If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

One night last month, a 9-year-old boy who had autism and talked about killing himself was among about 70 foster care children and youth under state supervision sleeping in hotels across Georgia.

Georgia’s designated health insurer for foster care, , had denied the boy placement in a psychiatric residential treatment facility, said Audrey Brannen, coordinator of complex care for Georgia’s child welfare agency. He stayed in a hotel for more than a month before receiving a temporary emergency placement in a foster home, she said.

The boy and the other children staying in the hotels lacked permanent placements, Brannen said, and many weren’t getting help for their complex mental and behavioral needs.

The frustration over gaps in care had gotten so bad that Candice Broce, commissioner of the Georgia Department of Human Services, sent a to the state Medicaid agency in August — signaling an unusual interagency conflict. She argued that Amerigroup, a unit of , isn’t being held accountable for failures in care, and that its foster care contract should not be renewed.

“Simply put, the state’s most vulnerable children cannot access the physical, mental, or behavioral health treatment they need — and deserve,” Broce wrote.

Amerigroup declined to comment on Broce’s remarks specifically, saying it had not seen her letter. But Michael Perry, an Amerigroup Georgia spokesperson, said the insurer hosts collaborative monthly meetings with state agencies to hear any concerns and will “continue to work on behalf of these vulnerable individuals to ensure they have access to the appropriate healthcare and support services they need to be successful.”

Such problems extend beyond Georgia, according to Sandy Santana, executive director of the national advocacy group . While foster care grabs headlines mainly in cases of abuse or neglect — even deaths — the failures of states and insurers in providing adequate health care for these children are widespread and occur largely without public scrutiny.

“These kids cycle in and out of ERs, and others are not accessing the services,” said Santana, whose group has filed lawsuits in more than 20 states over foster care problems. “This is an issue throughout the country.”

Nearly all children in foster care are eligible for Medicaid, the state-federal program for those with low incomes, but states decide on the delivery mechanism. Georgia is among at least 10 states that have turned to managed-care companies to deliver specialized services exclusively for foster kids and others under state supervision. At least three more — North Carolina, New Mexico, and Oklahoma — are taking similar steps. But regardless of the structure, getting timely access to care for many of these vulnerable kids is a problem, Santana said.

Obtaining mental health care for privately insured children can be a struggle too, of course, but for children in state custody, the challenge is even greater, said , a Milwaukee pediatrician and chair of the American Academy of Pediatrics’ Council on Foster Care, Adoption, and Kinship Care.

“This is a unique population,” she said. “They have experienced quite of bit of toxic stress prior to entering foster care.”

For states that use specialty managed care for these kids, transparency and oversight remain spotty and the quality of the care remains a troubling unknown, said , a research professor at Georgetown University’s Center for Children and Families.

Illinois, for example, has paid more than $350 million since 2020 to insurance giant Centene Corp. to manage health coverage for more than 35,000 current and former foster care children. But last year, an found Centene’s YouthCare unit repeatedly failed to deliver basic medical services such as dental visits and immunizations to thousands of these kids. Federal officials are now .

Centene said YouthCare has not been informed of any probe. In a statement, the company said Illinois Answers Project’s reporting was based on outdated information and didn’t account for its recent progress as it works “to ensure that families have the access they need to high-quality care and services.”

In some cases, child advocates say, the care kids do get is not appropriate. In Maryland, the local branch of the American Civil Liberties Union, Disability Rights Maryland, and Children’s Rights this month against the state accusing it of failing to conduct adequate oversight of in its foster care system. As many as 34% the state’s foster children are given psychotropic drugs, court documents said, although most of them don’t have a documented psychiatric diagnosis.

In Georgia, Lisa Rager said she and her husband, Wes, know well the hurdles to obtaining services for foster kids. The suburban Atlanta couple has cared for more than 100 foster children and adopted 11 of them from state custody.

She said one child waited more than a year to see a specialist. Getting approvals for speech or occupational therapy is “a lot of trouble.”

Rager said she pays out-of-pocket for psychiatric medications for three of her children because of insurance hassles. “It’s better for me to pay cash than wait on Amerigroup,” she said.

Such problems occur often, Broce said in her letter. Amerigroup’s “narrow definition for ‘medically necessary services’ is — on its face — more restrictive than state and federal standards,” she wrote.

“Far too often, case managers and foster families are told that the next available appointment is weeks or months out,” she told the state’s Joint Appropriations Committee on Jan. 17. Broce added that her agency has formed a legal team to fight Amerigroup treatment denials.

Amerigroup’s Perry said its clinical policies are approved by the state, and follow regulatory and care guidelines.

In a recent 12-month period, Amerigroup received $178.6 million in government funds for its specialty foster care plan that serves about 32,000 Georgia children, with the large majority being foster children and kids who have been adopted from state custody. The contract is currently up for rebidding.

David Graves, a spokesperson for the Department of Community Health, which runs Medicaid in the state, said the agency would not comment on Broce’s letter because it’s part of the contract renewal process. Graves said the agency regularly monitors the quality of care that children in state custody receive. He pointed to that showed Amerigroup did well on several metrics, such as use of asthma medication.

But Melissa Haberlen DeWolf, research and policy director for the nonprofit , said the majority of kids cycling through the state’s emergency departments for mental illness are in foster care.

“The caregivers we speak to are desperate for behavioral health care coordination help — finding providers and getting appointments, understanding how to manage behaviors and medication, and prevent crises, and sharing health information between providers,” she said.

To fix these problems, Zetley, the pediatrician, recommends creating a larger benefit package for foster kids, coordinating care better, and raising Medicaid reimbursement rates to attract more providers to these managed-care networks.

