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Lifting Up Solutions that Support Black Mothers


happy family with new baby sits in living room

Amid all the excellent media coverage of the US maternal mortality crisis in recent years, something has been missing. “Too much reporting on Black maternal health has been doom and gloom,” said Monica McLemore, PhD, MPH, RN, assistant professor at the UCSF School of Nursing. In an interview with Rewire.News, she called for the media to shift the maternal health narrative — “to lift up Black mamas and let them bring forward their solutions.”Essential Coverage

That was the theme of the Black Mamas Matter Alliance’s (BMMA’s) second annual Black Maternal Health Week from April 11 to 17, which focused on awareness, activism, and community-building. In an effort to revise the media narrative, BMMA events in 15 states and online highlighted solutions to help Black mothers and birthing people* have healthy pregnancies and thriving babies.

Black mothers are more than three times as likely as mothers of other races to die from maternal and childbirth complications. In Scientific American, McLemore, a BMMA advisory committee member, wrote, “Everyone — from doctors to the media to the public — needs to stop blaming women for their own deaths.” Researchers and reporters, she said, should focus instead on understanding the underlying causes of maternal health disparities — most notably, racism. “California has led in the pursuit of understanding root causes of maternal mortality,” McLemore wrote. “Structural racism is proving to be an intractable force.”

Doula and Midwifery Services Can Help

Community-based maternity care models could help break down the walls of racism. A new issue brief (PDF) from the National Partnership for Women & Families highlights community-based models like doula and midwifery childbirth services. These “go beyond the scope of services offered by conventional clinical providers because they also provide psychosocial support, cultural concordance, and care coordination that is grounded in reproductive justice,” the brief said. Research shows that women who receive continuous, one-on-one support during childbirth, like the services provided by a doula or midwife, are more likely to have positive health outcomes for themselves and their babies. Additionally, the Listening to Mothers in California survey showed high interest among women of all races, but especially Black women, for future use of midwives and doulas. (The survey was conducted by the National Partnership for Women & Families and funded by CHCF and the Yellow Chair Foundation.)

The city of San Francisco, recognizing the importance of childbirth support, especially for women of color, recently implemented a doula program for pregnant women with low incomes who identify as Black or Pacific Islander. Ashley McBride reported in the San Francisco Chronicle that the goal of the program “is to provide doulas to women who need help but can’t afford it, as well as training culturally competent doulas.” Former San Francisco Supervisor Malia Cohen, who spearheaded the program, said, “It’s an important vehicle for us to fill the gap on increasing positive health outcomes for the mother and baby.”

Another important vehicle is the California Birth Equity Collaborative, a new pilot project led by the California Maternal Quality Care Collaborative and funded by CHCF. It “aims to transform birth care for, by, and with Black mothers and birthing people in California in partnership with Black women-led community-based organizations; three participating pilot hospitals; and state, national, and local advisory groups.” The pilot, which began in January and is expected to run for two years, focuses on quality improvement in hospitals.

Including Black Women’s Voices in Policymaking

Sunshine Muse, a health disparities consultant who works in maternal and infant health, highlighted another solution in the online magazine The Root: Developing policies centered on Black women. “When policy development is led by Black women, the likelihood that Black women’s safety and care will be centered on its words and execution are high,” Muse wrote.

In Washington, DC, the first-ever congressional Black Maternal Health Caucus, launched by Representatives Lauren Underwood (D-Illinois) and Alma Adams (D-North Carolina) during Black Maternal Health Week, will focus on that goal. “Our caucus will elevate Black maternal health as a national priority and explore and advocate for effective, evidence-based, culturally competent policies and best practices for improving Black maternal health,” Underwood said, according to The Hill’s Rachel Frazin.

In Sacramento, two state lawmakers have introduced legislation to train health care professionals to provide culturally competent care. State Senator Holly Mitchell (D-Los Angeles) introduced SB 464, which would create an implicit bias awareness training program for perinatal care providers, Jazmine Ulloa reported in the Los Angeles Times. The measure would require the California Public Health Department to collect “better data on maternal mortality rates and require hospitals to provide patients with more information on how to file discrimination complaints.”

Assemblymember Sydney Kamlager-Dove (D-Los Angeles) introduced AB 241, which would require continuing education programs for physicians, surgeons, registered nurses, and physician assistants to include training on understanding implicit bias in medical treatment.

The wave of community and policy-oriented action around improving Black maternal health makes Dawes Gay optimistic, she told Rewire.News. “I am very hopeful that this work is ultimately going to lead to some meaningful change for Black mamas in the US,” she said.

*Using Inclusive Language Around Pregnancy and Childbirth

The use of the term “Black mothers and birthing people” by the California Birth Equity Collaborative pilot recognizes that not all people with the desire to become pregnant and give birth identify as a woman or a mother. In alignment with the values of BMMA, the pilot uses inclusive terminology, such as pregnant people, birthing person, and postpartum parent, to create a welcoming space for all families.

Check out #BMHW19 to catch up on the Black Maternal Health Week conversations. Have something to say? Tweet at me with #EssentialCoverage or email me.

The post Lifting Up Solutions that Support Black Mothers appeared first on California Health Care Foundation.

How Do Low-Income Californians Experience Health Care?

Carlina Hansen having a conversation.
CHCF Senior Program Officer Carlina Hansen. Photo: Avram Goldstein.

Over the years, CHCF has made a point of supporting research that enables leaders in California’s health care safety net to better understand the perspectives of the people they serve. The foundation has conducted various health care “listening” projects that focus on Californians with low incomes. These projects include Listening to Mothers in California and the California Health Policy Survey, and later this year CHCF will update its Final Chapter survey about Californians’ attitudes toward end-of-life care.

Now CHCF is launching a major research project to help California understand and document how people with low incomes experience their health care. Senior program officer Carlina Hansen is spearheading the project, which will last 18 months. I recently sat down with Carlina to learn more about the project.

Q. There are other surveys that address the health care experiences of Californians. How is your project different?

A. We designed it to build on existing research, not to replicate it. In California, we are lucky to have rich data from the California Health Interview Survey (CHIS) and Consumer Assessment of Healthcare Providers and Systems. Among other health care studies, there is also the recent CHCF/Kaiser Family Foundation statewide poll.

As valuable as those resources are, they do not paint a clear, comprehensive, and current picture of how Californians experience their care in the safety-net delivery system. For example, CHIS can tell you how many Californians had difficulty accessing care in the last six months, but it can’t tell you if it was because the local clinic wasn’t open when they needed an appointment, or that they couldn’t find a provider who spoke their primary language, or that they didn’t feel respected in the setting where they received care. Those are the kinds of details that we are trying to fill in with this project.

Q. Who is the audience for this research, and how do you hope they will use it?

A. Policies and programs work better when they are informed by the people they serve. We hope this project will give people making decisions in the health care safety net better insight into the needs and experiences of their clients. That includes people working in health plans, hospitals, the California Department of Health Care Services, consumer advocacy groups, and providers. We’ve designed this research to be as robust as possible so they can lean on the data with confidence.

Here at CHCF, we are excited to see how this project will inform our own work, especially the work we do to improve the delivery of care in the safety net and strengthen accountability in Medi-Cal. Listening projects like this are not new for us, but now we’re making a more concerted effort to ensure that all of our programs are grounded in the real-world experiences and concerns of Californians, especially those who struggle financially.

Q. What topics will you explore with the survey participants?

A. We want to understand the wants, needs, and experiences of Californians in the safety-net primary care delivery system. We’re focusing the research on people with incomes under 200% of the federal poverty level. We’ll explore issues related to the types of services available, hours, transportation, coordination within the health team and with specialty providers, language access, promptness of follow up, and communication of test results. We’ll also learn about whether they feel respected, understood, and cared for, about the availability of phone, video, and group care, and about their providers’ use of patient portals, text messaging, and apps.

Q. This sounds like an ambitious project. Who’s doing the research?

A. We are excited to be working with NORC at the University of Chicago, which has extensive experience researching health care for people with low incomes in California and across the country. NORC is one of Covered California’s lead research partners, and it has been conducting annual surveys of both uninsured and insured Californians. That includes Covered California members, Medi-Cal enrollees, Californians insured through individual health plans purchased off-exchange, and uninsured people at all income levels. That kind of research background is a real asset. In addition, Andy Bindman, a UCSF professor of medicine and health policy expert, will be advising on the project. He brings a wealth of knowledge as a researcher, a primary care physician, and policymaker. He will help ensure that we don’t reinvent the wheel and that we glean the most useful findings.

Q. Surveys are getting harder to do, and you’re focusing on a population that is one of the hardest to reach. How will that affect NORC’s approach?

A. Survey-based researchers used to rely heavily on random-digit telephone dialing to reach respondents, but with people answering their phone less than they used to, that has become more time consuming and expensive. So, we worked closely with NORC to combine those traditional approaches with a newer methodology called redirected inbound call sampling. We felt that this hybrid approach would ensure that the survey sample reflects a broad diversity of Californians with low incomes. Our sample must represent urban and rural perspectives, be racially and ethnically diverse, and include people who speak Spanish, Cantonese, or Vietnamese, in addition to people who speak English. And of course, it must focus on people who have recent experience with the safety-net delivery system. That’s a tall order, but it’s really the only way to ensure that the results are relevant, representative, and meaningful.

Q. Will you be doing other kinds of “listening” in addition to a telephone survey?

A. To really understand the lived health care experiences of people with low incomes, we believe you need to use both qualitative and quantitative research methods. This project gives us the best of both worlds. We’ll start by doing 12 focus groups in communities around the state in Modesto, Oakland, Los Angeles, and Shasta. Some of those groups will focus on subpopulations like Spanish or Cantonese speakers or members of the Black community. We will also do in-depth interviews with Vietnamese speakers. These focus groups and interviews will help us check our assumptions and pick up themes that we might otherwise miss. What we hear in the focus groups will help us set priorities in the second phase, which is the phone survey.

We will then follow up with in-depth individual interviews so we can dive even deeper into the key topics or themes that that have surfaced. Those personal stories can help connect the dots among different findings and give us a “whole person” perspective on the data. We will also try to capture some of those stories in audio or video to share in the final research package. All told, this will take 18 months to complete. I’m excited to fill in the gaps in our knowledge about these issues and share them with Californians.

A. Will you be sharing your findings before then?

A. While the research is underway, we will post occasional updates on The CHCF Blog about what we’re learning. In the meantime, readers can check out our complete collection of projects in our listening series.

The post How Do Low-Income Californians Experience Health Care? appeared first on California Health Care Foundation.

Lifting the Veil of Secrecy in Health Care Prices


Benjamin Franklin's portrair on a one hundred dollar bill peeks out from underneath a puzzle

The late, great Princeton economist Uwe Reinhardt once said that the system for determining prices in the US health care system was “chaos behind a veil of secrecy.” That was in 2006, and clearly, the chaos persists today: In San Francisco, the price for a basic blood test ranges from $80 to $564; in Los Angeles, $12 to $413; and in Portland, $15 to $44.

