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This has serious consequences, both for the individual children and for the country as a whole. The infant and toddler years are a critical time period for child development, and they can shape a person’s outcomes for the rest of their lives.  And since our country is growing more diverse every year—the majority of young children are now children of color—the soaring poverty rates among children from diverse backgrounds is risking our long-term economic stability.

Home visiting programs, which connect families with trained professionals who help create healthy and safe home environments, are proven to directly address many of the harmful impacts of poverty before the effects take hold. The benefits are dramatic—families who voluntarily participate in these programs have improved child and maternal health, increased school readiness, prevented child abuse and neglect, and reduced participation in the juvenile justice system.

Here’s how it works

When parents bring their baby home from the hospital, they don’t come with a handbook. Home visiting aims to be the next best thing, by connecting parents and families with professionals—who may be nurses, social workers, or other trained parent educators—in their own homes through regular visits. Home visitors partner with parents to develop strong parenting skills, ensure child and family safety, and access other community resources and social services.

The services families receive during a home visit can vary depending on the specific needs of the family. A home visitor may work with a new mom to help her understand the importance of breastfeeding, or how praising a child can reinforce positive behavior. They may screen for signs of child abuse and neglect or domestic violence, and refer families to other health and social services. Home visitors will also help parents to set goals for the future—they might work together to develop a plan to go back to school, look for a job, or identify safe and reliable child care.

The results are impressive

Home visiting programs have been proven to benefit everything from child and maternal health, to increasing school readiness, to reducing child abuse and neglect. In 2014, 70% of federal home visiting program grantees saw reductions in the rate of tobacco, alcohol, and illicit drug use among enrolled mothers.  Similarly, 79% of grantees saw an increase in the household income of families participating in home visiting, and 76% saw an increase the rate at which women and families are screened for domestic violence.

These programs are so effective that they end up saving taxpayers money in the long-run. For example, improved health among participating families can lead to Medicaid savings by reducing health care costs, and improved school readiness can boost a child’s academic achievement later in life and lower participation rates in special education. In fact, for every dollar invested in these programs, we see a return of up to $5.70 in reduced federal and state costs and social benefits.

But it doesn’t reach enough people

Home visiting only reaches a small portion of families living in poverty. In 2015, 145,500 children and parents—less than 10% of families in poverty across the US—received federally-funded home visits. Even when home visiting services are available, many of the people who would benefit are unaware that they exist or unfamiliar with how they work.

What’s worse, federal funding is at risk of expiring if Congress fails to act. The Maternal, Infant, and Early Childhood Home Visiting, or MIECHV, program is the single largest funding source for home visiting—it’s the only guaranteed source of funding in all 50 states, and it provides $400 million per year to expand evidence-based programs. Since it was established in 2010, MIECHV has expanded home visiting programs so that they now reach families in every state, the District of Columbia, and 5 territories across the United States. After the original authorization ended in 2014, MIECHV received two short-term reauthorizations—the most recent of which is slated to run out at the end of September 2017.

Where do we go from here?

Without action from policymakers, the families who currently participate in the federal home visiting program may lose a critical source of support. Worse yet, millions of others will never benefit from a highly effective program. In many states, MIECHV is the only source of financial support for home visiting, and without it services would disappear.

Rather than letting a highly effective program expire, Congress should increase MIECHV funding and extend the program for a minimum of five years. That way the program will reach more of the families who need it, and states will be able to focus on providing services rather than worrying about finding sustainable funding.

As we see from last week’s Census data release, there are still too many young children and children of color bearing the burden of poverty. In the long run, this will only exacerbate inequality and harm our country’s economic outlook. Home visiting has the potential to address inequality before its effects are realized—if the program is given a chance to succeed.

Two Census reports—the Current Population Survey and the American Community Survey—are critical resources for advocates, researchers, journalists, and policymakers alike. They provide rich information on issues that impact people’s health and economic wellbeing, ranging from their living situations, to public benefits usage, to how much money they earn.

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These data, which are for 2015, inform us about what is working to cut poverty and reduce inequality, and how we might do better from a public policy perspective. Here are four key trends wonks will be examining closely:

Incomes are rising—likely for minimum wage workers, too

Some researchers are forecasting that real median household income might see the largest one-year jump in more than a decade. Low-wage workers should see a rise, too—especially in states that raised their minimum wage. This increase is particularly important for women, who make up nearly two-thirds of all minimum wage workers.

Rising wages, particularly for low-wage workers, could mean that this is the year we learn that the gender wage gap among full-time workers—which stood at women earning 79 cents for every dollar earned by their male counterparts—finally broke the 80 cent-barrier. (Not quite shattering this particular glass ceiling, but moving a step closer!)

Anti-poverty advocates will also examine these data to see if the income gains will reach families in deep poverty—those who have incomes of less than half the poverty line (approximately $12,000 annually, for a family of four).

