HealthyCal.org

Photo of Sunshine Cardenas: Callie Shanafelt/California Health Report

By Callie Shanafelt
California Health Report

When Maggie Cardenas heard she could get her children’s teeth cleaned at her Women, Infants and Children’s Program (WIC) office in Yreka, she brought three of her children in right away. The dental hygienist who cleaned her eldest daughter’s teeth told Cardenas that she saw a grey spot on one of six-year-old Sunshine’s back molars that needed to be checked by a dentist.

Cardenas, whose husband is out of work, has been on Medi-Cal since 2006. Her four children have dental coverage for most prevention, restoration and emergency services through the Denti-Cal program.

That same day she called the only local dental clinic that accepted Denti-Cal and was put on a six-month waiting list.

“It was just a little tiny grey spot and it took so long to get in there that it had to be pulled,” Cardenas said.

Cardenas’ story is not unique.

More than four million kids are covered by Denti-Cal, but with only 35 percent of dentists accepting their insurance, they are having a difficult time getting their oral health needs met. With more than a million more children expected to enroll as health reforms take effect, advocates worry dental access will only worsen.

About half of the children enrolled in Denti-Cal saw a dentist in 2011. In smaller rural counties the utilization rate is even lower. In Siskiyou County, where Cardenas lives, more than 60 percent of Denti-Cal patients under 21 did not see a dentist in 2011.

Jenny Kattlove researches the issue for the national non-profit advocacy group The Children’s Partnership. She attributes the lack of care to many factors, one of which is a lack of dentists accepting Denti-Cal. But there are also other difficulties, such as the challenges low-income parents face in getting to dentists because of work schedules and transportation issues.

By 2014, one million more children are expected to enroll in Denti-Cal. With the difficulty serving those currently covered by the program, Kattlove is concerned there will be a severe dental crisis if the state doesn’t do something now.

Health-care reforms simplify and expand federal Medicaid eligibility. In California, this means rolling many different safety net programs into one Medi-Cal umbrella. One of those programs is Healthy Families, the program that previously covered uninsured children and teens whose families earned too much money to qualify for Medi-Cal. On January 1, the state began transferring all those patients to Medi-Cal.

Children still enrolled in Healthy Families as the transfer takes place are in a managed care dental plan with a network of Healthy Families dentists. The state Health and Human Services Agency expects most of the 860,000 children and teens will be covered under the pay-per-service Denti-Cal program once the transition is complete.

Kattlove worries that the state isn’t doing enough to transition Healthy Families dentists to Denti-Cal along with their patients.

Denti-Cal administrators plan to analyze the numbers of former Healthy Families enrollees by county.

“This will help highlight areas where the beneficiary to provider ratio is high, and show us which counties need concentrated provider outreach to boost participation,” wrote Norman Williams, deputy director of the Department of Health Care Services, in an email.

Denti-Cal reimbursement rates are about one-third to one-half of what most dentists charge for their services, according to the California HealthCare Foundation. The majority of dentists who don’t accept Denti-Cal payments cite the low reimbursement rates and a cumbersome enrollment process as their reasons.

“Increasing provider reimbursement rates is a budget issue that would have to be reviewed in light of the current fiscal environment and potential fiscal impact on the program,” Williams wrote.

Williams went on to explain that for the past year, the Department of Health Care Services has been working with stakeholders including the California Dental Association to improve the application and billing process.

Kattlove expects that in 2014 more than 100,000 additional children will enroll in Denti-Cal under the expanded Medi-Cal qualifications. At that point more than half of California’s children will be covered by Denti-Cal.

With little faith that reimbursement rates will be raised in the near future, Kattlove advocates for other methods to get California’s children access to the oral care they need.

“One of the solutions is to bring dental care to children where they are,” Kattlove said. “School based programs are very successful in addressing access issues.”

Training other medical professionals in preventative oral care is another way to improve oral health without adding more dentists Kattlove said.

“Oftentimes children end up in the emergency room because they never got the preventative care they needed early on,” Kattlove said.

“Certain dental procedures are already performed by primary care providers that bill the medical side of the program,” Williams wrote.

But Denti-Cal does not cover teledentistry, something that Kattlove said could help reach underserved rural areas.

