Download - Thursday, December 6, 2012
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
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 ForumAbout the
National Minority Quality ForumPartners
National Minority Quality ForumDisease 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
National Minority Quality ForumOur Portfolio
National Profile of Diabetes
National Health Index
National Minority Quality ForumKey Finding
National Minority Quality ForumConsumer 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 ForumStable 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 ForumConsumption Patterns Can be Shaped
This stability is knowable, predictable and algorithms can be built that can anticipate consumption patterns.
Critical Intelligence
National Minority Quality ForumHealth Care in the 21st 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,
2010
73%
44%
50%
68%
45%
59%
11%
15%
22%
10%
20%
18%
16%
42%
28%
23%
35%
23%
Private Medicaid/ Public Uninsured
28.7 M
122.4 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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
White Black Hispanic Other
20022005
2009
US Medical Expenditures By Race/Ethnicity
Health Care Reform and the Emerging Market
35Million
25 Million
17Million
16Million
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 MarketCurrently Uninsured
Expanded MedicaidHealth Exchange
Source:
Emerging Market Segmentation
National Health IndexSupport 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 ExchangesAbsolute 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
White 69 58Non-white 31 42• Hispanic 12 25• Black 12 11• Other 7 6
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/ethnicityo 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 mechanismsStates 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
ChallengeHistorically, 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 2Case Study:
The California Experience
Thursday, December 6, 2012
13
The Bridge to ReformOn 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 2016
1
California’s Bridge to ReformClosing the Gaps with the Affordable Care Act
13
UninsuranceThe 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 ReformClosing the Gaps with the Affordable Care Act
133
California’s Bridge to ReformClosing the Gaps with the Affordable Care Act
13
Insurance Coverage and Quality Improvement RequirementsThe 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 ReformClosing the Gaps with the Affordable Care Act
13
ImpactMedicaid 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 ReformClosing the Gaps with the Affordable Care Act
136
California’s RealignmentAB-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 ReformClosing 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
The Solano County, California
Experience
* Jail Profile Snapshot Race, Sex and Age of Jail
Population TodayWednesday December 4th, 2012
43%
16%
35%
6%
Black HispanicWhite Other
2%
9%
52%
38%
60 + 50-5930-49 18-29
0100200300400500600700800900
810
129
Male Female
Jail Population TrendOctober 1st, 2011 – December 4th, 2012
650
700
750
800
850
900
950
1000
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 3Experiences From Other Early
Adopter States
Thursday, December 6, 2012
Panel 4Envisioning the Future
Thursday, December 6, 2012
Thursday, December 6, 2012
Health Reform and Criminal Justice:Addressing Health Disparities
Among the Racial and Ethnic Minority Populations in Jails