It can be republished for free.

But like hospitals across the country, the institutions have done little to address the root causes of asthma. The perverse incentives of the health care payment system have long made it far more lucrative to treat severe, dangerous asthma attacks than to prevent them.

Hopkins, UMMC and other hospitals collected $84 million over the three years ending in 2015 to treat acutely ill Baltimore asthma patients as inpatients or in emergency rooms, according to the news organizations’ analysis of statewide hospital data. Hopkins and a sister hospital received $31 million of that.

Executives at Hopkins and UMMC acknowledge that they should do more about asthma in the community but note that there are many competing problems: diabetes, drug overdoses, infant mortality and mental illness among the homeless.

Science has shown it’s relatively easy and inexpensive to reduce asthma attacks: Remove rodents, carpets, bugs, cigarette smoke and other triggers. Deploy community doctors to prescribe preventive medicine and health workers to teach patients to use it.

Ben Carson, secretary of the Department of Housing and Urban Development, who saw hundreds of asthmatic children from low-income Baltimore during his decades as a Hopkins neurosurgeon, said that the research on asthma triggers is unequivocal. “It’s the environment — the moist environments that encourage the mold, the ticks, the fleas, the mice, the roaches,” he said in an interview.

As the leader of HUD, he says he favors reducing asthma risks in public housing as a way of cutting expensive hospital visits. The agency is discussing ways to finance pest removal, moisture control and other remediation in places asthma patients live, a spokeswoman said.

“The cost of not taking care of people is probably greater than the cost of taking care of them” by removing triggers, Carson said, adding, “It depends on whether you take the short-term view or the long-term view.”

The Long View

Asthma is the most common childhood medical condition, with rates who often live in run-down homes, than among kids in wealthier households. The disease causes nearly in the United States a year, about and thousands of deaths annually.

That drives the total annual cost of asthma care, including medicine and office visits, .

Keyonta lives in a two-bedroom row house on the 1900 block of Lemmon Street, which some residents call the “Forgetabout Neighborhood,” about a mile from UMMC and 3 miles from Hopkins.

Reporters spent months interviewing patients and parents and visiting homes in 21223, a multiracial community where the average household income of $38,911 is lower than in all but two other ZIP codes in Maryland.

To uncover the impact of asthma, the news organizations analyzed every Maryland inpatient and emergency room case over more than three years through a special agreement with the state commission that sets hospital rates and collects such data. The records did not include identifying personal information.

For each emergency room visit to treat Baltimore residents for asthma, according to the data, hospitals were paid $871, on average. For each inpatient case, the average revenue was $8,698. In one recent three-year period, hospitals collected $6.1 million for treating just 50 inpatients, the ones most frequently ill with asthma, each of whom visited the hospital at least 10 times.

shows that shifting dollars from hospitals to Lemmon Street and other asthma hot spots could more than pay for itself. Half the cost of one admission — a few thousand dollars — could buy air purifiers, pest control, visits by community health workers and other measures proven to slash asthma attacks and hospital visits by frequent users.

“We love” these ideas, and “we think it’s the right thing to do,” said Patricia Brown, a senior vice president at Hopkins in charge of managed care and population health. “We know who these people are. . . . This is doable, and somebody should do it.”

But converting ideas to action hasn’t happened at Hopkins or much of anywhere else.

One of the few hospitals making a substantial effort, Children’s National Health System in Washington, D.C., has found that its good work comes at a price to its bottom line.

Children’s sends asthma patients treated in the emergency room to  that teaches them and their families how to take medication properly and remove home triggers. The program, begun in the early 2000s, cut emergency room use and other unscheduled visits by those patients by 40 percent, a study showed.

While recognizing that it decreases potential revenue, hospital managers fully support the program, said Dr. Stephen Teach, the pediatrics chief who runs it.

“‘Asthma visits and admissions are down again, and it’s all your fault!’” Children’s chief executive likes to tease him, Teach said. “And half his brain is actually serious, but the other half of his brain is celebrating the fact that the health of the children of the District of Columbia is better.”

I call 911 so much since I’ve been living here, they know my name.

Darlene Summerville

The Close-Up View

Half of the 32 row houses on Summerville’s block of Lemmon Street are boarded up, occupied only by the occasional heroin user. At least 10 people on the block had asthma late last year, according to interviews with residents then.

“We have mold in our house” and a leaky roof, said Tracy Oates, 42, who lived across the street from Summerville. “That is really big trouble as far as triggering asthma.”

Two of her children have the disease. “I don’t even want to stay here,” she said. “I’m looking for a place.”

Shadawnna Fews, 30, lived with her asthmatic toddler on Stricker Street, a few blocks east. She kept a BB gun to pick off rats that doctors said can set off her son’s wheezing.

Delores Jackson, 56, who lived on Wilkens Avenue, a few blocks south of Lemmon Street, said she had been to the hospital for asthma three times in the previous month.

All three of Summerville’s kids have asthma. Before moving to Lemmon Street two years ago, she remembers, Keyonta’s asthma attacks rarely required medical attention.

But their new house contained a clinical catalog of asthma triggers.

The moldy basement has a dirt floor. Piles of garbage in nearby vacant lots draw vermin: mice, which are , along with rats. Summerville, 37, kept a census of invading insects: gnats, flies, spiders, ants, grasshoppers, “little teeny black bugs,” she laughed.

Often she smokes inside the house.

The state hospital data show that about 25 Marylanders die annually from acute asthma, their airways so constricted and blocked by mucus that they suffocate.

Keyonta missed dozens of school days last year because of his illness, staying home so often that Summerville had to quit her cooking job to care for him. Without that income, the family nearly got evicted last fall and again in January. The rent is $750.

About a third of Baltimore high school students report they have had asthma, causing frequent absences and missed learning, said Dr. Leana Wen, Baltimore’s health commissioner.

With numbers like that, West Baltimore’s primary care clinics, which treat a wide range of illnesses, as is the city health department’s asthma program, whose three employees visit homes of asthmatic children to demonstrate how to take medication and reduce triggers.

The program, which an analysis by Wen’s office showed cut asthma symptoms by 89 percent, “is chronically underfunded,” she said. “We’re serving 200 children [a year], and there are thousands that we could expand the program to.”

‘The Hospital Instead Of The Classroom’

The federal government paid for $1.3 billion in asthma-related research over the past decade, of which $205 million went to Hopkins, records show. The money supports basic science as well as many studies showing that modest investments in community care and home remediation can improve lives and save money.

“Getting health care providers to pay for home-based interventions is going to be necessary if we want to make a dent in the asthma problem,” said Patrick Breysse, a former Hopkins official, who as director of the National Center for Environmental Health at the Centers for Disease Control and Prevention is one of the country’s top public health officials.

Other factors can trigger asthma: outdoor air pollution and pollen, in particular. But eliminating home-based triggers could , one study showed.

Perhaps no better place exists to try community asthma prevention than Maryland. By guaranteeing hospitals’ revenue each year, the state’s unique rate-setting system encourages them to cut admissions with preventive care, policy authorities say.

But Hopkins, UMMC and their corporate parents, whose four main Baltimore hospitals together collect some $5 billion in revenue a year, have so far limited their community asthma prevention to small, often temporary efforts, often financed by somebody else’s money.

UMMC’s Breathmobile program, which visits Baltimore schools dispensing asthma treatment and education, depends on outside grants and could easily be expanded with the proper resources, said its medical director, Dr. Mary Bollinger. “The need is there, absolutely,” she said.

Hopkins runs “Camp Superkids,” a weeklong, sleep-away summer session for children with asthma that costs participants $400, although it awards scholarships to low-income families. It’s also conducting yet another study — testing referral to follow-up care for emergency room asthma patients, which Children’s National long ago showed was effective.

But no hospital has invested substantially in home remediation to eliminate triggers, a proven strategy supported by the HUD secretary and promoted by Green and Healthy Homes Initiative, a Baltimore nonprofit that works to reduce asthma and lead poisoning.

“We either go forward to do what has been empirically shown to work, or we continue to bury our heads in the sand and kids will continue to go to the hospital instead of the classroom,” said Ruth Ann Norton, the nonprofit’s chief executive.

Hopkins and UMMC say they do plenty to earn their community benefit tax breaks.

“It’s always a challenge to say, ‘Where do we start first?’” said Dana Farrakhan, a senior vice president at UMMC whose duties include community health improvement.

Among other initiatives, UMMC takes credit for working with city officials to sharply reduce infant mortality by working with expectant mothers. The organization’s planned outpatient center will include health workers to help people reduce home asthma triggers, Farrakhan said.

“What we do is perhaps not sufficiently focused,” Brown of Hopkins said. At the same time, “we have to have revenue,” she said. “We’re a business.”

After months of waiting, Summerville considered herself lucky to get an appointment with the city health department’s asthma program.

One of its health workers came to the house late last year. She supplied mousetraps and mattress and pillow covers to control mites and other triggers. She helped force Summerville’s landlord to fix holes in the ceiling and floor.

She urged Summerville to stop smoking inside and gave medication lessons, which uncovered that Summerville had mixed up a preventive inhaler with the medicine used for Keyonta’s flaring symptoms.

“The asthma lady taught me what I needed to know to keep them healthy,” Summerville said of her family.

That was late in 2016. Since then, Summerville said last month, she hasn’t called an ambulance.

METHODOLOGY:

Kaiser Health News and the University of Maryland’s Capital News Service obtained data held by the Maryland Health Services Cost Review Commission on every hospital inpatient and emergency room case in the state from mid-2012 to mid-2016 — some 10 million cases. The anonymized data did not include identifying personal information.

