Safety Net

The Cost of Addiction Treatment Keeps Poor People Addicted

I can barely remember the day I learned I was pregnant with my first daughter. Not because I was overwhelmed with emotions, but because I was high on heroin. I had been addicted for five years, and I had been trying to rid myself of that addiction for almost as long. I‘ve lost count of how many times I detoxed during that time. I just know that, even when I managed to make it through the week of withdrawal, I inevitably relapsed.

By the time I learned I was pregnant, I knew abstinence didn’t work. I also knew I had to do something if I wanted to have a healthy baby. So, I enrolled in methadone maintenance treatment. My doctor insisted on it—he told me it would keep my body from going through withdrawal, which could have caused a miscarriage. But I almost couldn’t afford it. I was in Colorado, one of 17 states that did not cover methadone through Medicaid or state funds. Luckily, I was able to get my treatment paid for through grant money specifically designated for pregnant methadone patients.

Because of that grant, I never had to worry about the cost of my treatment. I was able to stand to the side and watch while other patients came into the clinic, begging for an extra couple days to come up with their fee, only to receive the same response from the receptionist: “You could get together money for your drugs, why are you having a problem getting money for treatment?”

I lost count of how many times I heard her say that.

Approximately 2 million people in the United States are addicted to pharmaceutical opiates, and half a million to heroin. The latest report from the Centers for Disease Control and Prevention estimates more than 60,000 overdose deaths in the United States last year. Opioids are now more fatal than car crashes and gun violence. And those numbers don’t include the many people who survive but live with complications such as brain damage for the rest of their lives.

Your brain thinks it’s dying without the drug.

Despite the broad scope of the crisis, data compiled by Rockefeller University’s Addictive Diseases lab show that there are only about 350,000 Americans in methadone treatment, a long-acting

opioid agonist An agonist is a chemical that binds to receptors and causes a biological response (in the case of opioids, that response is pain relief). Methadone is an opioid agonist that causes a similar biological reaction to opioids without the euphoric high, preventing the severe physical symptoms of withdrawal.

that has historically been the gold standard of care for opioid addiction. Only about 75,000 are in buprenorphine treatment, a newer alternative that is similar to methadone in function and purpose.

There are some basic reasons that so few people receive treatment: More than 30 million people live in counties without a licensed provider of buprenorphine, and the daily process of receiving methadone maintenance treatment at a specialized clinic is incredibly time consuming.

And it’s expensive.

In addition to the limits on Medicaid funding, opioid treatment providers can decide whether or not to accept private insurance. Many decide against it, or contract with just one or two providers, because methadone treatment is difficult to translate into insurance billing terms. Every state provides coverage for buprenorphine/naloxone (naloxone is an additive that prevents abuse of the drug), but patients often have to find cash for treatment regardless of whether the medication itself is covered.

The National Institute on Drug Abuse estimates that the per-patient cost of methadone for providers is $4,700 yearly, but for-profit opioid treatment programs get to decide what they charge their patients. This means the actual cost to patients varies by clinic. Methadone patients I interviewed reported rates that ranged from $350 per month to $200 per week. Buprenorphine patients reported clinic costs between $100 and $300 per month, with medication costs broaching the thousands for those without insurance.

Zac Talbott owns two opioid treatment programs—one in Georgia and one in North Carolina—and is also a methadone patient (through a different provider). He explains to me over the phone that just because Medicaid covers methadone in a certain state, that does not mean the clinics actually accept it. Take Georgia, for example: Although Medicaid has covered methadone for several years, programs that were not directly affiliated with behavioral health entities could not bill Medicaid prior to 2016. Only two clinics met that standard, out of 62 in the state. The rules recently changed, and Talbott’s Georgia clinic, Counseling Solutions Treatment Centers, is now six months into the process of setting up Medicaid billing. He’s unsure how many other area clinics will actually take on the new insurance option.

