HealthyCal.org

By Joshua Emerson Smith

Despite a potentially disruptive U.S. Supreme Court decision expected this summer, California officials are moving forward with the creation of a new, online health insurance market that is expected to be the centerpiece of the federal health reform approved two years ago by Congress and President Obama.

“There are many different scenarios,” said David Panush, director of government relations for the California Health Benefit Exchange. “Rather than trying to crystal-ball what the court may or may not do, we’ve got our foot on the pedal and we’re going full speed ahead.”

The Exchange is designed to be a place where consumers who don’t get coverage through work can go and buy it at an affordable price and in a way that allows them to easily compare the costs and benefits of competing plans. For health insurers, it promises access to millions of potential new customers, many of whom will get subsidies to help them afford coverage.

But the Eexchange could hit a serious speed bump if the high court strikes down the federal health insurance mandate requiring almost everyone to have coverage, which is expected to drive up enrollment in states around the country.

In order for an exchange to be successful, a significant number of people need to participate.

The idea behind the Exchange is that private insurance companies will try to out bid each other for access to the exchange’s customers – roughly 1.6 million of who could qualify for federally subsidized insurance.

“Families can receive tax subsidies through the exchange to pay for coverage,” said Ken Jacobs, the chair for the UC Berkeley Center for Labor Research and Education. “This is a very large market that insurance companies will want access to.”

Under the best-case scenario, by 2019 about 3 million people will be enrolled in the California Exchange, according data from UC Berkeley and UCLA.

However, without the federal mandate that estimate drops by more than 500,000 people.

That’s concerning because the higher the enrollment, the more leverage Exchange officials have when negotiating prices with insurance companies, such as Kaiser, Blue Shield and Anthem Wellpoint.

“We’ll be doing solicitations with health insurance companies by the fall to determine which of them we want to contract with,” Panush said. “The Exchange will be providing a market place and we want to have quality products on our shelf.”

While losing the mandate requiring people to buy insurance is concerning, the Exchange could still be successful without it, Jacobs said.

“If the mandate was struck down federally, California could still enact its own mandate,” he said. “And there are other incentives that could be used. They won’t be as powerful or effective but they could help address the issue.”

Exchange officials have recently started designing strategies to make it as easy as possible for individuals to sign up, such as presenting information in multiple languages, designing a user-friendly webpage and training employees to offer help with online enrollment.

“The state has institutional relationships that private insurance doesn’t,” Jacobs said. “If you’re applying for unemployment online there could be links to the Exchange. If you’re changing your address at the DMV a clerk may offer you information on how to enroll. To the degree that we take advantage of all the points of contact, you bring people into the system. Outreach and enrollment is vital.”

Exchange officials are prioritizing ways to use existing government agencies to help enroll people, Panush said.

“Our efforts will likely include direct person-to-person contacts through assisters, people who are specially trained to explain the choices and options that consumers have,” he said.

At the same time, the Exchange hopes to have a user-friendly website so many people will be able to signup without assistance.

“Our goal will be to develop a process that is consumer friendly,” he said. “We want to develop a process that’s seamless, simple to use, that acknowledges that people have changes in their life circumstances.”

According to data from UC Berkeley and UCLA, even with the federal mandate and the Exchange in place, by 2019, over 1.9 million legal residents in Californian will remain uninsured.

Repeated exposure to violence may accelerate aging process

By Mary Flynn
California Health Report

Researchers and public health officials have known that the basis for adult health lies largely in childhood. The environment in which one is raised affects how healthy that person will be as they age. New research suggests that children who are repeatedly exposed to violence appear to be aging at a faster rate.

Researchers at Duke University and King’s College London report that the DNA of 10-year-olds who have experienced violence show signs of the wear and tear associated with aging.

Scientists determined the children’s DNA had shorter age-marker sequences called telomeres. Telomeres are special sequences of DNA found at the ends of chromosomes. Like the plastic tips of shoelaces, telomeres keep strands of DNA from unraveling.

“We know from studies on adults that stress is causing acceleration of telomere erosion, but we didn’t know that it can also happen in children,” said Idan Shalev, a post doctorate fellow at Duke University and one of the researchers involved in the study.

Shalev explained that if the telomeres get too short, the DNA degrades and the cell stops dividing, entering a state of senescence. “Senescence” is biologists’ speak for “aging.” In most cases, when the cell stops dividing, it eventually dies, Shalev said.

