Highlights

• Fact Sheet on HUD and Mixed-Status Households
• Consider a Pooled Trust for Individual MassHealth LTC Spend-Down
• ConnectorCare Advocacy Guide
• Vets Benefits Screening Tool
• MA Only State to Jail Men for Addiction Treatment
• New CORI Law Limited

Sections

• Program Highlights
• Health Care Coverage
• Policy & Social Issues
• Of Clinical Interest

Questions, comments about the newsletter? Contact Ellen Forman, 617-726-5807.

Effective July 1, 2019, a MassHealth member may receive home health aide services for hands-on assistance with activities of daily living (ADL) without the need for a concurrent home health skilled nursing or therapy service.

As of July 1, a member may receive medically necessary home health aide services without having a concurrent skilled nursing or therapy need when the member requires hands-on assistance throughout the task or until completion with at least 2 activities of daily living (ADLs). Assistance with ADLs provided by a home health aide is defined as activities related to personal care, specifically the following: bathing, grooming, dressing, toileting/continence, transferring/ambulation, and eating. Home health aide services for assistance with ADLs may be approved for periods of up to 90 calendar days.

The frequency and duration of the home health aide services must be ordered by the physician and must be included in the plan of care. The services must be “medically necessary” to provide personal care to the member, to maintain the member’s health, or to facilitate treatment of the member’s injury or illness.

While MassHealth does not pay for homemaker, respite, or chore services, when a home health aide visits a member to provide a health-related service, the home health aide may also perform some incidental services that do not meet the definition of a home health aide service (for example, light cleaning, preparing a meal, removing trash). However, the purpose of a home health aide visit must not be to provide these incidental services, since they are not considered health-related services.

Prior authorization (PA)of home health aide services for hands-on assistance with ADLs is required prior to the initiation of home health aide services when the member is not receiving concurrent skilled nursing or therapy services from the home health provider. Home health agencies may request an expedited PA if the member meets medical necessity for an expedited request. Expedited PA requests will be adjudicated within 72 hours of receipt.

While this revision extends the circumstances in which MassHealth members may receive home health aide services for 90-day prior authorization periods, other services remain available to meet the needs of members who require assistance with ADLs with one-year prior authorization periods. Such services include Adult Foster Care (AFC), Personal Care Attendant (PCA) services, or services available through a MassHealth Home and Community-based Services waiver (HCBS waiver).

- See the full June 2019 Home Health Agency Bulletin 54.

On May 23, 2019, President Trump issued a memorandum regarding the legal obligations of people who act as sponsors for their immigrant family members. This FAQ provides information about current sponsor liability policy before offering analysis of the White House memo.

NOTE: To date, nothing has changed because of the May 23 memo. The memo directs several federal agencies to take certain actions within time periods ranging from 30 to 180 days. In the meantime, the rules for sponsors remain the same.

How widespread will the effect of the memo be?
In practice, the five-year bar to federal benefits eligibility for most immigrants combined with sponsored immigrants’ reluctance to participate in benefit programs mean that few sponsored immigrants participate in benefit programs. However, like many of the Trump administration’s anti-immigrant actions, the practical effect of the memo will be much broader: deterring eligible immigrants from seeking essential services and deterring individuals from sponsoring their family members.

Current Policies on Sponsor Liability

What is sponsor liability?
Under the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), people who sponsor their family members to immigrate to the United States are required to execute an I-864, Affidavit of Support Under Section 213A of the INA to show that the sponsored immigrant will not become a public charge. The affidavit of support is a legally enforceable commitment by the sponsor to provide financial support, if needed, to maintain the sponsored immigrant at an income of at least 125 percent of the federal poverty level. Certain family employers are also required to assume sponsor liability.

The affidavit of support also requires sponsors to agree to reimburse the government for the cost of certain “federal means-tested public benefits” used by the sponsored immigrant while the affidavit of support is in effect, with certain exceptions. This obligation is generally referred to as sponsor liability. In practice, benefits-granting agencies have not prioritized the enforcement of sponsor liability. Their reasons include that enforcing liability is an administrative burden and that only a small percentage of their caseloads are affected.

Which means-tested public benefits may give rise to sponsor liability?
Eligibility for many public benefits is based, in part, on a person’s or household’s income. These benefits are generally referred to as being “means-tested.” The term “federal means-tested public benefit” is defined very specifically in the context of sponsorship. Under agency guidance issued after the 1996 immigration law (IIRIRA) and currently in effect, the benefits that are potentially subject to sponsor liability are nonemergency Medicaid and the Children’s Health Insurance Program (CHIP), the Supplemental Nutrition Assistance Program (SNAP, or “food stamps”), and Supplemental Security Income (SSI) and Temporary Assistance for Needy Families (TANF- called TAFDC in Massachusetts) (SSI and TANF comprise “cash assistance”). States may also designate state-funded means-tested public benefits that could give rise to sponsor liability.

