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Inaugural IssueCaliforniaHealthJuly 2012The (New)AffordableCare Actand YouThe Stork Returns!Home Birthson the RisePoor Patients =Long WaitsCan YouSee MeNow?Doctorson ScreenRePOrthealthycal.orgcommunity healer:Patricia Dennehy, NP

CaliforniaHealthRePOrtIssue #1 • July 2012 healthycal.org6environmentRace for abetter pesticideU.S. lags behind othernations in replacing soon-tobebanned chemicalBy robin urevich8agingGrandparentsturn to techNew software helps doctorskeep track of elders’ healthBy Matt Perry12Heath careCalifornians facemedical debtEven those with jobs andheath insurance find theysometimes can’t pay theirmedical billsBy Bridget Huber16HealthCare Reform:What does it meanfor you and yourfamily?How the Affordable Care Act—and the recent Supreme Courtruling —affects Californians.By Daniel WeintraubGot Docs?Poor patients face longwaits to see specialistsPage 23Departments4 Urban Farming • For people of color, city gardeningis a long-held tradtion.5 food deserts • Are more grocery stores really thesolution to high obesity rates among the poor?5 Work it out • Despite disparities in obesity rates,exercise programs aren’t tailored to people of color.8 Mobile Consulate • As the number of Mexicannationals in the Central Valley grows, so does the needfor services usually located in big cities. Enter the Movil!8 salt’s sneaking up on us • Most of our dailysodium intake comes from this diet staple.9 Can you see me now? • Telemedicine bringsdoctors to rural California.29Crime PolicyTraining teens totreat the sickA program gives young menin youth detention a chanceto become EMTsBy Callie shanafeltAct Fast!How to spot a strokePage 1014 NPs on the frontlines • Nurse practitionerPatricia Dennehy heads a clinic that’s pioneeringtreatment for the poor.27 The End of juvie? • California may start sendingall young offenders to county facilities.29 The stork returns • Home births are on the risein California. What’s behind the trend?31 Ditch the Car and start steering • Newrules let you have a say in planning communities.32 Sacramento focus • The California State Universitysystem is the engine of the state’s middle class.healthycal. org July 2012 California Health Report

Up Close : health briefstransforming careIn order to provide affordable, personalized, quality healthcare to all Californians, we must do nothing less than transformour current system into a true network of care – especially foruninsured and underinsured populations.That work is already underway – by Blue Shield of CaliforniaFoundation, our grantees, our partners, and others.Learn more about our vision and roadmap for achieving it at:www.blueshieldcafoundation.org2 California Health Report July 2012 healthycal. org

LETTER FROM THE EDITORWhat’s Next?What does the Affordable Care Act mean for you? Thatquestion confused most of us before the recent SupremeCourt ruling—but the picture is becoming much clearersince the June 28 decision. How will the law—and thecourt’s decision—change health care for Californians? In this inauguralissue of the California Health Report, HealthyCal.org and California HealthReport editor-in-chief, Daniel Weintraub, gives an in-depth look at how thehealth-care reform and the recent court rulingaffect us all (page 16).California has already started rolling outreforms, ahead of much of the nation. Theroad to reform has been bumpy so far, asRobin Urevich reports from Riverside County(page 23). Low-income patients enrolled inthe state’s new insurance program, an extensionof Medicaid, face long waits with potentiallyserious illnesses when they need carefrom a specialist. Their experiences beg thequestion—can more insurance really curethe health woes of the poor?In our profile, Patricia Dennehy tells writerRosa Ramirez that a lack of doctors doesn’tneed to hamper care for the poor (page 14). Dennehy is the director ofGlide Health Services in San Francisco’s Tenderloin District and a nursepractitioner. Glide is the only nurse-run health clinic on the West Coast,and Dennehy’s innovative approach to integrated, personalized care forthe poor is drawing national attention as the number of people with insuranceis expected to surge—and the number of primary-care physicianswill no longer be able to meet the demand.Also in this inaugural issue of California Health Report, you’ll find storieson the connection between obesity and grocery stores, the rise inhome births in California and the nation, and a program that trainsyoung people with juvenile offenses to work as EMTs.As news organizations across the nation shrink, HealthyCal.org continuesto produce comprehensive coverage of health and health policy inCalifornia, telling stories from communities that don’t always find aprominent place on the front pages of newspapers or the nightly news.We launched this magazine to create a platform for more in-depth reportingon the connection between place and health and the reasons behindthe health disparities that can be shockingly large from onecommunity to the next.Like what you see? Come over to our website, HealthyCal.org, whereexperienced reporters throughout the state cover stories that connect theCapitol, the community and the places in between.CaliforniaHealthRePOrtManaging EditorCalifornia Health ReportDaniel WeintraubEditor in ChiefHeather Tirado GilliganAssistant EditorCalifornia Health ReportNicole JonesJackie KrentzmanConsulting EditorCathy KrizikGraphic DesignerJudith DunhamCopyeditorAssociate EditorHealthyCal.orgReporter / EditorHealthyCal.orgContributing WritersHealthyCal.orgHelen AfrasiabiTodd R. BrownGenevieve BookwalterMelissa FloresMary FlynnRobert FultonHannah GuzikJulia LandauLynn MaddenClare NoonanMinerva PerezMatt PerryJessica PortnerSuzanne PotterRosa RamirezCallie ShanafeltRobin UrevichHealthyCal.org is an independent, non-profitjournalism project covering health and health policy inCalifornia, led by veteran journalist Daniel Weintraub.Heather Tirado GilliganManaging Editor, California Health ReportAssociate Editor, HealthyCal.orgCALIFORNIA HEALTH REPORThealthycal. org July 2012 California Health Report

Up CloseUrban Ag - Before It was HipWorking the tradition of urban farmingBy Rosa RamirezTexanita Bluitt has lemon, plum and orange treesbehind her house. In raised beds, she grows mustardgreens, cabbage, carrots, turnips, onions, celery andpotatoes. When Bluitt, age 62 and a native Texan,wants to make strawberry pie for her granddaughter, shedoesn’t head out to the grocery store—she simply goes to herbackyard.“About 95 percent of myfruits and vegetables comefrom my food garden,” saysBluitt, who lives in Richmond,Calif. People arecatching on to somethingthat she learned as a child:Eating what you grow isgood for your health. “Thetaste is different,” she says.The urban farming phenomenonhas taken root inempty lots, rooftops, hospitalsand culinary establishmentsacross the country. But somefood advocates fear themovement has failed to fullyintegrate people of color.“Communities and peopleof color, in some ways,are beginning to be shut outdue to the yuppification ofthis urban food movement,”says Gail P. Myers, an anthropologistwho hasworked extensively withblack farmers.Urban blacks, Latinos,Asians and immigrants havebeen planting vegetablesand fruits for years in bustlingcities like New YorkCity, Detroit, Atlanta and LosAngeles, more specifically inCrenshaw and Compton.“They did it out of the needto feed themselves,” saysRalph Paige, executive directorof the Federation ofSouthern Cooperatives.If there’s a perception thatAfrican Americans, Latinos,Asians and immigrants havebeen on the sidelines in thegrow-your-own-food-inthe-cityphenomenon, it’sbecause urban agriculture isbeing sold as a new trend,some food advocates say.Challenges like permitcosts make it difficult foryoung urbanites of color totake part in the movement,Myers says. Tensions can alsoarise between neighborswhen immigrants grow vegetablesin their front yardsor keep chickens and roostersin their backyards.Nonprofit groups with urbangardens need to make astrong effort not only to includepeople of color intheir food-growing programsbut also to trainthem to become leaders.“Make them feel they’reempowered—teach themthe gardening,” Myerssays. “It still feels like we’regiving folks the fish insteadof teaching folkshow to fish.”For Texanita Bluitt, growingfood is a way of life.“All I knew at one timewas raising your own andcooking your own. We hadour own chickens, turkeys,ducks and guineas,” Bluittsays. “And if my mom’sfowls were laying eggs, she’dmake us share with theneighbor.” CHRUrban farmer Texanita Bluitt shows offlemons and radishes from her backyard garden in Richmond.Rosa Ramirez4 California Health Report July 2012 healthycal. org

Up CloseAre food deserts a myth?Recent obesity studies question prevailing thinking on one cause of this deadly diseasethinstockphotosBy Heather GilliganIt’s no secret thatlow-income peopleand minorities havehigher rates of obesity.But new researchsuggests that health advocatesand policy-makers mayhave fundamentally misunderstoodthe reasons why.Expanding waistlines are anational problem, with aboutone-third of Americansweighing in with a BMI(body mass index) higherthan 30, the measure of obesity.People of color are particularlyprone to thiscondition—roughly 44 percentof African-Americansand 38 percent of Latinos areobese, compared to about 32percent of Whites.For a number of years, oneof the primary causes of obesityfor people of color andthose with low incomes hasbeen attributed to food deserts—low-incomecity neighborhoodswhere residents,mostly people of color, livewithout easy access to freshfruits and vegetables.As a result, national policy,including a campaignled by First Lady MichelleObama, has promotedopening more grocerystores in low-income areas.Tax breaks andfederal fundsnow encouragemore grocerystores inthese areas aspart of the nationalHealthy Food FinancingInitiative, aversion of which has alsobeen adopted in California.But a recent study of foodand diet in low-income cityneighborhoods, published inthe journal “Social Scienceand Medicine” yielded severalvery unexpected results.As expected, these neighborhoodshad higher concentrationsof fast-foodrestaurants and conveniencestores, says Helen Lee,the study’s author, asociologist and policyfellow at thePublic Policy Instituteof California.That, however, can bemisleading.“What they alsoseem to have greater orequal access to werelarge-scale grocerystores,” Lee says. “Now,that was surprising.”The study used aunique combinationof data—census tracts,information on allfood stores and a longitudinalsurvey of kid’shealth—in a sophisticatedanalysis of the relationshipbetween food availabilityand obesity.Overall, the picture thatemerged of low-income urbanareas was more consistentwith being a foodswamp—filled with conveniencestores, fast-food jointsand grocery stores—than afood desert, says Lee.Lee also looked for a connectionbetween the wealthof food on offer in theseneighborhoods and the increasedBMI among children.She didn’t find one.Fast food nearby didn’t increasekids’ BMIs, and grocerystores nearby didn’ttranslate into lower BMIs.“There was no impact,” Leesays. “What you have accessto in your neighborhooddoesn’t seem to matter.”Lee’s study is one of thefew national looks at the relationshipbetween food accessand obesity, but her findingsecho several earlier largestudies. These include a reportreleased by the U.S. Departmentof Agriculture incontinues next pageTailoring Workouts for People of ColorGetting a community to start exercisinginvolves a lot more than posting up fliers andhosting some aerobics classes.It takes community buy-in.A recent study from the University of Missourifound that exercise programs aimed atminority adults are doing some short-termgood, but most come across as culturallytone-deaf and are by and large failingto connect with the communities theyintend to help.Researchers analyzed 100 previousstudies that measured resultsfrom exercise programs lastingthree months on average and involving atotal 21,151 minority participants. Only a quarterof these programs delivered the interventionin a place considered culturally comfortable, suchas African-American or Latino churches. Evenfewer programs enlisted community members toassist with the fitness outreach.Overall minority adults are less physically activethan the general population, putting themat greater risk of developing diabetes, heart diseaseand other chronic illnesses, according tothe Department of Health & Human Services. Ifexercise programs are indeed trying to changethese downward health spirals within certaingroups, researchers say program organizersmust do a better job of recruiting people fromthese communities to help plan and lead the interventions.— By Julissa McKinnonhealthycal. org July 2012 California Health Report 5

