HealthyCal.org

By Heather Tirado Gilligan
California Health Report

People on parole or probation do not account for most new arrests in four cities in California, according to a new report. Instead, it is people who are not on supervision who are arrested most frequently.

“Most people would have stated before this report came out that probationers and parolees were the primary source of crime in their communities,” said Terri McDonald, undersecretary of operations for the California Department of Corrections and Rehabilitation. “At least in these four cities, this does not seem to be the case.”

The report showed that people on parole or probation commit only one in six violent crimes and one in five crimes overall. In comparison, more people on supervision committed drug crimes, but they were still not close to a majority of the offenders. In that category, people on probation or parole account for one in three arrests.

The report analyzed arrests between and 2008 and 2011 in Los Angeles, Sacramento, San Francisco and Redlands. It was produced by the Council of State Government’s Justice Center, a national, non-profit, non-partisan research group, at the request of the police chiefs of each city.

Though the report did not examine a representative cross-section of California, it captures what is going on in three major metropolitan areas where a significant chunk of the state’s population lives, said Robert Coombs, communications director for the Council of State Governments.

The report’s analysis covers the period just before prison realignment, or AB 109, began in October 2011. But it does highlight some of the potential that reform has to prevent people on supervision from committing new crimes, as well as ways that reform may be falling short in effective crime prevention.

“The question is one of how to best prioritize resources,” Coombs said. “Who do you provide services and programs for?” Asking where services can be cut is another important part of prioritizing scare resources, he added.

The higher number of drug-related crimes among people on supervision, for instance, indicates a need for more rehabilitative services.

Limited resources could also be used more effectively with better risk assessments, especially as the number of people on probation grows, to help decide which people need the most supervision. Risk assessments use a series of questions about criminal history, attitudes, personality and life circumstances to determine whether or not someone is likely to commit another crime.

“It’s really important that we implement a system of triage,” said Wendy Still, San Francisco’s probation chief. “The success of realignment depends on the ability of probation departments to supervise a larger number of people successfully.”

Since prison reform began, people who commit certain non-serious felonies receive jail time or split sentencing, a combination of county jail and probation, instead of state prison and parole. People who were sentenced to prison for one of these crimes before reforms began are also released to the supervision of county probation agents, rather than state parole agents.

But while the state’s parole division generally did a good job of using risk assessments to determine who was likely to commit another crime, and allocating resources accordingly, only one probation department in the study – San Francisco – used a risk assessment that was good at predicting who would reoffend.

These assessments determine how much contact people under supervision have with their probation or parole officer.

Aiming more resources at people more likely to commit crimes and less at low-risk offenders offers a better return in terms of crime reduction, Coombs noted.

Changing policing and sentencing practices to encourage more supervision for people who have been assessed as high-risk and more rehabilitation overall may prove difficult, despite the encouragement provided by reform.

It may be hard, for instance, to shake the perception that all people on supervision are high-risk, focus groups with police officers suggested. In the focus groups, conducted as part of the report’s research, police officers described situations where they arrested the same people on probation or parole multiple times. Such experiences could contribute to the widespread misconception that people on supervision are the primary source of crime, the report said. Police in the focus group also held misconceptions about what determines risk level, and had difficulty accessing information about people on probation and parole beyond a name and address.

A recent analysis of split sentencing by the Chief Probation Officers of California also suggests that judges continue to sentence people to jail much more frequently than they use other options meant to encourage the rehabilitation necessary to prevent more crime.

Split sentencing, a combination of jail and probation, is a new option under the reform law. Split sentencing is meant to offer support as well as supervision to people leaving jail as they return to the community.

Only 5,000 felony offenders affected by AB 109 have received split sentences since realignment began, according to the analysis by the Chief Probation Officers of California, which was released in December. In contrast, more than 16,000 received straight jail time.

Straight jail time means no supervision – or support and rehabilitation – from probation after release from jail, which is a critical time of transition. “This is the period when recidivism is most likely,” the probation chiefs’ report notes, adding that “the research is clear – these offenders will have a higher likelihood of committing more crime than those who have been given a split sentence.”

Data from some counties for the first year of reform indicates that many people affected by realignment who reoffend or violate the terms of their probation are committing drug-related violations.

