Impact of County-level health infrastructure on participation in a reform effort to reduce the use of jail for individuals with mental health disorders.

BACKGROUND: The national Stepping Up Initiative has attracted over 500 counties interested in reducing the use of jail for individuals with mental health disorders. This paper identifies socioeconomic, criminal legal, and health care factors that predict the likelihood of counties joining Stepping Up. RESULTS: After performing variable selection, logistic regression models were performed on 3,141 U.S. counties. Counties designated as medically underserved and/or mental health staffing shortage areas were less likely to participate in this initiative. Logistic regression models showed that larger counties (populations over 250,000) with better health care infrastructure, more mental health providers per capita, higher percent of Medicaid funded drug treatment services, and at least one medical school, were more likely to join Stepping Up. These counties had lower per capita jail populations, higher concentration of police resources, and higher pretrial incarceration rate. CONCLUSIONS: County-level health care delivery factors are major contributors to a county's likelihood, or willingness, of engaging in Stepping Up reform efforts to reduce jail population with mental health disorders issues. Therefore, improving availability and accessibility of medical and behavioral health care in different communities, may facilitate efforts to address the unnecessary incarceration of individuals with mental health disorders.

A Quasi-Experimental Assessment of the Effect of the 2009 WIC Food Package Revisions on Breastfeeding Outcomes.

Breastfeeding rates among infants participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are consistently lower than those of WIC nonparticipants. The 2009 WIC food package revisions were intended to incentivize breastfeeding among the WIC population. To examine the effectiveness of this policy change, we estimated an intent-to-treat regression-adjusted difference-in-difference model with propensity score weighting, an approach that allowed us to control for both secular trends in breastfeeding and selection bias. We used novel data from the Feeding Infants and Toddlers Survey from 2008 and 2016. We defined our treatment group as infants eligible for WIC based on household income and our control group as infants in households with incomes just above the WIC eligibility threshold. The breastfeeding outcomes we analyzed were whether the infants were ever breastfed, breastfed through 6 months, and breastfed exclusively through 6 months. We observed significant increases in infants that were ever breastfed in both the treatment group (10 percentage points; p < 0.01) and the control group (15 percentage points; p < 0.05); however, we did not find evidence that the difference between the two groups was statistically significant, suggesting that the 2009 revisions may not have had an effect on any of these breastfeeding outcomes.

Associations between use of specific social media sites and electronic cigarette use among college students.

OBJECTIVE: To examine dose-response associations between use of specific social media sites and the use of electronic cigarettes (e-cigarettes) and traditional cigarettes. METHODS: This was a cross-sectional study of 298 first-year college students enrolled in the fall 2019 semester at a large state university. Heckman selection and Probit model were used to estimate associations between use of specific social media sites and e-cigarette/traditional cigarette use. RESULTS: Each additional hour per day spent on Snapchat was associated with a 4.61% increase in the probability of lifetime e-cigarette use. In addition, among current e-cigarette users, more time spent on Snapchat was associated with more frequent e-cigarette use (marginal effects: 0.13, p = 0.001). Facebook, Twitter, Snapchat and Instagram were not associated with traditional cigarette smoking. CONCLUSION: Snapchat was the only major social media platform associated with both lifetime and current e-cigarette use.

The relationship between community public health, behavioral health service accessibility, and mass incarceration.