Up CloseRace for a betterpesticideCalifornia searches for safer pest-reliefFirst Lady Michelle Obama at a Philadelphia grocery storecontiued form previous page2009, which also found thatlow-income city neighborhoodswere slightly morelikely than better-off neighborhoodsto have a grocerystore. In 2010, Mario Small,a sociologist at the Universityof Chicago, did an analysisof 331 American citieswith similar results—noshortage of grocery stores inlow-income neighborhoods.A study published in the“Archives of Internal Medicine”in 2011, which collected dataon more than 5,000 subjects infour cities over 15 years, alsofound no connection betweensupermarket availability andwhat people ate.What does affect a child’sweight, according to Lee’sstudy, is the amount of timespent watching television. “Ifthat increased over time,”she says, “that was a hugepredictor of obesity risk.”The other important influenceon BMI rates washow much activity kids getoutside school. Childrenwho play a sport or didother vigorous exercise thatraised their heart rate for 20minutes or more a day areless likely to become obese.The basic problem is easilyunderstood, Lee says. Americansare eating more caloriesthan they burn. The solutionmay also seem as simple asrighting that imbalance: Eatless or move more. But Leecautions that it’s not that easy.Everyone’s lives havechanged in ways that encouragean imbalance betweenwhat they eat andhow much energy they use.“People who have foughtagainst it may join a gym orwatch what they eat,” Leesays—but better-off peopleadopt those solutions moreoften.“That’s why the food desertidea became so popular,”she says. Not everyone hasthe leisure time to exercise,for instance, or to deconstructfood labels, or to cookat home. “That’s not doablefor a lot of people. Andthrough policy we shouldaddress that.”Getting people movingand eating healthful food is agood goal, but Lee says weare far from a solution to theobesity crisis.“It took 40 or 50 years forobesity to emerge as problemof big proportions,” Leesays. “There is no silver bullethere.” CHRBy Robin UrevichAcross California,researchers arelooking for newways to grow fruitsand vegetables without toxicchemicals. In test plots upand down the state, they’redeploying an arsenal that includesmustard seeds, ricebran and solar heat to zapweeds, soil pests and plantkillingdiseases.For example, ProfessorSteven Fennimore at theUniversity of California, Davis,is using steam and mustardseed meal in test bedson a wind-swept strawberryfield in Salinas. “Steam simplyis sterilization. It’s justcooking,” he says, “like cookinga turkey.” Heating the soilto 158 degrees Fahrenheit for20 minutes kills weeds andsoil diseases. Together withmustard seed meal, which releasesa natural fumigant,using heat has beenproven as effective aschemicals in trials.Most currentstudies—likeFennimore’s—are aimed atdevelopingalternativesto methylbromide, afumigantthat will becompletelyphasedout in2015 undertheMontrealProtocol because it has beenshown to deplete the Earth’sozone layer. With just a fewyears before methyl bromideis banned altogether, thesearch for alternatives hasgrown more urgent.Fennimore’s postdoctoralresearchers Jayesh Samtaniand Raquel Serohijosshowed off the clunky toolsthey use to conduct their potentiallypathbreaking trials:an ancient, red steamingmachine called the SiouxBoiler and the hollow eightinchspikes that drive steaminto the soil. The two do thehard labor of laying downthe spikes, which are fittedonto heavy canvas strips,and run the boiler overthem. Later, they blanket thesteamed ground with aheavy carpet pad to trap theheat.Strawberry farmer AbelCorona and his twobrothers plant,Official White House Photo by Lawrence Jackson6 California Health Report July 2012 healthycal. org

Up CloseAlternate MethodsThough agricultural giants in the U.S. havebeen slow to change how they controlpests, farmers across the world haveadopted alternatives to toxic fumigantssince the phase-out of methylbromide under the Montreal Protocol.Here are a few of the methods used onvarious crops in other countries.steamingflowers(Belgium, Netherlands)ornamentals(Netherlands)nurseries(Africa)tend and harvest the testplants, carefully weighing theberries so the researchers cancompare yields of naturallyand chemically fumigatedfruit. In return, the Coronasplant their crop on U.S. Departmentof Agriculture(USDA) land free of charge.But Corona is skeptical aboutusing soil steaming on a widescale. With current technology,it takes about three timesas long as chemical fumigationand gobbles copiousamounts of fuel and water inthe process.Environmentalists, however,who’ve long raisedworker safety and ecologicalconcerns about fumigants,and growers, who worryabout rising fumigant costsand dwindling supplies, arekeeping an eye on researchlike Fennimore’s. “Therehasn’t been anything that’scome close to the effectivenessof methyl bromide,”says Norm Groot of theMonterey County Farm Bureauin Salinas.Further intensifying thepursuit is the surprise decisionin March by the makerof methyl iodide, Arysta Lifescience,to pull the controversialsoil fumigant, whichhad been touted as an easymethyl bromide replacement,from the U.S. market.To spur the search for alternatives,the California StrawberryCommission offeredabout $1.5 million in researchgrants in the last three years.The USDA allocated $13 millionin 2011 for the study ofboth chemical and nonchemicalfumigants.solarizationgrowing in greenhouselikesettings known aspolyhouses(Turkey)anaerobicdisinfestationnurseries,strawberries,greenhousevegetables(Japan)Small farmers in the Imperialand Central valleys aresuccessfully sterilizing thesoil for planting spring lettucemixes, parsley, cilantroand other crops with solarheat captured by coveringthe ground with plastictarps, says Richard Molinar,a Fresno-based small-farmadviser for U.C. Davis.At U.C. Santa Cruz, researchersare raising strawberriesfumigant free bystarving thesoil ofbiofumigantslike goat, sheep and cow manure, organicmatter from rice, mushroom, olive, brassicaeand garden residuepeppers(Spain)substratesvegetables(Netherlands)tomatoes(Israel, Australia)strawberries(China, Italy,Netherlands,New Zealand,UK)oxygen. They mix in ricebran, a carbon source, thenirrigate the ground andcover it with an airtight tarp.Soil microbes multiply andfeed on the carbon, resultingin the release of naturalcompounds that are toxic tosoil pests.There may be other processesat play in so-calledanaerobic soil disinfestation,says Dr. Carol Shennan,who directs the study. “Wereally don’t know how itworks,” she says, but Dutchand Japanese growers use itsuccessfully.Despite the researchers’optimism and the smallscalesuccesses, notes theStrawberry Commission’sCarolyn O’Donnell, none ofthe methods are ready forwide use in conventional agriculture.“The goal is to haveas many options as possible,”says O’Donnell. “Itwon’t be a onesize fits all.”CHRgraftingonto diseaseresistantrootstockwatermelon(Israel, Spain)cherry tomatoes(Japan)pepper, melon,cucumber(Spain)tomatoes(Japan, Morocco, Spain)eggplant(Spain, Turkey)healthycal. org July 2012 California Health Report 7

Up CloseMobile Mexican ConsulateDo c u m e n t s t h a tmake everyday lifepossible for immigrantsin the United Statesrequire a trip to a Mexicanconsulate in a big city likeSacramento or Fresno—butdistance makes getting tothese and other consulateshard for many Mexican nationalsliving in California’srural Central ValleyEnter the ConsuladoMóvil, which allows officesof the Mexican Consulate tomeet people halfway. ThemobileNew tech links older adults to careGrandma just sent her first e-mail.Tonight, she’ll log in to see the latest pictures ofher grandkids. And her doctors and childrencan monitor her health from around the worldat any time.Armed with mounting research linking socialisolation to illness, technology firms are marketingelectronic solutions aimed at older adults insenior living facilities.Larger graphics and other innovations makeit easier for elders to interact online, improvingtheir access to cyberspace.“The elderly have no problem with technology,”says Kian Saneii, CEO of San DiegobasedIndependa, an eCarecompany. “They have a problemwith poor design.”Some software allows elders tosee reminders when they log onoffice issues matrícula cards,the official consulate ID forMexicans living abroad.More than 200 peoplewaited in line, and 300 morehad appointments scheduledat a recent Móvil visit to ahousing project in Planada,an unincorporated town inMerced County, an houraway from the consulate.“People come to expect us tocome here,” said Press ConsulLluvia Ponce. “We arevery aware of the effort [ittakes] to go to Fresno.”AnaLaura NavaretteRamirez, 30, had made thetrip to Fresno before.Ramirez, originally fromMichoacán, was waitingfor her husband’sappointment toend. Her husbandwouldhave to takeoff a day ofwork if they go to Fresno,but with Móvil he only hadto take off half a day. “If theyask for another document,it’s easier for us to go back toMerced to find it,” she said.Because the Móvil computersare connected toMexican consulate databases,a matrícula card, usedas an identification card, canbe issued in just 20 minutes.Although useful in transactionslike opening a bankaccount, the card is neither adriver’s license nor a migrationdocument.The need for consulatevisits is expanding as thenumber of people of Mexicanorigin living in Californiaincreases. About 1.8million reside in countiesserved by the Fresno consulate,and about 1 million livein counties served by theSacramento office.— Minerva Perezto the Internet. Computer-illiterate seniors canopt to input health information with a phonecall instead.Results are recorded online, where doctors,family members and caregivers can track them.While the solutions are digital, the benefitsfor older adults and their caregivers are intenselypersonal.“It’s providing care like we used to do, whenwe lived next door to one another,” says HarryBailes, CEO of Family Health Network, a softwarecompany based in North Carolina.— Matt PerrySneakySodiumAbout 90 percent ofAmericans are overloadingon sodium—butdon’t blame your saltshaker.Sodium is creeping into ourdiets one bite at a time throughfoods that are a part of ourregular diet—bread, meats,pizza and poultry—according toa recent report released fromthe Centers for Disease Controland Prevention (CDC).Though a single serving ofbread is not especially high in sodium,it ranks as the top sourcein the United States because ofhow much we consume, says theCDC.Store-bought meats, the nation’ssecond largest source ofsodium, are commonly injectedwith a sodium solution—a preservativethat also gives meat aplumper, fresher look.Substituting fresh fruits andvegetables for these sodium culprits,the CDC says, is one of theeasiest ways to shed sodium.Americans on average eatabout 3,300 mg of sodium aday, far exceeding the government’srecommended daily intakeof 2,300 mg. Because 65percent of sodium in the U.S.diet comes from grocery storeproducts, the CDC recommendsshopping for low-sodium choicesor brands.— Julissa McKinnonthinstockphotos8 California Health Report July 2012 healthycal. org

