Individuals coming through jails and prisons are among the least healthy in the United States.  They often suffer higher rates of chronic and infectious diseases, mental illness, and substance use disorders.  According to national estimates, approximately 14.5% of men and 31% of women in jail have a serious mental illness with 65% having a substance use disorder.¹ Data collected by the International Society of Psychiatric-Mental Health Nurses (2008) reflects that between 50% and 75% of incarcerated or justice-involved youth, have mental health or substance use disorders.  Additionally, about 80% of the jail population has a chronic medical condition that has not been treated prior to incarceration.²  As a result, health care delivered in custody is often the first time (or the most consistent time) that an incarcerated person receives care.

Prison healthcare expenses continue to grow as the inmate population ages, individuals with mental illnesses are sent to jail in lieu of psychiatric hospitals, and barriers to healthcare delivery such as distance, persist. A Pew study found that 44 states spent $6.5 billion on prison health care in 2008.  States can decrease these costs by using their Medicaid programs to assist with the costs of prisoner health.  Legislatures are positioned to reduce the expenses of the criminal justice system and potentially reduce recidivism by working with their state agencies to ensure individuals who are incarcerated have access to resources.

State Solutions for Costly Healthcare Delivery

Under federal law, Medicaid funds cannot be used to pay for routine care for the incarcerated.  However, under the inmate exception,³ Medicaid reimbursement can be issued to cover at least 50% of a hospital stay that is at least 24 hours.  For inmates with long-term illnesses (e.g., cancer, HIV) or who require major surgery, it can be expensive for jails and prisons to deliver care in their facilities.  By treating inmates at hospitals instead of prisons, states can both increase the quality of care and significantly reduce state expenditures.  Mississippi, which began applying for federal reimbursements in 2009, saves about $6 million annually on inmate costs.⁴  Louisiana also saved $2.6 million in 2009 and 2010.⁵  Despite the savings, Mississippi and Louisiana join only 14 other states (Arkansas, California, Connecticut, Colorado, Delaware, Michigan, Nebraska, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Virginia, and Washington), that use the inmate exception.  Lack of participation is due to confusion over the Medicaid rule and lack of knowledge about the exception.  However, all states can take part in these savings, which are sure to be amplified in states where the legislature has expanded Medicaid.^*  State legislatures can work with their Medicaid offices and their departments of correction to ensure resources are there to use the inmate exception.    

Since Medicaid benefits may not be used for regular health care for inmates, several states choose to terminate Medicaid eligibility, which often results in a lapse in health coverage.  Once an inmate is discharged, it can take up to three months for Medicaid offices to determine and grant eligibility.  Suspension of benefits rather than termination, allows states to use Medicaid funds to pay for eligible services.⁶  The Centers for Medicare and Medicaid Services (CMS) have issued guidance letters to states supporting the suspension of Medicaid benefits upon incarceration as opposed to terminating eligibility.  Twelve states (California, Colorado, Florida, Iowa, Maryland, Minnesota, New York, North Carolina, Ohio, Oregon, Texas and Washington) suspend coverage and then reactivate upon release. This step saves states time and money by avoiding duplicative administrative processes and also helps former inmates maintain their treatment for mental illnesses and substance use disorders.  

Medicaid Expansion: Reaching Those Who Need It

Medicaid expansion allows states and counties to take advantage of federal funds by signing up inmates for health insurance, and the anticipated savings from Medicaid enrollment are significant. Colorado and Ohio are enrolling prisoners when they require extended hospital stays.  Ohio spent $225 million in 2010 on prisoner health care alone. Inmates who are eligible to have their extended hospital stays covered by the federal government are expected to save Ohio $18 million per year.⁷  Connecticut, Kentucky, Maryland, Oregon, and Washington State pre-enroll inmates into Medicaid before their release to ensure coverage can start as soon as possible.  Iowa is also developing plans to enroll inmates in its public health insurance program before they are released.  And most notably in Cook County jail in Chicago, Illinois, enrollment has been incorporated into the intake process with over 4,000 applications being completed since January 1, 2014. As more inmates continue their treatments after release, the likelihood of reduced interactions with the criminal justice system rises.  

Bridging the healthcare gap translates into millions of dollars saved by decreasing the number of arrests^† and resources put into criminal justice proceedings.  “Local jurisdictions will have the resources and motivation to connect people to community-based behavioral health services, which can deter people from becoming repeat offenders. This is an excellent opportunity to take advantage of cross-systems collaboration between stakeholders with an overall goal of providing comprehensive, coordinated, community-oriented healthcare in correctional settings” said Mike DuBose, Chief Executive Officer of Community Oriented Correctional Health Services (COCHS), a non-profit organization that works to create partnerships between jails and community health care providers.  

