** All transcripts are AI generated with minimal human editing, so are not without errors.

Spencer Cahoon  0:00  

Welcome to Emerging State Policy, an open source podcast, with me, your host, Spencer Cahoon. Today we’re going to be addressing prenatal care policy. And specifically, we’re going to be looking at the Centering Pregnancy model for group prenatal care, which has the power to reduce preterm birth rates, reduce or eliminate racial disparities in those rates, reduce medical costs, eliminate time spent waiting at the doctor’s office and increase patient satisfaction. The Centering Pregnancy model of group prenatal care has eight to 10 expecting mothers all meeting with their doctors for one and a half to two hour visits. It includes the standard wellness checks, but creates robust question and answer time and provides education on varying pregnancy and infant care topics throughout the prenatal visits. Joining us today will be Dr. Valerie good. A doctor specializing in family medicine with experience with both preterm births and centering. Angie Truesdale, CEO of the centering healthcare Institute, which provides training implementation support and advocacy for the Centering Pregnancy model, New Jersey State Senator Thomas Kean, who sponsored legislation in his states provide funding for Centering Pregnancy group prenatal care services through Medicare. In addition to working with New Jersey private insurance companies to ensure their support, we’re going to be contrasting the current model of individual prenatal care with the group prenatal care model, examining the penetration of the Centering Pregnancy model in the States, the political approaches to implementation that have been tried by various states, the research on centering and the position of some of the key organizations in the area. Finally, we’re going to be summarizing the benefits and the cost implement group prenatal care more broadly, we’re going to be looking at the cost savings, which is over $2 for every single dollar spent. We’re going to be looking at how it addresses the problem of preterm birth, which have been costing our state’s a combined $26.1 billion annually, and the potential for reduction in that preterm birth rate as well as other rates. 

And finally, we’re going to be looking at the real human impact of changes in the prenatal care model, so stay tuned to learn more about the potential impact of broader support for Centering Pregnancy in your state on this episode of emerging state policy,

 

Let’s take just a moment to explain the importance of this topic. So what is a preterm birth? A full term birth is a birth where the baby has been gestating for 39 to 40 weeks, and anything under 37 weeks is considered preterm birth. And to give you a feel for what the impact of this topic is, I’d like to share a couple stories. One cold winter night, I was rushing into the operating room due to fetal distress with my hubby and daddy to be sobbing outside alone. I had our micro miracle Jeremy holler Edwards the second on December ninth 2012 at 27 weeks, weighing two pounds, six ounces. I stayed by his side for 68 days praying for

 

Him, reading to him and holding him when allowed. He was fragile and kept in a dark incubator for many days. Some days he would quit breathing and his heart would stop. But this was quote normal in the nick you. We spent his first Christmas and then FQ and I cried holding him in his Christmas outfit, which was way too big for him. I can still smell the sanitizer and hear all of the beeps that became our world. I remember our calls throughout the night to quote tuck him in. As my husband and I stared in an empty crib. We made many Nikki friends as if we’d served in a silent war and finally came home. Victor’s Jeremy is now 11 months old and the happiest baby I’ve ever seen. Thank God for Nick you staff, less our Miracle on premier day and every day.

 

And one other story, and this is from Grahams Foundation.

 

Jennifer and I always thought that when we were ready to start our family it would come easily. Unfortunately, it didn’t happen that way for us. After six years of hope and frustration, the typical infertility procedures had still proven unsuccessful, still determined, we met a caring and compassionate doctor, Dr. Arthur Wescott and our first round of IVF, we learned we were finally pregnant. After the first ultrasound, the doctor was confident that we had one baby, but he thought there might be another. The next ultrasound confirmed it. We were expecting twins. Everything was progressing nicely until about 22 weeks when Jen developed preeclampsia. Jen was put on immediate bed rest. Jen did everything she could but unfortunately with her escalating blood pressure, the neonatologist said we needed to deliver immediately. Our daughter and son recent Graham were delivered on Thanksgiving Day, November 23 2006. By emergency c section at 25 weeks and three days gestational age. After Jen’s discharged from the hospital, she remained on bedroom

 

For six weeks, I spent day and night at the Nick you and took Jen back and forth, as she was only allowed to be there for brief periods. Graham had an incredibly difficult journey. Our intuition knew that his time with us during his lifetime would be brief. Graham was with us for only 45 days. And we are grateful for every moment. When we look back, Graham had only one truly good day.

 

It was the one and only day that Jen was able to hold him. He was still on a ventilator at the time. Jen and I remember our nurse telling us at least three times that day, Graham definitely knows that his mom held him today. He definitely knows. It turned out to be just days before we had to say goodbye.

 

Family and friends from around the country joined us to celebrate Graham’s life. There were at least a dozen Nick you staff and attendance as well. Having them there with us meant the world. We released 45 blue and white balloons at the surface to remember Graham

 

While Graham isn’t with us today and body, he will be with us forever and spirit.

 

This is the reason we are dealing with policy addressing preterm birth rates to help other babies avoid these types of situations. With that, we’re going to move into our interview with Dr. Valerie good. A licensed physician working in family medicine. Welcome to emerging state policy. 

 

Dr. Valerie Good  6:26  

Thank you. Great to be with you. 

 

Spencer Cahoon  6:28  

Now, as our listeners today might not be familiar with what a physician working in family medicine does. Could you tell us a little bit more about what that entails? 

 

Dr. Valerie Good  6:36  

Absolutely. My practice is pretty wide. So full spectrum family medicine, everything from working in the office without patients to running on my own patients in the hospital, working with residents, which means teaching younger doctors and then I also practice prenatal care with a focus in pregnancy and substance use disorder. 

 

Spencer Cahoon  6:56  

Gotcha. Well that sounds like plenty to keep you busy. So in your practice working with pregnant women and delivery, you’ve seen women who’ve been delivering preterm. What kinds of issues and impacts does that create for the mother and for the child?

 

Dr. Valerie Good  7:11  

Yeah, we absolutely see a lot of preterm delivery. When it comes to a mom who’s delivering a baby preterm. The biggest risks are really if for some reason her water has broken early, she’s at risk of infection. And then anytime there’s a complication in the delivery such as the baby coming preterm, there’s a higher chance that she could have any other complication and pregnancy like something like trouble with her blood pressure, preeclampsia for the babies, depends on how far along in the pregnancy they are. Babies are at risk for anything from trouble with their lungs that aren’t developed, their brains that aren’t developed, they can have problems with themselves, they can have problem. Simply feeding growing, getting bigger, maintaining their temperature, all those types of things, so they may end up with the DQ. As long as they’re far enough along to survive. Hopefully they can get the right care and come along pretty normally, but some of these kiddos have trouble Throughout their lifespan with developmental delays or chronic lung disease, chronic growing issues, product issues with their bellies, it really depends case by case.

 

Spencer Cahoon  8:10  

Not everyone listening to this necessarily has been engaged that much with family medical practices. Could you just tell our listeners very briefly what a NICU is and what the purpose of an NICU is?

 

Dr. Valerie Good  8:21  

Yeah, so a NICU is a neonatal intensive care unit. The idea of the NICU is the same thing as an ICU or critical care unit for adults, but it’s for babies who have just been born. So generally, it’s a place babies go if they’re having some trouble right after a delivery, but it’s also a place that babies can go. Usually within about four weeks. If the baby needs some extra support. They’re often an adult hospital, but they are also at children’s hospitals. 

 

Spencer Cahoon  8:45  

Gotcha. Forgive me if this seems like a very obvious question. But if it’s the neonatal equivalent of an ICU for an adult, I assume that care is probably quite expensive.

 

Dr. Valerie Good  8:57  

Yeah, one of the things we know about centering is that it reaches healthcare costs. It actually does that primarily through creasing NICU admissions, which is sort of a roundabout way of also saying that moms who do centering have a lower rate of preterm delivery. So you know, we know the farther along you get in pregnancy, the more likely you are to not need to your child to go to the queue. We know that moms who do centering are more likely to make it to full term deliveries. And we know that if a baby needs to go to the NICU It’s way more expensive to care for them there. Than in the well baby nursery. So it saves thousands of dollars per day, that they’re not needing to be in the NICU.

 

Spencer Cahoon  9:34  

I can certainly believe it.

 

Dr. Valerie Good  9:35  

And then for every one day longer than a baby is able to stay inside mom. They save about three days in a NICU. 

 

Spencer Cahoon  9:44  

Oh, wow. 

 

Dr. Valerie Good  9:45  

Each day that a baby stays in utero, it’s pretty impactful.

 

Spencer Cahoon  9:48  

Gocha, I didn’t realize the effect was so large. 

 

Dr. Valerie Good  9:51  

Yeah, it’s a really, really big deal. There’s just something really amazing about women’s bodies that we can’t replicate in our medical science.

 

Spencer Cahoon  9:59  

It’s true. With all of our advancement.  You mentioned that if a child is sufficiently preterm or has some of these early developmental delays they might have to spend some time in the NICU. What kind of impact Have you seen on families where they have a child who does have to spend some amount of time in the NICU?

 

Dr. Valerie Good  10:14  

It could be really significant ramifications for families, particularly unique challenges if those families already have children in the family and their parents are torn between home life and hospital life so kids can stay in the queue anywhere from a day to months and months on end, depending on what kind of support they need. Challenges specifically for moms and babies is trouble with the relationship between a mom and a baby when the mom would like to breastfeed the infant. So makes it particularly challenging if you are a mom trying to breastfeed your baby but they’re in an incubator or they’re on some kind of breathing support. And so, oftentimes, these moms are less pumping and having a lot of pressure to make enough milk for this little tiny baby that really gets a lot of benefit from it. Apart from the time constraints and the stress on the family of having children in multiple places, and especially one who’s tiny, and this is just a chronic stress of trying to navigate, how to raise that child and care for another child, all those things together can really put a lot of pressure on a family

 

Spencer Cahoon  11:16  

I would imagine. And with that, you also mentioned some of these children with developmental issues, end up with chronic lifetime issues. So presumably, these are children who would end up coming back to the doctor’s office on a regular basis for these various chronic issues.

 

Dr. Valerie Good  11:31  

A lot of times they do, you know, it really depends on the child, how long that goes on, some of them who are not extremely premature, end up kind of on a regular schedule. For example, I have a niece who was born seven weeks premature around 33 weeks. She needed a little time in the queue, but she’s actually the same age as my son and they meet milestones at the same time, and it’s really amazing to see how she’s overcome. Some kids are like that other kids aren’t quite as fortunate and end up on oxygen therapy throughout their lifetime or feeding tube. their lifetime. So it really depends what differences that child has, how much they’re going to need moving forward. Most of them end up with some early intervention therapies in the home and definitely have more visits to the doctor than the average.

 

Spencer Cahoon  12:13  

Gotcha. You’re a doctor who’s also been involved in using the centering model in your practice. 

 

Dr. Valerie Good  12:17  

Yeah, I love centering.

 

Spencer Cahoon  12:20  

I’m glad to hear it. How have you seen mothers responding to that type of approach.

 

Dr. Valerie Good  12:24  

Moms love centering. And it’s not a model that’s for everyone. But you get out what you put into centering. And the relationships that I built are really beautiful. For instance, we had a group maybe as women, each person is welcome to bring a support person with them. And there was only one girl in the group who brought us port percent turbo. And when it came time for delivery for all these women, that month, every single delivery, she was there for every single one of those girls. And that’s the kind of thing you’re not going to get in traditional care. And I think that’s part of what makes centering such a powerful thing. centering itself, meet basically all The maternal and infant mortality standards we’re trying to reach like a magic elixir. And I think a lot of what that differences is just that community being surrounded by other women and by other moms to really understand what you’re going through and provide a lot of support for you. Because when we look at the data about centering versus traditional care, moms with similar demographic have better outcomes and centering. So it’s pretty neat. 