Contracts with managed-care companies also should be performance-based, with financial penalties if needed, said , managing attorney of the National Health Law Program’s Los Angeles offices.

“Managed care is only as good as the state’s ability to manage the contract and to make sure that what they’re getting is what they are paying for,” she said. “It doesn’t work by just, you know, hoping for the best and ‘Here’s the check.’”

But in Georgia, the state has never financially penalized Amerigroup for failing to meet contractually mandated quality standards, Department of Community Health spokesperson Graves confirmed. He said the agency and Amerigroup work to resolve any issues brought to their attention.

Georgia has set up an oversight committee, with public meetings, to monitor the quality of Amerigroup’s performance. But the committee hasn’t met since August 2020, the state said last month. After KHN queries, Graves said the panel would start meeting again this year.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The Buckeye Community Health Plan of Ohio, Louisiana Healthcare Connections, and Peach State Health Plan of Georgia were among the companies that sent money to the Democrat, according to state campaign finance records, even though only one, SilverSummit Healthplan, provided insurance in the Silver State.

But a thread connects the companies: Each is a subsidiary of Centene Corp., ranked 26th on the Fortune 500 list, and the nation’s largest private managed-care provider for Medicaid, the government insurance program for people with low incomes or disabilities.

Centene had already sealed Medicaid deals in Nevada through its SilverSummit subsidiary — yet a potential new line of business was on the horizon. Sisolak, who is up for reelection Nov. 8, had just approved a new public health plan option that would later open up to bidding from contractors such as SilverSummit.

And then, less than two months after Centene’s subsidiary contributions were made, Nevada settled with the company over allegations the insurer overbilled the state’s Medicaid pharmacy program. The state attorney general’s office did not publicly announce the $11.3 million settlement but disclosed it in response to a public records request from KHN.

Sisolak — who has accepted at least $197,000 from Centene, its subsidiaries, top executives, and their spouses since August 2018 — issued a statement through his campaign spokesperson Molly Forgey that said Medicaid contracts are awarded by an independent group. “There is zero correlation between Centene’s donations and how the governor legislates,” Forgey said. “The governor in no way acts unilaterally in decisions to award state contracts.”

The contract went before the Nevada Board of Examiners for final approval. Sisolak is one of three voting members.

Centene has similarly amplified campaign contributions to governors in New York and South Carolina, two states where it has profitable contracts and such giving by multiple subsidiaries is allowed. And despite having , Centene has revealed to shareholders only a portion of its contributions — omitting much of its subsidiary giving from .

Under corporate law, each subsidiary is its own business, which allows companies to increase their political footprints in some states by giving the maximum allowed donations from more than one entity, said , a law professor at Stetson University in Florida.

“In some cases, they can increase it tenfold depending on how many subsidiaries and how much money they want to aim at a particular politician,” Torres-Spelliscy said. “They will exploit any loophole.”

Since 2015, the St. Louis-based insurance behemoth, its subsidiaries, its top executives, and their spouses have given more than $26.9 million to state politicians in 33 states, to their political parties, and to nonprofit fundraising groups, according to a KHN analysis of IRS tax filings and data from the nonpartisan, nonprofit group OpenSecrets. That total doesn’t include the millions of dollars Centene and its subsidiaries have given to state politicians’ political action committees because OpenSecrets doesn’t track those donations. The KHN analysis also does not include giving to congressional and presidential candidates.

It’s a purposeful political investment: Centene earns billions of dollars from governments and then uses its profits to back the campaigns of the officials who oversee those government contracts. The company has developed this sophisticated, multipronged strategy as it pursues even more state government-funded contracts and defends against sweeping accusations that it overbilled many of those very governments.

Centene declined to make a representative available for an interview and didn’t respond to specific questions about its political giving. But company spokesperson Suzy DePrizio said in a statement that the company follows all local, state, and federal laws and records all contributions from its political action committee. She said Centene’s contributions “are intended to serve as support to those who advocate for sound public policy healthcare decisions, which is evident by our nearly equal support of candidates from both parties.”

This year, according to IRS filings that go through Sept. 30, Centene has given $2.2 million, combined, to the Republican and Democratic governors’ associations, which help elect candidates from their respective parties. And Centene gave $250,000, combined, to the Republican Attorneys General Association and its Democratic counterpart.

Since last year, state attorneys general, whose campaigns are benefiting from the associations’ money, have negotiated massive settlements with Centene over accusations the company’s prescription drug programs overbilled Medicaid.

More than 20 states are investigating or have investigated Centene’s Medicaid pharmacy billing. The company has agreed to pay settlements to 13 of those states, with the total reaching about $596 million. And Centene told KHN in October that it is working to settle with Georgia and eight more states that it didn’t identify. It has denied wrongdoing in all the investigations.

KHN found that Centene, like many corporations, also pays dozens of lobbyists in state capitals across the country and in Washington, D.C. It courts officials with fundraising parties and perks such as tickets to sporting events like Sacramento Kings games. And it helps fund committees set up to pay for governors’ inaugural events — as it did for Sisolak, with a $50,000 donation, separate from its campaign contributions, according to the Nevada secretary of state’s office.

Executives and their family members make political contributions in their own names. For example, from 2015 through 2021, Centene’s then-CEO Michael Neidorff and his wife, Noémi, wrote at least $380,000 in personal checks to state candidates, with more than 60% going to California Gov. Gavin Newsom, a Democrat who governs a state where the insurer generated 11% of its revenue in 2019. The Neidorffs lived in St. Louis.

