Health Care Reform,Behavioral Health,and the Criminal Justice Population

The 2010 Patient Protection and Affordable Care Act (ACA) has a number of important features for individuals who are involved with the criminal justice system. Among the most important changes is the expansion of Medicaid to more adults. The current study estimates that 10% of the total Medicaid expansion could include individuals who have experienced recent incarceration. The ACA also emphasizes the importance of mental health and substance abuse benefits, potentially changing the landscape of behavioral health treatment providers willing to serve criminal justice populations. Finally, it seeks to promote coordinated care delivery. New care delivery and appropriate funding models are needed to address the behavioral health and other chronic conditions experienced by those in criminal justice and to coordinate care within the complex structure of the justice system itself.     

Health Care Reform and Young Adults' Access to Sexual Health Care: An Exploration of Potential Confidentiality Implications of the Affordable Care Act

One provision of the 2010 Affordable Care Act is extension of dependent coverage for young adults aged up to 26 years on their parent’s private insurance plan. This change, meant to increase insurance coverage for young adults, might yield unintended consequences.Confidentiality concerns may be triggered by coverage through parental insurance, particularly regarding sexual health. The existing literature and our original research suggest that actual or perceived limits to confidentiality could influence the decisions of young adults about whether, and where, to seek care for sexual health issues.Further research is needed on the scope and outcomes of these concerns. Possible remedial actions include enhanced policies to protect confidentiality in billing and mechanisms to communicate confidentiality protections to young adults.ON MARCH 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law, effecting the most significant change to the US health care system since the creation of the Medicare and Medicaid programs in 1965.1 All components of the health sector are affected: the legislation includes expansions of public coverage, new subsidies for private coverage, health insurance exchanges, insurance coverage requirements and mandates, and strategies to increase the efficiency of health care delivery and rein in health care costs. Such sweeping reforms bring a host of intended changes and potential unforeseen ramifications. One provision of the ACA expands access to dependent coverage for young adults on their parent’s health insurance up to age 26 years, regardless of marital, employment, or educational status, effective September 2010. Previously, the maximum age varied by state, with eligibility for dependent coverage often linked to factors such as educational enrollment status. The government Web site describes the intended benefits of this provision: “By allowing children to stay on their parent''s plan, the Affordable Care Act makes it easier and more affordable for young adults to get health insurance coverage.”2Young adults aged 19 to 26 years have the highest uninsured rate of any age group in the country; 30% were without coverage in 2009.3 The high rate reflects many contributing factors. Young adults are more likely than other working-aged adults to be unemployed; if working, they are more likely to be newly employed, employed in entry-level jobs, and working in part-time positions without access to employer coverage. Furthermore, most young adults do not meet the traditional categorical eligibility requirements for the Medicaid program—the parent of a child younger than 19 years or an aged or disabled individual—and so young adults, even those with very low incomes, seldom qualify for public coverage. The subsequent low levels of insurance result in limited access to care and high levels of unmet need for care.4By expanding access to health insurance coverage, the ACA addresses two Healthy People 2020 goals5: attaining a higher proportion of individuals with insurance and reducing the proportion of individuals who are unable to obtain or who delay obtaining necessary medical care. This provision of the ACA has already shown significant success in expanding health insurance coverage for young adults. The percentage of young people with health insurance increased by 3.8 points from the first quarter of 2010 to the first quarter of 2011, far outstripping gains in other age groups.6 However, the reliance on expanding dependent coverage to address the high levels of uninsured young adults contains the potential for unintended consequences, because concerns about confidentiality could disrupt access to care.     

Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults

Research Objective

To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent''s private health plan. Nearly one-in-three young adults lacked coverage before the ACA.

Study Design, Methods, and Data

Data from the Current Population Survey 2005–2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws.

Principal Findings

This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law.

Conclusions and Implications

ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.     

The Affordable Care Act: The Value of Systemic Disruption

It is important to recognize the political and policy accomplishments of the Patient Protection and Affordable Care Act (ACA), anticipate its limitations, and use the levers it provides strategically to address the problems it does not resolve.Passage of the ACA broke the political logjam that long stymied national progress toward equitable, quality, universal, affordable health care. It extends coverage for the uninsured who are disproportionately low income and people of color, curbs health insurance abuses, and initiates improvements in the quality of care. However, challenges to affordability and cost control persist.Public health advocates should mobilize for coverage for abortion care and for immigrants, encourage public-sector involvement in negotiating health care prices, and counter disinformation by opponents on the right.It is important to recognize the political and policy accomplishments of the Patient Protection and Affordable Care Act (ACA),1 anticipate its limitations, and use the levers it provides strategically to address the problems it does not resolve. Passage of the ACA was a historic political achievement, breaking the logjam that long stymied national progress toward equitable, quality, universal, affordable health care in the United States. It has survived considerable challenges: a fractious legislative road to adoption in 2009 and 2010, more than 30 votes for repeal in Congress in 2011 and 2012, a Supreme Court case, and the national election of 2012. However, the benefits as well as the limits of this complicated law are poorly understood by the public,2 and opposition will likely persist. In part, this is because major provisions of the law have not yet been fully implemented, in particular the expansions of coverage through health insurance exchanges and Medicaid, although implementation will create other problems. In addition, the ideological and structural barriers to a more functional health care system have been weakened but not eliminated.     

