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Take our Customer Experience of Government Survey!

Do you have 3 minutes to share your experience with government services? Take our Customer Experience of Government survey!

Why are we doing this?

At 17A, we believe services provided by government are critical to a strong community – and we want to hear how you experience them! We are distributing this survey to gauge public opinion related to state and local government services.

How will my information be used?

Participation is 100% voluntary and all responses are anonymous. No personally identifiable information will be collected so please do not include personal information in the free response. Insights drawn from aggregated responses may be published and/or shared with organizations distributing this survey.

Where can I go to learn more?

If you have questions about this survey please reach out to [email protected]. For more information on 17A and the work we do please visit group17a.com. Thanks so much for participating!

Fast facts and the areas in which we work

At 17A we are dedicated to making service delivery better for the public and building trust in government. We work with clients across sectors like healthcare, housing, courts, and transit to positively impact diverse and vulnerable communities. We think a big part of understanding these problems is understanding their scope. These questions and answers below provide a great reference point and reminder of the impact government policy has across different communities.

As of June 2021, how many individuals were enrolled in Medicaid? (estimated)

76M+

Source: CMS [1]

What is the Federal Poverty Level (FPL) in the US?

$12.9K for 1 person, $21.9K for family of 3

Source: ASPE [2]

What is the number of people incarcerated in the US on any given day?

2.3M

Source: The Commonwealth Fund [3]

As of 2022, what is the maximum federal reimbursement rate to state Medicaid spending (i.e. Federal Medical Assistance Percentages)

83% (Federal govt. will reimburse the state .83 for each Medicaid $ spent)

Source: Congressional Research Service [4]

As of the latest Census estimation (2019), what percent of families in Ohio live below the Federal Poverty Level (FPL)?

30% (Family defined as household with >2 adults and >1 child)

Source: KFF [5]

As of June 2021, how many individuals were enrolled in the Child Health Insurance Program (CHIP)?

6.9M+

Source: CMS [1]

What is the shortage of affordable housing units in the US?

3.8M

Source: White House [6]

As of 2019, what percent of the nationwide prison population is incarcerated for non-violent offenses?

25%

Source: Time [7]

As of the latest Census estimation (2019), what percent of families live below the Federal Poverty Level (FPL)?

29% (Family defined as household with >2 adults and >1 child)

Source: KFF [5]

As of February 2022, which states have not adopted Medicaid expansion through the Affordable Care Act (ACA)?

TX, FL, GA, MS, AL, SC, NC, TN, KS, WI, WY, SD

Source: KFF [8]

How many people in the US have a family member who is justice-involved?

Nearly 50%

Source: Equal Justice Initiative [9]

What is the number of people that experience homelessness in the US on any given day?

326K

Source: U.S. Department of Housing and Urban Development [10]

What is the US Federal Medical Assistance Percentage (FMAP) minimum?

50%

Source: KFF [11]

As of the latest Census estimation (2019), what percent of families in New York live below the Federal Poverty Level (FPL)?

27% (Family defined as household with >2 adults and >1 child)

Source: KFF [5]

As of 2022, what is the minimum federal reimbursement rate to state Medicaid spending? (i.e. the Federal Medical Assistance Percentages)

50% (Federal govt. will reimburse the state .50 for each Medicaid $ spent)

Source: Congressional Research Service [4]

What is the number of rental units available for Extremely Low Income (ELI) renters (per 100 households)?

35 per 100

Source: National Low Income Housing Coalition [12]

As of 2020, how many Americans are under the supervision of the adult correctional system? (e.g., probation, prison, parole, or jail)

5.5M Americans

Source: Bureau of Justice Statistics [13]

As of February 2022, how many states have adopted Medicaid expansion through the Affordable Care Act (ACA)?

