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Voices Speaking

January 15, 2019

Healthcare in 2019 - What to Expect

Karen Siegel, M.P.H.

Health insurance coverage rates are slipping

Connecticut’s HUSKY (Medicaid and CHIP) programs are key to our state’s health and economic success. Medicaid coverage has an enormous impact: it reduces poverty, provides lifelong benefits for children, and helps to reduce infant mortality rates. Children are more likely to have insurance and to see a doctor when their parents are insured; so, covering whole families is especially important. Being insured means parents with chronic conditions can stay healthy enough to work and parent well. It also means freedom from exposure to catastrophic medical debt for families and less uncompensated care for hospitals and clinics. Further, Connecticut’s HUSKY program is fiscally efficient, boasting the lowest per member per month Medicaid costs nationwide.

HUSKY expansion helped raise the rate of Connecticut residents who have health insurance to one of the highest in the nation. Yet, recently released 2017 American Community Survey data suggests that while insurance coverage rates in the nation continue to improve, in Connecticut they are at best stable and likely decreased by roughly 20,000 individuals from 2016 to 2017.

Since 2015, the legislature has twice voted to cut Medicaid income eligibility levels for parents/caregivers. We cannot afford to balance the state budget by putting families at risk of preventable disease and economic instability.

Health insurance quality at risk

Having health insurance helps people access care, but being insured alone is not enough. For Connecticut’s families to avoid preventable illness or complications, health insurance must pay for services that families need to stay healthy. Proposals at the state and federal levels threaten to erode what it means to have health insurance coverage. These include allowing short-term and “junk” insurance plans, consolidation of providers through hospital mergers and the Aetna/CVS merger—which could limit access and increase costs, and efforts to trim the state budget by covering fewer benefits for Medicaid enrollees. 

When parents have to choose between paying out of pocket towards a high deductible or paying a utility bill, they are likely to forgo or put off treatment. Inexpensive measures that could prevent a crisis—like a vaccination or a checkup—keep health care costs down.

Recent attempts to trim the Medicaid budget have targeted dental coverage and primary care provider rates. When Connecticut raised Medicaid reimbursement rates for primary care, provider participation increased, meaning more Medicaid patients were able to make appointments for routine care. Given the state fiscal crisis, Medicaid is likely to be targeted again. Additional cuts will cause real harm to real families.

Connecticut should join nearby states by adopting paid family and medical leave

Paid parental leave leads to a host of positive life outcomes for both parents and children, including decreased infant mortality, decreased child behavioral problems, decreased rates of maternal post-partum depression, and increased rates of father involvement throughout childhood. Children begin building vital brain architecture from the time they are born. By giving parents time to develop secure attachments with their new child, family and medical leave plays an important role in nurturing healthy child development for biological and adoptive parents.

Often, workers lacking paid family and medical leave hold low-income and/or multiple part-time jobs, and so cannot afford to take time off. Workers who take time off with no pay or reduced pay report borrowing money, enrolling in public assistance, putting off paying bills, and cutting their leave short. Family medical leave strengthens families’ economic stability and alleviates stress by allowing parents to care for their children without financial hardship.

Further, paid family medical leave is a smart way to improve Connecticut’s workforce. Access to paid family medical leave results in workers taking better care of their health, taking fewer risks, taking fewer and shorter sick leaves throughout the course of their careers, and having less inpatient care. Further, leave is paid for by employees, as detailed in the plan Connecticut has come close to adopting.

Opportunities to promote healthy, stable, and safe communities

Racial and ethnic disparities in health cannot be addressed in the clinic or hospital alone. To promote health equity, it is necessary to enhance community-based services and connect people to what they need in the places where they live, play, study, and work. For example, by connecting the parent of a child with chronic asthma to resources that can remove mold or offer pest-control for the family home, emergency room visits can be decreased while the family’s wellbeing increases. Community health workers can help bridge the gap between doctors’ visits and life at home, helping to identify non-medical causes of health issues and find resources to address these. Community health workers can also help empower families to play a bigger role in their care or help families to incorporate lifestyle changes in response to a diagnosis or addiction.

Opportunities to promote these strategies and to link communities to medical providers and vice versa include soon to be released proposals by the Office of the State Health Innovation Model, the recently announced federal Integrated Care for Kids grant and recently passed federal funding to address opioid addiction.