The news organizations measured asthma costs by calculating total charges for cases in which asthma was the principal diagnosis. Maryland’s hospital rate-setting system ensures that such listed charges are very close to equaling the payments collected.

To determine asthma prevalence, reporters calculated the per capita rate of hospital visits with asthma as a principal diagnosis — a method frequently used by health departments and researchers. This may exaggerate asthma prevalence in low-income ZIP codes such as 21223, because of those communities’ tendency to use hospital services at greater rates.

However, the data also point to high asthma rates in 21223 and other low-income Baltimore communities — for example, asthma prevalence within the population of all hospital patients in a ZIP code.

A Double Burden Of Prison And Disease

By Naema Ahmed, Marissa Laliberte, Catherine Sheffo and Daniel Trielli
CAPITAL NEWS SERVICE

Areas with high incarceration rates also tend to be sicker than average, as shown by HIV and imprisonment data for Baltimore. Linking released inmates to coverage and care could improve public health in these neighborhoods, advocates say.

Sources: Justice Policy Institute, Maryland Health Services Cost Review Commission

Dr. Rosalyn Stewart saw what happened to many chronically ill ex-offenders when she ran a recently completed pilot program to enroll former inmates in Medicaid and get them treatment and shelter.

“People frequently ran out of their medications and did not have access to the care they needed,” said Stewart, an associate professor at the Johns Hopkins University medical school.

McHoul, 40, spent two short stays last year in Baltimore’s Women’s Detention Center. The first time the facility released her without Medicaid coverage. Shortly afterwards she landed in a hospital with an inflamed esophagus. She got out after a second jail stay in August without knowing the hospital had enrolled her in Medicaid between incarcerations, she said.

At neither time did she have more than two weeks’ supply of any medication, including Depakote, a mood stabilizer, she said. For some prescriptions there was less than a week’s store.

“It was whatever was left in the blister pack,” said McHoul, who’s now in a Baltimore drug treatment program. “It’s like, ‘Here’s your supply. Sign this that we gave them to you. See you later.’”

State policy is to give exiting prisoners 30 days’ worth of medicine. But a court ordered McHoul released shortly after she was arrested the second time, which didn’t give the jail enough time to prepare medications, said a corrections spokesman.

There are many Stacey McHouls.

“Maybe somebody needs prescription services and they’re not enrolled and they don’t know where to go,” said Traci Kodeck, interim CEO of HealthCare Access Maryland, a nonprofit that connects consumers to coverage and has worked with the prison system. “Absolutely it happens. Many of them will end up in the emergency departments if we don’t attempt to connect them to services prior to release.”

Mark Pruitt, 46, was released from a Baltimore facility in October with no Medicaid card and a craving for heroin, which he said he had used before he was incarcerated for a parole violation.

He desperately wanted to enter a drug treatment program, but signing up for Medicaid to pay for it was going to take weeks — far longer than he could wait.

“I knew what I wanted. I wanted help,” he said. “I really wanted help. But it’s a struggle when you’re broke — no money, no insurance, feeling defeated. Where do you turn?”

If administrators at a Baltimore recovery facility hadn’t gotten him enrolled in Medicaid, he said, “I think I’d be dead.”

From January 2014, when the Medicaid expansion took effect, through this March, Maryland released almost 16,000 people sentenced to prison or jail, according to state data. Thousands more cycle in and out of jails each year without being convicted.

But the corrections department said it enrolled only 1,337 released inmates in Medicaid from the beginning of 2014 through late March. Another 1,158 prisoners joined Medicaid over that time when they were hospitalized. (Medicaid covers inmates if they spend 24 hours as hospital inpatients; most return to prison.)

Many ex-prisoners are enrolled only when they experience a crisis and end up in an emergency room — the kind of expensive care health officials are trying to reduce. The law requires hospitals to treat emergency cases regardless of insurance coverage. They can retroactively sign those patients for Medicaid.

‘They Don’t Want To Do The Paperwork’

Monique Wright, 35, got out of Jessup Correctional Institution last fall and began suffering acute head and neck pain caused by scoliosis, a spine curvature. Without Medicaid coverage or a doctor, she said she had to seek emergency care at Johns Hopkins Bayview Medical Center.

“It’s the paperwork” that keeps prison officials from making sure people like her have Medicaid upon release, Wright said. “They don’t want to do the paperwork. They don’t have the staff to do the paperwork.”

Advocates wonder why the corrections system is so poor at enrolling what, they often point out, is “literally a captive audience.”

“They’ve had them housed for the past 10, 15 years,” said a frustrated Andre Fisher, a case manager for ex-inmates at Druid Heights Community Development Corp., a nonprofit in West Baltimore. “What’s so hard about it?”

Enrolling inmates in Medicaid can take weeks, prison officials said. Sometimes the card doesn’t arrive until after they’re out. Computer problems slowed sign-ups in late 2014.

One mistake made by Maryland and most other states is not considering inmates for Medicaid until their release dates approach, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied the process.

“It’s a bad way to do it because you’re getting a very small number” of enrollees by waiting, she said. A better alternative is to enroll inmates when they are booked, as , she said. Those incarcerated are generally ineligible for Medicaid, but putting them in the system when they enter makes it easier to trigger coverage when they leave, she added.

Ex-Inmates Struggle To Get Medicaid Without Help

If it’s hard for the prison system to enroll inmates, it’s even harder for the individuals to enroll themselves. Those who emerge without Medicaid face a maze of applications, bus trips, phone calls and queues if they want to sign up. Many don’t bother.

For most leaving incarceration, “it’s up to you to go there, make sure you get your health insurance,” said Jamal McCoy, 21, who was living with family in West Baltimore on home detention before he was released. “Most people don’t go. Some people take it easy when they get home.”

Those who try often find that lack of identification is the first challenge. To prevent fraud, Maryland and other states require Medicaid applicants to show verified Social Security numbers.

But jails frequently lose inmate IDs, say prisoners and enrollment officials. Those locked up for years are non-persons for much of the system, with no credit records or driver’s licenses.

That can mean delays of many weeks when released prisoners are especially vulnerable. Gaps in coverage and care of even a few days after fragile patients leave the corrections health system can make the difference between life and death.

“If you’re the diabetic that hasn’t been compliant with your medication, you need your medication now,” said Henrietta Sampson, director of treatment coordination at Powell Recovery Center, a Baltimore addiction recovery agency that works with ex-inmates. “You can’t wait two weeks because you may drop dead.”

Compared to the rest of the population, ex-prisoners in Washington state were  in the first two weeks after release, according to research by Dr. Ingrid Binswanger, lead researcher for Kaiser Permanente Colorado’s Institute for Health Research. Drug overdose, cardiovascular disease, homicide and suicide were the leading causes of death.

“It’s very important to manage that transition, to make sure people have continuity of care,” she said. (Kaiser Permanente has no relationship with Kaiser Health News.)

Yet in some cases the prison system has stymied outside groups trying to arrange inmates’ coverage. Stewart’s group repeatedly sought permission — “continuously, for about three years,” she said — to meet vulnerable prisoners inside the facility to get an early start on enrollment and post-release appointments. It never happened.

Baucom blamed the problem on “competing priorities” and staff turnover.

Acceptance into Medicaid by the state isn’t the end of the story. Released inmates then must enroll in a private managed-care organization hired by Maryland to provide coverage. That can take weeks longer.

Even when insured, ex-inmates face the  experienced by other low-income Baltimoreans — or worse.

Many prison inmates are , which can cause liver damage or cancer over time. But the high cost of curing the disease has prompted Maryland’s and other Medicaid programs to to those whose livers are already compromised.

“I guess I got to wait until damage is done to my liver,” said William Carter, 50, adding that prison officials initiated Medicaid enrollment when he got out last year.

Released prisoners often have no idea that some Medicaid managed-care contractors allow them to use only certain doctors and pharmacies.

If you’re the diabetic that hasn’t been compliant with your medication, you need your medication now. You can’t wait two weeks because you may drop dead.

Henrietta Sampson

“So a patient goes to Walgreens or wherever to fill something and it’s like, ‘That’ll be $150,’” because he should have gone somewhere else, said Stewart. “They don’t understand what the problem was.”

Even checking all the right boxes sometimes isn’t enough for ex-inmates, who bear the double stigma of poverty and a criminal history.

One released prisoner got an appointment to renew his mental health prescription with a facility in Carroll County, Maryland — his home — that also accepted his Medicaid card, said Baucom. After the clinic learned he had a prison record it cancelled the visit.

“It’s not enough to have a card,” Baucom said. “You’ve got to have access.”

Neighborhoods are at risk when former inmates with chronic illness return.

“You really need to think about this as a public health issue,” said Scott Nolen, director of drug treatment programs for the Open Society Institute–Baltimore, a nonprofit that works on criminal justice policy. “There is transmission of communicable diseases that happens in prison, in confined spaces. And now those folks are coming back into communities, and we want to make sure they get health care.”

In few places is the burden greater than Sandtown-Winchester. Gray, 25, died of spinal injuries that prosecutors filing manslaughter and assault charges blamed on police who arrested him.

The Justice Policy Institute, a nonprofit, called Sandtown in Baltimore last year, estimating that is in prison.

At the same time, three West Baltimore ZIP codes including Sandtown showed the highest rates of HIV infection in Maryland in 2014, according to hospital data from the Maryland Health Services Cost Review Commission obtained and analyzed by Kaiser Health News and Capital News Service.

The corrections department could use more computers, release planners and other enrollment resources, Baucom said.

“If you do the checkoff list, we’ve checked off everything we can do,” she said, noting efforts to increase enrollment capacity and cooperate with the Maryland motor vehicle agency to get inmates state IDs.

