Issues | HealthyCal - Part 8
 

Issues

  

California’s long-term unemployed: a city the size of San Francisco

Published: March 13, 2010 | No Comments

By Michael Bernick

Not only have the rates of unemployment and underemployment (particularly involuntary part-time work) increased dramatically in California since 2007, but so also has the average duration of unemployment. In fact, long term unemployment (employment for 27 weeks or over), has increased more rapidly than other unemployment measures both in total numbers of Californians and percent of the unemployed .

These duration of unemployment data come earlier this week from Bonnie Graybill and EDD’s Labor Market Information Division. In March 2007, prior to the Recession, total unemployment stood at 865,000 Californians, of whom 16.8% had been unemployed 27 weeks or more. By March 2009, the number of unemployed had increased to 1,534,000, of whom 24.1% qualified as long term unemployed. Over the next year, the number of unemployed not only grew to 2,152,000, but also the number of long term unemployed shot up to 843,000.

Stated another way, by March 2010, the number of Californians unemployed 27 weeks or longer had reached 843,000, roughly the size of the City of San Francisco.

Who are the long term unemployed in California? Although EDD does not track this group by, say, occupation or skill level, discussions with local Workforce Investment Board (WIB) directors highlight the presence of older workers and higher skilled workers. These are workers with backgrounds in financial services, computer operations, commercial and residential real estate, human resources. Each of these jobs usually brings tens, hundreds of applicants when openings are announced.

Jeff Ruster, veteran director of the Silicon Valley WIB (Work2Future), notes that prior to this Recession, his One-Stop Career Centers saw mainly the lower income unemployed, or workers with barriers to employment. The recession changed this, and workers with college degrees and years of experience appeared in numbers.

These college-educated workers, like all workers who come to the Centers are offered an assessment, followed by either job placement assistance, and/or forms of training. With so many sectors as well as firms downsizing, there is an emphasis by staff on identifying transferable skills.

The Centers do not have jobs to give out, and nobody is guaranteed a job. So as the duration of unemployment grows, so often does the frustration, anger and desperation. Ruster recalls, “In July 2009, we had a job fair with Safeway, which was opening a new store with a need for cashiers, stockers, store operations. Though we only gave short notice, over 1000 people applied, and over 50% had college degrees.” Ruster’s story, of course, is not unusual in California today. Every WIB director in the state I know has a similar story of the surplus of job seekers, including the college educated, pursuing a limited number of jobs.

Ruster points to survey data of Silicon Valley employers indicating more intend to hire this year than the previous two years. But he acknowledges that the increased pace of hiring has yet to materialize.

Michael Bernick is the former director of California’s Employment Development Department and a fellow at the Milken Institute. This piece appeared originally at FoxandHoundsDaily.com

 

A modest proposal: break up the CSU

Published: March 11, 2010 | 1 Comment

By Michael Fitzgerald

The idea is simple, perhaps too simple.

Disband the California State University system and set the 23 campuses that make it up, free.

Let’s say it again: Disband the California State University system and set the 23 campuses that make it up free.

At this point the question probably being asked is: Are you nuts?

No.

But the State of California – more specifically the state Legislature, the CSU administration and CSU Board of Trustees- clearly are nuts if they believe the current arrangement is acceptable to anyone (except perhaps them…).

There have been so many egregious things happen because of the hapless (and occasionally malevolent) central administration of the CSU (the Chancellor’s Office and the Trustees) they are hard to even catalog.

No need here to rehash the Common Management System, the subject of a blistering report by the California State Auditor a few years ago. Or recently, the CSU’s stated position that it will not put any limits on lodging costs for any of its world-traveling (and well-paid) executives. (This while student fees soar, enrollments are cut, faculty are taking pay reductions – and teaching more students in their classes.)

The Chancellor’s Office needs to be shutdown, shuttered and perhaps its Long Beach building fumigated – or an exorcism performed – to banish the corruption, the bureaucratic thinking (and the anti-student & anti-faculty attitudes) to let ideas (and higher education) flourish again in the state.

Each of the 23 campuses should be set free to pursue their own destiny, freed from the bureaucracy of the central administration and the CSU Trustees.