Telomere erosion is associated with age-related disease, cancer, and high mortality rate. It is not, however, necessarily the cause of any of these problems, Shalev added.

The study used a subsample of 236 participants in a larger, Environmental-Risk (E-Risk) study that tracks the development of a group of over 2,000 children born in England and Wales in 1994-1995. The families involved represent a wide range of socioeconomic status and health in the general population. Researchers collected DNA samples from the children at five and ten years old and measured the mean telomere length of all the chromosomes at each age. Of the 236 child participants, 42% had experienced violence.

Researchers assessed three types of exposure to violence in children: domestic violence between the mother and her partner, frequent bullying, and physical abuse to the child. Cumulative effects of violence had the most impact; children who had experienced more than one type of violence showed the greatest telomere erosion.

Dr. Elissa Epel also conducts research on the cellular aging of children at the Center for Health & Community at the University of California, San Francisco, and she said that many influences can shape a person’s health between childhood and adulthood. While factors like low income and poor diet have been associated with early aging, the question remained of whether traumatic stress could impact telomeres in children.

She said that this information should be a huge warning about the importance of protecting children from violence. “Rather than assuming children are biologically resilient given their youth, such exposures leave imprints that may not just go away as we age,” she said.

Dr. Epel said that this study demonstrates the possibility that faster telomere erosion could put those subjects on a more rapid trajectory of aging and early onset of disease as adults.

Researchers will collect DNA samples for assessment again when the participants reach the age of eighteen.

By Mary Flynn
California Health Report

If you’re poor, you are also more likely to be sick with chronic diseases. Studies have demonstrated this truth time and again. For years, people have been trying to determine what exactly it is about poverty that causes poor health. Stress had always been a likely culprit, but scientists didn’t know how stress makes the body vulnerable.

New research from the Carnegie Mellon University sheds light on this question, and offers a biological explanation for how stress affects health and quite literally gets under one’s skin. The study, authored by Dr. Sheldon Cohen, a Professor of Psychology at Carnegie Melon University, determined that stress affects the body’s ability to regulate inflammation, the immune system’s response to illness that allows the body to heal.

When a person gets sick, say with a common cold, the symptoms they experience – the runny nose, congestion, coughing, etc. – are not caused by the virus itself. The symptoms are the body’s response, an inflammatory response, that helps rid the body of the disease.

Cohen and his group of researchers used the common cold as a model for testing their theory about the link between stress and illness. The team recruited 276 volunteers and interviewed them extensively to determine their level of stress. They then exposed the volunteers to the cold virus and quarantined them for five days. Researchers found that in the chronically stressed subjects, their immune systems were unable to regulate inflammation normally. Those subjects were more likely to develop full-blown cold symptoms.

A second experiment assessed the ability of 79 participants’ to regulate the inflammatory response. They, too, were exposed to a cold virus and researchers monitored their ability to produce pro-inflammatory cytokines, or protein messenger chemicals that trigger inflammation. The team found that those who had an impaired ability to regulate the inflammatory response before being exposed to the virus produced more of the cytokines when they were infected.

“The immune system’s ability to regulate inflammation predicts who will develop a cold, but more importantly it provides an explanation of how stress can promote disease,” Cohen said.

It has been thought in the past that an overproduction of the hormone cortisol was to blame for a weakened immune system. Cortisol is produced in the adrenal glands, and is important for body functions such as managing stress, regulating blood pressure, and metabolizing glucose for energy. Cortisol levels spike during times of stress, as part of the body’s ‘flight or fight’ response.

Cohen’s study suggests that it is not the amount of cortisol in the bloodstream that creates this effect, but rather the way immune cells are affected by the cortisol.

“It is likely that when stress continues for a long period of time, these immune cells adapt by becoming less sensitive to cortisol,” Cohen wrote in an email. “Thus, cortisol can no longer play its usual role in turning off inflammation.”

Chronic stress is associated with an increased risk of many common diseases, such as cardiovascular disease and diabetes. These diseases are also consistently rampant among those living in poverty. While Cohen’s study is about chronic stress and did not specifically look at poverty, other research suggests that persistent poverty is a source of chronic stress.

Dr. Amani Nuru-Jeter, an Associate Professor of Community Health & Human Development and Epidemiology at UC Berkeley’s School of Public Health, said that typically, the body has a normal way of adapting to environmental demands, a “fight or flight” response that may increase levels of cortisol or other inflammatory markers.

