Behavioral Health Services for Rural Immigrants

March 19, 2009

Presenters:

Leif Jensen, Ph.D.Department of Agricultural Economics and Rural Sociology and the Population ResearchDepartment of Agricultural Economics and Rural Sociology and the Population Research

Institute, The Pennsylvania State University

Ron Manderscheid, Ph.D.Director Mental Health and Substance Use Programs Global Health Sector SRADirector, Mental Health and Substance Use Programs, Global Health Sector, SRA

International, Inc.

The National Rural Behavioral Health Webinar Series is sponsored by the Federal Interagency Rural Behavioral Health Workgroup, in collaboration with the Western Interstate Commission for Higher

Education (WICHE), the National Center for Mental Health Promotion and Youth Violence Prevention, National TA Center for Children's Mental Health, as well as the Technical Assistance Partnership.

Welcome to Today’s Webinar

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Taken by Surprise:y pNew Immigrants in the Rural United

StatesStates

BackgroundBackground•The U.S. as a nation of immigrants•Immigration history repeats itself: waves and worries•New gateways and immigrant settlements•Immigrants in rural areas and small towns and•Immigrants in rural areas and small towns and cities

Immigrants in Rural and Small Town A i B Bl i ?America: Bane or Blessing?

•Blessing•Repopulating dying towns•Revitalization•Contributions to local tax base and economy•Contributions to local tax base and economy•Retention of businesses that might otherwise leave•Cultural diversity (e.g. language, music, food)

•Bane•Social conflict, racial/ethnic tension•Stressed services (e.g. education, housing, health)•Increased poverty•Depressed wages•Depressed wages

The case of Hazelton, PennsylvaniaPennsylvania

“But change has come rapidly to this former coal mining town … and has tested its ability to adapt. The arrival in just four years of an estimated 6,000 Hispanic immigrants and the efforts to accommodate them have angered some residents, even as the mayor has credited the newcomers

ith b inging ne life into this comm nitwith bringing new life into this community.

No one saw it coming.”

The case of Hazelton, PennsylvaniaPennsylvania

“The school system’s efforts to educate the new immigrants have angered some parents who think the district is catering to Hispanic students at the expense of others. ‘They redo everything for them’ [says one parent]. As she discusses her complaints, [she] notes that [one of her son’s] buddies is Hispanic. Hazleton’s bulging school s stem ma be its b ightest hope a place he eschool system may be its brightest hope, a place where kids – the town’s future – meet, mingle and become friends.”

The case of Hazelton, PennsylvaniaPennsylvania

“The mayor says the arrival of the immigrants … gives the area a chance for a new beginning ‘This was a town witharea a chance for a new beginning. This was a town with an aging population and a bleak outlook,’ [Mayor] Berlettasays. With the influx of Hispanic immigrants, the pace of life has picked up, new businesses are opening and propertyhas picked up, new businesses are opening and property values have increased. The grandson of a miner, Barletta says people are quick to forget this town was settled by immigrants. ‘Ninety-nine percent of them want the same g y pthing my grandfather wanted when he left Italy – a better life for their kids.’”

Definition of Rural•Rural is defined here as “nonmetropolitan,”; so what then is metropolitan?•The building blocks are counties•A metro area is a county with one or more urbanized areas (cities) of 50K+ with surrounding counties connected (c t es) o 50 t su ou d g cou t es co ectedeconomically to the central county through commuting for work•2052 (65%) of 3142 counties are nonmetropolitanO l b t 17 3% f th l ti i l b thi d fi iti•Only about 17.3% of the population is rural by this definition.

New Immigrants in the Rural United StatesWhere are they living?

Analysis of 1990 and 2000 U.S. Census data

Who are they?Demographic portrait using pooled March Current PopulationDemographic portrait using pooled March Current Population Survey data 1996-2003

What impact are they having?Evidence from the literatureChanging characteristics of placesChanging characteristics of places

What are the policy implications?y

Where are the New Immigrant S ttl t i R l A i ?Settlements in Rural America?