39 (including DC)

Source: KFF [8]

[1] https://www.cms.gov/newsroom/news-alert/cms-releases-latest-enrollment-figures-medicare-medicaid-and-childrens-health-insurance-program-chip

[2] https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references/2021-poverty-guidelines

[3] https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/medicaid-role-health-people-involved-justice-system

[4] https://sgp.fas.org/crs/misc/R43847.pdf

[5] https://www.kff.org/other/state-indicator/population-up-to-200-fpl/

[6] https://www.whitehouse.gov/cea/written-materials/2021/09/01/alleviating-supply-constraints-in-the-housing-market/

[7] https://time.com/4596081/incarceration-report/

[8] https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/

[9] https://eji.org/news/half-of-americans-have-family-members-who-have-been-incarcerated/

[10] https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_022

[11] https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/

[12] https://reports.nlihc.org/gap

[13] https://bjs.ojp.gov/data/key-statistics

Community-minded strategies in local courts – and how these approaches can work for other government agencies

Where local courts are today

Local courts play an important, central role in the lives of community residents, offering services beyond hearings that range from fine settlements and housing assistance to vehicle registration and family support. Amongst local government offices, courts see some of the highest foot traffic from community residents, with nearly 66% of Americans interacting with their local court in some form each year[1].

Yet engaging with the local court system is sometimes a daunting process. Despite 75% of court users reporting that they were satisfied with the overall outcome of their court engagement, only 33% were satisfied with the resolution process – citing confusion, inconsistencies, and overall process hardship as the main drivers for dissatisfaction[1].

These facts beg the ultimate question: if millions of residents go to their local court for assistance in dealing with legal disputes or for debt, housing, child custody, or divorce assistance, how can we make the courts work better for them? Some courts have answered this question by employing innovative approaches that can make a big difference in driving stronger community-court interactions and experience in a low budget environment. And, what’s more, these community-minded strategies can be deployed in other local government agencies. 

Promising community-centered strategies in local courts

To design the court of the future that is responsive to all constituent needs, courts must directly hear from constituents to understand their experiences, frustrations, and ideas. Feedback and satisfaction surveys are a great tool to measure and address those experiences while enlisting community involvement in the improvement of the court experience.

Feedback survey design and implementation can be executed excellently by local courts with minimal budget. Below are key considerations which are core to designing and implementing court feedback mechanisms well:

  • Design questions that are simple and easy to access. Survey instructions and questions should be written in plain English and at an accessible reading level to promote participation. Surveys should also be translated to the top-spoken languages in the community. It is important to clearly communicate the purpose of the survey, that it is confidential, and that the feedback recorded will not affect the outcome of any case.
  • Design questions that address social determinants of justice. Much like the social determinants of health, the conditions in which people are born, grow, live and work relate to their court experience and outcomes. Designing the court of the future requires recognition that the public consists of individuals with different needs.
  • Share the survey in digital and paper formats. Surveys should be as easy to access and complete as possible to maximize participation. Surveys can be accessed on cell phones enabled by QR codes placed across the courthouse, allowing visitors to easily record their satisfaction in the web browser of their phones at their own time and convenience. Hard copies should also be available for visitors that prefer pen and paper.
  • Share the survey at all high-traffic touchpoints. Survey access should be available, whether digitally or on paper, at all high-traffic areas, which can include the courthouse entrance, outside courtrooms, bathrooms, the help desk, parking structures, and on any material that visitors leave the courthouse with (e.g., fine payment receipt).
  • Earn buy-in from court stakeholders. Visitors of the courthouse engage with a host of government services to fulfill their needs, such as the Clerk of Courts, Probation Department, and Family Services. Having the support of such administrators is essential to creating a survey that is encompassing of the residents’ court experience and will encourage buy-in of other stakeholders.
  • Organize and analyze the data transparently. Collecting visitor feedback is merely the first step – courts must build trust with the community by transparently reviewing survey responses and deciding what changes might be made to address pain points. Courts can begin doing this by setting up an ongoing process for which survey results are tracked, monitored, and shared. 

Many courts across the U.S. have successfully implemented feedback surveys to enhance their court processes. Changes stemming from community feedback include clear court signage for navigation, a revamp of instructions and procedures for filing orders of protection that is more constituent-friendly, and staff training on best practices for delivering and communicating court services[2].

The court of the future will be centered around the resident experience and needs. There are a host of operational innovations that can create “quick wins” for courts and their constituents as far as improved experience, along with more frontier innovations that can radically transform the user experience in a low budget environment.