Due to federal law, inmates are prohibited from purchasing private insurance on a health insurance exchange.  However, several states use outside contractors or nonprofit groups to help their departments of correction enroll their inmates in Medicaid, or enroll them in Medicaid on their behalf.  In California, the legislature passed AB 720 last year, which authorizes counties to designate entities to help jail inmates apply for Medicaid, suspends Medicaid benefits upon incarceration, and establishes that incarcerated status does not preclude eligibility determinations.  Legislation that directs agencies to collaborate around registering inmates for health coverage, or increasing funding to departments of correction to augment their enrollment process, provides exiting inmates treatment faster and enables them to tackle pressing issues of reentry such as employment, housing, and reconnecting with family.  The legislature in Vermont passed S. 295, which is part of a pretrial services bill and directs the Agency of Human Services to assist the Department of Corrections in implementing the Affordable Care Act, including Medicaid enrollment for inmates.  

Using Medicaid funds can ease the burden of states trying to maintain a balancing act between delivering health care and preserving their coffers.  Although there are monetary benefits to states using Medicaid funds, access to care holds a significant benefit to those incarcerated once released.  Receiving proper medical and behavioral care for physical and mental illnesses has great potential to reduce costly emergency room visits and harmful episodes. Increased access to healthcare for this population could go a long way towards reducing recidivism and facilitating successful re-entry into the community.  

Resources

• Centers for Medicare and Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.
• Community Oriented Correctional Health Services (COCHS) is a non-profit organization that works to build partnerships between jails and community health care providers. Its goal is to establish medical homes for offenders in their communities. Their objectives include:

• • Supporting changes in public policy and practice that promote access to health preventive and treatment services both in jail and in partner community institutions
  • Ensuring that local health care systems are in place to treat incarcerated populations
  • Improving the ability of jails to connect offenders with health care
  • Developing health care delivery systems that are financially viable and sustainable.

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Steadman, H.J., Osher, F.C., Robbins, P.C., et al. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60(6). National Criminal Justice Association. (February 19, 2014). Beginning the Conversation; The Affordable Care Act, Medicaid Expansion and Your Justice Agency. Webinar Slides, p 13.  Retrieved: http://ncja.org/sites/default/files/documents/Begining-the-Conversation-Webinar-Slides.pdf Gates, A., Artiga, S, and Rudowitz, R. Health Coverage and Care for the Adult Criminal Justice-Involved Population, The Kaiser Commission on Medicaid and the Uninsured, p 4; September 2014. The Pew Charitable Trusts. (May 14, 2014). Managing Prison Health Care Spending. State Health Care Spending Reports. p 18; . Retrieved from: http://www.pewtrusts.org/en/research-and-analysis/reports/2014/05/15/managing-prison-health-care-spending  Ibid.  The Justice Center. (December 2013). Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System. Council of State Governments.  pp 2 – 3.  Goode, E. (March 2014) Little-Known Health Act Fact: Prison Inmates Are Signing Up. The New York Times. Retrieved from: http://www.nytimes.com/2014/03/10/us/little-known-health-act-fact-prison-inmates-are-signing-up.html?_r=0

From left to right, Kathy Jo Hayden, Director of Health Policy, Novartis; Greg Slyfield, U.S. Head, State & External Affairs, Novartis; Sara Johnson Davis, Assistant Director, State & External Affairs, Novartis; NBCSL President, Rep. Joe Armstrong (TN); NHCSL President Eduardo Bhatia (PR); Kathy McBride, Associate Director, State and External Affairs, Novartis; Rick Knapp, Executive Director, State And External Affairs (West) Novartis; Neely Frye, Assistant Director, State & External Affairs, Novartis. With the first round of enrollment completed and the second round underway, the National Black Caucus of State Legislators (NBCSL) in partnership with the National Hispanic Caucus of State Legislators (NHCSL) convened to discuss lessons learned, best practices, and current issues regarding the Affordable Care Act (ACA).  Through the continued support of the Novartis Pharmaceutical Corporation, over 60 legislators gathered to hear presentations from policy experts, health providers, consumer organizations, Congressional members, and the Obama administration on the state of the ACA and what is on the horizon. This year’s symposium was held September 11-13, 2014 in Chicago, Illinois, with the theme: Bridging the Gap: Strengthening Connections Between Health and Health Care.  The Windy City welcomed lawmakers from 33 states including Alabama, Connecticut, Hawaii, Minnesota, and Georgia, as well as Puerto Rico.  