During the first ten months of realignment in Alameda County, for instance, drug crimes accounted for 22 percent of new crimes committed by people who were under the supervision of probation because of prison reform. The next most common reason for re-arrest among people on probation instead of parole because of reform – a type of probation that is called post-release community supervision – was auto theft. It followed distantly at 9 percent.

In Fresno County, between April and August of 2012, people on post-release community supervision were sanctioned most often for drug-related violations. And during the first year of realignment in San Francisco, drug crimes were the single largest category of new offense, accounting for 48 of the 126 new crimes committed by people on post-release community supervision.

The Council of State Government’s report emphasizes the importance of substance abuse treatment options, said McDonald of the CDCR. “You cannot use a jail bed for every problem that you have,” she said.

The report’s final recommendations included improved risk assessment, more rehabilitative options and improving data sharing between police departments and departments of probation and parole.

By Rosa Ramirez
California Health Report

California children with special needs often receive less-than-adequate health care services, regardless of whether they are covered by private or public health insurance, a new analysis has found.

California was among the bottom six states in offering coordinated and family-oriented care to some of the state’s most vulnerable populations.

According to the report, 1 in 10 California children, or about one million, have special health needs.

Some key findings:

–California families are more likely than those in other states to reduce their working hours or stop working altogether to manage their child’s health care needs.

–41 percent of children with health insurance don’t obtain the services to meet their health needs.

–More than 40 percent of youngsters with complex health needs have a difficult time obtaining community-based services, such as finding doctors and scheduling appointments.

The health care they receive as children greatly impacts their ability to thrive as they grow and move through school, said Christina Bethell, lead author of the report and director of the Child and Adolescent Health Measurement Initiative at Oregon Health and Science University. The study was sponsored by the Lucile Packard Foundation for Children’s Health. (The Foundation is also a sponsor of HealthyCal.org.)

Part of the challenge is that researchers have only started collecting national child health data since 2001. “Even children with the least complex health conditions, the majority are not receiving the basic quality of care,” said Bethell.

In addition, a nationwide dearth of pediatricians with sub-specializations, as well as health providers who are able to care for these children as they transition to adolescence, has become worrisome.

Most pediatricians spend an additional two-to-three years on sub-specialty training, often with little economic incentives, said Edward Schor, senior vice president at the Foundation. “It extends their life as a trainee and postpones getting out into the world and working,” Schor said.

The study found that inadequate health care services places added financial and emotional burden on parents. About a third of California families with at least one child with health care needs are forced to cut back on working to manage their children’s access to care. These caretakers often manage multiple health services, including school-related programs, doctor’s appointments, and medical emergencies, Bethell explained.

San Francisco resident Maria de Lourdes Sanchez, 38, takes her 10-year-old son, who was diagnosed with cerebral palsy as an infant, to physical, speech, and occupational therapy, which keeps her from holding a full-time job.

But even outings to the Sunday mass or attending family birthday party have become rare occasions, especially now that her son is taller and stronger. Carrying him inside the family’s van is difficult for her and her husband. She’s applying to obtain a free or low-cost wheelchair ramp to make trips to her son school, medical appointments, and therapies feasible.

Echoing earlier studies, the January report found that communities of color are less likely to report their child’s special health care needs. Bethell said it could be attributed to their desire to use alternative health methods, feeling overwhelmed about having to arrange doctor’s appointments due to a language barrier, or holding jobs that do not offer them the flexibility to take time off.

With limited English skills, Sanchez recalled feeling frightened when she sought help for her son when he was months old. “I’d take him to the doctor and say, “My son is not breathing,’’ she said in Spanish. “The strength and courage to speak up for your children just comes out naturally.”

She now encourages other Spanish-speaking parents to ask questions, call service providers a second or third time, and show up at their offices if necessary to get health and educational services for their children. “We have to fight for children,” she said. “Parents are the only ones who can help them get ahead in life.”

Photo: Julien Haler/Flickr

By Elise Craig
California Health Report

Judith Baer is worried about how poor people, especially poor mothers, are labeled with diagnoses of mental health problems. Once a teenage mother, today she is a professor who understands the anxiety that comes with poverty— and she wants the diagnostic manual to reflect that kind of understanding, too.

“I was one of those people we study,” says Baer, an associate professor of social work at Rutgers University and an adjunct professor of psychiatry at New York University’s School of Medicine.