What is “sponsor deeming”?
Under “immigrant sponsor deeming,” the income and resources of immigrants’ sponsors are considered, or “deemed,” to be available to sponsored immigrants when they apply for SNAP, TANF, or SSI. Some states also deem sponsors’ income when immigrants apply for federal Medicaid or CHIP and certain state-funded benefit programs. Deeming rules usually make the immigrant ineligible for benefits because adding the sponsor’s income and resources renders the immigrant “over-income” for the program. Exceptions to the deeming rules are discussed below.
Sponsor deeming is carried out by agency personnel administering public benefits applications. These eligibility workers need to obtain information about a sponsor’s income from the sponsored immigrant. Many immigrants who would be eligible for essential services are reluctant to request financial information from family sponsors or are deterred from completing their applications when they learn that their sponsor is implicated.

When do the sponsor’s obligations under the affidavit of support begin and end?
The affidavit of support goes into effect when the sponsored immigrant becomes a lawful permanent resident (LPR, or someone who has a “green card”) and remains in effect until the sponsored immigrant becomes a U.S. citizen, obtains credit for 40 quarters of work in the U.S., dies, or leaves the U.S. permanently. A sponsor’s divorce from the sponsored immigrant does not terminate the affidavit of support.
Qualifying quarters of work are credited to individuals based on their earnings. In securing credit for quarters of work history, immigrants can add their own work to that performed by a spouse during the marriage, or work performed by a parent while an individual was under 18 (or not yet born). However, any quarters in which the worker received a federal means-tested benefit cannot be counted.

Are sponsored immigrants eligible for benefits?
Under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), more widely known as “welfare reform,” most sponsored immigrants are ineligible for means-tested federal benefits during their first five years as LPRs, with the result that many sponsored immigrants are ineligible for benefits. Sponsor deeming also limits eligibility.

What are the exceptions to sponsor liability and deeming?
Sponsor deeming does not apply to:

• immigrant survivors of domestic violence or “extreme cruelty” or
• immigrants who would go homeless or hungry without benefits

In SNAP:

• deeming does not apply to children
• deeming does not apply to members of the sponsor’s household
• there is no sponsor liability if the sponsor is receiving SNAP

In states that have exercised the option to provide Medicaid and CHIP to lawfully residing children and pregnant women without a five-year waiting period, sponsors are not liable for the cost of health services received by people in these categories.
More information about the current policy is available at www.nilc.org/affidavits/.

President Trump’s Memo of May 23 about Enforcing Sponsors’ Responsibilities

What did the May 23 memo change?

To date, nothing has changed because of the May 23 memo. The memo directs several federal agencies to take certain actions within time periods ranging from 30 to 180 days. In the meantime, the rules for sponsors remain the same.

Do the required agency actions change the federal means-tested public benefits that may give rise to sponsor liability?
It’s possible. The five benefits classified as federal means-tested public benefits (nonemergency Medicaid and CHIP, SNAP, SSI, and TANF) under current policy are administered by the U.S. Department of Health and Human Services (HHS), the U.S. Department of Agriculture (USDA), and the Social Security Administration (SSA). The memo directs the secretaries of Treasury, Commerce, Labor, Housing and Urban Development, Transportation, and Education, as well as the secretaries of USDA and HHS, to submit a report that includes:

• a review of their agency’s guidance and regulations governing the issuance of federal public benefits to noncitizens;
• the steps they have taken to comply with the provisions of PRWORA that restrict benefits eligibility for certain immigrants;
• their opinion about whether the federal public benefits they administer are means-tested public benefits subject to sponsor deeming and liability and whether any additional federal public benefits they administer should be regarded as means-tested public benefits; and
• their review of any additional regulations or guidance that should be updated to align with applicable statutes.

The agencies are directed to submit their reports within 30 days and to coordinate with the U.S. Department of Homeland Security where appropriate.

Do the required agency actions change the enforcement of sponsor deeming and liability?
Changing the enforcement of sponsor deeming and liability seems to be the memo’s primary intent. The memo directs the secretaries of USDA and HHS to take all appropriate steps to enforce the law related to sponsor liability. Specifically, it directs them, within 90 days, to establish or update their procedures and guidance on sponsor liability. It also directs the agencies to provide those procedures and guidance to all entities involved in the enforcement of sponsor liability, including federal and state agencies responsible for benefits administration.

When would federal agencies be required to communicate revised enforcement procedures to immigrants and their sponsors?
By the end of the current fiscal year (September 30, 2019), the Departments of HHS, Agriculture, and Homeland Security are required to communicate the enforcement procedures to current sponsors, people who may seek to become sponsors, people who may seek sponsors, and others who may be liable for the repayment of public benefits.