The ACA, President Barack Obama’s signature law, has been touted as one of the greatest achievements of his presidency.  What have been the results thus far?  Has the ACA reached those it intended to reach?  How is it impacting health providers?  Answers to these questions and more were discussed over the two-day symposium where legislators attended panels and policy sessions featuring health providers and experts in their field.  The symposium also featured breakout sessions and a town hall meeting with Health and Human Services (HHS) Region V Director Kathleen Falk.

NBCSL President Joe Armstrong opened the symposium by welcoming both caucuses and acknowledging Novartis for its continued support.  NHCSL President Eduardo Bhatia expressed gratitude for Novartis working to bring both caucuses together for the meeting.  Greg Slyfield, U.S. Head of State and External Affairs, spoke about Novartis’s healthcare reform priorities: transparency in plan offerings, fair appeals processes for unapproved medications in drug formularies, and benefits that do not discriminate against those with chronic diseases.  Serving as moderator for the symposium was Anton Gunn, Founder and President of 937 Strategy Group, LLC.  Mr. Gunn previously worked as the Director of External Affairs in the Office of Intergovernmental and External Affairs (IEA) at the U.S. Department of Health and Human Services (HHS) under Secretary Kathleen Sebelius.  He was also an active member of NBCSL while he served in the South Carolina House of Representatives. 

Opening speaker José Plaza, with Enroll America, gave an overview of the organization’s results in the first round of enrollment.  Enroll America reached out to those living in the 13 most uninsured states, with the majority of uninsured African Americans living in Florida, Georgia, Texas, North Carolina, and New York.  Mr. Plaza noted significant disparities among minorities, stating 15% of African Americans and 32% of Latinos are uninsured.  In order to reach the unenrolled, Enroll America went to community colleges, partnered with Latino organizations, and spoke to the faith-based community.  One barrier to enrollment is the lack of knowledge and information.  In the second round of enrollment, Mr. Plaza said Enroll America would enhance outreach by working with more Spanish-language organizations to provide materials and assistance to those in Latino communities.

The first panel focused on health providers and their challenges.  The panel’s first speaker was Julia Paradise, Associate Director of the Kaiser Commission on Medicaid and the Uninsured at the Kaiser Family Foundation.  She provided a systems overview of what health providers are now navigating (particularly related to Medicaid expansion), changes in provider payment and incentives, and delivery system reform.  Through each of these platforms, the ACA is able to increase the quality of care patients receive and improve health outcomes.  Dr. Blase Polite, a specialty doctor with the University of Chicago Medicine, and Dr. Carolyn Lopez, a family physician, reinforced those points.  Both doctors emphasized the need to connect primary and specialty care in maintaining healthy individuals.  It is futile to provide screenings at no or low-cost in the primary care practitioner’s (PCP) office without being able to offer comparable care with a specialty doctor when the diagnosis of those screenings are illnesses like cancer.  They also spoke about payment models and ensuring that doctors are not only paid for the quality of care they provide but are also fairly compensated for the time they put into treating their patients, which includes lab work and consultations.  Dr. John Jay Shannon, CEO of the Cook County Health & Hospitals System (CCHHS), shared that some hospitals face challenges in workforce diversity and delivering culturally appropriate services.  By partnering with community organizations, hospitals are better able to perform outreach and provide education to those greatest in need.  Congressman Danny Davis greeted the legislators during lunch and applauded their efforts in the states, and expressed continued support to President Obama and the ACA.  

The second panel consisted of a presentation and breakout sessions.  Brian Webb and Joshua Goldberg with the National Association of Insurance Commissioners (NAIC) began with policy considerations and concepts critical to creating a competitive insurance marketplace.  They also helped legislators understand the current insurance climate.  Armed with a series of policy levers such as rate review, standardization of cost sharing, and planned marketing and sales, legislators were broken into groups representing different perspectives (individual consumers, small employers, health providers, and insurance carriers) in which they discussed how each policy lever could be used to benefit each group.  

Policy experts provided insight to their assigned breakout group: Jose Plaza informed the Consumer group, Dr. Carolyn Lopez informed the Health Provider group; Jesse Greenberg with the Small Business Majority served as the session expert for the Small Employer; and Sinéad Madigan with Health Alliance Medical Plans was the session expert for the Insurance Carrier group.  

During dinner, Congresswoman Robin Kelly, a former state legislator, congratulated the caucuses on a successful symposium and for their work in the states.  Jesus Leal, Vice President and Head of the Novartis Critical Care Business Unit, spoke about the importance of screening and specialty care for cardiovascular diseases to end the day’s meetings.

