PubPol 3280 Prelim 1

Population/community health

the health outcomes of a group of individuals, including the distribution of such outcomes within the group

outercircle - community

Population health management

the delivery of health care services toward the achievement of specific health care related metrics and outcomes for a defined population... tied to value based contracts

inner circles - patients

Population health measures

debated

- life expectancy, mortality rates, health and functional status, disease burden, behavioral and physiological factors

Prevention River: Clinical Care

Prevention 1.0: provide medical care which is also preventive care

Prevention River: Still in Clinic

Prevention 2.0: Screening for health related social needs

social drivers of health

Prevention River: Community Conditions

collaboration with public health

issue: hospital doesn't want to reduce visits - money

Population health drivers

variation in public outcomes

on average 20% of variation is driven by access to clinical care

80% - health behaviors, physical environment, socioeconomic factors

Population health perspective

should make decisions based on race

risk stratification needed

notion of health equity has been politicized

US population health

The US spends more on healthcare than any other OECD nation

Yet lags behind other OECD countries on key health indicators

Health expenditure vs life expectancy

We spend the most and have lowest life expectancy of countries on graph

Life expectancy is a health outcome

Lead in adult obesity

This is issue population health is trying to solve

Why do we think we need to do different things in healthcare?

5% of population accounts for 50% of spending

6 in 10 adults have at least one chronic disease

7 of 10 leading causes of death are preventable

Quality shortfalls and evidence-based prevention (prevention 1.0)

We pay a lot for health care, don't have greatest health outcomes, and don't get prevention right

We get it right about 50% of the time

Clinical care drives only 20% of health outcomes yet accounts for more than 90% of healthcare spending

Other countries look very different

Access to Care

In 2009, 16.7% US population uninsured

In 2023, 8% uninsured yet

Goal of US health care act to reduce this

BUT coverage does not equal access

Our hospitals are often not safe places to stay

Might leave with an infection

Quality measures hospitals look at:

Documented conditions when someone enters hospital

If get more infections while in hospital, hospital may be penalized by federal government

Inequities in health outcomes

Average in 2023 - 78.4 US life expectancy

BUT a 14 year gap in life expectancy exists between asians and American Indian/Alaska Native peoples on average in 2023

African american, native american, and alaska native women die of pregnancy related causes at a rate about three times higher than those of white women

Place Matters

A 25 year life expectancy gap exists just several bus stops apart

America is getting older

For the first time in US history, older adults are projected to outnumber children by 2035

Older we get more chronic diseases → health care more expense

Geography also comes into play

Epidemiological transition (probably on test)

1900 - deaths due to infectious diseases

Life expectancy - 45

2000 - death primarily due to lifestyle related chronic diseases

Life expectancy - 79

Knowing about leading cause of death in community can give insight into that community

Leading causes of death in US

Still die from infectious diseases but not as much as chronic

Covid added to number of deaths by 20%

By 2024 covid not in top 10

Trends in leading causes of death over time (real vs. artificial)

Examining secular trends in rates

Important to identify real versus artifactual differences over time

Real: changes in age structure of population, changes in survival, changes in incidence

Artificial: changes in disease recognition, definition, classification

Shifting health care landscape: Traditional paradigm (medical model)

Treating sickness/episodic, symptom reduction

in-patient/facility centric

Specialty driven

Physicians E&M (evaluation and management)

Siloed - physical, health, mental - not integrated

Fee for service - get paid if the treatment occurs in clinic

Payment for volume

Shifting health care landscape: New paradigm (population health model)

Managing populations/prevention and wellness

Abulatory: PC, communities, homes, retail, virtual

Primary care driven - interdisciplinary teams + address SDOH (social drivers of health)

Integrated

Shared risk/reward

Payment for value

A national framework: The IHI triple Aim

Key word: "simultaneously"

Health of a population, experience of care, per capita cost

4 key policy drivers in Affordable Care Act

Access

Community and population based activities

Prevention and health promotion

Quality

Policy Drivers ACA: Access - Individual mandate

Key goal: extend health insurance coverage to 52M uninsured in 2009

Lever 1: individual insurance mandate with $ penalty if not insured (penalty lasted 5 years, TCJA (tax cuts job act - passed by trump) 2017 → penalty = $0)

To increase healthy individuals to buy insurance to balance risk pools and lower premiums for all