What would that pursuit of destiny look like?

I don’t know.

There are 23 campuses in 23 different geographic areas of the state with 23 different faculty, staff and students invested in the success of their campuses. And all 23 have spent years under the heel of an administration that treats all 23 campuses almost exactly the same, when they are clearly different.

And in that difference, in those 23 campuses filled with people who have a real stake in providing quality education (as opposed to simply protecting a bureaucracy) there are likely 23 models waiting to be revealed. Twenty-three!

It would be a beautiful thing to watch – and in which to participate.

But the idea is simple, perhaps too simple.

Michael Fitzgerald is a journalist and journalism teacher at California State University, Sacramento. See his blog here.

 

The Blue Cross business model

Published: March 11, 2010 | No Comments

By Anthony Wright
Health Access

It’s true, as Jonathan Cohn points out, that the nation’s largest health insurer, Wellpoint, has been “among the most hostile to reform.” And as unearthed by Ezra Klein, at least one investment bank states the reason clearly: “Should health reform fail, Wellpoint would be a primary beneficiary.”

You may not know Wellpoint’s name, but even if you don’t live in California, you may have heard of their California subsidiary, Anthem Blue Cross. Their rate hikes have been repeatedly spotlighted by the White House, and have been the subject of over a half-dozen inquiries.

The scrutiny comes with the eye-popping rate hikes, and with being the biggest, both in the nation, and in many states like California. But the scrutiny should go beyond the rate hikes to their overall business practices—and the broken health system that rewards bad behavior. To reinforce Ezra Klein’s point, they have perfected a business model based on collecting premiums from the healthy and avoiding as much as possible actually providing coverage to those who are sick.

It starts with their aggressive denial of people with pre-existing conditions—we have many stories of people being denied not just in their 50s but in their 20s, and even for relatively minor issues like heartburn.

Most controversially, Anthem Blue Cross of California had the most number of rescissions in the state, the odious practice investigating patients after a major claim for the purpose of retroactively cancelling a patient’s coverage–even if they have paid months and months of premiums–if they found an inaccuracy on the patient’s application regarding their medical history. They created even more of an uproar when they sent letters asking doctors to turn their patients about unreported pre-existing conditions.

The company also works to ensure that mostly healthy people come to them in the first place. They specialize in cheaper, “bare-bones” plans with high-deductibles or that leave out key benefits. At a recent Congressional hearing, Chairman Henry Waxman of California grilled Wellpoint executives about why the biggest increases were going to more comprehensive plans, including those with maternity coverage, with an effort to shift people into plans where consumer face more financial risk. As the committee staff report indicates:

“Internal documents suggest that WellPoint’s business plan includes moving consumers into less generous plans. This strategy appears to have three components. First, WellPoint’s highest rate increases seem to apply to their most comprehensive insurance plans. Maternity care is a marker for a more comprehensive package of benefits. A chart of proposed rates shows that WellPoint’s highest rate increases apply to the only two product families regulated by the Department of Insurance with maternity coverage. The chart also shows that for the most part, WellPoint proposed lower increases within specific product lines for the versions with higher deductibles than for the versions with lower deductibles.”

Anthem uses benefit design, but also marketing, to avoid older folks and get more than its fair share of young and healthy people—also called “cherry-picking.” A classic example is a product like “Tonik,” which is marketed to 19 to 29 year olds, and has higher cost-sharing and omits maternity coverage—the most likely need for coverage for young women. It was perhaps the only insurance product that has been mocked by The Daily Show.

With this and other strategies, the company has been able to send over $525 million from California policyholders to Wellpoint’s Indiana headquarters in just 2009. Wellpoint got over $4.2 billion in earnings since acquiring Anthem in 2004, according to reporting by Lisa Girion of the LA Times. This is despite an agreement with state regulators that the merger would not siphon California policyholder dollars to the out-of-state . Anthem Blue Cross waited out the three years of the agreement, and sent $950 million to the corporate parent the week after.

These practices, yielding these dollars, are why the company has been on the front lines of opposing health reform.

