HealthyCal.org

The fight may be headed to court, advocates say

By Tim Moran

About 7,700 low income Fresno County residents will miss an opportunity to gain primary medical care due to a dispute between the county and the private hospital that provides care for the county’s medically indigent adults.

The dispute involves a long-term contract between the two to provide low income care, and the unwillingness of either of them to risk incurring more medical costs than they already shoulder.

Fresno became the first county in the state to opt out of the expansion of healthcare to low income adults. The federally funded program would have provided health benefits similar to Medi-Cal for about 7,700 low income adults who do not have medical insurance.

Participating in the program would have involved altering the existing contract, which could shift medical costs for providing health care for the uninsured one way or the other.

The contract currently leaves $60 million of the cost on the hospital, with the county’s share capped at $20 million.

Under the state-federal Bridge to Reform program that Fresno rejected, low-income residents would get a primary care doctor, along with preventive medical care and early detection of potential health problems, instead of relying on sporadic clinic and emergency room visits.

No one disputes the need for low income health care in Fresno County. A quarter of the county’s population is at or below the federal poverty level, and 46,000 adults qualify for the county’s medically indigent health care program, according to Stephen Walter, chief financial officer for Community Health Centers in Fresno.

Community Health Centers operates a hospital and clinics in the county, and provides the county’s medically indigent health program under a long term contract. Just 15,000 of the eligible 46,000 are enrolled in the medically indigent program, Walter said. The program, mandated by the state, does not provide primary care.

Dr. Ed Moreno, the county’s health officer, estimates that 7,700 low income adults could be enrolled in the Bridge to Reform program under a proposal that was voted down by the county board of supervisors on Sept. 20.

Under that proposal, the county would shift $18 million of the $20 million it spends on the medically indigent program to the Bridge to Reform, along with $10 million for a similar program for mental health. Together, the county funds would qualify for $28 million in matching federal money.

But both the county and the hospital are concerned about the financial risk of participating in the program. At the center of the problem is the long term contract the county and hospital entered into 15 years ago.

Under the 30-year contract, Community Health Centers provides the low-income health program and inmate care for the county, for a fixed, $20 million fee.

In the initial years of the contract, the hospital made good money, Walter said. Hospital officials at the time figured they would get the low income patients anyway, through emergency room visits. There was a consumer price index factor in the contract to account for inflation.

“In 1996, it made financial sense,” Walter said. But medical costs rose faster than the consumer price index, Fresno County’s population grew rapidly, and by 2002, the hospital was losing money on the deal.

By 2009, the hospital was spending $40 million to $45 million on the program, and getting $20 million from the county. The situation got dramatically worse last year, when the county loosened eligibility standards to ward off a lawsuit.

The qualifying income level for the program had been set at $500 a month or less, and hadn’t changed since the contract began, Walter said.

San Diego County had a similar arrangement, and was successfully sued because the threshold was too low. Fresno County drew a similar lawsuit, and the county agreed to raise the qualifying income to $1,200 a month.

With the influx of additional patients, the hospital is currently losing $60 million a year on the program, and the number is growing, Walter said.

The county is reluctant to re-open the contract, for fear of getting stuck with a bigger share of that cost.

“We got out of the hospital business 15 years ago, and we capped our cost,” said County Administrator John Navarrette. “We are getting a heck of a deal, we acknowledge that. The hospital made money in the early years,” he said.

Community Health Centers initially went along with the county’s application for the Bridge to Reform program, Walter said, but then realized the risks it posed to the hospital.

The county’s administrator of the program, CalViva Health, would be publicizing the program to develop a client list in anticipation of the 2014 federal health care reform. Those who didn’t qualify for the Bridge to Reform would be referred to the county’s existing low income program. Community Health Centers would have to provide care for more people with what was left of the county’s indigent funds.

“We went to the county and said we want $9 million of the $30 million (the county spends on health and mental health for the poor), and some sort of risk-sharing. We don’t want to lose $240 million.”

