HealthyCal.org

By Robert Phillips

Health isn’t just about the doctor’s office. For all of us, but especially for a young person, health begins in our community. That truth was echoed throughout a two-day national town hall in Los Angeles to address the health disparities facing boys and young men of color.

Community leaders and experts from across California and the nation convened because a growing body of research shows that the health of boys of color stems from their neighborhoods, their schools, their environments.

If you grow up in a neighborhood with a good school, where the streets are safe for kids to play outside and where there is access to good food, you are far more likely to have a good job, be stress-free and live a long and healthy life.

But if you grow up in a neighborhood where you’re not safe, where your school is failing you and where the nearest park or basic grocery store is miles away, your health suffers. If you are viewed as more of a problem than an asset to the point that you begin to see yourself that way, too, then research shows that you are far more likely to die younger, earn less money, experience violence and to be less healthy emotionally and physically.

In California, African-American, Latino, Southeast Asian and Native American youth are likely to face not just one of these challenges, but many or even all of them.

Researchers who spoke at the town hall conversation looked at how communities either foster or limit the life chances that young people have. Their research shows how communities can give you access to resources like transportation, good schools, parks, health services and jobs. But communities can also expose young people to stressors – like crime, environmental hazards, joblessness and inadequate housing.

In other words, in some places, there is real opportunity. In other places, opportunities are limited or non-existent. While these issues touch every part of our communities, they are particularly tough for boys and young men. This is because the bad policies and practices that institutionalize disadvantage disproportionately affect boys and young men of color.

Here’s one example: The state’s efforts to make schools and communities safer with “zero tolerance” policies have produced the exact opposite effect. Rather than making our schools better places to learn, boys and young men of color are more likely to do worse. Studies have linked suspensions to an increased likelihood that a young man of color will drop out, which means that he will find it harder to get a job, is more likely to be connected to crime and prison and is less likely to be connected to community.

Of course, we want our children to grow up with a strong sense of responsibility to themselves, their families and their communities. But that’s only one half of the equation. We must also take responsibility to protect them from harm and provide them with an open door to opportunity.

How do we do this? The first step is to recognize that place – homes, schools and neighborhoods — matters. The second is to change the policies and practices that shape place.

To do this, The California Endowment is supporting work in three communities – Oakland, Fresno and Los Angeles – to build the community leadership that is needed to overcome the challenges facing boys and young men of color. At the same time, we are supporting the work of advocates, organizers, public officials and researchers to promote policies and programs to change the systems that limit life opportunities.

We will measure our success at achieving four big goals, which we see as the strongest indicators of a healthy community. These include ensuring that everyone has a health home (or usual source of care); reducing childhood obesity; reducing youth violence; and improving school attendance.

Doing so will have positive implications for California and the nation.

The good news that emerged from the town hall is that we know how to keep a child in school; we know how to help a young man become a productive community member. According to the California Dropout Research Project, doubling high school graduation rates would drive down the number of juvenile crimes in California and save the state $550 million per year.

One outstanding question remained: Do we have the collective will to do what it takes?

We’ll only do this if we all band together – businesses and beat cops, social workers and social change organizations, politicians and philanthropists – to take responsibility to make our communities places that foster health, hope and opportunity for everyone.

Robert Phillips is the Director of Health and Human Services for The California Endowment.

By Randi Sokul, MD, MPH

As a medical student and now family physician resident at UC Davis, I’ve attended numerous medical conferences over the past several years, and the same theme keeps coming up over and over again: “We need to find a way to market and sell Primary Care!” “We need to make Primary Care sexy!” Much like Grey’s Anatomy has made surgery sexy, I’ve even heard proposals for a Primary Care or Family Medicine-based reality show.

Indeed, the need for primary care has never been more recognized. Current evidence suggests that health care systems that focus on primary care provide greater access to care, higher quality care, and do so at lower costs.

Yet there is a critical shortage of primary care doctors: According to the Association of American Medical Colleges (AAMC), the US is projected to have a shortage of approximately 21,000 primary care professionals in 2015 (and others have estimated shortages of 40,000 by 2025 given overall population growth and a growing elderly population).

This shortage is most likely to disproportionately affect vulnerable populations, like the elderly, those who rely on community health centers, and people in rural or poor urban communities who have traditionally been underserved. In California, the population of elderly is expected to increase by 112 percent over the next ten years. And 45 percent of rural Californians live in areas where there is a primary care shortage, making the need for primary care services particularly crucial.

While there is great need for expanding the primary care workforce in California, the time to ‘market’ primary care to future physicians is likely as ripe as it ever will be. With the Obama administration’s recent commitment of $168 million to create more residency slots to train more than 500 new primary care physicians during the next five years and an additional $5 million for states to expand their primary care workforces by 10 percent to 25 percent during the next 10 years, the financial barriers to workforce issues are for the first time being addressed.

