HealthyCal.org

By Kate Karpilow

Every once in a while a report comes out that’s a game-changer, it makes you look at an issue in a different way . . . or at least it offers the opportunity to do so.

Falling Behind: The Impact of the Great Recession and the Budget Crisis on California’s Women and their Families is such a report, released Wednesday by the California Budget Project (CBP), along with the study’s funder, the Women’s Foundation of California.

CBP compiled truckloads of data to reveal the disproportionate impacts that the recession and California’s budget wars have had on women and their families.

The overall take-away is that when you focus on people, not just the social safety net programs, a disturbing pattern emerges.

Consider these key findings from Falling Behind:

Employment Rate

From November 2010 to November 2011, women’s employment rate in California declined by 1.2 percentage points to 49.5 percent, while men’s employment rate held at 62.6 percent.

In California and nationally, men experienced greater job losses at the onset of the recession, but appear to be recovering more quickly, while women’s re-entry into the workplace is lagging behind.

Average Hours Worked by Single Mothers

Mothers raising children without a spouse saw their employment rate decrease by a whopping 10.4 percentage points, from 69.2 percent in 2007 to 58.8 percent in 2010.

This dramatic decrease leaves single moms with their lowest employment rate since 1996.

Single mothers who worked also saw a decrease in the number of hours they were employed each week, decreasing from an average of 38.6 hours in 2006 to 36.6 hours per week in 2010 — the largest decline in at least 20 years.

Income and Poverty Rates

Family income (adjusted for inflation) for families headed by single mothers decreased from 2006 to 2010 by 8.7 percent — from $29,247 to $26,711.

During the same period, the percent of families headed by a single mother living below the federal poverty level (FPL) increased 3.7 percentage points from 31.7 to 35.4 percent, compared to an increase of 2.3 percentage points for married-couple families.

Talk about dramatic differences: In 2010, more than a third of families headed by single mothers lived in poverty, compared to just over 10 percent (10.6) of married, two-parent families.

Older Women

While women ages 55 to 69 saw a minor increase of .8 percent in their employment rate from 2006 to 2010, the poverty rate for California women 65 or older was 3.3 percentage points higher than that of their male counterparts in 2010 (it was 2.6 percentage points higher in 2006).

Cuts to Social Safety Net Programs

Welfare. About three-quarters of the adults in the state’s welfare program, known as CalWORKs, are women. Eighty percent of all recipients are children. From Fiscal Year 2008-09 to FY 2011-12, CalWORKs was cut by $3.3 billion, or about $3,000 for each of the 1.1 children served.

Child Care. Child care is essential for parents, and particularly single parents, to find and keep a job, but state child care and preschool programs were cut $1.5 billion from FY 2009-10 to FY 2011-12. In addition, income levels that establish eligibility for subsidized child care were reduced.

Taken together, these changes are expected to reduce services for at least 35,000 children in FY 2011-12.

And there’s a ripple effect. Cuts to child care programs mean that child care workers, mostly women, lose their jobs.

Medi-Cal. From FY 2008-09 to FY 2011-12, $2.4 billion was cut from Medi-Cal, the state’s version of Medicaid that provides health services for low-income families. About two-thirds of Medi-Cal adult recipients are women.

SSI/SSP and IHSS. About half of the 1.3 million low-income senior recipients on Supplemental Security Income/State Supplementary Payment (SSI-SSP) are women, which was cut by $4.6 billion between FY 2008-09 and FY 2011-12, about $3600 per recipient.

Nearly two-thirds of the 439,000 recipients receiving In-Home Supportive Services (IHSS) are women and girls. Hours of support were cut 3.6 percent in 2010, with a ripple effect of reducing earned income for the care providers.

At a legislative hearing on the report held Wednesday afternoon, Senator Loni Hancock reflected that the “statistics show us that women and children first doesn’t mean into the lifeboats, it means over the side….we need to look at ways of changing that.”

We also need a better understanding of how women of color, who historically have higher rates of poverty, were impacted by the recession and budget cuts.

Nevertheless, the CBP report is a game-changer.

By focusing our attention on people, not just programs, we see how the combined impacts of the Great Recession and budgets cuts have disproportionately affected women and their families.

And they are falling behind.

Kate Karpilow is executive director of the California Center for Research on Women and Families.