There’s no proof Centene’s contributions swayed politicians’ decisions, but campaign finance experts say money can translate into access and that can lead to influence.

“They’re trying to protect their market share,” said , a senior fellow at the UCLA Center for Health Policy Research. “They see it as necessary to maintain good relations with the agencies and with the individuals who are involved in decision-making because that’s the way government works.”

Billing Question Surfaces in Ohio

Health care industry players — from insurers, to doctor lobbying groups, to drug companies — routinely make large political donations. Centene rival Elevance Health, formerly known as Anthem, has spent at least $21.8 million on state political contributions since 2015, according to KHN’s analysis.

What makes Centene stand apart from competitors is the massive share of its business that is funded by taxpayers. Founded as a nonprofit in 1984 by a former hospital bookkeeper, Centene earned $126 billion in revenue last year — up from $5 billion a decade ago, according to the company’s annual reports.

Its rocketing revenue has been fueled by its thriving Medicaid managed-care business, takeovers of competitors, and growth in its Medicare Advantage membership and in enrollment in health plans it sells via the Affordable Care Act health insurance marketplaces. Centene’s Ambetter plans, available on the exchanges, have the highest enrollment nationally. The company has also locked up lucrative deals to deliver health care to state prisoners, military members, and veterans.

Centene has reported that two-thirds of its revenue comes from state Medicaid contracts that cover about 15 million people across the country.

So when Ohio Attorney General Dave Yost in March 2021 over what he called a complex scheme of “corporate greed” to “fleece taxpayers out of millions,” other states took notice.

Ohio investigators accused Centene of overcharging the state’s Medicaid program through the company’s pharmacy benefit managers, which provided medications to Centene-managed Medicaid patients. Pharmacy benefit managers, known as PBMs, act as middlemen between drugmakers and health insurers and as intermediaries between health plans and pharmacies.

Centene denied wrongdoing but faced immediate consequences. Ohio officials froze its application to renew its contract to offer insurance to state Medicaid enrollees.

“Ohio had Centene over a barrel,” said Antonio Ciaccia, a consultant who worked with the state on the dispute.

The company settled three months later for $88.3 million. Its application was soon unfrozen, and it won a Medicaid contract that summer for its subsidiary Buckeye Health, whose lobbyists include Michael Kiggin, a of Republican Gov. Mike DeWine.

Dan Tierney, a spokesperson for DeWine, said the state’s competitive bidding process was reviewed by a court, which “noted Buckeye Health Plan scored highly in the bid process.”

Since last year, 12 other states have settled with Centene over pharmacy services: Arkansas, Illinois, Kansas, Louisiana, Massachusetts, Mississippi, Nebraska, Nevada, New Hampshire, New Mexico, Texas, and Washington.

Of the states that have reached settlements so far, at least five have subsequently awarded government contracts to the company. Louisiana and just three months later awarded a statewide Medicaid contract to Centene’s subsidiary Louisiana Healthcare Connections. KHN learned of the settlement, which was not previously publicly announced, in October through a records request.

Nebraska officials also hadn’t publicly announced the state’s in December until they received a recent KHN public records request. Nine months after the settlement, the state awarded Centene subsidiary Nebraska Total Care a Medicaid contract.

One reason Centene keeps winning contracts, Kominski said, is that such large insurers don’t have much competition in some parts of the country. “It's not as if states can easily say, ‘OK, we're going to have an open competition’ and then they have hundreds of insurers willing to participate in the marketplace,” Kominski said. “Health care is not, in general, a very competitive marketplace.”

Some politicians are tired of that playbook. In Mississippi, the state House of Representatives voted in February to prohibit Republican Gov. Tate Reeves’ administration from awarding a contract to any company that the state had settled with for more than $50 million. Centene paid Mississippi $55.5 million the year before.

“I am for doing away with our business to a company who took $55 million of our money that was supposed to be spent on the poor, the sick, the elderly, the mentally ill, the disabled,” Republican state Rep. , who authored the amendment, told her colleagues on the House floor.

The House adopted Currie’s amendment, but the Senate stripped it out of the bill.

Reeves’ gubernatorial campaign committee has received $210,000 from Centene since 2015, according to OpenSecrets data, and Mississippi lawmakers and party organizations have reaped at least $600,000. Reeves’ office did not respond to multiple requests for comment about the donations.

In August, just over a year after the settlement, Mississippi a new Medicaid managed-care contract.

Showing Up “as a Partner in the Market”

In Georgia, reports of Medicaid overbilling by insurers surfaced in 2018. The following year, Republican Gov. Brian Kemp retained Mississippi-based law firm Liston & Deas to investigate, according to a letter KHN obtained.

But three years later, while other states have settled with Centene, Georgia has not. Centene is also currently trying to renew a Medicaid managed-care contract in the state.

Meanwhile, the company, its subsidiaries, and employees have given at least $139,500 in contributions to Kemp since his first bid for governor started in 2017, according to state campaign records.

Georgia Attorney General Chris Carr’s campaign has received at least $53,000 in Centene-related giving just this year, with most coming from company executives, including Centene’s new CEO, Sarah London, who gave $10,000. Carr, a Republican whose office would oversee any potential Centene settlement, and his spokesperson Kara Richardson said the state Medicaid agency is reviewing the billing data.

Centene is also trying to renew Medicaid managed-care contracts in Florida, Texas, and New Mexico. In angling for those deals, London told investors in September that she’s spending more time in states talking to key leaders because “our state relationships are a critical part” of the business.

“In the conversations that I have been having with governors,” she added, “I hear a lot of positive feedback about the way that Centene shows up as a partner in the market.”