 

Spencer Cahoon  13:25  

That sounds very neat. And before we wrap up, are there any specific stories of clients you’ve worked with who come to mind for people who’ve really been impacted by preterm birth?

 

Dr. Valerie Good  13:36  

Yeah, as far as preterm birth, one of my great friends had a baby at 24 weeks, and then acute care that he got in Columbus, Ohio really saved his life great. She was there every day for months and months and really got carry that had she had her baby in another place. He may not have survived because he was right on the edge of could he survive or not? And he’s a really healthy, funky, wild, very smart, little four year old now. So keys are definitely a place that we’re glad to have. And it’s a place you never want to need in your life or surely you hope you don’t need the next you but when you do need the NICU, Wow, they really do good work.

 

Spencer Cahoon  14:10  

Well, Dr. Good, thank you for joining us today on emerging state policy.

 

Dr. Valerie Good  14:13  

Thank you so much for getting the word out on this topic. It’s a big passion for me.

 

Spencer Cahoon  14:21  

Well, Dr. Good was able to share with us the impact of preterm birth and her experience and using centering in her practice. Let’s take a look at the scope of the problem from the 50,000 foot view. Currently, the Center for Disease Control reports that the 2017 preterm birth rate in the US was approximately one in 10 infants born were born preterm, a 10% rate. They also noted that there was a very strong racial divide. One in 11 infants born to white mothers was preterm 9% were one in seven infants born to black mothers was preterm 14%. That’s a 50 50% higher rate for black mothers. Now, obviously that is a very strong difference for black mothers compared to white mothers. Now let’s dive down a little bit looking at the single state level. Looking at the March of Dimes, Paris stats and they’re born to soon report, I picked a state at random in this case, Oklahoma, Oklahoma overall in 2017, had an 11.1% preterm birth rate. So a little bit above the national average. And that meant that approximately one out of nine children born in that state are born preterm. Now for comparison, that means that if you are a child and infants being born in Oklahoma, you are better off in Armenia, to Zika Stan, Ethiopia, Iraq, or Vietnam, not countries particularly well known for their excellent health care, but all countries that have a lower preterm birth rate than the state of Oklahoma. Now if you are a black woman in Oklahoma, Black women in Oklahoma have a 13.8% preterm birth rate, which is a little lower than the national average, but still notably higher than the white population. That means roughly one out of seven children born to black mothers is born preterm. And in addition to the countries I just listed countries that are doing better, RU ganda, Iran and Mongolia. So again, with this list, you can see that we are not doing particularly well with prenatal care compared to our neighbors, even our neighbors who we assume if you hadn’t looked at the numbers that you probably would be doing better than Now, before we look at the state by state implementation, which we are going to in just a moment, it’s important to understand the difference between our predominant system of individual prenatal care and group prenatal care through a Centering Pregnancy model. To lay out this background. Let’s take a moment to speak with Angie Truesdell, CEO of the centering healthcare Institute. Welcome to emerging state policy.

 

Angie Truesdale  17:00  

Thank you. It’s a pleasure to be with you.

 

Spencer Cahoon  17:02  

Now as our listeners might not be familiar with you or the centering healthcare Institute, could you tell us a little bit about yourself and your organization?

 

Angie Truesdale  17:09  

Sure, the centering healthcare Institute created and now is the quality organization responsible for the centering model. We do the implementation support for clinical practices that want to implement the models and support them. also collect the data and assure model fidelity. The centering model includes during pregnancy, prenatal care, centering parenting, pediatric care for early childhood zero to two and centering healthcare, which is group care for a variety of chronic diseases and other patient populations.

 

Spencer Cahoon  17:49  

Now, let me set up the background for a minute before centering came onto the scene. What was the model for women who are receiving prenatal care?

 

Angie Truesdale  17:56  

You know, there’s still a lot of traditional prenatal care going on. I want to be clear about That? 

 

Spencer Cahoon  18:00  

Sure.

 

Angie Truesdale  18:01  

Traditional prenatal care aligns with the schedule that set out by the American College of Obstetrics and Gynecology, and as a centering, and it’s a schedule that has women coming in, starting around 12 weeks to meet with their doctor for what’s largely quick belly checks. So a woman may wait for an hour in the waiting room for what is on average and eight to 13 minutes clinical visit, and the doctor asked a lot of a lot of questions, take some measurements, then ask usually, hopefully, if the women has any questions, and that’s it. And like I said, those are usually eight to 13 minutes visits and it’s pretty transactional.

 

Spencer Cahoon  18:50  

So very brief visit overall conventionally. How does Centering Pregnancy change that prenatal care model?

 

Angie Truesdale  18:57  

Centering pregnancy changes it completely. Centering pregnancy is group prenatal care around that 12 week visit, those women are informed that they’re going to be part of a closed cohort of women that have a similar due date. And they’ll be experiencing their prenatal care together to 90 minute to two hour visit with the clinical provider, and it also has a co facilitator. That can really be anyone that is appropriate for that community. It could be a doula, it could be a social worker, it could be a medical assistant, and it can be a tribal elder community health worker, you can really put any trained centering facilitator in that second chair supporting the group. And the support part is important. The goal of centering is to not only just get those traditional baby check metrics and measurement taken, but really to have time for discussion. community that’s built in the cohort to discuss what’s going on in their pregnancy and overall life that’s contributing their health and from common discomfort of pregnancy. What support systems you have when you’re going through your pregnancy, your plans for safe sleeping plan for feeding, busting some, some myths about breastfeeding, then it goes a little bit deeper and talks about your plans for birth control so that you can make sure not to get pregnant too rapidly for the next pregnancy to be healthy, giving them time to heal between pregnancies and talking about inner relationship violence and our partner violence and addressing that and really creating a safe space for the group to connect and dive into these critically important topics that are incredibly stressful and if not address can lead to poor birth outcomes.

 

Spencer Cahoon  21:00  

Sure, well, that sounds like a great collection of topics to be covering. And it sounds like that’s only just the tip of the iceberg.

 

Angie Truesdale  21:07  

It really has the visit gives a format that clinics really adapt to their community’s needs. And that extended time with the patient is really an opportunity for the women and the providers to really connect to support the pregnancy. But the biggest, probably most important thing is that the hierarchical structures between the patient and the provider are broken down through this we trained facilitators, clinical or otherwise, to be facilitated leaders. It’s their job to keep the conversations factual, particularly on the medical side. They also are trained to really elevate lived experience, and also to stay quiet so that the group, the group can explore these topics of it. And that’s really important. It’s really important for women to have trust in their group and then their providers and expect a different experience from the healthcare system at this critical time.

 

Spencer Cahoon  22:14  

Now, centering pregnancies been around since the 90s. But it’s still only a limited use. So what have been some of the difficulties implementing it more broadly?

 

Angie Truesdale  22:23  

That’s a great question. You know, we’re in about 600 clinical sites right now in 47 states. And I think we have maybe 1% of the birth nationally. There’s still a lot of work to be done.

 

Spencer Cahoon  22:38  

Sure.

 

Angie Truesdale  22:38  

Some of the barriers are purely structural. You know, the healthcare system is not set up yet to incentivize Value Based Payment. The reimbursements don’t yet align with that, until providers are paid by outcome, rather than by volume. It’s a little bit of a round hole in a square.

 

Spencer Cahoon  23:04  

Gotcha.

 

Angie Truesdale  23:05  

The clinical practices they have to invest in implementing the model and getting training and finding a space and outfitting it. Insurance companies, the payers, Medicaid system. All of those stakeholders are the ones that actually reap the benefit financially, on better outcome. Any avoidance of a nick you today is a huge thing for a pair. And so there’s a misalignment in terms of who has to make the investment to reap the reward. Our medical schools don’t train this way. Hmm. That’s an issue, believe it or not space as hard to come by, again, because the incentives are based on volume and rapid transactional patient care. You’ll have 12 patient rooms that are tiny little box, but no group space beyond the waiting room which has to be large because so many people are waiting in it.

 

Spencer Cahoon  23:59  

You know, I’d never actually thought about that, that group space element, but as a normal human being has been to the doctor’s office before. Those rooms are always very small. And you definitely could not fit 12 people in one of those rooms.

 

Angie Truesdale  24:12  

Yeah, now you really can’t. So then there’s some of the barriers, we’re making progress on all of them. The space is probably the one that we can’t influence the most. What we see on the space side is that size might start small because they’re limited by space. And then after a year or two, and they feel more confident and seeing the outcomes. They start fighting for space and figuring it out. But it can be a barrier. The other one says systemic issues, more making some progress on from a policy perspective.

 

Spencer Cahoon  24:44  

Yeah, and I guess looking at that progress and the state approaches, some states seem to be taking a grant based approach to implementing Centering Pregnancy, while others are focusing more on that systemic changing reimbursements in their Medicaid programs and private insurance providers to try to capture that value based medicine up front. So the providers are actually seeing that. Now, if you were speaking with a state legislator who’s interested in implementing Centering Pregnancy, what would you tell them about the value of those various approaches?

 

Angie Truesdale  25:14  

I would say they’re both incredibly valuable. My first ask of any state policy maker is to turn on a group care code in their state. If we can have clinical practices be able to notate centering in the claim tied to the outcome, then they get a data set that will make the case. And so just by doing that, or 10 steps ahead of where we start in anything. And then the first thing you mentioned were the grants. And I think the grants that we’re seeing states do and we actually do some ourselves as an organization, and work with funders to create grants programs, offset those initial startup investments. And so because it’s kind of accepting the system as it is and saying, All right, we can’t have these providers having to foot the bill for these. So we’ll offer grants to offset that. So it’s a bit of a band aid, but it’s how most sites get started with entering the payment incentives are the more meaningful opportunities for policy change. And what that says, hey, as payers, we are willing to share this saving and reward you for your efforts and your great outcomes that are generating savings. And so what those look like are enhanced reimbursement levels for patients who are seen in centering. And some of the states that have done it have really identified that it must be centering because we do have a commitment to quality and ensure the model fidelity that produces the outcomes we all want and the evidence base and so those payment instead can look like anything from $30 more per patient per visit. For the 10 visits, some tears outside of Medicaid system, some individual Medicaid managed care organizations are actually incentivizing at the hundred dollar level per patient per visit. That’s a pretty wide range, but we’re seeing most of them hover around that $30 level. We’ve also seen plan really focused on tying some of the birth outcomes to the heated measures that they’ve identified as part of their Value Based Payment incentive.

 

Spencer Cahoon  27:38  

Thank you. Well, finally, where do you see Centering Pregnancy implementation now? And where do you see it going in the next five years? 

 

Angie Truesdale  27:45  

In terms of our implementations support, we’re only getting better will continue to get better. We began a multi year scaling initiative about 18 months ago with the assistance of private philanthropy dollars. And that effort should wrap up around 2324 should get us to about 1500 sites nationally, well, at least, and also help us where possible, grow that percentage of patients being seen and centering and all of those practices. And so what we’re focused on is putting more centering staff on the ground to interact with stakeholders such as legislators, and policy audiences as well as the local medical society. So building out that regional and state infrastructure, it’s going to be really important for us to be able to navigate who makes decisions on Medicaid in a meaningful way and support our site.