When Governor Schwarzenegger proposed health reform in California in 2007, other insurers were willing (with caveats) to consider living by new rules, like guaranteed issue. As the biggest player in the market, Anthem Blue Cross of California stood alone apart, investing $2 million in an opposition campaign. (My organization and others launched a counter campaign, www.sickofbluecross.com, which continues today).

In the current federal debate just a few months ago, Anthem Blue Cross took the unusual step of sending misleading E-mails to their subscribers attacking the House health reform bill.

Other insurers have been ambivalent about health reform, which would mean more potential customers–but that includes sicker patients that they would rather not take, and more accountability and oversight over their operations. Health reform would mean a profound transformation for the industry: insurers competing on cost, quality, and customer service, rather than risk selection and avoiding sick people.

Anthem Blue Cross of California, and its parent company Wellpoint, has internalized the perverse and inequitable incentives of the current, broken individual insurance market: it thrives and profits from the status quo. The only surprise in the investment bank’s analysis that Wellpoint would be a primary beneficiary of reform failing was that it was stated so clearly.


Anthony Wright is Executive Director of Health Access California, a statewide health care consumer advocacy coalition of over 200 groups. This article has been re-published from the Health Access Blog.

 

One way to help solve the doctor shortage

Published: March 10, 2010 | 1 Comment

By Robert Hartmann, MD

California is experiencing a worsening shortage of doctors in rural and low-income communities, in part because of decades-old laws that no longer serve our needs.

I have worked as a “country doctor” for 22 years. It’s the kind of work I always wanted to do, but it’s a tough sell for younger doctors today – even for those who see it as their professional calling. College and medical school tuition and subsequent debt are exorbitant. More patients in rural communities are uninsured or on Medi-Cal than privately insured. The doctors who treat them are routinely paid less than half of the cost of care.

Here in Amador County we have tried to hire an additional internist for over two years without success. That’s an injustice to patients here.

A simple solution is to let rural hospitals and California Healthcare Districts hire the doctors they need. However, in California, state law prohibits hospitals from directly hiring physicians.

That statute made sense when it was originally instituted more than a century ago. Back then it prevented mining companies from determining if and how medical care was administered to employees. The argument for keeping the outdated law on the books is that hospital executives might interfere in the medical decisions doctors make. Today, that simply doesn’t and cannot happen. Laws are in place that explicitly prevent any such interference and make it punishable as a felony.

Unfortunately, the rural hospitals and urban hospitals that need doctors the most are still bound by the “physician hiring ban”, and as a result can’t effectively recruit and hire doctors. This directly contributes to a cycle of greater unmet healthcare needs, which have been shown to increase the rate of preventable hospital admissions by 60 percent. So, essentially, individuals who live in rural and low-income communities are set up for worse health outcomes than other Californians.

Health care policy in California needs to move past protecting the self-interest of organizations and look at the interest of patients. We need to find a way to let both rural and urban hospitals in under-served areas hire at least a handful of physicians directly onto their staffs. This would allow hospitals in areas that are short of doctors to offer physicians (especially recent medical graduates) stable employment, income, and benefits. It would also remove the financial barriers that keep aspiring “country doctors” and those who want to serve the poor from choosing that path.

Letting hospitals in areas with doctor shortages hire physicians would cost California taxpayers nothing and helps even the playing field between more affluent communities and rural and low-income communities in attracting doctors. There’s no good reason to wait – we need to do what we can now to bring doctors to all Californians.


Robert Hartmann, M.D. is the Amador County Public Health Officer and an internist in private practice.

 

Using medical efficiency to drive down California’s health care costs

Published: March 5, 2010 | No Comments

By Micah Weinberg

The news has been full of stories in recent weeks of how Anthem Blue Cross has been trying to increase health insurance premiums by as much as 39 percent for some people who buy insurance on their own, outside of the kind of group coverage a person gets from an employer. Almost entirely unnoticed, meanwhile, has been a more newsworthy development: in a time when medical costs have been rising rapidly, premiums for many public sector workers enrolled in a Blue Shield of California HMO have actually gone down.

How is this possible?

The explanation lies in the fact that large groups have dramatically more market power than individuals. CalPERS, which buys health insurance on behalf of its 1.3 million members, is the largest purchaser in California and the second largest in the nation after the federal government.