Why does the price of one of the most common tests in medicine vary so much? Multiple factors like the bargaining power of insurers, provider consolidation, and underlying economic conditions Essential Coverage may explain some of the differences, but the veil shrouding these striking price discrepancies has yet to be completely lifted.

Margot Sanger-Katz writes in the New York Times that health care prices are still hard to uncover because hospitals and insurers set them behind closed doors, and some claim those prices are legally protected trade secrets. She looked at a new analysis by the Health Care Cost Institute (HCCI) that found “enormous swings in price for identical services are common in health care.” To compile the pricing data, HCCI had to pool de-identified health insurance claims submitted to three large insurance companies. “Even the institute can’t say which insurers and providers are attached to the different prices, and it has eliminated certain markets with less competition where it might be easy to guess,” Sanger-Katz writes.

Price transparency is slowly becoming more prevalent. A few online tools exist that allow the public to estimate the price of some medical procedures. The FAIR Health consumer tool has a five-step process for looking up in-network and out-of-network prices for procedures based on a patient’s location. Healthcare Bluebook has a consumer search tool for price information. And HCCI runs guroo.com, a national and regional-level tool that provides average prices for bundles of health care services.

Government Efforts to Make Prices More Transparent

Federal and state policies are starting to complement these efforts. On January 1, 2019, a new national health care transparency policy took effect. The federal government now requires hospitals to post their price lists, called chargemasters, online in a format that can be easily processed by a computer. Critics of the regulation say that chargemasters are virtually incomprehensible to patients, and Vox journalist Sarah Kliff points out that they only lay out the list prices that hospitals charge for services, not the negotiated prices that insurers actually pay. However, the policy still takes the health care system one step closer to being transparent about costs.

In California, work continues on the creation of a new statewide Healthcare Payments Database. Once completed, the database could provide policymakers, patients, and the public with greater insight into the prices charged for medical services. A review committee comprised of health care stakeholders and experts is advising California’s Office of Statewide Health Planning and Development (OSHPD) about the creation, implementation, and administration of the database. The office has until July 1, 2020, to deliver its recommendations to the legislature.

Several other state-level efforts to increase price transparency have been proposed or remain pending in the current legislative session. Assemblymember Al Muratsuchi (D-Torrance) authored AB 1038, a recently stalled measure that would have required California physicians to provide OSHPD with information on the rates they charge the public as well as the different rates they negotiate with health plans for the same services. OSHPD would be required to aggregate the negotiated prices compared to Medicare rates by geographic region. State Senator Richard Pan (D-Sacramento) introduced SB 343, which would update current transparency and disclosure requirements for the health care industry to include data from Kaiser Permanente.

The Prices Are the Problem

Despite the fact that Americans do not use health care services at a greater rate than their counterparts in other advanced nations, such as the United Kingdom, Canada, and Australia, the US spends much more on health care than those countries. Researchers from Harvard University and the London School of Economics published a study in JAMA showing that “prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the US and other high-income countries.”

In other words, health insurance premiums and out-of-pocket costs are high not because Americans are sicker or go to the hospital too much, but because of soaring individual prices for services.

At a time when Californians are more worried about paying for medical bills than housing, policymakers and patient advocates will need to continue pulling back the veil of secrecy that obscures the true causes of inordinately expensive care.

Essential Coverage will be on hiatus the week of May 6, but in the meantime I want to hear from you. Have you or someone you know ever skipped medical treatment due to fears about cost? Tweet at me with #EssentialCoverage or email me.

The post Lifting the Veil of Secrecy in Health Care Prices appeared first on California Health Care Foundation.

California Journalist Moves from Writing Health Care News to Making It

Portrait of reporter, Anna Gorman standing outdoors, against a green hedge with yellow flowers.
Former California health care journalist Anna Gorman now is a Los Angeles County health official. Photo: Nick Agro.

Anna Gorman has been an award-winning reporter in California for two decades, focusing on health care for the last 10 years of that. After spending most of her career at the Los Angeles Times (L.A. Times), in 2013 she joined the staff of Kaiser Health News (KHN), the editorially independent publisher of CHCF’s California Healthline. Last year she earn a master’s degree in public health from UCLA, and now Gorman has left journalism to become director of community partnerships and programs at the Los Angeles County Department of Health Services (DHS). She will lead My Health LA, a no-cost health care program for uninsured county residents who lack access to health insurance. I talked with Gorman about the dramatic changes she witnessed in California journalism and about how her reporting background has prepared her for her new career. Our conversation has been edited for length and clarity.

Q: When you joined the L.A. Times, big city newspapers were at the pinnacle of journalism. What happened?  

A: When I started at the L.A. Times in 1999, the staff was huge, but over many years and many rounds of layoffs, it became a shell of its former self. Now the L.A. Times is seeing a resurgence and is growing again, but lots of other papers are not. Newspapers have closed their doors or seen their staff shrink. Many papers don’t have enough staff to have dedicated health reporter, so that has opened the door for KHN and their great health reporting. For young journalists there are a lot of opportunities, despite what’s happening with mainstream organizations. I’ve seen so many start-ups and new media models, such as Vox, ProPublica, and the Texas Tribune, that didn’t exist when I started my career. That’s exciting. Another big change is the cooperation among news organizations. When I started, we rarely collaborated with other news organizations. They were the competition and we just wanted to beat them to stories. Today, while there’s still competition, there’s  also cooperation — especially on big projects. There’s crowdsourcing too, because we’re seeing that readers and listeners are an integral part of news coverage.

Some examples include KHN’s collaboration with NPR on Bill of the Month, where they reached out to readers and listeners and solicited their health care bills. That wouldn’t have been done in the past. Another example: the California Dream on public radio. Readers, listeners, and TV news viewers don’t care where the coverage comes from, they just want it. Looking back on it, I think this competition that we embraced for so many years was mostly unnecessary and a vestige of a different era.

Q: You sound optimistic.

A: I am. The industry has been shrinking for years, and journalists continue to be underpaid — and under attack. But there are a lot of interesting developments in journalism, and the profession is not going away. When I talk to students, I say, “There will always be a need for reporters; there will always be a place to have an impact.” Most people don’t get newspapers delivered to their doorsteps any more. And by the time my kids have kids, there may not be print newspapers at all. But journalism will always be there. Journalists are essential. They educate society, hold powerful people accountable, and give voice to the voiceless. Right now we get news on our computers, tablets, phones. Who knows what future formats will be like?

Q: Some of these new models of journalism are supported by philanthropy. How important is foundation funding to setting the course for journalism?

A: It’s critical! I think foundations are essential to help fund journalism. There are news organizations today that depend on the support of foundations. I’ll use KHN as an example. I moved to KHN in 2013, and it was a great move. It was a completely different model of journalism from what I experienced at the L.A. Times. For starters, it was a nonprofit and was based on partnerships with other outlets. The Kaiser Family Foundation (KFF) invested heavily to launch KHN 10 years ago, and later KFF got outside funding to support more journalism. One of those funders is CHCF, whose support enabled more expansion. When KHN started producing California Healthline for CHCF, it hired more reporters and editors and could produce more and more high-quality health coverage in California. Now KHN is expanding in Missouri and Colorado in collaboration with local foundations. I believe we’ll see even more foundation-funded journalism around the country in the coming years.

Q: What will you be doing in your new job leading the My Health LA program?

A: In addition to providing free health care to low-income people in LA County who can’t get health insurance, My Health LA is expanding mental health and substance use disorder treatment to its participants. I’ll be working closely with the Department of Public Health and the Department of Mental Health to ensure these patients have access to that care as well. I also will be forming and strengthening partnerships between DHS and clinics, nonprofits, county agencies, funders, and other organizations. The hope is that through those partnerships, we will find new ways to improve access to care, to address the social factors that affect patients’ health, and to help patients became healthier.

It’s a big job and really exciting. There are so many possibilities, and Los Angeles County is really the place to do this work. DHS is invested in population health, and the department has already done so much work with people in jails and those recently released from incarceration as well as those who are homeless or have mental illness.

Q: How have 20 years in newsrooms prepared you for public service?

A: As a journalist, I’ve been able to evaluate issues from a 10,000-foot level and on the ground at the individual patient level. That will come in handy. I can weigh in from the program level  on what can be improved or strengthened, and from the patient level what barriers prevent them from getting care. I’ve also gained a deep understanding of local, state, and federal government health systems. And I’ve learned a lot about the safety net, from the shortage of providers to funding that is dependent on government programs. That knowledge will be very helpful.

Safety-net clinics and hospitals are essential, and they’re also where we see innovative programs and partnerships to provide better care and address health disparities. My Health LA is one of those programs because it helps people get access to preventive care so they don’t just end up in the emergency room. It’s also become more important for health care leaders to consider how much people’s health is affected by what happens outside a doctor’s office. As a journalist, I could write about all of these issues, but now I can be hands-on in creating and implementing solutions to some of the biggest problems in health care today.

Leaving the news business is bittersweet, because reporting is gratifying and important work, and I will miss my journalist colleagues around the nation. But I’m really excited about taking on a new challenge and using my skills and knowledge in a new way. And I’m looking forward to having a direct impact on the people I’ve been writing about for a long time. I hope to help improve both their health access and their health status.

The post California Journalist Moves from Writing Health Care News to Making It appeared first on California Health Care Foundation.

Committed Physician Recruits Young People to Diversify Health Care Workforce

Dr. Freeman Garrick talks to high school student about future medical career
Jocelyn Freeman Garrick, right, talks to student Jacquelyn Cervera of Hayward’s Tennyson High School during the Allied Health Expo at San Leandro Adult School in San Leandro, California. Photo: Michael Short.

Like all emergency department physicians, Jocelyn Freeman Garrick, MD, treats patients suffering from broken bones, chest pain, infections, and a host of other ailments. But she also makes time for a second, unpaid job that sets her apart from her peers: The no-nonsense doctor from Oakland’s Highland Hospital is constantly on the lookout for youth from low-income families and groups that are underrepresented in the health professions who could become future nurses, physicians, and respiratory therapists.

To help young people connect with educational and employment prospects that might not otherwise be an option for them, Profiles in LeadershipFreeman Garrick founded two nonprofit organizations that provide mentoring, training, and job opportunities for people of color: Mentoring in Medicine & Science (MIMS) and Emergency Medical Services (EMS) Corps. Both are dedicated to increasing diversity in the health care workforce at a time when California and many other parts of the country face a growing shortfall of trained professionals (PDF) to meet a rising demand for care.

“During my residency training, I noticed that most of the providers did not reflect the racial and gender diversity of the patients we were serving,” said Freeman Garrick, 49, who grew up in a working-class neighborhood in San Francisco. “It saddens me when I see someone from a lower socioeconomic background who is uneducated. I know that education gets you out of poverty, and I had to do something about this.”

Dr. Freeman Garrick speaks to students about health careers
At an event in San Leandro, California, Jocelyn Freeman Garrick addresses students considering health care careers. Photo: Michael Short.