Kattlove also points out that parents have an important role to play in getting their children to brush their teeth every night and taking their kids to a dentist by age one and every year after that.

Prior to the WIC cleaning, Sunshine had been to the dentist once at a free screening event in Redding when she was 4. Her teeth looked good then.

“My kids need to see a dentist,” Cardenas said. “I don’t want them to have a bad time on their first time seeing a dentist.”

During the six months that Sunshine waited to be seen for the grey spot on her molar, her tooth got more and more painful. Her parents would visit her school to rub Anbesol on it, but they didn’t want her to miss any school because of the pain.

Students with toothaches had four-times lower grade point averages than students without, in a 2012 study conducted in the Los Angeles Unified School District and published in the American Journal of Public Health.

Finally, on the last day of the school year, Sunshine was eating pancakes at school and she got syrup in the cavity. It was too painful to take anymore and Cardenas called for an emergency dental procedure. At that point the only option was to pull the tooth.

“It wasn’t a very good memory for her,” Cardenas said.

Now Maggie Cardenas makes Sunshine brush and floss her teeth every morning and night. But she’s still afraid of what will happen the next time one of her children need a dentist.

By Rosa Ramirez
California Health Report

As the number of women and men diagnosed with breast cancer continues to rise, an independent committee of medical researchers, community stakeholders and advocates are urging for more research that zeroes-in on preventive and environmental causes of the disease.

The Interagency Breast Cancer and Environment Research Coordinating Committee, which authored the 270-page report “Breast Cancer and the Environment: Prioritizing Prevention,” outlined seven recommendations, including increasing preventive research, intensifying the study of chemicals, promoting collaboration across agencies and organization, and training the next generation of interdisciplinary researchers.

Established by Congress in 2008, the committee emphasized the need to bring preventive-related research to the same level of early diagnosis and cure-related breast cancer funding.

“Our mantra is prevention,” stressed Michele Forman, co-chair of the committee, and professor University of Texas at Austin’s Nutritional Sciences department. Environmental factors, which can have a reaction in mixtures, are often found in the soil, air, food and consumer products. Those exposures can begin to impact an individual’s health starting in the womb and affect people’s health differently at different stages of life. The report broadly defined environment from industrial pollutants to alcohol use.

Some 227,000 women and 2,200 men were expected to be diagnosed with cancer in 2012, with the 2013 figures believed higher, according to the report. Most of the funding has been for diagnosis and cure. Prioritizing rather than reducing the funds in other areas of breast cancer research is necessary, Jeanne Rizzo, president and chief executive office with Breast Cancer Fund, told HealthyCal.org.

She said its essential to research and inform the public how cultural factors or behaviors can impact different racial and ethnic groups. “Risks for breast cancer varies by race and ethnicity, leading the study’s authors to recommend more participation of underrepresented groups to be included in studies.”

Incidences of the disease are highest for white and black women, followed by those who are Hispanic and Asian-American. Still, black women are more likely than white or Hispanic women to be diagnosed with aggressive tumors, likely the result of being diagnosed in advance stages of the disease and barriers to access to optimal health care treatments. Recent studies have indicated that black women are more likely to die of the disease than any other demographic.

“We’re finding that a lot of the personal care products that are marketed to African-American women are very highly concentrated in endocrine disruptors,” Rizzo said. Endocrine disruptors are chemicals that have been linked to cause cancerous tumors, birth defects and developmental disorders.

But one of the challenges for researchers and the public alike is that fewer than 10 percent of an estimated 84,000 chemicals that are currently in use have been tested. The report urges research to close the knowledge gap on how such chemicals affect breast glands.

When it comes to breast cancer, funding dollars have historically been larger for diagnosis and cure-related research, Rizzo said. Currently, only about 10 percent of spending by the two largest federal agencies that focus on breast cancer research has been specifically for environment and prevention-related research, authors of a new report say.

Between 2008 and 2010, the National Institutes of Health spent $357 million on preventive and environmental-related research, about 16 percent of all financing for the disease. The Defense Department, the only other federal organization that allocates sizable funds for breast cancer-related research, allocated even less. From 2006 to 2010, the agency spent about $52.2 million on prevention-oriented research, roughly 8.6 percent of the money allocated to breast cancer.