  • Visual handout guide to following legal processes
    • Constituents often express confusion around what to expect on the day of a trial, or how to follow legal procedures such as obtaining an Order of Protection or requesting tenant assistance services administered at various local courts.
    • Many courthouse procedures and FAQs can be conveyed in single-page handouts that visually provide step-by-step guidance for processes, such as opening a child custody case or navigating the day of a hearing. These handouts can be tailored to specific processes and be made available at various courthouse touch points (e.g., help desk, waiting areas) and online. Scaled versions of this can include How-To videos available online conducted by courthouse staff that walk residents through various court processes.
  • Clear courthouse navigation for improved wayfinding
    • Courthouses can feel confusing and intimidating, especially for those that arrive at court for the first time. Clear and ample court signage directing residents towards common court destinations, along with pictograms and uniform color palettes that are associated with specific courthouse services, have contributed to overwhelmingly positive results in user access and experience where implemented[3].
  • Court schedule transparency
    • The daily courthouse docket schedule is often opaque; visitors are expected to arrive at the courthouse upon opening and wait in the area until their name is called, with little to no view in how the day’s schedule is progressing. This can create inconveniences around time off work and finding childcare.
    • Progress tracking tools can go a long way in alleviating such inconveniences by providing real-time updates on estimated hearing or service appointment time, allowing constituents to plan to be at the courthouse only for the window that is required. Such tools can be visualized digitally in waiting rooms or connected to alerts & reminders that residents receive as part of any courthouse communications.
  • Pre-trial notification system
    • Constituents often fail to show to court due to confusion around knowing where and when to show, which can lead to further justice involvement.
    • Digital court reminders are a direct way to increase court-community interaction in a low-touch, yet effective manner. Notification system software such as UpTrust and RemindMe allow local court systems to send reminder texts days before a hearing and enable courts to include information on how to prepare and navigate their day at court or access human services (e.g., social workers, court liaisons).

Improving community-court interaction begins with driving court outreach in the community. Constituents often have little connection with judges and court administrators beyond court hearings and services, contributing to an archaic view of the courthouse in the community. Yet there are various ways to reimagine how the court can engage with its community to break down conceived notions of the court and help foster trust among its users:

  • Judicial listening tours throughout the community for court staff to court procedures and outcomes with specific interest groups and members of the community, and bring awareness to new procedures (e.g., new expungement laws)
  • Court-in-the-Neighborhood model that brings the court to the community. Low-level criminal offenses, family and housing disputes, and juvenile delinquency cases are heard at community centers such as churches and schools and incorporate local voices such as residents and community groups in the administration of justice. Such courts are designed to respond to the concerns of individual communities – taking into consideration particular economic and social landscapes – and often involve community service and engagement with local community programs as part of dispute resolution[4].
Community-focused approaches can work for other agencies, too

The above innovations are just a small sample of the initiatives that local courts can take to begin redesigning court processes to be more constituent friendly. More importantly, these innovations can be scaled to other local government agency contexts, such as the DMV, the post office, and public works – creating an ecosystem of local services that are more constituent-oriented. This local service orientation helps to promote and foster community trust and satisfaction, a fundamental pillar to a well-functioning and well-serving government.

[1] https://worldjusticeproject.org/our-work/research-and-data/global-insights-access-justice-2019

[2] https://www.ojp.gov/pdffiles1/bja/197109.pdf

[3] https://www.ojp.gov/ncjrs/virtual-library/abstracts/user-friendly-justice-making-courts-more-accessible-easier

[4] https://www.ojp.gov/pdffiles1/bja/183452.pdf

Promising models for investing in and scaling equitable housing solutions

Why focus on housing?

On any given day in the US, approximately 580,000 people experience homelessness with about 110,000 people of those experiencing chronic homelessness (defined as experiencing homelessness for more than one year or four homelessness events). This issue particularly affects the Black and Latinx communities, with Black people representing 39% of people experiencing homelessness and more than 50% of homeless families with children, despite only representing 13% of the US population. And, homelessness tells only part of the story – on average, nearly one in three renters experience housing insecurity (defined as a household spending spending more than 30% of its income on rent).[1] Multiple factors  contribute to the affordable housing crisis, including shortages of units available and decreasing affordability; for example, estimates of housing availability show that there are only 24 units available for every 100 extremely low-income renters (households making below 30% of the area median income), and on the affordability front one in four renters overall pay at least 50% of their income on housing.