By Eric Glassman

Difficult economic times are forcing many Californians to make difficult choices every day about whether to continue taking medication or to feed their families and pay rent, while many Californians are simply unable to afford quality health care.

Governor Brown’s recently proposed budget cuts, including reducing reimbursement rates and shifting more Californians into managed care, will make the strain even greater, and will have potentially deleterious health implications for California’s most vulnerable populations.

When patients do not adhere to their doctor-prescribed treatment regimes, we know that the health and economic costs are significant.

The New England Healthcare Institute (NEHI) has found that one-third to one-half of all patients do not properly take their medications due to financial constraints. Patients living with chronic illnesses such as heart and lung disease, cancer and diabetes are hit especially hard when they must take expensive medications simply to maintain their quality of life. To cope with high costs, some patients will skip doses so that their medicine lasts longer, or simply stop refilling their prescriptions altogether.

NEHI research indicates that patients who do not take their medication as prescribed cost the U.S. healthcare system an estimated $290 billion in avoidable medical spending every year.

Studies in the Journal of the American Medical Association report that when patient copayments increase, the use of prescribed medicines decreases. The Journal of Oncology Practice found that cancer patients with copays greater than $500 were four times more likely to abandon their medications than those who paid $100 or less. NEHI also reports that mortality rates among diabetes and heart disease patients who did not adhere to their medications were double those who took them as prescribed.

To help expand access to high-quality, cost-effective care for all California citizens, the California Academy of Physician Assistants (CAPA) has partnered with NeedyMeds, a national non-profit organization, to launch a prescription drug discount card that will help Californians lower the costs of their medications and other health care services. The discount card is free and can be used by all California families to save up to 80% off the cost of prescription medications.

Part of CAPA’s core mission is to expand access to high-quality and cost-effective care for all Californians. The CAPA drug discount card will help reduce out-of-pocket costs for California consumers, help patients stay healthy, and reduce long-term health costs for California families.

Anyone can use the card. The CAPA drug discount card is free and open to all Californians.There are no income, insurance or residency requirements, and no fees or registration process is needed to use the card. One card can be shared with friends and family members, or patients can print their own from the CAPA website. The drug discount card is accepted at over 60,000 pharmacies nationwide, including Walmart, CVS, Walgreens, Rite Aid, and other regional chains and local stores.

Patients cannot combine the card with insurance. The card can, however, be used instead of insurance if the insurance has no drug coverage, there is a high deductible, there is a low medicine cap that has been met, there is a high copay and the card offers a better price, of if a consumer is in the Medicare Part d “donut hole.”

To use the CAPA drug discount card, a California consumer simply presents the discount card to his or her pharmacist along with the desired prescription, at which point the pharmacist will tell the consumer how much can be saved using the card.

At a time when all California families are trying to stretch their budget dollars, every little bit helps. The CAPA drug discount card will help keep costs manageable while also helping to ensure that Californians stay on their doctor-prescribed treatment regimes. CAPA hopes that all Californians, but particularly thosefrom vulnerable or low-income communities, will use the discount card to help afford treatment and stay healthy.

For more information about the CAPA Prescription Drug Discount Card, or to download a copy of the card, please visit: www.capanet.org.

Eric Glassman is President of the California Academy of Physician Assistants (CAPA.)

By M. Stephanie Sario and Christine Solis

We get a lot of blank stares when we tell people what we do for a living. Our title is unfamiliar, but once we explain what we do, heads begin to nod.

We are Patient Navigators, a health care position that has emerged recently and must be commonplace if we’re to adapt to the changes that health reform will soon bring. While this emerging profession may seem specialized, it can have important implications for patients, insurers and the overall effectiveness and efficiency of the system itself. That is, if policymakers, insurers and health providers take action.

Let us explain.

Patient Navigators, where they exist, are essential members of clinical teams, providing highly technical and interpersonal skills. They help patients – and providers – with a range of things: figuring out insurance eligibility and coverage options; ensuring medical records are correct and bills are paid; facilitating referrals to specialists outside the patient’s medical home; and providing interpretation services for patients who may not speak sufficient English – or English-speakers confused with complex medical jargon.

In a state like California, interpretation and cultural competency are important. According to the UCSF Center for the Health Professions, California’s health workers don’t adequately reflect the languages and cultural backgrounds of their patients. As many as half of the newly insured do not speak English very well.