Up ClosethinstockphotosThe doctor will see you now, on-screenTelemedicine brings pediatricspecialists to rural CaliforniaBy Heather GilliganGrace Lee, five weeks old, swaddledin a pink-striped blanket, dozes inher mother’s arms in a room at ahospital in Redding. The baby failedtwo hearing tests in her first two days of life,and a follow-up exam a week later suggestedtrouble in one ear.Evaluating her hearing loss within the firstthree months of her life was essential. If follow-uptests indicated a permanentproblem, she’d need to be fittedwith a hearing aidto have the best chanceof developing unimpairedspeech and otherimportant skills later in life.Grace needed a pediatricaudiologist to do the tests.But her family lives in thewide swath of Californianorth of Sacramento, wherepediatric audiologists—andpediatric specialists generally—arehard to find.So instead of being examinedin her room at MercyMedical Center in Redding,Grace was beamed into anoffice at U.C. Davis MedicalCenter in Sacramento viavideoconferencing.University of California,Davis, has a well-establishedtelemedicine program,where specialistsconsult with doctors in remoteor underserved locations.The numbers suggestthat the need for specialiststo test kids’ hearing is acutein the far north of California.Depending on the year,between 20 and 40 percentof children in that regionwho don’t pass the newbornscreen don’t return for follow-uptests and treatment,according to Anne Simon,pediatric audiologist at U.C.Davis Medical Center.The pediatric audiologytelemedicine program hasseen all of its patients thisyear remotely, but the visitswent far beyond the typicalconsult. Simon wasn’t givingadvice—she was performingtests herself.Technicians Dawn Deinesand Debbie Nickell in Reddingact as Simon’s hands,attaching electrodes toGrace’s head and inserting aprobe into her ear as shesleeps on her mother’s lap.Data from the probes andwires streams to Simon’slaptop screen.“It doesn’t hurt,” Simonassures Jessica, Grace’smother, as Deines andNickell gently scrub the baby’sscalp before attachingthe electrode.The setup has its challenges.Simple tests areharder over a video monitor.A basic examination of theexterior of Grace’s ear tookseveral readjustments of thedigital camera, and Simonstill couldn’t get as good alook as she’d like. Seeing insidea baby’s ear with anotoscope is harder over avideo feed too, Simon says.“Audiologists by natureare very controlling,” Simonsays. “It’s a little tiny babyand I want it to be doneright.”Comforting the parents isanother part of the jobthat’s harder to do overvideo. “It’s really importantthat mom knows she has awonderful baby,” Simonsays, “no matter how thetest goes.”Although the distancemakes the exam more challengingfor the audiologist,the telecommute makes lifemuch easier for parents wholive in the farnorth of California.Adrive of sevenhours roundtripwith aninfant to seean audiologist—whichfor many familieswould alsomean an overnightstay anda day or two offwork—madethe follow-upappointmentdaunting.“It’s just difficultfor them to have todrive three or four hours tosee an audiologist,” saysJames Marcin, professorof pediatric critical caremedicine and director ofthe U.C. Davis HealthSystem Pediatric TelemedicineProgram.Rural areas can’t typicallysupport specialized careproviders like Simon, andthe costs of missing thewindow for early interventionare huge—for hearingimpairedchildren, theirfamilies and taxpayers. “Foreach kid that you are able tointervene in early, you willsave $1.4 million in lostwages, and health effectslike anxiety, depression, diabetesand heart disease,”Marcin says. “Our goal is tomiss no one.”The pediatric telemedicineprogram, funded bystate and federal grants andfree to patients, expects tosee 60 babies for hearingevaluations this year. CHRhealthycal. org July 2012 California Health Report 9

Living WellAct FastNew methods help California counties improve stroke responseBy Callie ShanafeltSeventy-five-year-old LeighWeimers realized his left armwasn’t working when he tried topull his Costco card out of hisback pocket. Luckily, he also had anothercard that helped him understand whatwas happening to him—one from theStroke Awareness Foundation, which hepicked up at a Rotary Club meeting.Weimers knew that his numb arm was asign of a stroke, so he asked his wife totake him to the hospital.The moment he walked into the KaiserPermanente Santa Clara MedicalCenter and said he was having a stroke,the staff scanned his brain. They quicklylearned that Weimers was right. A poolof blood was building up in his head.They immediately started treatment.Now, less than a year later, Weimers iscompletely recovered, with no debilitatingeffects.In large part, his happy ending is dueto the fact that he suffered his stroke inSanta Clara County—the first county inCalifornia to coordinate stroke identificationand treatment efforts.Stroke is the leading cause of longtermdisability in California and the thirdleading cause of death. Many gains havebeen made in the outcome of strokes inthe past decade, with new methods oftreatment and identification. But in orderfor treatment to save lives and preventdisability, it is crucial that patients get toa stroke center within three hours.“Time is brain,” says Dr. Lilly Chaputof the California Department of PublicHealth (CDPH).To improve stroke survival and lessenbrain damage, CDPH is coordinating aneffort to standardize stroke treatment inall 32 Emergency Medical Services(EMS) regions.The first step is for hospitals to getstroke certified. This means that theyhave 24/7 access to some kind of imagingsystem like a CT scan or an MRI toidentify if a patient is having a strokeand what kind.When a stroke occurs, the brain isn’tgetting enough blood. For most strokes(87 percent), this happens when there isa clot in an artery (ischemic stroke). Theless common type (hemorrhagic stroke)results when a blood vessel in the brainruptures, as in Leigh Weimers’s case.A drug called tissue plasminogen activator(tPA) was released in the 1990s. Ifdelivered within three hours of an ischemicstroke, tPA can bust a blood clotwithout invasive surgery, according tothe U.S. Food and Drug Administration.Some hospitals have found that the drugthinstockphotos10 California Health Report July 2012 healthycal. org

Living WellCovered — With BillsStruggling with medical debt?You’re not alone. Even many insured can’t pay the billsBy Bridget HuberWhen Mary Snyder losther job as a loan servicerin 2010, her and her husband’shealth insurancewent with it. The Ramona couple hadgotten coverage through Synder’s jobsfor the 32 years that she worked in thestudent financial aid industry, since herhusband, James, is self-employed as ageneral contractor.James started having chest pain notlong after the couple lost their coverage.He refused to see a doctor for twomonths because he didn’t want to runup medical bills. When the pain finallybecame severe enough to send him tourgent care he learned his left coronaryartery—called the “widowmaker” —was95 percent blocked. Three days later,James left the hospital with four stentsand $115,000 in medical bills.With that, the Snyders joined thegrowing ranks of Californians who are inmedical debt. A recent study by the UCLACenter for Health Policy Research found2.5 million Californians had medical debtin 2009. The number grew by 400,000 between2007 and 2009 as the Great Recessionwashed over California, taking awayjobs with benefits and prompting cuts tohealthcare for the poor.The study showed a clear link betweenlack of insurance and unpaidmedical bills. About 23 percent of peoplewho were uninsured for part of the yearhad medical debt, along with 18.4 percentof people with no coverage at all.About seven million Californianswere uninsured in 2009, says Shana AlexLavarreda, lead author of the study.Things probably haven’t gotten muchbetter since then because many of thejobs with benefits that were lost haven’tbeen replaced, she said. The initialphases of healthcare reform have expandedcoverage for some Californiansbut they’ve made barely a dent in theproblem. “These gains are significant, butwhen you’re looking at a starting placethinstockphotos12 California Health Report July 2012 healthycal. org

Living Wellnine percent of californians withjob-based coverage had medical debt.of covering seven million people, youneed to make very significant gains tosee an impact,” says Lavarreda.Surprisingly, the study found nearly afifth of adults enrolled in Medi-Cal, thestate program intended to provide comprehensivehealthcare to the poor, hadmedical debt. This was likely caused by2009 cuts that eliminatedservices such as dentistry,podiatry and psychiatryfor adult enrollees. “Peoplestill needed that care, butnow they had to pay for it.And because they’re of suchlow income they had to go intodebt.” Lavarreda says.But even Californians insured throughtheir employers aren’t immune to medicaldebt because that coverage can beincomplete and deductibles can be high.The study found 9.1 percent of peoplewith job-based coverage had medicaldebt. Jared Smith, a physicians’ assistantwho became quadriplegic in 2010, hadexcellent insurance through his pharmacistwife’s employer, Costco. But whenshe went down to part time after thebirth of their second son, his coverageceiling dropped from $2 million to $1million. That sounds like an enormoussum, but Smith reached the limit on hisfourth day of spinal rehabilitation. Hewas supposed to spend four months inrehabilitation, but left after less than amonth because of costs. Even still, he accrued$1.2 million in bills during thatperiod.About half of the Californians who reportedmedical debt don’t owe thousandsor millions of dollars, but less than $2000,a sum that can easily accumulate with adeductible, and a handful of doctors visitsand prescriptions. Lavarreda says the factthat people struggle to pay off even theserelatively minor amounts is indicative ofthe “thin margins” people are living on inthis economy.Experts say the Affordable Care Actwill significantly reduce the number ofpeople in debt when it takes full effect in2014 because it will dramatically expandhealth coverage and require non-profithospitals to offer more charity care. Still,Lavarreda says the problem won’t goaway entirely because some people willstill struggle to afford deductibles or copaysor will remain uninsured.Mary Snyder was able toreduce her husband’smedical bills to $30,000by negotiating withthe hospital andother care providers for lower prices. Todo so, she asked for discounts, paymentplans and invoked AB 774, the Californialaw that prohibits hospitals from charginglow-income and moderate-incomepeople more than they charge government-sponsoredprograms such asMedi-Cal.The Snyders paid down their medicalbills due in large part to contributionsfrom a church-based network, but theystill owe $19,000 to the hospital andhave only a year to pay it off before thebill is sent to collections. “We don’t knowhow things are going to move forwardfor us, financially,” Snyder says, “It’s stilla strain.” CHRManage your medical debtHealth crises don’t have to cause financial ruin. Medical debt can often bereduced to more manageable levels, though it can be an arduous process. Expertsrecommend the following steps:123See4Seek5If6Appeal7SeekFind out whether the bill is accurate. Were you charged for services thatweren’t provided? Did your insurance company refuse to cover things that itshould have?Don’t pay the sticker price. Hospitals often charge the uninsured individualshigher fees than they do insurance companies or Medi-Cal. But it’s illegal to doso for low and moderate income Californians, and even those with higher incomescan get their bills reduced. Groups like Health Access (www.health-access.org)can help you learn your rights.if you’re eligible for retroactive Medi-Cal benefits, which can cover costs incurredprior to enrollment.financial assistance. Many hospitals and medical providers have charitycare programs.you can’t get debts discharged, ask for a payment plan, preferably one thatdoes not charge interest or inflict huge penalties for missed payments. Ask providersnot to report you to the credit bureau while you are making payments.to foundations and your social networks. Some charities cover medicalexpenses related to certain illnesses and conditions and websites such as Redding-basedyoucaring.com are a platform for raising funds.expert financial advice to manage your debt and avoid taking out secondmortgages or paying for medical bills with credit cards.For more information:www.health-access.orgwww.healthconsumer.orgwww.familiesusa.org/assets/pdfs/medical-debt-fact-sheet.pdfhealthycal. org July 2012 California Health Report 13

