# data[].attributes.body
Van Gogh, Vincent. Prisoners Exercising (after Doré). 1890, oil on canvas, Pushkin Museum, Moscow, Russia.

# data[].attributes.body
America is the only wealthy nation that does not have a universal healthcare system.

Only 23% of released prisoners stay out of prison, with 77% going back to prison and 43% of that 77% going back within the first year they are released.

# data[].attributes.attachment_link.readable_text
Because health care is such a hot topic right now in politics, in the news, and in the popular consciousness, there is a lot of information being thrown around about the state of health care in America, and it's often hard to tell what is true, what is almost true, or what is completely false. So here at Meritage Medical Network, we have decided to compile a list of surprising facts about health care in the United States to help you do some of your own fact checking.

1. The United States spends over $8,250 per capita on health care every year - that's over 22% higher than the next highest country in the world and over 170% higher than the average of the highest-spending 50 countries in the world!

2. In 1960, the per capita cost of health care was $147 per person in America; adjusted for inflation, it would be $1,082 today; that means our current per capita cost has grown over 660% above and beyond normal inflation.

3. As a portion of the gross domestic product (GDP), health care spending accounts for 17.7 percent; the U.S. is second in the world and first among developed nations for the highest health care spending as a percentage of GDP.

4. The total amount of money spent on health care each year in the United States is $2.6 trillion, and it is expected to continue rising. By 2021, spending on health care each year is expected to be $4.8 trillion.

5. It is estimated that 30% (about $750 billion) of health care spending each year is wasted.

6. Life expectancy in the United States is 77.4 years for men and 82.2 years for women; overall, America has the 34th highest life expectancy in the 195 countries of the world.

7. The United States ranks 47th for infant mortality in the world.

8. The World Health Organization has ranked the United States health care system as 37th in the world.

9. America is the only wealthy, industrialized nation that does not have a universal health care system.

10. About 75% of all health care dollars are spent on patients with one or more chronic conditions, many of which are preventable, such as diabetes, obesity, heart disease, lung disease, and others.

11. Paying for health care is the number 1 cause of bankruptcy filing every year in the U.S. Almost 2 million people need to file bankruptcy because they cannot pay their medical bills each year, and outside of bankruptcy, over 20 percent of the population (about 56 million adults) between the ages of 19 and 64 struggle with health-care related bills each year.

12. A recent study found that lack of insurance coverage can be tied to 45,000 deaths per year in the United States and that people without health insurance have a 40% higher risk of death than those with private health insurance.

Although many of these statistics are less than encouraging, one of the best ways to improve the overall health and wellness of the population and avoid preventable deaths is to get more people insured so they can get the health care they need. Right now, it is the open enrollment period for people to purchase new insurance through the health insurance marketplaces; check out Covered California's website to see the plans that are available and find out if you qualify for subsidies or other programs such as Medicaid.

If you're searching for new insurance (or during open enrollment for your employer, Medicare, or other insurance plans), be sure that your policy covers health care from Meritage Medical Network. We are your health care network. As a select group of over 700 private practice physicians located throughout Marin, Napa, and Sonoma Counties, our expert staff members, both medical and administrative, are dedicated to ensuring that you receive the best quality health care available. Don't become a statistic - enroll in or update your health insurance policy today!

# data[].attributes.attachment_link.title
12 Surprising Facts about United States Health Care | Meritage Medical Network

# data[].attributes.attachment_link.description
Because health care is such a hot topic right now in politics, in the news, and in the popular consciousness, there is a lot of information being thrown around about the state of health care in America, and it's often hard to tell what is true, what is almost true, or what is completely false.

# data[].attributes.body
A program called Global Initiative on Caregiving for the Elderly, established by Harvard University, focuses on caring for the elderly and providing them with human interactions. Hospice care is an another organization which serves to provide the terminally ill with comfort and social needs. https://www.mayoclinic.org/healthy-lifestyle/end-of-life/in-depth/hospice-care/art-20048050

# data[].attributes.attachment_link.title
Family Care for the Elderly | Department of Global Health & Social Medicine

# data[].attributes.headline
Finland has Solved Some of These Societial Problems 

# data[].attributes.subject
Finland has Solved Some of These Societial Problems 

# data[].attributes.body
Finland provides services like employment insurance, free universities, give money to immigrants to create a life for themsleves, 36 paid vacation days, etc. Finland is the happiest country in the world because of this, and all of the citizens are happy with where they are.

# data[].attributes.attachment_link.readable_text
It's hard not to get jealous when I talk to my extended family.

My cousin's husband gets 36 vacation days per year, not including holidays. If he wants, he can leave his job for a brief hiatus and come back to a guaranteed position months later.

Tuition at his daughter's university is free, though she took out a small loan for living expenses. Its interest rate is 1%.

My cousin is a recent immigrant, and while she was learning the language and training for jobs, the state gave her €700 a month to live on.

They had another kid six years ago, and though they both work, they'll collect 100 euros a month from the government until the day she turns 17.

They of course live in Finland, home to saunas, quirky metal bands, and people who have for decades opted for equality and security over keeping more of their paychecks.

Inarguably one of the world's most generous-and successful-welfare states, the country has a lower infant mortality rate, better school scores, and a far lower poverty rate than the United States, and it's the second-happiest country on earth (the US doesn't break the top 10). According to the OECD, Finns on average give an 8.8 score to their overall life satisfaction. Americans are at 7.5.

Sometimes when I'm watching the web traffic for stories at The Atlantic's global desk, I'll notice a surge in readership in one of a couple of archival stories we have about how fantastic Finland is-usually thanks to Reddit or a link from another news site. One is about Finland's "baby boxes, " a sort of baby shower the Finnish government throws every mom. A package sent to expecting women contains all the essentials for newborns-everything from diapers to a tiny sleeping bag. (Want to choose your own baby clothes? You can opt instead for the box's cash value, as my cousin did.)

The other popular story is about Finland's school system, which ranks as one of the world's best-with no standardized testing or South Asian-style "cramming" but with lots of customization in the classroom. Oh, and students there also spend fewer hours physically in school than their counterparts in other Western countries.