When providers can’t communicate with patients, there’s an increased danger of misdiagnosis, which can lead to greater problems – and cost. And while language is critical, there is also evidence that patients trust and engage more with providers who reflect their cultural background.

Take Filipinos, for example, the country’s second largest Asian-American population. Their health problems are often understudied, so last fall Asian Health Services and Filipino Advocates for Justice presented survey results identifying the most pressing health problems and barriers facing Filipinos. One finding was the need for medical interpreters and bilingual doctors who spoke Tagalog. Even though many Filipinos speak English, the study revealed a preference for providers that also speak their language.

The survey prompted AHS to add Tagalog to the languages our Patient Navigators speak. The position is already making a big difference. We’ve recently helped clear up confusion for one Filipino patient who needed a colonoscopy but didn’t understand the instructions from a nearby hospital. Another Filipino patient lost her family’s Medi-cal coverage because of paperwork confusion, which we helped settle in time for necessary appointments.

Patient Navigators don’t just benefit people who struggle with English; they play vital roles assisting the chronically ill, poor and elderly. (As the enormous baby boomer population ages, older patients will need help deciphering confusing new coverage and payment options – and diagnoses and medical instructions.) By reducing confusion – for any patient – Patient Navigators can improve the efficiency and cost of care within the whole system.

Currently, Patient Navigators and other “professional enabling services” aren’t reimbursable through fee-for-service payment structures. That must change. The new coverage options and other changes coming when health reform is fully implemented in 2014 require us to plan ahead.

Services like Patient Navigators should be reimbursed for the value they provide patients and providers alike. Otherwise we’ll see more blank stares – not about our titles but rather patients dumbfounded by a complex, unhelpful health care system.

M. Stephanie Sario (Clinic Administration Specialist/Tagalog Interpreter) and Christine Solis (Filipino Patient Navigator) work at the Oakland-based Asian Health Services.

By Bruce Chernof, MD

As we ring in 2012, most of us take stock of this new beginning by creating New Year’s resolutions. We think about life’s everyday realities, such as what we eat, our exercise habits, our aspirations, and vow that this year will be different – better. As a physician, I encourage New Year’s resolutions, especially when they involve altering your lifestyle to support healthy aging. This year, I suggest a different kind of resolution, one that may be more difficult to consider. I invite you to think about what aging with dignity and independence means. Then take time to have the tough conversations with your loved ones about what is important to you as you grow older, and how you will get help should you require daily assistance.

Although not an easy discussion, it is vital that we know the preferences and choices of loved ones (and they know ours) regarding the kind of support you and those you love expect long before a crisis occurs. If you haven’t thought about this complicated and sensitive topic, you are not alone. Many Americans are dramatically unprepared, so there is no time like the present to think through and discuss these topics with the very people who will likely be part of your caring network.

To help you prepare, The SCAN Foundation has launched a guide titled, “10 Things You Should Know About Aging with Dignity and Independence.” It offers pointers that everyone should know about the cost and access realities of daily assistance along with five steps you can take today to help you age with dignity and independence.

Here are some key facts you should know. First, Americans live in an aging society whereby – thanks in large part to medical advances – we will live longer than ever before. Twenty years from now, 20 percent of our population will be over age 65. Tomorrow’s American senior will be better educated, experience lower poverty rates, and live in a more culturally diverse society. On the flip side, we will also live with more health problems and have fewer loved ones to help support us as we grow older. With this reality comes the fact that 70 percent of individuals who reach age 65 will need some form of daily living assistance, for three years on average. This is expensive care, and it is important to understand that right now Medicare does not pay for long-term care. Three options to pay for care include paying out of your pocket, having a long-term care insurance policy that are generally expensive and are not universally available, and being eligible for Medicaid, a poverty-based program that requires you to spend your life savings before getting help.

For the past two years, The SCAN Foundation has engaged California voters on this issue and found that once they are made aware of the realities of the cost and likelihood of needing long-term care, they become quite concerned and acknowledge they are not prepared financially or otherwise. They want their elected officials to take action on this matter as a “high priority” issue. This is true regardless of party affiliation, income level and ethnicity. The findings are not unique to Californians as additional polls from AARP and the Associated Press support our findings across the nation.