Do the required agency actions change how information about sponsors and sponsored immigrants is collected and shared?
The memo includes a vague statement that the procedures and guidance should include “procedures for data sharing with Federal agencies, as appropriate and consistent with law.” It also requires the SSA commissioner and the secretaries of USDA and HHS to coordinate with the secretaries of State and Homeland Security to implement procedures for keeping and managing records. Each of these actions is required within 180 days.

Does the memo include any new consequences for sponsors?
The memo also attempts to create new consequences for sponsors who fail, or are unable, to reimburse the government for means-tested benefits used by their sponsored immigrants.
Within 180 days, the Departments of State and Homeland Security are directed to issue guidance on whether sponsors who fail or are unable to reimburse the government for benefits used by their sponsored immigrants should be eligible to continue to serve as a sponsor or to sponsor additional family members.
The memo further directs the secretaries of Agriculture and HHS and the commissioner of Social Security to coordinate with the secretary of the Treasury to establish information-sharing procedures with the Treasury Offset Program, which collects nontax federal debts through withholding of federal payments that include tax refunds and benefits payments. This directive suggests an intent to use the program to collect benefit repayments.

How can I learn about this issue as it unfolds?
Additional resources will be posted on NILC’s website, www.nilc.org.

-See the full post: Frequently Asked Questions: Understanding the President’s Memorandum on Enforcing the Responsibilities of Sponsors, National Immigration Law Center, last revised June 4, 2019.

As reported last month (Immigrant Families in Public Housing Units Threatened by Trump Administration Proposal, MGH Community News, May 2019), the U.S. Department of Housing and Urban Development (HUD) has published a proposed rule that would prohibit “mixed-status” immigrant families from living in public housing and Section 8 programs. The National Low Income Housing Coalition and the National Housing Law Project have created a fact sheet to shed light on the facts behind the misinformation. Here’s an excerpt.

As a result of this proposal, 25,000 families, including 55,000 children, would be forced to either break up their family or face eviction and an increased risk of homelessness. 

HUD MYTH: The proposed rule will help U.S. citizens get off the wait list for housing assistance.
FACT: HUD’s own analysis states that this policy will not reduce waiting lists; instead, it will result in fewer families receiving the housing assistance they need. By law, mixed-status families do not receive housing assistance for any ineligible family members. Taking assistance away from mixed-status immigrant families to give assistance to other households would require HUD to provide full subsidies for each resident, costing the government at least $193 million. HUD admits that to pay for these additional costs, the agency could be forced to reduce the quality and quantity of assisted housing, such as providing fewer Section 8 vouchers for everyone. This proposal would only exacerbate the housing crisis and lead, in worst cases, to increased homelessness. 

HUD MYTH: A roof over someone’s head can’t be prorated.
FACT: Under current law, HUD already prorates rental assistance to only cover eligible family members. The family must pay for the remaining rent out of pocket. In this way, HUD is essentially prorating the roof over the family’s head. When enacting the law, Congress wanted to ensure that people legally eligible for assistance could remain in strong, stable families while making clear that ineligible individuals would not receive any assistance. Under HUD’s proposed rule, mixed-status families will face the impossible choice of either breaking up their families so that some members can continue to receive assistance or staying together and facing eviction and potentially homelessness.

-See the full fact sheet

A judge has barred federal authorities from arresting people at Massachusetts courthouses for civil immigration violations while a lawsuit challenging the practice plays out.

U.S. District Judge Indira Talwani issued the decision in the lawsuit brought against U.S. Immigration and Customs Enforcement (ICE) in April by public defenders and two Massachusetts district attorneys.

In her decision, Talwani ordered ICE to stop "civilly arresting parties, witnesses, and others attending Massachusetts courthouses on official business while they are going to, attending, or leaving the courthouse."
The lawsuit alleges the practice by ICE is scaring victims and defendants away from court and making it harder for prosecutors to hold people accountable.

Gladys Vega, the executive director of the Chelsea Collaborative, an immigrant rights group that is named as one of the plaintiffs, said she had tears in her eyes when she heard about the injunction."We were feeling hopeless because victims of domestic violence, there were victims of fraud, were not attending court hearings," she said, "or were not putting claims at the court because they were so afraid of the presence of ICE in the courtrooms."

The ruling doesn't affect the agency's ability to arrest people on civil violations when they're already in custody or detain people on criminal matters.

-See the full WBUR story.

The rising number of complaints about surprise medical bills is spurring efforts on Capitol Hill and at the White House to help consumers. Over and over again, the high cost associated with air ambulance service gives patients the biggest sticker shock — the subject has come up at nearly every Capitol Hill hearing and news conference on surprise medical bills.