Life Coaching and Mentoring

These programs have reached more than 1,000 students so far — people like Donte Glover of East Oakland. He dropped out of California State University, Northridge because he was becoming a father and wanted to provide for his son. Glover moved back to Oakland, but he found the 9-to-5 office jobs dull and unmotivating. He knew Freeman Garrick through his mother, who worked at Highland as a physician assistant. Freeman Garrick urged Glover to apply for the EMS Corps, a five-month program in San Leandro that includes emergency medical technician (EMT) training, life coaching, and access to a psychologist who helps students struggling with depression, anxiety, or other mental health issues.

“He had a kind spirit and was trying to be responsible, but I felt that he needed some help,” said Freeman Garrick. “I thought he would benefit from the life coaching and mentoring.”

She was right. Through the program, Glover learned that his love of sports was connected to his desire for teamwork and dedication, and an EMT role in a fire department would play to those strengths. He graduated from the program in 2012 and worked as an EMT in an ambulance until he recently landed a position with the Oakland Fire Department.

“The program really saved me,” said Glover, 29, whose son is now 10 years old. “And Dr. Freeman Garrick helped me throughout the process.” Since the EMS Corps launched in 2012, more than 300 young men have completed the training, and 200 have secured jobs.

“Now a shift doesn’t go at by at Highland where I don’t see one of my babies from the [EMS Corps] program,” said Freeman Garrick, who is quick to offer a hug and smile to familiar faces.

Origins of a Call to Service

Freeman Garrick’s passion to open doors for disadvantaged youth was born in part out of her experience growing up in Hunters Point, San Francisco. After excelling in elementary and middle school, her teachers recommended that she move to a college preparatory high school outside the neighborhood. She was accepted into the University of California, Berkeley, but she couldn’t ignore the stories about childhood friends who were struggling with drugs, teen pregnancies, and violence because they lacked education and job opportunities.

During college, Freeman Garrick volunteered at Highland and immediately loved the county hospital environment. “I was attracted to the microcosm of the community with so many cultures, languages, and classes of people,” she said. “In the emergency department, you just go regardless of your economic status. I was fascinated by that.”

After earning a medical degree at the University of Southern California, Freeman Garrick moved to New York for residency training at Jacobi Medical Center and two Montefiore hospitals. There, she witnessed how language and cultural barriers influenced the level of trust between providers and patients — a major factor affecting the quality of care. She vividly remembers when a respected medical resident ordered multiple diagnostic tests for a Black woman complaining about abdominal pain. But he didn’t have the full picture. When Freeman Garrick spoke to her, the woman admitted she had recently become homeless and started consuming starchy food because it was more affordable. She suspected that the woman was suffering from gastritis, and many of the tests were unnecessary.

“She trusted me because she could relate to me,” said Freeman Garrick. “Those little connections really matter.”

Experiences like this fueled her determination to diversify the health care workforce. She acted quickly, launching MIMS the same year she started practicing emergency medicine at Highland. She sought out colleagues and friends to help with mentoring, but without a source of revenue to support her dream, Freeman Garrick became exhausted.

What the Mentor Learned When She Was Mentored

Then she applied for a fellowship in the CHCF Health Care Leadership Program, which helps clinicians develop the skills needed for effective vision and leadership in the health care system. Through the experience, she learned how to create a business plan and advisory board and to hire people who could raise funds for MIMS. “I hadn’t been taught how to run a nonprofit, and I learned the value of building relationships with important people,” she said. “If you don’t tell the world about your organization, then you will not get the financial support you need.”

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Applications for the CHCF Health Care Leadership Program are open through June 7. This part-time program is for clinically trained health professionals in California with at least five years of leadership experience.
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Now MIMS has an annual budget of $350,000 and is run by a staff of four who organize mentoring and internships for middle school, high school, and college students. The organization’s Health Scholars program, which teaches students about CPR, the respiratory system, and the neurological system, provides an on-ramp for young men of color to enter the health profession.

Freeman Garrick’s vision to diversify the workforce also influenced the residency program at Highland. She partnered with another CHCF Leadership Program alumna, Berenice Perez, MD, an emergency department medical director at Highland, and several other providers to overhaul the review process for emergency department resident applicants. Now reviewers consider factors like resiliency, volunteer experience with disadvantaged communities, languages spoken, and socioeconomic hardship. After the initiative, the percentage of underrepresented minority residents more than doubled, from 12% to 27%. The Annals of Emergency Medicine recently published the team’s strategies to increase representation from diverse communities. Previous studies show improved outcomes when the patient and physician share the same racial or ethnic heritage. She says she is equally passionate about supporting young people who are interested in respiratory therapy, radiology, and other allied health profession roles.

Freeman Garrick further expanded her reach in the community when she became the first director of the Alameda County Health Pathway Partnership, which connects several county programs aimed at helping young people from diverse backgrounds pursue health careers. Before she stepped in, the programs were less effective because they lacked funding and communication between leaders. “We also needed to establish metrics to evaluate how the programs were doing and how to close gaps in the pipeline,” said Freeman Garrick. “We discovered that only 20% of the participants were male, so we needed to start recruiting more boys.”

Long-Term Relationships

Freeman Garrick isn’t interested merely in filling the pipeline with diverse trainees. She stays connected to those she has already taken under her wing long after they leave the programs — people like Nelly Gonzalez-Lepage, who was born in Mexico and moved to the United States when she was two years old. She met Gonzalez-Lepage while she was a student at UC Berkeley. Gonzalez-Lepage excelled academically, and Freeman Garrick encouraged her to apply for a MIMS summer internship through which she would shadow emergency physicians at Highland.

Gonzalez-Lepage loved the experience and thrived under the mentoring. “She told me I was one of the top students she’d met, and that she could see me being a physician,” said Gonzalez-Lepage. “That was the first time anyone had said that to me, and it was very powerful.”

But the costs of the placement test, applications, and medical school were too steep for her to afford. Freeman Garrick helped Gonzalez-Lepage get a job within the Alameda County Public Health Department and later hired her as project coordinator for MIMS. After several years, Gonzalez-Lepage still was uncertain about pursuing medical school. She felt financially responsible for her family and needed to take additional classes to boost her college GPA. Freeman Garrick encouraged her and said she would help at each step along the way. Gonzalez-Lepage, 32, is now a fourth-year student in the MD-MBA program at Loyola University Chicago.

“Dr. Garrick knew about my personal struggles but never gave up on me,” said Gonzalez-Lepage. “She is someone who truly believes in people, and that sets her apart from other mentors.”

Freeman Garrick’s impact is expanding as her mentees influence their own communities. Gonzalez-Lepage says she has mentored hundreds of students from underrepresented ethnic and racial backgrounds who are interested in applying to medical school, and she plans to continue working in management capacities while remaining in medical practice. By serving in roles like director of a clinic or residency program, Gonzalez-Lepage said she hopes to bring greater diversity to higher levels of leadership and advocate for patient populations that are underrepresented in boardrooms.

Her story is a case study in the way the physician’s vision is being realized within the communities she influences. “Many of these kids may not have people at home to serve as role models,” Freeman Garrick said. “They just need hope and motivation, and my job is to encourage them.”

The post Committed Physician Recruits Young People to Diversify Health Care Workforce appeared first on California Health Care Foundation.

Proposed Poverty Calculation Would Make More People Ineligible for Medicaid


pencil erasing a line on white paper and redrawing it in a lower position

The Trump administration has requested public comment on possible changes to the way the federal poverty guideline is calculated, which could reduce access to important safety-net programs for millions of low-income Americans. Medicaid (Medi-Cal in California), the Children’s Health Insurance Program (CHIP), CalFresh, California’s Supplemental Nutrition Assistance Program, and Head Start are just some of the programs that use the poverty guideline to determine eligibility.

The current federal poverty guideline is an annual income of $25,750 for a family of four, and an income of $12,490 for a single person.Essential Coverage

In a blog post for the Georgetown University Center for Children and Families, research professor Edwin Park notes that “while this sounds like a highly technical change, it would do considerable harm.”

Dylan Matthews reports in Vox that the Office of Management and Budget is soliciting comments on different ways to change the inflation rate used to calculate annual updates to the poverty guideline. “The administration could certainly change the inflation measure in a way that makes more people eligible,” he writes, “but given its calls for spending cuts, it appears likely it’ll pick a measure that reduces eligibility.”

NPR’s Pam Fessler writes that one possible change “would involve adjusting the poverty line annually using a different inflation measure, one that would result in a slower increase over time.” Using this different measure of inflation, the poverty guideline would rise more slowly, making fewer Americans eligible for assistance from programs like Medicaid.

Park explains how this would work: “With smaller annual adjustments to the federal poverty line, the income eligibility limits for Medicaid and CHIP (e.g., the maximum allowable amount of income a family can earn for a household of that size) will be lower than they otherwise would be in any given year, with the reductions growing larger over time. In other words, the administration is effectively proposing to impose an automatic cut to eligibility, adversely affecting low-income children (as well as parents, pregnant women, seniors, and people with disabilities), with the magnitude of the cut becoming sharper each year.”

Additionally, the Center on Budget and Policy Priorities warns in a press statement that if the administration uses a lower inflation measure to adjust the poverty line, it would “reduce the Affordable Care Act’s (ACA’s) premium tax credits — and thereby increase the out-of-pocket premium changes faced by millions of people who purchase health insurance through the ACA marketplaces.”

Change in Poverty Guideline Would Affect Middle Class Families

This could be bad news for middle-income Americans who make too much to qualify for Medicaid but struggle to pay their share of monthly premiums for health plans purchased through ACA marketplaces. Californians could receive less in federal financial assistance to pay for health plans purchased through Covered California.

The administration published a notice soliciting public comments about the poverty calculation methods on May 7. It will accept public comments until June 21. Information about submission of comments can be found in the Federal Register.

What have you read about the possible changes to the way the federal poverty guideline is calculated? Tweet at me with #EssentialCoverage or email me.

The post Proposed Poverty Calculation Would Make More People Ineligible for Medicaid appeared first on California Health Care Foundation.

California Surgeon General Puts Spotlight on Childhood Trauma

Dr. Nadine Burke Harris, California's first surgeon general, in her San Francisco office. Photo: Michael Short
Nadine Burke Harris, MD, MPH, California’s first surgeon general, answers questions in her San Francisco office. Photo: Michael Short.

In January, two weeks after taking office, Governor Gavin Newsom appointed pediatrician Nadine Burke Harris, MD, MPH, as California’s first surgeon general. Burke Harris is known nationally for her work serving the Bayview-Hunters Point neighborhood of San Francisco, a historically Black community with high rates of poverty and violence, and advocating for children exposed to trauma.

In 2012, she founded the Center for Youth Wellness, a national organization that raises awareness about the lifelong impact of adverse childhood experiences (ACEs) and trauma on the health and mental health of children. The concept of ACEs first emerged from a 1998 study that found that children exposed to abuse, neglect, and other negative experiences had an increased lifelong risk of many common chronic health conditions. Burke Harris has pioneered the development of screening tools to assess children’s exposure to ACEs and to treat them. Her TED talk on the effect of trauma on children has been viewed more than 5 million times.