Jesse Jannetta, a specialist at the Urban Institute in prisoner re-entry, believes Maryland’s low sign-up rate “is not unusual” in other states. A found prisons and jails nationwide had enrolled 112,520 people in Medicaid from late 2013 up to January 2015, although the authors believe the actual figure was higher.

Federal and state prisons released 636,000 people in 2014, Millions more to cycle through jails each year.

Few independent experts expect Maryland — let alone most other states — to come anywhere close to full enrollment of emerging inmates anytime soon.

“It’s fair to say we’re just at the tip of the iceberg” in prisoner enrollment, said Johns Hopkins’ Barry, a coauthor of the Health Affairs study. “Maryland is always an innovator. If Maryland is still at the cutting edge of how to do this, many areas of the country don’t have any of these types of programs in place.”

This story is a partnership with The Baltimore Sun and Capital News Service, which is run by the University of Maryland’s Philip Merrill College of Journalism. KHN reporter Shefali Luthra and CNS reporters Catherine Sheffo, Daniel Trielli, Naema Ahmed and Marissa Laliberte contributed.

Where Pharmacies Are Scarce

In certain Baltimore neighborhoods without retail chain pharmacies — such as CVS, Walgreens and Rite Aid — many residents do not have cars to drive to areas with more stores. Two examples are Sandtown-Winchester and Druid Heights.

Source: Maryland Board of Pharmacy and Baltimore Neighborhood Indicators Alliance.
Data analysis by Catherine Sheffo/Capital News Service.

CVS’ 10-month closure posed hardship for some customers. Cornell West, 51, said he took a half-hour bus ride to another CVS for insomnia medication and cortisone cream. Allen Johnson, 61, filled prescriptions at Keystone but couldn’t always get what he needed, he said, such as medications for his knees, blood pressure, cholesterol, heart and diabetes.

“That was a problem for the old people. You know what I’m saying? That was a hell of a problem,” Johnson said.

If we had as many pharmacies as we had liquor stores, it would provide us more opportunity to educate, and promote health and wellness.

Jennifer Joseph

Research suggests that low-income neighborhoods in major cities with higher black and Latino populations are likely to be underserved by pharmacies. A 2014 study in illustrated that pattern in Chicago.

West Baltimore’s shortage of exacerbates the need for pharmacists who can counsel patients about basic health issues. A pharmacist is often the first line of defense for someone with a health condition, said Natalie Eddington, dean of the University of Maryland School of Pharmacy.

“For people who can’t afford health care — they don’t know how to get something,” said Haywood McMorris, the CVS store manager. “They can come here instead of going to the doctor’s and we pretty much take care of it.”

CVS and Keystone compete for that role, but on different scales.

CVS, with 27 stores in Baltimore, is the nation’s largest retail pharmacy chain based on its 9,000 U.S. outlets. It outmatches Keystone, an independent small business, on product variety and supply plus offers better hours. CVS closes at 9 p.m. on weekdays and 6 p.m. on weekends. Keystone closes three hours earlier Monday through Saturday, and it’s closed Sunday. Neither CVS nor Keystone carries fresh produce.

Keystone patrons praise its intimate service and owner Dwayne Weaver’s generosity, sometimes giving them medications on credit when they can’t afford the co-pay.

Argin Henry, 46, shops at both. He goes to CVS for groceries, drinks and goods like toilet paper, but he fills his prescriptions at Keystone, which extends credit when he’s low on cash and delivers prescriptions to his home.

A generous credit policy and delivery service are two ways Keystone competes against its much larger neighbor. CVS is in-network for every Medicaid plan in Maryland. Seven of eight plans cover drugs bought at Keystone, Weaver said. In a week, Keystone might turn away 20 to 25 customers who are out-of-network.

“We kind of survive on servicing patients in a way that chains generally don’t,” he said.

Weaver took over the pharmacy in 1985 and it’s been at its current North Avenue location for about 30 years. CVS has been there since 1997.

Ellis Basnight, who lives a 15-minute walk from Keystone, gets his drugs for diabetes, carpal tunnel and high blood pressure there.

“I’ve been coming here for years!” said Basnight, 71. “That’s why I trust him.”

Weaver considered leaving after last year’s protests. He decided to stay put after neighborhood volunteers helped clean the mess looters left.

West Baltimore’s low-income residents do have some alternatives to retail pharmacies, including two clinics of Total Health Care. Patients there can get prescriptions right after seeing the doctor, but retail pharmacies such as CVS can sate their snack cravings too.

Willie Zuber, 50, goes to CVS four blocks from home for groceries and to get medicines for an older woman he said he looks out for. He often grabs a soda or iced tea there while he waits for her prescriptions.

Joseph, Total Health Care’s pharmacy director, said CVS and Keystone likely serve the most people in the area. But they aren’t enough, she added.

“If we had as many pharmacies as we had liquor stores, it would provide us more opportunity to educate, and promote health and wellness, as opposed to alcohol and cigarettes,” she said. “You ride down the streets and what do you see? Abandoned home, abandoned home, abandoned home and liquor store. Bringing that CVS back says a lot for the city.”

Jeremy Snow is a reporter at Capital News Service. CNS reporters Brittany Britto, Ellie Silverman, Catherine Sheffo and Daniel Trielli also contributed. CNS is run by the University of Maryland’s Philip Merrill College of Journalism.

Months To Qualify For Medicaid

“I think I have diabetes,” said Johnson. “I know I have high blood pressure. I know that. I get dizzy a lot, especially when I wake up in the morning. I need to see a doctor.”

But he can’t. Baltimore jail authorities lost his identification cards, he said, before releasing him in October from an 11-month stay related to a drug arrest. He spent weeks reapplying for a Motor Vehicle Administration identification card, which social workers said he needed to qualify for Medicaid.

“You need ID to get ID, you know?” he joked. Nobody told him he could use incarceration credentials to qualify.

Medicaid’s expansion to include low-income adults was seen as an unprecedented opportunity to cover former inmates such as Johnson as they rejoin the community. (Inmates are not usually eligible while incarcerated.)

But limited administrative resources for release planning means sign-ups are often limited to the most severely ill, said Lena Hershkovitz, a vice president with HealthCare Access Maryland, a nonprofit working to increase enrollment.

“I know for a fact that he’s not unusual,” she said of Johnson. “I would say the majority of people leaving the prison or detention system are leaving without Medicaid.”

Last year the University of Maryland Medical Center found hepatitis C was causing potentially life-threatening damage to Antonio Davis’ liver, said Janet Gripshover, a nurse practitioner at the Baltimore hospital. Hepatitis C can also cause liver cancer.

Davis’ Medicaid plan, run by UnitedHealthcare, thrice denied doctors’ prescriptions for Harvoni, a new drug that can cure hepatitis C with no side effects but costs up to $90,000 for a full treatment, documents show. Davis, 58, was ineligible because he tested positive for illegal drugs or alcohol, United said in two letters to him.

“I’ve been off drugs and alcohol for six years,” he said, although he acknowledges drugs are probably how he got the virus long ago. “I don’t even drink near beer” — nonalcoholic beer.

Only by switching to a different Medicaid plan, run by Amerigroup, was he approved for Harvoni. Like many states, Maryland contracts with private insurers such as Amerigroup and United to provide Medicaid coverage.

Gripshover and other professionals acknowledge the drug’s high cost but say it saves lives and can save equally large expenses for treating cirrhosis and cancer. “There are no data” to support withholding Harvoni or other treatment from those who use illegal drugs, according to of liver-disease professionals. United declined to comment on his case.

Communication barriers and “poor customer service” are also barriers to care in West Baltimore, according to a , a Boston consultant hired by an association of community health centers.

William Ferebee, 66, has obstructive lung disease and a stent implanted after a 2001 heart attack. He avoids doctors at a University of Maryland Medical Center clinic because “they don’t even really come look at me,” he said. Instead, they give orders to a nurse or resident, “and then he comes in and says, ‘OK, here’s what we’re going to do.’”

A doctor at a nearby, independent clinic “is a sweetheart,” he said. “But it’s so hard to get an appointment.”

Distrust of the system often ensures there’s no communication at all.

Deborah Stevenson, 57, limps so badly with a damaged knee that sometimes people think she’s drunk. She believes she needs a knee replacement, “but I’m scared to get it,” she said. Her orthopedist “wouldn’t answer my questions and deal with me like a patient,” she said.

Even though she doesn’t have diabetes and her leg is otherwise healthy, her son speculated doctors might cut it off.

“I’m handicapped now,” she said. “I don’t want to be crippled.”

Fear of legal consequences also keeps people away from the health system. Some men worry doctors will report their undocumented address to social services, which they believe could reduce aid for female partners who live with them, said Wilson, the New Song pastor.

Medical privacy laws to help law enforcement officials trace suspects and fugitives. Residents subject to outstanding warrants fear they’ll be arrested if they seek care.

“Some people got a case out there — they’re not going to the health clinic,” Wilson said. “They’re going to die without giving up their information.”

Even when patients get access, care is disrupted by physician turnover, poor follow-up or insurance companies’ changing medical networks.

“The system is fragmented,” said Debbie Rock, who has run LIGHT Health and Wellness, on Sandtown’s western edge, since the 1990s. “I think that people need to go back and talk to each other. I think the doctors and the health insurance companies need to sit down and listen to each other.”

One homeless West Baltimore patient left an oral surgeon’s office with a wired jaw and no way to pay for the liquid nutrition he needed to feed himself, said Carol Marsiglia, senior vice president at the Coordinating Center, a nonprofit consulting organization that is working to reduce readmissions and emergency visits in the neighborhood.