Saturday’s program began with concurrent breakout sessions to facilitate a greater understanding of specific populations impacted by the ACA, and determine how legislators can improve their outcomes.  Dr. Tim McBride of the Brown School, Washington University at St. Louis, led a discussion on how the ACA is working in rural communities and what legislators can do to expand outreach and healthcare delivery.  Chad Brooker, Policy Analyst with Access Health CT, spoke with the legislators about using the best technology options for developing and maintaining their state exchanges.  John Bouman, President of the Sergeant Shriver Center on Poverty Law, spoke with the legislators on how the ACA could enhance the health outcomes of children and youth.  In the second part of the day, HHS Region V Director Kathleen Falk elaborated on the results of the first round of enrollment. She also spoke about lessons learned and how the administration was working to fix glitches and increase outreach.  

The day concluded with a legislative workshop featuring Senator Mattie Hunter of Illinois and Assemblymember Roger Hernandez of California, discussing their work on Medicaid expansion bills in their respective states.  The panel also included Director Julie Hamos of the Illinois Department of Healthcare & Family Services and Dr. Nneka Jones-Tapia, who serves as the First Assistant Director for the Cook County Department of Corrections.  Both practitioners discussed the impact Medicaid expansion had in the communities they serve, including providing continuing care for behavioral health and substance use disorders.    

The ACA is a revolutionary policy that continues to unfold.  This year’s Promoting Healthy Lifestyles Symposium introduced legislators to diverse perspectives from across the country on the ACA’s progress and provided them with solutions to challenges that must be addressed.

The state of young women and girls is evolving and has been for the last few decades.  With a greater push towards higher educational attainment, professional development, and increased civic engagement, young women are poised to take the helm in new arenas.  The increase in Science, Technology, Engineering, and Math (STEM) curricula is giving girls and young women more opportunities to become skilled in careers that have been predominately male.  Those skills can also be parlayed into creating their own businesses developing software and creating tech companies.  Entrepreneurship is surging among girls and young women. 

Businesses operated by women of color, are growing rapidly and will continue to have an impact on our economy.  Young women are also impacting our economy through their civic involvement and their increased participation in the electorate.  Organizations are looking to cultivate leadership among women of color that will influence our nation for the better.  By concentrating on developing new skills for young women and girls of color, private and public stakeholders stand to make incredible changes that can and will revitalize communities.  Legislators can facilitate these changes by creating initiatives to build environments supporting the development of these and other skills that will improve the lives of girls and young women.

Ready, Set, Code!

In the race towards technological advancement, girls and women are often left behind.  While girls tend to outpace their male counterparts in reading and writing, they are still playing catch up in science and math.  Through targeted curricula and programs, more girls of color have an opportunity to close that gap.  The Obama administration has recognized a need to include more young women in STEM professions and has worked with different agencies, such as the Department of Energy, to create mentoring programs.  Several nonprofits have also recognized this need and are dedicating their efforts to providing mentorship and education to girls.  

Black Girls Code is a national nonprofit dedicated to developing coding skills in girls of color.  Its mission is “to increase the number of women of color in the digital space by empowering girls of color ages 7 to 17 to become innovators in STEM fields, leaders in their communities, and builders of their own futures through exposure to computer science and technology.” Through their programs and events, girls can become competitive players in their future occupations.  Girls learn how to build web pages, create mobile apps, and several other tenets of computer programming.  Another initiative that focuses on bringing girls and young women into science and engineering fields is the Imagine Engineering program through the Girls Scouts of America.  Imagine Engineering provides girls, aged 13-17 years old, with information on different engineering disciplines and ways to connect with professionals through other national organizations such as the National Society of Black Engineers.  Nurturing an interest in engineering and math is another way to prepare girls to be competitive players in the future workforce. 

Increased policy action on STEM education can impact the lives of girls by giving them more opportunities to get involved.  One way to increase STEM education in the classroom is to create incentives for STEM teachers to teach in underserved communities, such as Florida’s Critical Teacher Shortage Forgivable Loan Program, which provides individuals loan forgiveness to teach in critical teacher shortage areas.  Another way to improve STEM education standards is to provide classrooms with the technology needed to enhance learning.  The National Black Caucus of State Legislators has traditionally supported the E-rate program and increased broadband internet access in schools.  Additionally, legislators can increase STEM involvement by forming public-private partnerships geared toward providing youth with the skills employers seek.  Oregon and Maryland have both formed councils of education officials and private businesses working together to develop curricula that strengthen STEM courses and improve student STEM skills.  By bringing attention to the educational gap, organizations and legislators can be effective in increasing minority female participation in the STEM field. 

Winning the Purse

Women of color have been a growing population in the entrepreneur community.  Specifically, Black women are both the fastest growing group in the women-owned business population and the largest share of female business owners among women of color.¹  Black women are starting businesses at a rate six times the national average, and their 2.7 million firms are currently generating $226.8 billion in annual revenue and employing almost 1.4 million people.²  Entrepreneurship programs geared towards youth are giving communities of color a head start in building businesses and attaining wealth.  The Small Business Administration hosts an online course that teaches young people the fundamentals of starting their own business and how to run it successfully.  