Her book, The Deepest Well: Healing the Long-Term Effects of Childhood Adversity, was published last year. Burke Harris graduated from UC Berkeley and earned a medical degree from UC Davis. After earning a master’s degree in public health from the Harvard T.H. Chan School of Public Health, she completed a residency at Stanford University. She lives in San Francisco with her husband and their four boys.

Burke Harris sat down with me recently to talk about her new mission. The interview has been edited for length and clarity.

Portrait of Dr. Nadine Burke Harris, California's first Surgeon General, in her office overlooking San Francisco City Hall
Nadine Burke Harris, California’s first surgeon general, in her state office overlooking San Francisco City Hall. Photo: Michael Short.

Q: How do you and the governor define your new role?

A: It’s a wonderful opportunity for me to be a partner and adviser to the governor and a health champion. I work in partnership with the secretary of Health and Human Services [Mark Ghaly, MD], and my role is to get out there, work across systems, engage with ordinary Californians and with the medical community, and advance the health of Californians.

Q: How do you want to use this bully pulpit, and what are the big messages you want to communicate to the state’s health care workforce and policymakers?

A: The [US] surgeons general in the past who have been impactful have been able to move the needle on specific public health threats. I don’t see this as a role of doing a little bit of everything. Governor Newsom has a strong focus on health and the health and well-being of children. That’s part of the reason we see a pediatrician in this role along with my background in adverse childhood experiences and toxic stress.

I believe strongly that adverse childhood experiences and toxic stress constitute the major public health issue of our time. Toxic stress is essentially the germ theory of the 21st century, and we implemented everything from vaccines to pasteurization of milk to sanitation of our water supply in response to germ theory. Childhood adversity leads to long-term changes in the structure and function of our brains and bodies, and those changes can subsequently impact educational attainment and risk of violence or incarceration. They dramatically affect health, with significant risks for the leading causes of death in California, including heart disease, stroke, cancer, and Alzheimer’s disease.

For many of us, there’s medical care and there’s mental health, and they’re totally separate. But the body does not make that distinction.

A public health response requires not just early identification, such as routine screenings and early intervention within the health care space. It also requires that we look at how we’re doing our work in the educational field and in our justice system. I intend to do a deep dive on toxic stress and how it impacts health, and what we can do across systems, particularly from a health equity standpoint.

For the health care workforce, a big part of my effort right now is supporting implementation of AB340 the law that requires all individuals on Medicaid, children and adults, to be screened for adverse childhood experiences. We’ll be implementing AB 340 next January. We’re moving forward pretty quickly, and the Newsom administration has allocated $45 million in the proposed budget to reimburse providers screening for ACEs. There’ll be a billing code so they’ll be able to get a supplemental payment on top of whatever they would already have gotten for that visit.

Q: Are you seeing any concern or hesitation from the pediatric community?

A: I’m starting off my tenure as surgeon general on a listening tour of California. I’ve been in Sacramento, Orange County, Fresno County, LA County, Long Beach, San Francisco, and Oakland. I visited Butte County, which has the highest prevalence of adverse childhood experiences of any county. It also recently had the severe community trauma of the wildfires.

The thing that’s most surprising to me is how welcome this change is. But there are hesitations. Providers worry they don’t have adequate resources when they face a positive ACEs screen. It indicates a need for provider training. Part of the reason for moving toward universal screening is that for so many children and adults, the history of ACEs is not recognized. Every provider can understand that the health condition in front of them whether it’s headaches or abdominal pain may be stress-related. An ACEs score reminds a provider to help their patient understand how stress impacts his or her health and what to do about it.

Q: I’m guessing one hesitation may be: “Well, even if that’s so, where am I going to send these patients?”

A: That’s a really common question. There’s a lot we need to do to support our systems and make them more robust. When Vincent Felitti, the co-principal investigator of the ACE study, began screening for ACEs, he did a trial where he implemented the ACE question into the intake at Kaiser for 110,000 patients. They didn’t make any changes to their mental health or social work infrastructure, yet there was a significant drop in ER visits and in outpatient sick visit use. For many patients, it’s just having a medical professional make that connection and say, “Your history of adversity may be impacting your health.” We need to strengthen linkages between our mental and behavioral health systems, to improve access and coverage.

For many patients, it’s just having a medical professional make that connection and say, “Your history of adversity may be impacting your health.” We need to strengthen linkages between our mental and behavioral health systems, to improve access and coverage.

Q: So how do you break down the silos and integrate those services?

A: Access and the ability to share information between primary and behavioral health care providers are key, but it also requires a fundamental frame shift. For many of us, there’s medical care and there’s mental health, and they’re totally separate. But the body does not make that distinction. Many places are moving toward integrated primary care and behavioral health and team-based care.

Q: California has been leading the effort to improve maternal health and in the last few years has cut in half the rate of women dying in childbirth. But there’s still a huge disparity, especially with Black women.

A: The work on maternal mortality has been admirable, and it shows what happens when we systematically tackle a preventable health problem. But as we look at disparities that persist, I’m asking: Is this another place where toxic stress plays a significant role? How does cumulative adversity over the lifetime affect perinatal outcomes? We know women with higher ACEs have greater risk of chronic health problems cardiovascular disease, diabetes, mental health concerns, greater risk of depression before you get pregnant, higher likelihood of being in unsafe relationships, being victimized, and experiencing physical or emotional abuse. Women with higher ACEs have increased risk of preeclampsia.

The experience of discrimination can also contribute to the toxic stress response. Combine that with the different quality of care sometimes provided for communities of color, and there is a tremendous opportunity to view maternal mortality, particularly in the African American community, through the lens of toxic stress and to address some of the root causes.

Q: What is your strategy for ensuring you have the greatest impact as surgeon general?

A: Surgeons general who have been successful have really focused on moving forward one issue at a time. Classically, it’s C. Everett Koop and the work he did on tobacco in the 1980s during the Reagan administration. It took a lot of moral courage to do the work he did, to get people to really grasp the health risk around cigarettes. That was a big deal, and there was a lot of resistance. So coming into this role, my first surgeon general’s report will be on ACEs and toxic stress in California.

Q: When will that come?

A: I hope to have it out in 2020. Being the first surgeon general in the state of California, there is some basic infrastructure stuff that needs to happen first. Like, I don’t have a printer. Literally, right now I’m printing at home. Some time after I get a printer, we’ll have a surgeon general’s report.

Q: Final question. What’s your overarching message to policymakers and folks in California health care?

A: I believe a public health-scale intervention around adverse childhood experiences and toxic stress is going to be the biggest public health advancement of our time. I want folks to be educated about this issue and to support the implementation of routine screening, early detection, and early intervention, because the evidence shows that’s key. A lot of people have the sense of: “How can we screen? It’s so difficult and expensive to treat. We don’t have sufficient resources. We’re going to overwhelm the system.”

Right now, our system is only set up to detect toxic stress when it’s the equivalent to stage four. With breast cancer, stage four comes with a much lower survival rate than stage one. Treatment is more expensive, more intensive, and much more costly. The answer to many conditions is to move detection to stage one. The survival rate for stage one breast cancer is greater than 90%. Screening is not the thing you don’t do because you fear being overwhelmed. It’s the thing you have to do so you can intervene early and prevent the development of stage four.

Q: Actually do prevention instead of mopping up later.

A: Which is far more costly, and there’s a lower success rate. So let’s do it early on.

The post California Surgeon General Puts Spotlight on Childhood Trauma appeared first on California Health Care Foundation.

When the Practitioner Becomes the Patient

Kathy Brandt (right) and Kim Acquaviva sit together on an outdoor bench.
Kathy Brandt (right) and her wife Kim Acquaviva, both experts in palliative care, now manage Brandt’s own use of palliative care. Photo: Andrew Propp/Kaiser Health News.

Kathy Brandt has spent more than half of her life working in the fields of palliative care, hospice, aging, and caregiving. She has held leadership positions at the National Hospice and Palliative Care Organization and was tapped to write and edit the fourth edition of the National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care. She even met her wife Kim Acquaviva, a professor of nursing at the University of Virginia, when both were working for a Florida hospice.

But in Brandt’s successful career as a nationally recognized expert, nothing has acquainted her with palliative health care more intimately than her decision to seek it for herself.Essential Coverage

JoNel Aleccia reports for Kaiser Health News that Brandt, 53, was diagnosed with stage 3 ovarian clear cell cancer in January. It is a rare form of cancer, often resistant to chemotherapy, and Brandt was told she likely had months to live. After the shock of the diagnosis wore off, she promptly made a decision to pursue palliative care, which the Center to Advance Palliative Care defines as “specialized health care for people living with a serious illness … focused on providing relief from the symptoms and stress of an illness.”

Palliative care can be provided in tandem with curative care. In a letter to the editor of the New Yorker, Kate Meyers, a senior program officer with CHCF’s High-Value Care team, explains that “palliative care is additive — an extra layer of support — and it can serve an essential function in the experiences of patients and their families.”

While many patients receive palliative care alongside curative treatment, others opt out of disease treatments when they determine that the burden of the treatment outweighs the benefit. Aleccia writes that Brandt is “100% certain” about refusing chemotherapy, knowing that it would be futile. Instead, she is focusing on palliative care to relieve symptoms like pain and sleeplessness. “It’s what Kim and I have been working on for 30 years,” Brandt told Aleccia. “We need to not be scared of death.”

Raising Awareness of the Benefits of Palliative Care

The significance of Brandt’s decision to pursue palliative care and be vocal about it cannot be overstated. A new study in the Journal of Palliative Medicine found that an estimated 71% of US adults have never heard of palliative care. The researchers emphasize that “addressing this awareness gap is a priority to change norms around using palliative care services.”

A large majority of Californians want to talk to their physician about their wishes for care at the end of life but haven’t done so. A statewide survey in 2011 found that 79% of Californians would want to discuss their wishes for medical treatment with their physician if they became seriously ill. However, only 7% say their physician has asked about their wishes. CHCF funded that survey and is supporting an updated version to be released in the fall on attitudes and experiences with serious illness and end-of-life care with a focus on low-income populations.

Physicians may be reluctant to have these tough conversations with their patients because they feel unsure about how to handle the topic, according to a national survey of physicians commissioned by the John A. Hartford Foundation, the Cambria Foundation, and CHCF. While 89% of respondents said it was extremely or very important for providers to talk to patients about the options for care that best fit their personal wishes, only 29% reported having formal training in talking with patients and families about end-of-life care. Nearly half of surveyed physicians said they frequently or sometimes feel unsure of what to say during such conversations.

This lack of formal training has left many physicians with a misunderstanding of palliative care, said Jennifer S. Temel, MD, clinical director of thoracic oncology at Massachusetts General Hospital. “I think there are still a lot of misperceptions on the part of clinicians — physicians and nurses — that palliative care and hospice care are synonymous,” Temel told the American Society of Clinical Oncology. “Many of them still believe that if you are administering cancer-directed therapy, you can’t offer palliative care at the same time.”

Teaching Doctors About Palliative Care

There is a growing movement to educate physicians and the public about the benefits of palliative care. In an interview with journalist Rob Waters, Katy Butler, author of the recently published book The Art of Dying Well, said, “I think everyone should have palliative care from the first inkling of serious illness. [Early] palliative care … can improve quality of life throughout the course of a serious illness and prepare people for less medicalized deaths.”