Don’t kid yourself—racial and gender inequalities are alive and well

Any improvement in the poverty rate and the gender wage gap is critical, but we’re a long way from widespread economic equality. For example, the wage gap for women of color is severe: Last year, African American women typically earned only 60 cents, Native American women 59 cents, and Hispanic women 55 cents, for every dollar earned by their white Non-Hispanic male counterparts.

These gender and racial disparities apply to poverty rates, too. Hispanics and African Americans experienced poverty rates about 2.5 times higher last year than white Non-Hispanics. Women are also more likely to face poverty, as are individuals born in a foreign country, persons with disabilities, and single-parent families.

There is a hidden story in these data about who is more likely to be poor and paid unfairly that wonks and others need to shine a light on.

The data are seriously flawed—especially for LGBTQ people

Every year this Census release sparks conversation about how the stats themselves could be improved. Two topics come up repeatedly: The flawed way that we measure poverty and the shocking lack of data about LGBTQ people.

There is widespread agreement that the federal poverty line—$24,300 for a family of four in 2016—is far too low, which means many more Americans are experiencing serious economic hardship than are deemed officially “poor.” This disconnect isn’t surprising, considering the Official Poverty Measure (OPM) was developed more than half a century ago. A lot of things have improved since then—cars, phones, computers, Americans’ appreciation of soccer—but the OPM hasn’t, even as families’ needs and spending patterns have changed dramatically.

The OPM also fails to account for numerous public policies that relieve hardship. This is one reason why many wonks are fans of the Census Bureau’s alternative Supplemental Poverty Measure (SPM).

The SPM includes income households receive through assistance programs like the Supplemental Nutrition Assistance Program (SNAP), which lifted 4.7 million people above the poverty line in 2014; as well as tax credits such as the Earned Income Tax Credit and Child Tax Credit, which together lifted 9.8 million people out of poverty in 2014. The SPM also incorporates some of households’ necessary expenditures, such as clothing and utilities, and geographic variation in housing costs.

While these poverty measurements are less than ideal, they are far better than having almost no data at all—as is the case for members of the LGBTQ community. The lack of sexual orientation and gender identity data in these data sets is glaring, given that the limited data we do have demonstrate that LGBTQ individuals face higher poverty rates than many other communities. Since funding for anti-poverty initiatives often depends upon being able to show that economic need exists, this dearth of data can prevent the LGBTQ community from receiving help even when there is a clear need.

We must redouble our efforts to ensure we collect much-needed data on the LGBTQ community while also working to reform the way we are collecting and measuring poverty data.

Public policy choices reduce or exacerbate poverty, inequality, and hardship

Last year the Census data demonstrated the huge impact the Affordable Care Act had on Americans’ health care coverage, as uninsured rates fell to a historic low with declines in all 50 states and the District of Columbia. This year wonks anticipate a new low in the uninsurance rate—perhaps even below 9 percent—though it would be even lower if more states expanded Medicaid coverage.

Next week’s release will also show how other smart social programs are effectively reducing poverty. For example, last year’s SPM data revealed that without Social Security fully half of American seniors would have been poor, and that without refundable tax credits, nearly 1 in 4 children would have fallen below the poverty line as well. This evidence has fueled increasing calls from advocates and policymakers to strengthen and expand Social Security, refundable tax credits, and other key safety net programs.

Wonks look forward to continuing to assess our public policy choices based on this year’s data.  We already know a lot about what to do to reduce hardship, boost economic mobility, and increase opportunity.  The new Census data can help us move in the right direction—if we ask the right questions, and look for the answers.

One such product hit the shelves last year when oil behemoth Baker Hughes—which specializes in hydraulic fracturing, or “fracking”—joined forces with breast cancer foundation Susan G. Komen to produce pink drill bits. Fracking, a procedure by which oil is extracted from the ground, is highly toxic. More than a quarter of the chemicals used are known carcinogens, and some are linked to breast cancer. On top of that, fracking is more likely to occur in impoverished areas, where medical care—let alone care for breast cancer—is already difficult to come by.

A few years prior, Susan G. Komen teamed up with an unlikely ally: Kentucky Fried Chicken. The fast-food chain packaged its signature dish in pink and pledged a donation to its partner for each “Bucket for the Cure” sold. The campaign stirred a fair deal of controversy—and rightly so, as fried meats are associated with breast cancer. In addition, the campaign marketed its product—with all of its adverse health implications—primarily to the poor in a dubious effort to access hard-to-reach populations. The fast-food chain is found largely in low-income neighborhoods, where healthier food options are often out of reach for most residents.

To be sure, not all campaigns against breast cancer have raised so many eyebrows. Some 67 percent of women at high-risk ages have received mammograms within the past two years, a statistic that, while far from perfect, attests to the success of many awareness campaigns. Billions of dollars are poured into breast cancer research annually, which is surely another part of the reason that breast cancer patients now enjoy a five-year survival rate of close to 90 percent, up from about 75 percent in 1980.