Beyond supply and financial issues, additional barriers push housing security further out of reach for many. For example, with those who are justice-involved, criminal records often prevent renters from passing background checks in public and private housing markets.[2] And more broadly, studies have shown that landlords in private markets have surreptitiously been biased against those using Section 8 vouchers, despite the provisions of the Fair Housing Act.[3]

Big ideas for investing and scaling

Beyond needed increases in federal investments (e.g., increases in housing development and rental assistance[5]), there are two scalable models of private and local efforts working to combat barriers to housing for those experiencing homelessness and housing insecurity.

Models in the private rental market have increased housing supply by working as middlemen between landlords and those seeking rapid rehousing or facing temporary homelessness. For example, HousingFirst Lab dually works with landlords and tenants and locates low-income renters wh need housing and guarantees these tenants’ rents in the case of missed payments.

Beyond providing novel solutions for landlords (e.g., rent guarantees, immediately filling vacancies), this model also actively works to eliminate barriers renters may face throughout the housing process (e.g., eliminating biases in application processes, mediation of tenant-landlord issues, providing rental assistance), crucial for equity in housing solutions.

Additionally, smaller municipalities have piloted research-backed Housing First programs for those who are chronically homelessness. These pilots often operate under the assumption that city resources (e.g., corrections, emergency room visits) can be spent on housing individuals that will prevent the need for future downstream costs.

For example, in Santa Clara’s “Welcome Home” pilot, the city identified and housed the “frequent fliers” of the emergency room and local jail systems with the highest need for services, while providing optional housing and healthcare services. By the end of the evaluation period, 86% of people remained housed, with a significant reduction in psychiatric emergency department usage (with other outcomes harder to measure due to covariates). A similar program in Denver (Denver Supportive Housing Social Impact Bond) successfully housed 77% of participants in stable housing after three years, with ~40% reduction in arrests, ~30% reduction in jail stays, and ~40% reduction in costly emergency department visits—which offset roughly 3/4ths of the original investment from the City of Denver.

What to do next

These pilots have demonstrated the impact of Housing First models; given the necessary investment capital, these social investments lead to decreases in people experiencing homelessness, reducing medical emergencies, and reducing avoidable justice-involvement, particularly for those who typically face the most issues in the rental markets. Though “return-on-investment” is not immediately recouped, these Housing First models are becoming more popular options for funders seeking to support social investments, and who can invest over longer time horizons.

[1] www.cepr.net/report/housing-insecurity-by-race-and-place-during-the-pandemic/

[2] https://endhomelessness.org/homelessness-in-america/what-causes-homelessness/inequality/

[3] https://www.americanprogress.org/article/preventing-removing-barriers-housing-security-people-criminal-convictions/

[4] https://www.nytimes.com/2021/03/15/nyregion/real-estate-lawsuit-section-8-discrimination.html

[5] https://www.nber.org/papers/w29516

[6] https://www.urban.org/urban-wire/one-four-americas-housing-assistance-lottery

States’ roles in improving household health for mothers and babies

American moms face grim reality

The statistics on United States (US) maternal health outcomes are grave, and the data reveals stark racial health disparities. As a country, the US is one of the worst wealthy nations in the world in terms of maternal morbidity.[1] Furthermore, poor maternal health outcomes disproportionately impact Black and Indigenous mothers, who are two to three times more likely than white mothers to experience maternal morbidity.[2]

Medicaid is a critical lever for improving these maternal health outcomes – particularly for diverse mothers (see Figure 1) – because of the large number of US births covered by Medicaid.

Figure 1: Kaiser Family Foundation

*Percent of births for each is roughly 2/3rds, per KFF calculations

Which state levers best support Medicaid moms and babies?

The data on US maternal health outcomes has established a clarion call for several states, and these states have pursued evidence-based strategies to improve outcomes.