As the US raises student loan rates, considers cutting food stamps, guts long-term unemployment insurance, and strains to set up its first-ever universal healthcare system, it's easy to get sucked into articles about a country that has lapped America in certain international metrics but has also kept social protections in place. Like doting parents trying to spur an underperforming child, American liberals seem to periodically ask, "Why can't you be more like your brother?"

It's a good debate to have, and in some ways, it seems like there's no reason why the US shouldn't borrow from Finland or any other Nordic country-we're richer and just as committed to improving education and health, after all. Here's the difference: Finland's welfare system was hardwired into its economic development strategy, and it hasn't been seriously challenged by any major political group since. And just as Finland was ramping up its protections for workers, families, and the poor in the 1960s, Americans began to sour on the idea of "welfare" altogether. What's more, some economists argue that it's because of all that American capitalism contributes to the global economy that countries like Finland-kinder, gentler, but still wealthy-can afford to pamper their citizens. With actual Pampers, no less.

Let's start with mandatory maternity leave, a favorite topic among the having-it-all, Leaning-In crowd. The US is one of the last countries on earth without it, but the Finnish state mandates four months of paid maternity leave, and on top of that, the mother and father can share an additional six-month "parental leave" period, with pay. After that, kids can either continue staying home with their mothers until they reach school age, or parents can instead send them to a publicly subsidized child-care center, where the providers are all extensively trained. The cost is on a sliding scale based on family income, but the maximum comes out to about $4,000 a year, compared with $10,000 for comparable care in the U.S.

This is just one of the many reasons Finland is "the best place to be a mom," as the nonprofit Save the Children declared in May.

Can't get a job? Not to worry. Unemployment insurance in Finland lasts for 500 days, after which you can collect a means-tested Labor Market Subsidy for an essentially indefinite period of time. (The unemployment rate is a high-but-not-awful 8.2%).

At this point, if you've literally turned green with envy and need to see a doctor, you're in luck! In addition to dirt-cheap universal healthcare, Finland offers compensation for wages you might have lost while you were away from work, as well as a "Special Care Allowance" if you need to take some time off to take care of your sick kids.

All of this adds up to the stress equivalent of living in what is essentially a vast, reindeer-fur-lined yoga studio.

"It seems to me that people in Finland are more secure and less anxious than Americans because there is a threshold below which they won't fall," said Linda Cook, a political scientist at Brown University who has studied European welfare states. "Even if they face unemployment or illness, Finns will have some payments from the state, public health care and education."

Eero Järnefelt, Burning the Brushwood, 1893. (Wikimedia Commons)

The Finns didn't always have it this good. For much of the early 20th century, Finland was agrarian and underdeveloped, with a GDP per capita trailing other Nordic countries by 30 to 40% in 1900.

One advantage Finland did have, however, was enlightened policies towards gender. The country focused on beefing up child and maternal care in large part because women were at the core of Finland's independence and nation-building efforts at the turn of the 20th century. Finnish women were the second in the world to get the vote in 1906, and they were heavily represented in the country's first parliament.

Ellen Marakowitz, a lecturer at Columbia University who studies Finland, argues that because women helped form modern Finland, things like maternity leave and child benefits naturally shaped its welfare structure decades later.

"You have a state system that was built on issues concerning Finnish citizens, both men and women, rather than women's rights," she said. "Government was created in this equal footing for men and women."

BBC

Finland's strong trade unions pioneered its initial worker protections, but the state soon took those functions over. Today, roughly 75 to 80% of Finns are union members (it's about 11% in the US), and the groups dictate the salaries and working conditions for large swaths of the population.

And as the country worked to industrialize in the 1960s, its economic policymakers took on a mentality similar to that of CEOs at tech companies with awesome employee perks like free string cheese and massages.

"The thinking was, 'for a country of 5 million, we don't have many resources to waste. If people are happy, they'll maximize their work ethic, and we can develop,'" says Andrew Nestingen, a professor who leads the Finnish studies program at the University of Washington. The theory of the welfare state was that "everyone should get a slice of the cake so that they have what they need to realize their life projects."

The country's unemployment and disability system was in place by 1940, and subsequent decades saw the expansion of child benefits and health insurance.

Meanwhile, thanks to the country's strong agrarian tradition, the party that represents the rural part of Finland pushed through subsidies for stay-at-home (or stay-on-farm, in their case) mothers-thus the current smorgasbord of inexpensive child-care options.

Over time, Finland was able to create its "cake"-and give everyone a slice-in large part because its investments in human capital and education paid off. In a sense, welfare worked for Finland, and they've never looked back.

"In the Finnish case, this has really been a part of our success story when it comes to economic growth and prosperity," said Susanna Fellman, a Finn who is now a professor of economic history at the University of Gothenburg in Sweden. "The free daycare and health-care has made it possible for two breadwinners-women can make careers even if they have children. This is also something that promotes growth."

With this setup, Finns have incredible equality and very little poverty-but they don't get to buy as much stuff. The OECD gives the US a 10 when it comes to household income, the highest score, while Finland gets a measly 3.5.

And there are some major lifestyle differences: Finns live in houses and apartments that are about half the size of Americans', and their taxes on the wealthy, like those on capital gains, are much higher than ours. (Hence why taxes make up a huge chunk of their GDP.) Professionals such as doctors make far less there, which helps medical care to stay reasonably priced. (The conservative Heritage Foundation ranks Finland as downright "repressed" in some categories, like government spending, on its " Index of Economic Freedom.")

It's also worth noting that Finland isn't a total economic Wonderland, either: It's not growing very fast and will probably have issues with its aging population in coming years. The Bank of Finland recently predicted that the country might soon exceed the 60% debt-to-GDP ratio mandated by the European Union-a common problem in Europe these days.

Some of Finland's more conservative politicians have suggested cutting public benefits there in the wake of the economic downturn-but even with those cuts, social protections there would still be far more generous than ours.

And the economic redistribution there doesn't always work perfectly. Some municipalities inevitably find themselves with lower-quality hospitals and day cares, even when they're supposed to be roughly identical, and recently some pro-business groups have tried to edge the country toward greater privatization (though unions have pushed back.)

Still, the country's small, well-educated population and investments in technology have allowed it to avoid some of the problems currently plaguing other, similarly socialist European countries. Overall, most Finns love the welfare system that loves them back.