The Affordable Care Act and Emergency Care

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.The Affordable Care Act (ACA) focuses on improving access and quality by expanding insurance coverage, using payment reform strategies, and increasing quality reporting.1 In the ACA, hospital-based emergency departments (EDs) are referenced as places to be avoided and reduced; no new payment models focus on ED care, and there are no plans to broadly address ED-specific quality through new measurement programs.Promoting value in ED care needs to be a greater focus for policymakers as the ACA is implemented. Emergency departments play a central role in health care delivery as the staging area for the ill and injured, and as an always-available resource for unscheduled care. Emergency department physicians constitute less than 5% of the US physician workforce, yet manage 28% of acute care encounters.2 Historically, the need for EDs arose from increases in vehicular trauma that accompanied the expansion of the Interstate Highway System in the 1960s.3 However, EDs also quickly became providers of low acuity unscheduled care as well.4 The Emergency Medical Treatment and Active Labor Act legislation passed in 1986 institutionalized EDs as provider of last resort for all, regardless of their ability to pay. Emergency departments have replaced the community physician’s office as the primary source for hospital admissions and provide a safety net for the uninsured, underinsured, and medically disenfranchised.5,6Several elements of the ACA—the insurance expansion, patient-centered medical homes, accountable care organizations, and bundled payments—will directly affect both demand for ED care and expectations for its role in providing coordinated care. We explore these effects and suggest some practical ways that EDs can be better integrated into these efforts.     

Determinants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act

Objectives. We examined preventive care use by nonelderly adults (aged 18–64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns.Methods. We used data from the 2005–2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income.Results. There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers.Conclusions. Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.The benefits of many preventive health care services are well-established.1 In the case of immunization, for instance, those who receive the recommended services are likely to avoid a variety of life-threatening diseases while promoting herd immunity and protecting individuals who are unable to be immunized.2 Those appropriately screened for cancer are likely to receive more timely diagnosis and treatment, which ultimately leads to better outcomes.3 Furthermore, early detection of heart disease, diabetes, and other chronic conditions can lead to the promotion of healthier lifestyles and better management of the diseases.4 Despite this evidence, many studies have shown the use of preventive services, including cholesterol checks, Papanicolaou (Pap) tests, mammograms, colon cancer screenings, and flu vaccines to be below recommended levels.5–9In recent years, the growing prevalence of obesity and chronic conditions and the evidence that modifiable behaviors are among the leading causes of death have led to a renewed emphasis on promoting health and wellness as opposed to treating disease.10,11 This emphasis on prevention was particularly evident in the national conversation leading up to the passage of the Affordable Care Act (ACA) in March 2010. Increasing access to preventive care was one motivation for expanding coverage to the uninsured, and was the explicit goal of an additional provision in the ACA requiring private insurers to cover recommended preventive services without any cost-sharing obligations to consumers. The effects of these ACA policies on preventive service use will depend on the extent to which preventive services are currently underused and whether expanding coverage will increase the receipt of these services.We examined the receipt of 8 preventive services by nonelderly adults in the years before the ACA (2005–2010), thus providing recent evidence on the extent of underuse of a variety of important services. Previous studies have found that lower rates of service use are generally associated with more limited education, low incomes, and a lack of insurance coverage12–14; we concentrated on the disparities in service use between