When Baer was growing up in Texas, her first couple of decades were fraught with challenges. Her father left her mother when she was only 3, and Baer never saw him again. At 19, she gave birth to her first child, a son. Eleven months later, she had her daughter. By age 22, she was a single mother with two toddlers, no money—and a passionate desire to get to college.

She graduated from the University of Houston, funding her education by working at a psychological institute called the Jung Center, pulling her kids around in a red wagon while she worked a paper route as a side job, and finding subsidized child care. Eventually she earned her Ph.D., also from UH.

Baer’s memory of that experience—balancing her kids, her jobs and her schoolwork, and desperately trying to make something of herself—has driven her to research risk and resiliency, and the factors that help people to overcome long odds like the ones she faced. It’s also led her to question how we define mental illnesses like anxiety disorder among the poor.

“We ate cereal two meals every day,” she says. “I used to look at people drinking a Coca-Cola and I would want one so bad, but didn’t have the money. Anxiety and distress about survival was an everyday phenomenon. Any life event beyond the ordinary, such as an ill child, was overwhelming.

Pathologizing Pain

Anxiety isn’t always necessarily mental illness. Sometimes it is a normal reaction to life’s challenges, such as the level of poverty Baer experienced.

In the 1960s, Baer and her children were living on $300 a month. Making the money stretch to cover their needs was no easy feat. She was stressed. But she wasn’t mentally ill. “The last thing I needed, on top of everything else, was to be called disordered,” she says. “I was very anxious—yes, but not disordered.”

Recently, Baer and colleagues at the Rutgers School of Social Work examined the relationship between poverty and generalized anxiety disorder (GAD), a psychological disorder characterized by “excessive anxiety and worry” that lasts for at least six months. According to the Diagnostic Statistical Manual of Mental Disorders IV (DSM), a set of diagnostic criteria published by the American Psychiatric Association, symptoms of the disorder cause “clinically significant distress or impairment in social, occupational or other important areas of functioning.”

But the symptoms associated with the disorder could also be caused by normal reactions to the stressors of life. Failing to account for factors like significant financial stress may lead to the overdiagnosis of the disorder in the low-income population. Environmental and social conditions are often overlooked, Baer and her co-authors wrote in the August 2012 “Child and Adolescent Social Work Journal.”

She worries that other young mothers now in her shoes might be diagnosed with a disorder, when their anxiety could really stem from a very natural reaction to financial stress. “I’m concerned about this disease narrative,” Baer says. “If as a poor woman, you are concerned about feeding your children or getting a job or all those things embodied in that situation, and you’re told have a disease, how is that helpful?”

The lowest-income mothers have a greater chance of reporting symptoms associated with the disorder, Baer and her co-authors found. Mothers who were the recipients of free food, for instance, were 2.5 times as likely to exhibit symptoms of general anxiety disorder as outlined by the DSM, while mothers who had problems paying utilities were 2.44 times as likely, and those who had to move in with others were 1.9 times as likely.

Ignoring those factors could have serious consequences be- yond the misdiagnosis of a single patient, says Kim Jaffee, an associate professor who coordinates the master’s in social work program at Wayne State University. “What particularly concerns me is that this overdiagnosis of GAD, without adequately assessing the social environmental factors, contributes to the racial and ethnic disparities in mental health.”

“People with mental illness are overrepresented in high-poverty neighborhoods,” she says, “where a disproportionate share of minorities live.” The environmental factors in those areas lead to social conditions that “exacerbate the impact of personal vulnerabilities.”

For Baer, fighting for changes in the next version of the DSM, which will come out in May of next year, is a necessity.

The loose definitions presented in the DSM, Baer and her co-authors say, have led to a widening of symptoms that can classify a disorder. One of their biggest concerns was a change between editions of the DSM, which is updated whenever enough new re- search has come out to merit a revision. Diagnostic criteria for GAD once included an evaluation of external factors like the social and financial context of the symptoms, but that piece of the entry was omitted in 1995.

Mark Olfson, a professor of psychiatry at Columbia University Medical Center who directs studies on mental health care in community settings, points out that the study has some flaws. It did not screen for one of the main criteria for making a GAD diagnosis: that the anxiety “causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” He does, however, agree with the authors’ conclusion that socioeconomic context is important in diagnoses.