Catholic Healthcare West's chain of hospitals is part of a CalPERS pilot project to try to hold down health care costs.

More important than mere scale, though, is how CalPERS uses its market power to drive down costs and improve quality. For years, both on its own and in concert with the other members of the Pacific Business Group on Health, a coalition of large purchasers, it has worked with insurers and providers to pioneer innovations in value-based benefit design, quality ratings for doctors and hospitals, and delivery system reforms such as the establishment of medical homes.

Over the course of the past year, CalPERS has partnered with Blue Shield of California, Catholic Healthcare West and Hill Physicians Medical Group to pilot a new “virtual integrated delivery system.” CalPERS members who are covered through the Blue Shield of California HMO and who already had a doctor in the Hill Physicians Medical Group as their primary care physician were automatically enrolled in the program.

What are the terms of the deal? The insurer, hospital system and physicians association are given mostly free rein to redesign their care delivery systems to promote better coordination and improve efficiency. For example, these partners are eliminating redundancies such as having the same patient participate in multiple chronic disease management programs. In return for this autonomy, Blue Shield will not be raising premiums this year for over 40,000 CalPERS members who are participating in the pilot. What this means is that the insurer and providers have a strong financial motivation to produce the efficiencies they seek as they are on the hook to pay for any increase in costs.

Ellen Badley, the interim Assistant Executive Officer for Health Benefits at CalPERS, points out that her organization has been an active partner rather than merely a passive purchaser. The relatively small scale of the project meant that CalPERS had to create a new rating region for the pilot that includes just three counties: Sacramento, El Dorado, and Placer.

The agency uses different regions to determine premiums because medical costs vary substantially among the different areas of California. In general, medical costs for CalPERS are somewhat lower in southern California where there is more competition among providers. Regional variations in cost and quality were brought to the attention of a larger audience by Dr. Atul Gawande in his New Yorker article, “The Cost Conundrum.” Understanding the drivers of these variations, and how to make higher-cost areas such as parts of northern California more efficient, is a major priority for CalPERS, according to Badley.

What does “efficiency” look like from the standpoint of the patient? Dr. Alvin Sockolov, a family physician who works in a small group practice in Sacramento says that we’ve only seen “the tip of the iceberg,” of the potential for the collaboration. However, he is already getting better information on discharges from Mercy General, a local Catholic Healthcare West hospital. This lets him know which of his patients he needs to follow up with to smooth their transition home and to avoid demoralizing – and costly – re-admissions.

According to Michael O’Neil of Blue Shield of California, the partners “are hopeful that we will be able to see more benefits over time and be able to replicate the pilot in other markets.” What these remarks emphasize, though, is that this project is still more promising than proven. In the estimation of Ellen Badley, “the jury is still out.” She is looking forward to meeting with the leadership of the groups that are running the pilot to learn more about the practical details of what they have been able to achieve.

In theory, the coordination that occurs through integrated delivery systems should allow them to be dramatically more cost-effective than those that operate under the fee-for-service model in which providers have an incentive to focus on the volume rather than the value of the care they deliver. This is the concept behind the Accountable Care Organizations envisioned in federal reform, which builds on California’s experiences both with fully integrated delivery systems such as Kaiser Permanente and the delegation of responsibility for patient care from plans to physician groups.

There is support for the idea that method of payment does affect delivery of care. The research of Dr. Laurence Baker of Stanford has shown that Medicare HMO patients in California spent fewer days in the hospital during the last two years of their life. However, there is a great deal of evidence, including in the Baker study, to suggest that variation in cost and quality is driven more by differences among doctors and hospitals than by who is paying for the care. These variations in physician culture and patterns of practice have also been brought to light by Dr. Gawande and by Dr. John Wennberg in the work that he has done with his colleagues at Dartmouth University.

It’s surprisingly difficult, though, to get a handle on which healthcare markets are the most efficient. Dr. Wennberg’s conclusions are drawn from examining Medicare reimbursements. According to these data, Sacramento is a very efficient, low-cost community and was celebrated for this in several conferences held last year that focused on variation. However, it is less clear that Sacramento is a low-cost community when examined through the lens of private reimbursement. A report funded several years ago by CalPERS and the Pacific Business Group on health called out Sacramento as one of the highest-cost markets in the state.