Yet air ambulance costs are not addressed in any of the proposals introduced or circulating in Congress. Even a congressional decision last year to set up a panel that would study air ambulance billing hasn't gone anywhere.

"We're doing a disservice to patients if we protect them from hospital bills but bankrupt them on the way there," said James Gelfand, senior vice president for health policy for the ERISA Industry Committee, a trade association for large employers.

The issue came up again at a recent House Energy and Commerce subcommittee hearing where Rick Sherlock, president and CEO of the Association of Air Medical Services (the industry group for air ambulances), was among eight witnesses. Rep. Ben Ray Luján, D-N.M., sharply questioned Sherlock as to why costs for air ambulance services have risen by 300% in his state since 2006. Sherlock explained that reimbursements from Medicare and Medicaid do not cover the cost of providing services. So charges to private patients, he told the legislators, must make up that difference.

Air ambulances serve more than 550,000 patients a year, according to industry data, and in many rural areas, air ambulances are the only speedy way to get patients to trauma centers and burn units. As more than 100 rural hospitals have closed around the U.S. since 2010, the need has increased for air services. More than 80 million people can get to a Level 1 or 2 trauma center within an hour only if they're flown by helicopter, according to Sherlock.

The service, though, comes at a cost. According to a recent report from the Government Accountability Office, two-thirds of the more than 34,000 air ambulance transports examined were not in the patients' insurance networks. That can leave patients on the hook for the charges that their insurers don't cover, a practice known as balance billing.

In 2017, the GAO found that the median price charged nationally by air ambulance providers was around $36,400 for helicopter rides and even higher for other aircraft. The total generally includes the costs for both the transportation and the medical care aboard the aircraft.

Additionally, the Bill of the Month investigative series by NPR and Kaiser Health News has received more than a dozen such bills, ranging from $28,000 to $97,000.

Since nearly three-quarters of flights are for patients insured by low-paying Medicare, Tricare and

States are hampered in their efforts to ease the strain for residents.

The Airline Deregulation Act of 1978, which was intended to encourage more competition, prohibits states from regulating prices for any air carrier, including air ambulances. What's more, many large employers' health insurance is not governed by states but regulated by the federal labor law known as ERISA.

So a remedy likely has to come from Congress. And it has proved to be a heavy lift.

-See the full NPR story.

It may behoove single adults to consider using a pooled trust for a nursing home spend-down.

Under the MassHealth rules, there's no transfer penalty for money deposited in a pooled trust for the benefit of the applicant for coverage. Pooled trusts, also known as (d)(4)(C) trusts in reference to the federal authorizing law, are run by non-profit organizations. Under their rules, if there's any money remaining in the client's account upon her death, some remains with the pooled trust and the rest must be used to reimburse Massachusetts for its MassHealth expenditures on the beneficiary's behalf. Only if there are still funds remaining after the state is fully reimbursed can funds go to family members. So in most instances it's not a great device for saving money for the family. However, there may be benefits for the needs and care of the disabled individual.

1. Cushion. So the first reason to use a pooled trust is to provide a cushion for unexpected care needs not covered by MassHealth. Things happen and the MassHealth rules are very rigid. Having some money set aside can provide some flexibility when needed.
2. Extra care. Often people in nursing homes or those receiving MassHealth covered care in assisted living facilities or at home can benefit from extra occupational therapy, or visits from home health aides, or just someone to take them out for walks or other activities. The pooled trust funds can be used for these purposes.
3. Professional fees. Situations arise where MassHealth beneficiaries need the assistance of a geriatric care manager, an accountant or an attorney. Visits from a geriatric care manager can be especially important when family members live far away. Pooled trust funds can be used for these purposes.
4. Home maintenance. MassHealth permits nursing home residents to keep their homes, but not to use their income to maintain the homes. All income except for a small monthly stipend must be paid to the care facility. Pooled trust funds can be used to maintain a family home.
5. Move expenses. Sometimes care facilities don't work out or it makes sense for the person receiving care to move to another part of the country to be near family members. MassHealth won't pay for the move. A pooled trust can.

The use of a pooled trust is more important for single MassHealth beneficiaries than for married ones, since presumably the healthy spouse will have some funds to pay for the nursing home resident's needs as they arise. The principal pooled trusts in eastern Massachusetts are the PLAN of Massachusetts and Rhode Island and Bristol County ARC Community Trust. The Academy of Special Needs Planners maintains a directory of pooled trusts nationwide.

-See the full Margolis & Bloom blog post.

ConnectorCare is the name given to Affordable Care Act insurance in Massachusetts. Mass. Law Reform Institute (MLRI) has long produced detailed and indispensable advocacy guides for various benefit programs, and has have now created a ConnectorCare Advocacy Guide. The guide is available to download or purchase for a nominal fee ($12.95).
  