Young invincibles were not buying insurance

Lever 2: eliminate medical underwriting (try to deny insurance to sick people) and denial for pre-existing conditions

Lever 3: Children covered on parents insurance until age 26

Increased age - more people covered

→ did increase number of insured

Policy Drivers ACA: Access - Medicaid expansion

Key goal: extend health insurance coverage to more low income individuals

Lever: eliminate medicaids "categorical eligibility" and replace with standard income based eligibility criteria (income below 138% FPL)

Federal poverty thresholds

Support states with enhanced federal matching rate for expansion pops

Supreme court 2021: Fed cant force states to expand

10 states that still have not expanded Medicaid

Still have categorical or low FPL

Access has expanded

Reduced uninsured in every state (Texas high outlier)

Compared to 2013

Policy Drivers ACA: Access - State insurance exchanges (with "MEC + 60% AV")

Goal: ensure quality affordable insurance

And comprehensive - 10 essential health benefits

Lever: state insurance marketplaces with "premium subsidies" (if income 100-400% FPL) to make quality health insurance more affordable for small business and individuals

MEC = minimum essential coverage refers to 10 essential health benefits

60% minimum actuarial value (AV) = Min % of expected healthcare costs a health insurance plan must pay (bronze plan = 60% AV

Insurance MECs (10 essential health benefits) → 2014 Supreme court case Burwell v. Hobby Lobby Stores = "hobby lobby exemption"

Insurance MECs (10 essential health benefits)

Insurance MECs (10 essential health benefits) → 2014 Supreme court case Burwell v. Hobby Lobby Stores = "hobby lobby exemption"

Many people think mental health and substance use should not be covered

Also preventative and wellness services and chronic disease management

Concern about counseling related to safe sex

Prescription drugs - birth control pills

Some employers said it violates mission - don't want to support birth control drugs

They won - hobby lobby exemption

Policy Drivers ACA: Access - Support for community health centers

Federally qualified health centers (FQHCs)

In medically underserved areas

Fed doubles FQHC funding to increase their financial stability

Medicaid expansion boosts FQHC revenue (fewer uninsured low income patients)

Fed increases training opportunities and tuition reimbursement to encourage providers to practice in FQHCs

Policy Drivers ACA: Community and population based activities - National prevention strategy

Increase number of people that are healthy at every stage

Policy Drivers ACA: Community and population based activities - Prevention and public health fund

Goal: prevent chronic diseases and eliminate disparities

Lever: PPHF - nations first mandatory funding stream ($15B over 10 years) dedicated to primary prevention of chronic diseases and eliminating disparities (e.g., reduce risk factors)

Administered via community transformation grants and capacity building grants

Hard to prove outcome from

Policy Drivers ACA: Community and population based activities - Incentives for workplace wellness

Goal: increase workplace wellness programs and supports

Lever: small business workplace wellness grants and discounts

Policy Drivers ACA: Community and population based activities - Community health

strengthens community benefit requirements for hospitals + CHNAs + CHIP, enforced by IRS

Most hospitals not for profit so dont pay taxes

Act says can not longer remain not for profit unless can prove community benefit

Whole lecture later on

Policy Drivers ACA: Prevention and health promotion - Expand primary health care training

Goal: increase by number of primary care practitioners, especially in rural areas

Levers:

Funds PC residency training programs (+500 PCPs by 2015)

Trains 600 new PAs who practice team based PC

Trains 600 NPs to provide comprehensive PC

Grants to states to expand PC workforce

Tuition reimbursement for high-need areas (rural)

10% bonus payments to PCPs to make practicing PC more enticing

Policy Drivers ACA: Prevention and health promotion - No cost-sharing for annual USPSTF recommended screenings

If go to annual wellness visit and have a USPSTF recommended screening - you shouldn't have to pay for those

Health insurers must pay for it

To reduce delayed care because of cost

But if have extra screenings - extra costs

Policy Drivers ACA: Prevention and health promotion - Policy Drivers ACA: Prevention and health promotion

People over 65 get health insurance now get annual wellness visits

Policy Drivers ACA: Prevention and health promotion - other

Medicaid expands children's free preventive services to adults

Accountability for patient populations (ACOs)

Policy Drivers ACA: Quality

Requires federal national quality strategy (triple aim)

Creates center for medicare and medicaid innovation (CMMI) to test innovative payment an delivery models

Authorizes value based payment programs

The ACA today: resilient or vulnerable?