Want to dig deeper?

Q&A: Prioritizing Prevention and Environmental Risks Research Can Lead To Fewer New Breast Cancer Cases

Jeanne Rizzo, a registered nurse and president and CEO of Breast Cancer Fund, an advocacy group that works to prevent breast cancer by eliminating exposure to toxic chemicals and radiation link to the disease, spoke with HealthyCal.org about why funding for preventive-related research has not received adequate funding, how the public can be better engaged, among other topics. Below are edited excerpts of her conversation with HealthyCal.org.

We just learned that two largest federal agencies that spend sizable amounts on breast cancer research are allocating relatively small percentages on prevention and environmental-related research. Why is that the case?

The environmental health science has grown over the last few decades. We went through the 60s and 70s putting all types of chemicals into the world without testing them fully, and certainly not for whether or not they cause cancer. At the same time, you had chemicals coming into the market without the level of pre-market testing needed. At some point, people began to ask questions.

At the same time, breast cancer rates began going up. The breast cancer movement began in earnest with women and families who had cancer asking why it wasn’t diagnosed early enough or saying that the surgeries were radical and horrible and treatment was extremely toxic. The reinvestment moved into how we can keep these women alive then how can we treat them. The argument went, ‘If we get it early enough then maybe they won’t get breast cancer and die.’ So that movement began and that was the health movement. How do we take care of people. The environmental movement was beginning to understand how there were toxic chemicals in our world but the environmental health movement–the idea that these exposures were creating health outcomes–is really only 15 to 20 years old. Studies were being done on external pollutions, such as air pollution and water quality. But we weren’t looking at the ubiquitous chemicals in the environment and their complex interactions.

But in the mid-90s breast cancer advocates began to raise questions. About a decade ago there were between 400-500 studies and now there are thousands as people began to see these correlations.

The study calls for collaboration, which in general, can be very difficult. Where are you seeing pressure points among organizations that do collaborate or areas that are working particularly well?

When it comes to collaboration, some in the environmental health are already working together in several areas, such as how to deal with chemicals, policy, the right to know and advocating fore more proportional funding for environmental sciences. We certainly advocate that in coalition.

Do you get a sense that more funding will spent on the environmental risks since there’s more information now?

We’d have to look at the sources of funding to understand where someone is going to place their priorities. That’s why the federal government needs to lead the way because the federal government funds come from us, the public.

Talk about the public aspect of this. How is the public and ordinary citizens being engaged with what researchers are learning from these studies?

We need to bring the science to everyday life. There’s a higher rate of breast cancer in pre-menopausal African-American women. We have to ask what are the unique exposures? Researchers are finding that a lot of the personal care products that are marketed to African-American women are very highly concentrated in endocrine disruptors. If there’s a cancer journal report on chemicals and health, it‘s our job to make sure it doesn’t sit on the shelf.

By Heather Tirado Gilligan
California Health Report

People in same-sex relationships face intimate violence as often as straight people do – but the victim services available now are not enough to keep gay, lesbian and transgender people safe from their abusers, advocates say.

The National Intimate Partner and Sexual Violence survey included information about lesbian, gay, bi-sexual and transgender (LGBT) people for the first time this year. Analysis of the survey by the Centers for Disease Control and Prevention yielded some surprising statistics about intimate partner violence in same-sex relationships.

Both lesbians and bisexual women experience intimate violence more frequently than heterosexual women. Forty-three percent of lesbians and sixty one percent of bisexual women reported abuse by an intimate partner at some time in their lives, compared to thirty-five percent of heterosexual women.

Gay men experience intimate partner violence slightly less frequently than straight men – 26 percent of gay men reported that they were abused by an intimate partner, compared to 29 percent of straight men. Slightly more than 37 percent of bisexual men also reported abuse by an intimate partner.

The data supports what has been apparent for some time, advocates say – the need for more services specifically for LGBT people.