First, these states have extended Medicaid postpartum coverage to one year, which enables more mothers to receive services, and at critical times. An additional 720,000 mothers (i.e., an approximately 45% increase) would be covered if all remaining states expanded postpartum coverage to one year, the period during which 50% of pregnancy-related deaths occur.[3] This extension would be especially critical for mothers with existing gaps in outcomes (e.g., postpartum depression).[4]

Secondly, these states cover additional benefits that can improve outcomes both by delivering critical care in new ways as well as providing supplementary services to improve current care delivery.  Benefits that create new care models (e.g., doula supports) can more holistically address a myriad of barriers that Medicaid mothers face, including coordination with physicians for appropriate care, among others. Studies have shown doula-supported births reduce C-Sections and increase positive birth experiences.[5] In addition, benefits like covered home visits have been shown to benefit both mother and child via decreased infant emergency room visits and increased breastfeeding rates.[6] Lastly, benefits that augment existing pathways can also target certain access gaps and specific needs outside of clinical settings (e.g., lactation consults for breastfeeding complications).[7]

Which States Are Pulling Promising Levers?

Leading states are taking a holistic view on supporting Medicaid moms and babies and are pulling the promising levers to promote better outcomes. The map and rankings below track current efforts across 50 states (and the District of Columbia) on their use of these levers.

Grading current state action

Figure 2: 17A, Usage of Medicaid maternal health levers

Ideas for where to go next

For covered benefit-related levers, holistic delivery model changes (e.g., home visits, doula supports) are the most promising interventions to improve maternal health disparities and promote better outcomes for Medicaid babies from birth. Additional ideas – broken out by providers, managed care organizations (MCOs), and agencies – are presented below.

  1. Payment model: Find ways to take on more and higher-risk agreements to pay for additional services

  2. Care model: Pilot high-touch, proactive care models (e.g., home visiting, doula supports) with focus on most vulnerable populations; telehealth (clinical and nonclinical) and home visits can be used break down barriers. Data-sharing and risk agreements can be used to get reimbursement; state Medicaid agencies may also reimburse for services provided to mothers with SUD or high-risk pregnancies

  1. Care delivery: Use data to pilot high-touch care delivery with highest risk populations to bring costs down; piece together disparate health care delivery (e.g., traditional ob-gyn follow-ups, lactation consults, doula supports)

    • Pay for levers that work and lobby state for additional reimbursements, especially focused on breaking access barriers; find ways to incorporate whole-family health interventions to bring down costs

  2. Data: Improve data collection (e.g., demographics, clinical goals), for internal tracking and to share with providers to improve outcomes

  1. Coverage and benefits: Increase coverage time periods and reimbursed levers

  2. Payment reform: Additional payment reforms (e.g., value-based care, payment disincentives for C-Sections, etc.)

  3. Data: Support data improvements to empower MCOs, providers to track outcomes

[1] https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer

[2] https://www.commonwealthfund.org/publications/issue-briefs/2021/oct/severe-maternal-morbidity-united-states-primer

[3] https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries

[4] https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5714a1.htm

[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647727/

[6] https://ajph.aphapublications.org/doi/10.2105/AJPH.2013.301361; https://pubmed.ncbi.nlm.nih.gov/24187116/; https://pubmed.ncbi.nlm.nih.gov/30399451/

[7] https://www.cdc.gov/breastfeeding/about-breastfeeding/why-it-matters.html

Bringing an MVP mindset to public problems – carefully

An MVP or ‘minimum viable product’ is a simple, fast, imperfect ‘first draft’ or starting point. The concept was initially introduced by the start-up world and is a mainstay in the Bay Area playbook.

What is an MVP?

An MVP is the most basic version of a solution. MVPs are designed to have the minimum set of features required to address a need. The premise of the MVP approach is that an initial solution – however imperfect – is real faster and quickly generates actual user feedback about all the ways it could be better. All that feedback enables fast iteration and the development of a better, more mature solution over time.

Why are MVPs are useful in public sector?

MVPs are extremely useful in public problem solving for many of the same reasons they are useful to start ups – with a few riffs and additional benefits of note.

  • Break down complexity, forcing a focus on entry points to big intractable issues
  • Make abstract problems tactical and operational, for example – making healthcare access equitable seems daunting (rightly); understanding how to make a 6 week pen-and-paper enrollment process more user friendly in 2021, less so
  • Force a citizen or frontline focus, which is sometimes conspicuously absent from even the most impact-oriented systems change efforts
  • Create bright spots, which can be critical to keep energy high in the face of grave and serious issues
  • Limit disruption that may not work or produces unintended consequences, which is particularly important when working on services or products that vulnerable populations depend on

What should a public problem solver have in mind when taking an MVP approach?