the lower-income adults most likely to benefit from the ACA coverage expansion and their higher-income counterparts. Using a regression-based decomposition analysis, we identified the roles of insurance coverage, education, and other factors in explaining these income-related disparities. The results provide important insights on the potential of ACA efforts to increase the use of preventive care through coverage expansion as well as on the limitations of such efforts.Our conceptual framework relies on human capital models, which suggest that the demand for medical care is derived from the demand for health.15,16 According to such models, critical factors that are expected to affect the demand for health and medical care include age, health status, education, and rate of time preference. In some cases, the effects of these factors on demand for preventive care may be distinct from their effects on demand for treatment. In the case of age, for example, the demand for treatment, or curative care, is expected to increase with age as an individual’s health depreciates, whereas investment in preventive medical care is expected to decrease with age as the payoff period for avoiding future illness shortens.13,17 This reflects a more general distinction between investment and consumption considerations in the demand for preventive care, which is also relevant with respect to the role of health status. From a consumption perspective, those in poor health are more likely to use preventive services, but healthy individuals and those who are future-oriented are also more likely to invest in health and preventive care.18,19 Lastly, although the effect of education on the demand for health and health care is theoretically ambiguous,15 considerable empirical evidence finds a positive relationship between education and prevention activities.13,20–22Another critical consideration is the influence of insurance coverage on the demand for medical care. The direct effect of insurance is to lower the out-of-pocket cost of medical care and thus increase the demand for services. The RAND health insurance experiment provides the most rigorous evidence that this is the case,23 but many other studies provide empirical evidence that having health insurance is associated with increased utilization of medical care.24–27 The possibility exists, however, that because insurance coverage protects against the financial costs of adverse health events, it may reduce the incentive to invest in preventive care.17 Despite this potential for “ex ante moral hazard,” most empirical evidence finds that those with insurance coverage use more preventive care, including blood pressure screenings, mammograms, and other cancer screenings.28–30 Furthermore, those with more generous coverage and lower cost-sharing exhibit higher rates of preventive service use.31–33The ACA includes several components that expand coverage and reduce cost-sharing and thus have the potential to increase the receipt of recommended preventive care. The ACA includes an optional expansion of Medicaid for those with incomes less than 138% of the federal poverty level (FPL) and federal subsidies to purchase coverage in the new health insurance exchanges for those with incomes up to 400% of the FPL. The law also includes penalties for not having health insurance coverage and enhanced enrollment and outreach efforts. When fully implemented, the ACA is expected to significantly expand coverage, particularly among adults with incomes less than 400% of the FPL.34 Many of those becoming newly insured under the ACA are expected to experience improved access to recommended preventive services, given that these services will be included at no or low cost in exchange plans and under most Medicaid plans.In addition to the broader coverage expansions included in the ACA, the law includes new requirements for private health insurance coverage of a set preventive services rated “A” or “B” by the US Preventive Services Task Force.35 After September 2010, many private health plans were required to cover the specified services, and to do so at no cost to members. Although coverage for some of the ACA-mandated services is already relatively common, other services, such as diet and tobacco counseling, are likely to see expanded coverage under the law.36 Furthermore, with the notable exception of mammograms, few of the mandated services are currently required to be covered by private plans under state laws.37     