 

Spencer Cahoon  28:49  

And we’ll be speaking with Angie Truesdell a bit more later in the show.

 

Let’s take a look at where the states are on implementation. of Centering Pregnancy and group prenatal care generally, looking at the states, it seems there are basically three stages they fall into their states where they’re independent sites that don’t have any specific state support. There are states where there is grant based support or temporary reimbursement based support. And there are states where there is reimbursement based support. And that can be with or without additional grant based support. So looking at those by category, North Carolina is an example of a state where there are independent centering sites, but there is no overarching state policy regarding centering. There’s about two dozen sites that have been started with startup funds from the March of Dimes, and they’ve had some great impact so far. The 2017 2018 stats were that there was a 26% decrease in preterm birth in areas where centering was being used. And that’s a comparison between women who are receiving group based prenatal care with the Centering Pregnancy model compared to women who are receiving traditional individual prenatal Care. The source for those stats are centering counts and the March of Dimes pair of stats. Now looking at our second category, and these are the states who have actually started engaging in some sort of policy support for group prenatal care. New York is a state that has reimbursement assistance only. And that’s for targeted areas. And it’s essentially a temporary pilot program. in 2017, New York started its first thousand days initiative. And there were a number of priorities in that first thousand days. One of those was to reduce preterm birth rates through enhanced use of centering. Now that project as part of the first thousand days initiative was funded starting in fiscal year 2019. And it’s a pilot program that has enhanced reimbursements at that $30 per visit amounts like Angie Tuesday was talking about, and that’s a two year period that the program is running for areas that have particularly high rates of preterm birth. So this is not a state that’s implementing it broadly for anyone who’s interested. But this is a state that’s using it for a targeted intervention to try to improve preterm birth rate numbers in the worst hit areas. Now, on the other side of that, you have Ohio, which has a grant based support only currently temporary. And when I say has perhaps I’m overselling that a bit. There’s a bill pending that has passed the House House Bill 11. In Ohio, that is pending in the senate at the moment. It’s worth noting, this is a bill that has had bipartisan support. Everyone has voted in favor, there have been no votes against in the house level. And that would put $6 million aside over a two year period for grants in the 20 2021 calendar years. And those grants would be to providers who are looking to start centering practices. And that would help them with the scale up costs, getting additional space going through their certification, those upfront costs that might otherwise be a disincentive for providers. But after that is done, those grants don’t cover anything else. So it gets it started. But once it started, it doesn’t provide ongoing support. And again, that’s a temporary program the way Ohio is looking at it. Now, there are other states that look at this a bit differently or have taken a different approach. Georgia has both changing their reimbursement and targeted grants. And it’s worth mentioning before I dig into this a bit, that this is something that for Georgia has developed over time. Because from back in 2008 2009, that’s when you had the first people coming out starting centering practices with March of Dimes funding, all the way to 2013. Where there was a telemedicine centering practice to help take the centering approach to rural areas that didn’t have access to good prenatal care. And the impacts that Georgia has had from that have been significant and this is still during their grant period. They have taken areas where the preterm birth rate was as high as 18.2% in the African American population. With centering, they have brought that down to 8.1%. So 18.2 to 8.1%. That’s more than cutting it in half. That is a dramatic impact. Now, using the same approach and another community that’s primarily Hispanic, literally 100%. Hispanic population served, brought the preterm birth rate down from 12.1% to 6.7%. Again, almost cutting that preterm birth rate in half. So really dramatic impact on infants being born in those areas. After that received some acclaim, they moved to the point where in 2018, the state put aside some grant funding for centering, and they have enacted enhanced Medicaid payments. That’s that reimbursement piece. So now George is at a place where they have grant funding to help center and practices on the front end, and they have the enhanced reimbursement to keep it going and provide that extra incentive to get providers to start using this model to start helping women And clearly based on their data, it has been helping women in that state. South Carolina similarly started in 2008 in the Greenville health system using the centering model, and they’ve been expanding ever since. And recently in 2017, their Department of Health and Human Services updated coverage in their Medicaid program for Centering Pregnancy. So they have that expanded reimbursement as well, though at the beginning back in 2008, when it started, it was targeted grants, it was philanthropic dollars, getting these programs started. Now they’ve seen the impact and they’ve moved to a more comprehensive state based approach. Montana has enhanced Medicaid payments for group prenatal care, Louisiana and 2015 approved enhanced Medicaid payments for group prenatal care. Virginia is on the same boat, New Jersey just recently in 2019. Passed Assembly Bill 5021 with both Republican and Democratic sponsors, it had unanimous votes in committee in both the Senate and the assembly.

 

With that, we’re going to take a minute to speak with New Jersey State Senator Thomas key who serves as the Republican leader in the Senate. Welcome to emerging state policy.

 

Sen. Thomas Kean, Jr.  35:12  

It’s great to be with you.

 

Spencer Cahoon  35:14  

For anyone who might not be familiar with you. Could you tell us a bit about yourself and your district?

 

Sen. Thomas Kean, Jr.  35:20  

I’m the Senate Republican leader in New Jersey, I represent 210,000 people across three counties in New Jersey 16 communities, serving the state legislature for about 18 years.

 

Spencer Cahoon  35:32  

Well, New Jersey is the first day to have passed legislation Assembly Bill 5021 to ensure that Medicaid covers group prenatal care with the Centering Pregnancy model. What originally brought this to your attention?

 

Sen. Thomas Kean, Jr.  35:44  

Local constituents. In fact, we meet with constituents all the time, my legislative office about issues on old range runs and local constituency came in as part of our conversations. We’re starting to talk about the health and prenatal and birth disparities, that exists in New Jersey and nationwide. So once we realized the vast health outcomes disparities that existed, we started to work on a bipartisan basis with Republican democratic senators Joe Vitale, Ron rice, Bob Seger, and I sent letters to every insurance company that covered New Jersey. And we wanted to see what were the best practices in health from around the country. And so we started to find some best practices, look down south carolina model. And we started to understand that the better care inputs throughout all aspects of pregnancy, the better it is the outcome overall.

 

Spencer Cahoon  36:39  

Now, there are studies showing that Medicaid accounts are about 40% of prenatal care spending. The other portion of that is private health insurance and individual payments, like you were just talking about. It sounds like you guys took a really comprehensive approach by making sure that private insurance was in the conversation with you about what best practices would be.

 

Sen. Thomas Kean, Jr.  36:58  

Oh, absolutely. We Want to make sure that we understood the issue that we were able to get in front of the issue that we were able to have access to information that we would not necessarily have outright? Certainly. And we want to come in and say, what’s the best way to make sure more people can go through the privacy that we do some of these health disparities and get information out to mothers at all ends of the brain to spectrum?

 

Spencer Cahoon  37:23  

That sounds fantastic. So let me ask you based on that, what sort of impact Are you hoping that this legislation will have on your constituents and your state as a whole?

 

Sen. Thomas Kean, Jr.  37:32  

Well, the more people who have healthy babies were brought the term, the more that we can make sure that the disparities in health are reduced in every way that we can. Back to them 18 people found that giving birth the United States women three times likely died and mother in Britain or Canada, and for the every one of those initiatives are stem, the near death experiences that are underreported, and so making sure that people who are going through the prenatal process are educated that their health is looked at, you can have these some of these group settings where people can have some broader conversations and understand by going through this process. At the time when other individuals are the exact same partner pregnancy, you can make sure that the health outcomes from the beginning to post birth are better than they currently are. Gotcha.

 

Spencer Cahoon  38:27  

Now, as you earlier noted, you took this on in a bipartisan sort of way. In the news, we’re always hearing claims that the parties can’t work across the aisle. But it seems like that’s exactly what you’ve done here. So Senator keen, what makes this issue a bipartisan one?

 

Sen. Thomas Kean, Jr.  38:42  

We all care about the healthy population. Sure, we all want to have the best possible information in this instance, but in many other cities, and I’ve always found that the best piece of legislation with those that can pass any legislative chamber on a unanimous basis, and by making sure that we have The best possible information with people who have the goal of reducing disparities and health and in other aspects of people’s lives, we can usually find strong bipartisan agreement that is in the best interest in the short term and the long term of not only the 210,000 people I represent, but the millions of people were proud to call New Jersey home. And then my hope is that because we were so early in the process that others can look to buy new jersey is done and said, that makes sense. They can make sure more and more people are born healthy. They have fewer risks throughout the pregnancy, prenatal and afterwards for the mother. And we can do find common ground across the country.

 

Spencer Cahoon  39:47  

Building on that, what advice would you give to other state legislators across the country who are considering proposing or voting for a similar group prenatal care legislation?

 

Sen. Thomas Kean, Jr.  39:57  

I think people have seen that this type of model works I think that anytime you can get more supportive environments, that you can make sure that you have a best possible outcome. And it can make people in every zip code across this country healthier.

 

Spencer Cahoon  40:12  

And do you see this as the type of legislation that can ultimately be scaled up to possibly even at the national level?

 

Sen. Thomas Kean, Jr.  40:19  

I think it makes a lot of sense of scale. Yeah, this is an issue that this disparities you’ve seen impacts the entirety of the country. And so we can handle it one state time, as well as on national focus that you’ve seen in New Jersey. This is not only a focus of legislative efforts, but first lady Tammy Murphy is also taken us on has been going around date focusing on this issue as well. So this is an issue that is truly bipartisan, and people who are engaged in also understand the importance of making sure that group p prenatal care services are funded.

 

Spencer Cahoon  40:52  

Well, Senator Keane, congratulations again on passing this first of its kind bill, and working to improve infant and child health and New Jersey. And thank you for joining us today. Today on emerging state policy,

 

Sen. Thomas Kean, Jr.  41:02  

Thank you very much for reaching out.

 

Spencer Cahoon  41:08  

Now that we’re all up to date about what the states are doing on this policy, and what some of the different approaches are, let’s turn our attention to the research behind these policies. And I’m grouped into two broad categories. There’s research about the impact that centering policies have. And then there is research about the cost savings related to that. Now, obviously, those two things are related. However, in terms of the arguments one might be making in favor of implementing a policy. The cost savings argument is usually seen as separate from the actual impact argument of avoiding preterm births.