BACKGROUND: The relationship between healthcare service accessibility in the community and incarceration is an important, yet not widely understood, phenomenon. Community behavioral health and the criminal legal systems are treated separately, which creates a competing demand to confront mass incarceration and expand available services. As a result, the relationship between behavioral health services, demographics and community factors, and incarceration rate has not been well addressed. Understanding potential drivers of incarceration, including access to community-based services, is necessary to reduce entry into the legal system and decrease recidivism. This study identifies county-level demographic, socioeconomic, healthcare services availability/accessibility, and criminal legal characteristics that predict per capita jail population across the U.S. More than 10 million individuals pass through U.S. jails each year, increasing the urgency of addressing this challenge. METHODS: The selection of variables for our model proceeded in stages. The study commenced by identifying potential descriptors and then using machine learning techniques to select non-collinear variables to predict county jail population per capita. Beta regression was then applied to nationally available data from all 3,141 U.S. counties to identify factors predicting county jail population size. Data sources include the Vera Institute's incarceration database, Robert Wood Johnson Foundation's County Health Rankings and Roadmaps, Uniform Crime Report, and the U.S. Census. RESULTS: Fewer per capita psychiatrists (z-score = -2.16; p = .031), lower percent of drug treatment paid by Medicaid (-3.66; p < .001), higher per capita healthcare costs (5.71; p < .001), higher number of physically unhealthy days in a month (8.6; p < .001), lower high school graduation rate (-4.05; p < .001), smaller county size (-2.66, p = .008; -2.71, p = .007; medium and large versus small counties, respectively), and more police officers per capita (8.74; p < .001) were associated with higher per capita jail population. Controlling for other factors, violent crime rate did not predict incarceration rate. CONCLUSIONS: Counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita. Increasing access to services, including mental health providers, and improving the affordability of drug treatment and healthcare may help reduce incarceration rates.

Promoting sustainable responses to the US opioid epidemic with community-academic partnerships: qualitative outcomes from a statewide program.

BACKGROUND: Drug overdose deaths in the United States have continued to increase at an alarming rate. The Substance Abuse and Mental Health Services Administration (SAMHSA) distributed more than $7 billion between January 2016 and June 2020 to address the drug overdose crisis. The funds support evidence-based responses, including medications for opioid use disorder, and other prevention, treatment and recovery activities. Although the State Opioid Response (SOR) grants finance much-needed community level interventions, many of the services they support may not be sustainable, without ongoing assessment, evaluation and planning for continuation. METHODS: This paper describes a statewide effort to support local entities through SAMHSA's SOR grants in Virginia. Community agencies across the state participated in detailed needs assessment exercises with VHEOC investigators, and developed requests for proposals (RFPs) to sustain their SOR programs. The RFPs were then distributed to prospective academic partners at the five VHEOC universities, based on the required subject matter expertise identified in the RFP. All responsive proposals were then provided to the local agencies who selected the proposal most likely to meet their needs. VHEOC investigators also conducted an inductive, three-phase content analysis approach to examine the RFPs submitted to the VHEOC to identify nominal categories of support requested of the VHEOC investigators. RESULTS: VHEOC Investigators received and coded 27 RFPs from ten community agencies representing four of five regions of the state. We identified six nominal categories of academic assistance with high inter-coder agreement. The six categories of support requested of the academic partners were program development and support, literature review and best practices, outreach and education, data analysis and interpretation, program evaluation, and grant writing assistance. Several RFPs requested up to three categories of support in a single project. CONCLUSIONS: Our analysis of the requests received by the consortium identified several categories of academic support for SOR-grantees addressing the drug overdose crisis. The most common requests related to development and maintenance of supportive collaborations, which existing research has demonstrated is necessary for the long-term sustainability of SOR-funded services. In this way, the academic partners reinforced sustainable SOR-funded programs. As the state opioid response program is implemented nationally, we hope that other states will consider similar models in response to the opioid crisis.

Trends in Use and Expenditures for Brand-name Statins After Introduction of Generic Statins in the US, 2002-2018.