“We kind of activate, and then we recover ,” she said. “That’s our bodies’ normal way of responding to stress.” But in poorer households, that stress is persistent and it builds up over time, she said.

The day-to-day life in impoverished homes is stressful in ways that don’t affect more affluent households, according to Helen Lee, a Policy Fellow at the Public Policy Institute of California.

“On a biological level, that constant exposure to stress – whether it’s how to pay my rent check month to month, or how am I going to feed the kids – these kinds of questions are prevalent among poor households” she said.

“That feeling of being stressed and trapped, that flight or fight mechanism, is sort of constant,” Lee said. “What this study can help us do is say it’s not just a social science theory [that stress negatively impacts health], it’s a provable theory in this biological way.”

Lee specializes in health inequalities – disparities between people of different racial, social, and economic backgrounds, and she said that being able to demonstrate a biomedical reason for a social condition is important. “That kind of evidence is really powerful to the public and to policy makers, “ she said.

Nuru-Jeter said that having this information may also change the way that experts will intervene on behalf of the patients. She pointed out that if the effects are not actually cortisol, but rather, as this new information suggests, a deficiency in signaling the inflammatory response, a different approach to treatment would need to happen.

Both Lee and Nuru-Jeter are quick to point out that stress is not the only pathway by which economic status impacts health. Other reasons might include that the neighborhoods in which they tend to live often lack recreation sources, they may lack adequate access to healthcare, or receive healthcare of poorer quality.

Although this new information is a helpful step in the right direction, more needs to be done. Lee suggested the next logical step might be to understand what determines a person’s ability to cope with stress – is it wealth? Housing? Social network? Education?

“Which of these factors do we address and how do we address them?” she said.

Nuru-Jeter said this type of work is important because it helps demonstrate to the general public that poverty is not associated with poor health because poor people make bad choices.

“We need to understand that one, environments constrain choices,” she said. “and two…what this article does is it gives us the biological evidence to demonstrate that something like economic strain – which we know is a chronic stressor – can actually have direct impact on the body, which takes us away from the victim blaming kind of discourse around poverty.”

“There’s not just one pathway through which economic status impacts health, even if you talk about stress,” Nuru-Jeter said.

By Heather Gilligan
California Health Report

Mold in substandard housing makes breathing hard for kids with asthma. Poorly planned streets and sidewalks make exercising outside, or swapping a drive for a walk, more difficult. Housing and transportation aren’t policy areas obviously related to health, but such decisions directly affect our well-being.

A study released earlier this month suggests that taking a holistic approach to policy, one that considers health in all decisions, may not be as hard as it sounds. A wide variety of laws already exist to allow what’s called health impact assessments, according to researchers at Arizona State University’s Sandra Day O’Connor College of Law. That kind of assessment looks at the impact a policy might have as a result of social, economic and environmental changes. The definition of health includes physical and psychological health and general well being.

The study, undertaken at the request of the Pew Health Group and the Robert Wood Johnson Foundation, looked at laws and rules in 36 jurisdictions, including states and cities and tribal and federal laws. Focusing on laws relating to energy, transportation, agriculture and waste disposal or recycling, researchers found many required a fairly broad evaluation of policy’s impact on health.

For instance, 22 out of the 36 jurisdictions evaluated, including California, use health assessments when making choices about environmental or energy policy. Seven jurisdictions require broad health assessments when making choices about agriculture or transportation and 11 use them when making choices about disposing of waste.

Organizations like the Institute of Medicine and the National Prevention Council started calling for a more health-centered approach in making decisions about policy and projects years ago, researchers note. Read the study here.

By Angela J. Bass
California Health Report

The first time Stacy Gannon called the cops on herself, she was in the middle of a psychotic delusion. It was early 2007 and pop star Britney Spears was in the news for having shaved her head. Convinced she had morphed into the famous singer, Gannon feared that the gardener, mail carrier and upstairs neighbors were watching her every move. Even the paparazzi, she thought, were hiding out, waiting to snap her picture.

When the cops arrived at her house in Davis, they tackled her in her living room and tied up her arms and feet, saying it was for her own protection. “They were like, ‘Yeah, this f—ing girl is crazy,’” recalled Gannon, 29. “I felt they hated me and looked at me with pure disgust.”

Gannon is one of 2.2 million Californians living with a mental illness, according to a 2011 report by the UCLA Center for Health Policy Research. Like many others, she faces stigma on a daily basis and in most areas of her life: in parenting, in finding work, in dealing with law enforcement and in seeking treatment for bipolar disorder and substance abuse.