That idea was quickly rejected by the county, which has its own budget problems to contend with, Walter said. “The county can’t afford anything, they are closing jails and cutting the sheriff’s department,” he said.

So the board of supervisors voted to opt out of the Bridge to Reform program, causing an outcry from social service agencies that deal with the poor.

Central California Legal Services, Inc. wrote a letter to the board spelling out what it felt were legal problems with the board’s rejection, including an inadequate environmental review, a potential conflict of interest with one supervisor who has a relationship with another medical facility, and discrimination against the rural poor.

“It looks like the members of the board of supervisors voted pretty much in isolation from the rest of the community,” said Chris Schneider, executive director of Central California Legal Services.

“The information from the staff was certainly incomplete if not misleading. I’m not sure the board acted with a full understanding of the implications of what they were doing, what the consequences of rejecting it would be,” Schneider said.

“It impacts the whole county. If my kids are going to school with children who don’t have access to health care, it affects my family. If you go to work with people who don’t have access it impacts your family. It’s a much wider public health issue involved (than just the indigent),” he added.

Community Health Centers, in an effort to revive the program, offered the county an alternative a week after the board of supervisors’ vote.

“We would like to get out of the situation of indigent patients using the ED (emergency department),” Walter said. “You get better quality when you manage patients, it’s a no-brainer, but someone has to take the risk,” he said.

The new proposal would use the county’s federally qualified primary care clinics to provide health care, with the hospital providing admissions and health care specialists and CalViva administering the program. Walters said the clinics are willing to provide the care.

But that plan shifts the risk back to the county and CalViva, Navarrette said.

“The hospital wants to cancel the current contract and put all the risk on the county and the third party administrator,” Navarrette said. “It’s still the board’s decision not to pursue it.”

Community Health Centers can no longer accept the risk either, Walter said.

“We can’t do any more. We are facing federal cuts, state cuts. We think we have done our share,” he said. “There’s a limit to what everyone can do.”

That means the situation is probably headed to court, Schneider said. “I can say we are on a litigation path at this point,” he said.

Schneider is sending another letter to the board of supervisors, urging them to reconsider in the light of the new offer from Community Health Centers.

“To me, it just makes sense for the board of supervisors to take whatever actions they can to assure a healthy community,” Schneider said. “I don’t know if what Community Health Centers offered will be the full answer. But it’s an opportunity to get the right players to the table to explore what can be done to improve the situation.”

If the board doesn’t act soon, Schneider said, Central California Legal Services will file a lawsuit.

Navarrette was unconcerned. “We get threats all the time, from all corners of it. This is not new to us,” he said of the potential lawsuit. “It has been examined by our legal counsel, and they have no standing to overturn our position.”

By Helen Afrasiabi

On a rainy Sunday this month, Maria Mendoza was at Santa Ana’s Roosevelt Elementary with her children, niece and nephews aged two to ten in tow. The immigrant mother of three had brought all six children to take advantage of the newly available playground, despite the weather. They’ve been coming every weekend since June, said her niece Nayeli Vasquez.

But until earlier this year, the children had no other options. Asked where they usually played on weekends, her nephew Alberto Vasquez volunteered: “my house.”

Pointing to the playground equipment, Nayeli Vasquez, a fourth grader at Roosevelt Elementary School, said she liked the playground much better than the ones her parents used to take her to.

“It doesn’t have any of this,” Vasquez said, pointing to the Spider Web monkey bar equipment with a smile.

The children had access to school grounds on the weekend thanks to efforts by a coalition including the California Endowment, Latino Health Access Together and the Santa Ana School District. They helped to make the Roosevelt Elementary School’s playground available on weekends by way of a Community Access Agreement.

“The whole principle was because they live in a densely populated area, the readily available options are school yards where neighboring residents would be able to use school ground as a park,” said Latino Health Access Hub Manager Gloria Giraldo.

The $200,000 project, financed by California Endowment, entailed negotiations between the district and both organizations as well as a renovation of the playground to include trees, additional equipment and resurfaced asphalt among other things.

