Twenty-two of Connecticut’s 30 hospitals charged these fees, bringing in $600.7 million in 2015 and another $488.8 million in 2016, according to an analysis by Conn. Health I-Team.

The state’s two largest hospital systems, Yale New Haven Health and Hartford HealthCare, accounted for almost half of the total facility fee revenue in 2016. Yale and its four hospitals billed $144.3 million; Hartford and its five hospitals, $80.9 million. Stamford Hospital charged $118.2 million, the most of a single hospital.

Photo Stamford Hospital

Stamford Hospital charged $295.9 million in facility fees over two years.

Patients have long complained about facility fees, which hospitals charge for outpatient services at facilities they own to cover operational expenses. Of the 1.4 million outpatient visits in 2016 facility fees were charged for everything from five-minute office visits to diagnostic tests such as MRIs and mammograms.

Connecticut, which had earned an F from health advocates for its lack of transparency in medical costs, passed a law in 2015 requiring hospitals to notify patients if they will be charged a facility fee. Hospitals must clearly identify facility fees in bills, notify patients if they acquire a physicians’ group and file an annual report with OCHA on how much they earn in fees.

Patient advocates say that the law has made consumers more aware of the fees, but it is often confusing for patients who get a second bill for hundreds or sometimes thousands of dollars for care.

The fees are paid by consumers, their private insurance, Medicaid or Medicare.

“It’s a trap for the unwary,” said Ted Doolittle, head of the state Office of Healthcare Advocate. “It’s still something that is happening.”

Doolittle says his staff is currently working a few cases where patients were charged large facility fees, including a woman who received outpatient surgical care and expected to pay a $50 co-pay and was hit with a $930 facility fee.

West Hartford resident Leslie Silverman said she took her 15-year-old daughter to their doctor’s office to get blood drawn for a tendon in her ankle that wouldn’t heal in 2014. The doctor’s office had difficulty drawing blood and sent her to the West Hartford Surgical Center, which is owned by Hartford Hospital.

“We had no idea we were going to get walloped with a $1,200 facility fee, it cost four times as much as we thought,” said Silverman, who added that because it was part of an experimental procedure not covered by insurance, they paid the fee out-of-pocket.

“Our doctor wasn’t trying to mislead us; it just wasn’t on anybody’s radar,” she said. “We went there because our doctor said we have to do this and then we see the bill and we go, ‘Whoa.’”

Hospitals say facility fees are necessary to upgrade infrastructure costs. “Generally, when a facility becomes part of a hospital, the technology, including software and hardware, must be of a certain standard,” said Michele Sharp of the Connecticut Hospital Association. “Additionally, these facilities must have emergency stand-by capacity and meet more stringent regulatory requirements. As a result, the infrastructure costs associated with hospital-owned facilities are greater than the costs of a standalone office.”

Patient advocates say the public filings are a step in the right direction, but there’s a long way to go.

“As a consumer representative, it’s flabbergasting,” said Lisa Freeman, executive director of Connecticut Center for Patient Safety. “We’re paying more and more and we can’t figure out how much it will be ahead of time.”

What The Filings Reveal

In 2016, Connecticut hospitals charged facility fees at 184 off-campus facilities, the reports show. Some of the most frequent types of care that patients were charged facility fees for include radiation treatment, echocardiograms, sleep disorder testing, colonoscopies and mammograms.

Ellen Andrews, executive director of the Connecticut Health Policy Project, says the fact that mammograms are among the most frequent service for which facility fees are charged is “stunningly stupid.”

“A mammogram is preventive care,” she said. “Every time you institute another hassle and you make it harder to go to the same place you’ve always gone, you are going to get some people who just don’t go through the trouble. So, if it’s a problem for people getting preventive care, that’s really penny wise and pound foolish.”

The fees that caused the most outrage a few years ago were facility fees charged at doctor’s offices owned by hospitals. According to a 2014 report by Attorney General George Jepsen, facility fees became more common as hospitals acquired physicians’ practices. Patients complained about showing up to the same doctor they’ve seen for years, expecting to pay the same co-pay as always, but were later hit with a big facility fee.

Some of those fees are now banned in Connecticut, however.

Effective Jan. 1, 2017, hospitals cannot charge existing patients facility fees for a routine doctor’s visit that is billed as Evaluation and Management, which was part of the 2015 health bill spearheaded by state Senate President Pro Tem Martin Looney, D-New Haven, and Senate Republican President Pro Tem Len Fasano, R-North Haven.

Yale New Haven Hospital charged $103.1 million in facility fees in 2016.