I asked my cousin's husband, Reijo, why he was willing to support such an arrangement even though he works full time.

"Money isn't everything. We value equality, not inequality," he said. Fair enough. But does he have any gripes about the Finnish way? Anything he would change? Perhaps kick some of those freeloaders off their indefinite unemployment?

No, he said, but he did point to one small issue: "I think that for university students it is not yet good enough. Many students have to work while they are studying."

Like Finland, the US also set up massive safety-net programs, in the form of Medicare and Medicaid, in the 1960s. But paradoxically, many Americans began developing a deep aversion to government handouts at the same time.

The 1960s saw a rise in poverty and children born out of wedlock, particularly in urban communities. Sensational media stories about families "abusing" welfare-especially when the putative abusers were portrayed as African-American-helped cement opposition to public assistance. One study found that in the early 1970s, nearly three-quarters of magazine stories about welfare or poverty featured images of African-Americans, even though African Americans comprised only about a third of welfare recipients.

"I do think that racial divisions are an important factor here-the sense among many people that universal benefits will take from 'us' and give to 'them'-to a part of society that is seen as different, less deserving, imagined as racially different," Cook, from Brown University, said. "I think that many middle-class Americans favor social benefits for what they see as 'deserving' people who have worked and earned them-so Medicare is good-but universal health care would provide benefits for people who are imagined as not deserving."

In a 1976 speech, Ronald Reagan made mention of supposed "welfare queens" who make six-figure salaries while drawing government funds, stoking a sense of outrage over perceived waste in public assistance. (It was later shown that he used an exaggerated anecdote). Arguing that social insurance dis-incentivized work, and prioritizing markets and individual liberty, the growing new conservative movement eventually joined together businesses and working-class voters in pushing for cuts in government programs.

Though we seemingly support spending on the sick, poor, and elderly, in 2006, 46% of Americans still thought the government spent "too much" on welfare, even 10 years after a total structural overhaul of welfare had passed.

Jefferey Sellers, a University of Southern California political scientist, found another key difference between the two nations: Finland has much more powerful local governments than the US, and they're tasked with executing the myriad functions of the welfare system-from helping the poor to operating the day cares. Municipal taxes are redistributed and supplemented with grants, thus largely eliminating the problem of under-resourced areas. Local public expenditures are 20 percent of GDP in Finland, but just 10% in the US, he points out.

"The national government provides local governments with the financial means, legal powers, and the expertise to perform well," he said. Meanwhile, "Fiscal redistribution among local governments assures equality in how those services are distributed."

What's more, some economists argue that the only way countries like Finland can be so well-off and yet so cushy is because countries like the US create the technology that powers the rest of the world-with huge rewards for success but few safety nets in the case of failure.

"The entire world benefits because of Apple's iPhones," said Daron Acemoglu, an economist at MIT, admitting it was a relatable but not necessarily optimal example (Finland gave us Nokia and Linux's Linus Torvalds, after all). "If the United States did not provide incentives for Apple to come up with and develop the iPhone, then the entire world economy would lose the benefits it obtains from this product. The cutthroat reward structure in the United States is encouraging the creation of many products and technologies like this."

If America were to adopt some of Finland's "cuddly" benefits, the thinking goes, the entire world economy might slow down. For Finns, it would be out with the baby boxes, in with the subsistence farming again.

So what about education reform, then? Finnish school expert Pasi Sahlberg has written that Finnish schools are based on "improving the teaching force, limiting student testing to a necessary minimum, and placing responsibility and trust before accountability."

It's true that Finnish teachers design their own curricula and don't have to deal with test-score-based evaluations, but school officials there are also placing young minds in very well-equipped hands: All teachers have graduate degrees in education and their subject areas of expertise. And schools are funded based on need, so the most struggling schools get the most resources. There is no "Teach for Finland," as Sahlberg has said.

But in some ways, even the Finnish way of educating requires a strong welfare system as a foundation. The country has an extremely low child-poverty rate, which likely makes teaching without testing or score-keeping much easier. And how many American teachers would love to get a master's degree but aren't willing to take on the student loans that come with it?

"The easiest is to say that Finland seems to be a well-performing system overall, as far as the international rankings are considered," Sahlberg told me. "So, it is no wonder the education system also works well."

The no-testing model also makes sense for a culture that's low on one-upmanship: "I think one of the more important things is that there's less of an emphasis on competition in Finland," Marakowitz said. "Many Finnish children don't know how to read before they go to school, and you need a certain kind of cultural setting for that. Some US parents would be quite freaked out."

When Americans hold up Finland as a model, their arguments are usually dismissed with two indisputable facts: Finland is indeed much smaller than the US, making it easier to disperse generous benefits on a national scale. It's also far more homogeneous, making disputes over payouts less frequent and less racially charged.

Still, Cook says, the claims of homogeneity are a bit over-stated. Finland has both sizeable Swedish- and Russian-speaking communities, and right-leaning parties like the "True Finns" want to pare back the little immigration the country does have. (Even the True Finns, though, love the welfare state.)

Building on the success of Finland's local governments, individual U.S. states could conceivably be more like mini-Finlands-just look at Massachusetts, which had a comprehensive health-care system before the rest of the nation. But creating and enforcing 50 separate safety nets would require a level of oversight the US federal government just doesn't have. Even Obamacare was challenged aggressively in court and has faced opposition from some two dozen states.

Fellman described Finland's welfare state as a "virtuous circle"-Finns' social cohesion props up the welfare state, which in turn promotes greater harmony. But in a way, America's economic competitiveness, focus on innovation, and lack of safety net all reinforce one another, too.

The very reason we're so frequently googling what we can learn from "Finland's school success," after all, is that we want to stay one step ahead.
Olga Khazan is The Atlantic's global editor.
This originally appeared at The Atlantic. More from our sister site:
This article is part of Quartz Ideas, our home for bold arguments and big thinkers.

# data[].attributes.attachment_link.title
The secret to Finland's success in education, employment, parenting-basically everything

# data[].attributes.attachment_link.description
It's hard not to get jealous when I talk to my extended family. My cousin's husband gets 36 vacation days per year, not including holidays. If he wants, he can leave his job for a brief hiatus and come back to a guaranteed position months later.