Indicator of recent immigrant growth:

Recent f-b population 2000 – Recent f-b population 1990 __________________________________________

Total population 1990Total population 1990

New York, Chicago, San Francisco

WashingtonWashington, Minneapolis

DDenver, Austin

Atlanta, Miami

A string of rural counties in North CarolinaA string of rural counties in North Carolina

Dulpin, Coounty, ~500 to 5,000 recent immigrantsimmigrants

Meat and other food processing, furniture manufacturingmanufacturing

High percentage African American.

North GeorgiaNorth Georgia

Example, Gilmer County, Georgia’s “Apple Capital”Capital

Recent immigrant population grew 30-fold, 46 to 1,286 over the 1990’s1,286 over the 1990 s

Near Dalton, Georgia, “Carpet Capital of the World”

Interior southern Florida

Example, Hendry Co., “Citrus Capital of Florida”

23 percent of workforce in agriculture

The Heartland

Meatpacking important here

Example, Cass County, Illinois

Recent immigrant populationRecent immigrant population grew 41 to 1,049

Note SW Kansas

Arkansas and East TexasArkansas and East Texas

Poultry and other meat processing

Rio Grande areaRio Grande area

Diverse economies: agriculture, some mining

Very high percentage Hispanic

Starr County, Texas is 98 percent Hispanic

The West

Skiing and recreation industries provide employment

Example: Eagle County, Colorado, where the recent immigrant population grew from 1,284 to 7,289

The West

Agriculture is also a draw for recent immigrants in California, Oregon, Washington and Idaho

Example: Grant County, Washington, #1 in apples, #2 in potatoes and peas. Its recent immigrant population grew from 3,628 to 11,850

In Summary• Recent immigrants remain primarily urban, but are moving

to periphery of metro areas and into rural and small-town lplaces

• New rural settlements are in all U.S. regionsg

• Primary draw is economic opportunities in agriculture, meat and other food processing, natural resource based p g,manufacturing, construction in high growth amenity areas

• Case studies suggest they are also attracted byCase studies suggest they are also attracted by perceptions of lower cost of housing, better schools, safer environments, better place to raise a family

Who are the New Immigrants in the gRural United States?

• Analysis of current population survey data

• Comparison of recent immigrants (post-1965 and post-• Comparison of recent immigrants (post-1965 and post-1990) living in nonmetro and metro areas

• Within metro areas, central cities versus suburbs

Figure 2. Race/ethnic distribution among natives, post-1965, and post-1990 arrivals

100%Total Nonmetro Metro Central City

80%

100%

40%

60%

20%

40%

0%Nat 65+ 90+ Nat 65+ 90+ Nat 65+ 90+ Nat 65+ 90+

White Black Mexican Other Hispanic Otherp

In summary, compared to their more urban counterparts, recent immigrants in nonmetropolitan areas are…g p

• More Hispanic (and Mexican in particular)• Less well educated• Less well educated• Poorer, but less prone to use assistance• More likely to be married

M lik l t b ki• More likely to be working…• …but more likely to be underemployed• More likely to own their own homey• Slightly more likely to have health insurance

What is the Impact on Rural Areas?

• Small size of rural areas inherently magnifies the impact of aSmall size of rural areas inherently magnifies the impact of a given absolute influx of immigrants

• Rural communities as crucibles in which the dynamics of immigration (e.g. conflict and assimilation) are intensified. Rural communities as “natural laboratories” to study thisRural communities as natural laboratories to study this social process

• Prevailing evidence on impact is emerging

Does Immigration Cause Rural Does Immigration Cause Rural P ?P ?Poverty?Poverty?

While rural and agriculture should never be thought of assynonymous, Martin and Taylor (2003) support the following at thecounty level….county level….