The Network for Teaching Entrepreneurship is another organization dedicated to teaching youth from low-income neighborhoods business skills through classroom applications and summer camps.  Youth entrepreneurship not only teaches valuable skills, but it can also help decrease youth unemployment.  Encouraging entrepreneurship education in the classroom is one way legislators can increase the number of young people, especially girls, developing businesses that can help their local communities.  Using input from private businesses, Indiana and other states have developed entrepreneurship curricula for middle and high schools students.  These curricula can be taught alone or incorporated into existing school materials.   

Support for female entrepreneurs can also increase the number of successful female minority-owned businesses.  Walker’s Legacy is a national organization dedicated to developing leadership, networking skills, and providing learning opportunities for women of color.  Through Walker’s Legacy, women find mutual support and exchange ideas.  In a world where women of color are the fastest growing population, it is imperative that they find equal access to opportunities.  Minority and women- owned business enterprises (MWBEs) often face difficulties in bidding for contracts.  Legislators can pass legislation that will encourage business owners to use MWBEs by providing them with incentives.  They can also pass legislation similar to SB 6667 in the state of Washington, which creates action plans with entrepreneurs to increase capital.

“Women Belong in the House….and the Senate” 

Young Black women are finding their voice, and the voting booth serves as one of their most powerful echo chambers.  In the 2012 election, Black women represented nearly 60% of Black voters.  Despite their presence at the polls, there remains a dearth of women of color in elected positions.  Of the 100 members of the United States Senate, only 20 of them are women; additionally there are 79 representatives in the House and three serving as delegates.³  At the state level, women of color make up 21 percent of the 1,789 women serving in state legislatures, with Black women totaling only 241 state legislators out of over 7,300.⁴  With such low numbers, organizations such as the Political Institute for Women and its Girls in Politics Initiative are working to introduce girls and young women to the political world at an early age. 

Girls in Politics reaches girls aged 7 to 17 years old through their Camp Congress for Girls and their Camp United Nations for Girls.  At Camp Congress for Girls, a year-round multi-city program, girls learn about the branches of government and how to operate in Congress.  Girls also learn how to create their own political campaigns, run for office, vote, and convene a session of Congress.  The program ends with the camp President signing a bill into law the girls have developed.  The Camp United Nations for Girls focuses on the world of international politics and allows the girls to work as UN delegates.  As a part of this program, the girls learn about the United Nations and its bodies and research their assigned countries.  They then call a General Assembly, draft a resolution and vote to adopt.  Between both camps, girls learn more about the political sphere and learn to become more aware of the world around them. 

Engaging girls and young women in politics is not out of reach for legislators.  Opportunities include working with school boards to strengthen civics and government education, sponsoring days at state capitols, and supporting organizations that have programs geared toward civic engagement. Involving girls in politics at an early age can ensure their participation when they get older.  In states such as Tennessee and Virginia, legislators are calling on school boards to incorporate civics education into their instruction for middle and high school students.  Civics education that discusses the branches of government, obligations of state, federal and local government, and includes the importance of citizen involvement, not only informs students but can encourage future participation in government.   

By developing and nurturing political interests, young girls can now turn that interest and passion into action by reaching out to groups like Higher Heights for America and She Should Run.  These organizations are cultivating Black women and other women of color for service in elected positions.  Candidates of color often face challenges in mounting successful campaigns.  Sometimes due to a lack of know-how or a lack of funds, female candidates find themselves lost in the political shuffle.  In their report, The Status of Black Women in Politics, Higher Heights notes that Black female candidates are less encouraged to run, often raise less money than their male counterparts, and suffer negative media portrayals.  Through programs pushed by these groups, women of color can find encouragement and support that will have a lasting impact on their political pursuits.

Girls and young women of color are embarking on new roads and looking for support from all sides.  Their growth and development in unchartered areas relies on an open and encouraging community.  Elected officials are a part of that encouraging community and can continue with the work they have done in addition to partnering with private entities.  Through these collaborations, these girls and young women of color will attain the necessary skills to become successful members of their hometowns and may impact the nation as a whole.

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Ahmad, Farrah Z., How Women of Color Are Driving Entrepreneurship, Center for American Progress, pg. 2, June 10, 2014. Ibid. “Women in the U.S. Congress in 2014,” Center for American Women in Politics, Eagleton Institute for Politics, Rutgers, The State University of New Jersey. “Women of Color in Elective Office in 2014,” Center for American Women in Politics, Eagleton Institute for Politics, Rutgers, The State University of New Jersey.