In addition to background and eligibility overview, topics covered include the impact of government-sponsored and employer-sponsored insurance eligibility, plan enrollment, special enrollment periods, renewals, coverage, appeals and eligibility for lawfully-present non-citizens.

- See the ConnectorCare Advocacy Guide.

Last month we provided an overview of Veterans Benefits (Veterans Benefits Reminder- VA, the Chapter 115 Program and More, MGH Community News, May 2019). This month we learned of a new service  - the Veterans Legal Clinic at the WilmerHale Legal Services Center of Harvard Law School (LSC) is piloting a new technology tool to help determine eligibility for the State’s “Chapter 115” veteran’s benefits.  The new tool is called the Mass Vet Benefit Calculator, and is being launched through a public-private partnership between LSC and three local veterans’ services offices participating in the pilot (the VSOs for Boston, Cambridge, and the Upper Pioneer Valley Veterans’ Services District).

Chapter 115 is one of the most underutilized needs-based programs in the Commonwealth. Chapter 115 can provide monthly financial assistance that, depending on income and circumstances, can range from a few hundred dollars per month to $1,000 per month to eligible low-income veterans and their dependents. It can also provide reimbursements for out-of-pocket medical costs, emergency payments to prevent eviction, foreclosure or utility shutoffs, and funding for home repairs, moving costs, and transportation to medical appointments.

These important cash and medical benefits - administered by local cities and towns with 75% state reimbursement - are for veterans and their dependents (spouses, widows/ers, children) who are low income. The veteran must have served a certain number of days, have an honorable (or other than dishonorable) discharge and meet certain income and asset criteria.  Veterans Services Chapter 115 benefits are NOT the same as federal Veterans Administration pension and compensation benefits. Indeed, veterans who receive federal benefits may be able to receive a Chapter 115 supplement depending on income.  Every city and town in Massachusetts has a Veterans Services Officer (VSO) whose job it is to take applications and administer these benefits. 

Please screen your clients for Chapter 115 benefits.  

• Here's the calculator that screens individuals with the key  eligibility questions and provides a summary of the potential benefits amounts   https://massvetben.org/calculator/   
• Also see the Chapter 115 benefits Self Help guide: https://massvetben.org/wp-content/uploads/2019/03/LSC-Ch115-Self-Help-Guide-August-2018.pdf

- Adapted from post to the FoodSNAPCoalition listserv on behalf of Pat Baker, MLRI, June 21, 2019 with additional material from the A Simple Online Legal Tool Helps Reduce Poverty for Military Veterans blog post, the Veterans Legal Clinic at the WilmerHale Legal Services Center of Harvard Law School, June 19, 2019.

A 31-year-old man named Jonathan stood up before a crowd in a State House lounge this month and spoke about a horrific experience. In April, he said, his family abruptly decided that he needed treatment for his drinking. So they took advantage of a state law called Section 35 to have him civilly committed — ordered into treatment by a judge.

Soon he was shackled in a police van and taken to the Massachusetts Alcohol and Substance Abuse Center, or MASAC, a Plymouth treatment program run by the state Department of Correction.

It was surrounded by tall fences topped with razor wire. Jonathan said he’d never been to prison, but this sure looked like one, and he hadn’t committed a crime. He was forbidden to leave for weeks.

This happens only in Massachusetts, to about 3,000 men a year. While most states have laws allowing civil commitment for addiction treatment, only Massachusetts turns the majority of civilly committed patients over to the care of the Department of Correction. Five years ago, the state outlawed jailing women for addiction treatment, but still allows it for men.

Jonathan, who asked that his last name be withheld, spoke to a room packed with advocates, legislative staffers, and a few legislators, at a briefing intended to promote two bills that would effectively put an end to MASAC.

The bills would require that people who are civilly committed for addiction treatment receive care at programs licensed by state public health or mental health authorities. The briefing was sponsored by Prisoners’ Legal Services of Massachusetts, which recently sued the state, saying that sending civilly committed men to a correctional facility constitutes gender discrimination, violates the Americans with Disabilities Act, and violates the constitutional right to due process.

At MASAC, Jonathan said, he was kept locked inside most of the time, denied access to papers to file for an extension to his taxes, and was even refused the parenting books that his pregnant wife sent him. (A Department of Correction spokesman said inmates are allowed to send and receive mail, and can have up to 10 books or periodicals, but they must come directly from the publisher.)

Jonathan called the atmosphere “toxic.”

Unlike Jonathan, 37-year-old Michael Perry has been to jail, he told the gathering. And he can attest that MASAC is definitely a prison, compete with solitary confinement, he said. “It feels like punishment and I hadn’t done anything wrong.”