Access to palliative care in California is improving. In 2014, former Governor Jerry Brown signed into law SB 1004, which requires Medi-Cal managed care plans to provide access to palliative care. Since then, the number and capacity of inpatient, clinic, and home-based palliative services in California has grown. CHCF has supported California public hospitals in implementing or expanding palliative care services and supported payers and provider organizations working together to provide community-based palliative care services, partnerships that were spurred by the 2018 implementation of SB 1004.

Removing Roadblocks

Exposure and education are key to demystifying palliative care for patients, experts say. When Amy Berman, a senior program officer with the Hartford Foundation, was diagnosed with terminal breast cancer, she talked to her oncologist, who was trained in palliative care communications, about the treatment options available. “If people aren’t participating in these conversations and decisions around their own health, they’re going to be guaranteed only to get the care and treatment that someone else thinks they should get,” Berman told the Center to Advance Palliative Care. She chose not to undergo aggressive treatments for the cancer and relies on palliative care to help her feel her best and live the life she wants. While less than 20% of patients with her diagnosis survive five years, Berman continues to work full time and travel more than nine years after the diagnosis.

Sunita Puri, MD, medical director for palliative care at the Keck Medical Center and Norris Cancer Center of the University of Southern California, said people should be exposed to realistic portrayals of serious illness and palliative care. “I think people feel an obligation, if they identify as a fighter, to keep trying any and every treatment offered to them — sometimes without a full appreciation of the risks of those treatments or whether those treatments might keep them in a place they don’t want to be, like an intensive care unit, instead of having the opportunity to go home,” Puri said in an interview with NPR. The result can be tremendous suffering related to medical treatments that don’t change the course of the disease.

Puri calls upon journalists to confront the “fight or give up” dichotomy. “Journalists have tremendous power in our country to tell stories that go against the grain, and that can inspire conversations that we wouldn’t otherwise be having,” she said in a webinar with the Center for Health Journalism. Puri thinks more journalists should be writing about people who have had good experiences with palliative care. When people learn about others who are open to palliative care or whose attitudes about it have evolved, they may seek out palliative care for themselves or their loved ones.

And that is the legacy Kathy Brandt wants to leave behind. “The story of palliative care is still being written,” Brandt said. “It’s so underutilized, and it can be so life-changing for people, and there are so many things that block people’s access to it.”

Do you or a loved one have a palliative care story to tell? Tweet at me with #EssentialCoverage or email me.

The post When the Practitioner Becomes the Patient appeared first on California Health Care Foundation.

To Switch or Not to Switch — That Is the Question

Hand points at computer monitor displaying electronic health records
Photo: Eric Kayne.

Electronic health records (EHRs) — repositories of patient medical histories, billing codes, and other crucial information — play a vital role in the operations of 90% of California’s community health centers (CHCs). Increasingly, this role has expanded to population health management, tracking social determinants of health, and enabling better care coordination for patients with complex needs, among other things.

This evolution is driving some clinic leaders to consider whether their current EHR system can keep up with growing demands. A recent survey of outpatient providers found more than one in four are actively considering switching EHR platforms. In the survey, numerous CHC leaders reported that they had reassessed their EHRs; they shared a wide range of reasons for considering a switch. Not every situation was alike, so each organization took its own unique decisionmaking journey. One thing they all shared, however, was the belief that having a guide to help them weigh options and forge the path forward would have been enormously useful.

To Switch or Not to Switch: A Guide for Community Clinics Considering Changing EHRs provides that help. The guide’s author, Walter Sujansky, MD, a consultant on EHR analysis and design, interviewed California safety-net leaders and EHR vendors. For many, the question of whether to change EHRs is a priority — and there is no right answer to it, he found. But interviewees did identify similar goals for updating systems:

  • Improving interoperability with specialists and hospitals that use a different EHR
  • Reducing complexity and cost by outsourcing day-to-day EHR management
  • Responding to clinic staff members who prefer a different EHR product
  • Sharing a common EHR across a CHC consortium, especially if its members participate in alternative payment and risk-sharing programs with payers

The guide offers a thorough and balanced decisionmaking process that applies to any clinic. Sujansky outlines key steps and includes helpful questions to ask at each waypoint.

Sabra Matovsky
Sabra Motovsky, CEO of the San Francisco Community Clinic Consortium, has led two organizations that considered EHR switches.

The Voice of Experience

Recently I spoke about the EHR updating process with Sabra Matovsky, MBA, CEO of the San Francisco Community Clinic Consortium and former executive vice president of Integrated Health Partners, a network of 11 health centers in the San Diego area. Here is our conversation, lightly edited for clarity.

Q: What motivates health centers to consider switching?

A: As we think about taking care of our managed care population in a more coordinated and data-informed way, the tools we use become a critical consideration. We can no longer look at an EHR merely as a tool to manage care patient-by-patient. As a result, CHC leaders are asking themselves, “Is our EHR system supporting us in offering the best care we possibly can to our patient population?”

Q: You’ve led two major organizations that considered EHR switches. What would you tell someone considering this for their operation?

A: Take a good look at all your options for a switch. People can have a preconceived idea of what they want. The existing solutions may only be able to meet a subset of those needs. Because of this, it can be particularly helpful to have an impartial person who will support you in evaluating and vetting vendors. And finally, while you may be able to identify why a switch would be beneficial, it’s important to carefully weigh the financial and operational impact and consider how, if, and when you can realistically resource the change.

Q: What did you learn about the process of planning a switch?

A: Don’t underestimate the challenges of group decisionmaking, either within the context of your own health center — with the staff and board — or if you are deciding as a network of clinics. People may have a big investment in their current EHR and can have very different ideas about what they need. Allow time to build consensus. If you are a part of a network of clinics, it may make more sense to go with a few early adopters rather than try to bring everyone along at the same time. Once a critical mass gets behind a single system, it presents an opportunity.

Q: What other advice do you have for those who do decide to move forward?

A: Going through the process haphazardly is not going to achieve results. You need to have discipline through implementation. You should also set up systems and allocate the needed resources to enable you to consistently improve and modify the system as your needs evolve. Otherwise, you may end up on another EHR shopping trip in a few years.

The post To Switch or Not to Switch — That Is the Question appeared first on California Health Care Foundation.

Former NIMH Director Joins Newsom Team as Mental Health Adviser

A man sits at his tent in a homeless encampment, along the Interstate 110 freeway in downtown Los Angeles.
The Newsom administration plans to take a coordinated approach to the related problems of homelessness and the limitations of the state mental health system. Photo: Associated Press.

California Governor Gavin Newsom has appointed the former director of the National Institute of Mental Health (NIMH), Tom Insel, MD, to be his principal adviser on mental health and to reorganize the state’s mental health delivery system. The governor said Insel will volunteer his time for this role. Most recently Insel has been president of the mental health technology company Mindstrong Health, based in Mountain View, California.Essential Coverage

Newsom announced Insel’s appointment as “mental health czar” at a May 21 press conference in Oakland on California’s homeslessness crisis. He said the physician will work with state Health and Human Services Secretary Mark Ghaly, MD, MPH, to reorganize the state’s mental health delivery system. Insel “will inform the state’s work as California builds the mental health system of tomorrow, serving people whether they are living in the community, on the streets or if they are in jails, schools or shelters,” said a press release from the governor’s office.

Newsom also announced the formation of the Homeless and Supportive Housing Advisory Task Force and appointed Sacramento Mayor Darrell Steinberg and Los Angeles County Supervisor Mark Ridley-Thomas as co-chairs.

Thomas Insel
Tom Insel, MD, who was appointed by Governor Gavin Newsom to be California’s principal adviser on mental health.

Before the appointment, Insel hinted at his likely priorities at a CALmatters panel discussion in Sacramento. He pointed to a lack of leadership and the difficulty of coordinating programs in 58 counties as two major reasons for California’s fragmented mental health system. “It’s like trying to play the piano with 58 fingers,” he said.

In April, Insel and co-author Seth A. Seabury, PhD, associate professor at the University of Southern California’s School of Pharmacy and the Leonard D. Schaeffer Center for Health Policy & Economics, wrote a CALmatters commentary that emphasized the importance of educational attainment in helping people with mental illness. “Interventions that identify and treat young adults who are first starting to struggle with serious mental illness, and that support their continuation in school and successful graduation, are a true bargain,” they wrote.

A Deep Résumé

Insel brings decades of experience to his new job. After earning undergraduate and medical degrees from Boston University, he trained in psychiatry at the University of California, San Francisco. He pursued a research career at NIMH, Emory University, and the Center for Behavioral Neuroscience before becoming NIMH director in 2002.

Throughout his tenure at NIMH, “Insel explicitly defined mental disorders as brain disorders,” David Dobbs wrote two years ago in The Atlantic. Critics argued that this approach dismissed the influence of the environment and social relationships in determining mental health. But Insel and his supporters said he successfully pushed NIMH to devote “more research to the most serious mental disorders, such as major depression, schizophrenia, and bipolar disorder.”

Insel stepped down in 2015 after 13 years as director. “The NIMH has accomplished so much during this past decade — progress in neuroscience, progress in diagnostics and therapeutics, and, most of all, progress toward a focus on the needs of people with serious mental illness,” he wrote in a farewell letter on the NIMH website.

He then came to California to lead a mental health program at Verily, a subsidiary of Google parent company Alphabet Inc. The offer from Verily was “intriguing and, frankly, a bit disruptive,” Insel told the Washington Post. “What was really the offer I couldn’t refuse was the possibility that a big tech company like Alphabet would want to do something in [mental health].”

There’s an App for That

By the time Insel left Verily in 2017, the company had developed the initial parts of its mental health products but hadn’t released any, Sara Reardon reported in Nature. Nonetheless, Insel told Reardon, “I felt like Verily was at a point where it was big enough and successful enough [that] I could walk away. I knew in moving to Verily it would be a transitional job until I could figure out what I really wanted to do, and I’ve had an entrepreneurial itch.”

That took him to the startup Mindstrong, where he joined founders Paul Dagum, MD, PhD, and Rick Klausner, MD. Dobb wrote in The Atlantic that “Mindstrong’s plan, much like that of Insel’s unit at Verily, is to use the smartphone’s powers to do two things that psychiatry hasn’t figured out how to do: easily detect early, or even predict, the onset of mental illness; and quickly get effective, affordable care to those who need it.”

The Mindstrong smartphone app collects “measures of people’s cognition and emotional health as indicated by how they use their phone,” MIT Technology Review’s Rachel Metz wrote. “The seemingly mundane minutiae of how you interact with your phone offers surprisingly important clues to your mental health, according to Mindstrong’s research — revealing, for example, a relapse of depression.”

In October 2018, Mindstrong was on “the cusp of a real-world deployment in California,” wrote STAT’s Kate Sheridan. That deployment was facilitated by California’s Mental Health Services Oversight and Accountability Commission, which selected two apps (PDF), including Mindstrong’s, to roll out to selected target populations. “Even before the app launched in the original five counties that had signed on, the pilot had expanded,” Sheridan wrote. “Another 11 counties have recently decided to join.”