Legal challenges: individual mandate (2012, 2017, 2021) and ongoing litigation over preventative services coverage

Political pressures: repeated repeal attempts; debates over medicaid expansion in non-expansion states

Marketing issue as came to be known as obama care

Implementation challenges: rising premiums, insurer participation, coverage gaps

Public opinion: More popular now than at passage, but still politically divisive

Guide to Measuring the Triple Aim - Upstream factors

physical environment, socioeconomic factors

Impact: behaviors, physiological factors (BMI, blood pressure)

Individual factors

Individual factors impact intermediate outcomes

Why multiple health outcome measures?

A single number alone tells us very little

Need context

Compared to what,whom, or over time

CHR give us this context

Looking at more than one population health outcome is important

County Health Rankings (CHR)

Measures organized from upstream health factors to downstream health outcomes

Nations first publicly available standardized dataset of validated community health data at the county level (CHR will not release a full dataset in 2026)

Years of Potential life lost (YPLL 75)

A measure of premature mortality

Gives greater weight to deaths occurring at younger ages

Can be aggregated by geography, race - ethnicity, gender, and other population characteristics

Life expectancy at birth: deriving life expectancy from a period life table

How long, on average, would a US baby expect to live if born in 2024 and subjected to 2024's age specific mortality rates throughout its lifetime

Its hypothetical

Math never adds up perfectly because probabilities change

Always assume starting at 100,000 people

Plot survival curves

"Shape of mortality"

Survival curves from life tables can be used to visualize shape of mortality and identify inequities

Using surviving column from table

"Rectangularization of mortality"

Super rectangular curve - almost impossible - means people do not die till old age

More rectangular the survival curve - on average the healthier that group is

Made life table for each group by race and gender

Health related quality of life (HRQOL) - measuring

Measuring HRQOL

4 questions used to measure self-reported physical and mental health and activity limitations

Simple, easily understood by survey takers and policy makers

Demonstrated validity and reliability across diverse populations and settings

Survey questions HRQOL

Q1: self rated health

• Health indicator: Percent of population reporting fair or poor health

Q2: Physically unhealthy days

Population health indicator: Mean count of unhealthy days (UHD)

Population health indicator: Frequent physical distress (FPD) = prevalence (%) of 14 or more physically UHDs in the last 30 days

Q3: mentally unhealthy days

Population health indicator: Mean count of unhealthy days (UHD)

Population health indicator: Frequent mental distress (FMD) = prevalence (%) of 14 or more mentally UHDs in the last 30 days

Q4: Activity limitations

Population health indicator: Mean count of ALDs

Population health indicator: Frequent activity limitation days (ALD) = prevalence (%) of 14 or more ALDs within the last 30 days

Healthy life expectancy (HLE)

Goals: max healthy life expectancy

Want to compress morbidity curve

So majority of lives at each age group are healthy versus unhealthy

Kind of abstract

In Sickness and in Wealth in Louisville, KY

Spend more than other countries on health, but do not have bang for buck

Idea of stress that arises from living conditions

Chronic stress

Racism adding even additional burden

Showed a lot of maps → different rates of chronic disease in different areas of the city

Story: different social classes and socioeconomic variables in each reason

Geospatial patterning to both poverty and health

Which graph shows the social gradient in health?

A and B

A: As years of education increase, find that life expectancy on average increase

Positive correlation

B: As household income increases (diff measure of socioeconomic status), the percent reporting fair/poor health decreases

Negative correlation

If health outcome is negative than the gradient can be negative

Make sure to look at graph and understand what is being shared

Social Gradient in Health - Real World Examples

describes the stepwise, continuous phenomenon where people lower down in the socioeconomic hierarchy have worse health outcomes and shorter lives than those directly above them

These graphs measuring same thing

What does relationship between y and x axis say

The Whitehall Studies

Expected to find those at top of hierarchy (CEO) had greatest stress, so greatest prob of heart attacks and death