But a closer examination of the numbers reveals a much more grim reality. Gains from the war on breast cancer have by and large sidestepped women of color and low-income women, and instead have accrued largely to more privileged patients. Prior to 1980, such shameful disparities did not exist. Black women and white women faced nearly identical mortality rates of about 33 deaths per 100,000. But today, black women are most likely to die from the disease. Researchers say that biological differences do not account for differences in survival.

A 2015 study found that black women were between 40 and 70 percent more likely to have a late diagnosis, when they are already in the advanced stages of breast cancer. Hispanic women were 30 to 40 percent more likely to be diagnosed in advanced stages. Late detection, of course, so often translates to higher costs of care and lower survival rates.

Race even impacts the quality of treatment that breast cancer patients receive. The same 2015 study concluded that black women were between 30 and 60 percent more likely than white women to undergo inappropriate treatment for the disease, and Hispanic women were 20 to 40 percent more likely.

Research cannot fully explain these disparities, but poverty is a clear factor, facilitated by woeful public policies and institutionalized racism. Women in low-wage jobs without paid sick leave—disproportionately women of color—are less likely to receive the preventive care necessary to detect breast cancer in its early stages. As a result, these women are more likely to die from the disease. One study found that, while 63 percent of women with paid sick leave had received a mammogram within the past year, only 52 percent of women without paid sick leave had gotten one. And it makes sense. The 40 million workers who toil without paid sick leave risk reductions in precious income or even the job itself for time away. Preventive care cannot be a luxury only afforded to those in comfortable jobs.

While breast cancer has no cure just yet, solutions to health disparities like these do exist. Paid sick leave is among them. Clinics funded through Title X—the federal grant program that is constantly under threat—offer mammograms to low-income women and serve as a lifeline for those otherwise on the margins of care. Medicaid, too, has proven an invaluable source to those in poverty, but 19 states have refused to expand the insurance program under the Affordable Care Act. This policy choice has dire consequences. It is in some of these states—like Alabama, Kansas, and Oklahoma—where women are most likely to die from breast cancer.

When black patients die from breast cancer three years before white patients, and low-income women face impossible choices between the care they need to survive and their livelihoods, we need to embrace policies—not pink drill bits—to curb our unjust health disparities.

This scenario is common. Hardworking direct-care workers give up their jobs because of untreated injuries and chronic illnesses that could have been managed if the worker had access to health coverage. Our new analysis, “Too Sick to Care”, finds that nearly 300,000 of America’s paid caregivers—nursing assistants, home health aides and personal care aides who provide care and assistance to millions of our nation’s elders and people with disabilities—have been denied coverage because they live in one of the 21 states, mostly across the deep South and Midwest, that have rejected federal funds from the Affordable Care Act for Medicaid expansion.

These workers fall into the “coverage gap”—that is, without expansion they are ineligible for Medicaid coverage but earn incomes below the minimum threshold (100 percent of the federal poverty line or $24,250 for a family of four) required to receive tax credits to buy coverage on a state market exchange.

Solving this coverage issue for direct-care workers is significant not only for them but for all of us.

With growing numbers of elders and people with disabilities, the demand for direct-care workers—particularly those who care for clients in their homes—is skyrocketing. The two home care occupations—home health aide and personal care aide—will create more new jobs between 2012 and 2022 than any other occupation.

If a large percentage of these workers are unable to access health coverage, we will find it increasingly challenging to find the care we need for ourselves or our loved ones. For people living with disabilities, this isn’t simply an inconvenience, it is a barrier to exercising their civil rights. On the 25^th anniversary of the Americans with Disabilities Act, it is important to remember that living independently in the community—a right that people have fought for, for decades—requires access to a robust and stable workforce.

But long-term care employers, particularly those who provide supports in private homes, are already reporting that they cannot find or retain sufficient numbers of workers to meet the demand for services. It’s not surprising: average wages are less than $10 per hour; injury rates are higher than in almost all other occupations; and employer-sponsored health coverage is uncommon. The reality is that one in two workers leave the job each year. This turnover is highly disruptive for clients and undermines the overall quality of care.

So what can we do to ensure that direct care workers don’t go without health coverage themselves?

First, and foremost, we need to continue to advocate for states to expand Medicaid coverage. Direct-care workers are 32 percent less likely than other workers to have employer-sponsored coverage, making Medicaid an important option.  Long-term care employers who depend on Medicaid reimbursement for the majority of their revenues often can’t afford to offer health coverage. For example, in North Carolina, the state pays only $13.88 per hour for personal care services. The average wage for a personal care aide is $9.18, making it extremely difficult for the provider to also provide health coverage.