Understanding the causes of anxiety is key, Baer says. If clinicians diagnose patients based solely on symptoms and ignore context, they run the risk of diagnosing a false positive. Also, mental health professionals who understand the causes of anxiety can create treatment plans that focus on practicality, self- empowerment and resiliency—helpful tools for low-income patients.

“For something to be a mental disorder, it needs to cause distress, but there also needs to be some breakdown of an internal mechanism that’s not functioning,” Baer says. “That’s a true disorder. We don’t know true disorder from the vicissitudes of life.”

Treating the Whole Person

At the Woman’s Clinic and Family Counseling Center in Los Angeles, the therapists not only focus on patients’ mental health issues such as symptoms of depression and anxiety, but also try to understand and treat their problems in the larger context of their lives. Although clients seek treatment for an array of issues, from anxiety and depression to abuse and addiction, monetary problems are a consistent concern.

“Financial pressures are bigger than ever,” says Carla Becker, director of counseling at the center and a private clinician. She started at the clinic in 1997 and now supervises the 25 volunteer therapists who work at the center.

Some patients who come into the clinic can clearly attribute their anxiety to occupational or economic stressors, says Jennifer Hayes Silvers, a counselor. “In my young career, when I think about GAD, there’s not a client that I have where [the anxiety] is not situational,” Hayes Silvers says. “It’s very much about whatever particular situation they’re dealing with at the time.”

Despite their shared belief in the necessity of considering financial and social factors when treating patients suffering from anxiety, the Women’s Clinic staff members aren’t that concerned by the exclusion of social and environmental context from the definition of GAD in the last version of the DSM. Neither is Columbia’s Mark Olfson.

Any counselor treating patients would have been trained to consider those factors, they say, and the DSM-IV does include general criteria for a multiaxial assessment, where counselors are expected to consider five different factors when treating their patients. The fourth axis is recent psychosocial stressors, like the loss of a job or a loved one.

But the DSM does have limitations. As Kara Hoppe, a fellow counselor, and Becker point out, it only allows six months for bereavement, for instance. “You only get six months to mourn a parent,” Hoppe says. “I don’t think you get more than that if you lose your job, according to the DSM.”

To Becker, the DSM should be used as a tool for understanding the cluster of symptoms associated with a particular disorder—but a clinician needs to think outside the manual and consider a client’s circumstances, too. Even biological issues like thyroid problems can cause anxiety. Clinicians need to consider those as well.

“Does that bug me that it’s not a holistic approach or view of the person? Yes,” she says. “I’ve never liked that.”

There are also dangers to being labeled with a stronger diagnosis. As Baer’s study points out, mental health care is often an entry point into the health-care system for low-income patients, and added social stigma could keep them out of the system. And for patients who do have insurance, Becker says, a diagnosis of GAD, a more severe condition than something like an adjustment disorder (anxiety related to a specific event and lasting for less than six months), could drive up future premiums or prevent coverage, depending, of course, on changes in health-care laws.

But to Baer, the real problem is that the health-care system is pathologizing a normal response to difficult situations.

“Psychology is creeping into what’s obvious and normal,” she says. “People in desperate circumstance feel anxious, as they should. I’m concerned about the narrative that if you’re suffering, you have a disorder.” 

This story originally appeared in the California Health Report magazine’s Winter 2012/2013 issue. Read the rest of the magazine here.

Photo: Marc Soller/Flickr.

The prison reform law that shifted responsibility for non-violent felons from the state to the counties is also affecting the management of more serious and violent offenders who have completed their prison terms, presenting a challenge for reform supporters and potentially undermining public support for the change.

Since the passage of Assembly Bill 109, also known as prison realignment, people who violate the conditions of their parole go to jail rather than prison – including those with sex offenses and other serious and violent crimes on their records.

But because of jail overcrowding, some county jails can’t house people for technical parole violations — including bad drug tests and missing appointments with parole agents. That lack of consequences can make it more difficult for parole agents to compel people to stay within the conditions of their release from prison and to keep track of offenders who are released from jail early.

“Realignment created a crack a lot of people fall through,” said Tom Tobin, vice president of the California Sex Offender Management Board.

Before the law took effect in October 2011, technical violations – when parolees do not adhere to the conditions of their release from prison, as opposed to committing a new crime – most likely would have meant a sentence of about 75 to 100 days in prison.

People cycling in and out of prison for technical violations contributed to the overcrowding that prompted the court order to reduce California’s prison population. Before reform, conditions in the prisons were so poor, that on average, one prisoner died needlessly per week.

