HealthyCal.org

By Daniel Weintraub
California Health Report

Gov. Jerry Brown’s revised budget for the coming year proposes deeper cuts in the health and social safety net, with hospitals, nursing homes and home care for disabled people and older adults taking the biggest hits.

Brown officially disclosed that the projected shortfall for the coming year has reached $16 billion. That’s the difference between projected tax collections and the amount it would take to fully fund all of today’s programs for another year at levels required by current law.

To close that gap, Brown proposed cuts in projected spending for almost every major program except kindergarten through 12th grade education, and he reiterated his call for voters to approve an increase in sales and incomes taxes this November. If Brown’s ballot measure fails, he said, the schools would bear the brunt of the additional spending cuts required to balance the budget.

But for now he’s aiming squarely at the state’s already tattered safety net.

Monday’s proposal, among other things, would cut hundreds of millions of dollars from hospitals and nursing homes, reduce in-home services for the disabled, and impose indirect price controls on subsidized child care.

Brown is proposing to shift about $200 million to the state’s general fund from a fee on hospitals that was designed to bring more federal money to California. The fee revenue is dedicated to care for the poor in the Medi-Cal program and is thus matched by the feds. But under an agreement with the hospital industry, that money was supposed to stay with the hospitals. Now a big chunk of it would be shifted to other state priorities.

The governor is proposing a similar shift of money raised by a fee on nursing homes. The state’s general fund would gain about $50 million from that shift, which would deny the nursing homes a planned, 2 percent increase in rates in the coming year.

Brown is also renewing his call for cuts in services to the home-bound disabled and older adults, a frequent target in recent years.

He is proposing a 7 percent, across the board reduction in these services, doubling an existing cut that is due to expire on June 30.

Beyond that, Brown wants to end domestic services – laundry, cooking, cleaning, etc – for recipients who live with others, reasoning that those things can be provided by the roommates.

In subsidized child care, Brown is proposing to limit payments to licensed providers to the 40 percent of the prevailing market rates, down from today’s 85 percent. This is expected to save about $185 million a year.

Diana Dooley, Brown’s secretary for health and human services, told reporters in a conference call that the proposed cuts are painful be necessary – given the state’s revenue shortage.

“The problem we have, and we will always have in Health and Human Services, is this is where most of the spending is,” Dooley said. “The spending is on education and health and humans services to a very large degree. The only places you can cut back is the places where you are spending.”

Brown’s revised budget did ease up on the poor in a couple of places.

In the CalWorks program, for example, the governor in January proposed to end grants to families after 24 months if the parent was not fulfilling federal work or job training requirements. Now he is saying those payments can continue if the parent is getting an education.

Most of Brown’s health and welfare proposals are expected to meet strong opposition in the Legislature. Democrats generally refused to make cuts by March 1 as Brown requested in January, reasoning that those cuts might be unnecessary if the economy recovered more quickly than expected.

Now the state’s shortfall has nearly doubled, and Democrats will be hard-pressed to find alternatives to what Brown is proposing, especially since these cuts already assume that the voters will approve the tax increase on the November ballot.

State Senate Leader Darrell Steinberg’s reaction to the latest proposals was muted. He called the economy a “stubborn beast” and said lawmakers’ “work obviously is not done.”

“The governor is doing a good job and has laid out a difficult proposal,” Steinberg said. “We are not looking for a big public fight over the next month but we will work assertively with the governor and the Assembly to find some alternatives to the most egregious cuts.”

By Mary Flynn
California Health Report

New data about the health of counties throughout the US tells us that Marin is the healthiest county in California. The least healthy? Trinity County, in California’s rugged and rural far North.

That’s according to The University of Wisconsin Health Institute and the Robert Wood Johnson Foundation (RWJF) recently released County Health Rankings and Roadmaps, an annual ‘check-up’ of over 3,000 counties in the United States.