So back to your 2012 New Year’s resolution, here are some things you can do to be better prepared for a living into your later years. First, start having these conversations with your family members – and have them routinely. This isn’t a one-time discussion but an ongoing dialogue about how to save, what assets you have available, and the kind of life you wish to have, regardless of age, illness, or disability. Second, learn more about what resources exist in your community, whether it is a faith-based organization that offers support and resources, or your local Area Agency on Aging that helps coordinate and link people to a wide array of community services. Third, make informed decisions with your health care dollars. Find out whether you qualify for long-term care insurance and determine whether or not it is the right product for you.

Seek out medical groups or providers that offer an organized approach to coordinating care that put your needs and preferences at the forefront of health care decision making.

Use our “10 Things” document as a guide. Pass it along to your friends, family and others who might find it useful. It is meant to be a starting point to help facilitate these tough discussions. As you share your expectations with your loved ones about what aging with dignity and independence means to you, we are curious to hear your story, and what you learned in the process. We invite you to share your experience on our Facebook page. Also, visit our Web site and follow us on Twitter for more information about aging with dignity and independence. By talking now with loved ones about the kind of care that you expect, this 2012 resolution can truly be one that pays rewarding dividends in the years to come.

Bruce Chernof, MD, President and CEO of The SCAN Foundation. The Foundation is a sponsor of HealthyCal.org.

By Wally Knox

For decades, Americans have debated health care reform as if it was one issue. But, in reality, there are two different issues. The first is how to expand access to care for the 30 million most vulnerable Americans. The second is how to seize control of escalating health care expenses and insurance premiums.

The 2010 reforms of the Obama administration were intended to address both problems, and the act’s name said it: The Patient Protection and Affordable Care Act.

During the debate on the reforms, the President made the cost control aspects clear saying, “My proposal would bring down the cost of healthcare for millions: families, businesses, and the federal government.” Today’s White House website explains, “Without reform, health care costs will continue to crush business and government budgets. The Affordable Care Act reverses this trend. Americans buying comparable coverage to what they have today in the individual market will see premiums fall by 14 to 20 percent and the total cost of care provided to Americans who get their insurance through the workplace could fall by as much as $3,000 per person.”

It was clear from the beginning that controlling costs was crucial both in itself and in order to secure wide public support for a dramatic expansion of insurance coverage for the most vulnerable. Unfortunately, as the plan has been more carefully examined, the assurances on costs are not holding up.

In August, the Administration’s arm for tracking health costs, the Centers for Medicare and Medicaid Services (CMS), reported that, rather than being a bold step toward controlling medical costs, the 2010 reforms will not significantly slow overall medical cost increases. Real, after inflation , national health expenditures per person will soar 34 percent by 2020, and the real total private health insurance premium bill will grow 44 percent. In short, the modest cost savings achieved by the complex morass of new panels and incentives in the reforms will be overwhelmed by cost increases elsewhere.

CMS’s results are only projections, but if these projections prove true, even in part, it will be a disaster for the 2010 reforms, for the national government’s finances, and for three hundred million Americans besieged by exploding health insurance premiums.

And, the explosion does, in fact, continue. Last month the Kaiser Family Foundation reported that the average annual premium for family coverage by an employer – the way almost sixty percent of us under 65 gain coverage – reached $15,073 in 2011 – up a breathtaking nine percent in one year. Added to the real, after inflation, increases since 1999, the cost of employment-based premiums more than doubled.

It is a bitter irony that analysts agree on the primary driver of health cost increases – newly created medical technology supplants its predecessors providing a modest improvement in our health, but at an astonishing increase in costs. That is, each year new technologies come into use, and the new medical treatments and procedures cost more, lots more, than the old ones.

A good example of that process is heart attacks. In 1984 only 10 percent of heart attack victims received surgical treatment. Fourteen years later, over 87 percent received catheters, angioplasty, or bypass surgery resulting in an additional year of life for the average heart attack patient. And the cost? The added surgery drove average treatment cost per patient up by $10,000 resulting in growth of the Medicare bill for heart attacks from $ 3 to $ 4.8 billion. Better health, bigger costs. The process for heart attacks is replicated throughout the system, though the improvement in outcomes is rarely as dramatic.