University of California, Irvine, was selected to conduct the evaluation, which has not yet been published.

A Mindstrong spokesperson said Insel will continue working with the company while he serves the Newsom administration, Sheridan reported.

Helping Struggling Students

Insel’s CALmatters commentary suggests that in his government work he may focus on helping struggling students stay in school, ensuring that people with mental illness get treatment, and bolstering the state’s mental health workforce. “By spending more now to expand the behavioral health system’s capacity, including the hiring and training of additional providers, we may be able to spot mental disorders early and give patients the opportunity that all Americans deserve: an education that can serve them for a lifetime,” Insel and Seabury wrote.

At the CALmatters briefing, Insel expressed optimism about the state mental health system’s future. “I’m actually hopeful that this is doable if we as a society, as a state, decide we want to make [mental health] a priority,” he said. “We can do it better than anyone’s ever done it.”

Now California has the chance to prove it.

What would you like Insel to prioritize as Newsom’s principal adviser on mental health? Tweet at me with #EssentialCoverage or email me.

The post Former NIMH Director Joins Newsom Team as Mental Health Adviser appeared first on California Health Care Foundation.


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Almanac Shows Slower National Health Spending Growth, But Major Challenges Persist


In an era when Californians are more worried about paying for medical care than paying for housing, we should take good news about health care spending from wherever it comes. CHCF’s latest California Health Care Almanac gives us a reason for optimism: Growth in national health spending slowed to 3.9% in 2017, the most recent year with available data. It’s the slowest pace since 2013 and lower than the overall growth rate of the US economy.

It is important to remember this particular data point reflects aggregate national expenditures for public programs like Medicare and Medicaid, all health insurance premiums, and total consumer out-of-pocket expenses. Reduced growth in national health spending means that, overall, consumers have more money for non-health expenses, and government can dedicate resources to other pressing social priorities like education, transportation, and housing. But it doesn’t change the fact that many individual Californians still face significant affordability challenges and are delaying or forgoing care because of cost.

And it is essential to note at least three facts when reviewing the new data:

1. The US is still a massive outlier on health care spending.

When broken down in terms of spending per person, total US health care expenditures per person are double to triple those of other developed countries around the world. The US spends $9,832 per capita, compared with $3,429 to $5,452 in high-income countries such as Italy, the UK, Canada, France, and Germany. These differences are largely attributed to higher prices rather than other factors such as the sickness of patients, the complexity of procedures, or the volume of services.

Health Spending per Capita and as a Share of Gross Domestic Product (GDP)

Selected Developed Countries, 2016

Bar chart depicting health spending as share of gross domestic product from lowest to highest, for Mexico, Korea, Italy, United Kingdom, Canada, France, Germany, and United States, withthe US as the highest.


In California, the same general pattern holds true. Health spending per capita in California was $7,549 in 2014, the latest year for which we have comparable data. This figure grew at an average annual pace of 4% from 2009 to 2014 — almost a full percentage point faster than state economic growth over the same time frame.  Widespread regional differences in aggregate spending persist after controlling for underlying costs such as higher salaries in parts of the state.

2. Total US health care spending growth is poised to accelerate. Without aggressive action, California’s probably will too.

Federal actuaries project that national health spending will rise at an average annual rate of 5.5% between 2018 and 2027 — faster than the economy’s projected 4.7% growth rate over the same period. Nearly half of this growth is expected to be driven by higher prices for a range of services. By 2027, health care spending is expected to total $6 trillion and account for nearly one-fifth of GDP.

While we don’t have comparable estimates for health care spending growth within the state, a look at the historical correlation between the national and California figures provides reason to be concerned. From 2004 through 2014, per capita health spending in California rose almost a full percentage point faster than the national rate.

Health Spending as a Share of GDP

United States, 1967 to 2017, Selected Years, and 10-Year Projection

Bar chart depicting the steady rise of health spending as a share of United States gross domestic product, from 1967 through2017, with an even higher projection for 2027.

3. Health spending can be significantly reduced without harming quality.

A robust body of academic literature suggests that perhaps 30% of US health spending is wasteful and could be eliminated without harming population health outcomes. The sources of waste can be accounted for in many different ways, but generally involve undertreatment, overtreatment, administrative complexity, excessive prices, and fraud.

Fortunately, it is possible to address each of these issues. For example, in California, health care providers, plans, patients, and purchasers have come together to reduce the overuse of low-value services like imaging for low back pain. Meanwhile, the California Technology Assessment Forum targets pricing failures by generating independent, evidence-based price benchmarks for new prescription drugs and medical treatments.

Digging Deeper into Spending in California

These trends point to an urgent need for richer data to track state health spending and the success of efforts to contain costs. In support of the latter, CHCF has commissioned RAND to produce an in-depth report on state-based approaches to cost containment. The authors have identified the most promising strategies to reduce unnecessary spending without harming access or quality for California families. The report will be released in the fall.

Another step in the right direction is the implementation of the Health Care Cost Transparency Database, funded with $60 million in the 2018 California budget. In the last two months, the California Office of Statewide Health Planning and Development brought together providers, payers, consumers, and other stakeholders to help make important decisions about which spending data will be collected, who must report it, and how much of that information will be publicly disclosed.

A well-designed cost transparency database could provide various stakeholders with new information about what drives health spending at the state level. With luck, future editions of CHCF Health Care Almanacs will show tangible progress toward eliminating the specific spending that is not making Californians and our nation any healthier.

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PRIMEd for Health: California Medical Schools Focus on Underserved Communities

Dr. Karla Garcia, PRIME-LC graduate and attending family physician at San Ysidro Health in Chula Vista, a border city, talks to patient Gloria Lamadrid de Santana at a wellness visit, while first year resident Dr. Alondra Cardenas looks on. Garcia oversees and trains resident doctors, discussing their cases with them, and also has her own patients.
Family physician and PRIME-LC alumna Karla Garcia, MD, MPH, left, talks to patient Gloria Lamadrid de Santana, right, at the San Ysidro Health Center in Chula Vista, California, while medical resident Alondra Cardenas Gonzalez observes. Photo: Padma Nagappan.

Growing up poor near the Mexican border gave Karla Garcia, MD, MPH, insight into the daily struggles faced by Latinos with low incomes. After her medical training, Garcia returned to the community where she grew up to practice family medicine at San Ysidro Health, which serves San Diego County through a network of clinics near the border.

At her alma mater, the University of California, Irvine (UCI) School of Medicine, Garcia received special training through the Program in Medical Education for the Latino Community (PRIME-LC) and it has been pivotal in shaping her decisions on where to practice, whom to serve, and how to start programs for her predominantly Latino patient base.

One of six PRIME programs statewide, the Irvine unit selects a dozen incoming Spanish-speaking medical students each year who are committed to serving the Latino community. Established in 2004 by Alberto Manetta, MD, a former senior associate dean at UCI, the program graduated its first candidates in 2009. PRIME trains committed medical students to focus on underserved populations and geographic areas, such as the Latino community or rural communities, through a five-year joint MD-master’s program. It provides students with tools for leadership, advocacy, and service. The other five PRIME programs address the medical needs of specific underserved communities in each region.

With PRIME-LC, participants develop skills, learn about issues faced by Latino immigrants, and rotate through community clinics in Southern California and a sister program in Peru. Many PRIME-LC students have overcome significant social and economic challenges to become physicians, which gives them insight into the their patients’ lives.

The other PRIME programs are at UC Davis (rural health and telemedicine), UC San Diego (health equity), UCLA (diverse, disadvantaged communities), a joint program at UC San Francisco and UC Berkeley (urban underserved and diverse, disadvantaged communities), and UC Merced (health needs of San Joaquin Valley).

California Future Health Workforce Commission Praises PRIME

In February, the California Future Health Workforce Commission (PDF) cited PRIME as an important approach to managing the state’s looming shortage of health care workers at a time when the population is increasing and skewing older. The Commission formulated a comprehensive plan to train new generations of workers who reflect the state’s diversity and who will ease the shortage of primary care and mental health providers.

“PRIME is a historic approach to medical education,” said Hector Flores, MD, a commission member and co-director of the family practice residency program at White Memorial Medical Center in East Los Angeles. “We saw this as a pipeline for the people we were recruiting into our residency program. It was a timely and critical program that the UC schools developed. I now see this reflected in private medical school curricula.”

The program shows that the way physicians were trained until 2004 lacked focus on special populations, didn’t give them the big picture of health care that comes with their master’s degree, and didn’t have the opportunity to develop leadership skills, he said. The Commission recommended that the state allocate $94 million to expand the PRIME program across all UC campuses in an effort to produce 630 additional PRIME graduates over 10 years. “It’s a wise investment in a very successful model,” Flores said. “By doubling down on the vision of PRIME we are making a statement that we continue to transform medical education not only across the state but possibly the country as well.”

At her community clinic in Chula Vista, Garcia sees a mix of patients, with an emphasis on maternity patients. PRIME-LC training gave her skills and resources that helped her establish a branch of the national Centering Pregnancy program, which arranges a group visit for pregnant women at which they are offered prenatal care, resources, and emotional support, she said. Garcia also trains and supervises medical residents.

Insights From a Tumultuous Childhood

“My childhood was tumultuous, and I see a lot of that in my patients,” Garcia said. “I understand their struggles. That’s why I want to make a difference for them.”

Garcia was raised by a construction worker father and a mother who worked as a housekeeper. She shuttled between National City, California, and Tijuana, Mexico, sometimes changing schools halfway through the year as family fortunes shifted. When they were in California, her family of five often stayed with relatives.

“Going through struggles makes you appreciate everything when you are older,” Garcia said. “I see it every day in my patients — not having insurance, not having a place to live sometimes… I remember what it was like, always living paycheck to paycheck. We were lucky to be able to go to school and college.”

Garcia has an open, warm, caring personality that helps her connect easily with patients. She speaks to them in rapid-fire Spanish, gently emphasizing the need to take care of their health. She shows the same warmth to resident trainees. “Keeping compassion and humanity in medicine is very important for future generations of physicians, and I want to try to continue to be a role model for them,” she said.

Garcia learned about PRIME-LC while majoring in biochemistry at UC San Diego and saw the program as a way to give back to her community. She applied to the program in medical school, was interviewed in Spanish about her motives and commitment, and was admitted to the second cohort.

International Training Opportunities

The curriculum starts with a summer immersion program to help students understand the cultural nuances and health issues of Latino communities. They travel to the Central Valley and California’s Mexican border, and Mexico City. Along with medical school classes, they study Latin American history and culture, and they debate policy, immigration, and ethnic issues. Then come clinical rotations at community clinics and an international rotation in Lima, Peru. Students take a break from med school after the third year for a graduate degree related to public health (a master’s in business administration [MBA], a master’s in science or public health) before finishing the final year of medical training and beginning a residency. The program offers $50,000 to defray the expenses of the master’s degree. Garcia used the support to obtain an MPH at Harvard University.