Terra Slavin works for one of the few programs in the U.S. to offer services specifically to gay and lesbian survivors of domestic violence as the lead domestic violence attorney for the Los Angeles Gay and Lesbian Center. “We’ve really seen a sea change,” Slavin said of attitudes towards LGBT survivors of violence. “But we still have a long way to go.”

Slavin supports changes to the Violence Against Women Act, the landmark federal legislation to protect victims and prevent domestic and sexual violence that first passed in 1994. VAWA established the first national domestic violence hotline, the national shield law for rape victims, required states to enforce restraining orders issued in other states, established grants that funded shelters and services to victims of sexual assault and established funding for trainings to help police departments and other systems that have contact with victims to better respond to sexual and domestic violence.

The new version of VAWA, which passed in the Senate in February, adds protections for people in same-sex relationships and transgender people. The revisions would include LGBT people as an underserved group, prohibit service providers from discriminating based on gender identity or sexual orientation and provide grant money to be used for services for victims in same-sex relationships and transgender victims.

A bill with similar provisions also passed in the Senate last year, but then died when the House failed to pass it without Republican support. Republicans proposed another version of VAWA without protections for people in same-sex relationships and also stripped of proposed revisions intended to better protect undocumented immigrants and Native Americans. When that version died in the House, the Act, which usually enjoys bi-partisan support, failed to be renewed for the first time since it passed in 1994.

“Advocates of this provision haven’t produced data that shelters have refused to provide services for these reasons,” Senator Chuck Grassley, one of the co-sponsors of the Republican version of VAWA, said of the proposed protections for LGBT people in a statement. “The provision is a solution in search of a problem. Instead, it is only a political statement that shouldn’t be made on a bill that is designed to address actual needs of victims.”

The new provisions are essential to protect gays and lesbians, who face different challenges and have far fewer resources than women in heterosexual relationships, said Slavin, who also serves on the National Task Force to End Sexual and Domestic Violence. “We really do have gaps in service.”

Among them are the most basic needs for shelter. There are only a handful of domestic violence shelters in the country, for instance, that accept men, Slavin said.

“That is a huge problem when we talk about gay men who are in need of emergency housing,” said Susan Holt, who manages the STOP Partner Abuse/Domestic Violence Program at the Los Angeles Gay and Lesbian Center, which provides counseling and prevention services for LGBT survivors of domestic violence.

Transgender victims face particular challenges too. Slavin recalls one client, a transgender woman, who was asked to leave a shelter when staff realized she was transgender. “It’s hard enough to leave,” Slavin said of the woman’s decision to walk away from her abusive relationship. “This person fled. She got to a shelter, and she got kicked out.”

And though shelters accept women as a rule, they are not necessarily hospitable to the needs of women in same-sex relationships, assuming that the victims who come through their doors are all heterosexual, Holt said. That assumption can pose real danger for women in abusive same-sex relationships, she added.

“It is very possible for the batterer to follow the victim to the shelter by presenting herself as a victim,” Holt said, adding that such scenarios are not uncommon in her experience. “There is no real screening process to prevent this,” she said, because the assessments issued to people coming to shelters assume that all women who arrive at shelters are victims rather than abusers.

Police officers responding to calls or victims who want to file reports also have trouble distinguishing the victim from the abuser in same-sex relationships. Rates of duel arrests, where both the victim and the abuser are arrested, are 30 times higher for same sex-couples than in cases with female victims and male offenders, according to the National Institute of Justice.

“I have had advocates tell me that if the cops show up and see two women, they just walk away,” Slavin said.

The way that VAWA is written makes it difficult to find funding for services for gay, lesbian and transgender victims of domestic violence, Slavin said. Though much of VAWA is written in gender-neutral language, the section of the act authorizing Services Training Officers Prosecutors (STOP) grants specify that they end violence against women. They are therefore not easily accessible to LGBT-specific programs.

“It has allowed states not to fund LGBT programs because they theoretically would not serve mostly women” if they also accepted gay men, Slavin said. Some states, she added, have no services specifically for LGBT people.

STOP grants account for a significant portion of money given to states under the Violence Against Women Act. They have been used to train (.pdf) police and prosecutors to more effectively respond to cases of domestic violence and used to fund shelters.

The House is expected to vote on the Violence Against Women Act again this spring.