# data[].attributes.body
In the prison system, the abusive behavior and “get tough” approach has caused negative impact on prisoners. It has caused prisoners to not care about the consequences of their actions and longer sentences can lead to more abusive and criminal like behaviors once their sentence is finished. It is proven that programs that are focused on rehabilitating prisoners have a higher chance of preventing crime and trying to make their communities safer after their sentence then prisoners in abusive and long sentences.

# data[].attributes.attachment_link.readable_text
A NSW programme in which prisoners train stray dogs as part of their rehabilitation is one of a number of innovations adopted in recent years. AAP

This article is part of the Beyond Prison series, which examines better ways to reduce re-offending, following the recent State of Imprisonment series.
Although criminal justice agencies in Australia have, in recent years, adopted an increasingly "get tough" approach, responses to crime that rely on punishment alone have failed to make our communities safer. Instead, they have produced an expanding prison system. This has the potential to do more harm than good and places considerable strain on government budgets.

Increasing prison sentences does little to deter criminal behaviour. Longer sentences are associated with higher rates of re-offending. When prisoners return to their communities, as the vast majority inevitably do, the problems multiply.

Exposing the limitations of punishment

In this context, it becomes important to think carefully about public policy responses that aim to punish and deter offenders. Psychologists have been studying punishment under well-controlled laboratory conditions with both animals and humans for nearly 100 years. Its effectiveness in promoting short-term behavioural change, or even in suppressing negative behaviour, depends on rather specific conditions being in place.

For punishment to work it has to be predictable. Punishment also has to be applied at maximum intensity to work, or else tolerance and temporary effects result. Yet applying very intense levels of punishment for many offences goes against our sense of justice and fairness.

The threat of punishment, no matter how severe, will not deter anyone who believes they can get away with it. It will also not deter those who are too overcome by emotion or disordered thinking to care about the consequences of their behaviour.

Punishment also has to be immediate. Delayed punishment provides opportunities for other behaviours to be reinforced. In reality, it often takes months - if not years - for someone to be apprehended, appear in court and be sentenced.

Working towards more effective rehabilitation

Many of the conditions required for punishment to be effective will not exist in any justice system. It follows that policies and programmes that focus on rehabilitating offenders will have a greater chance of success in preventing crime and improving community safety.

The origins of offender rehabilitation in Australia can be traced back to the early penal colonies and, in particular, to the work of Alexander Maconochie, a prison governor on Norfolk Island in 1840. Maconochie introduced the idea of indeterminate rather than fixed sentences, implemented a system of rehabilitation in which good behaviour counted towards prisoners' early release, and advocated a system of aftercare and community resettlement.

Wikimedia Commons/John Howard by Mather Brown (1789)

Maconochie's ideas built on those of the great social reformers of 18th-century Britain, notably Quakers such as John Howard and Elizabeth Fry. They were among the first to try to change prisons from what they called "institutions of deep despair and cruel punishment" to places that were more humane and had the potential to reform prisoners' lives.

These days, though, offender rehabilitation is often thought about in terms of psychological treatment. We can chart the rise of current programmes according to the broad traditions of psychodynamic psychotherapy, behaviour modification and behaviour therapy and, more recently, the cognitive-behavioural and cognitive approaches that characterise contemporary practice.

The earliest therapeutic work in the psychoanalytic tradition saw delinquent behaviour as the product of a failure in psychological development. It was thought this could be addressed through gaining insight into the causes of offending. A wide range of group and milieu therapies were developed for use with offenders, including group counselling and psychodrama.

In the 1980s, more behavioural methods - such as token economies, contingency management programmes and "time out" - replaced psychotherapy.

There are good grounds to develop standardised incentive models in Australia's prisons. Community-style therapeutic programmes for prisoners with substance use problems in Victoria, NSW and the ACT represent substantial advances in practice.

These programmes take advantage of the significant therapeutic opportunities that arise by looking closely at prisoners' social functioning and day-to-day interactions. They actively encourage offenders to assume responsibility not only for their own behaviour, but for that of others.

However, rehabilitation today is almost always associated with cognitive-behavioural therapy. This targets a relatively narrow range of crime-producing (or "criminogenic") needs, including pro-criminal attitudes - those thoughts, values and sentiments that support criminal conduct. Programmes also dedicate a lot of time to trying to change personality traits, such as low self-control, hostility, pleasure- or thrill-seeking and lack of empathy.

Not everyone can be successfully treated. Substantial evidence now exists, though, to suggest that this type of approach does produce socially significant reductions in re-offending.

Essential steps in making corrections policy work

The challenges lie in ensuring that the right programmes are delivered to the right people at the right time.

First, it is important that low-risk offenders have minimal contact with higher-risk offenders. Extended contact is only likely to increase their risk of recidivism. This has implications for prisoner case management, prison design and for the courts.

Courts have the power to divert low-risk offenders from prison and thus minimise contact with more entrenched offenders. Related to this is the need to develop effective systems of community-based rehabilitation, leaving prisons for the most dangerous and highest-risk offenders.

AAP/Rod McGuirk

Second, concerted efforts are required to develop innovative programmes for those who identify with Aboriginal or Torres Strait Islander cultural backgrounds. They are grossly over-represented across all levels of the criminal justice system.

Third, staff need to be properly selected, trained, supervised and resourced to deliver the highest-quality rehabilitation services to the most complex and challenging people.

Finally, it is important to demonstrate that programmes actually make offenders better, not worse. The types of evaluation that are needed to attribute positive change to programme completion are complex, require large numbers of participants and cross-jurisdictional collaboration. A national approach to programme evaluation is sorely needed.

This is not to suggest that criminal behaviour shouldn't be punished - only that we should not rely on punishment by itself to change behaviour. We need to create a true system of rehabilitation that can enhance the corrective impact of punishment-based approaches.

It also doesn't mean that punishment never works. It may work reasonably well with some people - perhaps those who are future-oriented, have good self-monitoring and regulation skills, and who can make the connection between their behaviour and negative consequences months later.

Unfortunately, many people in prison simply aren't like this. The challenge, then, is two-fold: to find ways to make punishment more effective and to tackle the causes of offending through high-quality rehabilitation.

Correctional services often get little credit for their efforts. They are widely criticised when things go wrong. However, their efforts to rehabilitate offenders are not only sensible, but also cost-efficient and practical.