But researchers who crunched the numbers on health want to go beyond a best and worst list. That’s why this year’s data also includes information about projections about counties’ future health and incentives, in the form of grant money, to take a turn towards healthful living.

“It shows people that there’s a lot more to health than healthcare,” said Bridget Booske Catlin, the Director of the County Health Rankings and Roadmaps program. “So much of what influences peoples’ health happens outside of the doctor’s office, and so the data that we provide reflects some of these other important factors that influence health.”

The Rankings site allows users to do a side-by-side comparison of the counties in their state. It uses two different sets of criteria, so a county ranked as the ‘healthiest’ is a current measure of how long its people live, the Health Outcomes, and their general quality of life, the Health Factors.

In California, Marin County is ranked the highest in both criteria, and its Health Outcomes score indicates a low rate of premature death (defined as deaths before age 75.) Marin residents lost 3,846 years of potential life before age 75 per 100,000 people. California averages 5,922 years of life lost before age 75 per 100,000 population, and the national benchmark, or the 90th percentile for the nation (that is, only 10% of counties are higher), is at 5,466 years lost. On the other end of the spectrum, Trinity County residents lost 10,546 years of potential life per 100,000 people.

Two counties in California – Alpine and Sierra – are not ranked. Catlin said this is because the population size of the data is not large enough to determine reliable indicators, but there is still some data available for them.

The other set of criteria used to rank the counties, is what are called Health Factors, or things that affect the health of the population. Health factors fall under four categories: health behaviors (things like smoking, physical activity, motor vehicle crash rate), clinical care (number of uninsured people, primary care physicians, or the percentage of people receiving diabetic screening), social and economic factors (percentage of unemployment, violent crime rate, level of education), and physical environment (air pollution measures, access to healthy foods or access to recreational facilities).

Catlin said that these health factors are actually a prediction of how healthy an area will be in the future. A high-ranking county now is Colusa, just shy of the top ten with a ranking of #11 in Health Outcomes. But taking the health factors into account, the county weighs in at #44. Two health factors that stand out in Colusa are unemployment (20.4% compared to 12.4% overall in CA) and the ratio of primary care physicians to patients (1763:1 compared to 847:1 overall in CA).

The ratio of primary care physicians to patients is important so that people have access to a doctor to get preventative and primary care, as well as referrals to specialty care when appropriate.

Unemployment is often associated with a number of unhealthy behaviors – like increased alcohol consumption, poor diet – that can contribute to disease. Unemployment is also associated with a lack of healthcare access, since employers are often the providers of healthcare. Unemployment is also related to an increased number of self-reported physical illnesses and deaths, including suicide.

These two pieces of data – high unemployment and a low number of primary care physicians – will likely mean that Colusa will have a lower health outcome in the future, whether that translates into poor health or more premature deaths. However, Catlin said that the specific contributors are likely to be more than just these two measures, and that education level, particularly some college, also has a significant impact on a populations’ health.

While the County Health Rankings have been released annually for the past three years, this is the first year for what’s called the County Roadmaps Project. The Roadmaps Project provides an action center where site visitors can learn strategies to mobilize their communities to take action to improve their health.

For Catlin, a longtime scientist whose roots are in data, it is exciting to work on the Roadmaps portion of the project that seeks to put the data into action. “[It’s] really providing tools and guidance for communities to really be able to move forward,” Catlin said.

As part of the Roadmaps Project, communities can also apply for grants to work on implementing policy or system change. Catlin said that communities are encouraged to apply for the Roadmaps to Health Prize Opportunity, where communities can compete for up to six awards of $25,000 for 2013.

Last year, Alameda County was awarded one of these community grants for the Alameda County Prosperity Project a program that aims to improve health by addressing problems with the economic tools available to low-income residents.

Many low-income people of color in Alameda County rely on short-term financial services – check cashers, payday lenders, or pawnshops – to meet their banking and credit needs. Many residents lack access to mainstream financial products and services like no-cost checking or short-term loans, and data indicates that 1 in 6 households in Oakland lacks access to a checking or savings account.