Importance: The high and increasing expenditures for prescription medications in the US is a national problem. Objective: To explore the association of generic statin competition on relevant use and cost savings and to provide use and expenditure trends for all available statins for private and public payers and for out-of-pocket spending. Design, Setting, and Participants: This survey study evaluated data from the January 1, 2002, to December 31, 2018, Medical Expenditure Panel Survey by using a difference-in-differences analysis. Participants included noninstitutionalized individual statin users. Data were analyzed from November 1, 2020, to March 30, 2021. Exposures: The market entry of 5 generic statin medications (atorvastatin, rosuvastatin, simvastatin, lovastatin, and pravastatin). Main Outcomes and Measures: National- and individual-level reductions in the annual number of statin purchases and total expenditures across private insurance, public insurance (Medicaid and Medicare), and out-of-pocket spending (presented in 2018 US dollars). Results: Between January 1, 2002, and December 31, 2018, an average of 21.35 million statins (95% CI, 16.7-25.5 million) were purchased annually, with an average total annual cost of $24.5 billion (95% CI, $18.2-$28.8 billion). The number of brand-name statin purchases decreased by 90.9% (95% CI, 56%-98%) nationally and 27.4% (95% CI, 13%-40%) individually after the end of market exclusivity. Among major payers, the end of market exclusivity was associated with individual cost savings of $370.00 (95% CI, $430.70-$309.20) for private insurers, $281.00 (95% CI, $346.80-$215.30) for Medicare, $72.34 (95% CI, $95.22-$49.46) for Medicaid, and $211.90 (95% CI, $231.20-$192.50) for out-of-pocket spending. Combining all payers, the decrease translates to $925.60 (95% CI, $1005.00-$846.40) of annual savings per individual and $11.9 billion (95% CI, $10.9-$13.0 billion) for the US. Conclusions and Relevance: Results of this survey study suggest that full generic competition of statins was associated with significant cost savings across all major payers within the US health care system.

Multilevel Matching in Natural Experimental Studies: Application to Stepping up Counties.

Among many approaches for selecting match control cases, few methods exist for natural experiments (Li, Zaslavsky & Landrum, 2007), especially when studying clustered or hierarchical data. The lack of randomization of treatment exposure gives importance to using proper statistical procedures that control for individual differences. In this natural experimental study, which has a hierarchical structure, we plan to evaluate the efforts of 455 counties across the United States to make targeted efforts to improve mental health services and reduce jail utilization over time. Nested within states, counties are clustered on health and social indicators, which affect the likelihood of making improvements in these areas. Similar to a randomized trial, prior to collecting survey data, it is necessary to identify matched control counties as study sites based on an array of state and county covariates. Accounting for the hierarchal structure of data, a blend of various probability-based models are presented to achieve this goal. Methods include multivariable models that control for observed differences among treatment and control groups, shrinkage based LASSO as a variable selection technique, and logistic models.

The emerging market for supplemental long term care insurance in Germany in the context of the 2013 Pflege-Bahr reform.

The growing cost of long term care is burdening many countries' health and social care systems, causing them to encourage individuals and families to protect themselves against the financial risk posed by long term care needs. Germany's public long-term care insurance program, which mandates coverage for most Germans, is well-known, but fewer are aware of Germany's growing voluntary, supplemental private long-term care insurance market. This paper discusses German policymakers' 2013 effort to expand it by subsidizing the purchase of qualified policies. We provide data on market expansions and the extent to which policy goals are being achieved, finding that public subsidies for purchasing supplemental policies boosted the market, although the effect of this stimulus diminished over time. Meanwhile, sales growth in the unsubsidized market appears to have slowed, despite design features that create incentives for lower-risk individuals to seek better deals there. Thus, although subsidies for cheap, low-benefit policies seem to have achieved the goal of market expansion, the overall impact and long-term sustainability of these products is unclear; conclusions about its impact are further muddied by significant expansions to Germany's core program. The German example reinforces the examples of the US and France private long term care insurance markets, to show how such products flourish best when supplementing a public program.

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.

Proportion of physicians in large group practices continued to grow in 2009-11.