Opportunities to promote lifelong mental health starting at birth

In the first thousand days of life, children’s brains develop rapidly, making this period an especially important one for promoting health and preventing illness. Identifying and addressing children’s and families’ needs early on can prevent a lifetime of struggling to learn or coping with mental health challenges. Whole-family approaches can support children in developing resilience and other protective factors while supporting caregivers to respond to challenges in productive ways.

Opportunities to access additional federal funding mentioned above and through the Families First Prevention Services Act could also be used to bolster our state’s behavioral health system, especially for young children. Connecticut is poised to take advantage of these resources and to leverage the State Health Innovation Model to promote positive outcomes for children by improving the links between pediatricians’ offices and the state’s home visiting and community-based early childhood efforts.  Connecticut is the birthplace of robust, best-practice initiatives like Help Me Grow and Birth to Three and home to an array of home-visiting and screening programs, but these programs remain underfunded and links between programs, schools, and medical care providers could be improved.   

Issue Area:
health, Healthcare, HUSKY, insurance
December 19, 2018

Updates: Farm Bill Passes and Legal decision on the Affordable Care Act to be Appealed

Karen Siegel, M.P.H.

It was a busy week in national health news. First, the long-stalled Farm Bill, which includes SNAP (Supplemental Nutrition Assistance Program, formerly Food Stamps), passed both houses of Congress. The final bill is a bipartisan compromise that preserves SNAP without imposing the draconian cuts included in earlier drafts.  This means that Connecticut families can continue to count on SNAP to put food on the table in lean times.

On the day the President is expected to sign the Farm Bill into law, the USDA announced a proposed rule to restrict states’ ability to provide SNAP benefits to adults without dependent children living in high-unemployment areas. This rule, which would affect roughly 39,000 Connecticut residents, will be posted for public comment in the near future.

Also last week, a judge in Texas declared the Affordable Care Act (ACA) unconstitutional. The ruling found that without the tax penalty for failing to purchase health insurance, which ends this year, the entirety of the Affordable Care Act cannot stand. Legal experts have responded by calling the ruling unsound. Should this ruling eventually take effect, it would abolish Medicaid expansion (HUSKY D in Connecticut), health insurance subsidies, and consumer protections, affecting hundreds of thousands of Connecticut residents.  The good news:  For now, nothing changes while the decision works its way through the appeals process. Individuals who are uninsured can still sign up for health coverage through Connecticut’s health insurance exchange, Access Health CT, through January 15. Many qualify for subsidies through the exchange. Residents may sign up for HUSKY throughout the year. 

Issue Area:
ACA, farm bill, food stamps, health, SNAP
November 28, 2018

How State and Local Fiscal Policies Impact Racial Equity

The Center for Budget and Policy Priorities has released a new report about how state and local fiscal policies impact racial equity and makes recommendations to overcome longstanding inequities. Michael Leachman, Senior Director of State Fiscal Research, in a blog post, explains:

“States and localities can do more to help undo the harmful legacies of racism and the damage of continuing racial bias and discrimination, a major new Center report finds. If state policymakers can design their budget and tax policies to better address these harms and create more opportunities for people of color, state economies would be more equitable and likely stronger, which in turn could benefit many state residents of all backgrounds.

States and local governments account for nearly half of all domestic public-sector spending, and most of the funding for education and certain other investments important for economic growth. As such, how states and localities raise and spend revenue, including what services they finance, has major implications for racial and ethnic equity. Yet, while people of color have made progress in many areas in recent decades, state and local fiscal policies too often haven’t contributed to that progress and, instead, have extended or cemented racial disparities in power and wealth.”

(Continue reading here).

The report highlights a number of ways that states, including Connecticut, can mitigate racial inequities, such as expanding tax credits for low-income families, ensuring sufficient funding for public schools, and improving the budget rules that artificially restrict the ability of policymakers to fund critical services for children and families.   

Connecticut took an important step in improving racial equity with the passage of  S.B. 256 this year.  Under this new law, legislators may request a racial and ethnic impact statement of any proposed legislation, recognizing the need to evaluate bills through a racial equity lens. 

Issue Area:
Budget and Tax
budget, disparities, income tax, property tax, taxes
November 19, 2018

Public Charge: Submit your comments today

Karen Siegel, M.P.H.

We have written before about proposed changes to the public charge determination used when individuals seek a change in their immigration status.

Connecticut Voices for Children recently prepared these comments for the Federal Register. To make the comment writing simpler for partners, we also created this template. Submit your comments here by December 10. Please share your story or experience before the December 10 deadline.

For more information on public charge, please see this FAQ sheet from Greater Hartford Legal Aid in English and Spanish, and our previous blog posts here and here.  