Some hospitals will feel the impact of this change. In 2016, Yale New Haven earned $9.9 million for five-minute outpatient visits—its highest facility fee charged—which is now banned.

Congress also tightened regulations on facility fees in its 2015 budget by limiting what hospitals can charge at facilities acquired after Jan. 1, 2017.

There are signs that hospitals got the message, too. A spokesman for Hartford HealthCare said that as they’ve grown they’ve tried to employ physicians at outpatient facilities through the Hartford HealthCare Medical Group rather than through one of their hospitals so their patients won’t be hit with extra fees.

“This helps us limit facility fees for patients,” said Hartford HealthCare spokesman Shawn Mawhiney. “We do our best to limit the financial impact on our patients. In order to provide the latest technology and the best care possible, we need to have a sustainable business model. In some cases, that means charging facility fees.”

Hospitals That Don’t Charge

Eight hospitals did not charge facility fees for outpatient services in 2015 or 2016, either because they did not have outpatient facilities or because they chose not to. They include, Bristol Hospital, Day Kimball Healthcare, Gaylord Hospital, Griffin Hospital, Hebrew Hospital, Natchaug Hospital, Sharon Hospital and Silver Hill Hospital.

Bristol Hospital did not charge fees in 2015 or 2016 but started charging them last year for certain services provided by its Bristol Multi-Specialty Group because they needed the money.

“We made a conscious decision going back years based on patient dissatisfaction and just our philosophy that we were going to not have patients get these fees,” said Bristol Hospital President and CEO Kurt Barwis. “When we made that decision, we were solely reacting to our community.”

“I’m not sure that it was the right choice,” Barwis added.

The decision to charge facility fees was made last summer after, Barwis said, an increase in the hospital tax caused them to end the 2016-17 fiscal year with a $3 million loss. The hospital’s tax bill increased significantly over the last few years according to state estimates. In fiscal year 2012, Bristol Hospital paid $2.94 million for the hospital tax, which increased to $7.6 million in fiscal year 2016.

Barwis said, “The initial reaction was very strong, we had quite a few patients say, ‘All of a sudden, I have to pay this additional fee?’ and obviously some of it is covered and some of it’s not covered based on the insurance carrier that they have.”

“If they are on a high deductible plan, it’s pretty significant for them,” he said.

You can listen to WNPR’s report on this story here.

About 170,000 people—roughly 5 percent of the state’s population—live within a mile of these facilities, risking exposure to a leak, explosion or adverse health effects.

Low-income people and children of color under the age of 12 are more likely than their white counterparts to live in these “fenceline” communities, according to a report by the Center for Effective Government.

Derek Torrellas Photo.

On Welton Street, New Haven, residents live near the Chlor-Alkali plant.

In its report “Living in the Shadow of Danger: Poverty, Race and Unequal Chemical Facility Hazards,” the center examined more than 12,500 facilities in 50 states, grading states based on the “disparities faced” by people living adjacent to or near these facilities. The center reported that children of color under age 12 living in the state were 2.2 times more likely than white children to live within a mile of one of these facilities. In many instances, residents are unaware of the dangers just blocks from their homes, the report said.

Connecticut, and 25 other states, earned a “D” grade for its inequities. But, like in many states, there’s little that can be done because many of the facilities were built under old zoning laws and are protected.

“I’ve been doing this for 25 years, and I don’t see things changing. It’s frustrating,” said Edith Pestana, administrator of the state Department of Energy and Environmental Protection’s (DEEP) Environmental Justice Program, which was formed to assist neighborhoods unfairly burdened by environmental hazards.

“I have to say I was traumatized that we got a ‘D,’ but … people are living where they were always living, and it hasn’t improved.”

“A lot of it has to do with terrible zoning. A lot of facilities are grandfathered in,” Pestana said. “Until cities start looking at public health again, when they are rewriting their planning and zoning rules, things are not going to change.”

But the dangers are real, especially for people of color, experts and advocates said. Between 2010 and 2014, incidents occurred more frequently at facilities in neighborhoods predominantly populated by people of color—one incident per six facilities compared with one per 11 in predominantly white neighborhoods.

In 2015 the EPA estimated that 150 “catastrophic” accidents occur nationwide at regulated facilities each year.

“These incidents keep happening and happening. It feels like we get a new report once or twice a week,” said Anna Fendley of United Steelworkers, which represents 30,000 workers in chemical facilities across the country, including Connecticut.

The most recent incident in Connecticut took place in December 2016, when an explosion occurred inside a warehouse at New Haven Chlor-Alkali bleach manufacturing plant. The incident did not cause any injuries, but it was a wakeup call to some nearby residents.