A home-oxygen company wouldn’t serve a discharged lung patient because he had a $27 balance, she said. A hospital directed two home-health companies to teach a patient how to deal with a new colostomy bag; neither showed up. The Coordinating Center fixed the breakdowns.

Poverty makes Sandtown’s health worse. Many say poverty causes Sandtown’s poor health.

Four Liquor Stores And Three Sub Shops

Many residents hold jobs in government or manufacturing, run churches or collect pensions from the military or Social Security. Even so, the median Sandtown household

Roofs leak. Mold and mildew grow. Baltimore Gas and Electric cuts off energy to Sandtown households for nonpayment at it does in the rest of the city. Lead paint violations like the kind that are nearly four times higher in Sandtown than in Baltimore as a whole.

Drug and alcohol use are common. Diets are often poor. Many lack cars and the nearest supermarket is more than a mile away from the church.

“If we walk around this block, we’ll pass four liquor stores and three sub shops,” said Derrick DeWitt, pastor of First Mount Calvary, on Fulton Avenue.

Even small co-payments required by many health plans dissuade low-income West Baltimore residents from seeking care, the John Snow report found. Some constantly switch doctors to find the lowest price, leading to “disjointed services” and potential harm if information falls in the cracks, it found.

“I change doctors like I change underwear,” said Eddie Reaves, 64, who tries to find practices that won’t charge him copays as little as $12 or $15. His income is $1,170 a month, he said. In 2014, he added, “I must have seen a good total of about 10 doctors.”

Reaves has diabetes and high-blood pressure. He’s on Medicare because of a disability. He has applied twice to Medicaid since the health law expanded coverage two years ago. That would improve his benefits. But he never received the paperwork, he said.

The best care he ever received, Reaves said, was when he didn’t need any insurance card — when he was homeless.

Health Care for the Homeless, a nonprofit a couple miles east of Sandtown, delivers comprehensive services to the homeless without regard for ability to pay.

“Didn’t have no bills,” Reaves said of the clinic when he used it a few years ago. “Your medicine they helped pay for. They did a lot for you. You could get your teeth done and everything. It was just great, man.”

The rest of the medical system is so unsatisfactory by comparison that low-income Baltimoreans sometimes claim to be homeless when they’re not, just to use the clinic, he said.

What happened after a 2004 car accident that broke Robert Peace’s pelvis is a glaring example of what many say is the kind of medicine that has been practiced too long in West Baltimore and what many say they are working to change.

Emergency surgery at UMMC fixed the fracture. But Peace developed a persistent bone infection. He received little or no follow-up care, he said, getting treatment only when the infection surged out of control and required repeated, expensive surgeries.

“The pain would be so intense — it’s like, wracking my body. I would literally sit there and shake,” he said. “That’s when I would know I had to go to the hospital, because I knew the infection was back.”

He said he required five more surgeries over a year and a half — the kind of return trips to the hospital, or “readmissions,” that the health industry and the Affordable Care Act of 2010 are trying to reduce by promoting coordination between hospitals and community doctors.

“I’m blaming it on the follow-up,” said Peace, 58. “They knew the infection wasn’t going away, but the only time they would really tend to it was when I was in the hospital.”

Today Peace walks with a cane and a pronounced limp.

It’s a story that’s still too common in West Baltimore, said Antoine Bennett, a lifelong Sandtown resident and an elder at New Song Community Church.

“We’ve got a joke here, but it’s a serious joke,” he said. “If they ain’t medicating, they’re amputating or operating. But what’s missing is the care. Primary care.”

When asked about Peace’s case, UMMC spokesman Michael Schwartzberg said, “Much has changed in the Maryland hospital environment” since his surgeries. Improvements include new emphasis on preventing readmissions and “significant investment” in care coordinators and other post-discharge management, he said.

Keeping People Healthy And Out Of The Hospital

By many accounts, hospitals, doctors, health plans and governments in Annapolis, Maryland’s capital, and Washington are making unprecedented efforts to bridge the medical divide with Sandtown and the rest of low-income Baltimore.

The grand idea is to save money and simultaneously improve lives by keeping people healthier in the community instead of letting them become ill enough to land in the hospital.

In October Bon Secours that it intends to turn into a primary care and wellness center. UMMC and Bon Secours are working with “transition coaches” from the Coordinating Center to make sure people leaving the hospitals take medicine and schedule follow-up appointments. UMMC’s transition clinic serves hundreds of recently discharged patients.

Maryland is developing one of the most advanced electronic networks for letting medical providers collaborate by sharing patient records. Health Care for the Homeless in Bon Secours.

Dr. Samuel Ross, Bon Secours’ CEO, talks about working more closely with the churches and continuing to improve the hospital’s outcomes and reputation.

“No, it’s not solved,” he said. “We need to keep doing what we’re doing, and understand that some of this is a person at a time. There is no wholesale campaign or branding message that’s going to cause people to say, ‘You’re wonderful.’”

In 2012 Maryland’s legislature created “health enterprise zones” to increase the supply of primary caregivers in West Baltimore and other underserved areas. UMMC puts emergency room patients in touch with a primary care doctor if they don’t have one.

In September hospitals proposed taxing insurance companies, employers and other payers so they could hire up to 1,000 caregivers directly from West Baltimore and other low-income communities with poor health results.

The Baltimore health department is pressing hospitals to collaborate on high-risk patients and is building ties with lower-income neighborhoods by hiring residents, said Dr. Leana Wen, the city’s health commissioner.

Baltimore’s B’more for Healthy Babies program has the city’s African-American infant mortality rate by nearly a third , to 12.8 per thousand births. But that’s still a fifth higher than the African-American rate for all of Maryland.

University of Maryland Medical Center has for high schoolers interested in health careers. The University of Maryland, Baltimore, got a to increase the number of African-Americans in health care jobs.

More and more professionals echo UMB’s Perman, who said a medical professional’s duty to patients does not end at the hospital or clinic door.

“As a profession, as an industry, we have not sufficiently appreciated, let alone done something about, the impact of social determinants” such as poverty, poor housing, lack of food choices and low education, he said. “Guys like me and gals like me can easily say, ‘I made the correct diagnosis. I wrote a proper prescription. I’m done.’ What I say to my students is, if you think you’re done — if ‘done’ means the patient is going to get better — you’re fooling yourself.”

Maryland’s ambitious overhaul of hospital reimbursement, authorized by the health law, is supposed to back that philosophy with powerful incentives. Starting in 2014, hospitals have been assigned annual budgets for all government and private payers, instead of being paid per admission or treatment.

The idea is to boost their motivation to contain costs by delivering preventive, community care — to pay them for keeping people out of the hospital. Hospitals are also getting penalized for excessive readmissions and preventable harm such as infections and accidental punctures.

“It’s a daunting task… when we talk about joblessness and poor nutrition and violence in the neighborhoods,” said Dr. Walter Ettinger, chief medical officer of the University of Maryland Medical System. “But we all feel driven by our mission to serve our communities in a better way, and now the finances are aligned to do that.”

Poor people, however, know that between ambitions and accomplishments is a chasm of disappointment.

In the face of wider primary-care shortages and the difficulty for doctors to make a living in low-income neighborhoods, the zone fell far short of its original goal of to West Baltimore.

“Some of the goals and objectives across almost all of the zones were a bit ambitious,” said Maura Dwyer, a senior policy advisor for the Maryland Department of Health and Mental Hygiene.

In 2014 People’s Community Health Center in Baltimore and later entered bankruptcy proceedings, demonstrating the difficulty.

Officials at Total Health Care, a federally supported nonprofit with several primary-care clinics near Sandtown, say they are proud of their service to West Baltimore.

“We want to bring the standard health in this neighborhood up to national standards,” Dr. Marcia Cort, Total’s chief medical officer, told students from the Merrill College. “We don’t want it to be the neighborhood and area [where] life expectancy is low and people are dying from preventable things.”

Still, she said, “Baltimore City is in a health crisis.”

Readmission rates for Bon Secours were still in 2014, although the Coordinating Center’s transition coaches helped reduce them by 14 percent from the year before.

Readmissions for UMMC’s midtown campus were second highest statewide after declining 5 percent, also with work by transition coaches. At UMMC’s downtown campus, readmissions were fifth highest in the state and declined 2 percent.

But state financing to pay for the transition coaches expires at the end of March. The Coordinating Center is optimistic it will be renewed but nothing is set, Marsiglia said.

In 2014 only that they understood their care after they left the hospital. For UMMC patients the figure was 51 percent.

Many resent that it took this long for the industry to try the very solutions — improving primary care, giving communities resources to help themselves — that residents of neighborhoods like Sandtown have been advocating for years.

“Unfortunately the hospitals didn’t hear us,” said Diane Bell-McKoy, CEO of Associated Black Charities, a Maryland nonprofit. “As a person of color giving that information — most people think we don’t know what we’re talking about.”

Distrust of the system, still more widespread than medical officials imagine, is passing to a new generation, residents say.

“It’s a culture that has come about over time, because younger people have seen or feel like their parents and their grandparents didn’t get the best medical treatment when they went to the hospital,” said First Mount Calvary’s DeWitt. “So they have this why-go attitude.”

On Dec. 9, Maryland regulators made three months earlier to create hospital jobs in poorer neighborhoods.

Other initiatives do little to address the low incomes and unemployment linked to Sandtown’s poor health. Nor do they simplify the shifting maze of private and government insurance plans and hospital and doctor networks that patients must navigate to get care.

One example: Nearly 2,000 low-income Medicaid members, including many in Sandtown and nearby, had to change coverage in August or get new doctors because United dropped University of Maryland Faculty Physicians from its Medicaid network in a contract dispute, said Shannon McMahon, deputy secretary of the Maryland Department of Health and Mental Hygiene.

