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The Patient-to-Prisoner Pipeline: The IMD Exclusion's Adverse Impact on Mass Incarceration in United States

Published online by Cambridge University Press:  06 January 2021

Michael E. Onah
Michael E. Onah*
Affiliation:
Boston University School of Law
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Abstract

A component of the 1965 Medicaid Act, the Institutions for Mental Diseases (“IMD”) Exclusion was supposed to be a remedy for the brutal, dysfunctional mental healthcare system run through state hospitals. In the years since Medicaid was created, the IMD Exclusion has instead barred thousands of those in need of intensive, inpatient treatment from receiving it. As a result, many severely mentally ill individuals are left without adequate care and without a home. They struggle in the street where they are otherized by those in their community and are susceptible to confrontational episodes with law enforcement. Many are ultimately incarcerated, where they are thrust into an abusive environment known to exacerbate mental health issues.

This Note's central contention is that the IMD Exclusion creates an access gap for the poorest Americans who suffer from mental illness. Subsequently, prisons and jails fill that gap to the detriment of those individuals. The Note will proceed first by explaining the IMD Exclusion and how it applies to state-run medical care services and facilities. This Note will discuss the nationwide movement, in the 1950s through the 1960s and ‘70s, to deinstitutionalize notoriously abusive state psychiatric hospitals, a movement that culminated in the passage of the Medicaid Act in 1965, along with the IMD Exclusion. This Note will then shift focus to criticize the practical effects of the IMD Exclusion and its extensive role in the mass incarceration issue today. In doing so, this Note will identify the major weaknesses of the IMD Exclusion and explain how these weaknesses create an access gap for mentally ill persons, while simultaneously making them more vulnerable to contact with the police and the criminal justice system.

Type
Notes & Recent Case Developments
Information
American Journal of Law & Medicine , Volume 44 , Issue 1 , March 2018 , pp. 119 - 144
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 2018

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References

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2 Jennen, Susan M., The IMD Exclusion: A Discriminatory Denial of Medicaid Funding for Non-Elderly Adults in Institutions for Mental Diseases, 17 Wm. Mitchell L. Rev. 339, 370 (1991)Google Scholar; Dahlia Lithwick, Prisons Have Become America's New Asylums, Slate (Jan. 5, 2016), http://www.slate.com/articles/news_and_politics/jurisprudence/2016/01/prisons_have_become_warehouses_for_the_mentally_ill.html [https://perma.cc/95MT-PR3T].

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8 Id.

9 Swanson, supra note 7.

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11 Swanson, supra note 7.

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19 1965 U.S.C.C.A.N. at 2085; Davoli, supra note 4 at 169; Edwards, supra note 18.

20 1965 U.S.C.C.A.N. at 2085; Davoli, supra note 4 at 169; Edwards, supra note 18.

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25 Id.

26 Id.

27 Id. at 465.

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31 Clarke, supra note 15 at 468; see also Davoli, supra note 4 at 168-69; Fahkoury & Priebe, supra note 22 at 313.

32 Fahkoury & Priebe, supra note 22 at 313.

33 Clarke, supra note 15 at 466.

34 Clarke, supra note 15 at 466-67.

35 Fahkoury & Priebe, supra note 22 at 313.

36 Id.

37 Legal Action Center, The Medicaid IMD Exclusion: An Overview and Opportunities for Reform, Legal Action Center, https://lac.org/wp-content/uploads/2014/07/IMD_exclusion_fact_sheet.pdf.

38 Jennen, supra note 2 at 346.

39 Id. at 346 (citing 42 U.S.C. § 1396d(a) (1988)).

40 La Couture, supra note 3.

41 Jennen, supra note 2 at 346-47.

42 Davoli, supra note 4 at 169.

43 Clarke, supra note 15 at 465-67.

44 Id. at 468.

45 Id.

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50 Id.

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56 La Couture, supra note 3.