“You have families that live on this street,” said 28-year-old John Smith, pointing to his son arriving home from school. He lives on Welton Street across from railroad tracks that bring 90-ton railcars of chlorine to and from the plant. “I like this street, it’s quiet except for the trains, but if I could I wouldn’t live near here.”

Federal, State And Local Oversight

An amendment to the Clean Air Act of 1990 mandated that facilities holding large quantities of certain potentially toxic chemicals submit a “risk management plan” to the EPA detailing the procedures to be followed if an explosion sends those chemicals airborne.

Peter Hvizdak - New Haven Register Photo.

The Chlor-Alkali facility was damaged following an explosion last December.

Connecticut’s 27 regulated facilities range from chemical manufacturers to food and beverage facilities and aerospace companies. The chemicals stored or processed include ammonia, chlorine, pentane, butane, propane and others.

The facilities employ more than 7,000 workers and are scattered statewide. In addition to New Haven, facilities are in Bridgeport, Norwalk, North Haven, New Britain, Wallingford, Bristol, Suffield and Windsor Locks, among other communities, according to reports compiled by the Houston Chronicle’s Right-To-Know Network. The newspaper created the listing because the EPA does not have a public database of “risk management plan” facilities online.

In 1993, DEEP created an Environmental Justice Program to help communities exposed to higher levels of environmental pollution.

No “segment of the population should, because of its racial or economic makeup, bear a disproportionate share of the risks and consequences of environmental pollution or be denied equal access to environmental benefits,” according to the state agency’s policy.

In 2009, the state enacted a landmark environmental justice law, which helps neighborhoods express community health concerns and negotiate with companies.

But that has done little to lessen the dangers because the law covers only new and expanding companies. Most facilities storing and processing chemicals existed prior to 2008.

The worst-case disaster scenario for the Chlor-Alkali plant would be a broken hose on one of those railcars, which would allow the chlorine to vaporize into the air, according to the company’s plan submitted to the EPA. An entire railcar of chlorine escaping could be toxic as far as 25 miles, impacting 1.6 million people, the documents report. The plant calls this “extremely unlikely,” but acknowledges the more immediate risk to those living nearby.

“However, even a chlorine release that is stopped within 30 minutes could be toxic to our nearby neighbors,” the documents read.

“There’s a really good chance you’re in danger if you’re that close,” said Sean Moulton, one of the contributors to the report who now works for the Project on Government Oversight. That organization took over much of the Center for Effective Government’s work in March 2016.

“Certain societal forces got us to this point,” he said. “We need to do something about future facilities and figure out a way to reach out to communities that are there now, ensuring that they have the proper tools and knowledge to deal with short-term emergencies and address long-term consequences of living near these facilities.”

 To view graphic details, click map’s upper left corner.                           Graphic by Marie Shanahan.

Changes In New Haven

What can change is how municipalities handle incidents. Sometimes it takes an incident—or an explosion—to bring about change.

In New Haven, residents have long complained about the Chlor-Alkali bleach manufacturing plant, formerly H. Krevit & Co., which shook their Cedar Hill neighborhood last December. A container explosion released sodium hypochlorite, a chemical dangerous to inhale and ripped a hole through the rear of the building. Residents heard and felt the morning blast but weren’t notified it was a chemical explosion for six hours.

After the explosion, the city’s Office of Emergency Management updated its notification system so if that were to happen again, phone calls and text messages would go to residents within 2 miles of the incident. The city also plans to distribute a chemical preparedness pamphlet citywide.

Chlor-Alkali’s business development manager, Arjun Murthy, now regularly attends meetings with neighbors to address concerns and said the plant has “made a number of process changes inside our plant and added new equipment to ensure that something similar never happens again.”

“Unfortunately, we had to have an incident to get to this point,” said Marie Gallo, a member of the Cedar Hill Merchants Association and owner of Gallo’s Appliance, which is a few blocks south of the plant. At a recent merchant meeting during which the city announced its plan, she said, “If we were taken a little more seriously three or four years ago, maybe we wouldn’t be at this point now.”

“These communities suffer disproportionately,” said Dr. Mark Mitchell, a public health physician who founded the Connecticut Coalition for Environmental Justice and currently serves as principal of Mitchell Environmental Health Associates.

“There’s a direct correlation between the percentage of people of color in a community and the number of environmental hazards in those communities—and the relationship is even stronger between poverty and environmental hazards.”

“People don’t know that it’s dangerous. They don’t know what they are living next to,” he said. “And particularly in low-income neighborhoods, people move very frequently and so even if you tell people today, then next year there could be a whole new set of people who won’t know.”