Issue Area:
October 17, 2018

Public Charge Open for Comments: Rule change would discourage non-citizens from using social services

Karen Siegel, M.P.H.

A few weeks ago, we posted about the “public charge” determination and proposed changes to this rule. The comment period on this rule change began this week and is open until December 10.

Specifically, how would the “public charge” determination change?

The proposed changes would continue to rely on “totality of circumstances” in making immigration decisions. However, they would:

  • Change the threshold from an applicant being “primarily dependent on” to being “likely to receive” a public benefit

  • Expand the list of benefits considered to include Medicaid, SNAP, housing assistance, and more

  • Consider factors such as health, age, and English proficiency

  • Impose a specific income test that makes those earning less than $26,000/per year for a family of three less likely to be approved

These changes include a complex set of rules designed to disqualify immigrants of low to moderate income and favor those with higher incomes (over $52,000/year for a family of 3). The “public charge” determination is considered when a lawfully present immigrant applies for a change in status (for example when applying to change from a student visa to Lawful Permanent Resident status or “green card” holder, or when a “green card” holder leaves the country for more than 180 days and seeks to reenter). See these scenarios explaining when and to whom these rules apply.

The end result will most likely be children and families going without health insurance and other key supports for fear of repercussions, whether or not the rules apply to their circumstances.

How would these changes impact children in Connecticut?

Connecticut’s current laws and rules provide extremely limited access to social services and public health insurance for non-citizens. Nonetheless, there are reports that the rule is already causing confusion, fear, and disenrollment. In Connecticut, an estimated 87,000 children who have at least one non-citizen parent live in families enrolled in a benefit program such as Medicaid (our state’s HUSKY program) or SNAP.  Even though very few of those families would be subject to a public charge determination, the rules are confusing. As a result, the state’s rate of families without insurance or access to adequate nutrition is likely to increase.

Connecticut Voices for Children will submit comments to the federal register and will share our comments here.

Take Action:

Issue Area:
Benefits, immigration, Medicaid, public charge, SNAP
October 16, 2018

Meeting the Complex Needs of Youth in State Residential Facilities

Stephanie Luczak, LMSW and Lauren Ruth, Ph.D.

The needs of youth who have experienced multiple traumas are complex and impact their physical health, education, behavioral health, and family stability. Children who have complex needs easily fall through systemic cracks or experience unmet needs.

On September 26th, 2018, the Connecticut Office of the Child Advocate (OCA) released a report regarding the state-run Psychiatric Residential Treatment Facility at the Albert J. Solnit South Center Campus (Solnit S.). Three months prior, a 16-year-old, known as Destiny, died by suicide in the facility. Destiny was both pregnant and in in the care of the Department of Children and Families (DCF) at the time of her death.

The OCA report and a subsequent legislative informational hearing provided insight into three main systemic issues:

  1. Adolescents, particularly those with a history of trauma and those committed to DCF, have complex mental health needs. The systems that serve these youths must be equipped to adequately serve those needs.

  2.  The assessment and monitoring of residential facilities for youth, including Solnit, must promote increased transparency, timely reporting, public access to these reports, and be an ongoing practice.

  3. There is a need for a legislative oversight council to help facilitate accountability, improve policy and practice, and increase cross-agency coordination to improve outcomes for children and their families.

The OCA report examines a brief timeline of events leading up to Destiny’s death, including Destiny’s historical trauma and presenting mental health needs, and identifies several risk factors that were present at the time of Destiny’s admission to Solnit S. It also provides an in-depth look at the systemic issues that increased youths’ risk of attempting suicide at Solnit, including Destiny, as well as seven other attempts that occurred between November 2017 and July 2018.

The report states that Destiny experienced the trauma of maltreatment during early childhood, after which guardianship was transferred to a relative when she was two years old. Experiencing childhood trauma increases the risk of negative lifetime impacts including suicidal thoughts and behaviors. A 2013 literature review examined several studies that explored the relationship between child maltreatment and adolescent suicidal ideation and attempts. The 2013 article determined that there is a clear link between childhood sexual abuse, physical abuse, emotional abuse, and neglect and suicidal thoughts and behavior (p. 12-13). While the harmful impacts of trauma compound with exposure to new traumas, clinical interventions, increased social support, and positive coping mechanisms can successfully decrease suicidal ideation among adolescents who have been maltreated (p. 22).