“[Opioid treatment programs] don’t speak in insurance terms the way the rest of health care does. Insurance bills based on codes. There’s no code for a daily bundled rate,” he explains, referring to the daily or weekly flat-rate most clinics charge their patients.

“For a lot of the bigger corporate entities, it’s easier and more profitable to just take that cash, baby,” Talbott adds, punctuating his point with a morose chuckle.

Patients who struggle to find the money for treatment may live with the threat of an administrative detox hanging over their heads. This is a common technique practiced by many methadone clinics, in which a patient who is no longer able to pay is placed on a rapidly tapering dose to wean him off the medication. The length of these tapers varies by clinic, but they often mean going down by 10mg a day, usually with one- or two-month limits. That’s a far cry from the slow, medically supervised taper recommended for patients choosing to withdraw from treatment.

Medication-assisted treatment is designed for long-term use—sometimes even lifelong. Mary Jeanne Kreek, who was part of the team that developed methadone treatment, explains that methadone and buprenorphine help correct brain changes that may require years of maintenance.

“It’s just like treating depressive disorders. Most people on chronic antidepressants need those for a long time or life,” says Kreek.  “I think they’re very analogous.”

But even these administrative detoxes are less harsh than what patients face at clinics that simply cut them off. Because methadone is designed to remain stable in the body for long periods of time, withdrawal from a therapeutic dose may take up to a week to begin. Once it does, however, it is nearly unbearable. It’s not necessarily the sweats and cold chills, aching bones, diarrhea, racing heart, nausea, and restless legs that make it so difficult. It’s the fact that your brain thinks it’s dying without the drug. That is part of the reason relapse rates after opioid detoxification are so high—some estimates say 88 percent within three years, and up to 70 percent within six months.

Liz Hock Clark, a 59-year-old woman who has been on methadone for 34 years, says her clinic is one of many that simply ceases to dose patients who come in without payment in hand. She isn’t sure if it’s legal, but she’s seen it done, and she’s terrified it will happen to her.

‘For someone my age, going cold turkey off 118 milligrams, I don’t know if I’d survive.’

Clark lives in a small apartment in West Virginia. She doesn’t have much furniture, and there’s no internet connection. If she needs to go online, she hops into her beat up 2000 Chevrolet Cavalier and drives to her cousin’s house. She picks up odd jobs, like house cleaning and dog walking, in order to pay for her medication. She does janitorial maintenance for her building in exchange for rent on the apartment. It’s tough on her body, but it allows her to put every penny she makes into methadone. Her clinic charges $15.50 a day. She says when she started methadone 34 years ago in Texas, it was $2 a day. She is terrified of the day when she doesn’t have the money for her clinic, which she fears will be soon.

“I’m not afraid of relapse,” she explains in her soft Southern drawl. “I’m afraid of dying. For someone my age, going cold turkey off 118 milligrams, I don’t know if I’d survive.”

Death from opioid withdrawal is rare, but because of her age, complications like cardiac arrest from a harsh detox are a credible fear.

“The thing is,” she adds wistfully, “I don’t want to get off methadone. I want to stay on it my whole life.”

How do we help patients like Clark access these essential medications without becoming enslaved by the exploitative tactics of some providers? For starters, the burden of methadone and buprenorphine regulations needs to fall on providers rather than patients. And we need to have a lot more payment options for low-income people, who are already more vulnerable to addiction in the first place.

The preliminary report offered by the White House opioid commission asks for expansion of access to medication-assisted treatment. It does not, however, express the need for a mandate on clinics to accept Medicaid, or for any kind of internal restructuring that will make accepting Medicaid and other forms of insurance more attractive to clinics. Trump’s attitude during his recent public health emergency declaration does not leave much hope that the commission’s advice will be followed—his $57,000 allocation will not come close to covering the cost gap. We’ll need to do a lot more if we are going to serve Clark and other patients like her—or like me—before it’s too late.

