Dr. Gilliam suggests that American’s both admire and fear immigrants and that significant “cognitive toggling”  occurs when many in the public are thinking of the subject.

Frameworks has tested an approach to discussing immigration that we should consider using  in our communities and in our advocacy.  It emphasizes the values of fairness across places, ingenuity and prosperity as the most effective approach when discussing immigration reform and immigrants rights.

Framing is a new tool for many  advocates.  Feedback on Dr. Gilliam’s suggested approach would be helpful as we incorporate new tools in the race equity toolbox.

In issuing the order, Judge Bolton found that that “[t]here is a substantial likelihood that officers will wrongfully arrest legal resident aliens,” The court granted in large part plaintiffs’ request for a preliminary injunction.

SB 1070 was scheduled to take effect on July 29, 2010.  It will do so now without its most controversial provisions.

Specifically, under Judge Bolton’s ruling, police officers will no longer be required to check a person’s immigration status while enforcing other laws.

Immigrants and other residents, moreover, will not be required to carry their “papers” at all times or risk being detained. Bolton’s decision also halts the provision that made it a crime for undocumented workers to solicit, apply for or perform work.

Finally, Judge Bolton enjoined the section of the law authorizing the warrantless arrest of persons where there is probable cause to believe the person has committed a public offense that makes the person removable from the United States.

Although NACCHO’s focus is working with local health departments to combat health inequity, NACCHO provides several resources that can also be used by advocates working on health equity issues.   First, they offer a Health Equity and Social Justice Toolkit.  This toolkit includes a database with information “ranging from social justice theory to public health practice, and includes journal articles, video clips, reports, PowerPoint presentations, book references, action guides, Web sites, and more.”  As part of the Health Equity campaign, they have also offer a seven-part PBS documentary series called “Unnatural Causes … Is Inequality Making Us Sick?” that examines racial and socioeconomic disparities in health.  The documentary series is particularly powerful because it shows us the face of health disparities.  Check out the five-minute trailer for more information.  There is also an incredible wealth of information from experts in the field and their take on health disparities.

Understanding and surfacing implicit bias is a central tool in the Race Equity Project’s toolkit for addressing and challenging racial disparities in institutions used by low-income people.

In this e-newsletter, we present three articles.  The first is advocacy-focused, written by advocates at Legal Services of Northern California.  The next two articles are fact-sheets which break down the impact of the health care reform legislation on impoverished communities of color.  We hope that you will find these articles provocative and inspiring.

Racial Disparities in Specialty Mental Health Services Programs – Stacey Wittorff & Gillian Sonnad, Legal Services of Northern California

What Health Reform Will Do For Women And Families – Raising Women’s Voices

Reducing Racial and Ethnic Health Disparities: Key Health Equity Provisions – Families USA

Do you have an idea for a future e-newsletter? Would you like to share the race-based work that you are doing with others interested in achieving race equity? Drop us an email. We would love to hear from you!

Recent Posts:

• How Poverty Affects the Brain
• Unemployment Continues to Affect Communities of Color Hardest
• Race Plays a Role in Pain Empathy
• Unconscious Bias and the Courts
• Affirmatively Furthering Fair Housing video and articles
• African Americans and the Legal Profession
• When Investors Buy Up the Neighborhood
• Liability for Unconscious Discrimination?
• Healthy City – A Resource for All Californians

1. Introduction

Minority patients in need of mental health services face unique challenges in seeking such services.  In 2001, a Supplement to the Surgeon General’s report was issued which focused directly on racial disparities in mental health treatment.  The main findings of the study were first that, “minorities have less access to, and availability of, mental health services.”  The study also found that “minorities are less likely to receive needed mental health services; minorities in treatment often receive a poorer quality of mental health care, and that minorities are underrepresented in mental health research.”[1] The study also points out that it is far easier to identify the disparities themselves than the reasons or causes for them.[2]

Legal Services of Northern California has identified such disparities in the County mental health program.  The Yolo County Department of Alcohol, Drug, and Mental Health (“County”) administers the Medi-Cal Specialty Mental Health Services program (“Program”) in County.  The Program provides eligible low-income persons with mental health services including assessment, therapy, and rehabilitation. The Program is designed to “reduce mental disability and improve and maintain Program beneficiary functioning consistent with the goals of learning, development, independent living, and enhanced self-sufficiency.”