If the pilot fails, the partnership is on the hook for the increased costs this year and premiums for CalPERS are likely to return to a more standard rate of growth for this market in coming years. If the pilot succeeds, though, it could help push the whole region, and eventually the entire state, toward better value.

Micah Weinberg is a Senior Research Fellow in the California Program of the New America Foundation. This year he ran the California Task Force on Affordable Care, a group of stakeholders that developed a strategy to move the state toward better value for its medical spending. Blue Shield of California, Catholic Healthcare West, and the Hill Physicians Medical Group all participated in this effort.

 

Stem cell agency facing new challenges

Published: March 2, 2010 | No Comments

By David Jensen

Photo from the California Institute for Regenerative Medicine

A little more than five years ago, visions of seemingly magical stem cell cures danced in the minds of California voters. Lured by the promise of human embryonic stem cells and the intransigence of the Bush administration, Californians voted to borrow $3 billion and give it away to scientists to come up with therapies for ailments ranging from Alzheimer’s to diabetes.

In approving Prop. 71, voters repudiated the Bush administration ban on funding of human embryonic stem cell research. The voter initiative also created the California Institute for Regenerative Medicine (CIRM), an enterprise unlike any in state history and one that is uniquely independent of the governor and the legislature. It is also an agency that is facing a new set of challenges as it enters its second five years of existence.

As of today, CIRM has approved slightly more than $1 billion in grants and one loan. That averages out to $48,000 an hour since the state treasurer first sold (on Oct. 4, 2007) California stem cell bonds, the agency’s only significant source of cash and a stream that flows directly to CIRM – unimpeded by California budget concerns. More than 300 California researchers are enjoying the agency’s largess. California research organizations and universities have engaged in a $1 billion plus lab building spree, fed by $271 million in CIRM seed money. And CIRM directors have seen $916 million go to institutions to which they have links.

No cure or therapy is yet ready for patients, despite campaign rhetoric that seemed to ignore the slow and tedious nature of scientific inquiry, not to mention the required approval by federal authorities.

This year, CIRM is facing challenges involving money, manpower and performance, along with legislation that is aimed both at enhancing the agency’s accountability and transparency and ensuring that Californians have affordable access to stem cell therapies that they have financed.

A leading state Senate Democrat, Elaine Kontomina Alquist of San Jose, a supporter of Prop. 71 and chair of the Senate Health Committee, earlier this month introduced the legislation. She said that the agency is “essentially accountable to no one given the way the initiative was written.”

Introduction of the measure followed a smattering of negative newspaper commentary about CIRM and a call by a sister state panel to CIRM for more openness. The group, the Citizens Financial Accountability and Oversight Committee (CFAOC), was also created by Prop. 71 and is chaired by State Controller John Chiang, the state’s top elected fiscal officer.

The committee unanimously endorsed many of the recommendations last year of the Little Hoover Commission, the state’s good government agency, to make CIRM’s practices more transparent and accountable to the public.

The stem cell agency responded to both the legislation and the oversight committee’s recommendation with “announcements” on its Web site (www.cirm.ca.gov). In a carefully worded statement, CIRM defended its processes and challenged thethe committee’s authority to conduct performance audits.

CIRM directors are expected to consider Alquist’s bill, which requires a 70 percent vote of both houses and the signature of the governor, at their March 11 meeting in Sacramento. However, CIRM Chairman Robert Klein, a Palo Alto real estate investment banker; vice chairmen Duane Roth, a San Diego businessman with ties to the biotech industry, and Art Torres, former state Democratic Party chairman, have already sent a five-page letter to Alquist, declaring that her bill is unnecessary. It is a position that the CIRM board has agreed with in previous years as the agency has successfully opposed other legislation.

