Thursday, December 6, 2012 Health Reform and Criminal Justice: Addressing Health Disparities Among the Racial and Ethnic Minority Populations in Jails

Racial and Ethnic Disparities in Criminal Justice and Health Status and How They are Reflected by Health Reform Thursday, December 6, 2012

Health Reform and Criminal Justice: Addressing Health Disparities Among the Racial and Ethnic Minority Populations in Jails

Vision. The Forum strives to prepare the health system in the United States to provide optimal health care for a diverse society.

Introduce the National Minority Quality Forum Structure of the Existing Market Health Care Reform and The Emerging Market Our Conversation Today

A DC-based, healthcare organization dedicated to the elimination of health disparities. The Forum has developed a comprehensive database comprised of over 800 million patient records to define disease prevalence, costs, and outcomes at the zip code level. Our database is used to inform, support, and catalyze advocacy, educational, marketing, and public relations activities National Minority Quality Forum About the

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National Minority Quality Forum Disease Based Indexes We consolidate these data by zip code into user-friendly, web-based disease indexes. Users can: Map any chronic disease by prevalence, cost, outcomes, co morbidities, socioeconomic status, Rx drug use, etc. for any state, MSA, congressional and state legislative districts Define where the unmet needs exist by identifying undiagnosed and uncontrolled populations Forecast trends

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National Profile of Diabetes National Health Index

National Minority Quality Forum Key Finding

National Minority Quality Forum Consumer Health Care Market Has Structure There are geographical bound health care market places in the United States that exhibit stable consumption patterns from one year to the next. Geography Matters

National Minority Quality Forum Stable Consumption Patterns These consumption patterns are the product of consistencies in the incidence and prevalence of diseases, underlying consistencies in patient response to those diseases, practices variation, and uniformity in the ways in which the health care financing and delivery system responds to patient needs. Forces that Shape Markets

National Minority Quality Forum Consumption Patterns Can be Shaped This stability is knowable, predictable and algorithms can be built that can anticipate consumption patterns. Critical Intelligence

National Minority Quality Forum Health Care in the 21 st Century An understanding of these consumption patterns can improve management of health care resources. The Value Proposition

Adults' Health Insurance Coverage by Race and Ethnicity, M M 22.6 M 9.7 M 1.2 M Number 2.2 M Black Multiracial White Hispanic Am. Indian Asian NOTES: American Indian category includes Aleutian Eskimos. Adults includes all individuals aged 19 to 64. Asian includes South Pacific Islander. Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.

National Health Index US Medical Expenditures By Race/Ethnicity

Health Care Reform and the Emerging Market

35 Million 25 Million 17 Million 16 Million Approx. 35 million Americans Will Now Have Health Insurance More than 25 million non-elderly Americans with a pre-existing condition will now have coverage Approx. 17 million will have health insurance through state run health exchanges Approx. 16 million will have health insurance through expanded Medicaid Market Size

Most new consumers will reside in a limited number of zip codes 43% of new consumers will be minority 70% of minorities reside in 4,500 out of 38,000 zip codes. These minority consumers will be served by approximately 500 minority servicing hospitals and 40,000 minority servicing primary care physicians Market Dynamics

50% uninsured population reside in 8 states; 80% in 22 states Source: The Emerging Market Currently Uninsured

Expanded MedicaidHealth Exchange Source: Emerging Market Segmentation

National Health Index Support Clinical Research

Panel 1: Can Medicaid Expansion Mitigate Health Disparities in the Criminal Justice Population? Thursday, December 6, 2012

1 Access – Medicaid and Health Insurance Exchanges Absolute insurance rates are expected to increase by: 18% for Hispanics 15% for Blacks 10% for Asians/other 9% for Whites Opportunities for the PPACA to Rectify Disparities 1

2 Health Insurance Exchange Projected Enrollees by Race Compared to General Population 23% of exchange enrollees will speak a language other than English at home Race% General Population % Projected Exchange Enrollees White6958 Non-white3142 Hispanic1225 Black1211 Other76 Opportunities for the PPACA to Rectify Disparities 2

3 Overlap Between Expansion and Jail Populations Age and Gender o Data suggest that low-income childless adults are more likely to be male and to be under age 35 Race/ethnicity o Racial and ethnic minority groups are projected to be overrepresented in the newly eligible population Employment o Almost half of the newly eligible population is expected to be unemployed (compared to below 10 percent of the general population ) Opportunities for the PPACA to Rectify Disparities 3

4 Washington state found that 30 percent of very low- income childless adults (up to 38 percent of FPL) have recent jail involvement. Although comparable data are not available for childless adults at higher income levels up to 133 percent of FPL, Washington’s finding suggests that the jail-involved subset of the expansion population warrants attention by state and local policymakers. Opportunities for the PPACA to Rectify Disparities 4

5 Arrests Decline Significantly After Drug/Alcohol Treatment Opportunities for the PPACA to Rectify Disparities 5

6 Inmate Exception Mental Health Parity Enrollment Mechanisms Opportunities for the PPACA to Rectify Disparities 6

7 Inmate Exception The PPACA states that individuals who are held pre-trial are eligible to enroll in, or to continue to receive benefits through, a state health insurance exchange The PPACA does not specify whether Medicaid enrollees are eligible to receive Medicaid benefits while in pretrial incarceration Regardless, Medicaid-eligible individuals can be enrolled into Medicaid while incarcerated, making it easier for them to maintain continuity of care upon release Opportunities for the PPACA to Rectify Disparities 7

8 Mental Health Parity Parity laws require health insurance plans to treat mental disorders with the same coverage limits as any other disease or health concern Prior to the PPACA, plans were not required to offer mental health or substance abuse services, but if they did, the services were required to be on par with other medical services Opportunities for the PPACA to Rectify Disparities 8