Found the opposite → surprise

Controlled for all factors - smoking, obesity, etc

Behaviors explained about ¼ of the changes in outcomes

Policy relevance - could enact policy that gets rid of poverty

If we gave them all some type of support to get them above poverty line

We would still have a social gradient just truncated

Socioeconomic Position and health are associated

Better access to healthy food, health producing resources

More time and energy

Time to cook, go to gym, go to doctor

Less environmental stressors

More access to preventative care

Maybe means you have health insurance

More education associated with better health outcomes

More access to therapy

More access to better employment benefits

Live in area less exposed to health hazards

Future thinking mentality to save money for health events

How might education affect health

Pathways through which education can affect health

Social causation

hypothesis

SES (socioeconomic status) causally

affects health (purple

Education can create opportunities for better health → most evidence points towards

Health selection bias

hypothesis

unwell children may be unable to attain higher levels of SES (blue)

reverse casualty

Confounding hypothesis

Conditions throughout people's lives can affect both education and health

Near perfect correlation between ice cream sales and drowning → driving affect: hot in summer

Can individual behaviors explain the social gradient

No more than 25% can be explained

Dr. Troutman says he believes in individual responsibility - but always within the context of social determinants

Don't like term lifestyle changes because makes it sound like you have control

Need to understand conditions in what patients live

Ex. Corey rule about where he lived → don't go further than a street because their are murders there

Twin Study

Dr. Nancy Kreiger's twin study find?

Studied identical twins to control for genetics

Why are twins useful for thinking about "nature vs. nurture"?

One got higher income and one got lower

One with higher got better health outcomes later

• Which hypothesis explaining the association between SES and health does this study tend to support?

1. Social causation

Best explained by this

What changes when stress becomes chronic?

If threat does not pass

Pay rent, secure job, safety of neighborhood

Stress response remains activated/is repeatedly activated

Cumulative physiological "wear and tear"

Immune, cardiovascular, metabolic, brian

Increased disease risk

Macaque Monkey study

Dr. Carol Shively

Same environment, same food, same sun

Found: difference in arteries

Want big gap but as glucose floods bloodstream - creates plaque - have heart attacks

Looked at connections between power, control, subordination, and health

Cold study

Looked at socioeconomic status

Whether your parents owned the home you lived in

For how many years

Mattered for how got a cold

Association between socioeconomic security, power control, and stress in humans

Policy response would be to ensure more people own homes

Allostatic load

Refers to the

cumulative burden

of chronic stress

and life events

which increases

chances of having

poor health

outcomes

Allostatic load is higher among individuals with low SES, racial and ethnic minorities, and persons with higher ACE scores

Racism poses an additional burden on health of people of color

Race, ethnicity, gender, immigration status and other dimensions of social identity shape exposure to stress, opportunity, resources, power, and control

Social drivers of health (SDOH) key definitions

Factors related to where pray, place, stay, etc

Often don't put health behaviors

Different people explain differently

Economic conditions, social factors, and the physical conditions in the environment in which people are born, live, learn, play, work, and age which, in turn, are shaped by the global distribution of money, power, and resources (WHO; HP 2020

population health model

Simplified model of upstream, downstream population health model

Differences in behaviors to the right are function of the drivers to the left

SDOH - lots of place based

Upstream from that → often due to policy → structural determinants

Why does place matter?

Places shape what we're exposed to (direct impacts on health)

Ex from video. Built environment of house → mold, asthma

Places shape what resources and opportunities are available (indirect impacts on health by making healthy choices easy, difficult, or impossible)

Ex. gang violence - influences whether go outside, how far, stress response cycle

Place itself is shaped by policy and investment

Built environment

How design, construction, and placement of buildings within a community, as well as the design of the surrounding community (e.g., zoning, sidewalks, parks, hazards), impact human health

Social environment:

Refers to behaviors, connections, norms, social capital, and socio-demographic characteristics of people (residents, business owners) in an environment that may impact health

Social or built environment? Direct or indirect impacts?