One solution would be to provide a “differential reimbursement rate” for high-road employers who make affordable health coverage for their workers a priority. Under this scenario, states would pay providers an additional amount per hour of service provided. Recognizing the recruitment challenges in their state, the Maine legislature recently increased Medicaid reimbursement to home care providers from $15 to $25 per hour. The legislation is essentially a “wage pass-through.” Almost the entire increase (85 percent) must be used to increase direct-care worker wages and benefits, including health care coverage, as opposed to being used to fund administrative or other agency expenses.

Finally, about 25 percent of direct-care workers are immigrants. Unfortunately, lawfully residing immigrants who have lived in the US for less than five years cannot access Medicaid coverage for themselves or their children, although 14 states extend some health benefits through state programs. Undocumented immigrants are not eligible for either Medicaid coverage or federal subsidies. Recently, the California State Senate passed a bill to offer coverage to undocumented immigrants in their state. A better solution would be for Congress to create a path to citizenship for direct-care workers, thereby expanding opportunities and improving wages and benefits, and growing and stabilizing the workforce.

As Rosalynn Carter once said, “You have either been a caregiver, you are a caregiver, you will be a caregiver, or someone will care for you.” Acknowledging this universal reality, we must expand coverage to all direct-care workers so that they can continue to provide quality care for those who need it while also caring for themselves and their families.

Throughout its history, Medicare has been effective at reducing poverty for older people and people with disabilities, and at increasing access to health care. In the program’s very first year, more than 19 million people over age 65 enrolled; access to care increased by one-third; poverty among older and disabled Americans decreased by nearly two-thirds; and personal economic security increased for older people and their families.

As Congresswoman Rosa DeLauro said, “Medicare is a bedrock part of the American social insurance system.” It has provided peace of mind for millions of Americans, who know they will have reliable health care coverage in retirement. The program covers people most in need of care—people who often wouldn’t be covered by private insurers or couldn’t afford such insurance. It also strengthens families by limiting the financial burden of health care costs for their older and disabled relatives.

Many people are unaware that Medicare has also helped change our society. For example, its creation was a huge boost for civil rights. Any hospital wishing to collect Medicare funds had to desegregate to qualify for payments. As a result, thousands of hospitals fully desegregated in only four months.

Medicare has seen many positive changes.  It added hospice coverage in 1982 and now almost half of beneficiaries who die use this important benefit. In 2008, Medicare coverage of mental health services changed, so that these services were reimbursed at the same rates as other Medicare-covered services delivered in the same care settings. As a result, hospital care for mental health services no longer costs more than hospital care for a physical health problem.

In 2010, the Affordable Care Act added a decade of economic security to the Medicare Trust Fund, increased free preventive services, and increased parity between traditional Medicare and private Medicare plans.

A recent “improvement” came about as a result of work by the Center for Medicare Advocacy – where I serve as the Executive Director – and by our partners at Vermont Legal Aid. When Medicare beneficiaries have a chronic condition, such as Alzheimer’s or Multiple Sclerosis, they often need skilled care in order to maintain their condition or slow deterioration. Medicare regularly denied such coverage because the beneficiaries weren’t “improving.” This harmful practice impeded access to necessary care and placed an unfair burden on families who were forced to pay for these services. As a result of a 2012 settlement with the Centers for Medicare & Medicaid Services, coverage for skilled care can no longer be denied simply because an individual isn’t improving. Coverage is available for skilled care to maintain an individual’s condition.

Despite Medicare’s success, it faces threats like never before. From privatization to coverage denials, to political pressure that would limit coverage and increase costs for beneficiaries in the future. However the Center for Medicare Advocacy is advocating for a number of common sense solutions that would better protect beneficiaries and help improve Medicare’s financial security, without cutting benefits or coverage. These include:

• Paying Medicare Advantage at the same rates as traditional Medicare. Private plans should not be paid more than traditional Medicare. This would save more than $132 billion dollars over 10 years;
• Adding a prescription drug benefit to traditional Medicare;
• Requiring Medicare to obtain the best prices for prescription drugs — — which would save more than $141 billion over 10 years;
• Fixing the broken Medicare appeals system by eliminating one of the first levels of review. The vast majority of reviews at the initial and second levels are “rubber stamp” denials which simply add bureaucracy and waste money. This would save around $100 million per year in operating costs.

Medicare works well for the American people and it has for 50 years. Let’s ensure that it stays strong and continues to open doors to health insurance and health care for our nation’s most vulnerable people and their families.

Now, I watch and wait for the Supreme Court’s Decision in King v. Burwell and the looming budget fight—each of which will decide the fate of the Affordable Care Act, a law I could have used in 2010.

Back then I was in the best shape of my life. Years of walking to work had helped. At 26, I learned to ride a bicycle and for one month, I flew. The hour that it took to get to and from work became fifteen minutes. I could buy cold food in the summer again. Bowling Green, Kentucky became small enough that I no longer had to factor in travel time.

And then I played basketball.