Community HealersReinventing Primary CarePatricia Dennehy, Nurse Warrior for the UninsuredBy Rosa RamirezHeather GilliganGlide, situated in the heart ofSan Francisco’s gritty Tenderloinneighborhood, is a havenfor the homeless.Outside the shelter’s door, though it isjust before noon, a group of men andwomen line up to wait for a bed for thenight or a hot meal. Some push shoppingcarts packed with their belongingsand hold tattered blankets, neatly rolledup. They press their backs against thewall as they try to shield themselvesfrom the gushing rain shower soakingthe street.Hints of the state-of-the-art healthcenter on the top floors of the onetimehotel start inside the lobby, in the formof posters and flyers announcing servicesranging from free HIV testing to tai chiclasses.Patricia Dennehy, the director of GlideHealth Services, has learned that lowincomepatients make better health decisionswhen providers focus on the entireperson, not just the illness that landedthem in the examining room. Challengessuch as poverty, inadequate housing andunemployment can eventually wreakhavoc on people’s health. “We can’t takecare of a complex person, who has hadvery little care for their whole lives, in a10-minute visit,” says Dennehy.Instead, Dennehy likes to say, theGlide clinic meets patients exactly wherethey are in life. With the right kind ofsupport, she says, even the longest-sufferingclients can make positive changesto improve their health.And that’s something that nurse practitionerslike Dennehy are uniquely positionedto do. Dennehy’s career hastaken her from working as a hospitalnurse to managing Glide, the largestnurse-practitioner health center on theWest Coast, and one that’s considered amodel for serving the poor.“We see this nurse-practitioner modelnot as being the only solution,” she says,Clockwise from top: Patricia Dennehy in Glide’s wellness center, talking with Karla Ballesteros,N.P., Glide’s waiting room.“but as being a great part of what we cando to answer the fact that the uninsureddon’t have primary-care access.”Nurse practitioners have advancedacademic degrees, such as a masters ordoctorate, as well as additional training,and are held to the same ethical standardsas physicians. There are nearly11,000 nurse practitioners in California,and 6,877 nurse practitioners licensed toprescribe medications, according to theCalifornia Association for Nurse Practitioners.Ninety percent of them alreadyprovide primary care.“We know we do not have enoughprimary-care physicians, and trainingprograms can’t fit the need,” says Dennehy.Nurses, she thinks, can help fillthat void.Studies have shown that nurse-run14 California Health Report July 2012 healthycal. org

Community Healersclinics reduce the cost of providing preventivehealth care. That’s mainly becauseof salary differences. Patientshave the same health outcomes whenthey’re treated by nurse practitioners aswhen they’re treated by physicians, accordingto a 2007 study titled Substitutionof Doctors by Nurses in PrimaryCare. What’s more, patient satisfactionwas higher when nurses provided thefirst contact during urgent care. Onelikely reason for this finding is thatnurses tend to give more information topatients and spend more time withthem during visits.Earlier this year, the James Irvine Foundationawarded Dennehy the 2012 LeadershipAward for tackling one ofCalifornia’s most pervasive challenges—delivering quality health care to poor communities.She won recognition for taking aholistic approach to providing care givenentirely by nurse practitioners. The prizecomes with $125,000 for the clinic.“Folks are thinking about the role ofhealth-care reform and how that may beimplemented in California,” says AmyDominguez-Arms, program director atthe Irvine Foundation. “By highlighting[leaders], others can learn from the policymaking and programs.”Holistic ApproachOn a recent afternoon, Dennehy walksacross the top floor of the health center.The room, which is being renovated, isbright, with fresh paint and large windows.People use it for Glide’s manygroup sessions on domestic violence,stress reduction and group therapy.Dennehy points to private rooms alongone wall, where clients in these groupscan speak privately to a counselor. Examrooms, a lab and rooms dedicated tomental health services are just below onthe fifth floor, all part of Glide’s model ofcomprehensive care.Glide, a federally qualified health center,is one of 250 nurse-managed healthclinics in the country. They integrate primarycare, such as immunizations andhealth screenings, with services like psychotherapy,medication management forchronic pain and urgent care.“Community health is the most excitingplace to be, because this is where youcan make your greatest impact,” Dennehysays, “working with families and communitiesto improve health and to feel caredfor and empowered.”Dennehy says she hopes Californiaputs more emphasis on preventive careGlide’s nursing model is personal.“It’s not the diabetic in roomseven. It’s Mary.”and extends medical benefits to includeadults who can’t afford individual healthinsurance.“There are very exciting opportunitiesfor people to work together with hospitalsand other institutions of care tomake sure we just do what we do better,”she says.Glide clients are screened for depressionand substance abuse, and are askedif they smoke—all during a regularvisit—so the conversations become partof a long-term dialogue that nurses havewith their patients. Health issues aren’tcompartmentalized.“Our nursing model is one that putsthe person at the center,” Dennehy says.“It’s not the person with hypertension ordiabetes. It’s not the diabetic in roomseven. It’s Mary who’s in room seven.Mary may have diabetes and hypertension.She may also be a smoker. She mayneed assistance with housing. She mayhave relapsed in her alcohol use.”“We treat the whole person,” Dennehyemphasizes.Dennehy makes this approach clear asshe walks through the clinic, a soothingspace of light colors and blond wood. Inthe waiting room, a man who appears tobe around 50 years old has his eyes gluedon the large flat-screen television. Flashingacross the screen isn’t a movie, Dennehynotes, but a PBS video about healthdisparities, just one way the clinic integrateseducation, compassion and patientempowerment into the work it does.Mentors MatterDennehy stops frequently to point outthe accomplishments of other nurses atGlide, as well as mention student nurseswho have moved on to work in otherclinics. Elizabeth Goldstein is part of theclinic’s residency program, which startedthis year and gives additional training andmentorship to nurse practitioners (NPs)who work with high-risk populations.As nurse-led clinics catch on, residencyprograms like this one will helpclear any doubts people may have aboutthe level of training that NPs receive.Dennehy was instrumental in bringingthe residency program to Glide.Goldstein, who had done six volunteerrotations at Glide, says her work at theclinic inspired her to change her careerfrom architecture to health care. “I have somuch to learn from the nurse practitionershere,” she says. “There’s an unbelievableamount of mentorship here.”In the center of it is Dennehy’s vision,Goldstein adds. “She doesn’t say much,but when she opens her mouth, everybodylistens. I just admire Patty tremendously.She’s a great role model for me.”Advocating for DignityFor the past two months, the health centerhas accepted only new patients comingfrom emergency care at Saint FrancisMemorial Hospital and Dignity Healthto receive follow-up primary care. Theclinic’s needs are greater than its resources.The lines for the food kitchenand the beds wrap around the block.“We can’t see everyone who comes,”Dennehy says.Still, Dennehy says, Glide’s social justicemission continues.“What we do is continue to advocate,to have a voice in many circles about theneeds and about the need to expandcare,” she says with a measured acceptanceof the limits of what one nurse’sclinic can accomplish. “That’s part of ourwork.” CHRhealthycal. org July 2012 California Health Report 15

Health CareThe new Affordable Care Act willbe a boon for California residentsByDanielWeintraubCalifornia has led the nation in implementingthe federal health reform knownas the Affordable Care Act (ACA). Andnow that the U.S. Supreme Court hasruled that the law is constitutional, thestate hopes to be a model showing the restof the nation how to make the law work.California already has in place what will become the centerpieceof the law—a Health Benefit Exchange—and the exchangeis moving toward opening shop to the public by October ofnext year. California has also passed several laws mirroring,and in some cases going beyond, what the federal lawrequires. And there is more to come.The litigation that ended in the Supreme Court in JuneHealthReformTimeline1930sFederal health insuranceprogram considered as part ofNew Deal, but tabled amidfears it might sink unemploymentand retirement benefits.1940sEmployee-sponsoredhealth insurance begins inearnest in WWII, as employersentice workerswith benefits.Information provided by Kaiser Family Foundation reports.1944President Roosevelt outlineseconomic bill ofrights that includes accessto health care in State ofthe Union address.16 California Health Report July 2012 healthycal. org

For Allthinstockphotosfocused on the individualmandate—a requirementthat nearly every American havehealth insurance. But the mandate isonly a small piece of the sprawling,2,700-page statute. The rest of thelaw expands access to insurance,offers subsidies to those who cannotafford it, provides new consumerprotections, and boostsprevention efforts by giving grantsto communities to make neighborhoodshealthier for the peoplewho live there.1946President Trumanproposes NationalHealth Insurance; bills toenact plan fail inCongress.1954President Eisenhowerproposes federal insurancefund to enable privateinsurance companies tocover more people.1956Government provideshealth insurance todependents of peopleserving in the military.1960Federal employees gethealth insurance throughthe government.healthycal. org July 2012 California Health Report 17

Health Care For AllWhen fully implemented in about 2016, the law is expectedto provide coverage to as many as 6 million Californians whodon’t have it now, with about 2 million of those people gettingcoverage through the government Medi-Cal program and therest eligible to buy it through the Health Benefit Exchange,which will largely operate online but will also have staff to assistthe public over the phone and in person.Peter Lee, the exchange’s executive director, says the SupremeCourt’s action was “a great day” for Californians and allAmericans.“It means we as a nation can continue our work to expandaccess to affordable health care to all,” he says. “We’re movingfull speed ahead.”Here, now, is an overview of the key provisions of the ACA,and how it will impact you and your family.Lifetime LimitsFor Julie Walters and her family, federal health reform ismore than just the hottest topic in the presidential campaign.Violet, Walters’ daughter, was born with a rare geneticdisease that causes a severe form of epilepsy. She has had hundredsof seizures, forcing her to spend weeks at a time in ahospital intensive care unit. Each episode carries a bill of abouta quarter-million dollars.Fortunately for the Walters family, an already enacted provisionof the ACA ended the practice of health insurance companiesplacing lifetime limits on benefits extended to patients likeViolet. Without that provision, the Walters would soon be approachingthe cap on the family’s policy, and Violet would loseher coverage. Without that coverage, keeping Violet healthywould mean financial ruin for the family, if they could find carefor her at all.“We’re not bankrupt today because of it,” Walters says of thefederal health reform. “Our daughter is alive because of it.”Walters says her family’s story should be a lesson for all Californians.Nobody, she says, could afford to pay for the kind ofmedical care her daughter’s condition requires.“It can happen to anyone, anytime, and people don’t realizethat,” she says. “People think, ‘Oh, I could pay for myself.’ Butwhen you look at the bills, they would bankrupt anyone. Peoplewant to be responsible for themselves. They say, ‘I’ll save enoughmoney for emergencies.’ But these are astronomical costs thatmost Americans can’t pay for.”Annual Spending CapsThe provision that helps the Walters family keep their insuranceeven as their daughter racks up millions of dollars inhealth-care costs is just one of many consumer protections thatare part of the Affordable Care Act.Another, related provision is already phasing out the annualcaps on how much an insurance company will spend on eachcustomer’s care.The law requires that those annual spending caps be set atno less than $750,000 for policies sold on or after Sept. 23, 2010,and $1.25 million for policies sold on or after Sept. 23, 2011. Theminimum allowable limit will rise to $2 million on Sept. 23 ofthis year and, as of Jan. 1, 2014, no annual limits will be allowed.Individual MandateThe most controversial piece of the law—a requirementthat most individuals have health insurance—was the focusof the Supreme Court decision in June.The mandate is a crucial part of the law. Without it, mostexperts agree, it would be difficult to retain one of the law’smost popular pieces: a prohibition on insurance companies denyingcoverage to people who have pre-existing medical conditions.The two rules go together, because if people are allowedto get insurance even if they are sick but are not required to buyit in advance, many people would simply forgo coverage untilthey need it. It would be the equivalent of letting people buyhome insurance while their house is on fire or automobile insuranceafter they have been in an accident.In health insurance, that would likely mean the pool of peoplewith insurance would be increasingly weighted towardthose who are sick and needing benefits, driving up the cost ofcoverage even more for those who remain in the pool. In aworst-case scenario, this could cause a spiral of people droppingcoverage, driving the prices ever higher until the entire systemcollapses.1965Medicare and Medicaidsigned into law as part ofthe Great Society reformsunder President Johnson.1970sHealth care reforms stalledin the midst of recessionand ongoing inflation—including rising health carecosts.1980sHealth care costscontinue to escalate.1986Emergency Medical Treatment andActive Labor Act (EMTALA)requires all hospitals that participatein Medicare to screen andstabilize people seeking treatmentin ER, regardless of ability to pay.18 California Health Report July 2012 healthycal. org