Nearly half of the adults in a national survey said they were unwilling to socialize with, work with, or live near someone with a mental illness. People living with mental illness often say the stigma and discrimination they face can be worse than the illness itself.

In Sacramento County — where Gannon spent several years cycling in and out of treatment facilities — the Department of Health and Human Services recently launched Stop Stigma Sacramento, a million-dollar, yearlong anti-stigma program and ad campaign. The program aims to change negative attitudes and false beliefs about mental illness with the help of billboards, radio spots, a speakers’ bureau and a dedicated, multilingual website.

“The underlying message [of the campaign] is everyday people living with mental illness,” said Frances Freitas, the program’s director and a licensed clinical social worker at the County’s Division of Behavioral Health Services. The program and campaign ads are paid for with funds from the Mental Health Services Act, which California voters passed in 2004 under the name Prop 63.

Senator Darrell Steinberg authored Prop 63 in his days as an assemblyman, following six years on the Sacramento City Council, during which he noticed that unchecked mental illness was the underlying cause of homelessness in the city.

Steinberg said 80 percent of the money raised by Proposition 63 originally went for treatment, with just 20 percent going for prevention. But the goal is to some day reverse those numbers.

“We can only do that if we are conscious about busting (the) stigma associated with mental health,” he said. “This campaign is just the beginning.”

The campaign’s slogan — “Mental Illness: It’s not always what you think” — is printed in bold letters at the bottom of ads featuring “normal-looking” people: a war veteran with bipolar disorder, a church pastor with depression, a farmer with post-traumatic stress disorder and an English teacher with anxiety, all from different age groups and ethnicities.

“Stigma exists on many levels,” said Freitas, pointing out that one in four adults will experience a mental disorder in their lifetime, as will one in five children. An estimated 355,000 people with a diagnosable mental illness live in Sacramento County alone, but only a third will seek treatment due to stigma. “It’s culturally widespread, it’s societal, it’s familial and it’s personally internalized,” she said.

Discrimination, shame, ridicule and stigma are all part of the same puzzle for people with mental illness, who are often thought to be incompetent, violent or psychotic — all the time, according to Gannon. “People’s assumptions – and mine was before, too – is that if you have a mental health disorder, you’re always nuts,” she explained. “Not many people experience psychosis, but when you do, it’s very short-lived and you can go on to be a very high-functioning person.”

The media are regularly blamed for public misconceptions about mental health. The 2001 feature film “A Beautiful Mind,” about a prominent mathematician with schizophrenia who eventually wins the Nobel Prize in Economics, has been touted by mental health experts as one of the best media representations of someone living with a mental illness. But positive portrayals, they say, are all too rare.

“It creates more stigma every time the media shows a murderer or someone that’s violent,” said Andrea Hillerman-Crook, the Adult Consumer Advocate at Mental Health America of Northern California and the manager of its peer partner program. Diagnosed with bipolar disorder 15 years ago, Hillerman-Crook now lives in remission. “I think it’s important to include those stats that mentally ill people are more likely to be victims of a crime.”

John Buck, the CEO of Turning Point Community Programs – which offers psychiatric services, support and advocacy to people in mental health recovery and is one of Stop Stigma Sacramento’s 110 stakeholders – shares Hillerman-Crook’s view, saying, “We don’t hear about people [with mental illness] achieving great goals.”

In the early stages of helping to create the Stop Stigma Sacramento ad campaign, Stephanie Yoder of Edelman Public Relations started by conducting a media audit to see how mental illness was already being covered in the news. “Ninety-plus percent of the stories were about someone who had done something [violent],” she said. “So, when you’re a person who has a mental health issue, you’re thinking, ‘Where’s the story of hope that I can attain?’”

Story of hope

Gannon’s first undiagnosed manic episode struck when she was just six months shy and two classes short of graduating from UC Davis with a degree in sociology. In this manic state, life felt suddenly amazing. Four-in-the-morning workouts, hard drinking at the bars and atypical one-night stands with random men seemed universal – until the termination of a brief romance triggered a deep depression, forcing her to sleep for 18-hour days and skip classes.

“When I did go to class, I wasn’t following the professor,” Gannon said. “My notes had become all disheveled, whereas they used to be totally organized.”