Payers and advocates for improved health care quality are raising expectations for greater care coordination and accountability for care delivery, and physician groups may be responding by becoming larger. We used Medicare claims from the period 2009-11, merged with information from the Medicare provider enrollment database, to measure whether physician group sizes have been increasing over time and in association with physician characteristics. All US physicians serving Medicare fee-for-service patients in any practice setting were included. The percentage of physicians in groups of more than fifty increased from 30.9 percent in 2009 to 35.6 percent in 2011. This shift occurred across all specialty categories, both sexes, and all age groups, although it was more prominent among physicians under age forty than those age sixty or older. The movement of physicians into groups is not a new phenomenon, but our data suggest that the groups are larger than surveys have previously indicated. Questions for future studies include whether there are significant cost savings or quality improvements associated with increased practice size.

As roughly 700,000 prisoners are released annually, about half will gain health coverage and care under federal laws.

During 2009, 730,000 prisoners were released from federal and state prisons--a 21 percent increase from the number of prisoners released in 2000. Poor health and poor health coverage have been major challenges for former prisoners trying to reintegrate into the community and find work. We discuss these challenges and the likely effect of recent federal legislation, including the Second Chance Act, the Mental Health Parity and Addiction Equity Act, and the Affordable Care Act. We estimated that with the implementation of health reform, up to 33.6 percent of inmates released annually--more than 245,000 people in 2009--could enroll in Medicaid. Similarly, we estimated that up to 23.5 percent of prisoners released annually-more than 172,000 people in 2009-could be eligible for federal tax credits to defray the cost of purchasing insurance from state health exchanges. This health insurance, combined with new substance abuse services and patient-centered medical home models, could dramatically improve the health and success of former inmates as they return to the community. States should consider several policy changes to ease prisoners' transitions, including suspending rather than terminating Medicaid benefits for offenders; incorporating corrections information into eligibility determination systems; aiming Medicaid outreach and enrollment efforts at prison inmates; and designing comprehensive approaches to meeting former prisoners' health care needs.

Increasing California children's Medicaid-financed mental health treatment by vigorously implementing Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program.

BACKGROUND: Children living in poverty-especially children living in rural areas and in areas lacking a commitment to providing mental health care-have considerable unmet need for mental health treatment. Expansion of Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program might help to address this problem. OBJECTIVE: To evaluate whether a legally compelled expansion of mental health screening, treatment, and financing under EPSDT would translate into higher Medicaid penetration rates. Our particular focus was on changes in rural treatment systems and systems historically receiving low levels of state funding (ie, "underequity" counties). METHODS: We used fixed-effects regression methods by observing 53 California county mental health plans over 36 quarters, yielding 1908 observations. Our models controlled for all static, county, and service system characteristics, and for ongoing linear trends in penetration rates. RESULTS: After controlling for previous trends, mental health treatment access increased following EPSDT mental health program expansion. The increase was greatest in rural systems, and counties that previously received less state funding which showed the greatest penetration rate increases. CONCLUSIONS: EPSDT mental health expansion and increased funding increased Medicaid-financed mental health treatment. The expansion efforts had the greatest effects in rural and underequity counties that faced the greatest barriers to mental health service use.

Incarceration and psychotropic drug use by youth.

OBJECTIVE: To determine changes in psychotropic medication use before and after juvenile justice incarceration, contrasting stays in long-stay commitment facilities and short-stay detention facilities. DESIGN: Statewide administrative data (July 1, 1998, through June 30, 2003) from the Florida Department of Juvenile Justice and Florida Medicaid. Medication prescriptions filled before entry and after release from facilities were determined based on paid claims. Psychotropic medication was categorized by drug class based on the National Drug Code. SETTING: General community services. PARTICIPANTS: All of the Medicaid-enrolled youth aged 11 to 17 years identified as having a stay in a juvenile justice facility. The total sample included 67 819 detention stays and 59 918 commitment stays. Main Exposure Incarceration in juvenile commitment and detention facilities. Main Outcome Measure Filled prescriptions for psychotropic medication by class 30 and 90 days before and after incarceration. RESULTS: Ninety days prior to detention, 3666 youth (5.4%) had psychotropic drug claims. Among these, 2296 (62.6%) had any psychotropic medication claims in the 30 days after release. Among commitment cases, 29.6% continued medication use after release. Onset of medication use after release from detention and commitment facilities was relatively uncommon (1.7% and 1.9%, respectively). Youth in commitment facilities were less likely than youth in detention facilities to resume their medication use across drug classes after 30 days (chi(2)(3) = 6.28; P = .04) and after 90 days (chi(2)(2) = 7.62; P = .02). CONCLUSIONS: The results find greater support for a disruption effect than a discovery effect from incarceration. The findings suggest several areas for further investigation and improvement of services for incarcerated youth.

