After three felony convictions and years of drug use, Tucson resident Jacob Kirk was facing a mandatory prison sentence.
Until he got another chance.
Kirk, now 25, spent three months in a residential drug-treatment program, signed up for mental-health care and for the first time got medication for his anxiety and depression.
He’s been sober for 27 months, is assistant manager of the transitional housing complex where he lives and has a newfound passion in writing and playing music under the name of J-Universe.
All of that happened through a Pima County Superior Court prison-diversion program for nonviolent offenders that in the future could be hobbled by congressional efforts to undo the Affordable Care Act (ACA).
While much of the debate over repealing and replacing Obamacare has focused on health-insurance exchanges and the cost of premiums, advocates say one of the most devastating impacts in Arizona may be the effect that proposed Medicaid cuts will have on people with substance-use disorders and mental-health issues.
The proposed cuts are severe — Arizona’s Medicaid program stands to lose $7.1 billion in funding through 2026, says a state analysis released Friday.
That’s why people who work in Tucson’s criminal-justice system are so worried. Their efforts to keep people out of jail and prison by getting them into drug- and mental-health treatment programs could be thwarted if those people have no insurance coverage.
“It is a tremendous, huge concern. The criminal-justice system is what happens when we don’t have well-funded health-care and education systems,” Pima County Public Defender Joel Feinman said.
“What has been proven time and time again is the less money we spend on high-quality health care and education, the more money we spend overall and in the criminal-justice system in particular.”
Under Obamacare, also known as the ACA, more of Tucson’s most-vulnerable residents have had access to much-needed care, much of it through Medicaid.
“It’s frustrating when you hear people say the ACA was a failure, that it didn’t work. I guess we can all find aspects that need to be improved or reformed, but the trouble is, there are aspects of it that truly have worked,” Tucson Police Chief Chris Magnus said.
“The ACA has been very successful so far in getting people insured who have serious psychological health issues,” he said.
Medicaid is a government insurance program for low-income people. In Arizona, the program is called the Arizona Health Care Cost Containment System (AHCCCS). AHCCCS now covers one in every four Pima County residents, which works out to nearly 300,000 people. It covers 1.9 million people statewide and more than 70 million nationwide.
The program’s growth spiked statewide in 2014, when Arizona both expanded Medicaid eligibility under the ACA and restored adults without dependent children to the program. Childless adults like Kirk had been previously ineligible for coverage due to an enrollment freeze that began in July 2011.
The American Health Care Act (AHCA) that passed the U.S. House of Representatives May 4 included $834 billion in cuts to Medicaid over the next decade. A discussion draft of the Senate health bill released Thursday includes even deeper Medicaid cuts, though it does give states more time to prepare for them.
A Congressional Budget Office report on the Senate bill is expected this week. The Senate could still make changes before a vote.
Public debate about undoing the ACA has largely ignored the bigger picture — severe cuts and restrictions on the nation’s Medicaid program, said Andy Slavitt, who was acting administrator for the U.S. Centers for Medicaid and Medicare Services under President Barack Obama from 2015 to 2017. He is now a senior adviser with the Bipartisan Policy Center, a Washington, D.C., think tank.
“The premise of repealing and replacing the ACA is a sideshow. This is entitlement reform,” Slavitt said during a recent visit to Tucson. “This is a generational change to the Medicaid program.”
In Arizona, the cuts to Medicaid being proposed by Republicans would, among other things, reduce enhanced federal funding that could affect the state’s ability to enroll childless adults in AHCCCS, as well as the Medicaid expansion population that gained coverage in 2014.
Those two groups amount to 425,000 people right now, including 114,000 who use behavioral-health services, the Arizona Council of Human Service Providers says.
Prior to 2014, people with mental-health issues were being evaluated under court order in some Arizona counties and found to be a danger to themselves or others, “but were released to the community because there were no funds for treatment. This is a public- safety issue,” the Human Service providers analysis says.
“The impact is that we are going to have more police calls for service, because if they are not on their medication they are not getting therapy,” said Magnus, the police chief. “Whatever is going on in terms of that serious mental illness is going to manifest itself in ways that involve other people, and we’re going to get called.”
Reducing Medicaid funding is a bipartisan issue, emphasized Feinman, the public defender.
“Fiscal conservatives should be as up in arms about cuts to Medicaid as social liberals,” he said. “The cuts to Medicaid are actually a bill to American taxpayers in the form of higher criminal-justice system costs. ... Nothing is more expensive than prison.”
Kirk said the 90 days he spent in rehab after being convicted of felony burglary was mostly boring. But it’s what he needed to treat his addiction disease, to get sober and to stop the endless loop of misery his life had become.
More than anything, it gave him time away from drug-using friends and time to consider all the damage he’d done to family members, and to himself, because of his disease. He wanted his old self back. Not the one driven to crime out of desperation.
His problems began when he was 14 and wanted to get high to impress his girlfriend, and also to forget things, like his parents’ divorce and the way it made him feel. He started with Adderall, which he got from a friend, and then progressed to other drugs, including methamphetamine and heroin.
Kirk had jobs, mostly at fast-food restaurants, but eventually drugs took over his life. He was both selling and taking them, and when he didn’t have enough money to buy more, he resorted to crime. He spent nine months in jail, but it didn’t help him get better.
“I was never patient enough and it became too difficult to go to rehab. I didn’t know how I’d make it happen,” said Kirk, who is a 2009 Marana High School graduate. “I needed a positive mind frame, but I didn’t have one.”
He also didn’t have health insurance. But after that third felony conviction for burglary — he broke into someone’s truck and stole gift cards — officials at Pima County Superior Court helped him enroll in AHCCCS. They also enrolled him in a program administered by the Pima County Attorney's Office known as DTAP — Drug Treatment Alternative to Prison.