These are two of the largest awards or settlements to go to motorists injured in crashes since Connecticut’s ban on talking and texting on cellphones went into effect in 2005, and a recent change to court procedure may pave the way for more large settlements.

iStock Photo.

Distracted driving “is getting rampant now. People are constantly using their cellphones,” said Attorney Garrett Moore Jr.

Despite the large awards, the incidence of fatalities and injuries from motor vehicle accidents in the state has continued to rise in recent years, state data indicates. The total number of car crashes increased every year from 2011 to 2016– from 78,433 in 2011, to 116,117 last year — according to UCONN’s Connecticut Crash Data Repository, which contains data that the state Department of Transportation collects. Whether more fatalities and injuries from those car crashes are caused by drivers distracted by their cellphones is harder to pin down.

In 2016, state data show that five people died in car crashes that involved drivers using a cellphone or other electronic device, up from three in 2015. Injuries rose, too. Last year, 31 people were listed by police as having a “suspected serious injury” in accidents that involved drivers using a cellphone or other electronic device– up 47 percent, from 21 in 2015.

The number of people police listed as having a “suspected minor injury” in crashes that involved drivers using a cellphone or other electronic device also rose — from 266 in 2015 to 314 in 2016. And reports of a “possible injury” linked to drivers using cellphones or other electronic devices went up from 459 in 2015 to 482 in 2016.

“Without a doubt, distracted driving has become more and more prevalent,” said Mark Kochanowicz, an attorney with Trantolo & Trantolo, LLC, who represented the New Britain couple. “We see cases where there is no braking, no skid marks, especially on a highway, and there’s a sudden stop in traffic, and that’s a strong indication that the driver was texting or using their phone or on some other app.”

In the two years before the $1.3 million settlement, drivers in other cellphone-related cases represented by Kochanowicz’s firm got settlements or awards of $136,000, $206,000 and $633,000.

Effective Jan. 1, the state judiciary altered its standard list of questions a plaintiff can ask in a motor vehicle lawsuit to require defendants to state if they were “calling, texting, e-mailing, posting, tweeting, or visiting sites on the Internet for any purpose” at the time of a crash.

Attorneys have long complained that it’s difficult to prove a driver was on a cellphone at the time of a crash if the driver did not admit it to police at the scene. Drivers now have to state under oath at an early stage of a lawsuit if they were using their phone, making it easier for attorneys to access texting or call records. If the records show the driver was using a cellphone, a plaintiff can allege recklessness — a much more serious charge that can result in loss of license. It’s also a way personal injury attorneys can gain leverage against responsible drivers.

“It’s getting rampant now. People are constantly using their cellphones,” said Garrett Moore Jr., an attorney with Moore, O’Brien & Foti who has litigated distracted driving cases. “But the thing is, it’s difficult to prove. You have to have the records.”

The Connecticut Judicial Branch does not track trends in motor vehicle lawsuits. A judiciary spokesperson said the department amended the procedure because of an increase in disputes between parties in motor vehicle accident lawsuits over access to phone records.

Police and safety experts say drivers continue to use their cellphones while driving, causing more accidents than they are able to report.

The National Highway Traffic Safety Administration reports that in 2015, drivers using their cellphones caused 476 traffic fatalities and 30,000 injuries nationwide. In Connecticut, data on crashes that involved drivers using cellphones or other electronic devices from the first five months of this year show a decrease in fatalities but a slight increase in injuries.

Arnold Gold/New Haven Register Photo.

A New Haven police officer pulls over a distracted driver in 2016.

The data is limited, however, because the standard crash report filled out by police across the state did not include a section for distracted driving until January 2015. The state also warns that the data does not present a clear picture of all traffic injuries caused by drivers on cellphones because it can be difficult for police to determine at the scene of an accident whether a driver was actually using a cellphone.

To bring awareness to the problem, in 2014 the state initiated its campaign: “U Drive. U Text. U Pay.” Last year, the state directed more than $1.1 million in federal funds to 49 local police departments and the state police to pay for overtime so police could specifically crack down on drivers using cellphones.

“It’s almost the way we see a drunk driver operate: You’ll see the weaving in the lane, you’ll see the speeding up and slowing down, you’ll see the slow drift of the vehicle operation and then the vehicle jerks back to within the travel lane,” said Col. Alaric Fox, Connecticut State Police commander.

Since 2009, in Connecticut police at all levels have issued between 29,000 and 47,000 citations for using a cellphone while driving each year.