We will examine here (1) how the Program was administered by the County, (2) how Program beneficiaries of color are underserved and are thus disparately impacted by the Program’s administration, and (3) possible causes of the identified disparities in services.

2. Background

In mid-2007, LSNC obtained information showing a gross disparity in the average dollar value of approved claims for Latinos and Whites, $1800 for each claim for Latinos and $4217 for each claim for Whites.  This disparity is four times larger than the average statewide disparity.

Based on the documents provided to LSNC by the County regarding the claim approval and denial rates by race and ethnicity, LSNC determined that the disparities in Program claim approval and denial rates likely implicated institutional bias in the Program administration.

3. Program Administration

The unit within the County responsible for the authorization of Program services is the Access Coordination Team (“AC”).  The County requires the AC exercise its discretion in approving or denying claims in accordance with the Medical Necessity Checklist tool (“Checklist”).  The Checklist allows the AC to exercise substantial discretion in determining whether a given claim meets the required criteria. For instance, the Checklist requires the AC to determine, among other things, whether a treatment is focused to address the condition diagnosed by the client’s medical practitioner or a treatment will benefit the client by significantly diminishing the condition.  If the AC determines that any of these conditions are not met, the AC must deny the treatment request.

However, the Checklist does not offer guidance on how the AC should apply the Checklist criteria to a given claim. Thus, the criteria may be applied in a subjective fashion.  Additionally, the AC has knowledge of a client’s race and ethnicity when approving or denying a claim as a client must submit demographic information to be eligible for Program services

4. Disparities in Services Provided

The data LSNC reviewed suggested that the County administered the Program in a manner that had a disparate impact on Program beneficiaries of color. In particular, the available data suggested that (1) the dollar value of approved claims is substantially higher for Whites than Latinos and (2) the claim approval rates for Whites was substantially higher than the claim approval rate for various racial and ethnic minority groups. If this data is accurate, Program beneficiaries of color were receiving, as a group, substantially inferior mental health services.

a. Disparities in the Average Dollar Value of Approved Claims for Whites and Latinos

According to the Quality Review, there was a large disparity between the dollar amount of claims approved for Whites and Latinos.[3] In Yolo County, the average dollar amount of claims approved for Whites ($4,217) is more than two times the average dollar amount of claims approved for Latinos ($1,880).  Statewide, the dollar amount of approved claims for Whites ($4,161) is only 16% more than the average dollar amount of claims approved for Latinos ($3,580).

b. Disparities in the Claim Approval Rate for White and Racial and Ethnic Minority Groups

According to the Quality Review, the County’s claim denial rate was more than twice that of the statewide averages.  A sample of claim denial rates by beneficiary rates and ethnicity revealed significant disparities.

Based on the sample, claims of White beneficiaries were approved at a higher rate than claims of Latino, Black, and Filipino beneficiaries. Claims of White beneficiaries were approved at a rate of 98.72%.[4] Claims of Latino beneficiaries were approved at a rate of 96.77%.[5] Claims of Black beneficiaries were approved at a rate of 69.23%.[6] Claims of Filipino beneficiaries were approved at a rate of 66.67%.[7]

5. Possible Sources of the Disparities

Several factors could account for the disparities in the dollar value of approved claims and the Program’s claim approval rate.  Possible causes could include the Program administrative processes, physician bias and cultural competency, as well as cultural stigma that different beneficiary populations attach to reporting mental health issues to physicians.   The County is obligated to select service providers whose practices and training mitigate the detrimental impact of physician bias, poor physician cultural competency, and cultural stigma on the level and quality of care Program beneficiaries receive.

6. Strategies and Potential Remedies

LSNC engaged in dialogue and negotiations with the County on the issue of disparities in the specialty mental health services.  We sent several letters which made extensive recommendations for the County to monitor the appropriate data and techniques to start addressing the disparities and hopefully reduce them.

LSNC also engaged in several attempts to determine if this disparity was directly reflected in the relevant client community.  We multi-lingual targeted outreach and advised people of their rights and how to contact us if they were having trouble receiving mental health services.