“Residents have not only been very receptive and involved, but also very grateful,” said Latino Health Access Director of Policy Dolores Gonzalez-Hayes.

Good health is not just about having an insurance card and a doctor, Giraldo said. It means making changes to the built environment, she added.

“Good health begins where there is green, open space,” Giraldo said. “We don’t want to see a liquor store on every corner.”

Santa Ana has challenges not faced by master-planned cities such as neighboring Irvine.

“Decades ago, planning wasn’t the same kind of holistic endeavor where the health of people in those communities was a consideration,” said Jay Trevino, Executive Director of the city’s Planning and Building Agency.

Planning that isn’t holistic occurs in “silos,” Trevino said, with consequences like great distances between recreational and residential areas, for instance, which promotes an isolated and stationary lifestyle.

“Back then, all the transportation engineers cared about was cars and moving them fast, somewhere where they won’t create noise and danger…and an educational institution was solely for educating kids,” Trevino said. “With over a hundred years of unholistic planning, this is what you end up with.”

Creativity is largely the solution in cities that are mostly built out, like Santa Ana, Trevino said.

Certain housing policies adopted generations ago also pose a problem for health, Gonzalez-Hayes said. Some apartment buildings, for example, both don’t let children to play in the halls and have no common area.

“With this density of population in buildings where apartment owners or property management companies say ‘don’t run in halls,’ what do you do with all that energy?” Gonzalez-Hayes said.

“What we’re doing is turning the lemons into lemonade,” Trevino said. “And there is lemonade to be made here.”
While the Roosevelt conversion is currently a pilot project, it shows promise.

Gonzalez-Hayes said they see this idea as worthy of spreading to multiple areas within the city.

Ironically, it wouldn’t be the duplication that presents challenges. It would be getting the word out. A community of predominantly working poor families, she points out, is not one that has the freedom to be at association meetings.

“When these types of things have not been available and people are not used to going there, there’s a delay in awareness,” Mejia said. “That has been the challenge, for the community to feel they’re going to a public place.”

‘The Wonder of Learning’ focuses on early education

By Melissa Flores

A set of twin boys sat at one table at the end of the room, snacking on pretzels, Cheerios, Chex and other healthy treats. Two girls made a beeline for a box of dress clothes when they entered the room. A group of toddler boys played with blocks. Parents signed their children into the childcare area to give them a chance to visit the exhibit, with headsets available for Spanish speakers, at their leisure.

This hands-on, family friendly learning experience took place at downtown Salinas’s National Steinbeck Museum in “The Wonder of Learning” exhibit, on display through Nov. 15. The family day event, hosted by First 5 Monterey, explains a teaching method developed in Reggio Emilia, Italy. Salinas is one of the stops it has made during a six-year tour that ends in 2014.

The method was developed after World War II, when residents were concerned about the blind way leaders from the era were followed, said Francine Rodd, the executive director of First 5 Monterey.

“They wanted to build creative thinkers,” Rodd said. “They developed a system of pre-K and elementary schools that believe children are born creative, curious and capable rather than helpless.”

Bringing such information to parents in underserved communities is part of the mission of First 5 Monterey, which supports programs that offer parenting development and quality child care and improve the mental and physical health of children.

Priority zones, where services are focused, were developed based on economic need, Rodd said. They include Salinas, as well as King City, Greenfield and other areas.

They looked at indicators including the number of Medi-cal births in hospitals to decide where to target their resources. In hospitals with the highest rates, 90 percent of the births were Hispanic or Latino. Ninety-eight percent of families served by First 5 Monterey are Latino, and the rest of the population is mostly African American and white.

Monica Melendez is one of the parents who lives in one of the priority zones. She heard about the playgroup programs offered through First 5 from a family member who had school-age children.

“I was having concerns about my son,” she said of her 3-year-old. “He’s an only child and he’s home all day with me.”

She said that her son seemed shy and didn’t want to play with his cousins when they got together with extended family. Now they attend the playgroups twice a week and her son is becoming more confident. She said he has learned to share and is less shy around other people.