Even with a glowing transcript, she ended up flunking out of Davis entirely. Undiagnosed and without a degree, she moved back to her Walnut Creek hometown to live with her drug- and alcohol-addicted mother, taking up residence in a dark, windowless room. “I’d get up to pee and eat an apple and then just crawl back in my hole,” she said.

After several hospitalizations, Gannon began haunting the bars of Walnut Creek, where she fell in with people who insisted that using small amounts of cocaine each night was no big deal. She got addicted, becoming part of the roughly 50 percent of people with severe mental illness who abuse drugs and alcohol.

“Drugs are just like bipolar disorder,” Gannon said. “That mania is like a drug and that crash is horrible. I was just doing it another way.”

The addiction intensified her delusions, which could surface on either end of the bipolar spectrum, from manic to depressed. Any bit of stimulation — the sound of helicopters flying overhead or a radio news report about a bipolar pop star — could drive her farther away from reality. It’s a frightening feeling, she said.

She eventually met a therapist at Kaiser Permanente who suggested she relocate to Los Angeles for an intensive, 90-day drug rehab program. While there, she got clean and married a man with whom she eventually had two children. But her husband struggled with his own addictions and diagnoses of posttraumatic stress and bipolar disorder.

When Gannon left him to his recovery, he retaliated by winning an initial custody hearing on the grounds that her bipolar disorder made her an unfit mother.

“The judge said, ‘You’re bipolar? Kids are gone. Weekend visitation. Supervised,’ ” recalled Gannon, but the temporary ruling was tossed out when her husband missed a crucial follow-up date in court. Although still married, she moved back to Northern California, eventually settling in Rocklin, to raise her sons — Kelly, now 2 and Connor, 9 months — alone.

But the $686 a month she collected in Social Security Disability Insurance wasn’t enough to make ends meet as a newly single mother.

In February 2011, she found a job in Sacramento as a peer advocate for Mental Health America. It was one of the few jobs she had applied for where she didn’t feel the need to hide her bipolar diagnosis during the interview.

“Sharing your diagnosis when you’re not sure how people will react is really hard because I know how people are and they treat you differently,” said Hillerman-Crook, who hired Gannon for the full-time position and is now her supervisor. “Because of the Mental Health Services Act, every county in the state has individuals living in recovery as part of their management teams.”

Today, Gannon guides up to 20 of her peers, many of them fresh from the facilities she herself used to frequent, toward mental health recovery by connecting them to tools and services. She does this while sharing her own history with bipolar disorder and substance abuse.

“It’s all come to this weird full circle,” Gannon said.

When Hillerman-Crook told Gannon of the organization’s plans to start training Sacramento area sheriffs and police officers in mental health sensitivity and stigma reduction, Gannon was chosen for the side gig because of her personal experiences with law enforcement. For the past year, she’s been facilitating once-weekly trainings.

“Now, I’m able to share my story with cops, and have these cops – who, in my mind, were just the biggest a–holes in the world – raise their hand and say, ‘I had to call the cops on my son because he has bipolar disorder.’ I mean, a cop saying that!” Gannon said.

Gannon’s life does seem to have come full circle.

She has been clean and sober for almost two years, thanks in part to the 12-step programs Alcoholics Anonymous, Cocaine Anonymous and Al-Anon. In the past, she needed as many as nine prescription drugs at once to treat her bipolar disorder; today, she takes only Trileptal, a mood stabilizer. And although she has yet to finish her degree in sociology, her experiences since her days as an overachieving undergrad have placed her squarely in the path of social work.

But Gannon is just one example of someone living in recovery and tackling the stigma of mental illness, Freitas said. “We can bring forth a number of articulate, bright, employed people who’ve had significant disruptions in their life and now are thriving.”

Statewide anti-stigma campaigns and resources:

• Peers, Alameda County (http://www.peersnet.org)
• Stories of Impact, Los Angeles County (http://tinyurl.com/6o47bk2)
• Campaign for Community Wellness, Placer County (http://www.campaignforcommunitywellness.org)
• It’s Up to Us, Riverside County (http://www.up2riverside.org)
• Stop Stigma Sacramento, Sacramento County (http://stopstigmasacramento.org)
• It’s Up to Us, San Diego County (http://www.up2sd.org)
• Anti-Stigma Initiative, San Mateo County (http://www.smchealth.org/node/179)
• SLO the Stigma, San Luis Obispo County (http://slothestigma.org)

• Call 211 for various social services in counties across the State of California. (http://www.211.org)