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Culture

Sexual Assault Is Universal. Recovery Isn’t.

When news broke of the seemingly bottomless Harvey Weinstein scandal, it released a flood of similarly harrowing tales of sexual harassment and assault in music, academia, science, media, restaurants, government, libraries, on and on and ever on. Near countless numbers of women and a decent number of men shared their own stories in private conversation, public essays, and as part of the #MeToo hashtag on social media. One inescapable fact immediately became manifest: Sexual harassment and assault are everywhere in the human experience, regardless of profession, ideology, ethnic identity, or financial privilege.

The question of financial privilege does, however, make one enormous difference: If you’re poor, you may find it that much harder to escape the abuse, or to recover and heal.

The reasons for this are myriad, complex, and mutually reinforcing, much like the causes of poverty itself, but they can be roughly assigned to two categories: Questions of power and questions of access.

Sexualized violence is a statement of power—harassment is not flirting, and assault is not sex. In both, the perpetrator is establishing themselves as having the right to treat another human being as they will. The victim’s right to safety is void; the perpetrator has the power to say or do what they wish, and the victim has no choice but to accept those choices.

Indeed, men who harass and assault women routinely prey on those who are clearly less powerful than their attackers. Harvey Weinstein consistently visited his depravity on Hollywood’s young and aspiring; R. Kelly has long been known for plucking girls from high schools on Chicago’s South Side. As Donald Trump said in 2005, “When you’re a star, they let you do it. You can do anything.”

One needn’t be a star to have relative power over a woman, though. In a society in which women are dehumanized in private, in public, in statute, and in practice, women as a class are axiomatically less powerful than men as a class. Poverty serves to exponentially increase that power differential.

Sexualized violence is a statement of power

Women in the lowest income bracket experience sexual violence at six times the rate of women in the highest. That statistic supports something poor women already know: The poorer you are, the more likely you are to endure a man’s unwanted attention. You can’t quit the job that barely pays, you can’t argue with the uncle in whose home you must live, and you can’t afford the classes that might allow you to leave both behind.

Poverty is not only a risk factor for harassment and assault, though—poverty is often the result of harassment and assault. The victim who leaves her job may have no other source of income, and more than one-third of women who leave their abusers’ homes end up homeless. Weinstein’s victims understood all too clearly that he ultimately held power over their ability to make a living, and a vindictive restaurant manager might be all that stands between a server and her ability to feed her kids.

Then there’s the question of access to medical or psychological support. Non-consensual sexual contact is often violent; rape can of course lead to pregnancy; studies have found that alarming numbers of harassment and assault victims develop PTSD; and even short-term experiences with shock and anxiety can be temporarily debilitating or permanently life-altering. But treating all of those things costs money. Even something as simple as transportation can present an obstacle—what if there’s no bus from your neighborhood to the nearest free clinic?

Every survivor’s experience is different, and trauma is not made untraumatic by a middle class income. Women of color, trans women, undocumented immigrants, and women with disabilities all face further hurdles, complications, and intersections, regardless of income.

Yet poverty places an undeniable additional burden on anyone who has survived sexual harassment or assault. Even as we reel from the unending revelations out of Hollywood or Silicon Valley, it’s worth remembering that even healing is a privilege.

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Media and Politics

Ivanka Trump’s Child Tax Credit is a Ploy to Pass Tax Cuts for the Rich

On Monday, Ivanka Trump kicked off her tour to stump for the Trump administration’s tax package with a town hall in Bucks County, Pennsylvania. She pitched an increased Child Tax Credit as a way to help families struggling with high child care costs and noted that the United States invests relatively little in early childhood education compared with other countries. Given how much Ivanka Trump’s reputation has suffered as she’s failed to impact White House policy on issues such as climate change and gender equity, she needs to show that she can deliver on promises she made during the campaign to make child care more affordable.