“We learn many things,” she said. “How to make toys and activities. They gave us a recipe for play-doh and I made it here at home.”

The funding for First 5 Monterey comes from state Proposition 10, a cigarette tax that is levied for early childhood education, as well as grant funding. In the most recent state budget, Assembly Bill 99 called for $1 billion of the Prop 10 funding to be moved over into the general fund. A legal challenge is currently underway. The cut will impact the number and amount of grants First 5 Monterey is able to give out each year.

Parents like Melendez helped set the priorities for which services would be offered through the program. The current priorities for First 5 Monterey were set after an intensive strategic planning process that they underwent in 2006 that included outreach to more than 1,000 residents.

Families wanted programs that were culturally and linguistically appropriate and coordinated between agencies. They also wanted flexible hours to accommodate their demanding jobs, many in the fields around Monterey County, and childcare.

First 5 collected donations to cover transportation costs for families and some day care employees to visit the exhibit. On family day, groups of parents and kids arrived on a bus to view the exhibit and dozens of parents arrived to check their children in to the free child care area. Volunteers took the children by the hand and led them to different activity stations until they become comfortable and their parents could look at the exhibit in the next room.

The exhibit featured large panels that showcased different ways to teach children using many senses and allowing them a variety of self-expression. Children listened to the noises made by different shoes, for instance, and drew pictures to represent the sounds. In the back of the exhibit, a light table was set up with different shaped items on top so kids could see what types of shadows they cast. Outside on a patio, volunteers set up a few work stations that included a mobile-making site that had shiny materials for children to adorn it; a table with gourds that children could touch with different textures; a table with mortars and pestles so that kids could grind up objects; a rock sifting station and more.

The method calls for using a lot of natural materials, rather than expensive, high-tech toys to teach students and engage kids and parents in interactive play.

In addition to hosting events like Family Day at the museum, First 5 Monterey funds a family resource center that provides many free programs and services in Salinas such as parenting workshops, playgroups for children and parents, home visits and application assistance for Medi-Cal, Healthy Families and Healthy Kids Insurance programs, and more.

During the regular parenting workshops, the lesson might focus on health or nutrition or social and emotional needs, “as well as equipping parents with some knowledge about how to be an advocate for their children,” Rodd said.

They also support a workshop that teaches parents about positive discipline.

Part of the emphasis of “The Wonder of Learning” is focusing on the whole child and allowing them to be creative in many different contexts. The panels show children engaged in indoor and outdoor activities, often in ways that allow them to move around and participate in physical activities. There is also a focus on being positive about the different ways in which children learn.

The families they service are not sure when to seek help for their child, Rodd said. That feeling of uncertainty doesn’t just happen in poor families, she added.

“Sometimes there is a stigma or concern, in any culture,” she said, “Of not wanting to admit it, or knowing where to go to get support.”

Peggy Kawoles (left) and Cindy Peters (right) are reviewing a diagram of the various stages of artery blockage.

By Brenda Duran

For every minute that a women’s heart beats in the United States, another women’s heart will succumb to heart disease.

Heart disease is now considered the leading cause of death among women in the United States. Nearly five times as many women will die from a heart attack than breast cancer, according to the American Heart Association.

In the city of Long Beach, a community resource center wants to turn those statistics around. Memorial Care Center for Women’s Cardiac Health & Research at Long Beach Memorial Medical Center is targeting women of all ages to give them the tools and information about heart disease before it’s too late.

The heart center opened its doors in 2008 with initial funding coming from a local family who had lost a daughter at the age of 35 to heart disease. Today, the center sees about 400 women a year and has full-fledged support by Long Beach Memorial Hospital.

“There is no referral needed,” said Cindy Peters, who works as the main nurse practitioner at the center. “The best part is that women who don’t have insurance and cannot follow-up with a cardiologist can come back for a follow-up with us anytime.”

For a one-time fee of $55, any woman can walk into the center without a physician referral or health insurance and receive a comprehensive review of their cardiovascular health, which includes an EKG, a full lipid panel of their cholesterol HDL, LDL and triglyceride levels as well as their blood sugar. The screening also includes a 12-lead electrocardiogram, which provides enhanced images of the heart, and a meeting with the nurse practitioner to discuss family history and risk factors.

