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Voices Speaking

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
Tags:
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:
Health
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:
Health
Tags:
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. Youth.gov, 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
Tags:
DCF, mental health, trauma
September 25, 2018

What is Public Charge?

Karen Siegel, M.P.H.

“Public charge” is a term used by immigration officials to determine that a person seeking to enter the United States, immigrate, or apply to become a Legal Permanent Resident or “green card” holder is or is likely to be dependent on public services.

To date, this determination has included only cash assistance (such as SSI and TANF) and publicly funded long-term institutional care. On Saturday, the Department of Homeland Security issued a press release and text of proposed changes to the “public charge” rule.

 

It is important to note that these changes are not yet in practice. Before changes can be implemented, the administration must give the public 60 days to comment on the proposed rule, consider those comments, and then wait at least 60 days after posting the final rule before implementing changes.

 

What changes have been proposed?

If undertaken, proposed changes would expand the benefits included in a determination of “public charge” to include:

  • Non-emergency Medicaid (with limited exceptions)
  • The Supplemental Nutrition Assistance Program (SNAP)
  • Housing assistance such as Section 8 housing vouchers
  • Low-income subsidy for prescription drug costs under Medicare part D

The draft also asks whether or not the Children’s Health Insurance Program (CHIP) should be included. Additional details about changes to how the rule is applied and to whom are available here.

 

Who would these changes impact?

These changes would affect individuals seeking a change in immigration status, though it does not apply when “green card” holders apply to become citizens.

The public charge statute requires immigration officials to consider overall circumstances, not just the use of services, in making an immigration status decision.  Finally, these changes would not be retroactive; so, they will only apply to enrollment in the specified services after the final rule takes effect.

In Connecticut, many lawfully present “qualified non-citizens” (see definition here) are eligible for enrollment in the state’s Medicaid and SNAP programs.

 

Who is exempt from a public charge determination?

Some groups—such as refugees, asylees, and other protected groups—are not subject to “public charge.”

Further, the determination will consider use of benefits by the individual applicant – not by family members.

Click here for more details about which groups are exempt and a detailed list of relevant programs.

 

Why do the changes to this rule matter?

The primary cause of concern is that fear of a potential rule change and confusion about what has not been changed will lead to lower rates of enrollment in programs that help families meet their basic needs—including SNAP and Medicaid. This “chilling effect” is already taking place according to some reports.

Should the draft rule take effect, lawfully present immigrants who work in low-paying jobs will be forced to choose between obtaining vital services and their immigration status. Many will likely stop using or fail to enroll in health insurance or nutrition programs for themselves or their families for fear that the rules may change again. Such uncertainty adds to the daily stress of living in an immigrant family in today’s political climate.

In Connecticut, 81,000 citizen children who have at least one non-citizen parent are enrolled in Medicaid or CHIP. Children make up 40% of the national Medicaid population and account for just 19% of Medicaid spending. Yet, the services they receive can have lifelong benefits. Further, when parents are uninsured, eligible children are less likely to be insured or see a doctor. Thus, this rule change jeopardizes the health and wellbeing of thousands of Connecticut’s families.

Providing access to health care and nutritional support for non-citizens is an investment in our state’s future and enables families to continue to work and contribute to the economic and social wellbeing of our state.

 

What can you do?

1.    Prepare to comment on the proposed rule change once it is posted—sign up for alerts here.

2.    Help to correct confusion about what the current rule is and who the changes would affect.

3.    Contact Senator Blumenthal, who serves on the Immigration Subcommittee of the Judiciary Committee, to thank him for his defense of our nation’s tradition of welcoming immigrants.

Issue Area:
Health
September 7, 2018

Connecticut Strives for Primacy of Health Equity in Primary Care

Karen Siegel, M.P.H. and Tekisha Dwan Everette, Ph.D., Executive Director, Health Equity Solutions; Eva Marie Stahl, Ph.D., Project Director, Community Catalyst

Connecticut’s federally funded effort to introduce primary care innovations (through the State Innovation Model or SIM grant) is entering its final years of implementation. In the coming months, the state will present and finalize its proposals (to review and comment on proposals as they are released, see here). Right now is an opportune time to ensure these proposals can transform Connecticut’s health system to promote equity by investing in prevention and addressing social and economic factors that make some in our state far less healthy than others.

As a reminder, many states applied for the federal SIM grant funds to advance health reform. Connecticut has used this funding as an opportunity to explore new models of primary care delivery with a focus on health disparities. Specifically, SIM piloted a primary care health home model that incorporated community health workers into the care team for some patients. As with any pilot or model, there continue to be bumps that need smoothing and culture that needs shifting. The premise, however, is solid: the current system does not do enough to reduce the deep disparities in both individual and population health that reverberate through communities of color. Specifically, the current system does not do enough to connect families with community-based services where they live. 

Commitments to any one payment model can serve as a barrier to improving health outcomes. The fee-for-service approach of the Medicaid payment system is limited in flexibility and for too long some have safeguarded it as the only viable path. This is not an “us” against “them” situation but rather a recognition that, in its current form, fee-for-service is a barrier to scaling up efforts to connect primary care with community-based services in long-term and meaningful ways. With an innovative approach, Connecticut can adapt the state’s health systems to the needs of all of our residents while simultaneously safeguarding access to quality health care and vital services.

As advocates and stakeholders disagree about what payment or delivery system approach will meet the triple aim of lower cost, high quality care while maximizing access – the question is: what do consumers want? What do consumers need? And how do consumers define success? And if the goal is to center on health equity in this work, what systematic and systemic changes are needed? Connecticut’s approach of focusing on primary care to meet these needs is admirable. Primary care is the first touch point for many people when they interact with the health care system and a venue of frequent contact with parents and young children. It is also a space ripe for culture change given the right supports. A whole-family and integrated care approach is, without a doubt, the future of health care delivery and what is needed to advance health equity in Connecticut.

How we get there while ensuring that any system reflects the needs and wants of consumers themselves is less clear. Listening to consumers is hard work; it requires patience, resources and time to build trust. Specifically, it is essential to build trust with communities of color and those communities left out of economic progress; it also demands a long-term commitment from key stakeholders and decision makers. Finally, it requires advocates and stakeholders to be listeners and innovators.

As Connecticut’s decision makers contemplate next steps regarding how to implement some of the learnings from their SIM work over the next six or so months, those advocating for better care and health equity should consider what mechanisms would support needed changes that reflect consumer feedback. Reconsidering the pathways – the “how” – as we forge ahead with advocacy in a financially scarce environment will be important to meeting our goals for health equity and readying the system for more ambitious work around social determinants of health. Let’s get to work together.

 

Tekisha Dwan Everette, PhD*, Executive Director, Health Equity Solutions and Karen Siegel, M.P.H., Health Policy Fellow, Connecticut Voices for Children contributed to this blog as guest bloggers.
*Dr. Everette is a subcontractor with the Consumer Advisory Board but the opinions written here are wholly her own and do not represent any other entities.

Click here to see the original blog post on Community Catalyst's website.

Issue Area:
Health

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