The details of the Child Tax Credit are not yet public, including the amount of the expansion and whether she would make changes to help children in families with very low incomes who cannot currently receive the full credit. But one thing is very, very clear: This credit is clearly designed to help make the Trump tax plan, which is heavily skewed toward tax breaks for the wealthy, more politically palatable.

The nonpartisan Tax Policy Center found that 80 percent of the tax breaks would go to people in the top 1 percent of earners. In other words, people like Ivanka Trump.

Just repealing the estate tax—which is only one of many planned tax cuts—would amount to a $1.1 billion windfall for Ivanka Trump and her siblings. That’s enough to pay for 100,000 children to go to child care for an entire year. And that’s before accounting for the trillions it would cost to slash the top income tax rate, give low rates to pass-through businesses, and re-open loopholes for the wealthy.

Just repealing the estate tax would amount to a $1.1 billion windfall for Ivanka and her siblings.

But Trump, the dutiful soldier, is sticking to her message. That means continuing to insist that her child care plan will support most Americans, even though the plan she pitched during the campaign would have given the average family in a county that swung heavily toward Trump in the 2016 presidential election just $5.55 per year. (Residents in Ivanka Trump’s former Manhattan neighborhood would stand to gain more than $7,000 in tax benefits.) A year later, the same principles apply. The Trump administration is looking to use empty rhetoric to appeal to working women to sell a major tax break for wealthy people like her.

To be clear, the Child Tax Credit can provide a vehicle for improving economic security among families with young children. The Center on Budget and Policy Priorities estimates that 16 million children in low-income working families would not receive the benefit because their families’ earnings are too low. Proposals to make the credit refundable would allow lower-income families to actually benefit, and proposals to make it more generous could go a long way to defray costs associated with raising children.

If she wanted, Ivanka Trump could go even further than taxes. She could support Sen. Patty Murray (D-WA) and Rep. Bobby Scott’s (D-VA) bill to guarantee child care assistance to low-income and middle-class families, or she could challenge her father’s requests to cut the program that offers child care assistance to low-income working families and eliminate on-campus child care and afterschool programs.

Or, if taxes are really what speak to her, she could move on to expanding child care assistance through the Child and Dependent Care Tax Credit (CDCTC). Right now, the CDCTC primarily reaches upper-middle-class families, and the $1,050-per-child credit pales in comparison to the $10,000 annual price tag at a child care center.

If Ivanka Trump wanted to make a difference, there’s no shortage of ideas. But instead, she’s selling another “by Ivanka, for Ivanka” child care plan that won’t work for the millions of families who struggle to pay for the child care they need.

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Media and Politics

Meet the Congressman Trying to Bring Fresh Food to Low-Income Neighborhoods

The grocery industry is increasingly consolidated. Amazon’s recent purchase of Whole Foods for $14 billion sent grocery stocks tumbling and had many analysts worrying about the end of local mom and pop grocery stores.

Nowhere would be harder hit than food deserts—areas, mostly low-income, without access to fruits, vegetables, or other healthy food. According to the USDA, 6,500 census tracts, or about 10 percent of American communities, are food deserts, and 25 million Americans lack access to a grocery store.

One of the leading champions on issues of food insecurity in Congress is Indianapolis Rep. André Carson (D-IN). In 2014, a study by WalkScore.com rated the city as the worst in the country for food deserts. The following year, the iconic Double 8 Foods supermarkets—which served neighborhoods largely neglected by other chains—closed its four locations, citing declining revenues.

I spoke to Rep. Carson about his efforts to expand access to healthy meals and his recent legislation addressing food deserts.

Jeremy Slevin: What made you decide to take action on food deserts?

Rep. André Carson: In recent years, Indianapolis has been one of the worst food deserts in the country. Around 2014 we saw four Double 8 grocery stores close, and then last year it got even worse when several Marsh stores closed their doors. Many assumed that those customers would just get their groceries elsewhere. But unfortunately I think the implications were greater than that, and overnight we saw thousands of Hoosiers effectively lose access to the only grocery store they had available.