The low-cost of care allows any woman to get the attention she needs and it also allows the center to accomplish its main goal – educate the community, said Peters.

“A lot of women want to do health prevention, they want to start a new routine and they want to know what their baseline is,” said Peters. “We give them all of that information so they can take advantage of it and significantly reduce their risk of heart disease.”

Peters said in recent years she has seen an overwhelming number of women with weight issues. As many as 60 percent of the local women who come to the center are at risk for high blood pressure and hypertension the precursors to fatal heart disease.

“Counseling women on weight loss is one of our biggest issues,” said Peters.

The center has been looking to get younger women in for check-ups since there has been a steady rise in obesity particularly in younger woman, which puts them at risk for a long list of cardiovascular problems later in life.

In recent months, the center has devoted a lot of its attention to tracking the progress of one of their youngest patients, Paula Perez, 24, of Long Beach. At her young age, Perez is faced with numerous health obstacles. A few years ago, Perez’s mother passed away from cardiac arrest and her father passed away from stroke. Before she passed, Perez said her mother urged her to make her heart health a priority by going to the center.

A year ago, when Perez made her way to the center she weighed 360 pounds, her blood pressure was in the 200 range – well above normal. Peters immediately urged her to focus on weight loss to kick start her way back to health.

“It was a good experience,” said Perez. “I’ve gotten so much better since I went. I changed my complete lifestyle from eating to exercising.”

So far, Perez has lost 83 pounds and said she will be continuing her annual check-ups with the center to stay on track.

“It’s great to have younger women come in because there are a lot of misconceptions about heart disease,” said Peters. “A lot of women don’t think they are at risk.”

Peters noted that most physicians do not perform an EKG for any woman under 55 because it is not covered by insurance. Being able to offer women this procedure at the center has allowed for a more comprehensive exam for women of all ages to make changes earlier.

Manhattan Beach resident Kate Hellmers, 54, said like many women she didn’t give much thought to her heart health, even though people in her family have died from heart disease. Before a friend referred her to the center a year ago, she didn’t give much thought to how her family history of high cholesterol and heart problems could be affecting her.

“It was really interesting to see what the report would look like and what they would be able to tell me above and beyond what my regular doctor had told me,” said Hellmers.

After an extensive check-up with Peters, Hellmers learned she had an irregular heartbeat that could become a potential problem down the line. She took her results to her doctor and immediately began a new regimen to help her stay out of the trouble zone.

“They gave me specific questions to ask my regular doctor that no one has ever suggested before,” said Hellmers. “I had never seen an EKG graph and have someone explain it to me. The suggestions turned out to be very good. It is fantastic information.”

Hellmers added since her visit she has been able to get her cholesterol down by five points and has decided to make her regular visits to the center bringing along other women she knows.

“It’s fantastic information,” said Hellmers. “If women like me can get a grasp on this now and know I can check up on it without having to pay thousands of dollars its great.”

By Minerva Perez

Chambers of commerce have long been known for furthering the interests of local businesses. Now, more consumers want an economy that is steering toward sustainability, too, and that’s made Merced’s own chamber a champion of green business practices.

The Greater Merced Chamber of Commerce launched a Green Team this past summer. The team of local business people is quickly getting into small mom and pop stores and large companies to call attention to ways they go green and save money in the process.

“Environmental stewardship is an added positive but in reality businesses aren’t going to do anything unless it positively affects their bottom line,” said Adam Cox, communications and public relations representative for the chamber.

The Green Team works on two levels. There is a public education component, focused on communicating the different ways to be more environmentally friendly, and a task force, called the REACON team, which goes out to business sites and assesses their recycling, energy and conservation and air pollution mitigation efforts.

The REACON assessment is voluntary, and at the end of the visit, the business is left with a checklist of suggestions – from what kind of bulbs to use to what types of practices reduce paper waste. Business decide which changes they want to make, but it is the chamber’s hope that they move forward to receive a Green Sustainable Business Certification.