Uninsured Veterans Who Will Need to Obtain Insurance Coverage Under the Patient Protection and Affordable Care Act

Objectives. We examined the number and clinical needs of uninsured veterans, including those who will be eligible for the Medicaid expansion and health insurance exchanges in 2014.Methods. We analyzed weighted data for 8710 veterans from the 2010 National Survey of Veterans, classifying it by veterans’ age, income, household size, and insurance status.Results. Of 22 million veterans, about 7%, or more than 1.5 million, were uninsured and will need to obtain coverage by enrolling in US Department of Veterans Affairs (VA) care or the Medicaid expansion or by participating in the health insurance exchanges. Of those uninsured, 55%, or more than 800 000, are likely eligible for the Medicaid expansion if states implement it. Compared with veterans with any health coverage, those who were uninsured were younger and more likely to be single, Black, and low income and to have been deployed to Iraq and Afghanistan.Conclusions. The Patient Protection and Affordable Care Act is likely to have a considerable impact on uninsured veterans, which may have implications for the VA, the Medicaid expansion, and the health insurance exchanges.The Patient Protection and Affordable Care Act (ACA)1 represents one of the most significant overhauls of the US health care system and is expected to affect millions of uninsured people across the country. Military veterans constitute a particularly important segment of the population because of their service to the country, access to US Department of Veterans Affairs (VA) health care, and other special benefits after their service. However, little has been written on the potential impact of the ACA on the health and health care of veterans.2 Although the VA operates an integrated national health care system that offers free or low-cost services to eligible veterans, many veterans are not enrolled in VA health care, and some are ineligible. Enrollment in VA health care satisfies the ACA’s requirement for insurance coverage, but eligibility for VA health care is determined on the basis of a complex system of priorities, mostly based on service-connected disability, income, and age, and it generally requires a military service discharge that is other than dishonorable (i.e., honorable, general).One study estimated that only 13% (3.6 million) of veterans report receiving some or all of their health care at the VA, and the vast majority (> 20 million) receive no health care from the VA.3 Most veterans thus rely on non-VA health care and are covered by various private or other public forms of health insurance, including Medicare and Medicaid. A small, albeit important, minority of veterans have no health insurance coverage. Estimates based on data from 1987 to 2004 showed that 7.7% of veterans were uninsured (including having no VA coverage), which equates to nearly 1.8 million veterans and represents 4.7% of all uninsured US residents.4Lack of health insurance coverage is an important problem because it can hinder access to effective health care, including needed medical visits, preventive care, and other services, and it can ultimately lead to poor health, premature mortality, and high medical costs.5,6 Being uninsured is a growing problem in the United States that the ACA addresses by requiring virtually all legal US residents to have health insurance. The ACA includes various provisions to help US residents, including veterans, accomplish this.One major provision that is optional for states to implement is the expansion of Medicaid coverage to all individuals aged 18 to 65 years with incomes at or below 138% of the federal poverty level. Although not all states will implement this expansion, and the number of participating states is currently unknown, many poor, uninsured adults will be able to obtain Medicaid coverage in states that implement the Medicaid expansion. Uninsured adults who have incomes above the Medicaid expansion limit or who live in states that do not implement the Medicaid expansion will have to purchase health insurance and may participate in the health insurance exchanges.A second major provision of the ACA is the creation of health insurance exchanges in each state whereby individuals may purchase competitive health insurance plans that are eligible for federal subsidies, but those subsidies are only available to those with income above the federal poverty level. Both of these major ACA provisions are planned for implementation in 2014 and will introduce a variety of coverage options for US residents, including veterans.There has been little study of uninsured veterans and no study of the potential impact of the ACA on veterans in general. Moreover, most data that exist on veterans are based on VA data, which only contain information about veterans who use VA health services and do not include information about those who are uninsured or not covered by VA health care. However, 1 population-based study7 has provided some evidence that a substantial number of veterans are uninsured (particularly those younger than 65 years) and that many uninsured veterans are in poor health, often forego needed health care because of costs, and have equal or worse access to health care than other uninsured adults in the general population. As the country moves toward a new era of health care with the ACA and continues to engage in conflicts in the Middle East, the impact of the ACA on the health care of veterans needs to be considered.We used a recent nationally representative survey of veterans to (1) describe the proportion and characteristics of veterans who are currently uninsured because they will likely be required to obtain coverage under the ACA; (2) determine, among those who are uninsured, who will likely be eligible for the Medicaid expansion; and (3) compare the sociodemographic and health characteristics of those who are uninsured and likely eligible for Medicaid expansion (LEME), those who are uninsured and not LEME, and those who currently have health insurance coverage. The results provide information about the number and health characteristics of veterans who will likely be affected by different provisions of the ACA and inform planning efforts for the VA and states that implement the Medicaid expansion and health insurance exchanges.     

Women’s Health and the Affordable Care Act: High Hopes Versus Harsh Realities?

Our population-based survey of 1078 randomly sampled US women, aged 18 to 55 years, sought to characterize their understanding of and attitudes toward the Affordable Care Act (ACA). Most women, especially socially disadvantaged groups, had negative or uncertain attitudes toward the ACA and limited understanding of its health benefits, including its relevance for their own health service coverage and utilization. Our findings are important for continued research, policy, and practice, with implications for whether, when, and how improved coverage will translate to improved access and outcomes for US women.Women’s health clinicians, researchers, and policymakers are hopeful that expanding health care coverage under the Patient Protection and Affordable Care Act (ACA)1 will improve the health of US women. By requiring coverage, increasing access to affordable health plans, incentivizing utilization of high-value services, establishing benefit mandates, and reducing cost sharing, the ACA is expected to improve health outcomes and reduce health disparities for women. Since ACA implementation began, however, it has become clear that the public’s participation in its programs and benefits is compromised by widespread confusion.2–6 Recognizing that the ACA can only have an impact on women’s health (individual and population) if women are aware of available benefits and act upon them,7–9 we conducted a study to examine women’s understanding of and attitudes toward the ACA. Specifically, we sought to determine (1) whether women were aware and approved of the ACA and the women’s health benefits attributable to it, (2) whether women expected their coverage of women’s health services and subsequent service utilization to change as a result of the ACA, and (3) whether women’s awareness and attitudes differed across sociodemographic groups.     