We need to support efforts to create a true system of rehabilitation. Such a system will be comprehensive, coherent and internally consistent in applying evidence-based practice at all levels.
This article is based on the author's keynote presentation to the 2015 APS College of Forensic Psychologists Conference in Sydney. You can read other articles in the Beyond Prison series here.

# data[].attributes.attachment_link.title
Crime and punishment and rehabilitation: a smarter approach

# data[].attributes.attachment_link.description
This article is part of the Beyond Prison series, which examines better ways to reduce re-offending, following the recent State of Imprisonment series. Although criminal justice agencies in Australia have, in recent years, adopted an increasingly "get tough" approach, responses to crime that rely on punishment alone have failed to make our communities safer.

# data[].attributes.body
Many organizations exist to become a penpal of a prisoner, which gives prisoners the ability to feel less isolated, boosts happiness, allows them to make a change for the better, and allows them to look forward to life and have hope for life out of prison.

# data[].attributes.attachment_link.readable_text
November 9, 2015 by Nicola Jones, University of Warwick

Prisoners' lives can be significantly improved - and sometimes even saved - for the price of a stamp.

A prison pen pal scheme, currently operating in 52 prisons in England and Wales, is contributing to prisoner wellbeing, offering early warning of potential suicide and improving the chances of successful rehabilitation, says an in-depth study from the University of Warwick.

"We found that something as simple as a pen pal relationship can lead to tangible benefits for prisoners," says researcher Professor Jackie Hodgson. "Given the recent rise in prison violence and suicides, increased prison overcrowding and the current resource pressures on the prison system, letter-writing seems an extremely valuable way to provide greater support for prisoners, based on genuine relationships of care and trust, at remarkably little cost."

The potential of the Prisoners' Penfriends scheme and other initiatives to improve prisoner wellbeing will be discussed by prison campaigners, practitioners and policymakers at an event, 'Prisoner wellbeing and the experience of punishment', on 14 November at Warwick Arts Centre, held as part of the Economic and Social Research Council (ESRC) Festival of Social Science. At this one day, multi-format event Professor Hodgson will highlight evidence from unique research into the experience of more than 90 offenders, sex offenders and their volunteer pen pals.

Prisoner pen pals, her study (conducted together with PhD student Juliet Horne) shows, are typically male, serving long or indeterminate sentences and experiencing little or no contact with anyone else outside of prison. A quarter of prisoners surveyed said they had no contact at all with anyone outside the prison walls before they started writing to their pen pal.

Prisoners said having a pen pal helped them:

feel less isolated,

make changes to their self-identity,

boost their happiness through having a distraction from the routine of prison life, and

raise their hopes for life beyond prison.

"Prisoners told us about growing feelings of engagement with 'the outside world' and, as a result of being 'accepted' by their pen friend and experiencing friendship with someone who believes in their capacity for change, they began to see themselves as more than just a prisoner," Professor Hodgson, from the University of Warwick School of Law, states. "All of this raises the prisoners' chances of successful rehabilitation."

As one prisoner wrote of his pen friend: 'He is very helpful and caring and very understanding. He makes me feel like I can achieve things in life. It's made me want to be a better man when released and achieve my dreams if possible.'

Virtually all prisoners said they intended to remain pen pals for the length of their sentence: the longest pen pal relationship being nine years. As volunteers are generally aware of their pen pals' usual state of mind, they have been able (through the pen pal scheme coordinator) to alert prisons to increasingly depressed or suicidal prisoners. The scheme, Professor Hodgson points out, is viewed very positively by prison governors, not only because it helps prisoners feel happier and more positive but also because it's recognised that having someone to listen is important for prisoners who are at risk of suicide and self-harm.

Most prisoners expressed great satisfaction with their pen pal experience and gratitude to their volunteer pen pals, despite the restrictions imposed on the correspondence. To protect volunteer safety, boundaries are firmly protected and all volunteers receive training in the letter-writing process. Volunteers' personal details are never revealed, all letters - both ways - are sent via a box number and correspondence is supervised, and correspondents are not allowed to meet, even on release.

"Volunteers give no information about their families or personal circumstances, but despite these constraints, I was surprised to hear how warmly the volunteers described the people they were corresponding with and how much, despite keeping a certain distance, they enjoyed writing to their pen pal and looked forward to receiving a reply," she points out.

With more funding and more assistance from prison staff to advertise the scheme in prisons, researchers believe Prisoners' Penfriends could have far wider reach with the prison system, including, perhaps, young offenders. "Writing letters is simple but potentially quite powerful," she says. "There is so little rehabilitation in prisons that schemes such as this, which our study shows to be highly valued by prisoners, offer a win-win situation for all those involved at very little financial cost."

Provided by: University of Warwick

# data[].attributes.attachment_link.title
Pen pal is powerful boost to prisoner wellbeing

# data[].attributes.attachment_link.description
November 9, 2015 by Nicola Jones, University of Warwick Prisoners' lives can be significantly improved - and sometimes even saved - for the price of a stamp. A prison pen pal scheme, currently operating in 52 prisons in England and Wales, is contributing to prisoner wellbeing, offering early warning of potential suicide and improving the chances of successful rehabilitation, says an in-depth study from the University of Warwick.

# data[].attributes.body
The Office of Refugee Resettlement provides refugees with healthcare and helps to recognize any ailments and reduce the number of diseases. In the case of the homeless, hospitals are required to offer them medical care. Individuals who do not receive any income will not be billed. Immigrants are required to wait five years to receive Medicaid, and are less likely to be considered for healthcare than U.S. citizens. https://www.quora.com/In-the-United-States-when-a-homeless-person-receives-care-in-a-hospital-emergency-room-and-cannot-pay-for-services-who-foots-the-bill-the-hospital-or-the-taxpayers https://www.healthcare.gov/immigrants/lawfully-present-immigrants/

# data[].attributes.body
The Affordable Care Act (ACA) has helped many people attain health insurance, but there is still 28-31 million people that go without it. It is a rising problem that organizations like ACA are trying to fix, but it is still an epidemic in our world. ACA has helped over 20 million adults attain health insurance, and they are working to help more people and hopefully fasmilies.