Conversations about the importance of primary care are cropping up everywhere- from politicians’ platforms to mainstream media to the agenda of prominent health care organizations. In fact, the American Medical Association, which represents physicians of all specialties, stepped up to advocate that more medical students and residents choose a career in primary care. At the recent 2010 Annual meeting of the AMA House of Delegates in June, they announced their plans to promote training in the patient-centered medical home.

While the funding, the number of residency positions, and the lingo shockingly appear to be heading in the right direction for primary care for the first time, will all of this change the number of students who actually choose a career in primary care?

There are numerous ways that medical students, residents, and physicians can impact the pipeline that steers future physicians into a primary care career:

Before Medical School

Studies have consistently shown that this is the area offering the most bang for our buck. Those who enter medical school expressing an interest in primary care are highly likely to continue with this pursuit. And, those that come from rural or underserved backgrounds are most likely to practice in a rural or underserved area, where primary care physicians are needed the most. Those with strong community service backgrounds and low income expectations are also likely to choose a career in primary care.

So, how can primary care physicians aid in bringing these types of students into medical school?

-Early exposure. Medical students, residents, and primary care physicians should mentor pre-med students and even high school students; those civic minded individuals from rural or underserved backgrounds might not have considered that a career in medicine is even possible; with the right mentor, they just might!

-Primary care doctors should get involved in the selection committee that chooses who comes into medical school

During Medical School

Studies have shown that the first two years is critical (before students even start the wards). While many students consider primary care as a career choice early in their undergraduate experience, this number drops significantly during the second year of their curriculum. The most cited reasons by students for not choosing a career in family medicine in particular include prestige, income, and the breadth of knowledge required.

This is where exposure becomes critical and this is where we, as practicing residents and physicians, have the opportunity to make primary care truly sexy and sell it.

Exposure, exposure, exposure. Exposure to underserved populations, community health centers, families and communities and faculty involved in Family and Community Medicine is key. In fact, four new medical schools that have recently opened their doors (last fall) are embracing this philosophy.

Medical Students at the Commonwealth Medical College in Scranton, PA, are assigned a ‘continuity mentor’ (either a Family Practitioner or General Internist ) and a family that they follow through all four years of medical school, visiting their families’ homes to learn about the socioeconomic context of health care and the health care system.

Medical students at Florida International University are exposed to a team-based approach: they are partnered with nursing, social work, and public health students and visit households in medically undeserved, multicultural communities twice a month, working as a team to provide patient care. And FIU has even committed to having a 10:1 student to family medicine faculty member ratio, increasing medical school students’ exposure to family medicine and primary care.

Innovations in care delivery. The patient centered medical home is perhaps one of the most brilliant marketing tools at our fingertips. With its implications for improved quality and access to care and for restructuring physician reimbursement, it is the ‘buzz’ word we now hear even politicians and mainstream media using in the ongoing health care debate. And, family medicine and primary care is at the forefront of this conversation. It’s time we use the PCMH to our advantage and sell it to medical students who are excited to be involved in this cutting-edge model of care delivery.

Other avenues. With national organizations like the American Academy of Family Physicians (AAFP), Society of Teachers of Family Medicine (STFM), and the Robert Graham Center, students have opportunities to get involved in leadership, health care policy and advocacy, and research, advocating for their patients not only at the individual level but also at the policy level. Medical Schools and Residency programs should embrace students’ and residents’ interests and help design opportunities and tracks that appeal to those interested in primary care.

With fellowships in Obstetrics, Sports Medicine, Preventive Medicine, and Geriatrics, Family Medicine and primary care docs have opportunities to embrace areas they are particularly passionate about.

After Medical School

We must be advocates for policies that forgive student loans, offer scholarships to students, and reduce the salary gap between primary care doctors and specialty care doctors. Such methods include expanding the National Health Services Corps (NHSC) and advocating that public and private payers develop enhanced funding and related incentives that allow physicians to practice in rural and other underserved areas.

While the projected shortage of primary care physicians appears quite daunting, we are actually at a unique crossroads in health care reform history where the financial, political, and cultural winds of change favor primary care. We must help fuel the future direction of our physician workforce by working with high school students, giving students the opportunities to experience longitudinal care of families in a team-based community setting, exposing students to policy and advocacy, touting opportunities to master OB or be on the forefront of innovative models of care delivery.

Primary Care is indeed a sexy field. We must thus make efforts to sell it that way.

Randi Sokol, MD/MPH is a second year Resident at UC-Davis Family & Community Medicine Program. Her opinions expressed here are her own and do not represent UC Davis.

By Michael Bernick

Will hiring ever return in California?