Sharing a Playbook: Integrated Care in Community Health Centers in the United States

Objectives. We investigated basic measures used to assess collaboration between colocated providers and to gauge the extent to which health centers practice integrated care.Methods. We used the Assessment of Behavioral Health Services survey and the 2010 Uniform Data System to explore the elements of integrated care for behavioral health conditions. We used multivariable regression models to examine the correlates of integrated care.Results. More than 85% of health centers provided mental health services in 2010, and almost half offered substance use treatment. Health centers commonly reported shared access to information among behavioral health and medical providers and joint care planning. A higher degree of integrated care involving joint case conferences was less common. Health centers without electronic health records and those with lower percentages of total staff composed of behavioral health workers were less likely to provide integrated care.Conclusions. A 2-pronged strategy involving financial incentives and technical assistance to spread best practices might increase integrated care, particularly among health centers that are not maximizing the potential of electronic health records and health centers with low behavioral health staffing levels.The treatment of behavioral health conditions is a key component of quality care.1 Behavioral health encompasses mental health and substance use disorders as well as health behaviors.2 Improving access to screening and treatment services for mental health and substance use disorders is critical to the success of wider efforts to improve the health care system to pursue the triple aim3 of better health, better care, and lower per-person costs.4,5 However, medical and behavioral health care providers have historically practiced in isolation, with little communication or coordination. The need to better integrate behavioral and medical care is especially pronounced for underserved patients; according to the Institute of Medicine, “[t]he single greatest flaw of the mental health safety net is its nearly total disconnection from the core [general medical] safety net.”6^(p189)Mental health and substance use disorder services are frequently provided in primary care settings; in fact, many patients with behavioral health disorders never receive care in a specialty behavioral health setting.7,8 Community health centers are key portals of access to medical and behavioral health services in underserved communities.9 Community health centers are also called “federally qualified health centers” or “health centers.” We used data from federally qualified health centers that received grant funding in 2010 under Section 330 of the Public Health Services Act through the Bureau of Primary Care at the Health Resources and Services Administration of the US Department of Health and Human Services. Because many health center patients face additional access barriers—40% of health center patients were uninsured in 2010—treatment initiation and engagement might be improved if on-site behavioral health services are available where patients access medical care and links to social services.10 The “warm handoff” to a behavioral health provider can create trust, because colocation with medical services can destigmatize behavioral health treatment. Patients already visit health centers for medical and other types of services, so accessing behavioral health services on-site at the health center is likely to be convenient.11 In addition, colocating primary care and behavioral health services is a strategy to mitigate barriers to accessing care related to cultural beliefs among patients.12Health centers are required to provide mental health and substance use disorder services on-site or by referral. Most health centers have on-site behavioral health specialists, particularly larger health centers, those located in urban areas, in the Northeast and West, in local areas with greater availability of behavioral health specialists, and in states that allow Medicaid same-day billing for medical and behavioral health services.13,14 Health center capacity is expanding under the Affordable Care Act (Patient Protection and Affordable Care Act, Pub L No. 111-148, 124 Stat. 855 [March 2010]) to increase access to care for underserved patients and communities.15 Improving access to behavioral health services at health centers is currently a priority; more than 1 in 3 health centers received funding to expand behavioral health capacity in 2014 of more than $105 million.16Building on the foundation of colocated behavioral health specialists and primary care providers, health centers are exploring how to integrate behavioral health services into primary care.17,18 A commonly used continuum specifies 3 basic levels of orchestration between behavioral health and medical care: coordinated from 2 separate locations, colocated in a shared space, or integrated.10,19 The definition is still evolving, but integrated care is distinguished by colocated, team-based care and, optimally, a shared care plan with both behavioral health and medical elements.10,20–23Integrated care typically refers to providing behavioral health services in the primary care setting, whereas the closely related terms “coordination” and “collaboration” are used to describe shared access to information, communication, and consultation between medical and behavioral health providers, regardless of whether the services are colocated.24,25 We examined the processes used by primary care and behavioral health clinicians in health centers to conduct evidence-based activities to improve integration: colocating medical and behavioral health services, shared access to information in patient records, joint case conferences, and joint care planning.26It is important to note that colocating medical and behavioral health services does not necessarily lead to communication and collaboration; sustained technical assistance might be needed to support providers as they make the necessary changes to cultures, structures, and processes to allow more interdisciplinary communication and collaboration.27,28 Barriers to integrated care include a lack of consensus regarding team members’ roles29,30 and interprofessional conflict stemming from differing cultural norms and mental models of practice.31 The siloed and fragmented reimbursement landscape is another factor, particularly because reimbursement is often fee for service on the basis of the volume of patient encounters; funding streams that cover provider-to-provider communication might be necessary to support integrated care.32^,33Prohibitions on same-day billing for medical and behavioral health services are another roadblock.13,34 Additional financial barriers include staffing costs and health information technology (IT) implementation costs.35 There are many other issues related to health IT, including usability issues of care coordination and registry functions, limited interoperability hindering health information exchange, and additional privacy protections for information on substance use disorders.20,36–39We explored some basic measures that can be used to assess collaboration between colocated providers and to gauge the extent to which a health center is practicing integrated care. We asked 2 main questions. First, to what extent is integrated care occurring for health center patients with behavioral health conditions? Second, which health center characteristics are associated with practicing integrated care? We hypothesized that larger health centers, those with electronic health records (EHRs), and those with higher percentages of total staffing composed of behavioral health specialists might be more likely to provide integrated care.Our study makes a unique contribution to the literature by presenting nationally representative data on the elements of integrated care for patients with behavioral health conditions in health centers. The findings on contextual and health center characteristics associated with practicing integrated care in health centers might guide policies designed to reduce unmet needs for behavioral health treatment services among underserved patients.     