London, her fellow top executives, and their spouses have given just over half a million dollars since 2015 to gubernatorial and attorneys general candidates across the country. Their checks were often dated the same day for the same amount to incumbent politicians whose governments oversee Medicaid managed-care contracts in states, including in Arizona, Kansas, and North Carolina.

“The optics of this are pay to play when decisions are made,” said , executive director of Common Cause Georgia, a nonprofit watchdog group. “It could be perceived as this health care company buying influence from lawmakers and elected officials.”

Giving Down the Ballot

Centene brands its health plans under local names, such as Peach State Health Plan in Georgia and SilverSummit in Nevada. Because Centene has more than 300 U.S. subsidiaries, the insurer has many avenues for political giving.

As it did for Nevada’s governor, Centene lined up its health plans nationwide to support the governor of South Carolina — three times — while it had and renewed a Medicaid contract in that state.

In 2017, according to OpenSecrets data, Republican Gov. Henry McMaster’s campaign received $66,500, combined, from Centene and 17 of its subsidiaries. In 2019, Centene and 10 subsidiaries gave $38,500 on a single day. Then this year, on April 28, 11 Centene affiliates sent the governor a total of $36,000.

This year’s contributions to McMaster’s campaign weren’t included in reports that Centene has published about its political spending since 2020. The McMaster campaign did not respond to questions about the donations.

Also omitted from Centene’s published disclosures on its website were most of the contributions made by its California-based subsidiary Health Net, which is among Centene’s most politically active health plans and is a huge revenue maker for the company. Together, Health Net and another Centene subsidiary, California Health & Wellness, gave at least $3.8 million to ballot measure campaigns and state and local politicians from 2015 through Oct. 25, 2022, according to the California secretary of state’s office. Health Net also gave $50,000 to Newsom’s inaugural committee in 2018, according to the California Fair Political Practices Commission.

“We’d be surprised if it was an accident that contributions were not included in the website report to shareholders,” said Bruce Freed, president of the , a nonprofit advocacy organization that rates companies on their disclosure of political donations.

Former Centene CEO Neidorff, who died this year, and his wife gave Newsom $240,800 from 2018 through 2020, according to the California secretary of state’s office. That’s on top of the $121,800 that Health Net has contributed to Newsom’s campaigns since 2015. All of those fell within state campaign contribution limits. Neither the governor’s office nor his campaign returned requests for comment.

The governor has pushed proposals expected to help Centene and other insurers — including expanding insurance subsidies, requiring Californians to have health insurance, and extending coverage to immigrants regardless of their legal status. Noémi Neidorff did not respond to requests for comment.

At the moment, the company has billions of dollars at stake in California: The state is among those currently investigating its pharmacy billing practices, KHN has reported. And the company is appealing the state’s decision this summer not to award key Medicaid contracts to Health Net in Los Angeles, Sacramento, and other counties.

While these decisions are pending, the company has continued to send checks to campaigns, including to dozens of local leaders — mayors, city council members, and county supervisors — in regions critical to its business.

Now, some of those local leaders are writing to state officials, asking them to reverse their decision and give Health Net a Medicaid contract locally, according to letters KHN obtained.

Sacramento County Supervisor Phil Serna and two of his fellow supervisors were among those whose campaigns received checks from Health Net. They declined to comment.

“It certainly doesn’t mean that we can’t use our meager bully pulpits to affect, perhaps, reconsideration of their selection,” Serna told a group of Health Net employees who showed up in pink T-shirts to testify at a public hearing in September.

He had to state officials urging them to reopen the bidding six days earlier.

Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this article.

This story was produced by , which publishes , an editorially independent service of the .

Methodology

KHN analyzed data from , a nonprofit, nonpartisan organization that collects campaign finance data about political candidates and committees. Its state-level data was analyzed to determine how much money Centene Corp., its subsidiaries, its top executives, and their spouses gave to state candidate campaign committees and ballot measure campaigns across the country from Jan. 1, 2015, through Oct. 4, 2022.

OpenSecrets does not track state political action committees or have complete data for 2022 because of inconsistent state campaign finance reporting deadlines and other factors. So to find additional contributions and cross-check the ones in OpenSecrets’ data, KHN downloaded state-level campaign data, including for political action committees tied to specific candidates, directly from state election websites in Florida, Georgia, Tennessee, Mississippi, and Nevada, and searched the California secretary of state’s website for donations to both state and local officials. Those numbers are not included in the overall tally of contributions but are used to supplement KHN’s reporting.

By searching OpenSecrets’ database and Centene’s , KHN identified eight nonprofit political groups that supported state candidates and received contributions from the company during the same time frame, including the national associations for electing governors and attorneys general from each party. To calculate the contributions Centene made to those nonprofits from 2015 through 2018, KHN relied on data compiled by OpenSecrets. For contributions from 2019 onward, KHN scoured the those nonprofits filed annually with the IRS, known as Form 8872, because the OpenSecrets data was not yet complete.

KHN identified Centene subsidiaries through the company’s annual reports to the U.S. Securities and Exchange Commission and the National Association of Insurance Commissioners. In some cases, subsidiaries made donations before they were acquired by Centene. Those donations were excluded from the analysis.

The findings of the analysis were compared with Centene’s corporate giving reports — which are posted on the company’s website and date back to Jan. 1, 2020 — and KHN determined that those reports did not show all the giving by Centene subsidiaries that KHN had documented from campaign finance data covering that time period.

KHN conducted the same analyses of OpenSecrets and IRS data for Centene’s competitor Elevance Health, formerly known as Anthem.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The 18-year-old Hampton, who has a long history of mental illness, sat in jail east of Atlanta for four months waiting for an expert to evaluate whether he was mentally fit to stand trial. In February, a state psychologist found Hampton incompetent.