NBCSL members gather around Mr. Nate Miles of Eli Lilly to discuss breaking through depression in the African-American community.On October 10 - 11, 2013, the National Black Caucus of State Legislators (NBCSL) hosted its 20^th Annual Black America’s Dialogue on Health symposium in Indianapolis, Indiana.  Through the continued support of Eli Lilly and Company, NBCSL has remained proactive in the quest for proper health education in the African-American and minority populations.  This year’s theme was Breaking Through Depression: What Is It, What It Looks Like, What to Do About It.  The symposium featured health professionals, speakers from the faith community, and insurance providers who presented attendees with legislative solutions and information on depression in the African-American community.

The opening speaker, Dr. Shelvy Haywood Keglar, President of Midwest Psychological Center, Inc., detailed ways legislators could use the Affordable Care Act (ACA) to create more access to behavioral health screenings and treatment for their constitutents.  With the implementation of the ACA, behavioral health services are a part of the Essential Health Benefits (EHB) that must be included in marketplace plans.  Moreover, for states that have opted to expand Medicaid, this will mean an increase in coverage to include behavioral health services for the previously uninsured or underinsured.

The symposium was moderated by Oklahoma State Senator Constance Johnson, Chair of NBCSL’s Health and Human Services Policy Committee.  Senator Johnson highlighted NBCSL’s commitment to the ACA and discussed how increased access to mental health treatment will help numerous individuals who may be struggling with depression and unable to find ways to cope. 

In the first session titled Cultural Connections to Depression: Risk Factors for Depression and Major Causes, Dr. Jeff Gardere detailed different forms of depression, such as postpartum and manic depressive illness emanating from bipolar disorder.  “African Americans, especially African-American women, are at great risk for depression but seldom reach out for treatment,” said Dr. Gardere.  Cultural risk factors such as discrimination, unemployment, and poverty put the African-American community as whole at greater risk for depression and chronic mental illness.   Dr. Gardere rounded out his presentation by stating that African-American culture is an overall source of strength. Dr. Gardere stated, “We have survived slavery, we have survived discrimination, we have survived poverty, and so I think a lot of these things make us much, much stronger in dealing with mental health issues.”

The second panel, Manifestations, Proper Diagnosis, and Treatment Options, featured three mental health professionals.  Dr.  Keglar, who served as the conference opening speaker, spoke about the importance of proper diagnosis and treatment.  Dr. Keglar noted that while depression can occur without regard to race or ethnicity, more prevalent factors in the African-American community can trigger depression, like alcoholism or substance abuse in the absence of access to affordable medicines and therapy.  Ms. NaKaisha Tolbert-Banks, Director of Education and Public Affairs for Mental Health America of Greater Indianapolis, spoke on the increase in suicide in young African-American males and how stressors, such as “re-entry” after incarceration and its challenges, can create feelings of desperation. Ms. Tolbert-Banks also talked about the stigma of depression and mental illness in the African-American community and how it can prevent people from asking questions and seeking treatment.  She promoted mental health awareness as a way to decrease the stigma and normalize conversations about mental health.

The third panelist was Ms. Aja Casey, who works as a community mental health therapist and sits on the Board of Directors for the National Alliance on Mental Illness Indianapolis.  As a therapist primarily working with children, Ms. Casey noted that depression can manifest itself differently in children than in adults.  Children suffering from depression may be withdrawn, act out, or engage in troublesome or dangerous behavior.  Ms. Casey reiterated Dr. Keglar’s earlier point about the importance of proper diagnosis.  Misdiagnosing a child can have an even more lasting impact than on an adult. Ms. Casey also pointed out that crisis intervention training is one way that health professionals are providing help to those with mental health issues. 

Crisis intervention training is emergency care aimed at helping individuals in crisis with the goal of returning them to a level state and minimizing the likelihood of physical trauma. Training police officers to use crisis intervention can decrease incidents of arrest, force, and even deadly force for unwieldy behavior that may stem from depression or other mental illnesses.  Family therapy is another solution that can help children and young adults with depression.  By engaging the entire family, children may feel less isolated and open to talking about their depression.

Luncheon keynote speaker, singer/actress Ms. Jennifer Holliday, detailed her battle with depression while living in the limelight. Ms. Holliday recounted a time where she felt lost in her depression because of how isolating it felt, stating, “A lot of times, I used to think I was the only one in the world who suffered from depression.  I used to think that I was obviously so weak that I couldn’t shake this depression.”  After a suicide attempt at age 30, Ms. Holliday dedicated herself to finding treatment and being open about her battle with the disease.  Using psychotherapy, medication, and support from the faith community, Ms. Holliday was able to overcome the darkness of her depression and, in turn, help others be open about their struggles. Ms. Holliday performed three songs following her speech.