9 Mental Health Parity The PPACA contains a number of provisions that extend the reach of existing federal mental health parity requirements: o Beginning in 2014, mental health and substance use disorder services must be covered by all insurance policies through the Exchanges and Medicaid o Pre-existing conditions apply to all mental health diagnoses, so an individual can no longer be denied coverage for an existing mental health condition Opportunities for the PPACA to Rectify Disparities 9

10 Challenges to Enrollment and Provision of Services Jails lack staff capacity Fast turnover of jail inmates Appropriate identification No information on billing/receiving exchange benefits Opportunities for the PPACA to Rectify Disparities 10

11 Enrollment mechanisms States are required to create a “no wrong door” system, supported by a website that allows for enrollment and reenrollment, ensuring that individuals seeking coverage are screened for all health subsidy programs and processed through to enrollment without requiring additional application forms or multiple eligibility determinations Challenge Historically, providers have not been eager to treat this population given the high concentration of chronic conditions and low insurance rates Opportunities for the PPACA to Rectify Disparities 11

Panel 2 Case Study: The California Experience Thursday, December 6, 2012

13 The Bridge to Reform On June 3, 2010, California submitted a 1115 Medicaid Demonstration waiver, dubbed the “Bridge to Reform” in response to the Affordable Care Act The waiver allows counties in the state to expand Medicaid coverage to low-income uninsured, non-pregnant adults with Federal matching funds California’s uninsurance rate (7 million) is projected to decrease by more than half by California’s Bridge to Reform Closing the Gaps with the Affordable Care Act

13 Uninsurance The state has extended coverage to low-income adults through the Low Income Health Program (LIHP) that is provided at the option of each county to: Medicaid Coverage Expansion (MCE) adults: non-pregnant adults between ages 19 and 64 who have family incomes at or below 133% of the Federal Poverty Level (FPL) Health Care Coverage Initiative (HCCI) adults: non-pregnant adults between ages 19 and 64 with family incomes between 133% and 200% FPL 2 California’s Bridge to Reform Closing the Gaps with the Affordable Care Act

13 3 California’s Bridge to Reform Closing the Gaps with the Affordable Care Act

13 Insurance Coverage and Quality Improvement Requirements The waiver funds public hospitals to achieve population-focused improvement Included are low-income populations with chronic conditions, including mental health, and substance abuse — conditions also common in the criminal justice population Enrollees must be assigned to a medical home Medical homes enable providers to develop the expertise and provider teams needed to serve challenging populations like those involved in the criminal justice system 4 California’s Bridge to Reform Closing the Gaps with the Affordable Care Act

13 Impact Medicaid expansion in CA will enroll populations that have had historically low access to mental health/substance abuse services In addition to potentially preventing mental health-related interactions with the criminal justice system, Medi-Cal expansion can also provide newly-released prisoners with medical treatment, which could be crucial to reducing recidivism 5 California’s Bridge to Reform Closing the Gaps with the Affordable Care Act

13 6 California’s Realignment AB-109 The law, effective October 2011, mandates individuals sentenced to non-serious, non-violent, non-sexual offenses will serve their sentences in county jails instead of state prison Many low-level offenders are being placed under community supervision rather than serving jail time in order to make room for higher-level offenders that historically would have gone to prison As a result, there are increased opportunities for offenders to access health care in the community

1 California’s Bridge to Reform Closing the Gaps with the Affordable Care Act Los Angeles County’s Low-Income Health Program: Healthy Way LA As of August 2012, 204,878 low-income residents were enrolled in Healthy Way LA The estimated ACA-eligible population in Los Angeles County is 637,000 Approximately 430,000 residents are eligible and NOT enrolled 7

Health Care Reform and Corrections Realignment to Counties

939

There is HOPE!!!

County Medical Services Program 35 out of the 58 California Counties pool their dollars to provide care for indigent adult population 40k California Indigent residents utilize this service Revenue source County General Fund, Vehicle License Fee, and Sales Tax Initially used for catastrophic care, ER visits Solano County big champion of managed care done right can lower costs & deliver quality services Proved it with a piloted a managed care program- County Operated Health System- Results Lowered Costs, client satisfaction, provider satisfaction, staff satisfaction above 90% Now Managed care for all 35 Counties

There are Ways to Lower County Costs for Jail Inmates 1115 Medicaid Waiver- Implementing Health Care Reform for indigent adults Medicaid rules say you cannot draw down federal dollars if you have a person incarcerated… technically behind the “walls of a jail or prison.” Lower your costs by providing health services outside of the “walls of a prison or jail” If you integrate your health care with psychiatric care, you can minimize appointments and tie the care to the whole person.

The Solano Plan for Reducing Recidivism In and out of custody service- Continuum of care Use Evidence-Based Programs/ Evidence Informed Appropriate MH (Cognitive Behavioral and Evidence Base Substance Abuse Services Day Reporting Center Get them appropriate benefits- I’m bringing my whole HSS arsenal to help. Help clients get a new peer group-Funding a peer network of successfully recovering individuals to be the connection and fall back when things are starting to look bleak Employment Services Partnership and Trust We are in this together- Don’t let a partner hang out there. Don’t overpromise – Single digit improvements to recidivism reduces crime significantly

Impediments Lack of split sentences No room for services in the jail Fear of elected Judges and District Attorney to release prisoners Unsure if these elements will work despite evidence that shows it does Lock em up mentality- Feels good but doesn’t help

Panel 3 Experiences From Other Early Adopter States Thursday, December 6, 2012

Panel 4 Envisioning the Future Thursday, December 6, 2012

Health Reform and Criminal Justice: Addressing Health Disparities Among the Racial and Ethnic Minority Populations in Jails