The current penalty for using a cellphone or other electronic device while driving is a $150 citation on the first offense, $300 on second offense and $500 on third offense. A bill to increase those penalties was introduced in the state legislature in January, but it never made it out of the transportation committee.

“Everybody talks about distracted driving, everybody knows it’s a problem and the serious injuries that are received, and yet they don’t really put teeth into the law,” said attorney John Haymond of Haymond Law, which handled the $1.4 million jury award to the Torrington woman.

He said the only way to give a distracted driving charge some teeth in court is to link it to reckless driving, which is much more severe than a negligence charge.

Most distracted driving cases settle, sometimes even out of court, in mediation before the distracted driving charge is concluded in court. That’s what happened in a case last year, when a 72-year-old Stamford man was killed on his bicycle in May 2016 by a driver who was charged with talking on his phone while driving. The driver is facing a $150 fine for using a cellphone while driving and is next due in court this September. But the defendant’s insurance company already settled in mediation with the estate of the deceased cyclist for $3.125 million.

“We see carnage from drunk driving accidents. We see carnage from texting while driving. We see carnage from just inattentiveness. I would encourage anyone to engage in safe driving behavior all the time,” said Fox, the state police commander.

From the outside, the 95-bed, single-story facility set back from the road looks like any other nursing home. But many of the elderly and ill residents are actually paroled prisoners, and the home is being watched nationally as a potential game-changer for states grappling for ways to care for their aging inmate populations.

60 West is the first facility in the country to win approval from the Centers for Medicare & Medicaid Services (CMS) for federal nursing home funding—a designation that has national significance, experts say, because it’s a new option for cash-strapped states looking for ways to care for growing populations of older and sicker inmates.

“Connecticut has tried to be innovative in our criminal justice reforms. This is one of them,” said Michael Lawlor, the state’s undersecretary for criminal justice policy and planning.  “What we are doing is being copied in other parts of the country. It’s this kind of innovation that helps reform the criminal justice system nationwide.”

Tina Maschi, a Fordham University professor and former prison social worker who studies aging prisoners, said that the state “responded to a difficult problem of caring for seriously, terminally ill prisoners, and [its approach] managed to survive, despite community pushback. This program is a role model.”

Derek Torrellas Photo.

Afua Animwah, a licensed practical nurse, prepares a patient’s medication in the hallway at 60 West.

In December, 60 West, a privately-owned facility under contract with the state, was notified that CMS had reversed its 2015 rejection for federal certification and granted the facility the same status as thousands of other nursing homes across the country, making it eligible for federal funds—a development first reported by the website the Crime Report. CMS previously had ruled that paroled inmates did not meet federal guidelines.

Ailing inmates who qualify for nursing home-level care and who the state deems are not public safety risks are referred to 60 West. Medicaid covers half the cost of their care, which will save the state about $5 million annually.

Lawlor said that federal approval is a boon to Connecticut, where the over-60 population increased by more than 40 percent from 2010 to 2016.

“There is a need for this type of facility in every state in the country,” Lawlor said. “It’s way more expensive to provide this care in the context of a prison. … If they are in a real nursing home, you get 50 percent [funding] from the feds; in prison, you get zero percent.”

In addition to funding concerns, caring for the growing population of elderly prisoners is difficult because “prison infirmaries were not designed to serve chronically ill people or people who need hospice care,” said Judith Dowd, director of health and human services for the state’s Office of Policy and Management.

While Connecticut’s total prison population decreased by more than 3,000 inmates between 2010 and 2016, the over-60 population increased from 301 inmates to 426, according to December population counts posted on the state Department of Correction (DOC) website. In 2010, inmates ages 46 to 60 made up just 16 percent of the state prison population; that percentage inched up steadily to 19 percent last year.

As the number of elderly and sick prisoners rises, so, too, does the cost of their care. The annual price of care for an inmate increased from $4,814 in fiscal year 2010 to $5,201 in 2015, as more inmates required regular health care. In 2016, 27 percent of the prison population required health care, up from 20 percent in 2011. And most Connecticut’s prisoners are on some form of medication: 56 percent in 2016 up from 40 to 45 percent between 2008 and 2010.

Connecticut is not alone in dealing with growing numbers of elderly prisoners. Due largely to the “tough on crime” laws of the 1980s and 1990s and strict release policies, the percentage of older prisoners behind bars nationally has exploded in the past decade, experts say. The crisis has states scrambling to come up with ideas to lower costs.

The success of Connecticut’s community-based approach is a signal to other states that they can secure federal funding to help care for ill, aging prisoners, which until recently was viewed as impossible, prisoner advocates said.

“It’s pretty exciting,” said Maschi. “I do think that the idea will spread. It is inspirational, and people are taking notice.”