Even though committee members themselves are in the recycling or solar business, Cox said, the REACON visit is not a sales call.

“What those members get out of it is the hope that if your business is interested in solar that you would call our solar guy but we don’t leave anything more than a business card,” he said.

Cox said that since July, about 20 county businesses have taken them up on a REACON visit. Most of the businesses that Cox visited himself had already been practicing sustainability in one form or another.

A few businesses had been recycling paper, no small feat, Cox said, because there is no commercial recycling. Others had taken advantage of renovations to make their facilities more eco-friendly, as was the case with Label Technology Inc., a label and packaging company located in Merced.

Dale Reschenberg, vice president of manufacturing of Label Technology, said their sustainability efforts truly started about a year and a half ago, when they had to upgrade their lights and decided it would be a good opportunity to look into saving energy.

“The more you do, the more you find out and the more you want to do,” he said. “You never truly finish. You start thinking about it, how to defray costs and help the environment.”

Since then Label Technology has become more sustainable. The company now mixes ink using computers to reduce error and waste, upgraded its HVAC system to web base control of the manufacturing and offices facilities heating and cooling. They have also installed motion controlled low energy lighting, used LED lighting where possible, expanded its paper-recycling program, worked with material vendors to promote eco-friendly materials and packaging and have invested in a satellite irrigation system that waters landscaping depending on the weather forecast.

Plant engineering and facilities manager Albert Gabriel said that although the company already had a commitment to sustainability, he and his colleagues were happy to participate in the Green Team to become more informed about new vendors and the different solutions and opportunities available in the field.

“It’s a learning process and learning to think out of the box,” Gabriel said.

Merced is not the only chamber that is adding committees and task forces on Green practices as a way to help business keep up with trends and add value to their chamber membership.

Bev Jorgensen, vice president of corporate and member relations for the Carlsbad Chamber of Commerce, said that the chamber’s board of directors decided to start a sustainability committee in 2007. She said back then it was still a new philosophy but to everyone’s surprise, it quickly took off.

“This is one of the committees I am in charge of and honesty I went dragging my feet in,” she said. “But the task force is made chamber members, volunteers, and they have done such a great job. They understand it and get it and they want to implement it.”

Carlsbad also offers its own certification program, which it is currently upgrading, and is looking to how to facilitate green jobs and work with the local community college on feedback for a green education certificate program.

The chamber’s president and CEO Ted Owen said the education and workshops the sustainability committee offers has increased their membership, now standing at 1,500. He has noticed changes in committee members themselves.

“We put out bottles of water at our meetings and nobody takes it, but when we put out a pitcher everyone brings out their cups,” he said adding that in his office they have made some energy saving upgrades and buy green products too.

The Long Beach Chamber of Commerce has started a Green Business Council too, but one more geared towards helping businesses that already offer green products or services.

The group is still relatively new, according to Kent Peterson, the council’s president. About 30 companies are involved that already offer green products and services. Like Carlsbad and Merced, they also promote sustainable business practices to the chamber members.

Cox and Jorgensen each said they spend a lot of time educating chamber members and non-members on the myths of sustainability. There are some upfront costs, they acknowledge, but going green is getting cheaper and the return on investment is well worth it.

Gabriel at Label Technology said it would be too difficult to calculate how much the company has saved on the improvements, but they have noticed their energy bills have gotten smaller and they take advantage of as many rebates as they can.

While some businesses may not have the budget that Label Technology does, chambers suggest small improvements like switching to CFL light bulbs, using reusable water bottles or encouraging biking to work. One significant but small thing Label Technology has done is switch to 100 percent recycled paper for the employees to use in the office.

“Recycled paper costs more than new paper but it’s the right thing to do,” Gabriel said.
Cox said attendance to the monthly meetings keep growing and he attributes it to consumers own environmental awareness which Jorgensen agrees

“This is a huge thing nowadays so at least embrace it,” she said.