My best friend at the time, Emily, texted me asking me to meet her at her apartment so we could walk over to the nearby basketball court—which was actually just a basket at the edge of a church parking lot—and shoot hoops for a couple hours. Emily played basketball in high school and I lack basic hand-eye coordination skills, so when I landed awkwardly after coming down from a layup, grabbing the post for support, she didn’t think anything about it. But then, I didn’t let go. I held my left foot off the ground.

She asked me if I was alright and I told her I hoped so. She asked me what it felt like and the first thing that came to mind was that scene in Indiana Jones and the Temple of Doom when Indy drops the guard into a rock crusher. Emily cringed and asked me which hospital we should go to.

I laughed.

She asked me what I wanted to do since I wouldn’t go to the hospital. I didn’t know. I asked her to bring me my phone. She came back with it and asked me if I’d be okay if she left for a minute. She was going to get me an ice bag and a slushie. Blue Raspberry.

Slushies make everything better.

I laid down in the parking lot and watched its parking lights go out and called the owner of the restaurant I worked at. When he asked me about the hospital, I could only manage a chuckle. He asked me what he could do for me and I asked him if he had the crutches he brought back from his last failed ski trip and if I could borrow them for a while. “Absolutely.”

Next, I called a couple of the marijuana enthusiasts from work and asked them to meet me at my apartment. An hour later we met up at the front door and Emily helped me climb up the flight of stairs while the others kept asking why I couldn’t go to the hospital. “Obamacare passed,” they said. “It hasn’t kicked in yet,” I answered.

I fell onto my bed and waited while the saintly stoners sparked a joint. While it worked wonders otherwise, the weed wasn’t strong enough for my ankle. Even though I didn’t feel any better, I was content not to care.

The next day my roommate, Travis, drove me to work for comfort food—a Reuben. While I sat in the dining room with my engorged ankle propped on a chair, one of my new hires came over to me and asked what I meant to do about the ankle. “First, I’m going to eat this Reuben. Then, I’m going to go to Lowe’s and get some scrap wood and nail together a brace… thing.” She smirked and told me her fiancé was an MMA fighter (the pale guy), that he broke his foot the year before and held on to the walking boot. “I mean, you shouldn’t walk on it now, but it’ll hold it in place until you can.”

I was on the crutches for six weeks.

I gave up on trying to self-medicate. Not only did the weed fail to do the trick, but also Kentucky’s burgeoning crackdown on prescription drug abuse meant that I couldn’t score so much as a pity Vicodin. I stayed in the walking boot for six months and even managed to shower four times a week without falling.

Then, one day in November, I woke up, strapped my leg into the boot and started itching. My leg wouldn’t go for the walking boot anymore. I grabbed the cane I had bought to mark the occasion and headed down the stairs and out the door. What had been a ten minute walk down to the city square took twenty. My left leg was half the size of my right. When I got on my bike I had to pedal twice as hard with my right leg as I could my left.

I was lucky when I broke my ankle. I knew the right people and (the Commonwealth notwithstanding) could procure the right supplies.

But there is a reason this story stays with me: I live in the USA, the richest, most powerful country in the world. Why did we and do we leave our health and well-being up to luck? Shouldn’t the “Shining City on a Hill,” the birthplace of modern democracy, the land of the free be shining and modern and free enough to manage the health of its citizens with something other than luck?

That’s something to celebrate – but the celebration could be short-lived for many people. Instead of figuring out how to get more people health coverage in 2015, many newly-elected and re-elected state legislators and governors are actually plotting how to take health care away from people who just received it for the first time.

It’s a real threat to people who’ve just gained coverage through Medicaid expansion – especially in states where incoming lawmakers are openly hostile to anything related to the Affordable Care Act. Those at greatest risk of losing coverage are women and people of color.

In Arkansas, where 211,000 people recently gained coverage, the state legislature must reapprove the Medicaid expansion plan by a three-quarters majority again in 2015. The incoming Republican governor is unenthusiastic about the plan – and expansion opponents won seats in the legislature. That doesn’t bode well.

In Ohio, where more than 400,000 people have coverage under Medicaid, the state legislature is also required to reauthorize the program in 2015. And in New Hampshire, where more than 20,000 people enrolled in just three months, the new Republican majority in the NH House of Representatives will also take a fresh vote on the program as well.

The continuing failure of more than 20 states to adopt any expansion plans at all, and the prospect of newly elected legislators revoking expanded coverage for hundreds of thousands of residents, represents a serious health threat to women.

A recent 50-state report card on women’s health by the Alliance for a Just Society clearly shows that most of the states that rejected Medicaid expansion have poor or failing records on women’s health. When it comes to ensuring that women have access to health care, the majority of legislators in these states have turned their backs on women.

The 2014 Women’s Health Report Card ranks and grades every state in the country on 30 distinct measures of women’s health. The results: 17 of the 21 states that rejected Medicaid expansion received final grades of C, D or F – and 13 of those states received a D or F.

Politicians in these states are failing women, but they are especially failing women of color who are more likely to be working low paying jobs, not covered by health insurance, and are least likely to have access to medical care.

