriously from the start," said Reaver Bingham, deputy director of the Los Angeles County Probation Department. "We knew that if we didn't address those risk factors, people would revert to what they know, and that is committing criminal activity."

Realignment, which began Oct. 1, has been bumpy. Many released inmates came without comprehensive medical records. It was up to the patients to pass along information about their diagnoses and medications to probation and mental health staffers. When county workers requested mental health records from the state, they often were told to get the information from individual prisons.

Communication has improved, but getting complete medical and mental health records remains difficult, officials said. One complication: Prisoners can block the transfer of records.

"A lot of it depends on the inmates' attitude at the point of the release — do they want to be treated more or to be left alone?" said Don Kingdon, deputy director of the California Mental Health Directors Assn.

Kingdon stressed the importance of counties having complete information on prisoners before they are released to local supervision. "That can create a problem in the community if they release prisoners and they have mental health needs and you didn't know," he said.

California prison officials "made a whole lot of effort to make the [transition] be as smooth as possible," said Denny Sallade, deputy director of the state's Division of Correctional Health Care Services. But inmates may be in one mental state when they leave the prison and another when they arrive in the community, often because they stop taking their medication along the way, she noted.

The inmates also may turn down help once they arrive. In Los Angeles County, about 30% of the released state inmates seen by mental health staff refused to either meet with clinicians or be referred for treatment.

Bingham, of the probation department, said the state has tried to address problems. "If we can be successful in Los Angeles County, we can be successful in the rest of the state," he said.

But county officials are warning there may not be enough resources to accommodate former inmates in need of supervision. The state allocated $18 million to Los Angeles County to pay for mental health and substance abuse treatment and other social services. But the money isn't guaranteed to continue past June.

"Supervisor Mike Antonovich is very concerned about the inadequacy of realignment funding to effectively rehabilitate this population, which includes costly mental health services, housing and supervision," said his justice deputy, Anna Pembedjian. "It all boils down to resources."

Los Angeles, like most counties around the state, is already stretched thin after years of budget cuts and may not be equipped to close gaps in health and social services for the newly released inmates, said Davis, of Rand. To help defray some costs, counties across the state are working to enroll the eligible released prisoners in public programs such as Medi-Cal.

Counties are at the very early stages of understanding how to make realignment work, especially for those former inmates with mental illness, Davis said. "It is going to be a challenging time for the next couple years," she said.