I know many of my former classmates would have loved to be in PRIME-LC. It’s a tight-knit family, and we can count on each other and on our faculty. It’s something my friends don’t have in other medical schools, where they feel no one has their back. The network we have is incredible. — UCI medical student Mariana Gomez

Charles Vega, MD, the PRIME-LC director at UCI and a family medicine physician who has spearheaded the program since it began, said its alumni are having a significant impact. “They’re working hard to push the frontiers to help the Latino community through health education and their clinical practice,” Vega said.

After medical school, the PRIME network continues offering moral support and helps alumni write grants to launch programs.

Many PRIME-LC graduates have started such initiatives as nonprofit organizations and community education efforts. One alumna who practices emergency medicine at UCLA-Harbor Medical Center returns once a month to her native Orange County to give a health education talk at a community center. It’s entitled Una Hora con la Doctora — an hour with the doctor. Another graduate helped launch Mi Mentor, a national organization run by undergraduate students to help people of color with low incomes overcome barriers to health careers. A third has become a leader with the nonprofit California Health Professional Student Alliance, which advocates for universal coverage through rallies, lectures, and calls to action.

“I know many of my former classmates would have loved to be in PRIME-LC,” said Mariana Gomez, a UCI medical student now working on an MBA. “It’s a tight-knit family, and we can count on each other and on our faculty. It’s something my friends don’t have in other medical schools, where they feel no one has their back. The network we have is incredible.”

From Translator to Physician

Gomez volunteered at free clinics while an undergraduate at UCLA and acted as translator for Latino patients.

“PRIME-LC has given us a skill set that helps us approach problems from a different mindset,” she said. “We have a deeper understanding of how Latinos are treated, how a patient’s zip code affects health and life expectancy. Most students [elsewhere] won’t know where to go to get help to begin addressing these issues. Most of all, we learned there are no cookie-cutter patients. Their socioeconomic backgrounds impact their health and who they are.”

Gomez plans to be an anesthesiologist. She enjoys being in the operating room, and she finds Latino patients to be grateful that she can communicate in Spanish before surgery. When she starts working in the field, she plans to teach and help students chart paths to health care careers.

“I’d like to mentor future medical students, create more streamlined processes for people in high school, and launch a pipeline program from when they’re younger,” she said.  “I’m hoping to use my administrative skills from my MBA. I’ve seen physicians win grant money but then see it frittered away by administrative costs. I’m hoping with my training that I can retain more of the grant money in the program itself and sustain the program better.”

In Chula Vista, Garcia stays close to her PRIME-LC roots by mentoring medical residents who are alumni of the program.

“Seeing today’s PRIME graduates and how excited they are is really inspiring,” she said. “Now that I’m out, I carry the skills I learned from PRIME-LC with me every day.”

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Dreaming of a Career in Health Care

Jirayut Latthivongskorn co-founder of Pre-Health Dreamers, a national organization that helps undocumented students enter medical professions
Jirayut Latthivongskorn, the first undocumented student to enter UCSF School of Medicine, celebrates at the school’s commencement exercises at Davies Symphony Hall. Photo: Elisabeth Fall for UCSF

In 2012, Jirayut Latthivongskorn was about to graduate from UC Berkeley with a bachelor’s degree in molecular and cellular biology. He wanted to go to medical school, but as an undocumented student whose parents brought him to the US from Thailand when he was nine, he didn’t know how to get there. School advisers, admissions counselors, mentors — no one knew how to help him.

So Latthivongskorn and Denisse Rojas, another undocumented classmate who wanted to pursue a medical career, set out to pave the way themselves, Tatiana Sanchez reports in the San Francisco Chronicle. Latthivongskorn and Rojas “made a spreadsheet titled Essential Coverage‘We’re going to med school’ to map out a game plan and keep themselves motivated,” Sanchez wrote. With their friend Angel Ku, also an undocumented student, they founded the organization Pre-Health Dreamers to share insights and resources with others like them who aspired to practice medicine.

With his UC Berkeley degree, Latthivongskorn applied to his first choice, the UCSF School of Medicine, but was rejected. He tried again, and in 2013 he entered UCSF as its first undocumented medical student. After pausing his studies for one year to earn a master’s degree in public health from Harvard, he graduated from UCSF this spring.

Jirayut Latthivongskorn sitting at a desk, taking notes.
Jirayut Latthivongskorn. Photo: Steve Babuljak for UCSF

Catherine Lucey, MD, executive vice dean and vice dean for education at UCSF, said in a statement that Latthivongskorn “has consistently given his time to advocate for the type of society that welcomes and celebrates the contributions of immigrants, ensures that all have access to high-quality health care, education, homes, and jobs, and builds communities in which all thrive.”

Contributing to Culturally Appropriate Care for Communities of Color

Latthivongskorn’s story underscores how challenging it can be for even the brightest, most hard-working immigrant students to achieve their medical career goals. As California’s population continues to grow past 40 million and a growing share of it is people of color, immigrants can play a critical role in meeting the state’s health care needs by providing culturally and linguistically appropriate care. Although communities of color will make up more than 65% of California’s population by 2030, they are severely underrepresented in the health care workforce and educational pipeline, according to a report (PDF) by the California Future Health Workforce Commission. (CHCF is one of five organizations that funded the Commission’s work.)

Workforce underrepresentation disproportionately affects California’s largest ethnic group: Latinos. They represent nearly 40% of the state’s population, but only 7% of California’s physicians, according to the Healthforce Center at UCSF. The UCLA Latino Policy & Politics Initiative forecasts (PDF) that if current growth trends hold steady, it could take five centuries for California to eliminate the Latino physician shortage.

What’s more, about 7.3 million Californians have limited English proficiency and need access to multilingual providers, the Commission reports. “Not finding a pathway to communication can make adequate care impossible to give,” writes Nadya Agrawal on the online news website Splinter. “And it can make patients uncomfortable with those trying to help them, frustrating care even more.”

Expanding the Health Care Profession Pipeline

To address California’s urgent need for a health workforce as diverse as its population, the Commission emphasized the importance of expanding health care pipeline programs and supporting scholarships that recruit and prepare students from underrepresented and low-income backgrounds. Research shows that physicians from such backgrounds are more likely than others to practice in areas with provider shortages and care for patients who belong to racial or ethnic minority groups, are uninsured, or are in Medicaid programs.

The Commission recommended the creation of a California Health Corps to expand the pool of health workers. “The corps would recruit and continuously engage and support the following audiences throughout their health career journeys: high school, college, and health profession school students and recent graduates; workers in health and other sectors; and groups outside of traditional pathways, including older adults and retirees, at-risk youth, unlicensed health workers, and immigrant health professionals.” (Emphasis added.)

California’s health care system relies heavily on immigrant workers. Nearly one in three health care workers is foreign-born, compared to one in six nationwide, according to the Public Policy Institute of California. And immigrants fill key shortage positions like rural primary care and nursing senior care, Shelly Hagan reports in Bloomberg.

Some programs, like Mentoring in Medicine & Sciences and the Program in Medical Education for the Latino Community (PRIME-LC), already exist. They help students from underserved communities — many of them immigrants or the children of immigrants — get mentoring and training to become health professionals in the areas with the greatest need. “Many immigrants work in clinics and hospitals that serve rural America,” writes Bruce Y. Lee, MD, associate professor of international health at the Johns Hopkins Bloomberg School of Public Health, in Forbes.

Policy Change Creates Barrier for Dreamers

Additionally, a growing number of medical schools accept applications from young undocumented immigrants who were brought to the US as children, like Latthivongskorn — the group known as “Dreamers.” In 2012, President Barack Obama created the Deferred Action for Childhood Arrivals (DACA) program, which grants Dreamers temporary legal status in the US. The Stritch School of Medicine at Loyola University was the first to consider Dreamers for admission, according to The Atlantic. A spokesperson for the Association of American Medical Colleges said that today 65 US medical schools accept DACA applicants.

But in 2017, the Trump administration rescinded the DACA program, jeopardizing the futures of all DACA recipients. Darrell G. Kirch, MD, the CEO of the Association of American Medical Colleges, lamented the change, writing, “For the health of our nation, it is up to all of us in academic medicine to ensure that the doors of America’s medical schools and teaching hospitals remain open to DACA recipients and to future physicians and scientists from around the world.”

For now, DACA remains in place thanks to judges in three separate US district courts (including one in northern California) who issued preliminary injunctions requiring the government to maintain the program. But DACA’s future is hanging in the balance. The Supreme Court will have to review DACA, and the San Francisco Chronicle reports that this is unlikely until 2020.

If Dreamers lose their DACA status and the accompanying authorization to study and practice medicine in the US, our health workforce will suffer — and so will patients.

Does your community suffer from lack of access to culturally and linguistically competent care? Tweet at me with #EssentialCoverage or email me.

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Proposed Change to Federal Poverty Definition Would Cut Aid to Millions of Californians


In May, the Trump administration announced it was considering changing the way the federal poverty line is adjusted annually for increases in cost of living. It is seeking public comment until June 21, 2019. The alternatives it is considering could take away Medi-Cal eligibility for tens of thousands of Californians, reduce subsidies for more than one million Californians with subsidized insurance from Covered California, and reduce the number of people eligible for dozens of other programs, including CalFresh. The Center on Budget and Policy Priorities estimates that nationally, millions of people could lose or see reductions in their benefits.

Currently, the federal poverty line is adjusted each year according to the growth of the Consumer Price Index for All Urban Consumers (CPI-U) (PDF), which measures the price level for goods and services purchased by residents of urban or metropolitan areas. The Trump administration is considering using the Chained Consumer Price Index for All Urban Consumers (Chained CPI-U) (PDF), which tries to take into account changing purchasing decisions caused by price increases.

Continue reading this article at the UC Berkeley Labor Center site. Members of the public may comment on the proposed changes on the Federal Register.


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Medical Interpreters Bridge Crucial Gaps Between Patients and Providers

Sonny Le stands in front of a restaurant in downtown Oakland
Medical interpreter Sonny Le helps Vietnamese-speaking clients navigate a maze of medical services in the Oakland area. Photo: Michael Short.

Sonny Le recalls the first time in his career as a medical interpreter that he thought he was going to faint. The Oakland-based Vietnamese translator was in a hospital at an appointment with a client when a labor and delivery care team paged him to rush across the complex to the operating room. “’Put this on!’, they told me. ‘There’s been a complication. You’ve got 10 seconds to tell her she’s getting an emergency c-section,’” he said.

Medical interpreters usually aren’t brought into life-and-death emergencies, but they do provide a vital service in all types of health care events. In most cases, when a patient doesn’t speak the same language as the provider, a medical interpreter is assigned to meet the patient at the front desk, help navigate the building, and sit in on the session with the health professional. Interpreters help share some of the most important words a person can hear or speak in their entire lifetime. Good news, bad news, or no news — interpreters play an important role in ensuring patients and families understand and can communicate about their health care.