# data[].attributes.attachment_link.readable_text
Safety-net health systems provide essential care to low-income people in the United States, including those who are uninsured. Although the Affordable Care Act (ACA) has reduced the number of uninsured persons, an estimated 28 million to 31 million Americans will remain without health coverage even after full implementation. 1,2 Inpatient, emergency, and ambulatory services for this population - as well as for millions of other patients, particularly Medicaid beneficiaries - continue to be provided by safety-net health systems.

In many communities, safety-net organizations are the sole providers of critical services such as inpatient behavioral health. However, the ACA has set in motion a number of payment reforms that create a more uncertain financial outlook for these systems. Safety-net providers must navigate these changes along with rapid shifts affecting all health systems, such as the growing emphasis on ambulatory, community-based care.

Even after full implementation of the ACA coverage expansions, an estimated 28 million to 31 million people will remain uninsured and will continue to rely on the safety net for care."

The Institute of Medicine defines "core safety-net providers" as providers who by mandate or mission offer access to care regardless of a patient's ability to pay - and whose patient population includes a substantial share of uninsured, Medicaid, and other vulnerable patients. ³ By this definition, safety-net providers are distinguished by their commitment to provide care to people with limited or no access to care. ⁴

In aggregate, safety-net providers have low operating margins and often rely on subsidies to offset the costs of uncompensated care. For example, in 2014, members of America's Essential Hospitals, an organization of safety-net health systems, averaged a 0% operating margin, as compared with the 6.4% average operating gain for all U.S. hospitals. 5,6 In 2014, among the members of America's Essential Hospitals, approximately half of all inpatients who were discharged and patients who had outpatient visits were uninsured or Medicaid patients (Table 1).

Although the safety net encompasses public hospitals, community health centers, and providers of specialized services, such as school-based clinics, our focus here is on health systems that are anchored in hospitals. In this report, we examine how the coverage provisions of the ACA are affecting safety-net health systems, characterize the responses of these systems to payment reform, and chart future directions in scaling up improvements and innovation in delivery systems.
INSURANCE EXPANSION AND SAFETY-NET FINANCING
The ACA has created both opportunities and challenges for safety-net providers as they adapt to a post-reform environment. The most direct effect of the ACA on the safety net has been the decrease in the number of uninsured adults - by approximately 20 million from 2010 through early 2016. These reductions have been driven by Medicaid expansion, health insurance marketplaces, the employer mandate to provide health insurance, and a provision permitting young adults to remain on a parent's health insurance plan until 26 years of age. Expansions in health coverage in the U.S. health care system as a whole were projected in 2014 and earlier to increase revenues from newly insured patients while reducing the proportion of uncompensated care. ⁷

Some observers have noted that ACA-related decreases in DSH allocations may provide an opportunity to better triage funding toward safety-net hospitals that need it the most."

Preliminary analyses have shown that hospitals have had a financial benefit from the ACA coverage expansion, with an overall decrease in uncompensated care from $34.9 billion in 2013 to $28.9 billion in 2014 nationwide. ⁸ In anticipation of these changes, the ACA also included provisions to reduce Medicaid and Medicare Disproportionate Share Hospital (DSH) allotments, which provide supplementary income to hospitals that treat uninsured or underinsured patients. Reductions in Medicare DSH allotments, which began in fiscal year (FY) 2014, are estimated to total $22.1 billion by FY 2019. ⁹ Meanwhile, Medicaid DSH cuts have been delayed until FY 2018. Medicaid DSH payments totaled $18 billion in 2014 and are scheduled to be reduced by 16% in FY 2018, gradually increasing to a cut of approximately 55% by FY 2025. ¹⁰

Even after full implementation of the ACA coverage expansions, an estimated 28 million to 31 million people will remain uninsured and will continue to rely on the safety net for care. Hence, for some safety-net providers, the expansion in coverage may not be sufficient to offset reductions in federal payments for uncompensated care. In one study, ¹¹ researchers examined the potential effect of the ACA Medicaid DSH reductions on the financial stability of public hospitals in California. When the high number of people who will remain uninsured, low Medicaid reimbursement rates, and inflation in medical costs were factored in, the researchers estimated that the unmet costs of uncompensated care would be between $1.38 billion and $1.54 billion by 2019.

Furthermore, safety-net providers could face competition for newly insured patients, particularly for persons with private coverage through health insurance marketplaces. The concentration of uninsured or high-risk patients with costly or complex conditions who are cared for by safety-net providers could increase as newly insured persons seek other sites of care. 12,13 Further study is needed to understand the accessibility effects of Medicaid and marketplace plans that shift considerable costs to the patient in order to keep premiums lower. ¹⁴

Given the broad shift toward value-based payment in the health care marketplace, safety-net systems and Medicaid managed care plans are likely to pursue deeper collaboration."

The net effect of insurance expansion on a particular safety-net system depends on a multitude of factors, the most important of which is the decision of the home state to expand Medicaid. In states that expand, the federal government will finance 100% of the Medicaid costs of persons who became eligible for Medicaid in the period from 2014 through 2016. That share will gradually decrease to 90% in 2020, and it will then remain at that rate in perpetuity. Thus far, 31 states and the District of Columbia have expanded Medicaid and 19 states have not; this has led to a divergence of payer mix in hospitals located in expansion states (where Medicaid utilization increases and utilization by uninsured patients declines) as compared with nonexpansion states (where the trend is essentially stable).

Figures 1 and 2 show this phenomenon in a set of 48 safety-net health systems that were members of America's Essential Hospitals from 2009 to 2014. The 48 health systems were those that responded to the survey each year (annual response rate, 81% to 95%). Similarly, an analysis of hospital discharge rates in 16 expansion states, as compared with nonexpansion states, showed increases in inpatient stays by Medicaid patients and decreases in inpatient stays by uninsured patients beginning in 2014. ¹³

Safety-net providers that are located in nonexpansion states face the risk of reductions in federal subsidies, such as DSH payments, for uncompensated care while continuing to carry a large share of uninsured patients. In some nonexpansion states such as Texas, financial pressures on safety-net systems are further augmented by state reductions in Medicaid DSH allocations. ¹⁵ The implications of DSH reductions may be most stark in states such as Georgia, which is not expanding Medicaid but which also allocates DSH funds across a broad swath of hospitals, instead of more narrowly targeting these funds to safety-net hospitals. Therefore, some observers have noted that ACA-related decreases in DSH allocations may provide an opportunity to better triage funding toward safety-net hospitals that need it the most. 16,17

In order for value-based payment initiatives to succeed, state Medicaid agencies, at a minimum, must address obstacles to timely sharing of information about beneficiaries with health systems."