In prison, Perry said, you have to keep up a facade of toughness. But to recover from addiction, “you need to be vulnerable and express yourself.” “It’s the wrong place for recovery,” he said.
A legislative commission is studying the effectiveness of involuntary commitment for addiction and plans to issue its report shortly.

-See the full Boston Globe article.

On the face of it, Baystate Health’s plan for a new mental health facility in Holyoke seems like a boon for the region.

The proposed new facility will have approximately 130 beds, increasing the total number in the region by 30 percent. The new facility also offers mental health beds for geriatric and pediatric patients, as well as those who are disruptive or have a substance abuse problem. Right now, many of these hard-to-place patients “board” for days if not weeks in emergency rooms waiting for inpatient care.

“Because of the increase in bed capacity and an improved environment of care, we envision that we will be able to treat a broader spectrum of patients in the new facility, including patients who have historically needed to be sent to the Boston area for care,” said Dr. Barry Sarvet, chair of psychiatry at Baystate Health.

But as it opens the new facility, Baystate plans to close smaller mental health units at three of its community hospitals in Westfield, Palmer, and Greenfield. According to mental health patients, providers, and advocates in these smaller communities, that’s not a fair trade.

Each of the smaller hospital-based units slated to close are deeply rooted in the communities they serve.  Patients and service providers rely on them as part of a web of supports that help people with serious mental health conditions stay in their communities. In contrast, the new facility is relatively far away in a region with spotty and circuitous bus service.

The new facility will also be operated as a private entity, which has stoked the concerns of advocates and patients who wonder whether the focus will be on profits instead of patient care.  Baystate will be a minority partner (33 percent) in the project with US Healthvest, a behavioral health services company based in New York that runs half a dozen behavioral health for-profit companies around the nation. US Healthvest is also opening a 120-bed facility in Worcester this year.

Donna Stern, a nurse on the Baystate Franklin mental health unit in Greenfield and a local leader of the Massachusetts Nurses Association, said closing community hospital beds and investing as a minority partner in a private company means Baystate Health is “essentially washing their hands clean of mental health.”

As a for-profit, she said, the new facility will have no requirement to admit people who are uninsured, and will accept a smaller percentage of people covered by Medicaid, the health insurance program operated by the state and federal government. “We take people every day who do not have insurance,” she said. “We are the last safety net for these folks.”

According to Stern, profit margins are higher still when patients are discharged as quickly as possible, in what she calls “spin-cycle admissions.”  She said people with serious mental illness often need more time in an inpatient programs in order for their condition to stabilize before discharge into the community.  Sometimes they can’t be stabilized and must wait for a longer term placement.

Sarvet disputes the notion the new facility will be less accessible to poorer people. “As in all of our current Baystate psychiatric facilities, decisions to accept and admit patients will be on the basis of clinical need and regardless of financial means,” he said. “We anticipate that the proportion of patients with public and private insurance will be similar to our current facilities.”

Over the past decade, dozens of hospitals across the state have closed units or eliminated services that have a high cost relative to insurance reimbursement ratios. Frequently, these hospitals then open or expand services such as surgery or neurology with better reimbursement ratios. According to Stern, hospitals closing services often promise to compensate for loss of essential services by admitting more indigent patients or providing transportation, but don’t follow through.

Sarvet said the transportation needs of patients, and how to address them, are currently being discussed.

Last month, Baystate Health announced plans to close intensive care units at Baystate Noble in Westfield and Baystate Wing in Palmer, converting them to medical surgical beds. In addition, Baystate plans to close six pediatric beds in Westfield, reducing the inpatient capacity.

-See the full Commonwealth Magazine article.

A new law allows people to wipe clean their Massachusetts criminal histories, but only a handful of requests to do so have been approved, according to a review of state data.

The law, part of a criminal justice bill signed last year by Gov. Charlie Baker, allows juvenile records and some adult crimes to be permanently removed from a person’s criminal record. But records from the Office of the Commissioner of Probation, which administers the law, show only a handful of petitions have been approved.

The probation office has received 173 expungement requests since January, but only a dozen were ultimately accepted, according to agency data obtained through a public records request.

Advocates say the large number of rejections illustrates the shortcomings of the law, which was touted by Beacon Hill leaders as the largest overhaul of the criminal justice system in decades.

“Clearly the juvenile expungement law has been a failure,” said Leon Smith, executive director of the Boston-based group Citizens for Juvenile Justice. “This is impacting peoples’ ability to move on and live productive lives. We need to fix it.”

In April, the most recent month for which data were available, the probation office received 62 petitions for expungement of juvenile records but rejected 56. Of the 18 requests it deemed eligible and forwarded to district attorneys for consideration, only two were ultimately approved by the courts, the data show.

Courts have approved another 22 direct requests for expungement so far this year, in which people asked judges to erase their criminal records. The probation office didn’t say how many requests directly submitted to courts were rejected.