A swath of laws, beginning with the 1964 Civil Rights Act, have stipulated that people must have “meaningful access” to the translation and interpretation services they need to make informed decisions about their care. California’s statutes on language access in medical care were updated as recently as two years ago, when former Governor Jerry Brown approved SB 223, which adds qualification criteria for interpreters and requires patients to be informed about how to access language services.

Essential Services for Patients with Limited English

These services are vital in California, where virtually all patients with limited English proficiency struggle to find providers who share their language, according to recent research from the UCLA Latino Policy & Politics Initiative (PDF). The problem is more acute for patients in rural areas. Linguistic and cultural concordance — speaking the same language and living the same culture — is vital to assuring high-quality care for these groups. Harvard researchers reported (PDF) that care without concordance results in lower patient satisfaction scores across a wide variety of measures. Concordance correlates with better continuity of care and higher satisfaction scores, and it can affect patients’ choices about their care.

The obstacles to good care multiply when your culture or history isn’t understood in your environment. Le often works with older Vietnamese people who came to the US as refugees in the 1970s. Many grew up in an agrarian society, farming from childhood and speaking regional dialects. Explaining an MRI procedure and why it might be necessary — in the right dialect with the right regard for the person’s background — is a delicate challenge. “How do you explain those things? You can’t just say it’s a computer involving a huge magnet,” said Le. “That’s why it’s called interpretation, not translation… You can’t say ‘thingy.’ You have to be precise.”

Le’s career in interpretation began in the 1980s, when he worked with refugee resettlement programs in San Francisco’s Tenderloin district, helping newly arrived Vietnamese, Cambodian, and Laotian people navigate social services. In the process he became an advocate and activist. His work included accompanying people to the doctor’s office and translating for them, leading him to gain formal certification with the California Healthcare Interpreters Association.

While having a skilled interpreter like Le to accompany patients is ideal, it isn’t always possible. A national survey of 4,586 hospitals found that only 56% offered linguistic or translation services in 2016. Solutions like machine-translated care notes and interpreters who attend patient visits by video can help, but they aren’t perfect. A video interpreter can’t offer help at the check-in desk or be in the exam room to read body language. Machine-translated visit notes bring the risk of mistranslations: Le recalls an instance when the notes presented the Vietnamese phrase for “the doctor will draw a blood sample” as “the doctor will paint a blood sample.” Mistakes like these can undermine a patient’s confidence in the care team. Some human medical interpreters can have challenges too if they have not had the necessary training or can’t meet performance standards.

As Need Grows, So Does Shortage

California faces a historic shortage in its health care workforce that exacerbates the problem of health care providers who don’t look like patients they’re serving. Without the right providers, culturally and linguistically concordant care will be more difficult to obtain in the safety net. Compounding the problem, a 2017 Health Affairs study found that data on race, ethnicity, and language is largely incomplete for patients in managed care plans.

Getting a better understanding of a patient’s culture is the first step. “There’s a ton of research on ‘Asian’ as a category,” said Joe Lee, training and technical assistance director at the Association of Asian Pacific Community Health Organizations, a Bay Area organization that represents more than 30 community clinics serving Asian and Pacific Islander communities across the US. “But there are over 50 ethnicities and 100 languages in that one word. So you might look at the number of Asian providers and patients and think it’s representative — but then you break it out, and you find that it’s not.”

The challenges aren’t just in Asian languages. In California, 38% of Medi-Cal patients identify as Latino, but only 5% of physicians do. The Latino Politics & Policy Initiative estimates (PDF) that in California, there are only 62 Spanish-speaking providers for every 100,000 Spanish-speaking patients with limited proficiency in English. There are 344 providers per 100,000 English-speaking patients. And the ratio of Spanish-speaking providers doesn’t account for the fact that a wide variety of different indigenous languages and dialects fall under the catch-all term “Spanish,” meaning that not all Spanish-speaking providers are able to speak with all Spanish-speaking patients.

Patient Experience Enhanced by Ability to Speak Their Own Language

“In order for community health centers to thrive and expand and provide care and access, these providers need to be able to be like the people they’re treating,” said Eddie Chan, PharmD, president and CEO of North East Medical Services (NEMS), a San Francisco-based community health center that is the nation’s largest clinic focused on Asian communities.

NEMS has made language access a key part of its strategy for providing culturally and linguistically appropriate care. It has full-time, in-house interpreters and translators who cover appointments, notes, instructions, and pharmacy. Its protocol is to always ask patients for a preferred language and to offer phone menu trees in that language. Chan stresses how much this positively affects the patient experience: “Not just the provider but the staff around them [should be culturally competent] so that they feel that they’re part of the community. They’re able to express their illness much more easily.”

Patients value providers who can communicate with them in their preferred language and express an understanding of their culture. Right now, California is struggling with a shortage of both interpreters and linguistically competent providers.

“Let’s start with our youth,” said Lee. “Let’s raise awareness of all the primary care and behavioral health professions where you can make money, do good work, and care for community… Federally Qualified Health Centers serve 28 million people across the country. These can be employers of choice.” Until the pipeline catches up, patients will continue to depend on interpreters to obtain care. As California’s population continues to become more diverse and grow older, the need for multilingual health care is only going to increase.

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Researchers: Medicaid Expansion Equals Better Coverage, Better Outcomes


California has long been a leader in expanding the eligibility criteria for enrollment in Medicaid. Under the Affordable Care Act (ACA), states can expand Medicaid to cover more adults with low incomes, and California was among the first to do so with its program, Medi-Cal. To date, 36 states and the District of Columbia have adopted the expansion, and newly released research suggests residents in those places are experiencing tangible improvements in their health and well-being as a result.Essential Coverage

As the country grapples with high rates of maternal and infant mortality, Medicaid expansion provides a reason for hope. Research summarized by the Georgetown University Center for Children and Families suggests that Medicaid expansion states saw a 50% greater decline in infant mortality than non-expansion states, with the greatest decline among Black babies. “States that have not expanded are really missing a clear opportunity to begin to address this unacceptable racial inequality among racial and ethnic mortalities,” said Adam Searing, a Georgetown associate professor and co-author of the report, according to FierceHealthcare.

States that made it easier to qualify for Medicaid provided reproductive-age women with increased health coverage, earlier prenatal care, and better overall care, which led to lower rates of maternal mortality. Among expansion states, the uninsured rate for women of childbearing age was almost half that of the non-expansion states. “Better coverage is the starting point for better care overall,” the Center emphasized in its report.

Racial Disparities Reduced

Research presented at the annual meeting of the American Society of Clinical Oncology also links Medicaid expansion “to a reduction in racial disparities in the care of cancer patients,” Laurie McGinley reports in the Washington Post. States that expanded Medicaid nearly eliminated the gap between Black and white patients in beginning treatment within a month of receiving diagnoses of any of eight advanced cancers, showing that timely initiation of cancer treatment is key to optimizing health outcomes.

Additionally, Medicaid expansion is linked to lower cardiovascular mortality rates, according to a new study published in JAMA Cardiology. While cardiovascular death rates among middle-aged adults in non-expansion states increased during the study period, they remained constant in expansion states, reports Lisa Rapaport for Reuters.

Extending coverage to people who were uninsured “could lead to better access to preventive care and protective heart medications such as aspirin and cholesterol medications,” said study author Sameed Khatana, MD, a fellow in cardiovascular medicine at the Hospital of the University of Pennsylvania. “Additionally, prior studies have shown that lack of insurance leads people to delay care, even when having a heart attack.”

Benefits Not Limited to Health Care

Researchers from Columbia University and Boston University show that the benefits of Medicaid expansion extend beyond health care. The researchers hypothesized that out-of-pocket medical costs could contribute to some people’s inability to pay rent and their subsequent evictions, and that gaining Medicaid benefits might help mitigate this situation among those struggling financially. At the annual research meeting of Academy Health, the researchers presented their finding that, indeed, there was a reduction in eviction rates following the Medicaid expansion in California. Specifically, they estimated that “for every 1,000 new Medicaid enrollees, there were 53 fewer evictions per year. Effects were concentrated among counties with the highest rates of uninsured residents.”

This study contributes to the growing body of research that links Medicaid expansion to financial stability. CHCF blogged about a few of these examples in 2017, including a Health Affairs study that showed the Medicaid expansion in California was associated with residents taking out fewer payday loans, a form of short-term, high-interest borrowing that is considered a major financial hazard.

Coverage Gains for Undocumented Adults in California

As early as January 1, 2020, even more Californians will have the opportunity to gain Medi-Cal coverage. The state budget, passed by lawmakers on June 13, would make California the first state to make all low-income residents under the age of 26 eligible for Medicaid regardless of immigration status.

In response to the legislature’s vote, CHCF President and CEO Sandra R. Hernández, MD, said in a statement, “At a time when the federal administration continues to erode health coverage for Americans and threaten hardworking immigrants, California is showing a different path is possible.”

Have you read any interesting studies about Medicaid expansion recently? Tweet at me with #EssentialCoverage or email me.

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California Takes Historic Step Toward Universal Coverage

close up-photo of latina woman in mid 20s with man in background
Young adults who are undocumented and in California would be eligible for Medi-Cal benefits under a budget passed by the state legislature. Photo: Juan Monino.


California has taken a historic step toward universal coverage by making sure all young people with low incomes are eligible for Medi-Cal and by making it easier for many Californians who purchase their own insurance to afford coverage.

On June 13, the California Legislature voted on a budget that would allow all low-income Californians under the age of 26 to enroll in Medi-Cal — the state’s Medicaid program — regardless of immigration status. It would also raise the income eligibility threshold for seniors and people with disabilities seeking to enroll in Medi-Cal; offer new financial help to low- and middle-income Californians who purchase coverage on the state’s health insurance marketplace; and reestablish an individual mandate to buy insurance or pay a fee — an Affordable Care Act provision until Congress removed it in 2018.

At a time when the federal administration continues to erode health coverage for Americans and threaten hardworking immigrants, California is showing a different path is possible. With the latest budget, California becomes the only state in the country to open its Medicaid program to all low-income residents, regardless of immigration status, under the age of 26. The state also closed a small but important coverage gap by raising Medi-Cal’s income eligibility level for seniors and people with disabilities to align with that of most adults under age 65. These bold actions speak to our state’s values of inclusion. Californians recognize that our future prosperity depends on the health and well-being of all our residents.

Californians recognize that our future prosperity depends on the health and well-being of all our residents.

California leaders have also recognized the challenges that too many of our residents and small businesses face in trying to afford health insurance on their own. The budget adds protection for those with the lowest incomes who struggle to purchase their own insurance, and it recognizes that, in a state with a high cost of living, Californians with moderate incomes also need help. Reestablishing the individual mandate penalty will encourage more Californians to maintain health coverage, which benefits all of us.

While these decisions are surely worth celebrating, we must acknowledge the work ahead. We must find a way to cover all Californians, including the low-income undocumented adults and seniors who remain ineligible for Medi-Cal. We must rein in the cost of coverage for consumers. And we must protect access to care in the face of harmful federal actions, including the federal administration’s proposed changes to the public charge rule.

We are still a long way from a health care system that works for all Californians, but the state budget shows that progress is possible. Step by step, staying true to our values, we will get there.

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