That’s a question policymakers, job seekers and friends and relatives of job seekers are asking in the wake of the recent state unemployment numbers released a few weeks ago. Despite some attempts to put a positive spin on the numbers (the unemployment rate went down from 12.6% to 12.4%, the payroll jobs increased by 28,300) the numbers showed an economy that remains sluggish in terms of hiring.

The payroll job gain was the result entirely of additions in federal government employment, which were the temporary census jobs. Private sector jobs showed a net decline, as did jobs in state and local government.

Years after economic downturns, historians place the job declines and subsequent job growth in a narrative that neatly explains the reasons for and timing of the recovery. But during the time of the downturn, the depression or recession, job growth seems like it will never come.

Beginning in August 1981, the state unemployment rate climbed steadily from 7.4% to 11% by November 1982. This was the highest unemployment rate in several decades in California. At the time I was the director of a community job training group, the San Francisco Renaissance Center. Automation and technology were eliminating jobs, and manufacturing jobs in California were disappearing rapidly We saw job seekers every day, and wondered if the California economy of the future had a place for them.

In the early 1990s, the state unemployment rate again soared, driven by the aerospace and defense cuts. State unemployment grew from 7.1% in January 1991 to 9.9% by October 1992. By this time, I had left Renaissance, but was still involved in community job training as a volunteer.

Again, I recall a good deal of concern that California was encountering a new form of structural unemployment, and that the emerging economy had no place for many workers. There was a good deal of speculation at this time that we had to rethink our idea of work, including a book, The End of Work by Jeremy Rifkin, that attracted a lot of attention for its thesis that the concept of a job was becoming outdated.

Today, the conventional wisdom among economists is that the job hiring will be slow throughout the end of 2010, and likely the first quarter of 2011. Given no major economic changes, this is as good a projection as any. Each of the job numbers in California for the first 5 months of this year show private sector employers reluctant to take on additional workers.

But as anyone can testify who lived through the previous two major recessions in California, in the midst of the downturn, job prospects always look hopeless. It appears during the downturn that hiring will never return; until it does return.

Michael Bernick is the former director of the state Employment Development Department and a fellow at the Milken Institute. This piece first appeared on FoxandHoundsdaily.com.

By David Quackenbush

California has one week.

If the state budget is not passed by the constitutional deadline of June 15, health care providers like us will soon begin to experience a delay in payments.

The state has previously instituted payment delays in June for Medi-Cal providers, and with a budget delay, providers will realize additional delays in their payments for services they have already provided to low-income families enrolled in Medi-Cal.

Moreover, as California continues to suffer from economic crisis, our State Legislature must once again grapple with making tough decisions regarding cuts and possible elimination of meaningful health care and social service programs. Despite this annual exercise, it is critical to remember the dangers of yet another budget impasse and the direct impact it has on our state’s health care providers, who care for the most vulnerable populations.

There is little doubt that proposals such as the elimination of state’s only funding for uninsured families— the Expanded Access to Primary Care (EAPC) Program—will have a devastating effect on California’s communities. The absence of having a budget bill passed by the Legislature would exacerbate financial problems for institutional providers such as non-profit Federally Qualified Health Centers (FQHCs) due to delays in Medi-Cal payments. Those delays threaten the maintenance of services to a growing unemployed and uninsured patient population.

In recent years, these health centers have incurred millions of dollars in loans from delays of Medi-Cal payments, making it difficult to maintain hours of operation and the ability to retain doctors and other health professionals while sustaining the expected level of services for patients.

The majority of patients of FQHCs are enrolled in the Medi-Cal program. The Central Valley Health Network (CVHN) is made up of 130 FQHC sites that provide care to nearly 700,000 patients, of which 50 percent are covered through Medi-Cal and continue to receive services even when a budget impasse delays Medi-Cal payments for months.

However, the ability of these centers and clinics to withstand a continued series of deep budget cuts to health care programs and a possibility of another long drawn out budget impasse is unlikely as the centers are still trying to recover from previous budget cuts. Another budget impasse would create an environment that would almost make it impossible for FQHCs and other safety net providers to continue to meet the increased needs of the medically underserved and the over 4 million uninsured Californians who currently receive services.

Earlier this year as California struggled with decreased revenues, Congress passed and President Obama signed Health Care Reform into law through which millions more individuals will receive coverage through Medi-Cal and receive services at health centers. With additional strain on the fragile Medi-Cal Program, California must invest in the program and ensure predictable payments in order for the health centers to fulfill the expectations of both the Federal and State governments.

Governor Schwarzenegger recognized that delays in budgetary actions prove to be costly in his revised budget, issued May 14. Delays in adopting budget solutions before March 1, he said, led to the lost of $2.8 billion and the need for even deeper cuts to balance the budgetf $2.8 billion and necessitated deeper cuts.

Time is not on our side. If the Legislature and the governor do not act quickly, California will witness a devastating situation in an already fragile health care system.

David Quackenbush if chief executive officer of the Central Valley Health Network.