Families struggle to afford basic health needs like food, shelter, transportation and healthcare, and as a result they’re unable to save for the college or buy homes, both of which are also related to improving health outcomes.

“We know that economic wellbeing is fundamentally related to personal health and the health of our communities,” said Alexandra Desautels, a Local Policy Manager for Alameda County Public Health Department.

As part of its Roadmaps project, the Robert Wood Johnson Foundation awarded the Public Health Department and its multiple partners a $200,000 grant over a 2-year period. The funding is intended to help make consumer-focused banking services available to low income neighborhoods and educate people about cost-effective methods for handling their money.

“This grant has been an excellent opportunity for us to push strategies that we know will help eliminate health inequities,” Desautels said. “It is great to have an opportunity to bring in resources to work on some of these efforts that address the structural and root causes of the health inequities we see.“

By Daniel Weintraub
California Health Report

Gov. Jerry Brown’s proposal to shift nearly 1 million children from subsidized private insurance into the state Medi-Cal program is running into a wall of opposition from children’s advocates, health care providers and faith-based groups.

Brown included the proposal to eliminate the state’s Healthy Families program in his January budget and is expected to stick with it when he releases his revised budget next week.

But the coalition of 40 groups opposing his plan is backing an alternative that seems likely to win more support among the Democrats who control the Legislature and will be writing the final version of next year’s spending plan. The coalition includes Children Now, the Children’s Defense Fund, the California Medical Association, PICO and many other groups.

The option backed by the coalition would preserve Healthy Families but move about 200,000 children between the ages of 6 and 18 into Medi-Cal next year.

Those children – from families with incomes below 133 percent of the federal poverty level – are already scheduled to be moved to Medi-Cal in 2014 as part of the implementation of the federal Affordable Care Act, if the health reform law passed two years ago survives a challenge pending in the US Supreme Court.

“We’re concerned that the governor’s proposal is being driven by questionable estimates of budget savings, rather than ensuring that these children get the best health services possible,” said Kelly Hardy, who monitors health policy issues for Children Now, a non-profit group.

“Without sufficient preparation, we think this could undermine the successful Healthy Families program as well as the health and welfare of the kids currently enrolled in Medi-Cal.”

Both Medi-Cal and Healthy Families are joint state and federal programs offered to low-income families, but they serve different populations in different ways.

Medi-Cal, which serves adults and children from families at or below the poverty level, serves some children through managed care plans and others with fee-for-service reimbursements to individual doctors and hospitals that agree to care for the poor. Families are not required to pay any premiums for their coverage. Generally, the federal government matches each dollar the state spends on the program.

Healthy Families is aimed at children up to 19 years old in families that don’t qualify for Medi-Cal and have incomes up to 250 percent of the poverty level, or about $46,000 for a family of three. Families are given private insurance and pay premiums on a sliding scale, according to their income. The federal government provides $2 for each dollar the state spends.

Because Medi-Cal rates are lower than what the state pays in the Healthy Families program, Brown is hoping to save about $64 million next year by cutting rates paid to the managed care plans under Healthy Families in October and then shifting all of the children into Medi-Cal by the middle of 2013.

But the non-partisan Legislative Analyst’s Office has suggested that Brown’s hoped-for savings might be overly optimistic. The office also questions whether the move can be accomplished without disrupting care for the children involved.

One problem with the governor’s proposal is that the managed care plans serving Healthy Families children now might not agree to a 25 percent reduction in their fees. That would leave those children without coverage until they could be transitioned into Medi-Cal.

But even once the affected kids are shifted to Medi-Cal, there might not be enough doctors to serve them. In many counties without managed care where Medi-Cal clients see individual doctors on a fee-for-service basis, there is already a shortage of participating doctors, which makes it difficult for people to get an appointment. Adding still more potential patients to that program could overwhelm it.

Hardy said it would make more sense to start slowly, moving only those children who are already scheduled to be shifted a year later as part of the Affordable Care Act.