In February 2016, the Medicaid and Children's Health Insurance Program Payment and Access Commission issued a report to Congress on Medicaid DSH payments. ¹⁰ The commission pointed out major data limitations but concluded that there was little meaningful relationship between the magnitude of state DSH allotments and important factors such as the number of uninsured persons in a state. The report concluded, "DSH allotments and payments should be better targeted toward the states and hospitals that serve a disproportionate share of Medicaid and low-income patients and that have disproportionate levels of uncompensated care." A first step could be changing eligibility criteria to further concentrate DSH funding among so-called deemed DSH hospitals, which serve a particularly high share of low-income patients.
HEALTH SYSTEM RESPONSES TO PAYMENT REFORM
In addition to expanding health coverage, the ACA included a variety of provisions to advance health care payment reform. Many of these payment models operate through Medicare. For example, the Hospital Readmissions Reduction Program, Hospital-Acquired Condition Reduction Program, and Hospital Value-Based Purchasing Program all create incentives for providers to deliver higher-value care through payment adjustments that are based on quality and efficiency.

Since nearly all hospitals receive Medicare payments, these reforms are not specifically targeted toward safety-net health systems. However, studies of all three programs have shown that safety-net hospitals face a higher risk of being penalized through reductions in payments than other hospitals. ¹⁸⁻²¹ For instance, the Hospital Readmissions Reduction Program has come under scrutiny for potentially unfairly penalizing safety-net systems for factors that contribute to readmissions but that may be beyond their control, such as patients' socioeconomic status. 22,23
Alternative Payment Models
Safety-net health systems have also responded to the shift to alternative payment models such as bundled payments and accountable care organizations (ACOs). ACOs are networks of providers that take responsibility for the quality and costs of care for a defined population of patients. ²⁴ The model has proliferated rapidly, with an estimated 750 such arrangements currently in place, mostly through Medicare and private payers. As of 2016, Medicaid ACOs have been launched in 8 states and are being developed in 10 more. ²⁵ For example, in Oregon, the Centers for Medicare and Medicaid Services (CMS) allocated $1.9 billion over 5 years to ACOs that accept full financial risk for their attributed Medicaid population. ²⁶ The state of Oregon agreed to reduce its per capita Medicaid spending growth from a historical 5.4% annual rate to 3.4%. It is on track to meet this target, which would result in net savings to CMS.

Among innovations in delivery systems, perhaps the most promising are efforts to address the social needs of patients who are served by safety-net institutions."

Performing well in these new financial arrangements often requires grappling with long-standing challenges with adequate access to care, particularly primary care and behavioral health, and ensuring that care is integrated across providers and delivery settings. Expanding access requires increasing efficiency and patient throughput, adding capacity, partnering with other systems, or some combination thereof. For example, Harris Health System in Houston opened multiple primary care clinics and added capacity for approximately 50,000 encounters in 2014. ¹⁵

However, adding capacity and partnering with other systems often adds to the complexity of coordinating patient care. Efforts in this domain have often focused on making improvements in the delivery of primary care (as with the patient-centered medical home model of care) and in integrating services through information technology and care management. In some ways, safety-net systems have natural advantages with respect to coordination of care. Fred Cerise, MD, the Chief Executive Officer of Parkland Health and Hospital Systems in Dallas, has described a safety-net system as being " an ACO before ACOs existed." In other words, the realities of caring for a vulnerable population with few resources spurred delivery-system transformation. ²⁷ For example, at Parkland, an emphasis on team-based care spanning inpatient and outpatient settings contributed to the development of a physician-led diabetes program. This program has established universal standards of care such as standardized protocols for insulin titration and has implemented the standards with electronic decision support and regular provider feedback. Similarly, Montefiore Medical Center, a safety-net institution in the Bronx, New York, created a care management organization in 1996 in response to patients' needs. This organization involves telehealth, house calls, and a centralized contact center to help patients navigate the health system. ²⁸
Other Value-Based Payment Reforms in Medicaid
The multibillion-dollar Delivery System Reform Incentive Payment (DSRIP) program is a pay-for-performance approach to Medicaid financing. ²⁹ The first DSRIP initiatives were approved in California, Texas, and Massachusetts in 2010 and 2011, followed by New Jersey and Kansas in 2012, New York in 2014, and New Hampshire in 2016. Washington State is awaiting approval to implement its program.

Although the exact structure and requirements of each DSRIP program differ from state to state, these programs generally encourage the development of infrastructure and system redesign (e.g., expansion of primary care and integration with behavioral health) to improve outcomes across populations of patients. ³⁰ In states with DSRIP waivers, funding flows to health care providers when performance targets (e.g., reducing avoidable hospitalizations) on specific projects to reform care are met. ²⁹ For example, the New Jersey DSRIP waiver, which includes all acute care hospitals in the state, offers its hospitals a menu of 17 potential projects under 8 priority health conditions such as cardiovascular disease and substance abuse.

Although such bright spots may be growing, policy aimed at expanding these approaches must confront technology and workforce limitations in safety-net systems."

Meanwhile, in April 2016, CMS announced sweeping new regulations for managed care plans that contract with state Medicaid programs to provide benefits to enrollees. ³¹ Managed care arrangements have grown rapidly in recent years and now cover approximately 73% of all Medicaid beneficiaries, as compared with 10% approximately 25 years ago. 32,33 The new CMS rules, the first since 2002, address improvements in accountability and quality of care, modernizing regulatory requirements, and ensuring protections for beneficiaries. ³⁴ Most notably, the regulations specify a medical-loss ratio requiring that at least 85% of the revenue of managed care plans be spent on medical care. Major implications for provider systems include time and travel standards to measure adequate access to care. These regulations also allow for short-term Medicaid funding of inpatient treatment for mental illness and addiction disorders.