Watching, Waiting

At least three states—Kentucky, Michigan and Wisconsin—have explored creating facilities like 60 West. But some have been waiting to see how the CMS approval would play out.

Al Pscholka, a former Republican state representative from Michigan, introduced a bill last year that would have permitted medically frail inmates to be cared for in licensed health care facilities rather than prisons. The bill passed the House, but did not make it through the Senate because of funding concerns.

The federal approval “is great news and should help efforts in Michigan,” said Pscholka, who is now the state’s budget director. “I believe this is a cost-effective and compassionate way to deal with terminal prisoners.”

Other states are taking different approaches. Missouri is modifying prison housing units to accommodate disabled inmates. Virginia has a designated assisted-living unit inside a prison to care for infirm and geriatric inmates. New York has a prison unit for the cognitively impaired. Iowa opened a prison hospice unit. Nevada has a preventative health program called True Grit for inmates over 55.

Derek Torrellas Photo.

Irene Rivera, a licensed practical nurse, cleans a patient’s room at the Rocky Hill nursing home.

“States are using a variety of strategies,” said Maria Schiff, director of state and local fiscal health for the Pew Charitable Trusts. “They are trying to accommodate both sides: to treat these individuals as they need to, but to try to contain some of the costs.”

60 West is not the first Connecticut innovation to address the aging prison population. The state is one of a few with a prison hospice program in which fellow inmates care for dying prisoners.

The program started in 2001 at the MacDougall-Walker Correctional Institution in Suffield and was expanded to Connecticut’s only prison for women, York Correctional Institution in Niantic, in 2003 and to a second men’s facility, Osborn Correctional Institution in Somers, in 2007.

Most states also now have compassionate release parole, which lets dying inmates out of prison at the very end of their lives. Connecticut began releasing such prisoners in 2012, and the federal government started a similar policy in 2013. But compassionate release and medical parole, another form of relief for sick prisoners, are rarely used, records show. In 2016, Connecticut’s Board of Pardons and Parole granted one compassionate parole and two medical paroles; in 2015, there were three compassionate paroles and one medical parole.

“It’s so bureaucratic that by the time [the prisoners] get considered, they die,” said Maschi. “There’s a fear about letting people out, especially about how the public would react to letting them out.”

Many of the 60 West residents are on nursing-home-release parole, a form of parole the state legislature created in 2013. To qualify, the DOC must determine that inmates are “suffering from a terminal condition, disease or syndrome” and “be physically incapable of presenting a danger to society.”

These “offenders are so medically compromised, they don’t have the physical ability to commit a crime,” said Dr. Kathleen Maurer, DOC’s director of health services.

‘We’ll Take Care Of Them’

The idea for a facility like 60 West began under former Gov. Jodi Rell. Inmates eligible for release often languished in prison, as nursing homes refused referrals from DOC and the Department of Mental Health and Addiction Services (DMHAS), according to Lawlor.

In 2011, the Malloy administration sought a facility operator for 60 West, and SecureCare Options LLC submitted the winning bid. The facility started accepting paroled inmates in 2013.

But the process of gaining acceptance was anything but smooth.

Some neighbors opposed the facility, and the town of Rocky Hill filed a lawsuit against SecureCare, arguing that the nursing home violated local zoning regulations. The state Supreme Court tossed out that lawsuit, but others are still pending. The town of Rocky Hill filed a second lawsuit alleging a separate zoning violation, and two neighbors have a pending lawsuit alleging the facility has decreased their property values.

In the 3½ years since 60 West opened, state officials say, no criminal incidents have been reported. “There hasn’t even been a workers’ comp claim,” Lawlor said.

Currently 72 residents live at 60 West: 45 were referred from DMHAS, which includes referrals from inpatient psychiatric units; 19 residents were referred from DOC; and eight are from the community.

Diagnoses vary, and include dementia, brain injuries, HIV, cancer, Huntington’s disease and psychiatric conditions, such as schizophrenia, depression, personality disorders and anxiety, said Diana Lejardi, a spokesperson for DMHAS.

Jessica DeRing, the administrator of 60 West, said staff members know where the residents come from, so that they can accommodate their needs, but “they don’t necessarily know their histories.”

“From our end, these are nursing home residents,” she said. “And they are here and we’ll take care of them.”

This initiative, which gives ex-offenders the opportunity to see a primary care physician on a regular basis and access critical mental health and drug-abuse treatment programs, exists because of the Affordable Care Act (ACA), and Medicaid pays most of the costs.