“Then we need to do some rigorous evaluation about Medi-Cal’s capacity to handle an influx of new kids, and sign up adequate networks of providers to handle those kids,” she said. “We’ve been able to get a lot of weight behind the view that we should wait on the majority of the children.”

By Heather Gilligan
California Health Report

Michelle Harvey’s son has severe Attention Deficit Hyperactivity Disorder. By middle school, when he was diagnosed, he could not read at grade level, and he struggled in math. Harvey, who is an elementary school teacher, worked closely with school administrators on her son’s needs, and was a frequent volunteer at his middle school. Then he went to high school, and things fell apart.

ADHD is the most common childhood behavior disorder, with symptoms including inattentiveness, over-activity and impulsivity, which are usually treated with stimulants. Harvey’s son struggled with the anxiety caused by his ADHD medication, a drug that usually wore off before the end of the school day. He self-medicated with marijuana, Harvey said, and that contributed to the problems he had at school.

But teachers at his Sacramento-area high school too often did not follow his individual education plan (IEP), a document that spelled out the necessary accommodations for his disability, she added. And his time at the school, Harvey said, coincided with the introduction of stiffer penalties for misbehavior and an increasing number of children of color in the school district. Ultimately, her son, who is African American, was suspended 10 times.

“He felt like he was not a part of the school,” Harvey said. “He was spiraling out of control. He was starting to act out. It was a self-fulfilling prophecy.”

His problems at school are all too common, according to data recently released by the U.S. Office of Education’s Office for Civil Rights. African American students with disabilities run the highest risk of school suspension in California, according to an analysis of that data by The Civil Rights Project at UCLA in the report Suspended Education in California. Overall in the state, African Americans with disabilities have a 28 percent risk of suspension, compared to an 11 percent risk for white students.

Break that down by gender and region and the suspension risk gets higher for boys of color, especially young black men, according to the Civil Rights Project’s report. The suspension risk for African American males with a disability is highest in San Bernardino County, where suspension rates are as high as 59 percent.

These numbers are consistent with a broader racial disparity in suspensions in California. The risk of suspension for African American males in Los Angeles Unified, for instance, is 23 percent, compared to five percent for white males. On average, black students were suspended at rates 20 percent higher than white students in the state. A similar disparity is also reflected in national data. Black students make up 18 percent of the students in the study, but 35 percent of the students suspended once.

Higher rates of misbehavior are not the cause of the racial disparity, analyses of school suspensions suggest. One study analyzing 11,000 school records in a Midwestern city showed that teachers referred African American students to the office more frequently, but for more subjective infractions like disrespect, excessive noise and loitering. They were also punished more frequently for “threats.” White students were sent to the office most often for clearer infractions: smoking, leaving without permission, obscene language and vandalism.

Students with disabilities like ADHD and other behavioral or emotional diagnoses can find it hard to meet basic classroom expectations, and may behave in ways that teachers consider unduly noisy and disrespectful, said Heather Jones, an assistant professor of clinical psychology at Virginia Commonwealth University, whose research focuses on ADHD and minorities.

Sitting still, paying attention, speaking in turn and following multi-step directions are all big challenges for any student with ADHD. “School is really the worst place possible you could match a child with these difficulties,” Jones said. “They require that you do all of the things that are difficult for children with ADHD.”

There is little research on ADHD and ethnicity, Jones said, but studies suggest that teachers generally perceive African American students as the most hyperactive in the classroom regardless of their disability status.

Students with disabilities, like Michelle Harvey’s son, are entitled to accommodations under federal law. “There are additional protections for students with disabilities, and they are in place because we know that kids with disabilities have been disproportionately impacted by out of school suspension and removals,” noted Laura Faer, Director of Education Rights at Public Council Law Center, which is sponsoring several bills before the Legislature to change approaches to school discipline in California.

“Frankly, from the data, it seems like they [the protections] are not strong enough,” Faer said.