7. Recommendations

In dealing with this particular case we were able to learn much about how these disparities can be formed and what programs can do to identify and start to remedy them.  First and foremost, legal services agencies should find out what their local programs are doing, which includes getting the relevant data and looking through it carefully.  If the program does not keep this type of data you should focus on advocacy efforts which will encourage and perhaps motivate them to start keeping such information.  The data necessary to identify the disparities which often occur should be kept for multiple years and be easily accessible to Program staff and advocates.   Advocates should also provide and promote cultural competency training for Program and Provider staff as this is one the biggest areas in which the disparities can be directly addressed.   Finally, advocates should encourage their Programs to hire and retain diverse and multi-lingual staff.

[2] Id.

[3] The Quality Review does not provide the average dollar amount of claims approved by race or ethnicity for groups other than White and Latino. The California Health and Human Services Agency Department of Mental Health (HHSMH) collects and makes publicly available statistical information about how counties administer Medi-Cal specialty mental health service programs. The most recent data available from HHSMH for County administered Medi-Cal specialty mental health services is for fiscal year 2002-2003.  The average expenditure per non-SSA eligible client by race and ethnicity was: White $3,282.30, Hispanic $2744.26, African American $1,951.54, Asian/Pacific Islander $2,180.31, $2,285.73, Other/Unknown $1,717.00.

[4] 77 out of 78 claims submitted by White Program beneficiaries were approved.

[5] 30 out of 31 claims submitted by Latino Program beneficiaries were approved.

[6] 9 out of 13 claims submitted by Black Program beneficiaries were approved.

[7] 2 out of 3 claims submitted by Filipino Program beneficiaries were approved.

* Stacey Wittorff is a staff attorney at Legal Services of Northern California and works at the Health Rights Hotline.  Gillian Sonnad is a staff attorney at Legal Services of Northern California and works at the Yolo County field office.

By Raising Women’s Voices

This fact sheet lists major provisions included in the Senate health reform bill and accompanying reconciliation legislation now slated for a vote in Congress. Updated March 19, 2010.

What women and families will get right away (in 2010, within six months of enactment)

• Insurance companies will be prohibited from canceling our policies if we get sick.
• Insurance companies will no longer be able to set lifetime limits or “unreasonable” annual limits on the amount of medical care they will cover under our existing policies.
• We will be able to keep our dependent children on our family policies until their 26th birthdays, unless they get coverage through their employers.
• People on Medicare Part D whose prescription drug expenses are high enough to put them into the non-reimbursed “donut hole” this year will be eligible for a $250 rebate this year. (The donut hole will be closed completely over time.)
• All new insurance plans will be required to cover preventive health care and screenings (such as pap smears and mammograms) without charging co-payments to the patients.
• Small businesses and non-profits (25 or fewer workers) with low-wage workers (under $50,000) will be eligible for tax credits to help them buy health coverage for employees.
• Children with pre-existing conditions cannot be denied coverage.
• Adults with pre-existing conditions will have new, more affordable coverage options through a “high-risk” pool to be established within 90 days of enactment of the bill.
• Early retirees will be able to get more affordable health coverage until they are old enough to qualify for Medicare. This will be done through creation of a “reinsurance pool.”
• People shopping for health insurance coverage will be able to better compare plans and their costs because of a requirement for standard policy documents and establishment of a website identifying coverage options in each state.

What we will get next year (2011)

• People on Medicare will each get a free annual wellness visit and will no longer have copays for preventive care.
• Insurance companies will have to begin reporting how much of our premiums they are using on medical care and then provide rebates to us if they are spending too much of our money on executive salaries and advertising or are just taking the money out in profits.

What we will get after that (2012 though 2014)
Between now and 2014, federal and state governments will be working with health insurance companies to create major improvements that will go into effect in 2014, including:

Coverage Options:

• An estimated 16 million more people will qualify for Medicaid coverage, when income eligibility is increased to 133% of the federal poverty limit ($29,327 for a family of four).

• Increases in payments to doctors who take Medicaid will make it easier for those on Medicaid to get treatment.

• Uninsured individuals and families who don’t qualify for Medicaid because they earn too much can shop for coverage in new insurance “exchanges” that will be set up. Plans will be available at four different price and coverage levels. People with incomes up to 400% of the federal poverty limit ($88,400 for a family of four) will be able to get federal subsidies to help them afford coverage.