But, the era in which we can afford to buy progress with vast increases in our bills is over. We cannot indefinitely sustain that process either as individuals paying premiums or as a society running government deficits.
What is needed is simply stated: better medical technology that also reduces our expenses. Not every new device or pill costs more. New, better treatments are constantly developed which cost less than what they supplant.

A classic example of how far better treatment can be a cost saver is the use of amoxicillin, a dirt-cheap antibiotic, to cure peptic ulcers. Dr. Barry Marshall was awarded the Nobel Prize in 2005 for this discovery. For decades, peptic ulcers had been treated by use of acid blockers that became the world’s number one drugs at an annual cost approaching $8 billion – and they didn’t cure the ulcers. Marshall discovered that a bacterium caused peptic ulcers and could be wiped out for pennies and with continued annual savings of over $7 billion.

Every year there are cost-saving breakthroughs like Marshall’s. But, the number and impact of improved, but more expensive, treatments overwhelms the cost savers. The solution is to develop a broad, ongoing stream of new technologies that are cost savers to fully offset cost inflators.

Given the importance of the issue, you might think that there already exists a vigorous national drive to increase the number and impact of breakthrough technology to lower medical costs. Not so. In fact, the federal government spends over $40 billion a year on medical research. But, by law, not one dime of those funds is targeted to produce less expensive medical techniques.

A grim, silent consensus rules that nothing can be done about the costs of medical treatments themselves; and official, if un-admitted, government policy is to not even try.

At a minimum, here is what we should be doing. Each year dedicate a portion of new National Institutes of Health projects to those that demonstrate a likelihood of producing significant cost savings. And, follow the advice of pharmaceutical critic Bernard Munos to dramatically increase breakthroughs and reduce costs by shifting research from in-house, overly bureaucratized institutions to vast numbers of nimble, independent researchers.

In 2010, the central health care debate was how to expand coverage with short shrift given control of costs. Today, with costs exploding and no prospect of an end to that explosion in the coming decade, it is time to focus on seizing control of costs by creating an ongoing stream of better, less costly medical care.

Wally Knox is a former member of the California state Assembly.

By Karla Hampton

Photo by Pepino. See link below.

Here in California, a school garden makes an ideal outdoor classroom throughout the year, offering a fun and interactive way to teach students about science, nutrition, math, collaboration, and more. School gardens are sprouting up all over the state, ranging from just a single small bed with a few plantings to more elaborate gardens and orchards filled with fruit, vegetables, herbs, and flowers.

With escalating obesity rates and growing interest in “eating local,” many schools are looking to add their schoolyard harvest to cafeteria lunches. But school administrators may be wary of the prospect, citing concerns about food safety, sanitation, and state and federal rules about school meals.

The Los Angeles Unified School District (LAUSD) even issued an official memo several years ago, stating that its school cafeterias can’t use school garden produce because the food doesn’t come from an “approved source.” The district’s claim, however, was based on a misreading of state law, and relied on an outdated provision in the first place. In fact, the state code the district cited only requires that fresh produce come from sources that “comply with all applicable laws.” Even if the provision did apply, it would be easy to meet just by transporting any school garden produce in leak-proof, washable containers.

And there are no other state requirements that should keep schools from serving school-grown produce in the cafeteria. In California, school cafeterias are governed by what’s known as the California Retail Food Code (part of the state’s Health and Safety Code), designed to ensure that food provided to consumers is “safe, unadulterated, and honestly presented.” It requires that produce from any source be washed thoroughly to remove soil and other contaminants, and that any chemicals used to wash or peel produce meet certain requirements. But as long as proper handling requirements are followed, there is nothing stopping the use of produce from a school garden.

What’s more, the federal government actually encourages garden-to-cafeteria programs. Congress recently made a strong show of support for garden-to-cafeteria programs when it passed the “Healthy, Hunger Free Kids Act” in December 2010. With this new law, the Secretary of Agriculture is now required – not just permitted – to provide competitive grants and other support to schools to implement farm-to-school programs making local foods more accessible, and the law specifically states that these grants can be used to develop school gardens.

Most school cafeterias are subject to requirements for participating in the National School Lunch Program, which gives public and nonprofit private schools cash subsidies and food donations for student lunches as long as the schools satisfy certain criteria – for instance, meeting minimum nutritional requirements, offering free or reduced-price meals to eligible students, and using foods donated by the U.S. Department of Agriculture as much as possible. None of that rules out the use of school garden produce in school meals.