Given the broad shift toward value-based payment in the health care marketplace, safety-net systems and Medicaid managed care plans are likely to pursue deeper collaboration. For example, Cook County Health and Hospitals System in Chicago launched a Medicaid plan in 2013 to cover many of its previously uninsured patients and contribute to the overall financial health of the system, according to hospital executives. ³⁵ The challenges of integration of safety-net systems and Medicaid managed care plans are manifold and parallel those in non-Medicaid plans, such as maintaining adequate capital reserves. ³⁶ However, in order for value-based payment initiatives to succeed, state Medicaid agencies, at a minimum, must address obstacles to timely sharing of information about beneficiaries with health systems, and these agencies may help to play a convening role in risk-bearing arrangements such as ACOs.
SCALING UP DELIVERY-SYSTEM IMPROVEMENT AND INNOVATION
Coverage expansion and payment reform under the ACA have provided an impetus for transformation of the safety-net delivery system. Improvement of the delivery system encompasses the following changes: increasing capacity, particularly in ambulatory care; extracting efficiency gains through streamlined operations and procurement; better coordinating care, both within systems and across safety-net providers in a given community; investing in information technology and other infrastructure; and retaining existing patients and attracting new ones. ³⁷ The ability to respond to the evolving policy milieu often depends on local factors such as the stability of funding sources, a political commitment to safety-net systems, and the competitiveness of the market for health care services.

Among innovations in delivery systems, perhaps the most promising are efforts to address the social needs of patients who are served by safety-net institutions. ³⁸ For example, Hennepin Health, a Minnesota safety-net ACO, comprises a public health department, a county hospital, a community health center, and a nonprofit health plan. This ACO showed favorable initial results in managing the cost and quality outcomes of a small Medicaid population. ³⁹ The intensive, collaborative approach to high-risk patients combines medical care with delivery of social services such as housing support and vocational counseling. More generally, improved integration across city and state agencies could help generate a more holistic approach to people's needs, whether they are patients in the health care system or clients who need housing support or social services such as Supplemental Nutrition Assistance Program benefits. ⁴⁰

The challenge at all levels of policy development is to guide improvement in delivery systems while preserving the essential services provided by safety-net health systems in communities across the United States."

Although such bright spots may be growing, policy aimed at expanding these approaches must confront technology and workforce limitations in safety-net systems. ⁴¹ Succeeding in new delivery-system arrangements may require up-front seed investment for information technology, hiring, and training. Financial pressures and regulatory flexibility, as in some instances of Medicaid DSRIP waivers, have already begun to shape the restructuring of the health system among safety-net providers. In many cases, this has led to a shift in the center of gravity of safety-net systems from inpatient capacity to ambulatory care - and particularly primary care. Yet, although federally qualified health centers received an infusion of funding under the ACA, safety-net health systems, which also often operate ambulatory clinics, face a more uncertain financial future. 42,43

Persistent financial challenges up the ante for safety-net health systems to prioritize higher-value care delivery. Generally, financial strategies distill down into increasing revenue or reducing costs. ¹⁵ On the revenue side, for example, the Virginia Commonwealth University system is diversifying its payer mix to increase the proportion of commercially insured patients. It is augmenting clinical services such as oncology and a transplantation program around this strategy. Efforts to reduce the cost structures of health systems, particularly fixed costs associated with inpatient services, could also help mitigate the effect of declining governmental subsidies. Several systems have pursued gains in efficiency by addressing clinician productivity and adopting process-improvement approaches. Denver Health is perhaps the best-known example of a safety-net system that disseminated a "lean" approach, derived from the Toyota Production System, across its enterprise. The former Chief Executive Officer of Denver Health, Patricia Gabow, attributed approximately $170 million in savings (from 2006 through 2012) - and a considerable increase in patient-satisfaction rankings - to the lean approach. Improving patient satisfaction, in turn, can help safety-net systems stay competitive in health care markets with multiple options for newly insured patients.

More could be done to align the incentives for community health centers with those for safety-net hospitals. For example, health centers could move toward value-based payment models that blunt the financial rationale for increasing the volume of visits. Approximately 17% of Medicaid and uninsured patients received care at federally qualified health centers in 2014. ⁴⁴ Given the considerable overlap in populations served, several hospital-based systems such as San Francisco General Hospital and Boston Medical Center are exploring tighter partnerships with neighboring community health centers. ⁴² States such as Colorado, Oregon, and New York are moving toward a regionalized approach to care for Medicaid beneficiaries. This approach seeks to lower the regulatory barriers to such collaboration.

Beyond Medicaid, the municipalities of San Francisco, Los Angeles, and New York City, as well as the state of Massachusetts, have all organized direct-access programs for uninsured people seeking care, including undocumented immigrants. These programs also require new arrangements for care coordination among various types of safety-net providers. Federal policy could build on these local and state initiatives by judiciously permitting additional flexibility in blending funding streams toward increasingly seamless care for both Medicaid beneficiaries and uninsured persons.
CONCLUSIONS
Understanding the effect of the ACA on the safety net will require additional study, particularly of the local dynamics of changes in insurance status and the financial ramifications for health systems. Yet federal and state policymakers may have to make major decisions, such as how to rationalize DSH funding, with imperfect information. Downstream of these decisions, local policymakers are already confronting difficult choices about the character - and even the continued existence - of certain safety-net health systems. The challenge at all levels of policy development is to guide improvement in delivery systems while preserving the essential services provided by safety-net health systems in communities across the United States.
The views in this report are those of the authors and do not necessarily reflect the views or policies of New York City Health and Hospitals. SOURCE INFORMATION
From New York City Health and Hospitals (D.A.C., J.E.C., R.M.W.), New York University School of Medicine (D.A.C.), and New York University College of Global Public Health ( J.E.C.) - all in New York.

For the full list of references, click here.
This Health Policy Report originally appeared in The New England Journal of Medicine and then in NEJM Catalyst on November 18, 2016.

# data[].attributes.attachment_link.title
Health Reform and the Changing Safety Net in the United States

# data[].attributes.attachment_link.description
Safety-net health systems provide essential care to low-income people in the United States, including those who are uninsured. Although the Affordable Care Act (ACA) has reduced the number of uninsured persons, an estimated 28 million to 31 million Americans will remain without health coverage even after full implementation.