The final panel, Solutions for Individuals, Faith-Based Communities, and Policymakers, was moderated by Illinois State Representative Ken Dunkin. Rep. Dunkin spoke about legislation he cosponsored to provide funding for the expansion of community mental health centers.  Focusing on the theme of using legislative solutions to address mental illness, panelists offered several ideas. Ms. Nancy Jewell, President and CEO of the Indiana Minority Health Coalition, talked about how a communication gap between patients and doctors can cause their illnesses to go unrecognized or untreated.  Cultural competency, a topic discussed in several NBCSL Black America’s Dialogue on Health symposia, is an important component in receiving treatment.  Ms. Jewell also talked about how a lack of resources can keep mental illness from being recognized and diagnosed.  She stressed not only the importance of Essential Health Benefits plans including behavioral health coverage but also making sure there are doctors in the areas that people need them.  

Dr. Caroline Carney Doebbling, Chief Medical Officer of MDWise, Inc. spoke from an insurance provider’s perspective.  Medicaid expansion, Dr. Carney Doebbling mentioned, would open the door to coverage and treatment for several individuals.  She also echoed Ms. Jewell’s comments about cultural competence and how it can impact what kind of care is delivered and how it is received.  As a member of the Board of Directors for Mental Health America Indiana, Dr. Carney Doebbling encouraged legislators to partner with organizations that focus on mental health advocacy and mental health parity in insurance coverage.  Insurance plans should be evaluated for the kinds of behavioral health services they provide to their customers to ensure they are providing the best kind of services. 

Elder Reneé Vaughn, a licensed social worker and ordained elder talked about how, frequently, those deeply rooted in their faith are reluctant to pursue professional help, opting instead to “pray depression away”–viewing their mental illness as a sign of weakness or lack of faith. Ms. Vaughn encouraged those in the leadership of their local places of worship to initiate discussion on mental illness and counseling.  Ms. Vaughn also encouraged legislators to consider those who may be too ashamed to come forward with their mental illness or emotional health issues when drafting legislation aimed at creating an environment of openness and acceptance.  

NBCSL’s 20^th Annual Black America’s Dialogue on Health shed light on depression, an illness many in the African American community would prefer to keep in the shadows.  However, by illuminating its causes, its risk factors, and solutions, legislators will be able to help bring their constituents out of their own personal darkness.

Planes, trains, and automobiles keep Americans on the move.  For some, however, movement is often hindered by a lack of transportation options.  In fact, 700,000 Americans do not have a car or access to public transportation,¹ and this issue affects a vast spectrum – from the elderly to millienials, families to individuals.

Transportation limitations disproportionately affect vulnerable communities. African-American, Latino,² and low-income households³ are less likely to own a car, making them primarily dependent on public transit, walking, and other ways of getting around. This has a direct impact on health as streets are mostly designed to accommodate automobile traffic, which then presents safety challenges to people on foot.  The pedestrian fatality rate of African Americans is 75% higher than Whites, and the fatality rate of Latinos is 60% higher than Whites.⁴  Additionally, the pedestrian fatality rate for African American children is more than twice that of their White counterparts and 40% greater for Latino children.⁵  For low-income counties with households living under the federal poverty line, the pedestrian fatality rate is over 80% higher than the national average.⁶ 

Thankfully, investments in walkways, public transit, and other transportation options are generating opportunities and improving quality of health for all Americans.  In communities where transportation can be unreliable, unattainable (due to finances), or non-existent, legislative solutions, federal transportation grants, and municipal bicycle share programs are opening doors like never before.

Complete Streets and Safe Routes

Complete Streets is a type of transportation policy dedicated to creating comfortable and convenient access for all individuals regardless of age and ability, by creating sidewalks, pedestrian bridges, medians, bus lanes, roundabouts, and other means.

Complete Streets policies have been enacted in several states across the country. In Illinois, State Representative LaShawn Ford cosponsored SB 314 (Public Act 095-0665), which states that consideration will be given to bicycle and pedestrian ways in the development and planning of transportation facilities. The Michigan Legislature adopted HB 6151 – co-sponsored by NBCSL members, Representatives Coleman Young and Robert Jones – requiring the state transportation commission to develop a complete streets policy to be used by local entities.  In several states, transportation departments adopted their own policies to meet the needs of pedestrians and bicyclists, creating safer and better access for those in rural and urban communities. 

