Today’s story comes from Peter, who manages benefits at a non-profit addiction treatment center in New York state. I changed his name to allow him to speak freely about his work.
Peter signs patients up for Medicaid and other benefits, sometimes while they’re still high. His work ensures they can get the treatment and medication they need, and that his organization can pay the bills. But it’s not easy. Administrative hurdles and obscure requirements make it even harder to care for (and pay for) patients who are already going through an intense crisis. Sometimes, the coverage never materializes, and the center has to eat the cost of that care.
But there’s a rare ray of light: Peter said his facility is remarkably willing to do that, and make it work for people who have no coverage.
I’d like to draw your attention specifically to a couple anecdotes Peter relayed. First, his account of the local Department of Social Services making him check that his patients aren’t eligible for unemployment benefits, which require that recipients are “able and available” to work, is wild. Do you think you would be “able and available” to work if you were in an inpatient drug treatment facility? He forwarded me the emails he exchanged with someone in state government about applying that policy, and it’s as infuriating as he made it sound. Second, we talked a little about the impact that the advent of ID.me, the controversial and extremely flawed identity verification service used by many state government agencies, had on his work. (Check out Bloomberg’s story to learn how this company weaseled its way into so many parts of the government.) Once he had to start applying for unemployment for patients, he said, the extra stress added by the ID.me system was intolerable. The ridiculous steps Peter has had to take to try and verify the identity of his patients, many of whom are homeless, are worth special attention.
The work of people like Peter is becoming sadly more and more urgent. Annual overdose deaths topped 100,000 last year, a staggering increase from the 68,710 who died just two years prior, in part due to the spread of fentanyl. As the New York Times noted recently, the United States “has never had” any kind of treatment system for addiction—let alone a universal healthcare system that would include such treatment. The options for people who get addicted to drugs in this country are simply terrible.
Many of Peter’s patients are homeless. While the overlap between homelessness and addiction is often overstated—making the unhoused an easy scapegoat, and obscuring the role that simply providing housing could play—it’s true that a large minority of unhoused people struggle with addiction. This adds an additional layer of urgency and frustration to the work Peter does. When these patients leave the facility (or have to be turned away for lack of space), they might have nowhere else to go. Peter also explains how missing mail and other bureaucratic hurdles end up preventing eligible people from getting Medicaid, which is especially relevant for people without a fixed address. This is crucial: Every time you think of Medicaid as a safety net health insurance plan for the poor, you must also think of how many people have been kicked off or denied it for stupid administrative reasons. A safety net is only useful if it actually stops you falling.
Here are Peter’s words, as told to Sick Note last month. Thanks to him for sharing his story.
I manage the benefits of people who were admitted to a non-profit drug and alcohol rehab inpatient facility; on any given day, we have around somewhere between 70 and 80 patients, but we also have a waitlist of about 60 people. I started a little before the pandemic hit.
Day to day, I meet with individuals who are fresh off the street into addiction treatment. Some of them are straight out of jail. Many of my clients are homeless, either literally living outside or couch-surfing. I'm seeing people when they hit the bottom of the barrel. It's so corny, but I'm a big fan of the show M*A*S*H, and on that show they call what they do on the front lines “meatball surgery.”
I check on their insurance; if they don't have insurance, I'm a trained assistor through the marketplace, so I get them Medicaid. I'm dealing with them when they're throwing up, or getting medically stabilized. They might still be high when I’m seeing them for the first time. After they've settled a bit, I work with them and the local Department of Social Services (DSS) to get what's known as ‘temporary assistance.’ If they're looking to continue their treatment and the long term care they're going to need, this benefit covers room and board of any sort of long-term facility which isn't covered by Medicaid. Or, if they're trying to just move on with their life, to try and find an apartment or anything like that, it'll help pay for any sort of shelter or housing a little bit—up to about $350 per month. It’s a really pathetic amount of money.
When I have to ask patients about their insurance, I do have to force it a little. It's not like “I need your money,” it's “I need to get you Medicaid so we can get you the medication you need right now.” We've got a deal with our local pharmacy, where they understand the situation and they'll have the patients sign out of pocket forms until they can get Medicaid, saying that we'll pay for it if the insurance doesn't kick in. But still, I’m having to essentially say: “Hey, you feel like shit but hey, here's a bunch of paperwork I got to have you do.”