The number of black women without health insurance is at least 20 percent higher than for women overall in 17 states. The uninsured rate for Latina women is at least 50 percent higher in 44 states. Black, Latina, and Native American women without access to health care have dramatically higher rates of hypertension, diabetes and infant mortality than other women.

While it’s encouraging news that Wyoming, Montana, and even Idaho seem to be moving toward Medicaid expansion, it will also leave our nation with a disturbing illustration of how alive and well racial segregation is in America. Take a look at the map of states that are refusing coverage to their most vulnerable residents: being denied access to health care is the latest Jim Crow.

Lawmakers in states that haven’t expanded Medicaid yet should move quickly to adopt expansion plans this year. If they don’t, they will bear the responsibility for their states falling even further behind on women’s health, and worsening racial disparities in our health care system.

As for lawmakers considering a vote to take health care away from thousands of their constituents, all I can ask is: Seriously? Do you really want to do that?

It’s one thing to stand in the way of people gaining access to quality, affordable health care. But it’s something else when people have just experienced quality, affordable health care for the first time, and then you snatch it away from them.

I can’t imagine that many will take kindly to it. And just in case anybody’s forgotten, there’s another election just a couple years away.

This is not an issue unique to New York City. Across the country, people with mental health needs are too often warehoused in overcrowded, chaotic, and violent correctional facilities rather than treated in the community.

The Affordable Care Act (ACA), however, presents a tremendous opportunity to address this national crisis and ensure that patients like Murdough don’t end up on Rikers Island. The ACA provides one of the largest expansions of mental health coverage in U.S. history—extending it to 27 million people who previously lacked health insurance—and a wider range of benefits to 62 million U.S. citizens overall. Millions of uninsured, undertreated, and destitute people cycling through correctional systems will be covered for the first time.

This expansion of treatment opportunities, coupled with bipartisan agreement that we need a comprehensive overhaul of the criminal justice system, presents a rare opportunity for reform that we can and must seize.

The criminal justice system has expanded to such a degree that mass incarceration is now one of the major public health concerns facing poor communities, according to a new report from the Vera Institute of Justice. Since the 1970s, state prison populations in the U.S. have grown by 700 percent. Yet the nation’s overuse of incarceration succumbed to the law of diminishing returns long ago—creating more harm than good—with widening disparities in health as one of the results.

The concentration of incarceration and the omnipresence of the criminal justice system in the lives of residents in poor communities of color are well documented.  Now research is starting to reveal the extent to which mass incarceration impacts community health. For example, decades of disparate exposure to incarceration among communities of color has fractured families and exacerbated socioeconomic inequities in ways that have contributed to wider gaps in infant mortality rates between black and white Americans.

The criminalization of addiction and mental illness is a core driver of overall health disparities in the criminal justice system. The War on Drugs in essence delegated to criminal justice agencies what should be the responsibility of our community health system. As a result, people coping with serious clinical conditions are gravely overrepresented in correctional facilities. Yet the traditional punitive tactics that corrections departments too frequently turn to—such as solitary confinement—tend to promote the very behavioral problems that lead to incarceration.

There are signs that the social and political climate is changing. U.S. Senators Rand Paul (R-KY) and Cory Booker (D-NJ) have reached across the aisle to work on federal legislation that aims to remove the stigma and legal barriers that prevent millions of Americans with a drug conviction from securing employment and public benefits. Additionally, state officials are pursing legislative and programmatic solutions to trim their prison populations: A recent Vera study found that more than 29 states have amended, scaled down, or repealed laws that mandated lengthy prison sentences for drug and other crimes.

But undoing mass incarceration’s public health crisis will require more than changing sentencing laws and providing people with health insurance. We also need state and local investments to establish a robust network of community health centers and a culturally competent workforce in neighborhoods where mass incarceration is most entrenched.  These investments are needed in order to stop relying on jails and courts as default healthcare providers.

This strategy is being pursued in New York City, where Mayor Bill DeBlasio announced a sweeping plan to prevent people with mental health needs from ending up at Rikers Island when they encounter law enforcement. The plan includes the opening of a Public Health Diversion Center, under the auspices of the New York City Department of Health and Mental Hygiene. It would redirect people to community-based services—in lieu of arrest and prosecution—in communities where health disparities and incarceration are most prevalent. The diversion center would include a 24-hour drop-off location where people accused of low-level crimes could receive health services, withdrawal treatment, case management, overnight shelter, and food.

Finally, we need our political leaders to repeal unjustly harsh policies that deprive individuals who have served their time—and their families—of a fair chance at finding secure housing, entering the labor market, and rising out of poverty.

Momentum is building in the right direction. Ending mass incarceration and restoring the health of our communities is a mission that we all must get behind.