Alquist’s measure would ordinarily be headed for a gubernatorial veto, like the previous measures, if it were not for a bit of collateral damage that has emerged from Prop. 71. In an effort to convince voters they were not spawning another ungainly government bureaucracy, Klein and company wrote into the proposal not only a spending limit but a cap on the number of employees at 50. Klein now concedes that the cap was unrealistic. CIRM President Alan Trounson, who was lured from Australia to head the agency at a $490,008-a-year salary, told directors in December that the agency “can’t do the job properly” in some areas.

As a result, Alquist has included in her bill removal of the 50-person cap, which some might think would convince Klein, who for better or worse is the dominant force at the agency, of the wisdom of some of her other proposals.

The letter by Klein and the two other CIRM leaders said, however, the agency is looking at alternative ways to bypass the 50-person cap. Such a move would avoid legislative horse-trading but would raise questions about whether CIRM is violating the spirit of Prop. 71 if not the letter.

The legislation is only the latest challenge this year for the stem cell agency. Klein dearly wants to deliver on the promises of the Prop. 71 campaign, which he directed. Klein pushed hard for a $230 million effort last fall, the agency’s largest research round, aimed at bringing– within four years – therapies to the first stage of the federal approval process.

Klein knows that CIRM’s financial resources are not endless. It has bonding capacity for another $2 billion, but that can be eaten up quickly by $200 million grant rounds or perhaps even larger ones. He is now pushing for participation in the financing of clinical trials that can run into hundreds of millions of dollars each.

In a few years, tangible results from such efforts can be paraded before lawmakers and the governor to seek additional bond funding. CIRM could also use its success stories to generate contributions from wealthy philanthropists or the biotech industry.

In addition to the 50-person cap, Prop. 71 has “blessed” the stem cell research effort with built-in conflicts of interests. Seventeen members of its 29-member board of directors have ties to the institutions that have enjoyed CIRM’s bounty. The situation prompted the prestigious science magazine Nature to editorialize in 2008 about what it called “cronyism” on the CIRM board. As of this month, $916 million has gone to organizations that have links to past or present CIRM board members. The recipients include Stanford, multiple University of California campuses, the University of Southern California, the City of Hope and Salk, Scripps and Burnham institutes, all in La Jolla. Individual board members are barred from voting on grants to their institutions. But the board approves the concepts for grants and sets their rules as well as overseeing the administration of the grants.

The conflicts are not going away. It is all but politically impossible to change the structure of the board to remove the conflicts.The institutions represented on the board were powerful research centers prior to Prop. 71. It is only reasonable to think that they would receive the lion’s share of CIRM cash. Meanwhile, CIRM executives are looking for closer relationships with the biotech industry to help speed cures into the clinic, a move that poses additional conflict possibilities. Indeed, CIRM President Trounson expects to hire a new vice president of research and development soon with an industry background at an annual salary that could reach $332,000.

Controller Chiang’s committee made one recommendation that could help innoculate CIRM against perceptions of self-dealing and conflict – posting of the directors’ statements of economic interest and their CIRM expenses online. At least it would make it very publicly clear just who stands to benefit. Both Gov. Arnold Schwarzenegger and Chiang have begun the online posting practice for their top aides.

CIRM has not responded to the recommendation for online postings. In its letter to Alquist, it said it is “California’s most accountable state agency.”

Klein, who has led the agency since its very beginning, also presents another challenge for CIRM with his announced plans to step down in December. Klein has been far more than a figurehead. He has represented CIRM nationally and internationally. (He found Trounson down under.) Klein’s hand has been felt deep inside the agency, and he has built a reputation for micromanagement. With his departure, the agency will also be losing significant bond financing expertise. So far directors have done little public succession planning, a matter that Alquist’s bill would require.

Recently two UC San Francisco academicians published a study on CIRM funded by the National Science Foundation. It said that CIRM will have a “significant” impact on commercial and academic biotech research in the United States. But the study said that measuring the agency’s success is a “challenge for the future.”

How CIRM performs over the next year could well have a major impact on that future.

Jensen is a retired newsman who has written nearly 2,500 pieces on CIRM since 2005 on his Web site, the California Stem Cell Report . He has also written for other publications on the subject, including Wired News, The Sacramento Bee, Fierce Biotech and BioWorld.

 

Budget would cut support for seniors

Published: February 25, 2010 | No Comments

By Bruce Chernof, M.D.