The law allows for an individual’s criminal record to be wiped clean provided that the offense occurred before their 21st birthday and they’ve stayed out of trouble for a period of time.

For a felony charge, petitioners must wait at least 7 years until after their sentence was completed to request expungement. For misdemeanor, the wait is three years.

Major convictions — such as murder, felony assault, drunken driving, domestic battery, rape and other sexual offenses — cannot be expunged.

Advocates speculate that many of the petitions were rejected because the individuals had multiple charges as part of one conviction, or the charges were among 150 that aren’t allowed to be expunged. In many marijuana possession cases, for example, some defendants have been charged with intent to distribute if the drug was packaged in bags or rolled into joints.

Leon said juvenile records can haunt people long past their punishments, preventing them from landing jobs, renting apartments or getting into college.

He said studies show young adults who’ve been arrested or charged with crimes, and who stay out of trouble for four or more years, are less likely to get into trouble again.

Leon’s group is among those pressing lawmakers to revisit the law to allow multiple charges to be wiped clean, and to widen the list of offenses it covers. Lawmakers have filed several bills to update the law, but it remains unclear if they’ll be taken up by legislative leaders.

The expungement law was part of an overhaul of the criminal justice system that raised the minimum age of criminal responsibility from 7 to 12 years old and decriminalized minor offenses for juveniles. The law also changed how bail, fines and fees are levied, and it raised the threshold at which theft is considered a felony.

A major provision of the law allows juvenile records and those for some crimes committed as adults to be erased.

It created two categories under which individuals could seek an expungement: One allows a person with only one charge on their record, committed before they turned 21, to be permanently destroyed. The other allows people with adult and juvenile records to request expungement through the courts for multiple offenses if they are no longer illegal -- such as marijuana possession -- or for cases that resulted from misidentification, identity fraud or mistakes by law enforcement, court staff or witnesses.

Unlike sealing a criminal record, which can still be viewed by law enforcement, expungement permanently erases charges from someone’s official criminal record.

But advocates say the law is of limited use because people with juvenile records can only get one charge wiped clean.

Ed. note: this law only applies to state charges, not federal charges or charges from other states.

- See the full Newburyport News article.

Gov. Charlie Baker signed a bill this month to delay collection of the Paid Family and Medical Leave tax by three months.

The bill also sets aside $3.5 million to fund the new Department of Family and Medical Leave, which will oversee the benefit, and makes other technical changes to the law.

The state had planned to start collecting payroll taxes to fund the new paid leave program beginning July 1, 2019. Benefits are set to start in January 2021.

Now, the tax will be collected beginning in October. Both the Associated Industries of Massachusetts, a business group, and Raise Up Massachusetts, the labor coalition pushing for paid family leave, had asked for a delay to give employers more time to understand the rules and inform employees, and to allow insurers to offer a private sector-based paid leave option.

-See the full Mass Live article.

It started with a few people in a room, and a mountain of pain. But that handful of doctors grew into a vast, varied group of health care professionals determined to figure out how Massachusetts General Hospital might help prevent the gun violence that brought so many people to its doors.

MGH has announced the formation of the Mass General Center for Gun Violence Prevention, founded by two doctors whose lives were changed by shootings.

For Dr. Chana Sacks, an internist and researcher, it was the death of her cousin’s son, Daniel, at Sandy Hook Elementary School in Connecticut. He was 7 years old.

“As I went through that experience, I realized that we were treating this issue so differently” from anything else that kills roughly 40,000 people a year, Sacks said.

For Dr. Peter Masiakos, a pediatric trauma surgeon at MGH, the steady stream of gun injuries and violence made it clear that something had to change.

Now, through research, outreach, and clinical training, the center will join a growing national effort to confront gun violence in all its forms. And it arrives as physicians, hospitals, and health care systems around the country are emphasizing a public health approach to the problem.

That means everything from distributing free gun locks to patients — “the same way we hand out free condoms or bike helmets,” Sacks said — to helping fill the vast information void left by the 1996 Dickey Amendment, the federal legislation that effectively prevents the Centers for Disease Control from doing meaningful research on gun violence. An initial project, creating and conducting simulation trainings that will teach physicians how best to talk with patients about guns and gun safety, has already begun.

“We’re really good at asking patients about their safety. . . . Pediatricians do it all the time,” said Masiakos. “I think this is the opportunity that we have as health care providers to do the same thing for gun violence.”

Despite renewed congressional efforts to fund gun-violence research at the CDC, the MGH doctors said they are not counting on federal funding. “Most of the people that have been on the front lines of gun-violence research have either self-funded or have been able to get funding by means that superseded the government’s intention not to fund,” said Masiakos.

Initial money for the center includes $1.2 million from MGH and $200,000 from Harvard Medical School. Officials plan to raise more through philanthropy.