 

So let’s jump right into the cost savings first, because it’s a little bit more straightforward. Now, South Carolina, who’s been working with centering for some years now did a study in 2016, published in Maternal and Child Health Journal That was 7790 participants. And in order to determine cost, they looked at the claims paid data for all of these women. They found some great outcomes and results. But let’s talk about the cost savings. The cost savings was $22,667 per preterm birth. So the total savings was about $4 million for $1.7 million invested a $2.3 million return on investment. To look at it another way. There was $2 and 34 cents saved for every $1 spent in order to try to avoid preterm birth through centering where their weaknesses Yes, there are always weaknesses in any study, and this study is no different. Here, the participants were opt in as opposed to a randomized controlled trial. And the racial demographics of the study show a preference of white women for the group prenatal care model, which could potentially be throwing the numbers off also. weakness is the only cost considered here. We’re professional and inpatient costs, which are likely and underestimate. And it only looks during the period for the first year of life following birth. And obviously, as we heard from Dr. Good previously, many of these children can be born with chronic conditions, which can require care over their entire lifetime. So this is likely an underestimate of total cost. Now, there’s a separate study from the National Academy of Medicine in their 2006 reports, and they found that the total annual National cost related to preterm birth is $26.2 billion annually to break that down 40% of that is cost directly to Medicaid. And the remaining roughly half is to employers private insurance and individuals. Now, the basis that they have for coming up with this number is a lifetime cost estimate for one year worth of us preterm birth the 2006 Report relies on 2003 costs data from medical care, maternal delivery, early intervention services, special education, which is needed more often after preterm birth due to the incidence of disabling conditions, and last household labor and market productivity. And that market productivity part is only about one fifth of that total cost. So they’re finding broken down by infant was a total of $51,600 per preterm infant. And that was in $2,003. One nice thing about this study is it allows any states to reverse engineer their yearly share of those costs. So if you’re trying to make this argument, you can take a look at the March of Dimes pair stats for your states and the US preterm weekly births for the nation as a whole. Compute your state’s portion of us preterm birth and then multiply that by the annual cost estimate to see how much the impact is for your state for Example. Take Ohio, I happen to be in Ohio resident, Ohio using this method covers 3.7% of nationwide preterm births. And that means based on this $26.2 billion annual estimate, Ohio share of that is 960 $8 million in new costs that are accrued each year. Now, some of those are borne by the state, some by citizen, some by insurance, some by hospitals and doctors and charity. So it’s not that it’s all coming directly out of the state’s pocket, but they are things that are being borne by your citizens. And that provides a relatively clear basis to show why the money you invest in reducing preterm birth is saving your citizens money, your government money, not to mention the lives quality of life and health of the children being born in your state. With that, we’re going to move over to the research looking directly at impacts. But before we jump into that, let’s continue our interview with Angie Truesdell. 

 

Now moving over to the research side, it seems that there’s been a wealth of research into the Centering Pregnancy model at this point. What are some of the key benefits that the research shows for adopting a Centering Pregnancy prenatal care approach?

 

Angie Truesdale  46:13  

The most well studied outcome is a significantly reduced incidence of preterm birth in the 20 to more than 30% range and that reduced risk and incidents. That lowering of preterm birth is especially meaningful in the black community. Black women in this country suffer preterm birth twice as often as the white women. The preterm birth defects are really remarkable. They’re centering because you’re seeing a lower preterm birth rate overall, but and especially lowered one for black mom. There’s some real power in that group approach that goes beyond the medicine. What we’re providing Something that’s truly transforming for these women and getting through the stress during their pregnancy.

 

Spencer Cahoon  47:06  

That’s a fantastic intervention. Now, while the majority of research on Centering Pregnancy has shown positive impacts on preterm birth rates and other public health metrics, the 2018 five year strong START study, which was the largest of its kind, concluded the group prenatal care primarily using the Centering Pregnancy model did not impact preterm birth rates or other public health metrics, though it did save money. What would you say to a legislative staffer or an on the ground provider trying to contextualize that finding with all the other positive research?

 

Angie Truesdale  47:38  

Yeah, well, I would I would look at the original design of strong start and encourage them to look at that strong start did not require site to work with us to implement their group prenatal care model. The report acknowledges that most group prenatal care is centering Even though they didn’t require their grantees to go through our training, our accreditation process to support the system change that has to happen to implement the same centering didn’t require them to report data to us so that we can benchmark and set goals together. And so, you know, this isn’t a patient intervention. And it’s not a sign of setting intervention, like some of the other strong start initiatives. This is a system change intervention. And so it most clinical sites, if they don’t have significant support and the system change, then it’s not going to be successful. And I can tell you, selecting sites to start centering is a business of its own. We’re not sure how well the sites or screen we go through a pretty rigorous readiness assessment process, where sites tell us about their physician and clinical provider mix and the group space and Who’s bought into this across their organizations? And so I think it’s great that the federal government dabbled in group prenatal care, but I can’t say that strong start is indicative of centering.

 

Spencer Cahoon  49:11  

I think it’s going to be very interesting to see where Centering Pregnancy is going from where it is right now. Angie Truesdell. Thank you. And thank you to the centering healthcare Institute for continuing to educate the community about the benefits of centering and for joining us today on emerging state policy.

 

Angie Truesdale  49:26  

Thanks so much Spencer.

 

Spencer Cahoon  49:32  

Time for the impact research. So there was a randomized controlled trial in 2007. That was run by the Yale School of Public Health and Emory University. In terms of the setup, there were 1000 people who were part of the study, and it showed a 33% reduction in preterm birth and a 37% reduction in preterm birth for African Americans. Now it didn’t show any cost savings. However, their cost estimates were the costs only at birth through the care that was immediately needed right then it didn’t include the first year of life. And it certainly didn’t include any lifetime costs, which was a weakness of that particular study.

 

In 2012, there’s a study called the effects of Centering Pregnancy on preterm birth in a low income population. And this was run by the University of South Carolina and the Greenville health system. They were running with about 4000 people in that study, and that showed a 47% reduction in preterm births. And one interesting side note on this, it showed a 58% reduction in very early preterm births. And while we haven’t gotten into this much the earlier a child is born preterm, the less time the child has had to develop and the more likely they are to have various developmental issues. So this significant impact on those very early preterm births, it could have a huge impact on the quality of life for those children and could be a huge potential cost savings. The National Academy of Medicine report that we talked about earlier found that one third of all of the costs related to preterm birth were for these very early preterm births. So if you can lower that rates, you have the potential to make a real impact both on quality of life and on cost. North Carolina’s implementation 2017 and 2018 showed a 26% reduction in the preterm birth rates, still very significant. That’s from centering health care is reported stats and the March of Dimes Paris stats, South Carolina’s Centering Pregnancy expansion project, which was 2013 through 2015, is the first to really focus on the racial impact of this. And it noted that for black women, there was a 38% reduction in preterm birth. And significantly, it brought the rate of preterm birth down from 13.4% to 8.3%, which was almost the same as the one rate which was 8%. So 8% versus 8.3%, almost eliminating racial disparity in preterm births. Now, there were some weaknesses to that study, there could have been selection bias because it was a retrospective cohort study looking backwards. And they said a stronger version of it would be a randomized control trial. And we’ve already talked about one of those just a second ago. Another interesting race focus study was in Puerto Rico. And this study was perhaps on surprisingly, on Hispanic women, and this was with the University of Puerto Rico and Nova Southeastern University. And in terms of impact, it showed an 18.8% reduction in preterm birth rates. And also, I mentioned earlier about the 58% reduction in very early preterm births. This study had a similar finding, showing a 69.8% reduction in very early preterm birth rates. So this is a particular population that can be hugely impacted. If you can reduce those numbers. Now this study was all Hispanic women. So it showed the potential to significantly reduce preterm birth rates with Hispanic women. Now there has been some contrary research and as I just spoke about with Angie Truesdell, the strong START study is probably the single largest piece of contrary research. It ended recently in 2018. It was a five year study. The Urban Institute was involved the American Institutes of research the Center for Medicare and Medicaid Innovation Center for Medicare and Medicaid Services with Department of Health and Human Services. A lot of players huge sample size, shy of 50,000. Long runtime, like I said, five years and they were looking at group prenatal care versus birth centers versus maternity care homes as early interventions to try to reduce preterm birth rates. Now, in terms of their results, they found that group prenatal care, it did save money. It was about 15% cheaper in their study, but it didn’t show an improvement in rates. Now compared to some of the studies, this one really has a legion of problems with it. And I say I have a personal love for the Urban Institute. I think they do great work. I listen to their podcast. But in this particular study, things went astray. I can’t say who it was, or perhaps it was a little bit on everyone. But first off, they only reached half the number of women they were trying to target, which suggests a core lack of planning and implementation. There was a lack of time for the sites to plan there were many complaints from the sites that they just had to flip the switch immediately, and start without preparation and training time. They noted that providers withheld support for group prenatal care because of perceived competition with individual prenatal care, which meant people probably were not running it the way you would want them to, for a good study. There was opt in and opt out enrollment instead of randomized controlled trial. And there were problems getting study participants to sign up for group prenatal care, significant problems compared to the other interventions. And there were a lot of miscellaneous problems. There was a lot of transport and childcare. There were demands from school and employment that competed language barriers. In some places, people who dropped out early on the group prenatal care didn’t meet the suggested number of visits, which would be 10. On average, they only did 5.7 visits. So really, we’re talking about a population of women who only received half of the treatment, the treatment being group prenatal care versus individual, they only came to half their visits. Also on the provider side, there was very high staff turnover. There was extremely limited training. And that space issue that we talked about earlier with Angie Truesdell. They noted that it was very common for there to be improper space allotted for these group meetings. So in addition to scheduling issues and lack of retention, they noted that program funds were not able to be used to support transportation services or incentives. They noted there were problems with data collection. Now there was also some selection bias issues compared to the group prenatal care groups, because these were opt in the birth center is really had a prime demographic women who were better educated, healthier, less minority women in more stable relationships and who are less likely to have had prior complications with a birth 10 times less likely to have had a prior low birth weight baby and about only half is likely to have had a prior preterm birth. So it’s really no surprise that when people are able to opt in, and when the most healthy women all opt into one group, that that group has better outcomes. Conversely, this meant that the group of prenatal care group were starting with less healthy women who were at higher risk, again, because the lower risk healthier women had selected into the birth center groups instead of group prenatal care. The study initially had seven different awardees who are doing group prenatal care approaches. Of those seven, six of them had acceptance rates so low that no data from those sites was using In the final impact analysis. So to put it another way, the data and implementation quality of six of the seven group prenatal care awardees, and the program was so poor that even the strong START study itself did not consider their data when doing the impact analysis. That literally means that it was so poorly implemented, that they had to ignore 85% of their own awardees. Now, given the many problems I just ran down with this study, women who are going to centering at sites where there is actual preparation, buy in, then you see outcomes that are much more like the other positive research that I’ve just gone through. This is likely why large organizations like the March of Dimes has thrown their support behind group prenatal care. The March of Dimes has stated that it strongly supports enhanced payment models to make group prenatal care more accessible, noting that group prenatal care has numerous benefits. Additionally, the American College of Obstetricians and gynecologists, their committee on obstetric practice in 2018 noted that it supports expanded use of group prenatal care as an option for patients, and suggests that additional resources are needed to help cover startup costs, noting that enhanced reimbursement is not widely available currently.

 

There you have it. Centering Pregnancy is a group prenatal care model that has the potential to reduce preterm birth rates by 20 to 30%. improve the health and lives of our children to reduce or eliminate racial disparities, save money for governments, employers and our citizens and Garner bipartisan support. I hope that you have found this episode educational, and are able to help advance expanding prenatal care options in your state. If you enjoyed this episode, please leave us a review on Apple podcasts as that helps make the program more visible to other people. This is an open source podcast, so feel free to use any or all All of our episodes without additional permission, please do drop us a line on Twitter at Spencer the letter J. Cahoon. If you do end up using this episode, you can also find our transcripts at emerging state policy.org which is still under construction, but you certainly can find our transcripts there. thank you to Dr. Valerie good. Angie Truesdell and the centering healthcare Institute, and New Jersey State Senator Thomas Keane. Special thanks to Nick Allen for original music composition. Thank you again for joining us for this episode of emerging state policy.

 

Transcribed by https://otter.ai

Spencer Cahoon 0:00
Welcome to emerging state policy, an open source podcast with me Your host Spencer Cahoon. In this episode we’re going to be looking at in Clean Slate legislation. Clean Slate legislation is legislation that looks at how to make expunged or record ceiling automatic once the person has reached a certain amount of time and meets a number of additional criteria that we’re going to go into in a little bit more depth.