Health Care For AllUnder the new law, starting in 2014, those who forgo coveragewill face a financial penalty collected at the time they paytheir taxes. The penalty will be 2.5 percent of a family’s householdincome, with a maximum of $2,085 when the law takes fulleffect in 2016. There will be many exemptions, however, includingfor those who owe no income taxes and those for whom theleast expensive coverage available costs more than 8 percent oftheir income.Although the penalty is far less, in most cases, than the costof coverage, officials expect most people to comply becausethere will be a “culture of coverage” in which people are expectedto have insurance. Furthermore, since most people wantinsurance, experts believe more people will buy it once it becomesmore affordable, thanks to federal subsidies and newregulations that will limit how much insurance companies cancharge sick and older people for coverage.Adult ChildrenAnother provision of the new law that has already takeneffect: Adult children can now remain on their parents’policy until age 26. This applies to children even if they are notin college, if they are married, even if they move to anotherstate. The only exception is if the child works for an employerthat offers health benefits.The provision prohibiting insurance companies from denyingpeople coverage based on pre-existing conditions isscheduled to take full effect in2014. This rule will fundamentallychange the nature of the insurance industry, especiallythe market for what are known as “individual policies,”coverage that people purchase outside a group, typically groupsof employees working for one company.Universal CoverageCurrently, insurers spend millions of dollars and hugeamounts of time on what is known in the trade as “medicalunderwriting”—making an educated guess about the amountof risk each potential customer brings along with his or herpremiums. Insurance companies ask consumers to completedetailed applications disclosing every possible health issue intheir past. If anything looks amiss, the insurer will deny coverage,or the company will follow up with a telephone interviewseeking even more details. The company’s analysts will thendetermine the odds that the customer will pay enough in premiumsto cover the insurer’s costs. If those odds are too long,the application will be denied. And in some cases, even after anapplication is accepted and a customer needs benefits, insurancecompanies have reopened their background investigationsand kicked the customer off the coverage for allegedly omittingrelevant details in the applications. In other words, the peoplethinstockphotosPre existing Conditions1993President Clinton proposes theHealth Security Act, includinguniversal coverage andmanaged competition betweeninsurance companies, whereAmericans would have “healthsecurity cards.”1993Legislation for the HealthSecurity Act introducedin Congress, where itfails, as does othercompromise legislation.1996The Health Insurance Portabilityand Accountability Act(HIPPA) passes, restrictinguse of pre-existing conditionsin determining eligibilityfor insurance.199742.4 million, or 15.7percent of Americansare uninsured.healthycal. org July 2012 California Health Report 19

Health Care For Allwho need insurancethe most are the leastlikely to get it, or keep it.That will all change under theAffordable Care Act, because the law requiresthat insurance companies sell coverage toeveryone who applies for it and prohibits insurers fromcharging more to people who have been sick.High-Risk PoolAlready, the law prohibits insurance companies from denyingcoverage to children through the age of 18 who havepre-existing conditions. The Affordable Care Act extends thesame guarantee of coverage to adults beginning Jan. 1, 2014. Inthe meantime, California has received hundreds of millions ofdollars from the federal government to expand a state-run insurancepool for people who have been turned down by privateinsurers and gone at least six months without coverage. About8,600 Californians are now getting their coverage through thisprogram, which will end once the law requires insurance companiesto accept all applicants.Community RatingAnother important reform scheduled to take effect in 2014is community rating—a policy that limits how much moreinsurance companies can charge people they consider to be abigger risk. Currently in California’s individual market, insurerscan and do charge significantly more for people who have beensick, if they cover them at all. They also charge more for olderpeople even if they have a spotless health history, on the theorythat older people are more likely to need health care thanyounger people. In some states, though not in California, insurersare also allowed to charge women more than men becausewomen, generally, use more health services.This kind of pricing will be limited under the Affordable CareAct. Starting in 2014, insurers will be prohibited fromcharging you more if you have a medical history theydon’t like. They will be allowed to charge differentrates in different geographic areas, because thecost of care varies by region, but those premiumdifferences will be regulated by the state. Companieswill also be able to charge more for olderpeople, but rates for older people will not beallowed to rise to more than three times whatinsurers charge younger people. The only other permissibledifference in rates will be for tobacco use. Smokers andother users of tobacco will be charged up to 1.5 times the premiumspaid by nonsmokers.Low-Income Health PlansThe Affordable Care Act expands coverage to the uninsuredin two significant ways. For the lowest-income people, thelaw provides funding to the states to expand eligibility for Medicaid,known as Medi-Cal in California.In California, the expansion of Medi-Cal is expected to bringmore than 2 million people into the fold. Today, the programexcludes many adults without dependent children, regardless ofhow low their income is. Low-income people are also excludedfrom coverage if they have assets that exceed a certain level.Starting in 2014, these people will be eligible for Medi-Cal, withthe federal government paying almost all of the cost of theircare. But in California, some of them are already getting benefitsunder what is known as the “Bridge to Reform.”This program funds an expansion of coverage for low-incomepeople in almost all of California’s counties. Already, about300,000 people have been accepted into the county programs.Under the Bridge to Reform program, to get funding from thefederal government to expand coverage to their low-incomeresidents, the counties must show that their networks of doctorsand hospitals are big enough to serve the new clientele. Andthinstockphotos2002President Bush launchesthe Health Center GrowInitiative, increasing thenumber of health clinicsserving disadvantagedpopulations.2006Massachusetts launchesuniversal coverage, Vermontfollows suit, as doesSan Francisco.2007California tries—andfails—to enact universalcoverage.2007Slightly more than 15 percentof Americans are uninsured.20 California Health Report July 2012 healthycal. org

Health Care For Alleach patient must be given what is called a “medical home”—adoctor’s office that is in charge of all their care and keeps trackof their visits to specialists or the hospital, their lab tests, andany prescription drugs they are taking. Until now, many poorpeople have bounced from doctor to doctor, or clinic to clinic,with no one overseeing their care. Health experts believe thisleads to substandard care or worse: a failure to treat chronicdisease or complications from procedures, or prescribing drugsthat overlap and interact with each other.State officials estimate that a half-million people will be enrolledin the low-income health plans by 2014, and all of themwill then be rolled into Medi-Cal. Another 1.5 million peopleeligible for Medi-Cal will also be brought into the program after2014. By the time the ACA is fully implemented, about 10 millionpeople, or more than one in four Californians, will get theircare through the government insurance program.California’s Health Benefit ExchangeCalifornians who earn too much to qualify for Medi-Cal butdon’t get insurance through their employer will have anotheroption starting in 2014—the state-run online marketplaceknown as the Health Benefit Exchange. This will impact mostself-employed residents as well as those working for businessesthat do not provide insurance. California was the first state inthe nation to create an exchange under the federal law. It willgive individuals and small businesses with 100 or fewer employeesthe chance to purchase coverage in much the same waythat state employees and retirees do now through the CaliforniaPublic Employment Retirement System, or CalPERS.Insurance companies that want to sell to this pool of potentiallyseveral million Californians will submit their plans to theexchange’s administrators. The plans will be required to offerat least a set of “essential” benefits approved by the state legislature.Based on the coverage and the out-of-pocket costsinvolved, each plan will be rated as “platinum,”“gold,”“silver,”or “bronze.” The exchange’s website will include a calculatorthat is supposed to make it easy for consumers to compareplans and determine the potential cost of each under differentscenarios.People with incomes between 133 percent of the federal povertylevel ($29,000 for a family of four) and 400 percent of thepoverty level ($93,000 for a family of four) will be eligible forsubsidies to help them afford the coverage they buy through theexchange. The subsidies will work on a sliding scale accordingto income, but people earning less than four times the povertylevel will not have to pay more than 10 percent of their incomefor insurance coverage.The subsidies will take the form of tax credits but will be paidin advance to insurance companies on behalf of consumers sothat they can afford to buy coverage.EmployersUnder the ACA, companies with more than 50 employeeswill be required to pay a fee if they do not provide coveragefor their workers and at least one of their workers gets coveredthrough the Health Benefit Exchange and qualifies for a subsidy.The fee will be $2,000 per employee at the firm beyond the first30 employees.While some health policy analysts believe the relatively lowpenalties might prompt companies to drop their coverage andhave their employees buy insurance through the exchange, MicahWeinberg, who studies health insurance for the Bay AreaCouncil, says he does not see that happening.“It’s extraordinarily unlikely that employers will stop offeringhealth-care coverage to their current employees,” Weinbergsays. “But as they plan for the future and make sure they havethe funds to cover current employees, they may be thinkingabout whether the exchange is a good place for early retireesand part-time workers.”Small businesses, meanwhile, are already qualifying for taxcredits to help them afford the cost of covering their employees.Companies with fewer than 25 employees will qualify for taxcredits of up to 35 percent of the cost of providing coverage,with the maximum credit growing to 50 percent in 2014. But thesize of the credit shrinks on a sliding scale as the size of a company’spayroll grows.Virginia Donohue, owner of Pet Camp, a pet-care businessin San Francisco, is one of those taking advantage of the credit.Her company has provided insurance for its employees since2000 but has seen its rates increase dramatically. What startedas an annual cost of about $30,000 has now ballooned to morethan $100,000. This year the firm will qualify for an $8,000 tax2010President Obamareleases his proposal forhealth care reform.2010The Patient Protectionand Affordable Care Act isapproved by Congress andsigned by President Obamaon March 25.2010Thirteen states file suit to blockhealth care reform because itrequires everyone to carryinsurance and enforces thismandate with penalties.2012The Supreme Court hearschallenges to the law andupholds the individualmandate.healthycal. org July 2012 California Health Report 21