Why employers will continue to provide health insurance: the impact of the Affordable Care Act

The Congressional Budget Office, the Rand Corporation, and the Urban Institute have estimated that the Patient Protection and Affordable Care Act (ACA) will leave employer-sponsored coverage largely intact; in contrast, some economists and benefit consultants argue that the ACA encourages employers to drop coverage, thereby making both their workers and their firms better off (a "win-win" situation). This analysis shows that no such "win-win" situation exists and that employer-sponsored insurance will remain the primary source of coverage for most workers. Analysis of three issues-the terms of the ACA, worker characteristics, and the fundamental economics of competitive markets-supports this conclusion.     

Behavioral Health Care Needs,Detention-Based Care,and Criminal Recidivism at Community Reentry From Juvenile Detention: A Multisite Survival Curve Analysis

Objectives. We examined the provision of behavioral health services to youths detained in Indiana between 2008 and 2012 and the impact of services on recidivism.Method. We obtained information about behavioral health needs, behavioral health treatment received, and recidivism within 12 months after release for 8363 adolescents (aged 12–18 years; 79.4% male). We conducted survival analyses to determine whether behavioral health services significantly affected time to recidivating.Results. Approximately 19.1% of youths had positive mental health screens, and 25.3% of all youths recidivated within 12 months after release. Of youths with positive screens, 29.2% saw a mental health clinician, 16.1% received behavioral health services during detention, and 30.0% received referrals for postdetention services. Survival analyses showed that being male, Black, and younger, and having higher scores on the substance use or irritability subscales of the screen predicted shorter time to recidivism. Receiving a behavior precaution, behavioral health services in detention, or an assessment in the community also predicted shorter time to recidivating.Conclusions. Findings support previous research showing that behavioral health problems are related to recidivism and that Black males are disproportionately rearrested after detention.Detained youths have significant mental health needs, with the majority meeting the diagnostic criteria for a mental health disorder. Specifically, about 60% to 80% of detained youths have at least 1 mental disorder, compared with only 15% to 20% of the general adolescent population.1–4 Practice guidelines highlighting the need for mental health screening, assessment, and treatment have been developed, and juvenile justice mental health screening programs have become increasingly common in the United States.5 However, the role of detention-based mental health care on future outcomes has largely been unexplored.Recidivism is the repetition of criminal behavior and is usually measured as the occurrence or frequency of a rearrest or reincarceration in a specific period. Depending on the base rate of arrest and how recidivism is defined, as many as 40% to 70% of adolescents recidivate within 1 year of release from detention.6,7 Within the detained adolescent population, recidivism rates tend to be higher among boys, racial/ethnic minority youths, youths who are younger at first referral, and youths with a history of early childhood misbehavior or conduct problems.8 Other factors that significantly predict recidivism within 12 to 30 months include prior criminal history, poor academic achievement or attendance, relations with deviant peers, low socioeconomic status, large families, older siblings involved in criminal activity, out-of-home placements, and family instability.7,9Behavioral health problems (i.e., mental health and substance abuse problems) are also associated with recidivism. According to 1 meta-analysis of 23 studies and 15 265 adolescents, mental health disorders (e.g., anxiety, depression) are one of the strongest predictors of juvenile recidivism.10 Substance abuse, trauma and neglect, conduct problems, attention-deficit/hyperactivity disorder, and untreated mental health symptoms have also been shown to increase the risk of recidivism.6,8,11 A recent longitudinal study found that substance use disorders and comorbidity of substance use with mental health disorders were directly associated with an increased likelihood of recidivism.12 However, one study found that behavioral health needs, as measured by a behavioral health screen, failed to significantly predict recidivism among a group of juvenile defendants.8 In a longitudinal study of serious adolescent offenders, when several criminogenic and mental health risk factors were included as predictors, only substance use disorders, and not mental health problems, were consistently associated with negative outcomes.13 Hence, the results of research on the role of behavioral health problems in recidivism is mixed and further research is needed.Behavioral health treatment services are a promising avenue for reducing recidivism.14,15 Multisystemic therapy, functional family therapy, and multidimensional treatment foster care are 3 interventions that target mental illness, maladaptive family dynamics, and behavioral problems. Each has strong empirical support for treating detained youths.16 Specifically, these interventions have produced many positive outcomes, including better self-esteem, reduced psychiatric symptoms, reduced substance use, improved family functioning, decreased association with deviant peers, reduced number of rearrests and severity of charges, and delayed time of rearrest.16,17 It should be noted, however, that reduced recidivism stemming from behavioral health intervention is not a universal finding, and poorly implemented interventions have failed to demonstrate significant drops in recidivism.18Because of the benefits of behavioral health services, providing behavioral health care during and following detention may substantially lower recidivism. Currently, the National Commission on Correctional Health Care guidelines recommend that facilities administer behavioral health screens within 14 days of intake, provide 24-hour emergency behavioral health services, and grant detained youths the right to request behavioral health treatment services daily.19 However, facilities are not required to maintain accreditation with the National Commission on Correctional Health Care, so there is no consistent mechanism for monitoring services, keeping facilities accountable, or providing funding to facilities.20,21 As a result, many juvenile justice facilities with limited resources are unable to meet the established standards for behavioral health care.22,23 In fact, fewer than half of facilities comply with National Commission on Correctional Health Care accreditation standards19 and more than one third of facilities use correctional staff to administer behavioral health assessments and services, despite having little or no background or training in mental health.22Evidence indicates that detained youths have significant behavioral health needs, and interventions that target behavioral health issues have the potential to reduce recidivism. However, few studies have adequately examined the relationship between behavioral health needs, detention-based behavioral health services, and recidivism.24 Accordingly, we examined whether the provision of behavioral health services to youths during detention and referrals for behavioral health services after detention affect recidivism. In particular, we expected that, after controlling for behavioral health needs, the provision of behavioral health services would be related to lower rates of recidivism.     