To give you an idea of what to expect, we’re going to be hearing from Nila Bala with the R Street Institute of policy Think Tank. Jeffrey Crossman, a State of Ohio Representative and Criminal Justice Committee member and Orli Siegel with Community Legal Services of Philadelphia on the employment law team. Upon clean slate legislation, we’re going to be looking at the currently an active version in Pennsylvania, the currently inactive version and Utah post version in California. And then after that, we’re going to take a look at what some research based variants might look like. And we’re going to look into the related research the pros in terms of back economic impact on employment, citizen impact public safety, and broad bipartisan support, and some of the cons some of the research limitations, and the potential system costs to run an automatic expunged clean slate process, and then we’re going to tie it all up together. So stay tuned, and hopefully, you’ll learn something new exciting about clean slate legislation. As we get into clean slate legislation, every bill every piece of legislation is there to serve a particular need. In this case, clean slate legislation affects people who have a criminal record in their past. And before we get into the individual versions in Pennsylvania, Utah and some of the proposed versions, let’s take a look at what the need and on the ground impact are from this sort of legislation with Orli Siegel, from Community Legal services of Philadelphia.

Welcome to emerging state policy.

Orli Siegel 1:55
Thank you. Thanks for having me.

Spencer Cahoon 1:56
Now, before we jump into talking about clean slate legislation, I’m sure there are many of our listeners who are not familiar with you and what you do. So if you could take a moment to talk about your work in your organization.

Orli Siegel 2:07
Okay, so my name is Orli Siegel, I am a paralegal in the employment unit at Community Legal Services and Philadelphia. Mainly, I do a lot of work with the clean slate screening project, which evaluates people’s eligibility for criminal records ceiling under the Clean Slate law. And I also work with people individually to get their records cleared for employment purposes.

Spencer Cahoon 2:30
That sounds like some really needed work. You do.

Orli Siegel 2:33
Thank you. Yeah.

Spencer Cahoon 2:35
So regarding record ceiling, and I believe it’s called limited access and Pennsylvania. Who do you see coming in seeking this kind of relief? And why are they seeking it.

Orli Siegel 2:45
So a lot of people come in with criminal records, often very minor criminal records that are preventing them from getting hired. And some people come in because they have applied for public housing, they get denied, you know, there’s a huge need for record feeling. And it’s terms of the people who come in and people that I talked to, you know, spoken to a lot of people who have changed their entire career path, because they were afraid that their arrest record would keep them from doing the career that they’d always wanted to do. And I think a lot of people feel judged by an employer for having a criminal record. And that can really impact someone’s entire career direct trajectory, and just in general their way of life. Another person I spoke with, has been working at a large electricity company for several years, and his job barely pays me enough money to support his two children. But he’s avoided applying for higher paying positions that appeared at bill, they’ll run a background check, and they’ll reject him for having a criminal record.

Spencer Cahoon 3:41
Gotcha. Well, let me ask related to clean slate, and prior to its and certainly recently gone into effect in Pennsylvania. How did the need and demand in the community for this type of record ceiling relief compare with your agency’s resources to help people through the process?

Orli Siegel 3:57
So generally, at Community Legal Services and the employment you we help people who are a certain percentage below the poverty line, and we provide free wheat free legal assistance in a number of areas, filing stealing petitions and filing expensive petitions to help them clear their records. And at least in Philadelphia, there is a huge need for it. There’s a law in Philadelphia that appeal a lot of people who cannot records aren’t aware of where employers aren’t allowed to consider a criminal record, if it’s been if it’s more than seven years old. And employers can’t consider non convictions ever. And a lot of people don’t know that. And you know, some, some employers don’t follow the law, or they don’t really know how to interpret criminal record information when the background check comes back.

Spencer Cahoon 4:37
Now, prior to clean slate, Pennsylvania had a process for record ceiling which you were using on a regular basis, the same as many other states currently have. So tell us a little bit about what clean slate adds on top of that.

Orli Siegel 4:48
Clean Slate is basically a two pronged approach to getting your record sealed, the first part of it expands criminal record stealing. And the second thing that clean slate did was introduced what’s called automatic Records, which began on June 28 2019. So the Pennsylvania courts have one year from that day to steal eligible records using an automatic computer process. The exciting thing about clean slate is the automated portion, it completely changes the way that records are sealed, the automated feeling closes what’s called the second chance gap, which is the discrepancy between the number of people who are eligible for ceiling and the number of people who actually get it only 6.5% of people who are eligible for records, clearing file petitions to do so. And there are a number of reasons why that is many people can’t afford the filing fees, they can’t find or afford a lawyer or they’re not even aware that they qualify for stealing. And now it’s automatically going to get field. And this is huge benefit to that because a lot of people don’t know that they even have non convictions or minor convictions on their record that is affecting their ability to obtain employment or housing, with automatic ceiling everyone qualifies for it gets it. And that means no filing fees. No time spent trying defined a lawyer and it doesn’t require people to understand the law also means that we’re going to see more than 30 million records field which is huge. Those are numbers that this country has never seen before.

Spencer Cahoon 6:11
Oh, absolutely. And I guess that’s why there’s a year to phase it in if you’re talking about that volume of records, right?

Yeah. Well, given that it only started in June of this year, have you had a chance to see any of the effects on the ground level yet? Or is it changed the way you advise your clients with the new system?

Orli Siegel 6:27
Yeah, it’s definitely changed the way we advise our clients. So we’ve been helping a lot of clients understand their eligibility for records dealing. You know, it only didn’t go into effect two months ago, I have personally seen some of my clients records get sealed. For that for them. That means that they can go apply for jobs that they were nervous about applying for before. I’m guessing that we’re going to see a lot more in terms of people being able to kind of overcome those barriers to employment and housing within the next year and beyond because it is still associated in the process.

Spencer Cahoon 6:56
Gotcha. Now, before I let you go,

Is there any expansion or changes to the system that Pennsylvania is put in place that you think might better serve the needs of the people you see coming in from the community?

Orli Siegel 7:09
You know, a lot of people are interested in the possibility of expanding record ceiling to encompass more serious offenses like felonies. There’s a lot of support for that, but no action have necessarily been taken. But will auto feeling portion that clean slate in Pennsylvania introduced a whole new concept. It wasn’t until Pennsylvania law that people really considered it.

Spencer Cahoon 7:28
Absolutely. Well, Orli Siegel, thank you so much for joining us today for emerging state policy.

Orli Siegel 7:34
Of course, thank you so much for having me. Now, we

Spencer Cahoon 7:36
have a little bit of background to understand exactly what the need is for clean slate legislation, and exactly what some of the on the ground impacts are going to be.

So let’s take a look at the different versions of this bill that have been asked and at least one of them is being looked at right now. First off, we have the Pennsylvania version, in the Pennsylvania version of clean slate legislation that was passed in 2018 there they don’t have a

Record expunged or ceiling they call it limited access. The bill was sponsored by both a Republican and Democratic sponsor, and had a 188 to two vote in the House, and a unanimous senate and unanimous committee votes all the way through the process. So obviously, there was pretty broad support for this in the Pennsylvania legislature.

And here’s who qualifies. Anyone who received charges with a disposition that wasn’t a conviction. So anyone who had their charges dismissed anyone who was arrested but not charged, anyone whose case was dropped, anyone who has found not guilty, anyone who has given maybe some sort of diversion program where they finish it up, and then no further processes pursued. Also, the person has to have a misdemeanor, level two or below. And and this is probably the critical part, the person has to have 10 years without a conviction that is punishable by one or more years. So if you get a minor misdemeanor for litter in the yard, or jaywalking or something that’s not going to get in your way. But if you get something where you’re punishable by one or more years, that’s a little bit more serious, that’s going to disqualify you. Also, the person has to have no outstanding fees or fines. So whatever case is getting cleared out by this automatic, limited access in the case of Pennsylvania. It’s got to be one where they’ve paid all their costs. they’ve served their time for society, and they’ve paid off their costs. Now, are there exceptions? Oh, yes, all of these have exceptions. Exceptions in here, it doesn’t apply to people who have danger to person offenses, domestic violence, firearms or other weapons offenses, sex offenses, cruelty to animals, corruption of minors, indecent exposure, failure to comply with registration requirements, piece of a corpse, there are a few others as well. So as you can see, there are quite a few exceptions. So they are tailoring this to just the people whose convictions they think of as sort of the least serious and the subject to limited access. Additionally, the person can’t have any prior felony convictions. They can, however, have one level one misdemeanor conviction, and then this will work for up to three misdemeanor conviction. So that’s who qualifies for the Pennsylvania bill. Let’s look at the mechanics for a minute. Now the administration is going to be through the administrative of the Pennsylvania courts on a monthly basis. And they’re going to send all the records that are appropriate for limited access to the central police repository, who presumably keeps central records in Pennsylvania. And then within 30 days of disposition and payment of costs, or within 30 days of becoming subject to court ordered limited access, and court ordered limited access. That’s just like how in a lot of states, you currently have some sort of record ceiling or punishment process. Pennsylvania maintains that process, but also Institute’s this automatic ceiling, clean slate process on top of that. Now, the police repository, once they get these to be purged names of people, they have 30 days to review it. And then if they think there’s a mistake, the person isn’t eligible, they can notify the administrator of the Pennsylvania courts. And then the administrator will will remove that record. And the person wants to go through the more formal process if they want to get something sealed. Each Common Pleas court there every month will issue a order for limited access for the eligible records. So that’s the Pennsylvania version of the bill. And I shouldn’t even say bill, because it’s been instituted the Pennsylvania law. Obviously there are a lot of people who this is going to apply to Orli Siegel, with Community Legal Services of Philadelphia was saying that they’re looking at sealing a total of about 30 million records. So it is a very large volume we’re talking about here, it’s not going to be easy for them to make this happen overnight. So what they’re going to end up doing is they’re going to phase it in with the idea being that some point in 2020, they will have caught up with the backlog, it’s probably good idea if you’re a legislator to consider something like that, because it is going to take some time to get caught up. And once you’re caught up, of course, maintaining the system will be much easier than the initial startup for this. So that’s our Pennsylvania version. Okay, so now our Utah version in Utah, they signed this bill into law March 28, of 2019. This was originally House bill for 31. And this was a republican sponsored bill in Utah, it received a completely unanimous vote in the House, a unanimous vote in the Senate, and a unanimous vote at committee meeting seemingly bipartisan, it becomes effective may of 2020. So let’s look at who this one impacts. This one impacts anyone who has received an acquittal, or dismissal with prejudice conviction for a misdemeanor. If that misdemeanor is a controlled substance Class A, or a Class B or Class C, think of that like a second degree or third degree misdemeanor for many other states. And, and if you could see me you’d see the air quotes an infraction conviction, which is state specific, or traffic offense acquittals. Additionally, the total number of convictions the person has to be eligible for this clean slate record ceiling is going to be less than three convictions. If two of them are Class A misdemeanors, and they’re not drug possession, and they’re not in the same criminal episode. So in other words, if they’re in the same criminal episode, that counts as one, to be multiple, in Utah, they have to be in different criminal episodes. Now, that was for less than three convictions, they can be less than four convictions. If three of them are no higher than Class B misdemeanors, and they’re not drug possession. And or they’re not in the same criminal episode. They can be less than five for anything else. And for anything else, for other states, that’s going to look like 30 misdemeanors and down. And again, the Utah version is not for people with drug possession and not in the same criminal episode.