Poverty

ImmigrationAgricultural Employment

Analysis of Counties Analysis of Counties Found that…Found that…

• The fastest growth in recent immigrant population still in g g p purban areas

• Nonmetro counties with rapid increases in recent immigrantNonmetro counties with rapid increases in recent immigrant population had…– Lower employment in agriculture and manufacturing– Higher employment in construction and servicesHigher employment in construction and services– Lower poverty rates in 1990, but least decline– Lower public assistance receipt, but least decline

L t f d lt ith t hi h h l b t l t– Lower percentage of adults without high school, but least decline

– Lower percentage elderly

Implications for Policy andImplications for Policy and Programming g g

• Bring impact on rural locales into the immigration policy debate (now largely absent)

• Bring immigration into rural development policy (now largely absent)

• Reconcile the contradiction: Immigration policy is set at the national• Reconcile the contradiction: Immigration policy is set at the national level, but the burden is borne locally

• Recognize the policies aimed at undocumented immigrants can have a• Recognize the policies aimed at undocumented immigrants can have a chilling effect on legal immigrants (Hazleton revisited)

Implications for Policy andImplications for Policy and Programming, continued

• Study the benefits along with the problems

• Support and coordinate with NGO’s that serve the immigrant population

• Provide incentives to encourage the collaboration of immigrant groups and native populations

• Maintain a focus on the circumstances of the children of immigrants (the second generation)

The case of Hazelton, PennsylvaniaPennsylvania

“[Schools] have played a key role in helping Hispanic immigrants become part of this community – just as schools across America ha e t aditionall se edhave traditionally served as melting pots for immigrants.”

Questions?Questions?Please press *7 on your phone toPlease press 7 on your phone to

unmute your line.

Wh fi i h d lWhen you are finished, please press *6 to remute.p

New Immigrants in Rural Areas: fImplications for National Health

and Health Care Reforma d ea Ca e e o

Some Framing Issues for RuralSome Framing Issues for Rural Communities in Planning for Behavioral

Health Services to New Immigrants

• Stepping out of our comfort zoneM ki t ti• Making new system assumptions

• Developing key action vectors

Some Reform Drivers at the N ti l L lNational Level

• Economic meltdown (Health reform must beEconomic meltdown (Health reform must be related to national economic recovery)

• New front office in Washington (New approach g ( ppto health reform—President’s 8 principles)

• New approach to entitlement programs (SSA, pp p g ( ,Medicare, Medicaid)

• Addressing chronic disease (Current model doesn’t work!— http://www.pfcd.org)

President’s 8 Principles of Reform and their pImplications for Rural Behavioral Health

P t t f ili ’ fi i l h lth• Protect families’ financial health• Make health coverage affordable• Aim for universalityAim for universality• Provide portability of coverage• Guarantee choice• Invest in prevention and wellness• Improve patient safety and quality care• Maintain long-term fiscal sustainabilityMaintain long term fiscal sustainability

Sobering Statistics: N ti l L lNational Level

• Current cost of health care: $2.3 T/yr.$ y• Current cost of chronic care: $1.6 T/yr.• Estimate of waste in system: $685 B/yr.y y• Expenditures on “health”: 5%• 17% are uninsured (34% for MH/SU). 80% of

public mental health consumers are unemployed.

• US ranks in the low 30s on basic health• US ranks in the low 30s on basic health measures—behind Slovakia and Cuba.

We Have Been One-DimensionalWe Have Been One Dimensional

Focus only on disease:Focus only on disease:

No Disease Disease

We Need to Become Two Di i lDimensional

Focus on disease and health:Focus on disease and health:Health

No Disease Disease

No Health

Model of Wellness and Illness (1981)(1981)

New Thinking:gRecovery

WellnessIllness

ImplicationsImplications

• Illness dimension Illness careIllness dimension Illness care• Wellness dimension Promotion of

wellness and wellbeing (sometimes calledwellness and wellbeing (sometimes called positive health or health promotion)

• Representative Patrick Kennedy: “Stop it where it starts!”

Wellness EvolutionWellness Evolution

• Preventive and promotion interventions forPreventive and promotion interventions for immigrant children and families

• Preventive and promotion interventions for• Preventive and promotion interventions for new immigrant populationsP l ti “H lth C h ”• Population “Health Coaches”

• Population insurance

Moving Further UpstreamMoving Further Upstream

• Healthy People 2020 FrameworkHealthy People 2020 Framework emphasizes health determinants and interventions to address them; health careinterventions to address them; health care is a secondary objective.