United “had thorough continuity of care measures in place before the contract ended to ensure ongoing care was not disrupted,” said company spokesman Ben Goldstein.

For many residents, enrolling in a plan is too complicated and time-consuming, requiring time off from work to get coverage they don’t understand and can’t afford, said LIGHT Health’s Rock. In some ways the health law and its new coverage rules have made things more complex, she said.

“As the landscape is changing, people really just don’t know what to do,” she said. “They sit you down with somebody that’s supposed to help you fill [an insurance application] out, which is like a Charlie Brown episode. Once you start on the second page it’s like ‘Wah, wah, wah.’ You don’t hear nothing else. You walk out and it’s like, ‘What happened?’”

David Johnson, who was concerned about his blood pressure, dizziness and possible diabetes, joined Medicaid in December. It took two months, three trips to the motor vehicle bureau to get a new ID and two trips to social services to enroll.

An still hadn’t signed up for Medicaid as of October. As of early February, Eddie Reaves, the diabetic who gave up applying after his second attempt, was still among them.

This story is part of a reporting partnership between and University of Maryland College Park’s , which operates Capital News Service. KHN and students from the school are examining how Baltimore’s nationally respected health system serves the community where violence flared in April after Freddie Gray was fatally injured in police custody. The project is continuing. To see all the students’ work go to the .

shows that shifting dollars from hospitals to Lemmon Street and other asthma hot spots could more than pay for itself. Half the cost of one admission — a few thousand dollars — could buy air purifiers, pest control, visits by community health workers and other measures proven to slash asthma attacks and hospital visits by frequent users.

“We love” these ideas, and “we think it’s the right thing to do,” said Patricia Brown, a senior vice president at Hopkins in charge of managed care and population health. “We know who these people are. . . . This is doable, and somebody should do it.”

But converting ideas to action hasn’t happened at Hopkins or much of anywhere else.

One of the few hospitals making a substantial effort, Children’s National Health System in Washington, D.C., has found that its good work comes at a price to its bottom line.

Children’s sends asthma patients treated in the emergency room to  that teaches them and their families how to take medication properly and remove home triggers. The program, begun in the early 2000s, cut emergency room use and other unscheduled visits by those patients by 40 percent, a study showed.

While recognizing that it decreases potential revenue, hospital managers fully support the program, said Dr. Stephen Teach, the pediatrics chief who runs it.

“‘Asthma visits and admissions are down again, and it’s all your fault!’” Children’s chief executive likes to tease him, Teach said. “And half his brain is actually serious, but the other half of his brain is celebrating the fact that the health of the children of the District of Columbia is better.”

I call 911 so much since I’ve been living here, they know my name.

Darlene Summerville

The Close-Up View

Half of the 32 row houses on Summerville’s block of Lemmon Street are boarded up, occupied only by the occasional heroin user. At least 10 people on the block had asthma late last year, according to interviews with residents then.

“We have mold in our house” and a leaky roof, said Tracy Oates, 42, who lived across the street from Summerville. “That is really big trouble as far as triggering asthma.”

Two of her children have the disease. “I don’t even want to stay here,” she said. “I’m looking for a place.”

Shadawnna Fews, 30, lived with her asthmatic toddler on Stricker Street, a few blocks east. She kept a BB gun to pick off rats that doctors said can set off her son’s wheezing.

Delores Jackson, 56, who lived on Wilkens Avenue, a few blocks south of Lemmon Street, said she had been to the hospital for asthma three times in the previous month.

All three of Summerville’s kids have asthma. Before moving to Lemmon Street two years ago, she remembers, Keyonta’s asthma attacks rarely required medical attention.

But their new house contained a clinical catalog of asthma triggers.

The moldy basement has a dirt floor. Piles of garbage in nearby vacant lots draw vermin: mice, which are , along with rats. Summerville, 37, kept a census of invading insects: gnats, flies, spiders, ants, grasshoppers, “little teeny black bugs,” she laughed.

Often she smokes inside the house.

The state hospital data show that about 25 Marylanders die annually from acute asthma, their airways so constricted and blocked by mucus that they suffocate.

Keyonta missed dozens of school days last year because of his illness, staying home so often that Summerville had to quit her cooking job to care for him. Without that income, the family nearly got evicted last fall and again in January. The rent is $750.

About a third of Baltimore high school students report they have had asthma, causing frequent absences and missed learning, said Dr. Leana Wen, Baltimore’s health commissioner.

With numbers like that, West Baltimore’s primary care clinics, which treat a wide range of illnesses, as is the city health department’s asthma program, whose three employees visit homes of asthmatic children to demonstrate how to take medication and reduce triggers.

The program, which an analysis by Wen’s office showed cut asthma symptoms by 89 percent, “is chronically underfunded,” she said. “We’re serving 200 children [a year], and there are thousands that we could expand the program to.”

‘The Hospital Instead Of The Classroom’

The federal government paid for $1.3 billion in asthma-related research over the past decade, of which $205 million went to Hopkins, records show. The money supports basic science as well as many studies showing that modest investments in community care and home remediation can improve lives and save money.

“Getting health care providers to pay for home-based interventions is going to be necessary if we want to make a dent in the asthma problem,” said Patrick Breysse, a former Hopkins official, who as director of the National Center for Environmental Health at the Centers for Disease Control and Prevention is one of the country’s top public health officials.

Other factors can trigger asthma: outdoor air pollution and pollen, in particular. But eliminating home-based triggers could , one study showed.

Perhaps no better place exists to try community asthma prevention than Maryland. By guaranteeing hospitals’ revenue each year, the state’s unique rate-setting system encourages them to cut admissions with preventive care, policy authorities say.

But Hopkins, UMMC and their corporate parents, whose four main Baltimore hospitals together collect some $5 billion in revenue a year, have so far limited their community asthma prevention to small, often temporary efforts, often financed by somebody else’s money.

UMMC’s Breathmobile program, which visits Baltimore schools dispensing asthma treatment and education, depends on outside grants and could easily be expanded with the proper resources, said its medical director, Dr. Mary Bollinger. “The need is there, absolutely,” she said.

Hopkins runs “Camp Superkids,” a weeklong, sleep-away summer session for children with asthma that costs participants $400, although it awards scholarships to low-income families. It’s also conducting yet another study — testing referral to follow-up care for emergency room asthma patients, which Children’s National long ago showed was effective.

But no hospital has invested substantially in home remediation to eliminate triggers, a proven strategy supported by the HUD secretary and promoted by Green and Healthy Homes Initiative, a Baltimore nonprofit that works to reduce asthma and lead poisoning.

“We either go forward to do what has been empirically shown to work, or we continue to bury our heads in the sand and kids will continue to go to the hospital instead of the classroom,” said Ruth Ann Norton, the nonprofit’s chief executive.

Hopkins and UMMC say they do plenty to earn their community benefit tax breaks.

“It’s always a challenge to say, ‘Where do we start first?’” said Dana Farrakhan, a senior vice president at UMMC whose duties include community health improvement.

Among other initiatives, UMMC takes credit for working with city officials to sharply reduce infant mortality by working with expectant mothers. The organization’s planned outpatient center will include health workers to help people reduce home asthma triggers, Farrakhan said.

“What we do is perhaps not sufficiently focused,” Brown of Hopkins said. At the same time, “we have to have revenue,” she said. “We’re a business.”

After months of waiting, Summerville considered herself lucky to get an appointment with the city health department’s asthma program.

One of its health workers came to the house late last year. She supplied mousetraps and mattress and pillow covers to control mites and other triggers. She helped force Summerville’s landlord to fix holes in the ceiling and floor.

She urged Summerville to stop smoking inside and gave medication lessons, which uncovered that Summerville had mixed up a preventive inhaler with the medicine used for Keyonta’s flaring symptoms.

“The asthma lady taught me what I needed to know to keep them healthy,” Summerville said of her family.

That was late in 2016. Since then, Summerville said last month, she hasn’t called an ambulance.

METHODOLOGY:

Kaiser Health News and the University of Maryland’s Capital News Service obtained data held by the Maryland Health Services Cost Review Commission on every hospital inpatient and emergency room case in the state from mid-2012 to mid-2016 — some 10 million cases. The anonymized data did not include identifying personal information.

The news organizations measured asthma costs by calculating total charges for cases in which asthma was the principal diagnosis. Maryland’s hospital rate-setting system ensures that such listed charges are very close to equaling the payments collected.

To determine asthma prevalence, reporters calculated the per capita rate of hospital visits with asthma as a principal diagnosis — a method frequently used by health departments and researchers. This may exaggerate asthma prevalence in low-income ZIP codes such as 21223, because of those communities’ tendency to use hospital services at greater rates.

However, the data also point to high asthma rates in 21223 and other low-income Baltimore communities — for example, asthma prevalence within the population of all hospital patients in a ZIP code.

A Double Burden Of Prison And Disease

By Naema Ahmed, Marissa Laliberte, Catherine Sheffo and Daniel Trielli
CAPITAL NEWS SERVICE

Areas with high incarceration rates also tend to be sicker than average, as shown by HIV and imprisonment data for Baltimore. Linking released inmates to coverage and care could improve public health in these neighborhoods, advocates say.

Sources: Justice Policy Institute, Maryland Health Services Cost Review Commission

Dr. Rosalyn Stewart saw what happened to many chronically ill ex-offenders when she ran a recently completed pilot program to enroll former inmates in Medicaid and get them treatment and shelter.

“People frequently ran out of their medications and did not have access to the care they needed,” said Stewart, an associate professor at the Johns Hopkins University medical school.