Then Hampton had to wait to get a placement in a state psychiatric hospital so he could receive treatment to meet the legal threshold for competency. The treatment delay frustrated a Walton County judge, who said Hampton’s condition worsened in the crowded jail and in March ordered him to be transferred within 24 hours to a state hospital. The Georgia Department of Behavioral Health and Developmental Disabilities, which runs those psychiatric hospitals, didn’t comply, and the judge held the agency commissioner in contempt of court a month later.

Such long delays for state psychiatric hospital services are playing out in jails across the United States. People in jail with serious mental illness — and who cannot stand trial because of their condition — are waiting months, or even more than a year, to start receiving the care needed to “restore” their competency to stand trial. The legal standard is that an individual charged with a crime must be able to participate in their defense.

In Georgia, 368 people who have been deemed incompetent sit in local jails waiting to get treatment to stand trial, according to the state. More than 900 are waiting for just the first step in the process, a “forensic evaluation.”

Similar delays have sparked litigation in many other states.

The Indiana Protection and Advocacy Services Commission filed a lawsuit in May against state officials over the lag in psychiatric services, claiming the delays violate defendants’ due process rights. Oregon has faced strict time limits set through a 2002 court case, and its backlog stood at 55 people as of May 20.

Alabama faces a consent decree, but “folks are still waiting, on average, a couple hundred days to be admitted to the facilities to undergo either those evaluations or the treatment,” said , a senior staff attorney at the Alabama Disabilities Advocacy Program.

North Carolina’s waitlist for “restoration” treatment has risen to 140, while Colorado — another state under a consent decree — has 364 waiting. In Texas, the number is much higher — more than 2,000 — a backlog that has prompted a lawsuit. Montana has had dozens waiting as well.

“It would be hard to overstate how big a concern mental health issues are in county jails,” said , a criminal justice expert at the Lyndon B. Johnson School of Public Affairs at the University of Texas-Austin.

More than are booked into jails nationwide each year, often for nonviolent “nuisance” crimes such as loitering or vagrancy, according to a 2020 report from the National Association of State Mental Health Program Directors. Once jailed, people with mental illness are incarcerated twice as long as other defendants, the report said, and few receive treatment for their condition.

People with mental illness also typically get worse in jail during long waits for a psychiatric hospital bed, said , a senior staff attorney for the National Disability Rights Network. “It’s an obvious constitutional problem,” he said. “Jails are really chaotic, pretty violent places.”

For some people accused of a misdemeanor, the wait for what’s known as inpatient competency restoration can be longer than if the individual had been tried, convicted, and sentenced under such charges, said Dr. , chair of the American Psychiatric Association’s .

The delays in transfers to inpatient treatment facilities, state officials say, have increased during the pandemic, amid worsening shortages of state hospital staff. Yet several legal cases — including those in Alabama, Colorado, Oregon, and Washington state — were filed years before covid-19 surfaced.

Shannon Scully, senior adviser for justice and crisis response policy at the , said that as mental health provider shortages continue, delays in restoring defendants’ mental competency will likely get worse.

In Georgia, the state mental health agency said it has had a net loss of almost a third of its psychiatric hospital staffers since January 2020. Temporary workers are filling some vacancies, but the state reports several unfilled jobs for the forensic psychologists tasked with evaluating the competency of people in custody.

Beau Hampton has a history of psychiatric care beginning at age 3, including multiple hospitalizations, according to court documents. He is described as having autism, bipolar disorder, and other mental health diagnoses.

In March, while in custody at the Walton County Jail, Hampton was wounded in a fight and required stitches. He also faced a pending felony assault and a misdemeanor battery charge in a nearby county.

But state officials said Hampton didn’t rise to the top of the waitlist for inpatient treatment despite the court order, his age, his diagnoses, and his difficulties in jail. The list is based on the date of someone’s court order for hospitalization and the patient’s condition.

The average wait for a male inmate who needs such care in Georgia is 10 months, state officials said at a court hearing on Hampton’s case in April. The judge, Cheveda McCamy, gave the state 21 days under the contempt order to get Hampton placed in a hospital.

Hampton could not be reached for comment. The public defender assigned to his case, Julia Holley, said the competency questions — and not his actual criminal charges — consumed much of her time. Because of Hampton’s age and condition, and his being in the foster care system, she said, the case has “broken my heart the most.” She added, “He deserves a chance.”

Jails like Walton County’s are feeling the burden of caring for people who have mental illnesses. Such inmates often cannot afford bail or bond, said Trestman, and smaller jails have fewer services than big ones. Jails are “not places designed for treatment,” he added. “It’s not a warm and fuzzy environment.”

Incarceration costs are much higher for those with mental illness — about four times as much as for others, said Capt. Terry Mays, administrator of the Wayne County Jail, in southeastern Georgia.

In southwestern Georgia, Capt. Steven Jones, acting administrator of the Thomas County Jail, said one man waited more than a year for such a placement. During that time, Jones said, the man tried to kill himself by jumping from a railing, breaking both ankles and damaging his spine. The delay for the psychiatric hospital bed “was ridiculously long,” Jones said.

Especially for misdemeanor offenses, experts said, getting treatment more quickly in a community setting may make sense. And several states are moving to increase outpatient treatment.

, associate professor of forensic psychology at the University of Denver, said outpatient competency restoration has several benefits. “It costs a lot less,” he said. “Public safety is not compromised. Humanitarian-wise, it’s a civil liberty issue.”