Recidivism data show that the initiative is working, state officials say. Yearly, the Court Support Services Division (CSSD) refers approximately 20,000 adults on probation to various behavioral health programs and tracks them for 12 months. In 2016, CSSD reported that 23.1 percent of adults who completed their referral program were rearrested, a five-year low since CSSD started tracking in 2012. For those who dropped out or were kicked out of the program, 41 percent re-offended within 12 months.

But the re-entry health care programs, which rely on generous reimbursements under Medicaid, are in jeopardy, as President Trump and the Republican-controlled Congress continue to discuss plans to replace the ACA and trim Medicaid funding.

In late March, a Republican repeal bill, which would have also converted Medicaid to a block grant program and cut state funding, was pulled from consideration in the House because it did not have the votes for approval. The House speaker announced that the ACA “was the law of the land.” But now, weeks later, replacing the ACA and cutting Medicaid are back on the agenda.

State officials are closely monitoring to see if the new administration will roll back policy changes that have made it easier for the state to connect ex-offenders to health care and drug treatment programs.

And community-based organizations that now bill Medicaid directly for behavioral health services are also worried that funds will disappear, and that former prisoners will be left without health coverage.

“Access to health care plays a critical role” in prisoner re-entry, said Jeff Grant, executive director of Bridgeport non-profit Family ReEntry. “All of these returning citizens who return to the street without adequate wraparound services are going to return to the behavior that got them in trouble in the first place.”

Nationally, studies of similar re-entry initiatives in other states have found that programs that link individuals to a health care system contribute to reduced recidivism. In Connecticut, Gov. Dannel Malloy’s administration credits access to community health services as part of the reason overall recidivism rates dropped slightly, from 32.9 percent in 2011 to 32.4 percent in 2014.

Leveraging Medicaid After State Cuts

A year ago, community-based mental health providers took a big hit in the state budget, when the state terminated $5.4 million in service contracts.

But following the lead of other states, some providers started billing Medicaid directly for ex-offender treatment—a move they said has allowed them to continue providing services to at least some of their clients. It is that backup plan that is in jeopardy as Congress works to cut Medicaid.

Non-profits such as Central Naugatuck Valley Help, Inc., which operates in Torrington, Danbury and Waterbury, were surprised at the severity of the state cuts. After losing a $1 million contract, Help, Inc. cut staff and employment programs, reduced the size of its space at each of its locations, and shifted behavioral health programming to Medicaid.

“We’ve been trying to hold on by billing Medicaid for the behavioral health services, and it’s challenging.” said Roberta Murtagh, executive director of Help, Inc.

Murtagh said the agency didn’t see a big change in the number of clients in Torrington and Danbury, but in Waterbury the numbers plummeted from 200 clients a year ago to about 70.

Those who get treatment say it is working. Ryan Puzinski, 29, of Torrington, said drug abuse treatment at Help, Inc.’s Watkins Center has helped him stay clean after serving 18 months for selling heroin.

Medicaid pays for Puzinski’s drug-abuse counseling sessions, as well as methadone, urine testing and LogistiCare transportation so he can get to medical appointments.

“I get a lot out of it,” he said. “It’s definitely helped me with identifying my triggers and my issues. Talking to people, hearing peoples’ stories, talking about my issues, getting feedback, stuff like that helps.”

Christina Brague, 42, of Torrington, said the drug-abuse treatment she gets at Help, Inc. through HUSKY D has been a “life saver.”

“It’s been a hard road, but I did it,” said Brague, who is on probation and has been enrolled in the program since September.

Derek Torrellas Photo.

Dr. Lisa Puglisi checks the blood pressure of Adrian Heggie at Transitions Clinic.

Not all non-profits had the resources to switch to Medicaid. Family ReEntry, which operates in Bridgeport, New Haven and Norwalk, lost its $1.9 million behavioral health state-funded contract. They cut their behavioral health programs but kept employment, housing and mentoring programs.

“A lot of eggs were in the Department of Correction budget basket. We didn’t want to … put all those eggs in a Medicaid basket only to find out that basket will be empty as well,” Grant said.

Access To Primary Care

Community workers say taking care of general health is part of a successful re-entry.

The Yale New Haven Hospital – Primary Care Center operates Transitions, part of a network of 17 clinics nationwide providing primary care “to promote healthy reintegration, improve health care utilization, and decrease prison recidivism.” The clinic, which has 700 patient visits each year across its two locations in New Haven, is partly funded through grants from the Centers for Medicare & Medicaid Services, a program created under the ACA that Trump’s Health Secretary Tom Price has vowed to eliminate.