Under Construction: One State's Approach to Creating Health Homes for Individuals with Serious Mental Illness

Changes to the health care market associated with the Patient Protection and Affordable Care Act (ACA) are creating both need and opportunity for states, health plans, and providers to improve quality, outcomes, and satisfaction through better integration of traditionally separate health care delivery systems. Applications of the term “integrated care” vary widely and include, but are not limited to, the integration of care for Medicare-Medicaid dually enrolled beneficiaries, the integration of mental health and substance abuse (also known as behavioral health), and the integration of mental health and substance abuse with medical care, most commonly primary care. In this article, integrated care refers to well-coordinated physical health and behavioral health care. Medicaid Health Homes are emerging as a promising practice, with sixteen states having adopted the Health Home model through approved State Plan Amendments. This article describes one state''s journey towards establishing Health Homes with a behavioral health focus. We discuss a partnership model between the relevant state organizations, the contracted providers, and the behavioral health managed care organization responsible for many of the supportive administrative functions. We highlight successes and operational challenges and offer recommendations for future Health Home development efforts.     

Necessary Health Care and Basic Needs: Health Insurance Plans and Essential Benefits

According to HealthCare.gov, by improving access to quality health for all Americans, the Affordable Care Act (ACA) will reduce disparities in health insurance coverage. One way this will happen under the provisions of the ACA is by creating a new health insurance marketplace (a health insurance exchange) by 2014 in which “all people will have a choice for quality, affordable health insurance even if a job loss, job switch, move or illness occurs”. This does not mean that everyone will have whatever insurance coverage he or she wants. The provisions of the ACA require that each of the four benefit categories of plans (known as bronze, silver, gold and platinum) provides no less than the benefits available in an “essential health benefits package”. However, without a clear understanding of what criteria must be satisfied for health care to be essential, the ACA’s requirement is much too vague and open to multiple, potentially conflicting interpretations. Indeed, without such understanding, in the rush to provide health insurance coverage to as many people as is economically feasible, we may replace one kind of disparity (lack of health insurance) with another kind of disparity (lack of adequate health insurance). Thus, this paper explores the concept of “essential benefits”, arguing that the “essential health benefits package” in the ACA should be one that optimally satisfies the basic needs of the people covered.     

Reducing Ex-offender Health Disparities through the Affordable Care Act: Fostering Improved Health Care Access and Linkages to Integrated Care

Despite steadily declining incarceration rates overall, racial and ethnic minorities, namely African Americans, Latinos, and American Indians and Alaska Natives, continue to be disproportionately represented in the justice system. Ex-offenders commonly reenter communities with pressing health conditions but encounter obstacles to accessing care and remaining in care. The lack of health insurance coverage and medical treatment emerge as the some of the most reported reentry health needs and may contribute to observed health disparities. Linking ex-offenders to care and services upon release increases the likelihood that they will remain in care and practice successful disease management. The Affordable Care Act (ACA) offers opportunities to address health disparities experienced by the reentry population that places them at risk for negative health outcomes and recidivism. Coordinated efforts to link ex-offenders with these newly available opportunities may result in a trajectory for positive health and overall well-being as they reintegrate into society.     