He cited the in Olmstead v. L.C., a that supported the least-restrictive level of care for people with disabilities. “That can be a group home, that can be a supervised living arrangement, it could be independent living,” Gowensmith said.

South Carolina passed legislation this year that will allow both outpatient and jail-based restoration options.

Georgia has limited options for outpatient services. Ashley Fielding, assistant commissioner of the state mental health agency, said in a statement that it’s “actively working on solutions” to the competency backlog, citing raises given to all state employees and expansion of nonhospital restoration alternatives.

On the 20th day of the Walton County judge’s contempt order — one day before her deadline — the agency transferred Hampton to a state psychiatric facility in Milledgeville. The state mental health agency declined to comment on the case other than to say it had complied with the judge’s order. More than eight months had passed since Hampton was arrested.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The , introduced Jan. 26 by the powerful Georgia House Speaker , a Republican, is focused on improving the state’s mental health care system.

Tucked inside the legislation is a provision that would require the Medicaid managed-care companies to refund payments to the state if they don’t spend enough on medical care and quality improvements for patients.

Georgia Health News and KHN reported in September that Georgia was one of only a few states that doesn’t mandate a minimum level of medical spending for its Medicaid insurers.

Each year, Georgia pays three insurance companies — CareSource, Peach State Health Plan, and Amerigroup — a total of more than $4 billion to run the federal-state health insurance program for low-income residents and people with disabilities. For 2019 and 2020, the companies’ combined profits averaged $189 million per year, according to insurer filings reported by the National Association of Insurance Commissioners.

“Instead of ensuring adequate health care networks for Georgia’s children, Georgians with disabilities, and Georgians in nursing facilities, hundreds of millions of dollars go instead to the Georgia [insurers’] bottom lines,” said Roland Behm, a board member for the Georgia chapter of the .

Behm, who advised lawmakers on the bill, said the KHN and Georgia Health News article helped bring the issue to the attention of legislators crafting the bill.

Georgia is among more than 40 states that have turned to managed-care companies to run their Medicaid programs — and ostensibly control costs. According to an August report from the U.S. Department of Health and Human Services’ Office of Inspector General, 36 of those states and the District of Columbia set a benchmark “medical loss ratio” for the minimum spending by insurers on medical care. Besides Georgia, the report said, the five states not requiring a managed-care spending threshold were Kansas, Rhode Island, Tennessee, Texas, and Wisconsin.

Republican state Rep. Todd Jones, a co-sponsor of the new bill, told KHN that Georgia lawmakers should establish a strong benchmark for insurers to meet. “We should look at what other states are doing,” he said.

Most states with a spending requirement set that ratio at a minimum of 85% of premium dollars that insurers are paid. So when a Medicaid insurer spends less than that on medical care and quality improvements, it must return money to the government.

The Georgia bill also calls for setting the threshold at 85%. If the bill is approved, the Medicaid insurers would face the medical spending requirement in 2023.

If the benchmark had been in place in recent years, it could have forced a recoupment from the Peach State company, which has the largest Georgia Medicaid enrollment of the three insurers. State documents show it failed to reach the 85% mark from 2018 to 2020, KHN previously reported.

, a research professor at Georgetown University’s Center for Children and Families, called the 85% mark “a win for taxpayers, for Medicaid providers, and for Medicaid beneficiaries.” He also said it would be more than fair to the Medicaid insurers, which could keep 15% of what the state pays them for administrative costs and profit.

Because Ralston is the lead sponsor of the bill in the House, it’s expected to pass that chamber.

But the insurance industry likely will work to remove the medical spending provision.

An industry official, Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group, declined to comment on the legislation.

Fiona Roberts, a spokesperson for the state Department of Community Health, which oversees the Medicaid program, said the agency needs time to review the measure before commenting on it.

The main provisions of the bill require insurers to provide coverage for mental health care or substance use treatment at the same level as other physical health needs.

The legislation would provide education loan support for people training in the fields of mental health and substance use disorders and seek to expand behavioral health services for children. It would also facilitate “assisted outpatient treatment” — when a judge could order a person with a serious mental illness to follow a court-ordered treatment plan in the community.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Karisma had been at to have her gastrostomy tube fixed, Rockmore said. The 4-year-old, who has several severe medical conditions, has insurance coverage from Medicaid, which provides transportation to and from nonemergency medical appointments through private vendors.

After being told that a ride would not be available for hours, Rockmore said, she finally gave up and called her sister to drive them home to the South Georgia town of Ashburn, more than 160 miles away.

She said it wasn’t the first time she had run into trouble with the Medicaid transportation service.

“Sometimes they don’t ever come,” said Rockmore, who doesn’t own a car. Many rides have been canceled recently, she said; the company told her it couldn’t find drivers. “Sometimes they make me feel like they don’t care if my child gets to the doctor or not.”

Rockmore’s remarks would no doubt resonate with the Medicaid beneficiaries, relatives and advocacy groups across the country upset about problems patients have getting transportation for medical appointments. Not only are some shuttle drivers no-shows, but some patients have been injured during rides because their wheelchairs were not properly secured, according to lawsuits filed in Georgia and other states.

States are required to set up transportation to medical appointments for adults, children and people with disabilities in the Medicaid health insurance program. Transportation brokers — such as Modivcare, which Rockmore used — have subcontracts with local providers, often small “mom and pop” operations, to shuttle patients to and from needed appointments, including for dialysis, adult day care, and mental health and treatment for substance use disorders.