McHoul, 40, spent two short stays last year in Baltimore’s Women’s Detention Center. The first time the facility released her without Medicaid coverage. Shortly afterwards she landed in a hospital with an inflamed esophagus. She got out after a second jail stay in August without knowing the hospital had enrolled her in Medicaid between incarcerations, she said.

At neither time did she have more than two weeks’ supply of any medication, including Depakote, a mood stabilizer, she said. For some prescriptions there was less than a week’s store.

“It was whatever was left in the blister pack,” said McHoul, who’s now in a Baltimore drug treatment program. “It’s like, ‘Here’s your supply. Sign this that we gave them to you. See you later.’”

State policy is to give exiting prisoners 30 days’ worth of medicine. But a court ordered McHoul released shortly after she was arrested the second time, which didn’t give the jail enough time to prepare medications, said a corrections spokesman.

There are many Stacey McHouls.

“Maybe somebody needs prescription services and they’re not enrolled and they don’t know where to go,” said Traci Kodeck, interim CEO of HealthCare Access Maryland, a nonprofit that connects consumers to coverage and has worked with the prison system. “Absolutely it happens. Many of them will end up in the emergency departments if we don’t attempt to connect them to services prior to release.”

Mark Pruitt, 46, was released from a Baltimore facility in October with no Medicaid card and a craving for heroin, which he said he had used before he was incarcerated for a parole violation.

He desperately wanted to enter a drug treatment program, but signing up for Medicaid to pay for it was going to take weeks — far longer than he could wait.

“I knew what I wanted. I wanted help,” he said. “I really wanted help. But it’s a struggle when you’re broke — no money, no insurance, feeling defeated. Where do you turn?”

If administrators at a Baltimore recovery facility hadn’t gotten him enrolled in Medicaid, he said, “I think I’d be dead.”

From January 2014, when the Medicaid expansion took effect, through this March, Maryland released almost 16,000 people sentenced to prison or jail, according to state data. Thousands more cycle in and out of jails each year without being convicted.

But the corrections department said it enrolled only 1,337 released inmates in Medicaid from the beginning of 2014 through late March. Another 1,158 prisoners joined Medicaid over that time when they were hospitalized. (Medicaid covers inmates if they spend 24 hours as hospital inpatients; most return to prison.)

Many ex-prisoners are enrolled only when they experience a crisis and end up in an emergency room — the kind of expensive care health officials are trying to reduce. The law requires hospitals to treat emergency cases regardless of insurance coverage. They can retroactively sign those patients for Medicaid.

‘They Don’t Want To Do The Paperwork’

Monique Wright, 35, got out of Jessup Correctional Institution last fall and began suffering acute head and neck pain caused by scoliosis, a spine curvature. Without Medicaid coverage or a doctor, she said she had to seek emergency care at Johns Hopkins Bayview Medical Center.

“It’s the paperwork” that keeps prison officials from making sure people like her have Medicaid upon release, Wright said. “They don’t want to do the paperwork. They don’t have the staff to do the paperwork.”

Advocates wonder why the corrections system is so poor at enrolling what, they often point out, is “literally a captive audience.”

“They’ve had them housed for the past 10, 15 years,” said a frustrated Andre Fisher, a case manager for ex-inmates at Druid Heights Community Development Corp., a nonprofit in West Baltimore. “What’s so hard about it?”

Enrolling inmates in Medicaid can take weeks, prison officials said. Sometimes the card doesn’t arrive until after they’re out. Computer problems slowed sign-ups in late 2014.

One mistake made by Maryland and most other states is not considering inmates for Medicaid until their release dates approach, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied the process.

“It’s a bad way to do it because you’re getting a very small number” of enrollees by waiting, she said. A better alternative is to enroll inmates when they are booked, as , she said. Those incarcerated are generally ineligible for Medicaid, but putting them in the system when they enter makes it easier to trigger coverage when they leave, she added.

Ex-Inmates Struggle To Get Medicaid Without Help

If it’s hard for the prison system to enroll inmates, it’s even harder for the individuals to enroll themselves. Those who emerge without Medicaid face a maze of applications, bus trips, phone calls and queues if they want to sign up. Many don’t bother.

For most leaving incarceration, “it’s up to you to go there, make sure you get your health insurance,” said Jamal McCoy, 21, who was living with family in West Baltimore on home detention before he was released. “Most people don’t go. Some people take it easy when they get home.”

Those who try often find that lack of identification is the first challenge. To prevent fraud, Maryland and other states require Medicaid applicants to show verified Social Security numbers.

But jails frequently lose inmate IDs, say prisoners and enrollment officials. Those locked up for years are non-persons for much of the system, with no credit records or driver’s licenses.

That can mean delays of many weeks when released prisoners are especially vulnerable. Gaps in coverage and care of even a few days after fragile patients leave the corrections health system can make the difference between life and death.

“If you’re the diabetic that hasn’t been compliant with your medication, you need your medication now,” said Henrietta Sampson, director of treatment coordination at Powell Recovery Center, a Baltimore addiction recovery agency that works with ex-inmates. “You can’t wait two weeks because you may drop dead.”

Compared to the rest of the population, ex-prisoners in Washington state were  in the first two weeks after release, according to research by Dr. Ingrid Binswanger, lead researcher for Kaiser Permanente Colorado’s Institute for Health Research. Drug overdose, cardiovascular disease, homicide and suicide were the leading causes of death.

“It’s very important to manage that transition, to make sure people have continuity of care,” she said. (Kaiser Permanente has no relationship with Kaiser Health News.)

Yet in some cases the prison system has stymied outside groups trying to arrange inmates’ coverage. Stewart’s group repeatedly sought permission — “continuously, for about three years,” she said — to meet vulnerable prisoners inside the facility to get an early start on enrollment and post-release appointments. It never happened.

Baucom blamed the problem on “competing priorities” and staff turnover.

Acceptance into Medicaid by the state isn’t the end of the story. Released inmates then must enroll in a private managed-care organization hired by Maryland to provide coverage. That can take weeks longer.

Even when insured, ex-inmates face the  experienced by other low-income Baltimoreans — or worse.

Many prison inmates are , which can cause liver damage or cancer over time. But the high cost of curing the disease has prompted Maryland’s and other Medicaid programs to to those whose livers are already compromised.

“I guess I got to wait until damage is done to my liver,” said William Carter, 50, adding that prison officials initiated Medicaid enrollment when he got out last year.

Released prisoners often have no idea that some Medicaid managed-care contractors allow them to use only certain doctors and pharmacies.

If you’re the diabetic that hasn’t been compliant with your medication, you need your medication now. You can’t wait two weeks because you may drop dead.

Henrietta Sampson

“So a patient goes to Walgreens or wherever to fill something and it’s like, ‘That’ll be $150,’” because he should have gone somewhere else, said Stewart. “They don’t understand what the problem was.”

Even checking all the right boxes sometimes isn’t enough for ex-inmates, who bear the double stigma of poverty and a criminal history.

One released prisoner got an appointment to renew his mental health prescription with a facility in Carroll County, Maryland — his home — that also accepted his Medicaid card, said Baucom. After the clinic learned he had a prison record it cancelled the visit.

“It’s not enough to have a card,” Baucom said. “You’ve got to have access.”

Neighborhoods are at risk when former inmates with chronic illness return.

“You really need to think about this as a public health issue,” said Scott Nolen, director of drug treatment programs for the Open Society Institute–Baltimore, a nonprofit that works on criminal justice policy. “There is transmission of communicable diseases that happens in prison, in confined spaces. And now those folks are coming back into communities, and we want to make sure they get health care.”

In few places is the burden greater than Sandtown-Winchester. Gray, 25, died of spinal injuries that prosecutors filing manslaughter and assault charges blamed on police who arrested him.

The Justice Policy Institute, a nonprofit, called Sandtown in Baltimore last year, estimating that is in prison.

At the same time, three West Baltimore ZIP codes including Sandtown showed the highest rates of HIV infection in Maryland in 2014, according to hospital data from the Maryland Health Services Cost Review Commission obtained and analyzed by Kaiser Health News and Capital News Service.

The corrections department could use more computers, release planners and other enrollment resources, Baucom said.

“If you do the checkoff list, we’ve checked off everything we can do,” she said, noting efforts to increase enrollment capacity and cooperate with the Maryland motor vehicle agency to get inmates state IDs.

Jesse Jannetta, a specialist at the Urban Institute in prisoner re-entry, believes Maryland’s low sign-up rate “is not unusual” in other states. A found prisons and jails nationwide had enrolled 112,520 people in Medicaid from late 2013 up to January 2015, although the authors believe the actual figure was higher.

Federal and state prisons released 636,000 people in 2014, Millions more to cycle through jails each year.

Few independent experts expect Maryland — let alone most other states — to come anywhere close to full enrollment of emerging inmates anytime soon.

“It’s fair to say we’re just at the tip of the iceberg” in prisoner enrollment, said Johns Hopkins’ Barry, a coauthor of the Health Affairs study. “Maryland is always an innovator. If Maryland is still at the cutting edge of how to do this, many areas of the country don’t have any of these types of programs in place.”

This story is a partnership with The Baltimore Sun and Capital News Service, which is run by the University of Maryland’s Philip Merrill College of Journalism. KHN reporter Shefali Luthra and CNS reporters Catherine Sheffo, Daniel Trielli, Naema Ahmed and Marissa Laliberte contributed.

Where Pharmacies Are Scarce

In certain Baltimore neighborhoods without retail chain pharmacies — such as CVS, Walgreens and Rite Aid — many residents do not have cars to drive to areas with more stores. Two examples are Sandtown-Winchester and Druid Heights.