Seattle public health official James Krieger outlines neighborhood features that influence health

Proximity to environmental hazards

• Quality of schools

• Quality of affordable housing

• Frequency of violence and crime

• Opportunities for social interaction with neighbors

• Access to affordable, healthy food choices

• Places to walk or do other kinds of physical activities

• Billboards and advertising

Proximity to environmental hazards

Built

• Quality of schools

Social - funding

Built - poor physical buildings

• Quality of affordable housing

Built - buildings full of mold

Social - maybe could be argued

• Frequency of violence and crime

Social

• Opportunities for social interaction with neighbors

Social - rebuilt for intentional interaction

• Access to affordable, healthy food choices

Built

• Places to walk or do other kinds of physical activities

Built

• Billboards and advertising

Built

Place mechanisms: pathways through which neighborhood conditions could affect health

Another example of upstream downstream

Place based drivers → mechanism → impact health

Richmond, CA and Gwai Boonkeut

What caused Gwai's heart disease

Prolonged exposure to stress

Cardiologist David Weiland wonders why Gwai Boonkeut - a relatively young patient with no history of smoking, no family heart disease, no typical behavioral or genetic risk factors - ended up having a heart attack

Social or built

Social- violence

Built - near a polluting plant

Social causation hypothesis or health selection bias hypothesis

Social causation hypothesis

High Point, Seattle, WA and Stephen Truong

Upstream policy → to rebuild community

Knew there was an asthma problem

Built breeze easy units to fix built environment problem

Who had the power and control to change the neighborhood?

Community had stake in decision making

Used their thoughts to shape the policy

Describe the impact of Stephen Troung's new "breathe easy" unit on his health? His family?

Social or built environment?

Built - breathe easy unit

Social - socialize with neighbors was focused on

Social causation hypothesis or health selection bias hypothesis?

His health impacted his mom

Poor health influences social drivers

Put him in ER, missed school

Socioeconomic status of mother - had to take off work to be with him

Why did Richmond become an unhealthy place?

During WWll RIchmond was a booming racially diverse industrial community. After the war

Policy → racially restricted home loans

Government backed home loans so could afford home (less than 2% went to black families)

Describe the cycle of disinvestment that followed

Check cashing companies moved in, alcohol biz moved in

Created built environment hard to have positive health outcomes

Place matters

How might this cycle make it more expensive to be poor - the poverty tax

Things become more expensive

Food desert

neighborhood with poor access to healthful foods such as fresh and affordable fruits and vegetables, whole grains, low-fat milk, and other foods that make up the full range of a healthy diet

How does food environment/access impact choice? examples

Higher your income the more supermarkets

Ex. of built environment

Health wealth gradient

Lower income more liquor stores

Another study - how far different ethnicities had to walk to hit fast food and groceries

In Chicago Black residents had to go further to go to grocery store

USDA definition of food desert

A low income census tract (20% of pop below FPL) with 33% or more of population residing at least 1 mile (10 miles if rural) from a supermarket or large grocery store

Distance alone does not = access

Just because you do live near one does not mean you can afford

Violence and public health

The documentary touches upon the health effects of violence in Richmond. In what ways does violence affect the health of children

Cycles of disinvestment continue

Hard to say that will spend money now and save money in ER visits

If violence is presented as a public health threat rather than a crime issue, how might that affect the way policy changes are perceived?

How does the "YES" program protect kids from effects of violence?

Young kids have sense of no power or control - stress response - poor health

Gave kids sense of control

Health policy quote

What that means is that housing policy is health

policy. Educational policy is health policy. Anti-

violence policy is health policy. Neighborhood

improvement policies are health policies. Everything

that we can do to improve the quality of life of

individuals in our society has an impact on their

health and is a health policy."

Observed differences in rates of disease and unequal access to quality healthcare along race, gender, SES result in unnecessary healthcare spending due to:

Delayed care

Missed diagnoses

Later diagnoses

Repeated visits

Medical error

Lost productivity

** business and moral imperative

Upstream drivers of health

Systemic or structural drivers impact the social drivers of health impact behaviors more proximal to health outcomes

The Iceberg Analogy

Below the waterline

Policies, laws, institutional practices, historical decisions

Things that are imbedded - often cant see

Near the waterline

SDOH

Social and economic conditions people live with

Above the waterline

Behaviors and observable health inequities

Ex. redlining example

Discriminatory lending influence home owners, leave people of color behind, experience poorer health outcomes

Example of structural factor: Structural racism

The structures, policies, practices, and norms resulting in differential access to the goods, services, and opportunities (SDOH) of society by race

It is structural, having been codified in our institutions of custom, practice, and law, so there need not be an identifiable perpetrator

Race is not biology - but racism has biological consequences

Race is a social construct - created and defined by societies - not by discrete biological or genetic differences - and those categories can change across time and place

Clinicians and researchers focus on genetics and biology, the experience of racism, and SDOH inequities - not race - when describing risk factors for disease