It’s also considered appropriate if the person has up to three felony drug possessions. Or if the person has up to five drug possessions that are not felonies. And again, if they’re not in the same criminal episode, because in Utah, same criminal episode counts as one, not a separate convictions. Okay, so we’ve got the conviction for the misdemeanor, total number of convictions, Utah also requires that the person have no pending criminal case sounds like a good rule. And that the time from the date that the person was adjudicated, be five years for class C misdemeanors or infractions. Think third degree misdemeanor or minor misdemeanors, six years from class be misdemeanors think. second degree misdemeanors, seven years from class A convictions for controlled substances. That’s like a first degree misdemeanor. So that’s who gets impacted in Utah. Let’s talk mechanics for a minute. So they have to give notice to the prosecutor in Utah before experiment, the Department of Public Safety and their Judicial Council are the agencies running it. And this happens 60 days after acquittal for all charges 180 days after dismissal, if there’s no appeal, and then there’s a one year catch up period for old cases. So in other words, this went into effect March 28, of 2019. There’s probably a ton of people who meet that five, six or seven year criteria for misdemeanor charges, and would be eligible immediately for record ceiling. But the bill is written to give a one year period for the state agencies to get the system up and running. And to get caught up to current. Just like in Pennsylvania, there’s going to need to be a phase in period and it’s going to take them a minute to do that. So probably a good idea to have that is part of your bill. Now there are exceptions in Utah as well. Utah makes an exception for any case where the person was found not guilty by reason of insanity. And that’s an interesting one, because it’s not quite a not guilty finding. It is much more like a guilty finding. In some places, they call that guilty but insane. Other states call it not guilty by reason of insanity. So in Utah, that’s what they call it. And they decided to keep that out, since it is much more like a finding of guilt than it is like a finding of innocence. Anyone who has unpaid fines in Utah, no automatic ceiling, no violent offenses, no weapon offenses, no sexual battery, no acts of lewdness, no DUI, no damage or interruption of a communication device, and no domestic violence. And critically, and here’s something that is very different from the Utah version compared to the Pennsylvania version, they put in a right for the prosecutor to object, the prosecutor gets a 35 day notice. And if the prosecutor thinks the case is not eligible, or that restitution has not been paid in full to the victim, or if the prosecutor has reasonable belief of subsequent crimes that took place by that person outside the state, for any of those reasons, the prosecutor can object. And if the prosecutor objects, the record does not get automatically sealed. Just like Pennsylvania, there is a process for sealing records manually, you could say where the person applies, and the person can still apply if the record is not sealed automatically. But obviously, that’s a lot harder, many less records are sealed in that manner. So this is one more way that the automatic ceiling can be stopped through the prosecutor exercising their power. It’s an interesting provision. One worth thinking about, but not necessarily one that’s critical to making the clean slate legislation work the way it’s intended.

So that’s Utah, let’s talk California. Now California hasn’t passed, there’s, but they have put out a full bill. And there’s been committee hearings on it some debate back and forth, and a fair amount of writing. So it’s a nice one to look at to see what another state with a slightly different philosophical slant and their state legislature is doing with us. Unsurprisingly, the California version is sponsored by Democrats instead of Republicans, because California. So who qualifies, this would go into effect, assuming it’s passed at the beginning of 2021. And it will only apply to people with convictions from 1973 forward. That’s an interesting clause that I haven’t seen any other bills. And that’s a way of limiting the workload that clerks and the other people involved in this are going to have to do the catch up. Because if you make it to the beginning of history, obviously you’re talking about a huge volume of criminal records. 1973. Well, at that point, you’re talking almost 50 years ago, there probably aren’t a whole lot of people being haunted by misdemeanors from 50 years ago. So probably a reasonable clause, but different than the other bills. It also requires that the person have a misdemeanor, or have some sort of charge that was dismissed, misdemeanor arrest, with no prosecution, and one year since the date of arrest, or that the person has an acquittal, or they include felonies punishable by county jail time instead of prison that are non violent and non sexual in nature. Additionally, if there were no proceedings on a felony like that, and three years since the arrested, not every state has the equivalent of that, but I know at least one or maybe a couple other states have state jail felonies, something that’s a little bit less than your standard prison sentence. But a little bit more than your standard misdemeanor, and it is served in jail instead of prison. That’s something that California is going to be sweeping in assuming this version passes. It also will require a successful completion of pre filing diversion, drug diversion, pre trial diversion, some other sort of diversion program or a probation. And that’s for people who are getting these diversion programs or probation instead of conviction, you finish that it’s considered like a conviction in terms of being able to be sealed. Now, if it’s a misdemeanor sentence, and at least one year has passed, since the disposition dates, those are going to get swept in as well. And it will not apply to anyone who is a registered sex offender. Anyone who is still on active supervision, anyone who is currently serving a sentence, anyone who has pending criminal charges, or anyone who served state prison time, although there are some exceptions written into that. Put another way, in terms of how many other states will see it, they exclude anyone who has served felony time. Now the mechanics for it or not that dissimilar from the other states. There is a weekly review that takes place by the Department of Justice, they identify the eligible persons from state summary criminal data, it’s in a statewide database in that state. And then they provide notice to the Superior Court that had jurisdiction over the original criminal case, the court keeps that private that they don’t disclose who has been identified as eligible by the DOJ. Though there are certain exceptions, as there always are, if relief is granted, in other words, if it’s automatically sealed, then there will be a note added to the statewide criminal database. That will note that so anyone who has access to that database will be able to see that this has been something that has been sealed by clean slate. Additionally, it requires the DOJ to maintain that summary criminal history information probably seems like a good idea in general. Now, there are exceptions. And I should mention, all of these states in different areas of their statute tend to have exceptions to what this ceiling actually covers expunged, that means it’s gone forever, it’s gone completely record ceiling or limited access, when as Pennsylvania terms that are all something less where most people can’t get at it. But some people can in the California bill, they put it directly in that bill. So I’m going to read there’s but for reference, the other states do have things like this as well. In California, anyone who’s looking for police employments, they’re still going to be able to see their own criminal records seems reasonable. Anyone who is applying for public office, anyone who has a subsequent criminal case, and the prosecutor would like to use their criminal history for enhancement purposes. If there is a post conviction petition that’s filed later on that case, the court can see those records and those records can be opened. And the prosecutor can file 90 days prior to relief for new cases, not for old cases in California. But new cases that will be subject to ceiling. Within 90 days, prosecutor can file saying hey, there’s a problem.

You shouldn’t steal this record for reason x. And then the record will not be automatically sealed. Just like the Utah version of that. It is still something that is potentially eligible for individual application based ceiling, but not something that would be awesome, medically covered in clean slate. So they write that same sort of prosecutor escape valve into their legislation. All right now they come up with some interesting facts in the California piece that I’m going to throw out real quick just because they’re fascinating. They estimate that each petition for record ceiling that is manually processed in California, cost $3,757. Now, they don’t have a clear breakdown of where that estimate comes from. But presumably, judges time, bailiffs time clerk of courts time, the defendants time, the prosecutors time, the other required court personnel to make things run the victim if you’re bringing them in. And that probably doesn’t include the cost the defendant is paying to have an attorney to represent them. So $3,757 per application under the current system cost to the state. They note that 92% of employers subject their applicants to criminal background checks, and four out of five landlords use them. These stats are interesting, because it shows this is part of what California was thinking about when it passed. Well, I shouldn’t say passed, as it’s considering its version of the bill. Now, there is some opposition. Despite those facts, they note that the 90 day notice provision to the prosecutor doesn’t work on probation. Because in the situation where a person is still on probation, and where they would be subject to record ceiling immediately when probation finishes. A person on probation could get a violation up until the last day of probation. At any of those times, if they do something against the rules, they’re looking at a violation. Consequently, that 90 day notice doesn’t help because the prosecutor might not find out that a record shouldn’t be sealed until one day before it’s about to be sealed. Obviously, that’s an easy policy fix, you just change your 90 day period to start when it runs from the end of supervision. For people who are on supervision during this period, the prosecutors in California say that in general, it’s going to be a pain to keep track of. Now, that’s is sort of an artifact of the way this legislation is made. The Pennsylvania legislation doesn’t have any escape bell for prosecutors. Consequently, it will not be any harder for prosecutors in Pennsylvania, but the Utah version, the potential California version, because they write that in, that does create some additional burden on prosecutors. Now, maybe it’s a burden prosecutors want, maybe it isn’t. But that’s something that if you are looking at in your state, you should contact prosecuting attorney Association, whatever they might call that in your state, see whether they want that or not. Alright, last but not least, I’m going to do a really quick hit on federal legislation. Because anyone who’s looking around for this may see that there have been federal clean slate acts proposed multiple times. In fact, however, those are nowhere near as comprehensive as what we’re talking about at the state level. Those have been just targeting drug and marijuana offenses, and those being for acquittals and arrest only not for convictions. So really what has been proposed at the federal level is very, very different than what we’re seeing at the state levels. But if anyone asks about that, don’t get confused, it’s really a completely different animal. Now that we’ve looked into the details of what the states are doing, let’s take a minute to talk with policy organization and see what the people who spend their time looking at the research and thinking about these kinds of issues, or thinking that the states should be doing. We’re happy to have with us today, nella Bala, the Associate Director of criminal justice and civil liberties at the R street Institute. Thank you for joining us today.

Nila Bala 26:42
Thank you so much for having me. And if you could tell me

Spencer Cahoon 26:45
just a bit about the R Street Institute, as I suspect a number of our listeners probably are not familiar with the organization.

Nila Bala 26:51
Sure, the R Street Institute is a public policy organization is based in Washington, DC, although we do have offices across the country as well. The institute itself actually works on a number of different areas, including energy, insurance, harm reduction, the area that I work in is a criminal justice. And so our goals are to try to advocate for smart policy in the criminal justice arena. And specifically, one of the areas I work in is reentry policy. So the policies that govern and assist people as they are exiting jails and prisons.

Spencer Cahoon 27:25
Gotcha. So this clean slate legislation is right on par with that?

Nila Bala 27:29
Absolutely.

Spencer Cahoon 27:31
as something you’ve been looking at how have you been involved with clean state legislation to this point,

Nila Bala 27:35
I first got into this work actually as a public defender, both in Santa Clara County, California, as well as Baltimore City. And in both of those places, I actually performed a number of records dealings and experiments both for young people as well as adults. And I just saw the tremendous benefit that it could have on people’s lives when they were able to close a chapter of their life and move on from that.

Spencer Cahoon 27:59
Great, so you’ve actually had the opportunity to see it both from the policy side as well as from on the ground.

Nila Bala 28:04
Absolutely. And that definitely informed a lot of my policy recommendations because I know how challenging it can be to navigate the system, from working with my clients. And most of the individuals who are in the criminal justice system or are trying to a clean slate afterwards are often indigent. Individuals who don’t have a lot of money, who don’t have a lot of resources and are trying to figure out sometimes a very cumbersome process for clearing their records. And just to be clear, when we say clearing records, we’re not we’re not talking necessarily just about convictions, we’re talking even about arrest or not guilty, or cases where the person case was completely dismissed. And yet, they still have a criminal record. And it’s still holding them back.

Spencer Cahoon 28:47
I think too many people listening, the criminal justice system may seem very distant from their experience, and they might not know anyone who’s been personally impacted by it. So how many people could potentially be impacted because they have some sort of criminal record?