Usually, when someone comes into the facility, I sit down with them and I call the New York State of Health. I give the state my information, and they have all my information on their screen. But, for whatever reason, they are required to talk to the actual patient and just get them to repeat their name, their birthdate, their social security number.
At the start of the pandemic, they did a waiver so that I didn’t have to talk to the state on the phone for Medicaid applications. I could go bedside, get their information, and then just have this conversation from my house if I wanted to. I could get the information over email, even. Six months ago, they reversed this policy, so now I'm back to dragging people who are sick out of bed to give the state this information. Only then can I proceed with their application for Medicaid. These are people who are in the middle of receiving treatment; they may have used that morning.
I deal with a lot of homeless people, and I have a lot of repeat customers. Often, the reason they're losing their Medicaid is because Medicaid just loves to randomly send out paperwork, asking you to recertify or whatever. Whenever they receive any return-to-sender mail, they just shut their case down. We've got a homeless population who doesn't have a safe address to receive any mail, so I'm applying for the same person to get Medicaid sometimes three, four times a year, because they don't have an address. We can put down our address, but somehow New York State of Health knows that we're a facility and not a residential address, and will periodically also just shut them down for using our address. I know that's the reason, because whenever I access their account to get the Medicaid again, it tells me the address that they have on file is a bad address, so that's why I know that they've lost it that way.
It's a ridiculous level of churn, which you would think they would want to get rid of. I guess anytime that they can clean their roster of any homeless people so they look like they're doing a good job and getting people off Medicaid, they're going to take advantage of that.
The managed care Medicaid plans also take additional time to be added on the account, which is a giant pain in the ass. When you're applying for Medicaid, you have to wait: If you're applying on the 15th of the month or earlier, the managed care plan will start the following month, but if it's the 15th or after, it takes a whole additional month after that.
We are fine with it, we take people anyway—but if we have to send people out to appointments with other outside doctors and specialists, they want certain managed care plans, or for them to have a managed care plan before they will accept them. We are delaying that treatment because we're waiting on this bullshit managed care plan, which could take six weeks. If it’s not managed care, usually it's fairly instantaneous. It's more than likely it will get approved the day we apply, then it takes 24 to 48 hours to show active within all of the systems that any doctor is going to use to verify anybody's insurance.
Occasionally, patients will need to provide documentation to confirm eligibility based on the answers they give in the application. Whether it's just the online form, or you're actually speaking with a worker, the state might request some piece of documentation to verify eligibility—but there's also multiple other ways to verify the request. They just don't happen to mention those things. I run into a lot of people who think they’re ineligible, like: “I need to provide proof that I’m not working anymore, so they want a letter from my employer, but I was using on the job and he fucking hates me. He's not returning my calls. I guess I can't have Medicaid.”
In fact, there's a form the state provides that you can fill out and sign, stating that you're not working anymore, but nobody's telling you that. That's not listed below that question. I know the cheat codes and the secrets, but anybody out on the street doesn't. They think they're not eligible for so many things they're eligible for.
I meet with patients again when they have a better idea of what their next step may be. That’s when we apply for the social services benefit, which is going to help them have a roof over their head, hopefully, somewhere. But DSS wants to make sure that you have exhausted any and all available resources that you could access to pay for something before they're going to help. Out of the blue, once COVID and the additional $300 weekly unemployment benefit hit, the state was now telling people that they had to apply for unemployment benefits, where they were not doing that beforehand at all.
They're essentially pushing them off: If someone were to get unemployment benefits, they would've made too much income to be eligible for the public assistance benefit and therefore they wouldn’t have to deal with it. This puts me in a situation where either they don't apply for unemployment benefits and they get denied for not trying to access every resource possible, or they get unemployment benefits and they have too much money to be eligible.
So I was working with patients trying to get unemployment with them—when people show up at our building, they barely remember to bring shoes. But now we have a whole extra layer of stuff to do.