Health Care For Allcredit under the AffordableCare Act.“To me, affordable health care is a basic humanright,” Donohue says. “In this country, we get healthcare through our employers. That’s why we provide it.”Still, the company has had to limit its employees’ choice ofhealth plans and increase the employee contribution to the premiumand their out-of-pocket costs. Those cost pressures willresume, and might worsen, without the subsidies and tax creditsthat are part of the ACA, she says.“The system has been broken for a long time,” Donohue says.“I think until we are all in the system and we are all purchasinghealth care, that’s the only way to get it stabilized.”PreventionOne part of the Affordable Care Act that has received relativelylittle notice is its focus on prevention. That emphasisbegins with the law’s requirement that insurance companiesprovide preventive services at no out-of-pocket cost to consumers.But it does not end there.More significant, in the long-term, might be a new focus onkeeping people healthy in the first place. The law seeks to dothis by changing behavior, and by changing communities sothat the healthy choice for people is also the easy choice.The law requires chain restaurants to provide nutrition informationon their menus and menu boards, and it provides grantsto small businesses to offer wellness programs for their employees.It creates a new, cabinet-level council to ensure that healthand disease prevention are part of the conversation about everymajor domestic policy change.Another intriguing idea: The ACA, through the Centers forDisease Control and Prevention (CDC), will offer grants totransform low-income communities so that people will find iteasier to develop habits that prevent diabetes, heart disease andother chronic illnesses that account for a large and growingshare of the nation’s health costs.The CDC awarded the first grants last year, and more than 20percent of the money, about $22 million, came to California.What’s Next for CaliforniaThe next steps for the state of California will focus on theoperation of the Health Benefit Exchange.Already the exchange has agreed on a $360 million contractwith an information technology firm to designthe agency’s website, which will be crucial tosigning up the millions of people who will benewly eligible for insurance and subsidies.“We want this to be as easy as buying abook on Amazon.com,” says Peter Lee, executivedirector.The system is set to open for business on Oct.1, 2013, so that consumers can buy coverage thatbegins Jan. 1, 2014.In the meantime the exchange will embark ona massive public relations and outreach campaignto make sure Californians know that they are requiredto have insurance and understand that theycan get it through the exchange. The campaign will likely includetraditional advertising, public service announcements,social networking and the use of volunteers to get the word outthrough community groups and other grassroots channels.The regulation of insurance industry practices will also bestepped up. Companies will be required to spend at least 85percent of their premium revenue on medical costs, with 15percent available for administration, marketing and profit. Thefirms will also have to give public notice for any rate changesand justify those changes based on their costs and revenue. Therates will not be directly regulated, but those firms that participatein the exchange will likely face increasing pressure to keepcosts, and rates, at a minimum.In short, the insurance industry in California and elsewhereis going to become more like the utility industry. The playerswill still be largely private and, in many cases, for-profit firms.But how they run their business, how they deal with consumersand how much money they make will be largely dictatedby the government.Potential PitfallsThe biggest risk in the new reform is that healthy people willcontinue to opt out of the insurance system. If only the sicktake advantage of the new subsidies, the insurance pool couldface increasing costs without the revenue to pay those costswhile still charging affordable premiums. A similar danger isthat employers will increasingly opt to pay the penalty ratherthan insure their workers, especially once they see that theiremployees can get low-cost coverage through the insuranceexchange. Since the penalty employers will pay is generally lessthan the cost of coverage, that could also send the system intoan economic tailspin.That scenario, however, will likely take years to develop, if itever happens at all, and Congress could adopt new penaltiesand incentives to draw people into the market before it crashes.In the meantime, what is certain is that millions of Californianswho cannot get insurance today are about to become eligiblefor coverage that is more affordable than ever before. CHRDaniel Weintraub is the editor in chief of the California Health Reportat www.healthycal.org.thinstockphotos22 California Health Report July 2012 healthycal. org

poor POOR patients, PATIENTS, Long LONG waits WAITSGot Docs?Insurance may not fix health care woes of the poorby robin urevichAnita Montalbano sits in a crampedback office at Neighborhood Healthcarein the Riverside County city of Temecula.Her job at the safety-net clinic is to get insurance approvalfor patients who need appointments with specialists.Weeks before St. Patrick’s Day, Montalbano has paintedher fingernails green for the upcoming holiday and deckedout her workspace with shiny shamrocks. But the luckyclovers appeared to bring no favor to patients waiting tosee a specialist.What matters, she says, is another type of green altogether—howmuch specialists and the hospitals where theywork will get paid for their services. Programs ranging fromMedicare to private insurance to county programs for thepoor pay for visits for patients who have medical issues requiringa specialist’s care, such as kidneydisease, thyroid deficiencies andirregular moles in need of biopsies.The precise amount of payment,however, is not uniform, as it dependson the type of insurance carriedby patients.As a result, many poor patientsare not getting the care theyneed, when they need it. Thedifference in rates accountsfor the wait—sometimes lengthy and never good fortheir health—that some patients endure. Patients withMedicare or with Blue Shield, Health Net or other commercialplans are first in line for specialty care, followed byMedi-Cal recipients, who sometimes face months-longwaits. Dead last are those who rely on county programsfor the poor. “It all comes down to insurance,”Montalbano says.Unfortunately, there isn’t enough healthcare to go around right now, especially forpoor people in Riverside County, an area hithard by the housing bust and Great Recession.The county cuts a rectangular swaththrough Inland California, from the city ofRiverside and bedroom communities on itswestern edge through deserts, Indianland, and the rocky moonscapes of JoshuaTree National Park, east to the Arizonaborder. Refugees from highrentLos Angeleshealthycal. org July 2012 California Health Reports 23

POOR PATIENTS, LONG WAITSsettled into big tract homes that mushroomedon scrubby land in the boomyears of the past decade. Today, threeyears after the bust, unemploymentstands at about 12.9 percent, nearly twopoints higher than the statewide averageof 11 percent.A new county health plan for low-incomeresidents, Riverside County HealthCare, created in January 2012, was expectedto ease the economic burden andaddress health disparities. So far, however,it’s falling short of expectations. Thecompared to 71 in San Francisco, whichis less than half the size of Riverside. It isperhaps not surprising that RiversideCounty ranks below average in nearly everyhealth outcome, according to theCalifornia Department of Public Health.“Riverside County isn’t the only onethat’s struggling,” notes Anthony Wright,an outspoken advocate for health-carereform and the executive director ofHealth Access, a statewide health-careconsumer advocacy coalition. “Care delayedis often care denied,” he says. “Once“we have to work tomake sure that thecoverage is meaningful”plan promises a full range of medical services:primary care, mental health servicesand access to specialists. The idea isthat an up-front investment in comprehensivecare will have a long-term payoffin fewer emergency room visits and hospitalstays.Riverside County, as well as 46 othercounties in California, are in the processof rolling out new health plans for thepoor—essentially an expansion of Medicaid—inanticipation of the full implementationof the federal Affordable CareAct in 2014. A signature aspect of theACA is the expansion of Medicaid tomore people. In part, the work that Californiais doing to prepare early, an effortthat is getting significant support fromfederal funds, is a demonstration project,meant to highlight concerns that othercounties in California and other statesmay face as they implement reform.It’s an ambitious project, and the onthe-groundrealities have been challenging.Even counties with established localhealth-care plans, like Los Angeles, arescrambling to serve more people withfewer resources.Only 15 of California’s 58 counties,most of them rural and lightly populated,have fewer primary-care doctors per personthan Riverside. Specialists, especiallythose who will see patients with Medicaid,are also scarce. Twenty-two communityclinics operate in Riverside County,we get people insured, we have to workon making sure that the coverage ismeaningful.”Health-care reform, in other words, isabout more than putting an insurancecard in the pockets of low-income people.At Neighborhood Healthcare ona rainy spring afternoon, a pile ofpaperwork and a full load of patientsjammed Dr. Sarah Russell’s schedule.But the 30-something primary-caredoctor took time after work to point outhow her patients have been denied criticalcare. Take the case of a 55-year-oldman born with a single kidney. Dr. Russelldiagnosed him with stage two kidneydisease and referred him to the countyhospital’s nephrology clinic.“He has one kidney,” Dr. Russell says,“and that kidney is not working. If hedoesn’t get proper care, he could end upon dialysis a lot sooner.” He also coulddevelop a host of other debilitatingsymptoms like chronic fatigue, pain anddizziness. Still, the hospital refused herreferral, saying that only patients withstage four or five kidney disease, whosesole option by then is dialysis or kidneytransplantation, are accepted in its nephrologyclinic.Part of the difficulty with health-carereform in Riverside County lies with thecounty hospital itself, which has appearedto put paying patients ahead of itspoorest and most fragile, who sometimeswait more than a year to get the care theyneed, say critics of the system.The county hospital, Riverside CountyRegional Medical Center in Moreno Valleyhas long made it tough for patientswho have relied on the county’s pre-reforminsurance program for the medicallyindigent to see specialists, says NeighborhoodHealthcare’s Montalbano. Riverside,like most California counties, isthe provider of last resort for emergencymedical care for the poor. Dr. Russell’spatient, though, was signed up for RiversideCounty Health Care, the new andimproved insurance program.Riverside County Department of PublicHealth spokesperson Jose Arballo saysthat specialists are available to consultwith primary-care doctors and are opento reconsidering their denials.That hasn’t been Dr. Russell’s experience,she says. Montalbano points to twomore members of the county’s low-incomehealth plan whose referrals wererecently rejected. A colon cancer screeningfor a 55-year-old man, ordered by his doctor,was denied because Riverside countyhospital resources don’t permit such tests,even though they are recommended forpatients 50 and older. A 56-year-oldwoman with an atypical mole on her handwill have to wait and see if hospital dermatologistswill agree to remove it. Herdoctor must biopsy the mole and provideadditional documentation before arguingthe patient’s case again.“They have their guidelines that are sorestrictive,” Dr. Russell says. “This is thehardest county I’ve ever worked in.”County officials say the six-month-oldprogram is so new that they are stillworking out the kinks. It will eventuallycover some 20,000 low-income adults.One of the plan’s major promises is thatit will provide what is known as a “medicalhome,” which for patients is a moreseamless and preventive approach to carehelmed by a primary-care physician. Insteadof bouncing from doctor to doctorwith no one keeping an eye on the patient’soverall health, each patient in thenew system would be assigned a singledoctor who manages the full array oftreatment.24 California Health Report July 2012 healthycal. org