• Small businesses with up to 100 workers will also be able to shop in the new insurance exchanges for affordable coverage for their employees.
  Employers will be encouraged to offer health insurance to their workers, and those who don’t will pay a $2,000 fine for each employee who goes to the insurance exchange and buys their own individual coverage using federal subsidies.
  Anyone who has an insurance policy she/he likes (whether through an employer or individual purchase) can simply keep that plan.

Protections from unfair insurance company practices

• Insurance companies will not be allowed to deny us coverage for pre-existing conditions, such as cancer and diabetes.
• Insurance companies will not be allowed to charge women more than men for the same policy (a practice known as gender rating)
• Insurance companies will be limited to charging older people no more than three times more than young adults.
• There will be an annual cap on the out-of-pocket medical expenses we have to pay.

What would our responsibilities be?

If we do not get insurance we would face a penalty. In 2014, the penalty would be $95 a year or 1 percent of household’s income; in 2015, $325 or 2 percent of income; in 2016, $695 or 2.5 percent of income. There would be exemptions from this requirement for American Indians, people with religious objections to medical care, people who can show a financial hardship and households with very low incomes.

*This article was reproduced with permission by Raising Women’s Voices.  To access the original article, click here.  Raising Women’s Voices is a national initiative working to make sure women’s voices are heard in the health reform debate and women’s concerns are addressed by policymakers developing national and state health reform plans.

Reducing Racial and Ethnic Health Disparities:
Key Health Equity Provisions

By Families USA

Racial and ethnic health disparities continue to plague this nation and our health care system. People of color in the U.S. are more likely to lack health insurance, to receive lower-quality care, to suffer from worse health outcomes, and to die prematurely. The causes of these disparities are broad and complex. They range from societal issues like poverty, racism, and unhealthy environments, to health system factors like lack of health insurance, linguistic or cultural barriers, and limited access to health care facilities.

Health reform presents an opportunity to address fundamental inequities in the health care system and among communities. The newly passed health reform legislation includes a number of provisions that will help reduce racial and ethnic disparities and move us closer to ultimately achieving health equity.

These include:
Increased Access to Coverage
What health reform will do:

• Create a health Exchange in each state to serve as a gateway for individuals and small businesses so that they can easily compare coverage benefits and purchase insurance coverage in the private market;

• Provide individuals and families who participate in the Exchange with financial assistance to ensure that coverage is affordable; and

• Expand Medicaid eligibility to cover more people with low incomes (about $14,404 for an individual and $24,352 for a family of three).

Why these changes are needed:
Lack of health coverage is the biggest barrier to receiving timely and affordable health care services. People of color are more likely to lack coverage, accounting for 54 percent of the uninsured, but making up just 35 percent of the U.S. population. Because communities of color are also more likely to be low-income, Medicaid and the Children’s Health Insurance Program (CHIP) provide an important safety net. For many families, the Exchange will serve as an additional safety net by providing an essential gateway to affordable, quality coverage.

Improved Data Collection
What health reform will do:

• Direct a new Assistant Secretary for Health Information to set standards for collecting data, and coordinate analysis of health disparities with HHS and in collaboration with other departments;

• Ensure that federal health programs collect data (including race, ethnicity, primary language, and health literacy) on applicants and beneficiaries.

Why these changes are needed:

Any effort to reduce disparities must first identify where gaps exist. In our current system, data collection is fragmented; doesn’t always collect information on race, ethnicity, or primary language; and is not readily available to policy makers and the public.

Language Access and Cultural Competence
What health reform will do:

• Develop a uniform explanation and summary of coverage documents that is culturally and linguistically appropriate for all health care plans in the Exchange; and

• Provide grants for training health care providers on culturally appropriate care and services.

Why these changes are needed:

Health insurance alone does not guarantee access to health care services, especially when providers and systems are not equipped to deliver care to patients who might speak another language or have cultural beliefs that contradict Western medicine.

Support for Community Health Centers
What health reform will do:

• Increase funding to community health centers;

• Provide grants for the construction and renovation of community health centers over the next five years; and

• Encourage other entities to collaborate with community health centers to improve prevention and primary care services.