DTAP coordinated Kirk’s treatment and connected him to services like job assistance. AHCCCS paid for his care.
When childless adults were added to AHCCCS eligibility in 2014, the local DTAP program was able to double its size, reduce its reliance on federal grant money and become more sustainable, Chief Deputy Pima County Attorney Amelia Cramer said.
“Any clinically needed mental-health and drug-treatment services are covered,” she said. “Finding a bed can be a challenge at times, but once someone finds a bed, the services are covered.”
The DTAP program requires a three-year commitment and helped 65 new participants in 2016. Organizers say the program has a rolling success rate of 65 to 70 percent.
“When they enter DTAP, they are court-ordered as part of their plea agreement to treatment and it’s paid for under the ACA by AHCCCS,” Cramer said. “If they have private insurance under the ACA, it’s paid for by that. But that only happens basically in 1 in 100 cases.”
If the program were to get smaller, that means more people going to prison instead of getting treatment, she said.
“When Arizona expanded Medicaid, that meant the vast majority of people in our program all would qualify. That meant people could go directly from incarceration in the jail to treatment,” said Kate Lawson, who directs the DTAP program.
“People could immediately get into the services they needed to have and they could get the level of services that was medically necessary,” she said.
AHCCCS pays for residential treatment and intensive outpatient care. The DTAP program, using grants, pays for job help, uncovered benefits like dental care and glasses and assistance with rent.
“If this AHCCCS funding went away, we’d have no money for treatment, basically,” Lawson said.
“And all the money that we are using on employment, drug testing, enhanced supervision, resources like dental — all that would be focused on treatment.
“And even then, I don’t think, at our current level, that we’d be able to take more than a couple of dozen people per year.”
Lawson said the majority of people in the DTAP program lately have been addicted to opioids, including heroin. If not for DTAP, all face mandatory prison sentences. Many have lost jobs, relationships and custody of their children because of addiction.
“These are people with productive lives ahead of them if not for this addiction,” Lawson said. “Many of them also have significant mental-health issues. ... By the time they get to our program, almost everybody is AHCCCS-eligible.”
“Are you mental-health cops?” the 56-year-old Tucson man asked from behind his apartment door on a recent Thursday morning.
When Tucson Police Department Officers Todd Schladweiler and Darrell Hussman said yes, the man opened the door and came outside. The officers were there to take the man to Banner University Medical Center-South, where he’d be evaluated for involuntary mental-health treatment.
Rather than police uniforms, Schladweiler and Hussman wear khakis and polo shirts and drive unmarked police cars. They are part of the department’s 3-year-old Mental Health Support Team.
The man had recently been having a lot of contact with police — yelling in public, including making threats in a library. He went off his medication after a stint in jail, he explained to Schladweiler.
“I’m always better when I’m on my medication,” he said.
The man is enrolled in AHCCCS. Though he’d fallen off his treatment regimen, reconnecting the man with his caseworker and other health providers, Schladweiler said, could be all he needs to improve his quality of life and stay out of jail.
Schladweiler made sure the man left extra food and water for his cat before taking him to the hospital.
But Schladweiler and other mental-health-unit officers are going to have a harder time connecting people with services if childless adults can no longer enroll in AHCCCS.
“There’s a significant portion of the mentally ill population who are single, childless adults,” said Paula Pererra, who heads the health law unit of the Pima County Attorney’s Office.
“If Medicaid goes away or is limited to where childless adults no longer qualify, you are going to see a lot of people who are untreated and who will cycle through either the criminal-justice system or they will be homeless and not living a high quality of life.”
And left untreated, people with mental-health problems are more vulnerable themselves to being victims of crimes, Pererra said.
County officials know this firsthand: They saw more untreated mental illness before the restoration of childless adults to AHCCCS.
Back then, people who didn’t fit into the state’s parameters of “seriously mentally ill” and who didn’t qualify for AHCCCS could be hospitalized for mental-health issues at the county or hospital’s expense. And that was about it.
Those patients could not afford to go to the doctor, could not afford medication and, more often than not, did not believe they had a mental illness. They got no help as an outpatient and cycled through the system.
“The longer a mental illness goes untreated, it really does damage your brain,” Pererra said.
“The longer you go untreated, the less functioning you become.”
On the other hand, people who get treatment and stay in treatment can lead highly productive lives, Pererra said.
“Typically when they are not getting treatment on an outpatient basis they do end up in jail, they do cycle through the hospital multiple times.
“The county pays, the hospital also loses money on the deal. The person themself has a horrible quality of life and it’s very, very sad.”
Arizona state legislator Heather Carter, a Republican from Cave Creek who chairs the House Health Committee, wrote an op-ed in the Arizona Capitol Times saying she fears losing more than $800 billion from Medicaid. Those cuts could return Arizona to the “bad old days” of enrollment freezes and a rising number of uninsured people, she wrote.
“It is simply not realistic for the state of Arizona to make up for this loss of federal funding,” wrote Carter, who was not available to comment on the Senate bill last week.
On Wednesday, Republican Gov. Doug Ducey sent a letter about the repeal and replacement of the ACA to fellow Republican Arizona Sen. John McCain. The letter, which predates the Senate draft release, highlights five specific areas of concern Ducey has with the House version, including a federal funding formula change and timeline that could jeopardize Arizona’s childless adult Medicaid population.
“Based on the analysis so far of the Senate bill, it appears these five areas still need to be addressed,” Ducey spokesman Daniel Scarpinato wrote in an email Friday.
Kirk was surprised to learn his AHCCCS coverage could be affected by federal health reform. He hopes that as a childless adult, he’ll be able to continue getting his health care through AHCCCS.
“I don’t know what would happen if I couldn’t get my meds,” he said. “I don’t really want to find out.”