Individual school districts or private schools might pass their own policies: in Chicago, for instance, the public school district explicitly prohibits cafeterias to use fruits and vegetables grown at the schools. (The produce must be sold or given away instead.) But in the absence of a local policy like this one, there are no legal obstacles for California schools looking to include garden produce in their meals.

A garden-to-cafeteria program can be as simple as adding school-grown greens or tomatoes to a school salad bar, or a more formal district-wide initiative to incorporate a variety of garden produce into the menu. In California, where students can grow and eat nutritious foods all year long, a garden-to-cafeteria program can help cultivate healthy eating habits that last a lifetime.
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Karla Hampton is a staff attorney at Public Health Law & Policy (www.phlpnet.org), a nonprofit research and training center based in Oakland, California.

Photo by Pepino via flickr.

As the June 15 budget deadline approaches, rumors that the Legislature will send yet another spending cap to the ballot abound. These rumors are somewhat surprising, since voters haven’t even had the chance to weigh in on the last cap sent to the ballot – ACA 4 of 2010, approved as part of last October’s budget agreement – and the fact that California’s existing cap is arguably one of the toughest in the nation. Details of what may, or may not, be under consideration are well hidden under the cone of silence.

Some key points to consider when evaluating the impact of any such proposal include:

* The choice of a base year. As a widely displayed chart from the Governor’s May Revision shows, General Fund spending would be at a multi-decade low under the budget plan currently under consideration. Thus, locking in spending at the 2011-12 level, or any year in the near future when scarce resources are anticipated to continue, would prevent restoration of recent cuts and prevent the state from investing in public services and institutions that are essential to a competitive future.

* The choice of an inflation factor. As we’ve written before, tying spending to the Consumer Price Index (CPI) is incompatible with the Proposition 98 school spending guarantee, which in normal years – “test 2” – increases based on per capita personal income growth. Per capita personal income typically increases at a significantly greater rate than the CPI. Thus, tying spending to the CPI turns education funding into a budgetary “Pac Man.” Use of the CPI is also problematic with respect to health care. Nationally and here in California, health care costs typically rise more rapidly than the CPI.

* Whether it is really a cap masking as a budget reserve. Proposition 1A of 2009 and ACA 4 of 2010 both functioned as spending limits, but masqueraded as budget reserves. Both were designed to use complicated statistical formulas – linear regression – to prevent revenue growth that typically accompanies an economic recovery from being used to restore budget cuts made during an economic downturn.

* Whether it is really a new infrastructure funding program masquerading as a spending limit. Both Proposition 1A and ACA 4 created new funding streams for infrastructure spending, masquerading as spending “restraint.” Rumors currently floating around the Capitol suggest that this year’s version may include similar provisions. The problem with this is two-fold. First, money ostensibly destined for a budget reserve may not be there when it’s needed, having been spent, rather than deposited in a savings account, or used to pay down debt that might otherwise be paid from the General Fund. Second, such provisions embody a bias towards investment in “bricks and mortar,” rather than the state’s people, historically California’s greatest asset. While ACA 4, which is slated for the 2012 primary ballot, has been touted as a tool to pay down the state’s “wall of debt,” the infrastructure loophole will likely limit the measure’s impact on debt and minimize accumulation of a budget reserve.

* The voters have spoken. Some spending cap proponents also opposed extending the temporary taxes noting that the voters have spoken. By that standard, a spending cap is a “no go” – voters have spoken twice in six years, defeating former Governor Schwarzenegger’s Proposition 76 in November 2005 and Proposition 1A in 2009. As public opinion research suggests, no on Proposition 1A voters supported a balanced approach to balancing the budget, but viewed a permanent straitjacket on state spending to be too large a penalty to pay for a minimal extension of temporary taxes.

California’s recurring budget crisis since enactment of the “Gann Limit” in 1979 should cause anyone who thinks that constitutional spending limits prevent budget problems to take a second thought. As Rudolph Penner, the former head of the Congressional Budget Office, once noted, “The process isn’t the problem; the problem is the problem.” The only realistic solution to California’s budget problem is a balanced one that closes ineffective tax loopholes and provides the revenues necessary to support our core public services and institutions.

Jean Ross is executive director of the California Budget Project.