Even as awareness and engagement with the issue of gun violence have grown, public understanding of the reality is imperfect.

“Mass shootings understandably capture the nation’s attention and are horrific in a unique way,” said Sacks, who lost a family member in one of hardest to fathom. “But it’s important to note that they account for about 1 percent of gun deaths in the US.”

Many more gun deaths — nearly two-thirds — are suicides. And focusing only on those who die ignores the lasting scars, physical and emotional, that gun violence leaves behind, shattering and terrifying communities right here in Boston.

“By any metric, Massachusetts is one of — if not the — safest states in the country when it comes to gun violence,” Sacks said. “And that is not the experience of a lot of the communities within Boston. I think that disconnect is really important to delve into.”

-See the full Boston Globe article.

In Massachusetts, a state that prides itself on its top-quality health care, 20 percent of residents have experienced a recent medical error, and most of them said they “still feel abandoned or betrayed by their doctor,’’ a new survey shows.

Researchers also calculated that errors in the state totaled 61,982 in one single year and that it cost $617 million to provide the follow-up care required by those patients as a result of the mistakes — an amount researchers called a conservative estimate.

And despite a heralded Massachusetts law that requires health care providers to disclose medical errors that cause significant harm and encourages them to apologize — similar to laws in other states — only 19 percent of residents who reported an error said a caregiver apologized afterward.

The report by the Betsy Lehman Center for Patient Safety, a state agency, is one of the most comprehensive statewide examinations of medical errors.

The prevalence of medical errors reported by Massachusetts residents closely mirrors that found in national surveys and has not improved a lot over the past 20 years, underlining what medical safety leaders said is a discouraging reality. Doctors, nurses, and other providers across the country have made some progress in discrete areas: fewer patients contract certain infections in hospitals, and bar codes have reduced medication mix-ups. But widespread improvement has been elusive.

One bright spot in the survey shows that the right approach makes a positive difference for patients, she said. Of the 19 percent of residents who said a provider apologized after an error, the vast majority believed the apology was sincere. And when providers spoke honestly about mistakes, patients were less likely to feel angry, depressed, abandoned, and betrayed.

The Lehman Center’s data have limitations because they do not capture every type of error. Not included, for example, are diagnostic errors, such as when a provider misses a cancer diagnosis, a mistake that often leads to malpractice lawsuits.

More broadly, the Lehman Center plans to create a consortium to develop a comprehensive set of steps to improve patient safety in the state and measure progress.

-See the full Boston Globe article.

Under a project called My Life, My Story, volunteer writers seek out vets who are staying at the Madison VA hospital, and ask them all about their lives. Then they write up a life story, a thousand-word biography, and attach it to the patient's medical record so any doctor or nurse can read it.

Now more than 2,000 patients at the Madison VA have their stories in their charts. About 40 more VA hospitals around the country are looking into doing the same. And it's not just the VA. Hospitals like Brigham and Women's in Boston are also giving storytelling a try. That's a lot of confidence in the value of something that began as a simple solution to a pretty common problem. Back in 2012, Dr. Elliot Lee was a medical resident on rotation at the Madison VA. He wanted to find a way to bring new doctors up to speed on their patients. Not just their health histories, but things like their hobbies and who they trust to help them make decisions.

Lee says they tried getting patients to write it themselves, but not many people really wanted to. They tried surveys. That worked OK. And then someone realized they could hire a writer. And it just so happened there was a poet in town, named Thor Ringler, who also happened to be a therapist and knew how to talk to people.

Ringler's run My Life, My Story since 2013, and he says hospitals really only need one writer, working half or full time, to manage a storytelling program like this. That means spending as little as $23,000 to address the complaint that Ringler says is common to patients all over health care.

Says Ringler “I think everybody has the same complaints about health care - I don't get to see anybody for very long, and nobody knows who I am.”

There is research that suggests when caregivers know their patients better, those patients have improved health outcomes. One study, for example, found that doctors who scored higher on an empathy test have patients with better-controlled blood sugar. Another found the common cold was shortened by almost a full day in patients who thought their doctors were more empathetic. Professor Heather Coats at the University of Colorado studies the health impact of biographical storytelling. She points to a 2008 study that looked at what happened when radiologists were simply given a photo of the patients whose scans they were reading. They improve the accuracy of their radiology read, meaning less misspelled words, a better report that's more detailed.

It gives you a much better understanding of the entirety of their life and how to help them make a decision. Only about half of the people who undergo a lung transplant are still alive after five years. Madison VA Surgeon Jim Maloney says knowing a patient's life story makes it easier to have difficult conversations, like how aggressive to be if a complication occurs. My Life, My Story allows for near-immediate access of this background - what they've experienced and what they're about, and what their goals are - for the entire team.

-See the full NPR story.