The role of Medicaid enrollment and outpatient service use in jail recidivism among persons with severe mental illness.

OBJECTIVE: This study sought to determine whether having Medicaid benefits and receiving behavioral health services are associated with a reduction in recidivism for jail detainees with severe mental illness. METHODS: A quasi-experimental design with linked administrative data was used. All persons released over a two-year period from jails in King County, Washington (N=5,189), and Pinellas County, Florida (N=2,419), who had severe mental illness were followed for 12 months after jail release. Those who were receiving Medicaid benefits at release and those who were not were compared on three indicators: how many subsequent arrests occurred, how soon the arrest occurred, and how serious the associated offense was. The data were analyzed with negative binomial, Cox proportional hazards models and logistic regression with adjustments for dependent observations. RESULTS: In both counties, having Medicaid at release was associated with a 16% reduction in the average number of subsequent detentions (p<.001 and p<.01, respectively). After the analysis controlled for demographic and clinical variables, more days on Medicaid were associated with a reduced number of subsequent detentions in King County (p<.001) and more days in the community before subsequent arrest in both counties (p<.01 and p<.05, respectively). No association was found between Medicaid status and the seriousness of the subsequent offense in either county. CONCLUSIONS: Although Medicaid benefits and behavioral health services were associated with fewer rearrests and more time in the community, the observed differences were relatively small. Further research is needed to determine how greater reductions in jail recidivism can be achieved for this target population.

Criminal records of persons served in the public mental health system.

OBJECTIVE: The authors examined the frequency and severity of arrests of persons served by Medicaid as well as public mental health treatment patterns before and after arrest. METHODS: A random sample of 6,624 persons was drawn from claims of the public mental health system in Los Angeles County between July 1993 and June 2001. Clients' claims were matched to criminal justice records from 1991 to 2001. Cross-tabulations and logistic regression analyses were used to examine the likelihood and seriousness of criminal involvement, as well as clients' involvement in mental health treatment around the time of the arrest. RESULTS: Twenty-four percent of the sample had at least one arrest over the ten-year period. Sixty-two percent of arrested individuals had as their most serious offense a nonviolent crime. Half of all observed arrests did not lead to conviction. There was no statistical difference in the total treatment services received between arrested and not-arrested individuals. Among those arrested, there was only a small difference in the likelihood of receiving treatment services before and after arrest. CONCLUSIONS: Almost a quarter of persons with serious mental illness were arrested at least once over ten years. More than one-third of these individuals were arrested for violent crimes, with drug crimes the second most common category. The seriousness of the offense varied with diagnosis. Arrest was not associated with meaningful increases in service use, pointing to potential missed opportunities for treatment.

Medicaid policy changes in mental health care and their effect on mental health outcomes.

In recent years, Medicaid has experienced a dramatic increase in spending on prescription drugs in general and psychotropic medications in particular. The purpose of this study is to examine the effects of increased Medicaid spending on psychotropic drugs on improving the mental health and well-being of participants at the population level. Specifically, we study the effect on outcomes that are strongly correlated with mood disorders, including depression and Attention Deficit/Hyperactivity disorder, controlling for concomitant increases in Medicaid eligibility thresholds and expansion into managed care for mental health services. Knowledge of the effects of changes in the Medicaid program is crucial to policymakers as they consider implementing and expanding mental health services. Our results show that increased spending on antidepressants and stimulants are associated with improvements in some outcomes, but not in others.