Gov. Arnold Schwarzenegger’s proposed budget for the coming year has serious implications for California’s low-income seniors.

According to a recent analysis by the UCLA Center for Health Policy, the proposal would dismantle California’s home- and community-based long-term care system.

Full implementation of the proposed cuts would likely leave frail, low-income seniors – among the state’s most vulnerable residents – without needed support. Many could face a total loss of daily assistance, including those with serious functional limitations (e.g., inability to bathe themselves) and cognitive impairments such as Alzheimer’s disease. Left with few alternatives, many would be forced to turn to nursing homes for care. However, the state has neither enough open licensed beds nor the funds to pay for the increased demand on institutional services.

In California and throughout the country, efforts at long-term care policy reform have for years focused on helping people with disabilities remain in their homes and communities. To support the highest level of autonomy possible, the Americans with Disabilities Act of 1990, backed by findings of the U.S. Supreme Court in Olmstead v. L.C. (1999), holds the state accountable for providing care and support in the community where possible as an alternative to institutionalization. As a result, California’s community-based long-term care services have kept thousands of older adults and adults with disabilities out of institutional care. The UCLA Health Policy Center’s analysis of U.S. Census data found that nursing home rates have dropped from 5.1 percent of the population in 1980 to 2.8 percent in 2008. This time frame corresponds with increased access to publicly supported home-and community-based services.

These programs, designed to allow individuals to stay in their own homes rather than placing them in more expensive nursing homes, are subject to substantial cuts. For example, the In Home Supportive Services (IHSS) program provides personal care assistance to nearly half a million low income people who are over the age of 65, blind or disabled. Proposed cuts, according to data from the nine counties analyzed in the UCLA study, would eliminate services for 87 percent of all current recipients. More than two-thirds of elders with cognitive impairment would have their services totally cut, as well as 94 percent of those who live alone. But even the few who will retain services are at risk. If the state does not receive all $6.9 billion of federal assistance it requested, then “trigger cuts” would eliminate the entire program.

Seniors in jeopardy of losing IHSS also stand to lose Adult Day Health Care (ADHC), a community-based day care program that provides health, therapeutic and social services to 37,000 persons at-risk for nursing home placement. Cuts propose to eliminate this program all together.

Other cuts to programs that help seniors are up for discussion as well, forcing them and their families to scramble for long-term care alternatives should services disappear. Among the most unpopular of alternatives is going to a nursing home. Yet even this option presents challenges. The California Legislative Analyst’s Office estimates that up to 50 percent or 213,500 of those losing IHSS services could seek nursing home placement as a result of cuts, yet the state has only around 20,000 licensed nursing home beds available at any moment. The UCLA analysis suggests that – at most – 5 percent of those needing placement could be accommodated. Where will the rest go?

Left to fend for themselves, low income older and disabled adults with substantial impairments could likely turn to the more expensive acute care system – emergency room visits and hospital admissions – for help.

Compared to the rest of the country, California has the largest number of older adults in the nation and as baby boomers retire, that number will only grow larger. While the proposed reductions might save money in the near term, it could likely result in increased acute care costs and long-term care costs down the road.

Dismantling these programs would also have a negative effect on an already precarious California job market. If the cuts go into effect, unemployment will almost certainly rise. As many as 7,600 employees would lose their ADHC jobs and up to 370,000 paid caregivers would lose some or all of their IHSS work. Many would lose health insurance benefits provided by these jobs. Also, family caregivers who rely on these services to help care for loved ones so they can maintain employment outside of the home would be forced to find with alternative care or face jeopardizing their own jobs.

The current collection of home- and community-based services in California is not perfect. With little cohesion, this patchwork of programs often operates in silos and could benefit from a more comprehensive and effective coordination process. However, its overall contribution has been positive for seniors and family caregivers alike.

The State of California faces an overwhelming financial crisis that threatens to unravel the safety net for seniors. There are no simple answers to this painful crisis. Yet it presents an opportunity to create a more integrated, efficient and person-centered approach to care rather than leaving our poorest and most vulnerable Californians with no place to go.