• What are the implications for new• What are the implications for new immigrants in rural communities.

Healthy People 2020 ModelHealthy People 2020 Model

Some Key Behavioral Health “Needs” inSome Key Behavioral Health Needs in Serving Immigrant Populations in Rural Areas

• Need to implement more family-driven and youth-guided (consumer control) approach to health care and health (upstream factors)(upstream factors)

• Need to integrate principles of cultural and linguistic competence into service provision. N d ti l i t ti i d l• Need practical integration service models:– Integration of behavioral health strategies in child-focused

settings: schools, pediatric and other primary care settings

Some Key Behavioral Health “Needs” in Serving Immigrant Populations in Rural Areas continuedImmigrant Populations in Rural Areas, continued

• What the data tells us and what is unique to rural25 l t t t d th– 25 years lost to premature death

– MH/SU co-morbidities– Co-morbidities with physical illnessesCo morbidities with physical illnesses

• Need to update an aging workforce • Need “comparative effectiveness” results• Need to stem erosion of financial tools• Need care coordinators, peer counselors, utilization of

natural helpers that represent the communities of focusnatural helpers that represent the communities of focus

Expected Legislation d th R l C iti ’ V iand the Rural Communities’ Voice

• Senator Kennedy and Senator Baucus:Senator Kennedy and Senator Baucus:– Insurance coverage: 47 million +18/20 million (?)– System reform: Medical/Health Home Modely– Financing: Medicaid and SCHIP expansions,

potentially Medicare, paid through employers who do not insure employees and recoup of HHS fundsnot insure employees and recoup of HHS funds.

• Senator HarkinCover promotion and prevention interventions in– Cover promotion and prevention interventions in insurance benefits

Key UnknownsKey Unknowns

• Impact of massive change on the healthImpact of massive change on the health infrastructure

• Phase in period that will be required• Phase-in period that will be required• Implications for rural and frontier

iti d i i tcommunities and new immigrants

Some Key Questions for UsSome Key Questions for Us

• How will we develop and implement healthHow will we develop and implement health promotion/disease prevention services for immigrants in rural communities?

• How will we develop and implement disease prevention services for chronic behavioral health challenges across the life span?

• As the Medical/Health Home is developed—j l f i h ill hmajor role for primary care—how will we change

and what’s unique for rural communities?

Some Key Questions for Us, Continued y Q ,• Access, availability, and acceptability of behavioral health and

whole health in rural and frontier communities. • Models for Medical Home and cultural and linguistic

competency for immigrant populations and the broader population.population. – What are FQHCs? – Are we working with them? – Do we plan to do so? Other approaches to the

Medical/Health Home?– What would be different if principal funding for services p p g

were fully through an insurance model (by person)? – How are we going to get there?

American Recovery and Reinvestment Act of 2009

(Conference Version)(Conference Version)• Prevention and Wellness Fund: $1 B

C ti Eff ti R $1 1 B• Comparative Effectiveness Res.: $1.1 B• Federally Qualified Health Centers $2.5 B• HHS IT Initiatives $2 B• Workforce Training $500 MWorkforce Training $500 M

Looking ForwardLooking Forward• Representative Patrick Kennedy has

announced a White House Conference on Mental Health and Neuroscience.

• We all hope that this will represent anWe all hope that this will represent an outstanding opportunity for behavioral healthcare.healthcare.

What Are Your 2-3 Key Action Vectors?

Questions?Questions?Please press *7 on your phone toPlease press 7 on your phone to

unmute your line.

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Contact InformationContact Information• Leif Jensen

Department of Agricultural Economics and RuralDepartment of Agricultural Economics and Rural Sociology and the Population Research Institute, The Pennsylvania State Universitylij1@psu edulij1@psu.edu

• Ron Manderscheid, Ph.D.Di t M t l H lth d S b t U PDirector, Mental Health and Substance Use Programs, Global Health Sector, SRA Intl., Inc.240-514-2607 (V)

( )240-514-2601 (F)301-787-1414 (C)ronald_manderscheid@sra.com