It’s a lucrative business, with transportation management contracts that can be worth tens of millions of dollars for companies. The two companies that have contracts in Georgia have given extensively to political campaigns of elected officials in the state. The firms, Modivcare and Southeastrans, have also faced complaints, lawsuits and state government fines in Georgia and elsewhere. The two companies maintain, though, that the complaints relate to a tiny percentage of rides provided.

Medicaid nonemergency transportation “is absolutely a national challenge,’’ said Matt Salo, executive director of the . “This is something practically all the states we talk to are dealing with. I don’t think anyone has figured this out.”

Beth Holloway, 47, of Wharton, New Jersey, said she has had multiple problems with rides. “Sometimes they arrive late, other times not at all,” said Holloway, who has cerebral palsy and lives independently. “I’ve been stranded at doctors’ offices for hours, sometimes out in the elements.”

In Los Angeles, Rose Ratcliff and several other patients filed a lawsuit in 2017 against Modivcare, then known as LogistiCare; other local transportation brokers; and the insurers that run the state Medicaid program, known as Medi-Cal in California.

The pending suit alleges that Ratcliff and other patients like her missed crucial dialysis appointments and faced unsafe conditions during transport. It calls Modivcare the “broken link” in the Medicaid transportation chain and claims the company did not adequately respond to complaints from clients like Ratcliff.

Katherine Zerone, a spokesperson for Modivcare, said the company does not comment on pending litigation. In an initial legal response, it said the problems were linked to the independent transportation vendors and their employees, not Modivcare/LogistiCare.

After complaints were made about Southeastrans’ service across Indiana, the state appointed a special legislative commission to review the company’s performance. Indiana now publishes detailed complaint data for the Atlanta-based company each month.

In August, Timothy Mills, a Bloomington man who uses a wheelchair, filed a lawsuit alleging that the company had violated the Americans with Disabilities Act and other civil rights laws by not providing a wheelchair-accessible vehicle to transport him to and from his appointments. The lawsuit alleges that because of the lack of wheelchair accommodation, Mills missed needed medical care and was even kicked off the patient lists of some of his local doctors.

“While we’re unable to comment on pending litigation, we’re aware of the matter and strongly disagree with the allegations,’’ said Christopher Lee, an attorney for Southeastrans, which operates in seven states and Washington, D.C.

Two decades ago, Georgia was one of the first states to start using transportation brokers to manage its Medicaid transportation program. The two longtime providers in the state — Modivcare and Southeastrans — will receive a total of $127.6 million from the state this fiscal year. They are paid a per-member monthly rate that averages $5.60 in Georgia, regardless of how many rides, if any, a Medicaid user takes. The state was expected to announce new contracts for Medicaid transportation this month.

Georgia assessed a total of $4.4 million in penalties to the two companies over the period from January 2018 to December 2020 for failing to pick up patients on time and other problems. However, the state Medicaid agency essentially gave them discounts, charging the two companies only $1.2 million during that period, according to state Department of Community Health letters obtained through an open records request. In extending the brokers’ contracts in the 2018 fiscal year, the state Medicaid agency agreed to cap damages at 25% of the assessed amount, Department of Community Health spokesperson Fiona Roberts said.

Modivcare said it’s the largest transportation broker nationally, controlling about 40% of the market. The publicly traded company based in Colorado provides Medicaid transportation in more than 20 states.

Modivcare and other companies say only a tiny fraction of the rides they provide lead to complaints. “Our first priority is safe and reliable transportation,” Zerone said. In Georgia, 99.8% of its trips are complaint-free, she said.

Andrew Tomys, Georgia state director for Southeastrans, said 99.9% of the trips his company services in the state are “free of valid complaints.”

Both Modivcare and Southeastrans say they investigate each complaint to determine whether it’s valid. In Georgia, Modivcare reported to the Department of Community Health more than 3,200 late rides or no-shows over a year out of around 2.3 million rides. Southeastrans reported just over 900 such problems out of around 1.4 million rides.

But patients and their advocates say that in many cases problems aren’t reported, or complaints are ignored.

Georgia should peg any new contracts to timely rides, ease of use for beneficiaries and the overall ride experience, said Melissa Haberlen DeWolf, policy director of the advocacy group .

In recent election cycles, Southeastrans and Modivcare — through its former corporate name LogistiCare — have been generous donors to Georgia Republicans, who have controlled state offices in the state for nearly two decades.

Southeastrans, as a company, has donated $126,000 to Georgia Republican campaigns and committees since 2017, according to documents on the Georgia Government Transparency and Campaign Finance Commission website.

Additionally, Southeastrans’ co-founder and CEO, Steve Adams, has given at least $86,000 to Georgia Republican candidates for state office and to the state Republican Party since 2017, according to state filings. During that same period, Adams donated $3,800 to two state Democratic candidates.

“As a minority-owned business headquartered in Georgia for over 20 years, Southeastrans and its owner have contributed to a diverse mix of local causes and organizations,” Lee said.

Modivcare, through LogistiCare, has given $48,350 to Georgia Republican candidates in state races since 2017, according to the Georgia Government Transparency and Campaign Finance Commission. It gave $750 to former Democratic state Rep. Pat Gardner, also according to the commission. Modivcare’s Zerone did not answer questions about the company’s political giving because she said it would be “competitive information.”

Such contributions can help companies buy access to government officials, said Paul S. Ryan, a vice president at the government watchdog group Common Cause.

“Anytime a special interest doing business with the government can make big contributions to public officials handing out contracts or making other government decisions, it’s a cause for concern,” he said. “Average, everyday Americans can’t buy the same influence.”

Tranisha Rockmore said she’s so fed up that she wants to get a car so she can avoid the transportation problems. “I’m to the point where I feel like they don’t care about my daughter,” she said. “You don’t just do people’s kids like that.”