When we started doing all this unemployment bullshit, ID.me didn't exist yet, or wasn't used in New York. Even logging in through nys.gov was a big enough pain in the ass. If you want to go to the DMV, you have to log in through that. If you want to apply for Medicaid, you have to log in through that. So many people have logged in 10, 20 years ago to this stupid system, and they have no idea what their password is. They don’t have the phone number that the password is attached to. They just can't get in to do anything.
So the slog to get unemployment before ID.me was ridiculous, and then they added that additional step as well. Now I’m sitting there with patients and we are taking 20, 30 pictures of their photo ID, trying to get their stupid system to register it. As far as I can tell the program is trying to match their ID to the picture of the patient—I've got patients who weigh 50 pounds less or more than when they took the picture because of addiction, they don’t look the same at all.
They require you to set up a PIN through text message or phone so that you can recover your account. Again, I’m often dealing with patients who don't have cell phones; they sold it, or it was stolen. Maybe they gave it to their dealer before they came in, as payment for drugs. So we have this old, crappy phone lying around, which can receive text messages. I was trying to use that as the phone number for a patient; we got all the way through the process, and it came back and it said that the information that they received from the phone company didn't match the person's name. I couldn't use a phone that they didn't own to get the benefit. Once ID.me decides that you are doing something shady, they request you to send in documentation. I can't even remember the list of documentation you have to send in.
The major question unemployment asks you is: “Are you able and available to work?” These patients cannot work while they’re here. This is 24/7 inpatient intensive rehab. You cannot work. Asking them to apply for a benefit that they are obviously not eligible for is bullshit.
With DSS, you don't know you're denied until you're denied; you never know where you're at with them. So instead of gambling with it, I was trying to do this unemployment benefit process, just to do what they say. I tried to find a phone number to talk to anybody at the state level in Albany about this policy, but it was impossible. They refer you back to whatever county you're currently in or asking questions about, and every county handles everything differently. I've got other counties I'm dealing with, and they're like, "Why is that county doing this?"
I finally got an email address to somebody and I laid it all out. I quoted them the policy, and asked them: "Is someone in an inpatient rehab facility able to receive unemployment?" They refused to give me a straight answer. They would not give me a ‘yes’ or ‘no’ in the most obvious ‘yes or no’ question.
I gave up. I just said, we're just not doing this anymore. The amount of stress I was putting on these patients as well, to say, “Oh, can you call your mom? And maybe she can find your cell phone in your bedroom, and then she can call Verizon, and get it activated so that we can get into your email address that's on there because you don't remember your Gmail password?” I just said enough is enough. I used to work for social services in another state; I worked in the Medicaid department in a state that didn’t expand Medicaid. So I know all of the tricks and I know all of the bullshit.
I make a little less than $40,000 a year. I could never give up my job right now. Helping people is very rewarding. I can never go back to retail, I can never go back to fucking call centers, all that bullshit. We are a nonprofit, so because they don't pay us shit, they give us a lot of great benefits. Right now, I get to work flexible hours. I don't think I would take a job I would absolutely love if I had to be there eight hours a day.
It's tough to believe, but our facility does great at providing healthcare. We just had a patient who I helped apply for benefits. We found out she can't get social services benefits: She is sanctioned from something she did 20 years ago. Something that she went to jail for, something that she had to repay a substantial amount of money for.
She's still sanctioned, 20 years later. To complete her one year sanction, she needs to apply and be approved and then do everything that they say for an entire year, while receiving no benefit, to remove her sanction. And she never understood that, for 20 years. So she's here with us, and literally no one will take her. Her counselor was trying to pick the right homeless shelter to discharge her to, but a homeless shelter is no place to continue your recovery.
We put our heads together and realized we need to do what's right for the patient—that we're going to eat the cost, basically, and send her on to another facility where she should be fine. She can at least get rid of three to six more months of that crappy sanction before she has to go back in the world, and try and find a place to live.
We do right by a lot of people. There are a lot of facilities we work with, and a lot of our patients have been to other facilities before they get to us, or after they go to us. We do hear a lot of, “you guys are the best, you guys actually seem to actually care.” That is really nice to hear. We do right by people. I don't think I would be there if we didn’t.