Destiny was committed to DCF in October of 2016 when her mental health needs exceeded her caregiver’s capacity. From that date until her commitment to Solnit S. in February of 2018, she moved frequently from place to place including a group home, a foster home, and multiple stays in congregate care (p. 19-20). Separation from caregivers, such as when children enter foster care, is a traumatic experience that has been linked to increased risk for depression and other psychopathologies including suicidal ideation and behaviors., the federal website that promotes effective youth programs and resources, reports that: “children in foster care were almost three times more likely to have considered suicide and almost four times more likely to have attempted suicide than those who have never been in foster care.”

Destiny attempted to end her life in September of 2016, one month prior to entering DCF care. Prior to her admittance to Solnit S., Destiny had expressed suicidal ideation multiple times, as stated in the DCF record (p. 20).

Although the American Foundation for Suicide Prevention lists previous suicide attempts as a risk factor that may increase the chance of future suicidal thoughts or behaviors, upon Destiny’s admission to Solnit S., she was “considered a low risk for suicidal attempts, self-injurious behavior or assaults” (p. 20). This was a clear miscategorization because Destiny’s history of trauma, commitment to DCF, and prior suicide attempts collectively indicate a moderate to high-level risk for suicidal behavior, according to the Columbia Suicide Severity Rating Scale (C-SSRS).

Youth suicide is a devastating tragedy that continues to be the second leading cause of death for young adults ages 15-34, both in Connecticut and nationwide. However, it is also preventable in many cases.

Suicide prevention begins with promoting a process for understanding, screening, and treating suicidal ideation and behavior, made possible through increased education and communication about youth suicide. This includes the use of consistently and regularly administration of the Columbia Suicide Severity Rating Scale (C-SSRS) across state and private agencies, in congruence with the State of Connecticut’s Suicide Prevention Plan 2020 (p. 25). The C-SSRS is a widely-used scale that screens for risk of suicide and is supported by an “unprecedented” amount of research.

The C-SSRS has been widely supported and utilized within the mental health field. However, it is unclear how the scale was administered at Solnit S. Barrins & Associates—the independent consultants hired by DCF to examine the facility. They found that “the regular use of the C-SSRS is relatively new at Solnit South, and staff may not have developed the habits that facilitate its use” (p. 19). The September 20th report from Barrins & Associates goes on to further recommend that Solnit S. should prioritize and measure compliance with the use of the C-SSRS administration and documentation. Additionally, preceding Barrins & Associates reports from September 19th and August 28th, found that “risk assessments completed on admission are sometimes confusing, the form is ineffective in determining level of risk,” (p. 6) and “the policy governing the administration of the C-SSRS is not clear and appears to be internally contradictory” (p. 4).

It is unclear how the C-SSRS is administered at Solnit S., and it is also uncertain how the facility plans for youths’ discharge. DCF Commissioner Katz pointed out during her testimony that while hundreds of cases have been successfully discharged from Solnit S., all youth who are discharged from the facility must have adequate therapeutic, educational, and social supports in place to meet their needs so that they can thrive in the community.

The OCA report provides illuminating evidence that Destiny’s discharge was not carefully planned. The report makes clear that neither mental health services nor a clear educational plan were in place or communicated to the foster placement. (p. 23). This lack of discharge planning can provide for tumultuous placement change, which is a problem that is not unique to the Solnit S. facility. During Connecticut Voices for Children’s 7th Annual Youth at the Capitol Day event, youth currently in foster care in Connecticut discussed several experiences of moves with a lack of planning. When the youth were asked about what would make the placement change process smoother, they unanimously expressed that being given more time and information makes for a smoother and more positive transition.

In addition to the recommendations proposed by both the Office of the Child Advocate and Barrins & Associates, the systemic failures, in this case, provide further support for the need of an independent, legislative oversight council to improve outcomes for children and families in vulnerable situations across the state. The OCA report identifies that although the current DCF State Advisory Council (SAC) requires DCF to report information regarding facilities, including Solnit S., no reports have been made available on the SAC website (p. 11). An independent legislative oversight council would not only increase agency oversight, but it would convene a multidisciplinary group to “monitor, track, and evaluate DCF’s policies and practices,” such as the policy of administering the C-SSRS at Solnit S., or improving the coordination of discharge planning across agencies.

In some cases, like Destiny’s, the inability to identify a need and provide services can result in tragedy. Connecticut must do better in serving children with complex mental health needs and the families who care for them. This can be done by decreasing agency silos and working more collectively to improve how our systems support children with complex needs through an increase in systemic accountability, transparency, and collaboration.

Issue Area:
Child Welfare
DCF, mental health, trauma