Source: Maryland Board of Pharmacy and Baltimore Neighborhood Indicators Alliance.
Data analysis by Catherine Sheffo/Capital News Service.

CVS’ 10-month closure posed hardship for some customers. Cornell West, 51, said he took a half-hour bus ride to another CVS for insomnia medication and cortisone cream. Allen Johnson, 61, filled prescriptions at Keystone but couldn’t always get what he needed, he said, such as medications for his knees, blood pressure, cholesterol, heart and diabetes.

“That was a problem for the old people. You know what I’m saying? That was a hell of a problem,” Johnson said.

If we had as many pharmacies as we had liquor stores, it would provide us more opportunity to educate, and promote health and wellness.

Jennifer Joseph

Research suggests that low-income neighborhoods in major cities with higher black and Latino populations are likely to be underserved by pharmacies. A 2014 study in illustrated that pattern in Chicago.

West Baltimore’s shortage of exacerbates the need for pharmacists who can counsel patients about basic health issues. A pharmacist is often the first line of defense for someone with a health condition, said Natalie Eddington, dean of the University of Maryland School of Pharmacy.

“For people who can’t afford health care — they don’t know how to get something,” said Haywood McMorris, the CVS store manager. “They can come here instead of going to the doctor’s and we pretty much take care of it.”

CVS and Keystone compete for that role, but on different scales.

CVS, with 27 stores in Baltimore, is the nation’s largest retail pharmacy chain based on its 9,000 U.S. outlets. It outmatches Keystone, an independent small business, on product variety and supply plus offers better hours. CVS closes at 9 p.m. on weekdays and 6 p.m. on weekends. Keystone closes three hours earlier Monday through Saturday, and it’s closed Sunday. Neither CVS nor Keystone carries fresh produce.

Keystone patrons praise its intimate service and owner Dwayne Weaver’s generosity, sometimes giving them medications on credit when they can’t afford the co-pay.

Argin Henry, 46, shops at both. He goes to CVS for groceries, drinks and goods like toilet paper, but he fills his prescriptions at Keystone, which extends credit when he’s low on cash and delivers prescriptions to his home.

A generous credit policy and delivery service are two ways Keystone competes against its much larger neighbor. CVS is in-network for every Medicaid plan in Maryland. Seven of eight plans cover drugs bought at Keystone, Weaver said. In a week, Keystone might turn away 20 to 25 customers who are out-of-network.

“We kind of survive on servicing patients in a way that chains generally don’t,” he said.

Weaver took over the pharmacy in 1985 and it’s been at its current North Avenue location for about 30 years. CVS has been there since 1997.

Ellis Basnight, who lives a 15-minute walk from Keystone, gets his drugs for diabetes, carpal tunnel and high blood pressure there.

“I’ve been coming here for years!” said Basnight, 71. “That’s why I trust him.”

Weaver considered leaving after last year’s protests. He decided to stay put after neighborhood volunteers helped clean the mess looters left.

West Baltimore’s low-income residents do have some alternatives to retail pharmacies, including two clinics of Total Health Care. Patients there can get prescriptions right after seeing the doctor, but retail pharmacies such as CVS can sate their snack cravings too.

Willie Zuber, 50, goes to CVS four blocks from home for groceries and to get medicines for an older woman he said he looks out for. He often grabs a soda or iced tea there while he waits for her prescriptions.

Joseph, Total Health Care’s pharmacy director, said CVS and Keystone likely serve the most people in the area. But they aren’t enough, she added.

“If we had as many pharmacies as we had liquor stores, it would provide us more opportunity to educate, and promote health and wellness, as opposed to alcohol and cigarettes,” she said. “You ride down the streets and what do you see? Abandoned home, abandoned home, abandoned home and liquor store. Bringing that CVS back says a lot for the city.”

Jeremy Snow is a reporter at Capital News Service. CNS reporters Brittany Britto, Ellie Silverman, Catherine Sheffo and Daniel Trielli also contributed. CNS is run by the University of Maryland’s Philip Merrill College of Journalism.

Months To Qualify For Medicaid

“I think I have diabetes,” said Johnson. “I know I have high blood pressure. I know that. I get dizzy a lot, especially when I wake up in the morning. I need to see a doctor.”

But he can’t. Baltimore jail authorities lost his identification cards, he said, before releasing him in October from an 11-month stay related to a drug arrest. He spent weeks reapplying for a Motor Vehicle Administration identification card, which social workers said he needed to qualify for Medicaid.

“You need ID to get ID, you know?” he joked. Nobody told him he could use incarceration credentials to qualify.

Medicaid’s expansion to include low-income adults was seen as an unprecedented opportunity to cover former inmates such as Johnson as they rejoin the community. (Inmates are not usually eligible while incarcerated.)

But limited administrative resources for release planning means sign-ups are often limited to the most severely ill, said Lena Hershkovitz, a vice president with HealthCare Access Maryland, a nonprofit working to increase enrollment.

“I know for a fact that he’s not unusual,” she said of Johnson. “I would say the majority of people leaving the prison or detention system are leaving without Medicaid.”

Last year the University of Maryland Medical Center found hepatitis C was causing potentially life-threatening damage to Antonio Davis’ liver, said Janet Gripshover, a nurse practitioner at the Baltimore hospital. Hepatitis C can also cause liver cancer.

Davis’ Medicaid plan, run by UnitedHealthcare, thrice denied doctors’ prescriptions for Harvoni, a new drug that can cure hepatitis C with no side effects but costs up to $90,000 for a full treatment, documents show. Davis, 58, was ineligible because he tested positive for illegal drugs or alcohol, United said in two letters to him.

“I’ve been off drugs and alcohol for six years,” he said, although he acknowledges drugs are probably how he got the virus long ago. “I don’t even drink near beer” — nonalcoholic beer.

Only by switching to a different Medicaid plan, run by Amerigroup, was he approved for Harvoni. Like many states, Maryland contracts with private insurers such as Amerigroup and United to provide Medicaid coverage.

Gripshover and other professionals acknowledge the drug’s high cost but say it saves lives and can save equally large expenses for treating cirrhosis and cancer. “There are no data” to support withholding Harvoni or other treatment from those who use illegal drugs, according to of liver-disease professionals. United declined to comment on his case.

Communication barriers and “poor customer service” are also barriers to care in West Baltimore, according to a , a Boston consultant hired by an association of community health centers.

William Ferebee, 66, has obstructive lung disease and a stent implanted after a 2001 heart attack. He avoids doctors at a University of Maryland Medical Center clinic because “they don’t even really come look at me,” he said. Instead, they give orders to a nurse or resident, “and then he comes in and says, ‘OK, here’s what we’re going to do.’”

A doctor at a nearby, independent clinic “is a sweetheart,” he said. “But it’s so hard to get an appointment.”

Distrust of the system often ensures there’s no communication at all.

Deborah Stevenson, 57, limps so badly with a damaged knee that sometimes people think she’s drunk. She believes she needs a knee replacement, “but I’m scared to get it,” she said. Her orthopedist “wouldn’t answer my questions and deal with me like a patient,” she said.

Even though she doesn’t have diabetes and her leg is otherwise healthy, her son speculated doctors might cut it off.

“I’m handicapped now,” she said. “I don’t want to be crippled.”

Fear of legal consequences also keeps people away from the health system. Some men worry doctors will report their undocumented address to social services, which they believe could reduce aid for female partners who live with them, said Wilson, the New Song pastor.

Medical privacy laws to help law enforcement officials trace suspects and fugitives. Residents subject to outstanding warrants fear they’ll be arrested if they seek care.

“Some people got a case out there — they’re not going to the health clinic,” Wilson said. “They’re going to die without giving up their information.”

Even when patients get access, care is disrupted by physician turnover, poor follow-up or insurance companies’ changing medical networks.

“The system is fragmented,” said Debbie Rock, who has run LIGHT Health and Wellness, on Sandtown’s western edge, since the 1990s. “I think that people need to go back and talk to each other. I think the doctors and the health insurance companies need to sit down and listen to each other.”

One homeless West Baltimore patient left an oral surgeon’s office with a wired jaw and no way to pay for the liquid nutrition he needed to feed himself, said Carol Marsiglia, senior vice president at the Coordinating Center, a nonprofit consulting organization that is working to reduce readmissions and emergency visits in the neighborhood.

A home-oxygen company wouldn’t serve a discharged lung patient because he had a $27 balance, she said. A hospital directed two home-health companies to teach a patient how to deal with a new colostomy bag; neither showed up. The Coordinating Center fixed the breakdowns.

Poverty makes Sandtown’s health worse. Many say poverty causes Sandtown’s poor health.

Four Liquor Stores And Three Sub Shops

Many residents hold jobs in government or manufacturing, run churches or collect pensions from the military or Social Security. Even so, the median Sandtown household

Roofs leak. Mold and mildew grow. Baltimore Gas and Electric cuts off energy to Sandtown households for nonpayment at it does in the rest of the city. Lead paint violations like the kind that are nearly four times higher in Sandtown than in Baltimore as a whole.

Drug and alcohol use are common. Diets are often poor. Many lack cars and the nearest supermarket is more than a mile away from the church.

“If we walk around this block, we’ll pass four liquor stores and three sub shops,” said Derrick DeWitt, pastor of First Mount Calvary, on Fulton Avenue.

Even small co-payments required by many health plans dissuade low-income West Baltimore residents from seeking care, the John Snow report found. Some constantly switch doctors to find the lowest price, leading to “disjointed services” and potential harm if information falls in the cracks, it found.

“I change doctors like I change underwear,” said Eddie Reaves, 64, who tries to find practices that won’t charge him copays as little as $12 or $15. His income is $1,170 a month, he said. In 2014, he added, “I must have seen a good total of about 10 doctors.”