Now the most stringent punishment available for technical violations is 180 days in jail, but actual time served often falls well short of that. And some counties, including Fresno, San Joaquin, Merced and Shasta, have struggled to find any space at all for parolees in their jails, said Melinda Silva, president of the Parole Agents Association of California.

“This will grow as AB 109 continues to evolve,” Silva said. “We will start seeing this in more areas.”

Silva and Tobin both point out that incarceration is just one tool of many that can be used to keep offenders within the terms of the law and the conditions of their parole. Longer prison terms for technical violations, Tobin said, were not necessarily a better way to ensure public safety. But it is very challenging to supervise people on parole without the ultimate possibility of time behind bars.

Several California counties, including Fresno, have court-ordered caps on their jail populations.

“Once we reach capacity, we have to start releasing people,” said Fresno County Sheriff spokesman Chris Curtis. Parolees in jail for a technical violation, and without a charge for a new crime, are among the first out.

Parole agents aren’t necessarily notified when people under their supervision are released early from jail, though they can look up that information online. “Each agency is responsible to monitor their own people,” Curtis said.

Whether or not parole agents are notified of the early release of someone under their supervision depends on the county. “Sometimes they get the notice, sometimes they don’t; it’s kind of hit and miss,” Silva said. “It is not a formalized system.”

Jail overcrowding also makes it difficult to enforce the conditions of parole, Tobin said.

In April of last year, for instance, San Joaquin County jail released a high-risk sex offender two days into a 100-day sentence. Parolee Raoul Leyva was one of 300 people released because of jail overcrowding in San Joaquin County last April. He was in jail for technical violations of his parole. He’d failed to register as a sex offender, wear a GPS or report to his parole officer after his release from prison.

Four days after his release from jail because of overcrowding, Leyva violated his parole again, by allowing the battery on his GPS unit to die. A warrant was issued for his arrest, but he wasn’t found until he was already suspected of committing another crime.

Leyva allegedly brutally beat his girlfriend Brandy Arreola and left her on the floor of the room they shared for days after the assault. Arreola, 21, was expected to die from her injuries. She survived, but now has the mental capacity of a child and is partially paralyzed.

The case has become a key example for critics of prison reform, who say that Leyva could not have committed the crime if he had been behind bars, as he would have been before realignment.

The impact of reform on managing offenders is actually slightly more complicated than that criticism implies, Tobin suggested. Almost all prisoners are ultimately released. Leyva, for instance, was ordered to spend 100 days in jail, the same amount of time he likely would have served before prison reform. Under the old system, he might still have been behind bars on the day he allegedly assaulted Arreola, but he would have been free a few months later. One of the goals of the reform is to give more attention to offenders such as Leyva closer to home in hopes of preventing them from committing new crimes.

“There is the notion that if they are off the street, then we are safer,” Tobin said. “But sooner or later, they will be back.”

That’s why effective management of people once they are out of prison is so important to public safety.

Intermediate sanctions – punishments of increasing severity— are an essential tool for parole agents. They range from additional reporting requirements to jail time. The ultimate threat of incarceration is essential for the rest of the sanctions to work, Tobin said, and that consequence is undermined by jail overcrowding.

“When parole tries to get them in jail,” he said, “they are told there are no beds.”

Very short sentences aren’t effective, Tobin said. “Two days – many of them will laugh at that,” he said, adding that appropriate sentences for violations range from a week to a month.

When it comes to enforcing parole requirements, from attending drug treatment to wearing a GPS, “jail isn’t the best motivation, but it is something,” Silva said. “If there is no sanction, then there is little motivation.”

Photo: Flickr/United Nations Development Programme

By Leah Bartos
California Health Report

Babies living in California’s rural counties were less likely to be hospitalized in the first year of life than their urban counterparts, according to a recent study published in the journal Pediatrics.

Researchers analyzed records for more than 6.4 million babies born in California between 1993 and 2005, calculating the rate of non-birth hospital utilization before the babies’ first birthdays. They found that urban babies were more likely to be admitted to a hospital, had longer overall stays, and were more likely to be readmitted than rural babies. The mortality rate between the groups, however, was essentially the same.