“As a society, we tend to put health care on the back burner, but most of these guys never had a primary care physician,” said Jerry Smart, a community health worker for Transitions Clinic in New Haven. “If you get an illness that prevents you from working, how are you supposed to survive? Relapse is just around the corner.

“We are dealing with a population that is coming from an environment that’s plagued with violence, trauma, drugs,” Smart added. “There’s a lot of stress. I tell everybody who comes home, you may look good on the outside but you don’t know what’s going on the inside. Get some blood work, get a physical.”

Robert Nixon, 40, of New Haven, receives care at Transitions after serving 15 years in prison.

“Behind bars, it’s like a Motrin for everything,” he said. “When you come home, you start thinking where do I get the things that I need?”

After spending most of his adult life behind bars, Nixon said, he struggled in the outside world with simple things like crossing busy intersections in New Haven.

“It’s great you can go to a place where they know what you’re going through,” he said.

“Transitions is a community. They understand you. They explain everything to you. You walk out with a clearer head about how better to take care of yourself.”

Heidi Lubetkin, vice president of clinical and support services at Community Renewal Team, Inc., in Hartford, said many ex-offenders referred to the agency for mental health and drug abuse treatment were also in need of primary care. The agency connected with the University of Hartford’s Project Horizon to get its clients primary care help from volunteer registered nurses.

“I think it’s important to take care of the complete person,” she said. “You can’t take care of just one thing. Yes, take care of their substance abuse and mental health, but you can’t do that if they feel like crud.”

Reduction In Federal Funds

Since becoming the first state to expand Medicaid, Connecticut has relied more and more on federal dollars to pay for re-entry services and other programs.

In fiscal year 2017, $3.5 billion in federal Medicaid funds flowed into Connecticut, an increase of nearly $1 billion since the ACA was passed. Much of that increase is due to expanding Medicaid coverage to childless adults, aged 19 to 65, earning up to 138 percent of the federal poverty level, which Connecticut calls Husky D. Currently, 208,113 low-income residents are covered under HUSKY D, up from just 75,000 five years ago.

A significant number of those newly covered individuals are released prisoners. Numbers from the state Department of Social Services (DSS) show that 87.8 percent of new Medicaid sign-ups from January to November last year were HUSKY D.

Derek Torrellas Photo.

Daviana Contreras, case manager, meets with Jason Lerczak at the Community Renewal Team’s Hartford office. Lerczak started receiving services two years ago.

Until now, the federal government picked up 100 percent of costs under HUSKY D, which gave Connecticut a great incentive to sign up released prisoners for Medicaid. The federal share drops to 95 percent this year and notches down every year until it hits 90 percent in 2020. Still, that means Connecticut will pay just $32.1 million in fiscal year 2017 to make sure more than 200,000 low-income residents have health insurance, according to an estimate in the governor’s budget released in February.

According to the governor’s budget, the HUSKY D program will cost an estimated $1.46 billion in 2018. Under current law, the federal government will pick up 94 percent of that ($1.37 billion), while the state will pick up 6 percent ($87.5 million).

But if Republicans succeed in changing Medicaid funding to a block grant program, states would get a lump sum and less than what is given now. According to estimates from the state’s Office of Policy and Management, the GOP’s proposal from March would cut as much as $450 million in fiscal year 2020. This would force the state to make up the difference in funding or cut programs and reduce the number of people served.

A change in Medicaid funding “would shift money back to the state general fund and would likely mean reduction in services,” said Brian Hill, director of research, program analysis, and quality improvement at CSSD. If the state “continues to trim money [for those services] over the years, we don’t have that money sitting in a separate pot ready to supplant the Medicaid funds as they get cut,” Hill said.

“We’re talking about thousands of offenders who wouldn’t be getting the services they need,” Hill said.

Michael Lawlor, the state’s undersecretary for criminal justice policy and planning, said repealing Obamacare would lead to more crime and recidivism.

“Our goal is less crime. All the things we are doing, we believe, have the effect of reducing crime, and all the data we have show that it’s working,” Lawlor said.

Even after the Republican bill failed in March, Lawlor said, they were still concerned about changes to Medicaid — big and small.

“We have to be on guard with whatever proposals are being made,” he said.

In 2004, the Department of Health & Human Services encouraged states to suspend rather than terminate people on Medicaid when they are imprisoned, something Connecticut does. Lawlor said even without Congress, the new administration could roll back changes like this and add an obstacle for released prisoners getting help they need.

“Right now we’re concerned about the unintended consequences of even relatively minor changes that they could make that would have relatively large consequences,” Lawlor said.

“You could easily reverse all the progress that’s been made with a couple of minor changes to federal law.”