POOR PATIENTS, LONG WAITSNewly insured used ER...moreOne of the most common argumentsin favor of the federal Affordable compared to 20.2 percent of continucentof newly insured adults had done so,Care Act is that people without insurance ously insured people. About 26 percentoveruse emergency rooms because they of newly uninsured people had been tolack access to basic care.the ER, compared to about 19 percent ofBut new research released earlier this continuously uninsured people.year suggests that people without insuranceuse the ER no more than those who nection between their insurance statusAmong newly insured adults, the con-have health coverage. In fact, people and their visits to an ER was strongest forwho were without coverage and then obtainedit use the ER more than people government-subsidized health insurancethose who were newly on Medicaid, thewho have steady coverage or have no program for the poor.ongoing coverage at all. People who lose “As policy changes and economictheir coverage also use ERs more, the forces create disruptions in health insurancestatus,” the authors conclude, “newstudy finds, so a change in health insurancestatus, more than anything, seems surges in [emergency department] useto be what leads to an increased use of should be anticipated.”the emergency room.Policy-makers anticipated that the expansionof insurance coverage might leadThe study analyzed 159,934 adultswho took part in the National Health InterviewSurvey between 2004 and 2009. primary-care system. Many policy-makersto more visits to an already overburdenedSurvey respondents were divided into categoriesof newly insured, continuously in-emergency room visits. This would meanseem to have counted on a reduction insured, newly uninsured and continuously a savings not only for hospitals and theuninsured. The newly insured and the uninsuredwere placed in these categories if market as well, since hospitals are knowngovernment but for the private insurancetheir status had changed during the previous12 months.for the uninsured to their insured custom-to shift the uncompensated cost of caringResearchers found that, overall, about ers through higher fees. But if coveringthe same proportion—around 20 percent—ofcontinuously insured and unin-emergency rooms, those anticipated sav-more people leads to even more visits tosured people had visited an emergency ings may not materialize.room in the prior year. But almost 30 per-— Daniel WeintraubBut that model will work as designedonly if patients have access to specialists.That’s not happening currently. To illustratethat point, Montalbano pulls out awell-worn sheet of paper encased in aclear plastic folder. It shows wait timesfor the county hospital’s specialty clinics.The longest, at 16 months, is for cardiology,closely followed by nephrology andgastroenterology at 14 months, with neurologyat a year. Referral clerks at otherclinics report waits of six to 12 months forspecialist care.These referral rates are out of compliancewith state standards, which requirethe county to provide most specialtycareappointments within 30 days. Thecounty has 60 days to make dermatologyand gastroenterology appointments becauseof the shortage of specialists inthose areas.County health department spokespersonArballo insists that the county hascomplied with these rules. But LettyPerez, manager of the Temecula NeighborhoodHealthcare clinic, disagrees.Members of the new plan for low-incomepeople appear to be facing much longerwaits, she says. “We were all excitedthinking they will get in a lot sooner. Butit seems about the same.”Dr. Lawrence Clark, a Riverside neurosurgeon,says that one reason for the epictime lags is that higher paying patientscrowd out those who depend on countyprograms. “The neurosurgeons who workout of that facility also want to makemoney and see workers’ comp and personalinjury patients in addition to Medi-Cal and uninsured patients,” says Dr.Clark. “There’s a bit of competition fortheir services and time.” Hospital administrators,he adds, want it that way. “Theadministration wants the hospital to beprofitable,” he says.Dr. Clark and three partners ran thecounty hospital’s neurosurgery clinicfrom about 1992 to 2001 and got patientsin quickly, he says. Although they alsosaw higher paying patients at other hospitals,they exclusively treated low-incomepatients at the county hospital.Not all specialists share Dr. Clark’sview of the allocation of care. Dr. SilvioHoshek, a neurosurgeon who currentlypractices at the hospital, insists that allhealthycal. org July 2012 California Health Report 25

POOR PATIENTS, LONG WAITShis patients—about 60 percent of whomhave insurance—are treated quickly now,regardless of who pays for their care.(Riverside County Regional MedicalCenter CEO Douglas Bagley declined repeatedinterview requests and didn’t answere-mail questions about access tospecialty clinics.)Still, one endocrinologist, who askednot to be named, acknowledged thatwaits are a big issue in his clinic. That’swhy he has refused to see paying patientsat the hospital. He also refused a hospitalrequest to give priority to county employeesinsured by the county health plan,Exclusive Care.Now, both he and Dr. Hoshek note,the county hospital may be moving awayfrom its policy of allowing doctors to treatprivate patients at the hospital.Long delays for specialty-care appointmentsalso have an effectthat’s antithetical to the logic ofhealth-care reform. When family practicephysicians are left to manage complicateddiseases without help from specialists,patients resort to emergency roomcare to ease their symptoms. This is bothcostly and, in many cases, ineffective,even dangerous, for the patient.Fifty-eight-year-old Chris Hernandez,newly enrolled in the county’s plan, visitedtwo emergency rooms in as manyweeks. His pain from two hernias, he explainedto the clerk who signed him up,was constant and intense. It was an 11,he joked to health-care providers, on theone to 10 pain scale that health-careworkers use. Uninsured on and off foryears, Hernandez went as long as hecould before seeking care. His boss on aCaltrans landscaping crew noticed himwincing in pain and laid him off last fall,saying it was too dangerous for him towork.Severe pain is a criterion for an urgentprimary-care appointment under RiversideCounty Health Care. But Hernandezsoon learned that, despite his new insurance,it would take more than a week toget into a clinic near his home in theCoachella Valley town of Indio. So beforethe ink was dry on his insurance card,Hernandez headed for the county hospitalemergency room, where he got painpills and other medication.But he developed a raging allergy tothe pain medication. “I was scratchinglike a monkey,” Hernandez says. Hestopped taking it and hoped he’d finallyget relief at his primary-care appointment.Hernandez waited and then ranheadlong into another obstacle. His doctorprescribed alternative medication forpain, but Hernandez learned he’d eitherhave to journey 60 miles to Riverside toget it or have to pay out of pocket.Riverside County covers an area nearlythe size of New Jersey, and patients infar-flung areas who can’t get drugs bymail face treks of up to 150 miles to pickup prescriptions. Riverside CountyHealth Care does have a prescriptiondrug-by-mail plan for members, but painmedicine is excluded because of the potentialfor theft. Again unable to standthe pain, Hernandez visited anotheremergency room, at Eisenhower MedicalCenter near his home.Last summer the county released a requestfor proposals for pharmacy servicesand received no bids, reports Arballo, thecounty health department spokesperson.The county is currently in talks with acommercial pharmacy, he says, andhopes to solve the problem.As for Chris Hernandez, after a frustratingthree-month struggle, an end isfinally in sight. He has an appointmentwith a surgeon. Better yet, his blood pressureand diabetes are under control,thanks to his work with a primary-caredoctor at the Indio clinic, who says he’sfit for surgery.Riverside County Regional MedicalCenter CEO Bagley said in an e-mailthat, although imperfect, the low-incomehealth plan represents a step forwardfor previously uninsured patients.“It’s a major improvement,” he wrote,“especially given that funding is extremelylimited.”But the entire burden for the spottycare for the poor cannot be laid at RiversideCounty’s door. Other culprits arerazor-thin budgets, a sluggish economyand the most severe physician shortageof any other urban county in California. “Iwould be the last person who’s an apologistfor the system and what it costs,”Health Access’s Wright says of the crisesthat counties are facing. “But the kind ofcuts we’ve seen in state and the countieshave been with a meat ax.”Some argue that the best hope for asolution to the county’s health-care issueslies on the grassy expanse of theUniversity of California, Riverside,campus, where Dr. Richard Olds isstruggling to open what could be California’sfirst new public medical schoolin 40 years.“The first thing the medical school willdo is hire more primary-care doctors,”says Dr. Olds, dean of the school, notingthat those faculty members will alsopractice in the community. By 2014, theschool’s residency programs will sendmore than 150 newly minted physicians,more than half of them in primary careand internal medicine, to train in clinicsthroughout Riverside County. Dr. Oldscites studies showing that 40 percent ofdoctors set up shop where they servedtheir residencies, a hopeful finding forRiverside.But Dr. Olds needs $100 million, orcommitments of $10 million annually over10 years, to get the school off the ground.Last year, he was forced to put plans onhold when the $15 million in state fundinghe counted on was snatched away, acasualty of the budget squeeze. So Dr.Olds took his case to whoever would listen.Most of the funding has come fromlocal health-care institutions. The bulk ofthe money is pledged, and once the commitmentsare all in, he’ll apply for accreditation.He hopes to admit his first class inAugust 2013.In Riverside County, where getting basichealth care is a struggle for many, thehardscrabble beginnings of its first medicalschool seem somehow fitting. If theschool is successful, it might eventuallybe the salvation of a cash-strapped regionof the state where health outcomesare worse than average.But no such cure is on the horizon forother parts of the state suffering fromsimilar problems. Relief won’t come onlyfrom minting new doctors. “It’s been veryclear,” Health Access’s Wright says, “thatif we’re trying to provide more care in thesame way to lots more people, we justcan’t do it.” CHR26 California Health Report July 2012 healthycal. org

Policy and PerspectivesEMT Training Program forDetention Center YouthTeaching troubled teens to help the sick and injuredBy Callie ShanafeltthinstockphotosCareer day is a regular eventfor teens at Alameda County’sCamp Sweeny, a juvenile justiceresidential program thatis an alternative to jail or prison. Whencamp officials asked the county’s EmergencyMedical Services (EMS) divisionto come to career day, it didn’t just set upa card table stacked with pamphlets.EMS pulled out some stops to impressthe kids, including flying a helicopterinto the camp. Firefighters and paramedicsalso volunteered to talk to the 70or so teens serving time.After career day, camp staff asked thekids what they wanted to be when theygrow up. “Historically, they said police orprobation officers, because those werethe adults they had positive experienceswith,” says Alex Briscoe, director of theAlameda County Health Care ServicesAgency. This time, they gave a differentanswer. Fifteen young men said theywanted to be emergency medical technicians(EMTs). That day, and the impressionEMS left on the teens, started anunusual collaboration that’s changingthe lives of troubled youth.It all started with a few volunteertaughtfirst responder classes at thecamp. When those proved popular, EMSoffered free first responder trainingclasses Monday and Wednesday eveningsthat were open to anyone in thecommunity and were attended by manyCamp Sweeny graduates. EMS then developedan intensive training programfor EMT certification. Many spaces in theclass were reserved for Camp Sweenyyouth. The program, called the EMSCorps, graduated its first class of 11young people in January 2012.The Health Care Services Agencycontracts with Paramedics Plus to provideall ambulance services in the county.Paramedics Plus hires at least 30 to 40new EMTs a year, as current employeesbecome paramedics or firefighters orchange careers. The company agreed tohire at least 10 graduates of the EMSCorps annually, including young menlike Jorge Villanueva.Villanueva was at Camp Sweeney as aconsequence of a fight with a classmate.The camp director noticed Villanueva’sknack for working with people and suggestedthat he enroll in a first responderclass offered at Camp Sweeny.Before Camp Sweeney, Villanueva hadbounced from home to home and had atough time finding stability. “My momwanted more the drugs than us,” Villanuevasays of his childhood. He actuallyappreciated his time at Camp Sweeneybecause of the stability and three mealsa day and a chance to turn his lifearound. “While I was at camp,” he says,“it really opened my eyes, to see that Ididn’t want to give the same life mymom gave me to my kids.”Villanueva took the first responderclass and liked it. When he left CampSweeney in the summer of 2010, he gota job working at a bakery in Hayward. Assoon as the EMS Corps program startedsoliciting new applicants, Villanueva applied,one of 300 people vying for 22open spots.And he got in.Now spends his days learning how tohealthycal. org July 2012 California Health Report 27