We’re talking about low-income families, often without vehicles or even access to public transit, and they’re living miles from the closest store. They had nowhere to go to buy fruits and vegetables and bread and milk, so they really relied on what they could find at their local convenience stores and fast food restaurants. The closure of these stores has created food deserts throughout the district.

JS: So tell us what your bill does to address this.

AC: The bill tries to address the absence of nutritious foods in many urban and rural communities by providing loans for the operation of grocery stores. The Department of Agriculture would provide grants to each state to establish a revolving fund, and each state would provide loans from its revolving fund for the construction (and even operation) of grocery stores, specifically for underserved communities. These loans would be made available to for-profit, non-profit, even locally-owned entities.

The states would handle loan processing and make awards to organizations that meet the requirements, but they have to have an emphasis on unprocessed nutritious foods, providing fresh fruits and veggies, providing staple foods like milk, bread, and wheat, charging prices below market average, and be sufficiently qualified to operate a store.

I think it’s important to note that priority will be given to applications that include a plan to hire workers from those underserved communities and provide information about healthy diet. They’re going to get their food from local gardens and farms, and a lot of these entities will not have beer and wine or tobacco products readily available—but I think in the future that’s an option that they can pursue if they want to go through the Alcohol and Tobacco Commission.

JS: So what’s at the root of this problem? Why are these stores closing in Indianapolis, and what’s the impediment to opening up new grocery stores in low-income areas right now?

AC: I think we haven’t brought enough attention to the issue nationally. It’s not specific to urban centers—rural communities are impacted as well. I think corporations and entities make corporate decisions that address their bottom line, but we have to make sure that the NGOs and other entities are in place so we can [incentivize] them to provide resources to these communities.

JS: Is part of the issue that it’s just not as profitable, unfortunately, in lower-income communities to have these grocery stores, and that’s why they need this leg up?

The demand is always there.

AC: Perhaps some would make that argument, but I would counter that and say that the demand is always there. If you look at the Double 8’s, there were customers there, but the facility was unkempt, the food offerings were spoiled or nearing spoilage, and it just wasn’t a great place to get food to attempt to live a healthy lifestyle. It wasn’t a sustainable existence. But the demand is always there. If you see a clean facility where healthy options are being presented, there’s a sense of pride that people will in doing business with that kind of operation.

JS: You mentioned transportation earlier, which seems like another huge driver of this. Do you think more investment in public transit in low-income communities could help stem this crisis as well?

AC: Absolutely, that’s always an issue. Folks who are on fixed incomes or have fewer means to purchase a vehicle, they have to rely on public transportation or friends and family.

JS: Do you see a path to this passing in Congress?

AC: We’re hopeful. It’s going to take a concerted effort to educate members of Congress, but also constituents and constituencies across the country to encourage and force their representatives to support this legislation. And the farm bill is a critical part of that conversation.

JS: And this is something that you’re hoping to be included in the farm bill negotiations?

AC: Absolutely.

JS: What’s been the response, if any, from the other side of the aisle?

AC: I think we’re in the midst of an austerity push, but we’re not in Europe. There are budget hawks that would be concerned about the cost of this, and understandably so. But this proposal helps their constituents. It helps spur economic growth, it helps their constituents live healthier lives, and have some sense of dignity about being able to go to a store that’s clean—where customer service is paramount, where food offerings are healthy, and the presentation is very professional.

JS: Obviously, we’re talking specifically about food deserts, but food insecurity is a problem that affects this entire country, particularly kids, that is not often talked about in the media. What more do you think we can do to shine a light on food insecurity more broadly?