Maybe you’ve heard about the tragic death of 12-year-old Deamonte Driver.  His mom couldn’t find a dentist who would accept Medicaid and she couldn’t afford the $80 extraction for his infected tooth. Sadly, Deamonte’s dental-related death is not an isolated incident. In fact, the American Dental Association (ADA) reports that over an eight-year period, 66 people died after being hospitalized for a dental infection.

The good news is we already know how to dramatically improve access to dental care: allow mid-level dental providers—similar to physician assistants and nurse practitioners—to perform routine care. It’s a safe, cost-effective and productive solution to the crisis.  However, progress is being blocked by an organization that you might least suspect would stand in the way—the ADA.

Mid-level dental providers have been utilized by more than 50 countries for almost a century and are now practicing in Alaska, Minnesota and Maine. In all, more than 20 states are currently considering allowing these health professionals to provide routine and preventive care like cleanings, fillings and some extractions.

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While studies show conclusively that mid-level dental providers deliver safe, quality care, these workers also boost the economy. They allow dentists to grow their practices and increase revenues while treating more patients. The model creates new, good jobs that offer a career ladder for current dental employees. Finally, by improving the health care options available to employees and their families, implementing mid-level dental  helps communities attract new businesses.

While the ADA’s own journal acknowledged “a variety of studies indicate that appropriately trained mid-level providers are capable of providing high quality service,” the organization remains opposed.  The ADA continually cites “safety” as its primary concern, claiming that these dental professionals are not properly trained to perform “surgical” procedures. However, the organization has never been able to point to a single study that supports that view. In contrast, there have been thousands of studies on the quality of care provided by dental mid-levels, and none has ever shown it to be unsafe. The ADA’s voice of opposition is an increasingly lonely one, as the list of supporters of reform is growing—from the American Academy of Pediatrics to AARP.

Change is never easy. When dental hygienists were introduced in the early part of the last century, organized dentistry opposed them.  Likewise, the medical community initially pushed back against physician assistants and nurse practitioners. Now, however, dentists and doctors can’t imagine functioning without these skilled team members, and our health care is far better because of it.

It’s just a matter of time before mid-level dental providers make their way to all 50 states.  Millions of Americans living in pain will then have something to smile about.

We frequently talk about stigma and a lack of access to healthcare as primary obstacles to ending this epidemic, and commit ourselves to addressing these issues. But one thing we don’t talk about enough is poverty. When it comes to contracting HIV, living in poverty is one of the greatest risk factors of all.

It’s no coincidence that African Americans—only 13 percent of the US population—constitute 46 percent of the people who are newly diagnosed with HIV, and also suffer a poverty rate 11.5 percentage points higher than the nation as a whole.

It’s no coincidence that men who have sex with men account for 65 percent of new HIV infections, and that LGBT men and women are more likely to live in poverty than their heterosexual peers.

It’s no coincidence that injection drug users are more likely to share needles if they are living below the poverty line.

And it’s no coincidence that counties with high HIV rates also have poverty rates nearly 7 percentage points higher than the rest of the country.

Our fight against HIV is inextricably tied to the fight against poverty. Earlier this year, Jim Yong Kim, President of the World Bank Group, said, “Just as money alone is insufficient to end poverty, science is powerless to defeat AIDS unless we tackle the underlying social and structural factors.”

The barriers that prevent us from ending HIV/AIDS are no longer scientific, they are societal. According to the Center for Disease Control and Prevention (CDC), “Poverty can limit access to health care, HIV testing, and medications that can lower levels of HIV in the blood and help prevent transmission. In addition, those who cannot afford the basics in life may end up in circumstances that increase their HIV risk.”

Imagine not knowing your status, and being unable to take a day off work to get tested for fear of losing your job. Imagine having to choose between groceries and the gas required to drive yourself to the HIV clinic, or going without heat so that you can afford to stay on your medication.  Worst of all, imagine your financial situation is such that risky behavior like transactional sex feels like the only way you can survive.

Poverty is a disease that affects not only individuals but entire communities. Poorer communities lack the resources to adequately treat and fight the virus. Therefore, regardless of your personal income, living in impoverished areas dramatically increases your vulnerability to HIV.

In 2010 the CDC found that 2.1 percent of heterosexual residents in low-income urban areas are infected with HIV. These are epidemic levels—far higher than the national average of 0.45 percent. Further, the residents in these areas who were living below the poverty line were twice as likely to be infected with HIV as those living above the poverty line.  Regardless of race, as incomes fall, the likelihood of being infected with HIV skyrockets, leading the CDC to conclude that “poverty is the single most important demographic associated with HIV infection among inner-city heterosexuals.”

Fortunately, there are organizations that are beginning to make gains in the fight against this trend.

Medical AIDS Outreach of Alabama (MAO) works in the rural areas of the Black Belt Region of southern Alabama—where rates of HIV infection are alarmingly high—to provide treatment and combat stigma for hundreds of people, 75 percent of whom live in poverty. When transportation from rural areas to urban clinics is too expensive and prevents people from receiving treatment, MAO uses telemedicine to check in with patients and to ensure that they are adhering to their treatment regimen.  The Elton John AIDS Foundation supports the MAO community health workers who connect patients in rural areas with the care they need, which is their fundamental right.