Dr. Kristin Ray, the lead author of the study, wanted to better understand the experience of rural babies and families, and whether the difference in health-care environments — such as relatively fewer doctors and longer travel distances to get to them — was contributing to poorer outcomes. But what she found surprised her.

“I would have expected decreased access to care in rural areas to result in delays in care, and that this would translate into more hospitalizations in rural areas. We saw the opposite,” Ray said. “So, while access to care is certainly an issue in rural areas, its impact on hospitalizations appears to be more complicated than one might expect.”

Further research will be needed to determine the causes of this discrepancy in hospitalization rates.

“The underlying question is whether we’re seeing too many hospitalizations in urban areas, too few hospitalizations in rural areas, or the right amount of hospitalizations in areas with different needs and resources.”

One explanation for the discrepancy could be that babies in urban areas were simply more likely to get sick. To tease out whether there was actually a difference in medical need between the populations, researchers looked at occurrences of specific illnesses that they believed should always require hospitalization. For instance, researchers found babies affected by sepsis (bacteria in the blood stream, which is typically treated with intravenous antibiotics) do show up more often in urban hospitals.

But while the data did show a greater rate of some illnesses among urban babies, it did not translate to a higher death rate. As Ray explained, increased mortality in one group might suggest the children were sicker than the others and not getting the care they needed. “Instead, we found similar mortality rates across all county types, so mortality data does not appear to point clearly towards more illness or more foregone care in any particular area.”

Ray says the findings call for a closer look at some of the other possible factors contributing to the difference in hospitalization rate. “This study definitely raises questions about whether differences in hospitalizations are due to differences in illness or differences in hospital use for more subjective or systematic reasons.”

Some of those other factors might include a difference in the quality and quantity of care in rural areas — for instance, as previous studies have shown, patients who are seen continuously by the same doctor tend to have better health outcomes than those who experience more fragmented care. Differences in physician approach and decision-making in rural areas may also contribute to the difference in hospitalization rates, as could parents’ expectations in those areas. Ray says studying outcomes other than hospitalizations — such as collecting data on the frequency of infants’ doctor visits or how often parents stay home from work to care for sick children — could help lead to a better understanding of the different healthcare environments.

Steve Barrow, executive director of the California State Rural Health Association, has also observed social and cultural factors contributing to health outcomes — everything from attitudes toward vaccination to domestic violence at home can take a toll on a child’s health. Barrow also noted that diseases such as diabetes, obesity and asthma tend to be common in rural areas and cautions not to assume that the results of this study indicate that rural babies are facing an ideal health-care landscape.

“If there are healthier babies that need hospitalization less, is it because they just don’t have enough facilities to get hospitalized, which is often the case, or is there something else going on that whatever illness they get, they are able to deal with it before they have to get hospitalized?”

He added, “If there is something that’s going on that’s good, we’d want to understand that and replicate it.”

The vast majority of registered voters in rural California say obesity is a serious problem nationally and in their communities, and many say they wish business, government, community groups and individuals were doing more to fight the problem, according to a new poll released Tuesday.

The survey, conducted by Field Research for the Public Health Institute, also found that rural voters from both political parties believe that government programs designed to keep peole healthy pay for themselves in the long run.

“California residents want their communities to be places that help them lead healthier lives,” Mary A. Pittman, president and CEO of the Public Health Institute, said in a statement.

Pittman noted that nearly 75 percent of health care spending goes to treat chronic diseases such as diabetes, heart disease and cancer, many of which are linked to obesity.

According to the poll, 96 percent say doctors and nurses should be involved in preventing obesity, 91 percent say the local schools should be involved, 79 percent say food and beverage companies should play a role, 67 percent support employers being involved, and more than 65 percent believe local, state and federal government have some responsibility for helping to fight obesity.

Nearly 8 in 10 rural voters say that public spending designed to keep people healthy — such as building parks and promoting neighborhood safety — are cost effective because they prevent disease and reduce health costs.

The Public Health Institute supports a program known as Community Transformation Grants, which are part of the federal Affordable Care Act. The grants have gone to programs designed to make it safer for children to walk to school, make fresh drinking water available, and reduce exposure to second hand smoke.

The 12 counties surveyed were: Calaveras, Humboldt, Imperial, Madera, Mendocino, Merced, Monterey, Shasta, Siskiyou, Solano, Tulare and Tuolumne.

To see the full poll results, go here.

–Daniel Weintraub