Racial inequities in health and well being (life expectancy, mortality) exist regardless of income and education

Dr. James Marion Sims

Father of modern gynecology - designed the speculum

Performed surgery without consent or anesthesia on enslaved women he purchased or rented

Observed racial health inequities are rooted in historical and contemporary racism and implicit bia

Tuskegee Syphilis Experiment 193201972

USPHS and CDC withheld treatment to study natural progression of syphilis

Black poor ranchers told they were being given medicine

"As I see it, we have no further interest in these patients until they die" - study doctor

Goal was to watch them die to observe the process

Cure for syphilis became available during the later end of the study - and still withheld the treatment

Observed racial health inequities are rooted in historical and contemporary racism and implicit bia

1933: Home owners loan corporation (HOLC)

"Residential security maps" assessed risk/creditworthiness for real estate investment

If tie to cold study - owning a home is positive for health

HOLC grades codify legal discriminatory practices because mostly based on race

Graded based on who lives in the neighborhood - race and immigration status

Banks issue loans to higher graded neighborhoods

Redlining: Neighborhoods impoverished by design

1934: National housing act

Part of New Deal to restore housing market after Great Depression

Established FHA and Federal Home Loan Bank Board to increase - and segregate - homeownership

Cycle of disinvestment - people with wealth move out because loan available - left behind - schools leave - tax base leaves

Redlining: Neighborhoods impoverished by design

"Redlining"

Deprives Black homebuyers of wealth accumulation and intergenerational wealth transfer

Influences neighborhood trajectories re: infrastructure, services, and employment (investment v. disinvestment)

Green - "homogenous neighborhoods"

Red - hazardous, pronounced "detrimental influences"

Dr. Debbie Salas Lopez, SVP of Community Population Health

Mapped COVID-19 incidence and mortality to redlined communities using HOLC maps

The legacy of redlining is still visible in population health today

Sever COVID 19 risk is higher today in neighborhoods graded red or yellow in the 1930s (Louisville, KY)

Redlining, extreme heat, and health

Historically redlined neighborhoods are hotter today

Reflecting decades of less investment in trees and green space and more heat trapping pavement and development

Cycle of disinvestment

Redlining and risk of preterm birth in NYC 2013-2017

Upstream - downstream model

Structure (redlinging) - neighborhood trajectories of disinvestment - place based resources and other socioeconomic - embodied exposures - inequities in risk of preterm birth

Lower grade HOLC aras are associated with higher odds of preterm birth

Detroit segregation barrier

No specific redlining but related

Only way lender would give money is if built a wall between neighborhoods - segregation barrier

Now its a road but was a wall (8 mile road)

Can see clear demarcation between green and blue

Blue dots = white

Green dots = african american

Red dots = asian

Orange dots = latino

Brown dots = all others

racial covenants

Legal documents all over the country to keep people who ere not white from buying or even occupying land/property

Ruled illegal by supreme court in 1948 but continued for decades

Ex. how systems create inequity

Unequal treatment examples

50% medical students and residents believe at least one race related false belief

Coming from stories we have created

Lead to biases in pain perception and less accurate treatment recommendations

race correction in clinical algorithms

Cardiology, nephritis, obstetrics, urology

Race correction?

Built in tools - input variables, use of race, equity concern

Systemic - does not make sense

EGFR indicates better kidney function (systemic)

Non-african american number vs african american number

Built into the algorithm - electronic health record

Optum racially biased clinical algorithm

Black patients assigned the same level of risk by the algorithm are actually sicker than white patients, because the algorithm uses health costs as the measure for health needs

Systemically, less money is spent caring for Black patients for white patients

This racial bias reduces the number of Black patients identified for extra care by more than half.

Additional examples of structural drivers of health

School funding based on property taxes

- Value of home - structure

= Inequities in education - inequities in health

Opioid addiction treatment and policy (buprenorphine vs methadone)

- Methadone - have to go to clinic daily - black people get given more

Medicaid paying less than cost; maternity bundle not long enough

Water rights and river diversion

Unequal sentencing guidelines

- Powder vs crack cocaine

Non-inclusive health intake forms

Grad school entrance exams

Voter restriction/gerrymandering

Walmart hiring < 40 hours/week

Online applications for income based supports

Bail policy and "poverty incarceration"