According to Harvey, her son’s high school did not comply with his IEP as he struggled with his classes. He could read stories and novels, but had a hard time with academic writing. He rarely got the audio books he was entitled to because of his disabilities. He was also subject to increasing surveillance by school security, according to Harvey. Meetings with administrators to develop a plan for her son didn’t help, she said.

“His behavioral plan was to check his pockets at school,” Harvey said.

Anita Contreras, whose eight-year-old son is a student in the Los Angeles Unified School district, tells a similar story. Her son, who is African American, has ADHD and bi-polar disorder. He was “informally” suspended from school 15 times this year – days when teachers called Contreras to tell her to pick up her son because his behavior was unmanageable. They were supposed to put him in a special classroom to help him calm down, Contreras said, but they did not.

“Everything is just piling up on our family,” Contreras said. Her son has been out of school since the end of March, she said.

Removal from school can significantly affect young people. A recent and extensive study of school suspension in Texas indicated a connection between school suspensions and dropping out and school suspensions and involvement with the juvenile justice system. About 10 percent of students suspended between seventh and twelfth grade dropped out during the study period, while more than one in ten students who were suspended in those grades had contact with the juvenile justice system.

Several bills to create a different approach to discipline in California schools are currently under consideration in the Legislature, including one that limits suspensions for “willful defiance” and another to create an accurate database to track school suspensions. A third, AB 1235, would require schools with suspension rates that exceed 25 percent of student enrollment to adopt an evidence-based system of positive behavioral intervention (PBiS).

Ravenswood City School District in East Palo Alto, where almost 80 percent of students are Latino and most of the rest are African American or Asian Pacific Islander, adopted PBIS in 2003. The district developed simple and clear expectations for student conduct and encouraged students to meet them, with rewards for good behavior and consistent consequences for bad choices. Schools in the district focused on three or four core principles – such as safety, responsibility and respectfulness – and defined what that would look like in different environments in the school, like the classroom, the bathroom, or the cafeteria.

The schools first adopted PBIS as part of a plan to integrate special needs students into mainstream classrooms. Sheldon Loman, then a special education teacher in the district and later a coordinator of the PBIS program, helped to lead that integration. Before the switch, discipline was based on a student conduct handbook with many rules that required subjective interpretations. Where PBIS tries to prevent misbehavior, the conduct book approach punished misbehavior after it happened. That wasn’t creating the safest environment for kids, including special needs kids, said Loman, now an assistant professor in the Department of Special Education at Portland State University.

School suspensions in the district dropped by 686 after two years of PBIS, Loman said. The simpler, clearer standards paved the way for teachers to teach students about good behavior, rather than the reactive approach that was standard before PBIS, he said.

Harvey decided to pull her son out of his Sacramento-area public school after his suspensions. He’s now in his senior year at a charter school, and Harvey describes his experience there as “night and day” compared to his first few years of high school. He still misbehaves and is punished, but his punishments are no longer designed to isolate him from school, she said.

There is no reason why any teacher cannot be trained to properly accommodate disabled students, no matter their ethnicity, said psychology professor Heather Jones. Teachers sometimes don’t understand that ADHD children need to be rewarded for meeting basic expectations like sitting still. But like other students, ADHD students respond very well rewards, she said.

Harvey said that she understands, as a teacher herself, why it may be challenging to give additional assistance to students with special needs. Her experience with her own son means that she is especially careful when student with disabilities show up in her classroom. But, she said, she always understood that such accommodations are part of her job.

Perhaps racial bias was at work in the treatment of her son, Harvey said.

“If you have a child of color who acts up and a white child who acts up, the child of color is going to get more consequences,” Harvey said. ”If the child looks like you, you are more likely to say, boys would be boys.”

Harvey noted, though, that the staff at her son’s new school, where he is doing well, is mostly white. “So I don’t think it’s a race thing,” Harvey said. “I don’t care who teaches my son. As long as they treat my son with dignity and respect.”

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.