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

But whether the state — and Medicaid patients — are getting an optimal deal on Medicaid is up for debate.

Georgia pays three insurance companies — CareSource, Peach State Health Plan and Amerigroup — over $4 billion in total each year to run the federal-state health insurance program for low-income residents and people with disabilities. As a group, the state’s insurers averaged $189 million per year in combined profits in 2019 and 2020, according to insurer filings recorded by the National Association of Insurance Commissioners. Yet Georgia lacks some of the financial guardrails used by other states.

“Relative to other states, Georgia’s Medicaid market is an attractive business proposition for managed-care companies,” said , a professor at Georgetown University’s Center for Children and Families.

Georgia is among more than 40 states that have turned to managed-care companies to control Medicaid costs. These contracts are typically among the biggest in these states, with billions of government dollars going to insurance companies. Insurers assume the financial risk and administrative burden of providing services to members in exchange for a set monthly fee paid for each member.

The health plans, though, have at times drawn questions both on spending and quality of care delivered to Medicaid members.

“The transition to managed care was supposed to save states money, but it’s not clear that it did,” said , a senior policy adviser at the Robert Wood Johnson Foundation. (KHN receives funding support from the foundation.)

States can require Medicaid insurers to pay back money if they don’t hit a specified patient-spending threshold. That threshold is typically 85% of the amount paid to the insurance companies, with the rest going to administration and profit.

But Georgia does not require its Medicaid insurers to hit a specific target for spending on patient care, . Though paid to its Medicaid insurers, it could have lost out on recoupment dollars, the report indicated.

And state documents show that the Peach State company, which now has the largest Medicaid enrollment of the three insurers, failed to reach the 85% mark from 2018 to 2020.

Overall, Georgia’s Medicaid “medical loss ratio,” which assesses how much was spent on patients’ claims and expenses, was fifth from the bottom nationwide last year, behind only Mississippi; Washington, D.C.; Wisconsin; and Arkansas, according to data from the insurance commissioners association. Spending rates on patient care in the state . (The NAIC uses a different method for calculating the ratio than the state and federal governments do.)

“Profits for Georgia Medicaid HMOs are very healthy,” said , an independent analyst and consultant.

When asked whether Georgia planned a spending requirement in the new contract, Fiona Roberts, spokesperson for the , which runs Medicaid, said “a number of considerations are being discussed.” She noted that the state having a low medical loss ratio does not necessarily translate to “unreasonable profit” for the insurers.

The insurers also make money off their management services firms. In 2020, the insurer Peach State paid a subsidiary of its parent company, Centene Management Company, $114.7 million for administrative services. The nonprofit CareSource paid its management services firm $86.5 million in 2020.

“Fees paid to subsidiary companies represent another source of revenues for the parent companies,” said Baumgarten. “And it’s done in a way that does not allow the state to hold the HMOs accountable.”

The state’s , which covers 2019, shows the plans did as well or better than the national median on many measures, including on access to a primary care provider.

But low birthweight rates appear to be on the rise despite the state’s goal of bringing them down to 8.6% or less. The companies hovered at an average of about 9.8% in 2019, the latest available data.

“We continue to hear stories from families and health care providers about children in Medicaid managed care who have considerable trouble getting the services they need — whether it’s medication to control their asthma, getting connected to behavioral health care after a mental health crisis lands them in the emergency room, or any number of health challenges,” said Melissa Haberlen DeWolf, who directs research and policy at the advocacy group.

Compared with other states, Georgia has a of referring poor children to specialty services under Medicaid, according to a recently released . DCH said recently it’s investigating why the rate is so low.

And, currently, the state is reporting low covid vaccination rates for those 12 and older covered by the Medicaid managed-care companies. A shows the rates for the three companies are each below 10%, far lower than Georgia’s overall rate.

The companies, when asked about profitability, quality of care and administrative costs, directed a reporter to Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group. He said he could not comment on individual companies’ financial performance.

“Our goal is to continue to drive quality improvement, and successful patient outcomes, in the most cost-efficient manner for taxpayers who fund Georgia Medicaid,” Weathington said.

Georgia is expected to open the high-stakes bidding process on a new Medicaid contract next year. The bid process typically is fierce and the results often contested.

It’s not clear, though, when Georgia’s new contract process will be completed as the timelines have hit snags in several other states. North Carolina after two years of delays. It will spend $6 billion annually, the largest contract in the state health agency’s history.

Last year, after insurers that lost out disputed the results. And Centene and other companies are not to award them contracts, delaying implementation.

St. Louis-based Centene has more Medicaid managed-care business nationally than any other company. Centene last year acquired WellCare, a Medicaid insurer in Georgia, then closed down that operation in May.

Centene has also faced questions about overbilling. Ohio settled an $88 million pharmacy fraud lawsuit it filed against Centene , while Mississippi . Now Georgia is expected to to settle with other states affected by the pharmacy overbilling.

Consumer groups want the state to take stronger steps to advance the health of those who rely on Medicaid and to make the deals with the insurers more transparent.

“Medicaid members are best served when they have ready access to providers, insurers are eager to resolve their health care needs, and policymakers exercise strong oversight to ensure members’ health and well-being are prioritized over profits,” said , executive director of Georgians for a Healthy Future, a consumer advocacy group.

A bill that aimed to bring more transparency and accountability to the state’s health care plans was . The legislation would have allowed a committee to examine records of health care contractors and compel the state to respond to questions about them. Kemp said the bill would have violated the separation of powers doctrine between the executive and legislative branches of government.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).