Reject the “move fast and break things” mentality that start-ups tout, and instead use the MVP to move fast more carefully. Small tests and pilots can help reduce unintended harm in public services, by forcing a focus on frontline feedback and observed outcomes before scale.

Look for ways that the MVP mindset can be adapted to systems and org problems that often hamper public and social sector work – e.g., solving for a minimum viable operating model to help sustain small community based organizations (you don’t have to be developing a product to use the MVP approach).

Share details about the MVP mentality with the groups that engage in the process – to spread the word and the thinking about how this kind of mindset can be imported, adjusted and most fully realized for good.

Just Health

17a launched our “Just Health” initiative in 2019, focused on achieving more equitable outcomes in community health and county corrections.

Just Health works to reorient county court and corrections activities and spend toward healthcare and other community supports. We do this through better information sharing and coordinated action.

Understanding county jail stays

Across the country, jail officials and other community leaders are often quick to point out the abundance and futility of short jail stays, particularly for community members with clear problems that the criminal justice system was never meant to fix—the latest oft-cited example of this problem is the fact that roughly two thirds of the population in county jails have a substance use disorder. Jail time should not be a common prescription for the sick and vulnerable in a civilized society.

Today, local jail systems are acting—ineffectively—as stewards of last resort for community health and wellness.  Placing county corrections in such a role reinforces and worsens inequities; it also wastes valuable opportunities to promote the sort of wellness and support actually required for justice in many cases.  As part of fixing the many serious problems with the corrections system in America today, the county jail must be redesigned to better integrate with community healthcare delivery. 

Unlike prison stays, most county jail stays are short: for example, in one large county, stays are an average of 7 days for misdemeanor charges and 14 days for felony charges. Short stays are disruptive, costly and generally unhelpful to resolving the underlying issues that may have led to legal system involvement in the first place. A short stay is very effective at little more than shaking any existing stability in daily work and family life, disrupting access to important community and health services, and introducing additional stress, trauma and cost.  

Mediciad in the county jail population

When they are not incarcerated, most people booked into county jails are Medicaid beneficiaries if they live in states with Medicaid expansion. In both expansion and non-expansion states, many more of the individuals in jail are likely eligible for Medicaid but just not enrolled. Our team refers to the population that is enrolled in Medicaid and is booked into the county jail at least once a ‘multisystem member’.  Outside of jail, healthcare for the vast majority of multisystem members is led by Medicaid Managed Care Organizations (MCOs).

Where Jail-Health overlaps matter

Missed opportunities for information sharing and coordinated action between the criminal justice system and healthcare delivery system begin well before incarceration. In a standard pretrial process today, determinations about candidacy for diversion are made with incomplete information about whether someone meets the eligibility criteria. At best, attorneys and pretrial workers rely on clients to self-report health conditions that are relevant to eligibility for diversion; as a result, many people are not recommended for diversion even though they are eligible—leading to unnecessary, disruptive jail time and missed opportunities for treatment.  MCOs hold data that could be used for more informed eligibility determinations and more diversions to treatment; MCOs also have an existing incentive to support diversion to treatment, given that many conditions lead to more costly healthcare utilization when left untreated and also given that short jail stays may worsen health outcomes and costly forms of utilization (e.g., high ED admission rates after county jail discharge, mainly to access medications).

The problem does not end with pre-trial; once someone is booked into a county jail, the jail assumes responsibility for their healthcare.   Healthcare delivery inside and outside of the jail is not integrated. Jails pay for and directly contract with health providers for services delivered while people are incarcerated—and generally do not have access to general health records beyond some limited pharmacy data. As a result, jail health providers operate with limited knowledge of member health status and have little opportunity or incentive to intervene on non-acute health issues given the typical length of a county jail stay; instead, they typically work with jails to simply mitigate risk of health emergencies during incarceration.  When multisystem members are booked into jail, the treatment they will receive while incarcerated is determined based on self-reporting, a cursory scan of prescription databases and a short evaluation to determine acute or emergency needs.  No detailed health assessment is administered at intake and no detailed health records are available to the jail health provider.  This means that treatment in jail is often inadequate. Instead, short stays are harmful to members who have conditions where continuity of care is important. MCOs hold data that would improve continuity of care for these members during incarceration, and have an incentive to ensure continuity of care (e.g., for bipolar disorder, costly Hepatitis C treatment, pregnancy). 