57 Jennen, supra note 2 at 346. Although the IMD-defining “overall character” provision was not added to the language of the Medicaid Act until 1988, HHS has long-used the following criteria to determining whether a facility qualified as an institute of mental disease:

  1. The facility is licensed as a psychiatric facility for the care and treatment of individuals with mental diseases;

  2. The facility advertises or holds itself out as a facility for the care and treatment of individuals with mental diseases;

  3. The facility is accredited as a psychiatric facility by the JCAH [Joint Commission on Accreditation of Hospitals];

  4. The facility specializes in providing psychiatric/psychological care and treatment. This may be ascertained through review of patients' records. It may also be indicated by the fact that an unusually large proportion of the staff has specialized psychiatric/psychological training or by the fact that a large proportion of the patients are receiving psychopharmacological drugs;

  5. The facility is under the jurisdiction of the State's mental health authority;

  6. More than 50 percent of all the patients in the facility have mental diseases which require inpatient treatment according to the patients' medical records;

  7. A large proportion of the patients in the facility have been transferred from a State mental institution for continuing treatment of their mental disorders;

  8. Independent Professional Review teams report a preponderance of mental illness in the diagnoses of the patients in the facility (42 C.F.R. 456.1);

  9. The average patient age is significantly lower than that of a typical nursing home;

  10. Part or all of the facility consists of locked wards. Id.

58 Id.; see also Davoli, supra note 4 at 172.

59 Jennen, supra note 2 at 369.

60 Id.

61 Id.

62 Davoli, supra note 4 at 174.

63 Id.

64 Id.

65 Id. at 173.

66 Davoli, supra note 4 at 175.

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70 Id.

71 Id.

72 Emma Sandoe, What Is the IMD Exclusion Everyone Is Talking About?, Harv. L.: Bill of Health, (Feb. 27, 2016), http://blogs.harvard.edu/billofhealth/2016/02/27/what-is-the-imd-exclusion-that-everyone-is-talking-about/ [https://perma.cc/5X4C-DMZV].

73 Mat DeLillo, Institution for Mental Disease (IMD) as an “In Lieu of” Service, Milliman: Insight (May 18, 2016), http://us.milliman.com/insight/2016/Institution-for-Mental-Disease-IMD-as-an-in-lieu-of-service/ [https://perma.cc/VB5M-AQ7C]; see also La Couture, supra note 3.

74 Chicago Sun-Times, ‘Devastating’ Closure of Mental Health Centers to Hit 10,000 Patients Next Month, Chicago Sun-Times (Jun. 24, 2016), http://chicago.suntimes.com/news/devastating-closure-of-mental-health-centers-to-hit-10000-patients-next-month/ [https://perma.cc/FAE5-NDAS]; see also Kristin Fawcett, What Happens to Patients When Mental Health Centers Close?, USA Today (Sep. 20, 2014), http://health.usnews.com/health-news/patient-advice/articles/2014/09/30/what-happens-to-patients-when-mental-health-clinics-close [https://perma.cc/33KE-VDJL].

75 Kenneth Lovett & Larry McShane, Deborah Danner, Schizophrenic Bronx Woman Killed by NYPD, Wrote Essay on Cops' Inability to Deal with Mentally Ill, N.Y. Daily News (Oct. 20, 2016), http://www.nydailynews.com/new-york/bronx/bronx-woman-killed-nypd-wrote-essay-cops-mentally-ill-article-1.2838291; Eli Rosenberg & Ashley Southall, In Quick Response, de Blasio Calls Fatal Shooting of Mentally Ill Woman ‘Unacceptable’, N.Y. Times (Oct. 19, 2016), https://www.nytimes.com/2016/10/20/nyregion/nypd-sergeant-fatal-shooting-bronx-woman.html?_r=0.

76 See Lovett and McShane, supra note 75.

77 Shaun King, The Killing of 66-Year-Old Deborah Danner is Wrong on Every Level, N.Y. Daily News (October 19, 2016), http://www.nydailynews.com/news/national/king-nypd-killing-66-year-old-deborah-danner-wrong-article-1.2836652.

78 See Rosenberg & Southall, supra note 75.

79 Andy Mai et al., Deranged Woman, 66, Shot Dead After Attacking Cop with Baseball Bat in Bronx; NYPD Probing Why Police Officer Used Gun Over Taser, N.Y. Daily News (Oct. 19, 2016), http://www.nydailynews.com/new-york/nyc-crime/police-shoot-emotionally-disturbed-woman-bronx-article-1.2835758.

80 Graham Rayman et al., NYPD Sergeant Charged with Murder in Fatal Shooting of Deborah Danner in the Bronx, N.Y. Daily News (May 31, 2017), http://www.nydailynews.com/new-york/nypd-sergeant-charged-murder-deborah-danner-bronx-article-1.3209720.

81 John Parry, Criminal Mental Health and Disability Law 23 (2009).

82 See infra Figure 1, originally published in The Economist, (Aug. 3, 2013), http://www.economist.com/news/united-states/21582535-costly-criminalisation-mentally-ill-locked.