Bruce Chernof, MD, is the president and CEO of The SCAN Foundation in Long Beach, California. The SCAN Foundation supported the UCLA Center for Health Policy analysis of the governor’s proposed budget.

 

The Emerging Strawberry Crisis: Innovate or Else

Published: February 16, 2010 | No Comments

By Paul Towers

Paul Towers

Sitting before a panel of legislators, a Santa Cruz area farmer recently compared the potential fate of California’s strawberry industry to the current state of American automakers. He argued that if agriculture doesn’t innovate, it faces a bumpy road ahead. And, he argued, that the decisions of regulators today will create the roadmap for the future of farming. It’s no easy task–the direction of the state’s agriculture system is at stake.

One set of choices sets us down the road of producing food that continues to poison humans and contaminate our soil, water and air; the other turns a corner to widespread adoption of methods that, though they are more sophisticated and foreign to most conventional growers, produce safe and healthy food for all.

The strawberry industry is at this crossroads. It’s no doubt then that strawberries are big business in California and demand doesn’t appear to be slowing down. Each year, beginning in Santa Cruz and continuing down Highway 1 to Santa Barbara, black tarps are plastered to valleys and hillsides. When the tarps are removed, over 1.8 billion pounds of strawberries from over 32,000 acres are harvested. It’s what’s below those black tarps that is increasingly shaking up the entire industry.

The fields are wrapped in plastic tarp to curb the escape of highly toxic pesticides known as fumigants—chemicals applied as gases to sterilize the soil before planting. Yet the gases invariably escape through drift on to workers in the fields and children and other rural community members while at schools, homes and parks. California agriculture, especially strawberry growers, has become increasingly reliant on these pesticide fumigants in order to produce greater and greater yields.

The latest chemical that conventional strawberry growers want to add to their fumigant toolbox in California is called “methyl iodide,” marketed as the product Midas. It is intended by some to be a replacement for methyl bromide, a chemical banned under international treaty.

The toxicity of the potential new pesticide is well established. Methyl iodide is a tightly regulated laboratory chemical that scientists use to create cancer cells in laboratories. It is a nervous system poison that causes thyroid disease, late-term miscarriages and is listed on California’s Proposition 65 list of “chemicals known to cause cancer.” It also has the potential to contaminate groundwater for decades to come.

Last Thursday, a panel of internationally respected scientists added fuel to the debate about the chemical after months of review, stating, “We have concluded there is little doubt that the compound possesses significant toxicity.” These findings concurred with a letter penned in 2007 by scientists across the country, including five Nobel Laureates in Chemistry, noting they were “astonished” that a chemical posing such high risks to human health would be considered for use in agriculture. California’s own regulatory agencies estimate that workers could be exposed to levels of methyl iodide 3,000 times higher than the “acceptable” dose.

Concern over the potential registration of methyl iodide hasn’t been limited to scientists. In August, Assemblymember Bill Monning (Monterey) and Senator Mark Leno (San Francisco) co-authored a letter signed by 33 state legislators in opposition to the proposed use of this new fumigant in California.

With increased global trade and climate change, California agriculture faces unprecedented challenges. Yet alternatives to pesticide soil fumigation such as crop rotation, soil solarization, use of green manure treatments, and steam treatment of nursery container stock are already available. Groundbreaking research on disease resistant varieties and anaerobic soil disinfestation are coming out of the University of California and show great promise as both safer and easier to use alternatives. Commodity groups, recognizing its importance, are helping to fund this research because of its long-term potential for reducing costs.

Despite the risks posed by methyl iodide and the availability of safe alternatives, many growers feel caught between the ways they know and the uncertainty of new techniques. This reluctance to make changes now sits uneasily with the fact that many in the agriculture industry see the public’s concerns over health as the writing on the wall that the future of farming is one without chemical fumigants. Ultimately, California regulators will help determine one course or the other.

In choosing short-term profits over investing in clear, long-term trends, American automakers bet the farm on the Hummer: let’s hope that farmers don’t make the same mistake.

Paul Towers is the State Director of Pesticide Watch Education Fund and The California Food Project where he works side-by-side with communities to prevent pesticide exposure, support local farming, and build healthier communities.

 
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