AC: Studies have shown that when kids don’t have the nourishment they need, it impacts brain activity, it impacts retention in terms of memory, it impacts performance as it relates to their ability to contribute as a student and process information. And I think addressing these food deserts and having our schools be a part of this discussion will close the gap on many of these concerns. I even think that there are several attempts to get rid of the designation for free lunches for students because it removes the stigma. Schools have to be a part of this larger conversation if we’re going to address many of the issues in some of our schools that are underperforming.

JS: And we’ve even seen reports of school districts shaming kids for getting subsidized school lunches.

AC: That stigma’s been around for years. Kudos to those school districts and states that are attempting to remove the stigma. That’s something that’s been a source of bullying; it’s been a source of increased absences, so I think taking away that stigma will go a long way.

This interview has been lightly edited for length and clarity.

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Justice

It’s Time to Stop Using Inmates for Free Labor

Last week, a Louisiana sheriff gave a press conference railing against a new prisoner release program because it cost him free labor from “some good [inmates] that we use every day to wash cars, to change oil in the cars, to cook in the kitchen.” Two days later, news broke that up to 40 percent of the firefighters battling California’s outbreak of forest fires are prison inmates working for $2 an hour. Practices like these are disturbingly common: Military gear, ground meat, Starbucks holiday products, and McDonald’s uniforms have all been made (or are still made) with low-wage prison labor.

Inmates are exempt from the Fair Labor Standards Act, which requires that workers are paid at least the federal minimum wage. That makes it completely legal for states to exploit inmates for free or cheap labor. More than half of the 1.5 million people in state and federal prisons work while incarcerated, and the vast majority only make a few cents per hour.

Most inmates work in their own prison facilities, in jobs such as maintenance or food service. These jobs pay an average of just 86 cents an hour, and are primarily designed to keep the prison running at a low cost. Others may be employed in so-called “correctional industries,” where inmates work for the Department of Corrections to produce goods that are sold to government entities and nonprofit organizations. The highest median wages for these jobs top out at less than $2 an hour, and they’ve dropped over time—an incarcerated worker is paid less today than they were in 2001. In Alabama, Arkansas, Florida, Georgia, and Texas, most inmates working in prison facilities aren’t paid at all.

It is impossible to discuss prison labor without acknowledging the deep ties the criminal justice system has to the legacy of slavery in the United States. Targeted mass incarceration policies, racial bias, and other structural disadvantages have led to an overrepresentation of people of color—particularly African Americans—in prisons and jails. As activist and author Shaka Senghor notes in Ava DuVernay’s 2016 documentary 13th, “The 13th amendment says, ‘no involuntary servitude except for those who have been duly convicted of a crime.’ So once you’ve been convicted of a crime, you are in essence a slave of the state.”

Though we run the risk of stating the obvious, there is a clear solution available: treating prisoners like people rather than chattel. That means paying prisoners a minimum wage for their work, and making sure the employment options in prison are designed to help people transition into their communities once they are released.

The median starting wage is 7 cents an hour.

Apprenticeship programs, which provide paid training that combines on-the-job learning with classroom instruction, may be the perfect solution. These programs can equip inmates with a marketable skill, a wage, and a credential that holds value in the labor market and can help them get a job upon release. A recent Center for American Progress report suggests using paid apprenticeships during incarceration to help inmates and their families support themselves after incarceration and reduce recidivism.

However, these programs frequently suffer the same pitfall as other prison work programs—they pay breathtakingly low wages. Since 2008, the median starting wage has been 7 cents an hour and the median exit wage 35 cents an hour—hardly enough to put inmates on the road to financial stability.

If these programs paid decent wages, they could increase economic stability of inmates, effectively easing the path to re-entry. They would allow inmates to pay off debts from their interactions with the justice system and reduce recidivism. They’re not a panacea, but well-paid apprenticeships can help put returning citizens on the road toward a good job and a secure future.

The criminal justice system has historically relied on a system of punishment and exploitation instead of rehabilitation, but we can change this going forward. Treating incarcerated people like human beings by paying them for their work is a good place to start.

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