Safe Routes to School is a movement that encourages the development of sidewalks and bicycle pathways, promotes physical activity, and allows children to travel safely to and from school.  In 2005, Congress allocated $612 million for program implementation.  NBCSL members, Representative T.W. Shannon and Senator Constance Johnson cosponsored SB 399 to create safe routes to schools in Oklahoma to improve student safety and encourage walking.  Through Safe Routes, schools in Oklahoma have hosted walk-to-school days where students and their parents walk to school, engaging the student body in physical activity.  

TIGER Grants and Public Transit

The Transportation Investment Generating Economic Recovery (TIGER) discretionary grant program within the U.S. Department of Transportation provides funds for roads, rail, public transit, and port projects aimed at achieving critical national objectives.⁷  Established in 2009 as a part of the American Recovery and Reinvestment Act, more than $4.1 billion in TIGER grants have been disbursed.  State and local governments and private corporations are just a few examples of grant applicants. 

The New York Department of Transportation applied for grant funding for the Rochester Intermodal Transportation Center in 2012.  The Center will replace the existing Amtrak station and offer more access to the trains, minimize delays, create a pedestrian bridge, and improve sidewalks.  Construction is expected begin in December 2014.  The Nashville Metropolitan Transit Authority also applied for grant funding to improve their Bus Rapid Transit, increase safety for users by repairing and replacing current traffic control systems, and connect travelers to economic areas growing business traffic. 

The Indianapolis Public Transportation Corporation that operates IndyGo – Indianapolis’s public transportation system – received funds in 2013 to repair the line of buses and purchase buses that have been converted from diesel to zero-emission electric vehicles.  The electric buses will require one-fifth of the maintenance of diesel-powered buses, and the repaired buses will improve reliability and ridership. With public transportation use being its highest in 57 years, according to the American Public Transportation Association (APTA), investments in public transit are crucial in connecting people to work, stores, and other places needed for everyday living.
 

Bicycle Sharing Programs

Bicycle sharing has been a global trend within recent years, offering people alternatives to public transportation and cars.  Bike share programs work by having users sign up for membership and use the bikes for a limited time - essentially to get from Point A to Point B.⁸ Biking has several benefits to communities, such as increased physical activity and reduced emissions.

Several cities have adopted different models of bike sharing including Denver, CO; Boston, MA; Miami, FL; and Washington, D.C. Bike shares can be managed and maintained by the local jurisdiction, nonprofits, or for-profit organizations.  Washington, D.C.’s Capital Bikeshare and Boston’s Hubway are examples of bike shares that are owned and operated by the local jurisdiction.  Some of the factors a jurisdiction will consider when putting in a bike share system are (1) population density (higher populations usually mean higher demand for bikes); (2) employment density (higher employment density can increase the number of potential bike users); (3) proximity to colleges and universities (lower rates of car ownership); and (4) available transit (bike shares are often used as the “last mile trip” in a commute).⁹ 

Despite its benefits, minority and low-income communities are not using bike shares as much as other populations.¹⁰ A lack of knowledge of the system, low demand, income, and a lack of credit cards are among the reasons attributed to lower use. To help low-income communities sign up for membership in their bike share, Boston’s Hubway launched a subsidized membership program giving membership for $5 a year to low-income individuals and those receiving public assistance. To help those without credit cards, often referred to as “the unbanked,” D.C.’s Capital Bikeshare partnered with financial institutions to enable residents to open a bank account without a minimum balance or monthly fees.  Through participating financial institutions, Capital Bikeshare offers a discounted membership rate for individuals who do not have a debit card or bank account. By prompting people to sign up for bank accounts and debit cards, more members of low-income and minority communities have access to not only affordable and healthy transportation, but also financial empowerment. 

Whether biking, walking, driving, or riding, Americans need to get around.  Advancements in transportation and increased options enable residents to take charge of their lives and take advantage of opportunities that may not be present in their neighborhoods. 

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Puentes, R. and Tomer, A. Transit Access and Zero-Vehicle Households. The Brookings Institution. (2011). http://www.brookings.edu/~/media/research/files/papers/2011/8/18%20transportation%20tomer%20puentes/0818_transportation_tomer.pdf Ernst, M. and Shoup, L.  Dangerous by Design. (2011). http://www.transact.org/PDFs/2009-11-09-Dangerous%20by%20Design.pdf Ibid. Ernst, M. and Shoup, L. Dangerous by Design. Ibid.  Ibid.  http://www.dot.gov/tiger/about Prepared by Toole Design Group and Pedestrian and Bicycle Information Center. Bike Sharing in the United States: State of the Practice and Guide to Implementation.  United States Department of Transportation Federal Highway Transit Administration. (2012). http://www.pedbikeinfo.org/pdf/Programs_Promote_bikeshareintheus.pdf Ibid. Toole Design Group and Pedestrian and Bicycle Information Center, Bike Sharing.