83 Caitlin Klevorick, Our Unhealthy View of Mental Health (and Mental Illness), The Huffington Post (Mar. 2, 2013), http://www.huffingtonpost.com/caitlin-klevorick/our-unhealthy-view-ofmen_b_2797892.html [https://perma.cc/926H-LE53].

84 Risdon N. Slate et al., The Criminalization of Mental Illness 42 (2d ed.) (2013).

85 See Parry, supra note 81 at 23.

86 See Mental Illness and Homelessness, Nat'l Coal. for the Homeless, http://www.nationalhomeless.org/factsheets/Mental_Illness.html [https://perma.cc/QJT2-Y5PT]; Council of State Governments, Criminal Justice/Mental Health Consensus Project 8 (2002).

87 How Many People with Serious Mental Illness Are Homeless?, Treatment Advocacy Ctr. (Apr. 2, 2016), http://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/2596-how-many-people-with-serious-mental-illness-are-homeless [http://perma.cc/K58Q-DUJB].

88 Id.

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91 Id.

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93 See Parry, supra note 81 at 26. The court's findings above are particularly striking because they simultaneously reveal the deficiencies in the overall condition of mentally ill people caused by the IMD Exclusion and deinstitutionalization and show the additional harms they perpetuate. A dearth in adequate, community-based treatment centers, combined with the closure of state hospitals, left many to struggle to adjust to society at large without the proper means to. Unwilling to adjust their own biases, “mentally healthy” (in very general terms) citizens work to constructively expel the mentally ill from their communities. Such tactics include barring community treatment centers from entering their neighborhoods, a measure which would undoubtedly help patients manage their illness better. Instances like the one described by the federal court exemplify the kind of perpetual cycle of denial of healthcare that is devastating to people with mental disorders, especially as they cope with living outside of an inpatient care setting.

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103 Id.

104 Doris J. James & Lauren E. Glaze, Mental Health Problems of Prison and Jail Inmates 1, Bureau Just. Stat. (2006).

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111 La Couture, supra note 3

112 Enos, supra note 109 at 7.

113 La Couture, supra note 3.

114 Why Do Drug Use Disorders Often Co-Occur with Other Mental Illnesses?, Nat'l Inst. on Drug Abuse (Last visited on Jan. 4, 2018), https://www.drugabuse.gov/publications/research-reports/comorbidity-addiction-other-mental-illnesses/why-do-drug-use-disorders-often-co-occur-other-men [http://perma.cc/PFF6-6T6Y].

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116 For a list of the HHS “overall character” factors, see Jennen, supra note 2.

117 Marybeth Musmeci, Key Themes in Medicaid Section 1115 Behavioral Health Waivers, The Henry J. Kaiser Fam. Found., (Nov. 10, 2017), https://www.kff.org/report-section/key-themes-in-medicaid-section-1115-behavioral-health-waivers-issue-brief-9118/ [http://perma.cc/S3NT-WA9R].

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119 Julia Zur & Marybeth Musmeci, Medicaid's Role in Financing Behavioral Health Services for Low-Income Individuals, The Henry J. Kaiser Fam. Found. (Jun. 29, 2017), https://www.kff.org/medicaid/issue-brief/medicaids-role-in-financing-behavioral-health-services-for-low-income-individuals/ [http://perma.cc/UTD4-A7PA].

120 About Section 1115 Demonstrations, supra note 118.

121 Musmeci, supra note 117.

122 Id.

123 Ctrs. for Medicare & Medicaid Services, Letter Approving Massachusetts' Section 1115 Waiver Demonstration Proposal, Table C (2017).

124 Manatt on Medicaid: 10 Trends to Watch in 2016, Manatt, Phelps & Phillips, LLP (Jan. 2017) (unpublished report) (on file with author), https://www.jdsupra.com/legalnews/manatt-on-medicaid-10-trends-to-watch-86181/ [http://perma.cc/KGU6-R2D3].

125 Behavioral Health Treatment and Services, Substance Abuse & Mental Health Servs. Admin., https://www.samhsa.gov/treatment [http://perma.cc/CQ3E-4TG5]. (“Medications for mental and substance use disorders provide significant relief for many people and help manage symptoms to the point where people can use other strategies to pursue recovery.”)

126 Sean Eckhardt, Rehabilitating Former Prisoners Starts with Affordable Housing, TakePart (Nov. 9, 2016), http://www.takepart.com/article/2016/11/09/affordable-housing-felons.

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