Nila Bala 29:02
It’s funny that you say that most people probably don’t know someone with a criminal record, because I venture to guess that, that you actually do know somebody with a criminal record, given the numbers. But of course, it’s something people probably don’t want to advertise. So the estimates are between 70 million and 100 million Americans, that’s one in three that have some type of criminal record. Wow. Yeah, it’s pretty bad. So if you’re talking about a third of Americans, that’s that’s like a lot of people. But like I said, that criminal record can really vary. For some of these individuals, that might just be an arrest, a lot of people might just have an arrest with with a no further prosecution. And then there might be people with, you know, of course, longer rap sheets. And so when you ask the question of who’s affected by clean slate legislation, or punishments, it’s not going to be all those individuals, because most exposure and policies don’t, for example, say that a person can get a clean slate after, you know, committing a serious felony or rape or murder, of course, but there’s a good number of those people who will benefit from this kind of policy.

Spencer Cahoon 30:08
You recently wrote an article for the New Haven register, noting that these criminal records can carry serious economic costs. So what kind of impact are we talking about on the states from this?

Nila Bala 30:18
There’s huge impacts economically, I mean, you can look at it from a couple of different perspective, there’s the perspective of the individual who themselves has a criminal record, they’re very impacted, because it’s very difficult for them to get a job. When they do get jobs. They say, under employment, a criminal record reduces a job seekers chance of getting a callback or job offer by nearly 50%. So it’s an enormous impact. And then it percolates out from there. So the individuals families, of course, expected because when they can’t get a job, they might have difficulty with housing with, you know, helping their children, even keeping their children it can affect of course custody. And then it has economic impacts on the state because we know what people are employed and their consumers in our market, it affects our economy. So communities benefit when individuals are fully employed, because they can be full consumers.

Spencer Cahoon 31:11
Okay, well, let’s transition from there, you have the opportunity to look at the research and look at some of the different state practices. And if you are in the position to be able to speak directly to a legislator who is looking at introducing a clean slate bill, what type of clean slate legislation would you recommend based on that knowledge and research and why?

Nila Bala 31:31
Here, the first thing I would say is the initial period when somebody is released from jail or prison is incredibly important, we know that if they are able to get some kind of employment right away, that can be really helpful. And so for the lowest level things, I mean, like I said, especially if it’s not a conviction, there should be something in place that considers the possibility of having it expunged automatically. In most places, there’s a very long waiting period. For some things, we might want there to be a waiting period, because we want people to show that they’re able to live a crime free life. But I think that the waiting period should be structured, so that the more serious offenses are the ones that take longer to expunge, and that there are ways to expunge some things more quickly. The other thing that’s enormously effective, and all the research shows us is some automatic expansion, we know that individuals have a great deal of difficulty, first of all, and knowing that something is even able to be cleaned off of their record, then the second piece is actually accessing the court system, paying the fees, filling out the forms often is so complicated that you need an attorney to help you with this whole process. And access to justice is an enormous issue, along with thinking through the waiting periods, I would definitely want to lower the cost. So there are costs, I mean, in some states that can cost 500 600 $700 to clean your slate, and those are enormous prices for individuals. And so we need to increase user access, we reduce costs, and just include more offenses under the expendable umbrella. Like I said, a lot of states just will only expunge the most minimal of things like things that, of course, seems like a no brainer. Non conviction records not guilty. But we should give people a second chance even when they have committed, you know, misdemeanors and even some felonies because people can change. I mean, that’s that’s sort of, to me part of the American dream that we we think that people are capable of more they’re capable of changing and they’re capable of growing and our law should recognize that.

Spencer Cahoon 33:33
Absolutely. And to sum up what you’re saying and tell me if I have this wrong. It seems like this is a change. That is not a government regulation. It’s not a subsidy. It supports business and the free markets. And it literally gets government regulation out of people’s way to allow them to get jobs and be productive members of society.

Nila Bala 33:53
Absolutely. I mean, R Street is coming from a center right libertarian perspective. And we completely support this policy as you focus on the left, because it’s absolutely a no brainer, it’s it is about limited government, it is about government being efficacious. And at this point, having criminal records that are you know, 10 2030 years old, laying people down, it doesn’t just hurt them and hurt public safety. Because we know when individuals aren’t employed, when they aren’t able to be consumers in the economy, they’re actually more likely to resort to crime. So it’s just smart policy smart. You’re looking at it from an economic lens. And it’s smart, if you’re looking at it from a public safety lens. And it’s definitely smart, if you’re looking at it from an individual dignity perspective of that individual who’s impacted.

Spencer Cahoon 34:35
The scalar, thank you so much for joining us, this was very helpful. And thank you for sharing the perspective of both yourself and the R Street Institute.

Nila Bala 34:43
Absolutely, thank you so much for having me.

Spencer Cahoon 34:45
Okay, now that we’ve seen what the states are doing, let’s talk a little bit about a research based variants. Now, this is just taking the policies of state have made, and then adjusting them a little bit to reflect what the research is showing. So who cover obviously, it should cover people were there was only an arrest, no prosecution, or the case was dismissed, or it was found not guilty. And those things should be done as soon as possible, just like you were hearing from R Street, there’s no reason to hold up on those, you don’t want someone to get denied for a job, because they were arrested and released for something that never came to anything. So those should get done as fast as possible. Doesn’t matter if it’s a misdemeanor or felony, because at the end of the day, it’s nothing the person hasn’t been convicted. Now, for felonies, this is where it gets interesting. So the research, there was a recent Michigan study that shows that once the person has been about five years out from criminal conduct, so the person had a felony conviction, they serve their time, they get out there living a normal life, it’s been five years since their release dates. The Michigan study shows that there’s only a 1% risk of felony recidivism at that time, which means about 99 people out of 100 are not going to get a new felony conviction. That sounds pretty safe to me. And that’s what the people in the study thought as well. They do note that there if you measure not just felony recidivism, but whether the person might get a misdemeanor conviction or a felony conviction, it jumps up from 1% to 4%. However, that’s still 96 people out of 100, who are not going to run into any problem at all, and three out of 100, who are going to run into maybe a minor misdemeanor issue. So five years is a point you might want to cut if you are going to do automatic ceiling for felony records. Now, alternatively, there is a scarlet letter study, as well as information from R Street that notes that at about six to seven years out, the risk level of people who are coming out with felony offenses is roughly comparable to the risk level of people who have never had an offense. In other words, their risk of committing new offenses has gone down to the baseline, meaning they’re no more risky than any other person on the street. So that’s a kind of obvious point where if you want to be a little more conservative, six or seven years, puts you in a safer place for limiting recidivism even further. However, there is University of Maryland study that has a higher date, that notes that the risk is equal to the risk you have in the general population. Instead of finding that six to seven year figure. They find that to be about 10 years, to 13 years depending upon the type of offense. So 10 years would be more than cut that would be recommended by that study. But what that does mean is even for felony crime, and this includes violent crime, in fact, a number of these studies have specifically looked at violent crime versus drug crime versus property crime. The U Maryland study found that your risk of new arrest goes down to 10%, meaning only one out of 10 people would have any sort of problem for violent crime in seven years. And for drug or property crime in four years. So if you were going to make a tiered system for felonies in your state, you would might want to set up a separate tier for violence, which would be at the top points, and then another tier for drug and property or drug and then separately for property. Because that same you Maryland’s study notes that the risk rate goes down to 3%. For violent offenders and 11 years, drug offenders 10 years, property offenders in eight years. So again, that would be suggesting a tiered system might be more appropriate.

Now, that’s felony con, all these that we’ve been looking at so far have looked at just misdemeanor conduct. So what do we have for misdemeanor, most of the research doesn’t really break down misdemeanor versus felony conduct, the limited amount that does the Michigan study notes that after five years, there’s a 4% recidivism chance of misdemeanor or felony conduct put together. So five years seems like a completely reasonable cut off or misdemeanors based on that. But again, the research on misdemeanors specifically is lacking. Now, there are some exceptions, multiple cases do increase recidivism risk. The studies have found that that tops out around four cases. And as I’ve already noted, people with violent offenses are more likely to reoffend than people without violent offenses. So on the research, if you were to make a variance from that, you might want to have tiered structures for violent drug property offenses. If you were going to break it down, you would want somewhere between a five to 10 year period for felony offenses, probably no more than five year period for misdemeanor offenses. And you might want to have something that looks at it differently for people who have multiple cases, versus people who just have a single case.