An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act

The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability.     

Why Uninsured Free Clinic Patients Don’t Apply for Affordable Care Act Health Insurance in a Non-expanding Medicaid State

Even after the introduction of the Patient Protection and Affordable Care Act (ACA), uninsured visits remain high, especially in states that opted out of Medicaid expansion. Since the ACA does not provide universal coverage, free clinics serve as safety nets for the un- or under-insured, and will likely continue serving underserved populations. The purpose of this study is to examine factors influencing intentions to not apply for health insurance via the ACA among uninsured free clinic patients in a state not expanding Medicaid. Uninsured primary care patients utilizing a free clinic (N = 551) completed a self-administered survey in May and June 2015. Difficulty obtaining information, lack of instruction to apply, and cost, are major factors influencing intention not to apply for health insurance through the ACA. US born English speakers, non-US born English speakers, and Spanish speakers reported different kinds of perceived barriers to applying for health insurance through the ACA. Age is an important factor impacting individuals’ intentions not to apply for health insurance through the ACA, as older patients in particular need assistance to obtain relevant information about the ACA and other resources. A number of unchangeable factors limit the free clinics’ ability to promote enrollment of health insurance through the ACA. Yet free clinics could be able to provide some educational programs or the information of resources to patients. In particular, non-US born English speakers, Spanish speakers, and older adults need specific assistance to better understand health insurance options available to them.     

The Role of School Health Centers in Health Care Access and Client Outcomes

Objectives. We describe the impact of school health centers in Alameda County, California, on adolescents'' access to care and their mental and physical health outcomes.Methods. We used a multimethod evaluation of 12 school health centers to track data on clients (n = 7410), services, and provider-reported outcomes; client pre–post surveys (n = 286); and student focus groups (n = 105 participants).Results. School health centers were the most commonly reported source of medical (30%), family planning (63%), and counseling (31%) services for clients. Mental health providers reported significant improvements (P < .05) from baseline to follow-up in clients'' presenting concerns and resiliency factors. Medical providers and clients also reported general improvements in reproductive health, particularly in the use of birth control other than condoms. Student focus group participants noted that school health centers helped improve access to services students might not seek out otherwise, particularly counseling and family planning services. Furthermore, students noted that they liked school health centers because of their confidentiality, free services, convenience, and youth-friendly staff.Conclusions. School health centers increase access to care and improve mental health, resiliency, and contraceptive use.School-based and school-linked health centers (hereafter “school health centers”) represent a model of care that responds to the unique physical and mental health issues of adolescents by offering care in an accessible, youth-friendly environment. Studies have found that access to school health centers increases use of primary care, reduces use of emergency rooms, and results in fewer hospitalizations.^1–3 School health centers also expand access to and quality of care for underserved adolescents; one study found that school health center users were more likely than were traditional outpatient clients to have received primary and preventive care services despite the fact that they were less likely to be insured.⁴ Furthermore, adolescents with alternate forms of health care report high degrees of comfort-seeking care at school health centers.⁵Adolescent mental health outcomes have also improved because of school health centers. Studies have shown a significant decline in depression among students who received school health center mental health services⁶ and a reduced likelihood of suicide ideation among students attending schools with school health centers.⁷ Studies have also documented the positive impact of school health centers on reproductive health outcomes,⁸ including improved contraceptive use.⁹Although research has demonstrated how the school health center model of care can affect health access and outcomes, many studies have been limited by relatively small sample sizes. Collecting uniform outcome data from larger coalitions of school health centers is challenging, given the obstacles of different school districts, community health providers, service structures, and data confidentiality regulations. Our aim was to demonstrate the impact of 12 school health centers on clients'' access to care, satisfaction, and reproductive and mental health outcomes. We incorporated data collection from both client and provider perspectives through a standardized evaluation process that documents services provided, as well as provider assessments of 2 outcome measures that school health centers have been known to affect: reproductive health and mental health.     

Women and Health Reform: How National Health Care Can Enhance Coverage,Affordability, and Access for Women (Examples From Massachusetts)

BackgroundMassachusetts women have the highest rates of health insurance coverage in the nation and women's access to care has improved across all demographic groups. However, important challenges persist. As national health reform implementation moves forward under the Affordable Care Act (ACA), states will likely encounter many of the same women's health challenges experienced in Massachusetts over the past 7 years.MethodsA review of the literature and data analyses comparing health care services access, utilization, and cost, and health outcomes from Massachusetts pre- and post-2006 health care reform identified two key challenges in women's continuity of coverage and affordability.ConclusionThese areas are crucial for state and national policymakers to consider in improving women's health as they work to implement health care reform at the state and federal levels.