Photo: surroundsound 5000/flickr

By Callie Shanafelt
California Health Report

Health-care seekers visiting the federal Pre-Existing Condition Insurance Plan website February 16th were met by a window with large red letters reading “Enrollment Suspension.” The plan has stopped adding new subscribers and state administers of the plan will do the same March 2nd.

The program was created as a stopgap to cover people without insurance due to a pre-existing condition until they can no longer be denied in 2014 thanks to federal health reforms. By imposing a mandate that everyone have health insurance, legislators were also able to forbid insurers from denying coverage. The rational is that companies can afford the risky patients if they also have additional healthy patients.

But the very reason for the bridge program is also preventing it from reaching its goal—covering these patients is too expensive.

“PCIP enrollees have serious and expensive illnesses with significant and immediate health care needs,” reads the website’s notification.

Congress authorized a limited pot of money for the program, and administrators project that if they add to the more than 100,000 current enrollees, the money may not last until the 2014 transition.

California was the last state to start a Pre-Existing Condition Insurance Plan and it quickly became the largest in the nation with more than 15,000 currently enrolled.

“We’ve had phenomenal growth, which demonstrates there is phenomenal need in California,” said program spokeswoman Jeanie Esajian.

Patients with pre-existing conditions who are participating in the plan agree with Esajian.

“The only thing I have that can give me health insurance is Obamacare and that’s it,” said 31-year-old enrollee Scott Palmason.

Palmason moved to Los Angeles in 2004 to pursue his dream of performing in improvisational theatre. He’s been able to support himself working various office jobs throughout the city.

“I have not run into a job situation in almost seven years that offers insurance,” Palmason said.

Potential employers told him that with the poor state of the economy, he was lucky to get $10 an hour without benefits.

In 2007, Palmason paid $2,000 for a 20-minute hospital visit during an asthma attack. A couple years ago he decided to get individual coverage and avoid potential huge hospital bills in the future.

But Palmason has Wolff-Parkinson-White syndrome, which sends an extra electrical current through his heart on occasion.

“It’s not life threatening, it was uncomfortable as a kid,” Palmason said. “It’s basically tapered out, in the last five years I’ve never had it happen.”

He applied to five different insurance companies but all of them rejected him because of the syndrome. One added that his asthma prevented coverage and another said that at 5’10’ and 240 pounds he was overweight.

One company told him that if he paid out-of-pocket to have an expensive surgery and went six months without a Wolff-Parkinson-White episode he could qualify.

Eventually an insurance broker told him a commercial insurer would never cover him and he should try the state’s Pre-Existing Condition Insurance Plan.

“I applied and I was immediately accepted,” Palmason said. Now he pays $218 a month and easily found a doctor near his house.

If he met Obama today he said he would tell the President he saved his life, he said. “I never quite understood what it was like to have other people make decisions for you and your body,” Palmason said.

More than a quarter of the current California Pre-Existing Condition Insurance Plan enrollees live in Los Angeles County like Palmason. Fifty-seven percent of enrollees are white and 96 percent are English-speakers. Nearly 45 percent of all participants are between 50 and 64 years old. Premium payments range between $107-$557 a month.

The program has averaged more than 1,200 new enrollees a month since its inception. With ten months left in the year, a potential 12 thousand more Californians would have signed up before the transition in 2014.

The California Managed Risk Medical Insurance Board administers the federal program in the state. Last Friday they received a notice that they have 15 days left until they have to close enrollment.

Californians can still enroll in the state Major Risk Medical Insurance Program, but the premiums are higher and there is a yearly limit of $75,000 and a lifetime limit of $750,000.* There are currently more than 5,500 Californians in the program but there is also a cap of 7,000 enrollees.

If Palmason had enrolled in the state program, he would have paid more than $350 a month for Kaiser insurance and $645 a month for a PPO plan. Since he was already enrolled, the federal program will cover him until he switches to a commercial insurer through the private marketplace or the state exchange in 2014.

“This program literally saved me from having to be in a situation where I would have to make very difficult decisions,” Palmason said.

* The story has been updated. An earlier version stated incorrectly that the lifetime limit on the state Major Risk Medical Insurance Program was $175,000.