Let’s talk about what we’re actually getting out of this type of policy, there’s going to be an economic impact. That’s probably the main thing. That’s your headliner, unemployment. research notes that 34% of unemployed men have a record and review of approximately 200,000, Virginia job ads showed that only 8.2% of them would accept an applicant who had a criminal record. What does that mean? Looking at what adds about 92% of people turn somebody away for a criminal record. And if you’re talking about roughly one third of unemployed people who have a record, well, then that means 92% of jobs that these people might hypothetically be able to apply for, we know offhand are going to turn them away. We know that expansion improves employment chances by roughly 7%. And that is for people at the individual level, it leads to wage increases of roughly 25%. And that’s not for people who have already applied to jobs and have already been hired and are working full time. This is primarily growth, from unemployed people going to work, and from underemployed people getting more stable work. So in other words, the people we want to help most in the labor pool, this is literally who that’s impact. This is going to mean and improve tax base for states. And it’s a cheaper system than job training programs. But it has a similar impact on getting unemployed people and underemployed people into jobs. So that’s unemployment. In terms of business. Well, in Utah, where they’ve passed this, Salt Lake City Chamber of Commerce, said that this would be a huge workforce driver is currently nine in 10. Employers use background checks. Now about background checks. Employers often are concerned about potential liability, if they hire somebody who’s a criminal offense, there’s always the concern in the employers mind. If that person does something new, that’s a crime, and it affects my consumers, then are those people going to be able to sue me, by taking this out of the hands of employers to review with you, we’re also taking away that liability, because that liability attaches only when the employer knows about it, it’s you knew this person had a criminal record, you hired them anyway, you put me at risk. By taking that out of the employers hands, you empower the employer to actually hire the person they want to hire, without making them worry about lawsuits. So it’s good from an employer’s perspective, which is why the Chamber of Commerce was behind it in Utah, the Pennsylvania Chamber of business and industry noted, and I quote, we have a workforce problem in this Commonwealth and this country, we have a large number of jobs without people to fill them. And we do have people without jobs, how do we make a system to break those barriers down, we sleep clean slate as a way to do that. It gives employers color to take the step and hire someone who is going out and trying to improve themselves, unquote. So literally, they’re saying exactly the same thing. I was just saying that this is good for employers, because it reduces their concern about incurring legal liability for hiring somebody who has a prior criminal record. And in terms of potential system savings, because California estimates it costs $3,757 within the system to clear each record. Obviously, this is going to be much cheaper on a per record cost, because you’re primarily automating the process. Now let’s look at GDP. Because everybody always likes to talk GDP when you’re talking economic impact. estimates are that it is 78 to $87 billion in lost us productivity. So that’s a huge number, that’s a billion with a be lots of money. And that means since we have less than 78 to 87 states, really you’re looking at roughly a billion or billions of dollars for any given state, depending upon how large your state is in reference to the whole country. One example, because I ran the numbers for Ohio, Ohio, given where they sit would be looking at a $2.69 billion gain, if they could get rid of this productivity bar from criminal records. Now, of course, this is never going to be eliminated completely. Because there’s some criminal records we want to keep no one’s saying we should get rid of all the criminal records. But for the ones that we think, are not doing us any good, why not regain that economic productivity, maybe you don’t get $2.69 billion Ohio, but you get a big chunk of money. And it still might be an amount in the billions. So definitely something to think about. So that’s the economic and the citizen impact. Different states have found that only between 3% to six and a half percent of people who are eligible for current record ceiling laws, or punishments, use it. Now there are a lot of different reasons for that, it can be costly, a lot of people don’t understand the legal process. If you have to hire a lawyer that’s out of reach for many people. Again, we’re talking about impact on people who are unemployed and underemployed. These are people who don’t necessarily have large amounts of free funds sitting around. So now you’re taking something that’s only utilized a single digit percentage of the time making it automatic, that means it’s going to be utilized in the high 90s. So you’re going to have a lot more impact on your citizens. Stats note that about half of children have at least one parent with a criminal record. That means that if you’re clearing those criminal records and empowering those parents to go back to work, you are also supporting child welfare, because the people who are paying the bills at home for those children are the same people this is going to impact. So children benefits 25% wage improvement is going to help stabilize at risk families. So that means someone where there’s five financial conflict, breaking a couple of parts, maybe that’s going to ease that maybe that’s going to keep that family together, and other people who are at risk of losing their children, or who don’t have primary custody and have Child Support obligations. You’re empowering people to meet those obligations, you’re empowering people to pay for the things they need to make sure they keep custody of their children in the first place. So this is a good thing for child welfare. Also, it will support broader access to housing. Four out of five landlords use background checks. That means if suddenly criminal records of this type are not showing up on background checks, just like with businesses, you’re going to empower landlords to rent to people who had a criminal record that’s been sealed, without the landlord worrying about liability from that. And obviously, if there are areas that you have concerns about people with violent offenses, sex offenses, whatever it might be in your state, there are exemptions and every one of these state versions. So that’s the impact on your citizens, public safety. Now, this stat, I find this just staggering. People with one year of work, are 70% less likely to new crimes 70%. That’s crazy to me. And here’s the one that really makes it insane. Not only that, but people with even 30 days of work. That reduces the risk of recidivism by 62%. So even somebody who doesn’t have a full year of work who has a less stable job, even someone who just has a little bit of part time job here and there, their risk of recidivism goes down 62%. so empowering people to get more jobs means you are going to have a significant public safety impact 70% reduced risk of new crimes with one year of work 62% reduced risk with 30 days of work, man, those are just staggering numbers in terms of reducing risk of new criminal conduct. Now, that’s all the positive research. Let’s talk about the cons for a minute. There are some limitations. As I said previously, most of this research does not break down felony versus misdemeanor conduct. That means from a practical reality, the states only have limited guidance on what works for misdemeanors. So the tools we see saying somewhere between the five and 10 year range, that’s including felony conduct. So if you’re taking that out, one might presume that a shorter period would be appropriate for people with misdemeanors. But again, the research is really hasn’t dug in on that. Additionally, the research because it studies people who are using the current experiment tools, the people who are applying now are most likely the people think they see the greatest personal benefit in getting their records expunged. Consequently, the effects, like the increase on wages, the increase on bringing people back to work, they might actually be a bit more muted when it’s distributed much more broadly in society through an automatic process. And that’s going to be the limitation of any research on this right now, because you are stuck system we are currently, one thing that also hasn’t been looked at in much depth is the cost of the system to run. Obviously, on a per record basis, it is going to be much much cheaper than the current system, an automated system is still going to require personnel hours to run an overall this cost could be similar or hypothetically even greater than current cost, since so many more records will be affected. And as far as I know, there are no researcher estimates on what the overall system costs for this to be processed will be. The more it’s automated, the more it’s done by computers and email notices and things that are sent out automatically, the cheaper it’s going to be. The more escape valves you write into it’s noticed prosecutors prosecutor chance to object, the more expensive it’s going to be because the more it starts to look like the non automated version. So those are things to keep in mind. And some of the cons are the limitations of research.

No discussion of potential legislation would be complete without speaking with someone actually working on the legislative side of things. Today we have with a state of Ohio house representative Jeffrey Crossman, also a member of the criminal justice committee in that state representative Crossman, welcome to emerging state policy. Thank you. How are you today? I’m doing well. Thank you. Now for anyone who might not be familiar with you. Could you tell us a little bit about yourself and your district?

Jeffrey Crossman 50:19
Yes, well, I am an attorney by trade. That done very much criminal practice, of course by practicing on civil side. But I’ve been a practicing attorney since 2001, and was elected to the State House or from the Ohio’s 15th district which represents Parma, Ohio, which is the seventh largest city in state of Ohio, also my district and encompasses portions of Cleveland heights, Brooklyn Heights, so compact district here up in the pretty well populated areas of state of Ohio, and my first test term started in January.

Spencer Cahoon 50:55
Well, today we’ve been talking about clean slate legislation. And what is it that’s interest DU in clean slate legislation? Or what brought it to your attention?

Jeffrey Crossman 51:04
Well, quite frankly, you know, I deal with a lot of other attorneys in the community. And the best ideas come from practitioners that have experience in navigating their clients through some of the challenges that they have post conviction, you know, it started as an idea really involving juvenile reform, been been looking at a lot of things we can do to make lives better for juveniles getting out of the system and getting on the right track to becoming productive adults. Absolutely. Getting out of the criminal justice system. So that’s where it started. And then I saw what’s going on in Pennsylvania and Utah, some other states that are looking at clean slate legislation, you know, it was really encouraging to see that this issue is not divided along political lines. But there are supporters among different political parties different, you know, interest groups. And so that gave me sort of the idea of maybe broadening the focus beyond juveniles and really taking a look at Clean Slate legislation and moving it forward and state of Ohio.

Spencer Cahoon 52:11
That sounds great. Now, do you have any of your constituents had experiences that you see as someone who would benefit from this type of legislation?

Jeffrey Crossman 52:20
Well, based on the research, and I’m sure you’ve covered a lot of this in, in your episode here, that by a third of Americans across the country had some criminal conviction. And, you know, my most recent stint as Assistant General Counsel for the local real estate company with apartment buildings, I can tell you, and we do screen as many landlords do for criminal background, that presents a barrier for folks, obviously. So to the extent that we can remove barriers, to housing to employment, that’s the real goal here is to make sure that people have an opportunity to gain that second chance that we all get America want people to have, people should pay their dues. But we do want I think in America, we do believe that people should have opportunities at second chances. So that’s kind of where this all began, that ends for me is this whole interest of opening doors for people because there is such such a number of people out there that have low level misdemeanor charges out there on the records, and it does present annoyance or embarrassment, all the way to being denied enough to have a job does he have to check a box of employment application.

Spencer Cahoon 53:25
I think that’s the same experience, people are having it in all the states across the country.

Jeffrey Crossman 53:31
And, you know, even I’ve had a criminal charge in the past of the misdemeanor, you know, I was not a perfect use by any measure. And you know, I had my running, run in and get caught up in a misdemeanor charge. And, you know, for me, it was more of an annoyance and embarrassment than anything, and I did get it expunged, years later. So I am familiar with the process, I had to get an attorney, I’d pay them money, I had to go to a court hearing for a very, very low minor misdemeanor charge. And so, you know, obviously, as those charges escalates, cost, the burdens the barriers become more difficult to get that charged, removed. You know, I was fortunate and obviously went to college, graduate Law School graduate, those opportunities for me were available, you know, even after I had this criminal charge out there, I can only imagine folks that don’t have those advantages, trying to navigate the system and trying to figure out ways to remove a barrier to employment and housing. Having this personal experience definitely helps inform, you know, my decision to move forward with this type of legislation.

Spencer Cahoon 54:35
Now, as a legislator, you’re in a unique position. Unlike the other guests that we’ve had from policy, think tanks and agencies working with record ceiling on the ground, you get to work directly with the legislative process. So what advice would you give to other legislators who are considering sponsoring or voting for clean slate bills?

Jeffrey Crossman 54:52
I’d say do the homework. I think there’s a lot of interest groups out there, they’ve done a very nice job of providing the information on what means to remove these barriers, what the risk of removing these charges are, which is pretty low level, depending on how you structure this and we’re not talking about expunging violent felonies, I think they’ve done a really good job of making the case. So I would encourage legislators to examine those pieces of information, the evidence out there that has been gathered in support of this type of legislation, because I think it’s very compelling. And I think that the argument speaks for itself and why it makes a lot of sense to do this.

Spencer Cahoon 55:31
Well, perfect. Thank you so much. Well, we’ll be watching for Bill coming down the road representative Crossman, thank you for your time and for joining us today on emerging state policy. Thank you for your time, looking at the political reality for this kind of Bill. One thing that’s fascinating about this, is there’s broad support. Today, we live in an age of hyper partisanship, and people are always saying we’re as divided as we’ve ever been. But this is something when surveyed has 70% overall based support. Now, obviously, there’s a bit of a split between Democratic voters and Republican voters. Democrats, when surveyed support this about 75%, three out of four people, Republicans supported 66%, two out of three people. Now, you might note, even 66% is a super majority. So we’re really talking broad bipartisan support here. And when you look at some of the breakdowns, from these studies, people agreeing that the main goal of the criminal justice system should be to ensure appropriate punishment, instead of rehabilitation. 71% of those people support clean slate legislation, people who think that crime victims have to live with consequences of their crimes throughout their lives. So people who commit the crime should have to suffer the consequences of those crimes throughout their lives as well. In other words, people who are focused on the punishment side of that 72% of those people support clean slate legislation. So we’ve got these really high numbers. And here’s one thing that is fascinating about that. People who oppose, so the 30 percent of people who are not on board of those 30% 30% of them flip when they find out that sealed records are still available to law enforcement and the courts in the case of future crimes, and 29%. More people also flip, if there are told that automatic ceiling reduces court workloads and saves taxpayer money. So when you put that together, if you have those elements in your legislation, you’re looking at about 87.7% support. And that is just a astonishingly high number in today’s age. There is also a great organizational coalition behind this already. There are 25 organizations from across the aisle, conservative liberal and everything in between. You’ve got Koch Industries to the Center for American Progress. And that survey research that I was just citing you that’s from the Center for American Progress. There are multiple think tanks focused on free markets and reduce government role, who are all in favor of this, you heard from the students to today, also the American Conservative union Foundation, fair and just prosecution rights on crime. And they look specifically for conservative solutions on crime. And the seminar network, which was founded by Charles Koch, and the Koch brothers political network has put out a press release. They’re going to be using their political network to help get this message out and go state by state help get people the information they need to set up clean slate bills in their states. I hope you found our discussion of clean slate legislation today helpful. I hope that it will help you in your state’s determine if this is the kind of bill that you or your representative should be pursuing. Thank you so much for tuning into emerging state policy, an open source podcast being an open source podcast. That means you may reuse any or all portions of this podcast without permission just to please drop us a line. If you decide to use portions of this podcast, just so we can know where our exposure is going to. You can drop us a line at Spencer j Cahoon on Twitter. Please rate us on iTunes, Google Play stitcher or Spotify. Special thanks to Nick Allen for music composition. And soon we hope to have web page up so that we can drop show notes with direct links to the studies and the different research we talked about in this podcast. Thank you so much for tuning into emerging state policy.

Transcribed by https://otter.ai