Reaves has diabetes and high-blood pressure. He’s on Medicare because of a disability. He has applied twice to Medicaid since the health law expanded coverage two years ago. That would improve his benefits. But he never received the paperwork, he said.

The best care he ever received, Reaves said, was when he didn’t need any insurance card — when he was homeless.

Health Care for the Homeless, a nonprofit a couple miles east of Sandtown, delivers comprehensive services to the homeless without regard for ability to pay.

“Didn’t have no bills,” Reaves said of the clinic when he used it a few years ago. “Your medicine they helped pay for. They did a lot for you. You could get your teeth done and everything. It was just great, man.”

The rest of the medical system is so unsatisfactory by comparison that low-income Baltimoreans sometimes claim to be homeless when they’re not, just to use the clinic, he said.

What happened after a 2004 car accident that broke Robert Peace’s pelvis is a glaring example of what many say is the kind of medicine that has been practiced too long in West Baltimore and what many say they are working to change.

Emergency surgery at UMMC fixed the fracture. But Peace developed a persistent bone infection. He received little or no follow-up care, he said, getting treatment only when the infection surged out of control and required repeated, expensive surgeries.

“The pain would be so intense — it’s like, wracking my body. I would literally sit there and shake,” he said. “That’s when I would know I had to go to the hospital, because I knew the infection was back.”

He said he required five more surgeries over a year and a half — the kind of return trips to the hospital, or “readmissions,” that the health industry and the Affordable Care Act of 2010 are trying to reduce by promoting coordination between hospitals and community doctors.

“I’m blaming it on the follow-up,” said Peace, 58. “They knew the infection wasn’t going away, but the only time they would really tend to it was when I was in the hospital.”

Today Peace walks with a cane and a pronounced limp.

It’s a story that’s still too common in West Baltimore, said Antoine Bennett, a lifelong Sandtown resident and an elder at New Song Community Church.

“We’ve got a joke here, but it’s a serious joke,” he said. “If they ain’t medicating, they’re amputating or operating. But what’s missing is the care. Primary care.”

When asked about Peace’s case, UMMC spokesman Michael Schwartzberg said, “Much has changed in the Maryland hospital environment” since his surgeries. Improvements include new emphasis on preventing readmissions and “significant investment” in care coordinators and other post-discharge management, he said.

Keeping People Healthy And Out Of The Hospital

By many accounts, hospitals, doctors, health plans and governments in Annapolis, Maryland’s capital, and Washington are making unprecedented efforts to bridge the medical divide with Sandtown and the rest of low-income Baltimore.

The grand idea is to save money and simultaneously improve lives by keeping people healthier in the community instead of letting them become ill enough to land in the hospital.

In October Bon Secours that it intends to turn into a primary care and wellness center. UMMC and Bon Secours are working with “transition coaches” from the Coordinating Center to make sure people leaving the hospitals take medicine and schedule follow-up appointments. UMMC’s transition clinic serves hundreds of recently discharged patients.

Maryland is developing one of the most advanced electronic networks for letting medical providers collaborate by sharing patient records. Health Care for the Homeless in Bon Secours.

Dr. Samuel Ross, Bon Secours’ CEO, talks about working more closely with the churches and continuing to improve the hospital’s outcomes and reputation.

“No, it’s not solved,” he said. “We need to keep doing what we’re doing, and understand that some of this is a person at a time. There is no wholesale campaign or branding message that’s going to cause people to say, ‘You’re wonderful.’”

In 2012 Maryland’s legislature created “health enterprise zones” to increase the supply of primary caregivers in West Baltimore and other underserved areas. UMMC puts emergency room patients in touch with a primary care doctor if they don’t have one.

In September hospitals proposed taxing insurance companies, employers and other payers so they could hire up to 1,000 caregivers directly from West Baltimore and other low-income communities with poor health results.

The Baltimore health department is pressing hospitals to collaborate on high-risk patients and is building ties with lower-income neighborhoods by hiring residents, said Dr. Leana Wen, the city’s health commissioner.

Baltimore’s B’more for Healthy Babies program has the city’s African-American infant mortality rate by nearly a third , to 12.8 per thousand births. But that’s still a fifth higher than the African-American rate for all of Maryland.

University of Maryland Medical Center has for high schoolers interested in health careers. The University of Maryland, Baltimore, got a to increase the number of African-Americans in health care jobs.

More and more professionals echo UMB’s Perman, who said a medical professional’s duty to patients does not end at the hospital or clinic door.

“As a profession, as an industry, we have not sufficiently appreciated, let alone done something about, the impact of social determinants” such as poverty, poor housing, lack of food choices and low education, he said. “Guys like me and gals like me can easily say, ‘I made the correct diagnosis. I wrote a proper prescription. I’m done.’ What I say to my students is, if you think you’re done — if ‘done’ means the patient is going to get better — you’re fooling yourself.”

Maryland’s ambitious overhaul of hospital reimbursement, authorized by the health law, is supposed to back that philosophy with powerful incentives. Starting in 2014, hospitals have been assigned annual budgets for all government and private payers, instead of being paid per admission or treatment.

The idea is to boost their motivation to contain costs by delivering preventive, community care — to pay them for keeping people out of the hospital. Hospitals are also getting penalized for excessive readmissions and preventable harm such as infections and accidental punctures.

“It’s a daunting task… when we talk about joblessness and poor nutrition and violence in the neighborhoods,” said Dr. Walter Ettinger, chief medical officer of the University of Maryland Medical System. “But we all feel driven by our mission to serve our communities in a better way, and now the finances are aligned to do that.”

Poor people, however, know that between ambitions and accomplishments is a chasm of disappointment.

In the face of wider primary-care shortages and the difficulty for doctors to make a living in low-income neighborhoods, the zone fell far short of its original goal of to West Baltimore.

“Some of the goals and objectives across almost all of the zones were a bit ambitious,” said Maura Dwyer, a senior policy advisor for the Maryland Department of Health and Mental Hygiene.

In 2014 People’s Community Health Center in Baltimore and later entered bankruptcy proceedings, demonstrating the difficulty.

Officials at Total Health Care, a federally supported nonprofit with several primary-care clinics near Sandtown, say they are proud of their service to West Baltimore.

“We want to bring the standard health in this neighborhood up to national standards,” Dr. Marcia Cort, Total’s chief medical officer, told students from the Merrill College. “We don’t want it to be the neighborhood and area [where] life expectancy is low and people are dying from preventable things.”

Still, she said, “Baltimore City is in a health crisis.”

Readmission rates for Bon Secours were still in 2014, although the Coordinating Center’s transition coaches helped reduce them by 14 percent from the year before.

Readmissions for UMMC’s midtown campus were second highest statewide after declining 5 percent, also with work by transition coaches. At UMMC’s downtown campus, readmissions were fifth highest in the state and declined 2 percent.

But state financing to pay for the transition coaches expires at the end of March. The Coordinating Center is optimistic it will be renewed but nothing is set, Marsiglia said.

In 2014 only that they understood their care after they left the hospital. For UMMC patients the figure was 51 percent.

Many resent that it took this long for the industry to try the very solutions — improving primary care, giving communities resources to help themselves — that residents of neighborhoods like Sandtown have been advocating for years.

“Unfortunately the hospitals didn’t hear us,” said Diane Bell-McKoy, CEO of Associated Black Charities, a Maryland nonprofit. “As a person of color giving that information — most people think we don’t know what we’re talking about.”

Distrust of the system, still more widespread than medical officials imagine, is passing to a new generation, residents say.

“It’s a culture that has come about over time, because younger people have seen or feel like their parents and their grandparents didn’t get the best medical treatment when they went to the hospital,” said First Mount Calvary’s DeWitt. “So they have this why-go attitude.”

On Dec. 9, Maryland regulators made three months earlier to create hospital jobs in poorer neighborhoods.

Other initiatives do little to address the low incomes and unemployment linked to Sandtown’s poor health. Nor do they simplify the shifting maze of private and government insurance plans and hospital and doctor networks that patients must navigate to get care.

One example: Nearly 2,000 low-income Medicaid members, including many in Sandtown and nearby, had to change coverage in August or get new doctors because United dropped University of Maryland Faculty Physicians from its Medicaid network in a contract dispute, said Shannon McMahon, deputy secretary of the Maryland Department of Health and Mental Hygiene.

United “had thorough continuity of care measures in place before the contract ended to ensure ongoing care was not disrupted,” said company spokesman Ben Goldstein.

For many residents, enrolling in a plan is too complicated and time-consuming, requiring time off from work to get coverage they don’t understand and can’t afford, said LIGHT Health’s Rock. In some ways the health law and its new coverage rules have made things more complex, she said.

“As the landscape is changing, people really just don’t know what to do,” she said. “They sit you down with somebody that’s supposed to help you fill [an insurance application] out, which is like a Charlie Brown episode. Once you start on the second page it’s like ‘Wah, wah, wah.’ You don’t hear nothing else. You walk out and it’s like, ‘What happened?’”

David Johnson, who was concerned about his blood pressure, dizziness and possible diabetes, joined Medicaid in December. It took two months, three trips to the motor vehicle bureau to get a new ID and two trips to social services to enroll.

An still hadn’t signed up for Medicaid as of October. As of early February, Eddie Reaves, the diabetic who gave up applying after his second attempt, was still among them.

This story is part of a reporting partnership between and University of Maryland College Park’s , which operates Capital News Service. KHN and students from the school are examining how Baltimore’s nationally respected health system serves the community where violence flared in April after Freddie Gray was fatally injured in police custody. The project is continuing. To see all the students’ work go to the .