The Fortune Society in New York City works with formerly incarcerated individuals to provide housing, job training, and, for those living with HIV, connection to medical treatment. By taking a holistic view of each of their clients, The Fortune Society combats poverty and HIV one person at a time, with the knowledge that one dramatically affects the other.  The Elton John AIDS Foundation is a proud funder of this work as well.

Whether fighting AIDS abroad or here at home, the words of Jim Yong Kim ring true: “To end both AIDS and poverty, we need sustained political will, social activism, and an unwavering commitment to equity and social justice.”

Just as poverty and HIV are inextricably linked, so too must our efforts be to end them.

The short answer is that over a half million people – in a state of only 4.4 million – sign up for healthcare. About 75 percent of those who signed up didn’t previously have health insurance, so the uninsured population has dropped by 42 percent and the uninsured rate has gone from more than 20 percent to less than 12 percent.

Although the health-care exchanges that were created by the Affordable Care Act have gotten most of the news coverage so far, it’s the expansion of Medicaid that has had the biggest impact, with about 80 percent of the newly insured in Kentucky getting coverage through Medicaid.

In the Supreme Court’s June 2012 decision upholding the constitutionality of the Affordable Care Act, the court ruled that states could opt out of the Medicaid expansion without losing any of their current Medicaid funding. Many policy analysts didn’t think the ruling would have a major impact, since the federal government is paying for the entire expansion for the first three years and gradually reducing to 90 percent in 2020. As MIT healthcare economist and Affordable Care Act architect Jonathan Gruber put it, “When the Supreme Court decision came down, I said, ‘It’s not a big deal. What state would turn down free money from the federal government to cover their poorest citizens?’”

More than a few, as it turns out.

Only 27 states and the District of Columbia have opted into Medicaid expansion.  In Kentucky’s case, it found that expansion would actually save money, delivering a $15.6 billion boost to the economy while creating almost 17,000 jobs—all while insuring its most vulnerable citizens. As Governor Steve Beshear wrote in a New York Times op-ed defending the decision, “…to those more worried about political power than Kentucky’s families, I say, ‘Get over it.’ … and get out of the way so I can help my people. Here in Kentucky, we cannot afford to waste another day or another life.”  He called the reform “the single most important decision in our lifetime for improving the health of Kentuckians” and said the state would “come out ahead in terms of both health outcomes and finances. In fact, if we don’t expand Medicaid, we will lose money.”

In contrast, as Gruber notes, the states choosing not to expand Medicaid “are not just not interested in covering poor people, they are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.”

The non-expansion states already have, on average, poorer health outcomes and large uninsured populations, and now they will fall even further behind healthier states. The difference is already visible in survey data, according to Gallup.

If the 23 states that haven’t expanded Medicaid were to instead opt-in, nearly 7 million additional people would likely receive coverage. These states are also passing up on more than $400 billion in federal funding.

This slow expansion of Medicaid is not unprecedented. In 1966, when federal funds for Medicaid were first available, only 26 states had programs up and running by the end of the year. By 1970, however, 48 states offered Medicaid. It wasn’t until 1982 that the last hold-out, Arizona, finally opted-in.

One of the tricks for providing healthcare in states where Obamacare is politically unpopular is—well, not too tricky: call it something else. Although ‘Obamacare’ remains unpopular in Kentucky, ‘Kynect’—the name of the state’s health insurance exchange—is popular.

The faith community is also playing a major role in pushing for expansion, arguing that it is a moral issue, and noting Jesus’ role as a healer. Rev. Raphael Warnock, the Senior Pastor of Ebenezer Baptist Church in Atlanta, reminded policymakers that the millions of people caught in the Medicaid gap “are not numbers, these are our church members and family members. So for us, this is a matter of life and death.” Towards the end of August, the Moral Monday Movement marched on 12 state capitols urging governors and legislators to expand Medicaid.

In my own church in Kentucky, I have already seen the benefits of expansion.  One of our members who works for wages that are too low to afford health insurance, but were too high to qualify for Medicaid prior to expansion, finally has access to healthcare. For the first time she stopped worrying about what would happen to her if she were to get sick before she was old enough to qualify for Medicare.

The Robert Wood Johnson Foundation and the Urban Institute have provided a state-by-state breakdown of what opting-out of Medicaid expansion is costing in both human and financial terms. Find out what your state is missing out on, and then urge your decision-makers to follow Kentucky’s lead.

Editors Note: Listed states had not expanded eligibility as of July 2014. They include Indiana, Pennsylvania. and Utah, which have pending waiver proposals to expand eligibility. Totals may not add because of rounding. Note that Pennsylvania announced last month that it will expand Medicaid.