Why these changes are needed:

Community health centers play an important role in the U.S. health care safety net. Typically located in medically underserved areas, community health centers provide culturally and linguistically appropriate care to all residents regardless of insurance status, citizenship status, or ability to pay.

Strengthen the Federal Office of Minority Health
What health reform will do:

• Reauthorize the federal Office of Minority Health and make it report directly to the Secretary of the Department of Health and Human Services;

• Authorize a Deputy Assistant Secretary for Minority Health; and

• Establish specific Offices of Minority Health within the following Department of Health and Human Services agencies: Centers for Disease Control and Prevention, Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration, Agency for Healthcare Research and Quality, Food and Drug Administration, and the Centers for Medicare and Medicaid Services.

Why these changes are needed:
The reauthorization of the federal Office of Minority Health and establishment of additional Offices of Minority Health within other government agencies will play a critical role in monitoring and improving minority health and the quality of health services that minority populations receive. With the passage of health reform legislation, the new offices will obtain more leverage over eliminating disparities.

Workforce Diversity
What health reform will do:

• Create a permanent advisory committee that would—among other responsibilities—monitor the diversity of the health care workforce and provide recommendations to improve it; and

• Increase funding and scholarships for disadvantaged students, providing special consideration to institutions with a track record of training individuals from minority communities.

Why these changes are needed:
While people of color make up more than a third of the U.S. population (and will constitute more than half in a few decades), this diversity is not reflected in our current health care workforce. A diverse workforce is beneficial to communities of color: Providers of color are more likely to work in underserved areas and areas with large racial and ethnic minority populations. But diversity is also essential to improving the overall health care system. Working alongside providers who share the linguistic and cultural background of their patients can sensitize other providers and help them provide better care.

Prevention, Public Health, and the Social Determinants of Health
What health reform will do:

• Establish community transformation grants to promote community-based prevention initiatives aimed at addressing chronic diseases and reducing disparities;

• Develop a national prevention and wellness strategy, including an investment fund that would be set up to promote prevention and public health;

• Provide grants for areas with diverse community representation that seek to work together to address health disparities; and

• Promote health impact assessments as a tool for analyzing the effect of the built environment on health outcomes.

Why these changes are needed:
Where someone lives, works, and plays is central to his or her health and well-being. People of color are more likely to encounter structural barriers to good health: substandard housing, transportation difficulty, low job availability, less access to education, and limited geographic access to fresh, healthy foods and medical providers. Prevention efforts must be designed to improve not only individual health, but community health as well.

Reauthorization of the Indian Health Care Improvement Act (IHCIA)
What health reform will do:

• Set goals for addressing the health needs of Indian country and eliminating health disparities;

• Attract and increase the retention of qualified Indian health care professionals who service the Indian Health Service (IHS) and tribal health programs;

• Allow the IHS to develop and carry out a plan for implementing innovative mechanisms for addressing the backlog of health facility upkeep needs; and

• Revise and update the law to provide for modern methods of health care delivery in the Indian health care system.

Why these changes are needed:
The reauthorization of the federal Office of Minority Health and establishment of additional Offices of Minority Health within other government agencies will play a critical role in monitoring and improving minority health and the quality of health services that minority populations receive. With the passage of health reform legislation, the new offices will obtain more leverage over eliminating disparities.

The Bottom Line
The passage of health care reform legislation is a historic and significant achievement that will move us closer toward health equity. In addition to covering millions more people, reducing costs, and improving quality, health reform addresses widespread inequities that fuel racial and ethnic health disparities. But our work is not done and the road ahead will not be easy. We must ensure that communities are able to benefit from the new law and that we continue to build upon this critical foundation to advance health equity. More importantly, we must ensure that we do not lose the gains we have made so far—they are worth fighting for.

*This article is reproduced with permission from Families USA.  The original article is available here. Since 1982, Families USA has worked to promote high-quality, affordable health care for all Americans.

• About the REP – this link gives some background on how and why we started the REP at LSNC
• REP Cases and Advocacy – this link gives summaries of some REP casework and advocacy efforts over the last several years
• e-Newsletter Archives – by clicking here, you can access our past e-Newsletter issues, listed by topic

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