Meanwhile, MCOs are not able to identify members who are being incarcerated for short stays; without access to real-time booking data, MCOs are unable to invest in resources for multisystem members to establish continuity of care for chronic conditions, re-engage them in treatment at re-entry, and link them to new, more intensive services that incarceration has helped indicate might be needed. Bookings for short stay-charges could serve as an important indicator of underlying health access and utilization challenges, if properly shared with the community provider organizations that serve multisystem members. 

There is also some potential for better integrated health and booking data to be used to improve the role of short jail stays in linking multisystem members to services that improve their wellbeing through better health outcomes and lower recidivism; a booking in the county jail can serve as an additional potential opportunity for service providers to find and reach hard-to-engage populations for services offered far outside the jail.  In pilot work we are currently leading with an MCO in one county jail, care management staff are excited about the simple ability to use a short jail stay as an opportunity to meet with a member they have been unable to reach. 

Across the courts and corrections continuum, officials, administrators and service providers operate with an incomplete picture of multisystem members.  Despite the potential for better cross-system decision-making, investments in efforts to better use combined criminal justice and health data are limited.  Basic criminal justice and health data remains disconnected even when policies require integration for simple program administration purposes –though all states have regulations in place to ensure that Medicaid enrollment is not active during incarceration, fewer than half even have the basic electronic and automated systems to operationalize those regulations. 

A valuable, whole-person view of multisystem members is lacking across the board:

  • Courts lack information about diagnoses and treatment history, which can be useful to facilitate diversion to community services in lieu of short stays for certain charges and for members with specific conditions.
  • County corrections systems, including jail administrators and jail health providers, lack basic information about the health status of people incarcerated in order to provide proper care during incarceration; they also lack information about population health trends among multisystem members, which is important for planning and preparedness.
  • MCOs and community health providers operate without knowing who is (or has been) incarcerated, leaving them unable to support needs at re-entry; further, they unable to incorporate incarceration patterns into a whole-person view of the members needs for specific forms of treatment and other community supports
  • All state and community leaders lack a holistic understanding of the health status and incarceration patterns of the short stay population – impeding the development of new insights about potential high value interventions that might be used to improve outcomes for multisystem members, particularly through more support via Medicaid managed care networks and dollars.

What comes next

Better use of combined criminal justice and health information is the first step in reducing the number of short stays and improving the impact of the short stays that continue to occur.  Today, even basic information about health status is not shared with courts or corrections agencies, though it is relevant to many of their decisions and services. Similarly, basic information about criminal justice involvement is not shared with health providers well positioned to use that information to inform care delivery decisions as well as pathways through the courts and corrections system.


Foster care 101

The big idea

The foster system needs more attention and more innovation.  The embedded primer includes information about the foster system today and potential areas for innovation (system re-designs, program changes, new tools) to improve outcomes. Below is an overview of why you should check it out and consider what you might be able to do or build to improve the space.

Why focus on fixing foster care?

The foster system is responsible for a small, concentrated group of many of the most vulnerable children in the United States.

  • Less than 1% of US children, roughly .5M, are in the foster system
  • Children in foster care are 3.4x more likely to experience childhood trauma
  • Most children in foster care are removed from parents due to household and parental factors, not child-specific circumstances
  • Children from certain demographic backgrounds are overrepresented in the foster care system (i.e., black children, LGBTQ+ children)

Children’s experience of foster care comes at a critical time in their development and is heavily influenced by external factors.

  • ~50% of kids entering foster care are 5 years old or younger
  • Childhood trauma (i.e., abuse, neglect) permanently affect brain development and is correlated with risk of medical/behavioral conditions
  • Children’s pathways and outcomes are varied and depend on many factors, including judicial discretion, case manager turnover, placement setting, parental case plan performance, and caregiver characteristics

The child welfare system has the potential to be a nexus for better interventions for a vulnerable population more broadly.

  • Many children remain in the care of high-need / at-risk families upon exiting the system
  • Spend on programs for foster system alumni who age out of the system is 10x more than the cost of foster care
  • The foster system can serve as a center to coordinate interventions across multiple systems during childhood and into adulthood and through family-centered interventions