Policy and Perspectivestake vital signs and assess patients.Eventually, he wants to become a paramedic,which requires even more training.“I gotta crawl before I walk,”Villanueva says of the learning processahead of him.Briscoe thinks that the life experiencesof Camp Sweeny teens have preparedthem well for what they’ll likelysee while working in an ambulance. Thatgives them an advantage over other applicants.“They’re 18 going on 50,” Briscoesays.Creating this kind of employmentpipeline also contributes to the overallhealth of Alameda County, he adds, andprovides a uniquely qualified and diversepool of EMTs.But preparing low-income teens—many of whom have criminal records—for employment has its challenges. Sothe EMS Corps includes training insoft skills, like how to shake hands.Participants wear uniforms and arerequired to stand up when an adultwalks into the room. “We do a lotof life coaching work and developmentof positive self-outlook,”Briscoe explains.After completing the programin May, Villanuevaand his classmates willhave to pass the NationalRegistry ofEmergency MedicalTechnicians Exam tobecome certified EMTsand meet ParamedicsPlus hiring requirements.If they don’t passthe first time, the EMSCorps is committed tohelping them pass eventually.Briscoe plans to expandthe program to 40 participantsand hopes that othercounties will replicate theprogram in their jurisdictions.For Villanueva, the mostimportant thing is that he’llget to help people. “I’ll savelives,” he says. “I’m not just acriminal, I’m becoming a hero.”CHRThe End of Juvie?When legislators created the California Youth Authority in the 1940s,they intended to rehabilitate delinquents with job training and education, ratherthan punish them by sending them to prisons for adults. Six decades later, theagency, by then renamed the Division of Juvenile Justice (DJJ), clearly wasn’t fulfillingits mission. Front-page newspaper articles in the early 2000s alleged a range ofabuses in youth facilities, from unlicensed medical and mental health treatment toextreme use of force and solitary confinement.County and state personnel have been realigning the juvenile justice systemsince the turn of the 21st century. The process has been similar to the realignmentof adult prisons, where less serious offenders were kept in countyfacilities, closer to families and local rehabilitation options. Thepopulation of youth in state facilities has dropped by 88percent since 1996—without an uptick in juvenile crime.The number of youth in DJJ facilities hit an all-time highof 10,112 in 1996. The population had steadily risen sincethe 1970s in part because of decreased state funding for localprograms, which essentially made it cheaper forcounties to send kids who break the law to state facilities.Instead of building more facilities to deal withthe increasing population, legislators passed SB681, a law that used monetary incentives to encouragecounties to keep juvenile offenders.Today, DJJ houses about a thousand of themost serious youth offenders. Barry Krisberg isa court-appointed monitor of the DJJ. The facilitiescould still improve, Krisberg says, but they’vecome a long way since realignment started.The reforms were expensive, though, since the overallbudget of the department didn’t shrink even as the numberof inmates declined. In January of this year, Governor JerryBrown proposed eliminating the DJJ in three years by not acceptingany new inmates from counties beginning January2013—a move he says will save the state more than $100 milliona year. — Callie Shanafeltthinstockphotos28 California Health Report July 2012 healthycal. org

Policy and Perspectiveshealth officer for Ventura County PublicHealth and a pediatrician.“In terms of the mother’s health,home births appear to be as safe as hospitalbirths, but there is some concernthat with planned home birth, there’s asmuch as a twofold increased risk of neonataldeath,” he notes. “The neonataldeath rates are still quite low, but they’resomething we look at every year in Californiaand the United States.”Two in every 1,000 newborns died duringplanned home births, according to the2010 study by the Committee on ObstetricPractice, while 0.9 in every 1,000 diedduring planned hospital births. Meanthestork returnsHome Births on the RiseMore soon-to-be moms say no to the hospitalBy Hannah GuzikFawn Peterson opted to givebirth at home last year after havingthree kids in the hospital.“The home birth was just easier,”Peterson says. “We didn’t have to packbags and go anywhere, and we could enjoythe comforts of our own home.” Shegave birth to her son, August, on the bedshe and her husband, Jeff, share. Underthe guidance of a licensed midwife, Jeff“caught” August as he slid down thebirth canal. “At the hospital I would havehad an I.V.,” Peterson says, “and wouldn’thave been able to move around as muchwhile I was in labor.”A growing number of California babiesare taking their first breaths not inthe fluorescent glow of hospital rooms,but, like August, in their parents’ bedrooms.Although the percentage ofwomen giving birth at home is stillsmall, home births in the state jumpedby 37 percent between 2004 and 2009,says a Centers for Disease Control andPrevention report released in January.Nationwide, the percentage of birthsthat occurred at home jumped 29 per-cent during the same period.“I think part of it is the economy drivingpeople to have home births,” saysSue Turner, a licensed midwife in Ventura.“Maybe they’ve lost their job anddon’t have health insurance, and sothey’re wanting the cheaper way to go.”Giving birth at home is about a third thecost of a hospital birth, Turner says, butonly about half of health insurance companiesin California cover home births.“Also, I think many people want fewermedical interventions,” Turner adds.“There’s more awareness that givingbirth can be a natural experience.”The American College of Obstetriciansand Gynecologists does not recommendhome births because of safetyconcerns. The state of California, in contrast,takes no position on home births.Studies have shown that while homebirths can be more dangerous for babies,they may result in fewer complicationsfor mothers, says Dr. Robert Levin,thinstockphotoshealthycal. org July 2012 California Health Report 29

Policy and Perspectiveswhile, 1.2 percent of women whohad a planned home birth receivedthird- or fourth-degree lacerationsduring the delivery, compared with2.5 percent of women who had aplanned hospital birth. Rates of maternalinfection were also loweramong those who delivered duringa planned home birth, at 0.7 percent,compared to the 2.6 percentamong those who had a plannedhospital birth.The lower complication ratesamong those who deliver at homecould be because state laws onlyallow midwives to care for womenwith low-risk pregnancies, Dr.Levin says. If women are consideringa home birth, he adds, it’s importantto make sure they select amidwife certified by the AmericanMidwifery Certification Board,have a low-risk pregnancy andhave not had a previous cesareansection.Turner, who also operates theVentura Birth Center, a place wherewomen can give birth outside the hospital,says that she’s seen her business increase15 percent each year in the pastdecade. She is typically booked aboutfour months in advance and frequentlyhas to turn pregnant women away. “Thisweek I’ve gotten calls for people due inOctober,” she said in a March interview.“We’re halfway booked now for October.”Women opt for home births, she says,because they’re afraid of hospitals, or associatethem with negative experiences.“Perhaps they’ve had atraumatic experience giving birthpreviously in a hospital,” Turner says,“or maybe they’ve had a loved oneor previous child pass away in a hospital.”Some women also choose to stayhome because they want more controlover their environment and theirbirth attendants, or because theywant a more traditional experience.“It just seems like things go full circlethis way,” Turner says. “For somuch of history, women gave birthat home.”In 1900, almost all U.S. birthshappened at home. By 1940, 44 percentof births happened at home.Home births dropped to 1 percentby 1969, where they remainedthrough the 1980s.Knowing that women traditionallygave birth at home helped persuadePeterson to do so as well—butshe wasn’t opposed to being transferredto a hospital if something wentwrong. “I had nothing to prove,” shesays. “I think it’s silly if someone’s highrisk and she still wants to grit her teethand stay at home. The baby’s safety iswhat’s most important.” CHRHomebirth: A HistoryFor most of human history, women have given birthat home, aided by a midwife and female friends.Fathers would wait outside and doctors, if available, would becalled only in emergencies, often to try to save the mother’s lifeafter the baby had died, says Anita Trudell, a nurse midwife whohelps teach resident obstetricians at UCLA Ronald Reagan MedicalCenter in Westwood.In many cultures, women squatted on the ground to delivertheir babies. In others, they delivered in bed, but the lithotomyposition, where a woman lies on her back with her knees in stirrups,wasn’t widely used until French King Louis XIV ordered hismistress to give birth that way so he could watch, Trudell says.More women began to give birth in hospitals in the late 1800s,when an effort to standardize healthcare in the United States ostracizedmany midwives from the medical community.“There was an effort to get rid of unlicensed practitioners andone of the professions they looked at was ‘granny midwives,’those midwives who served the population they were born into,”Trudell says. “Immigrants coming into the United States. broughttheir midwives with them and, despite the new regulations, theycontinued to serve in the barrios and tenements.”Hospital births increased significantly after World War II, becausesoldiers returning home had good health insurance, and by1950, hospital births were commonplace, Trudell says.“There was the idea that medicine was going to save everybaby,” she says.30 California Health Report July 2012 healthycal. org

Policy and PerspectivesDitch the car!Planning for a safer – and healthier – community.By Pilar Lorenzana-CampoGr o u n d b r e a k i n g l e g i s l a-t i o n t h at pa s s e d a fewyears ago could be a majorstep forward in changingneighborhood design throughout thestate, curbing sprawl and creating safer,more walkable communities. The law,known as SB 375, is also an unprecedentedopportunity to improve publichealth —especially if Californians get involvedin the planning process that’s goingon right now.California’s Sustainable Communitiesand Climate Protection Act is the firstlaw in the nation to link transportationfunding, land use planning, and housingpolicy with an effort to reduce greenhousegases. The law has the potential tomake it safer and easier for all Californians—includingelderly, disabled, andlow-income residents—to be more active,breathe cleaner air, and even buyhealthier foods.What does this have to do with improvingpublic health? Just about everything.Many policies, including SB 375,aimed at reducing car use and greenhousegases, not only cut back on pollu-tion but also help create neighborhoodswhere people can walk safely and easily.Pedestrians getting hit by cars nowaccount for up to 12 percent of all roadwaycollision deaths nationwide. Speedis closely linked to the severity of pedestrianinjuries: when a car traveling 20miles per hour hits a pedestrian, the pedestrianwill be killed only 5 percent ofthe time; if the car is traveling 40 milesper hour, the pedestrian will be killedabout 80 percent of the time. Nationwide,collisions with pedestrians aremore than twice as likely to occur inplaces without sidewalks, and close tohalf of pedestrian fatalities occur whereno crosswalk is available.Connecting public transportationwith compact, walkable communitiesmeans that people can safely take transit,walk, or bike to school, work, or thegrocery store. And that kind of activity isa boon to public health: almost a third ofAmericans who commute to work onpublic transit meet their daily recommendationsfor physical activity (30 ormore minutes a day) by walking to andfrom their transit stop.One of the goals of SB 375 is to reduceautomobile use in the state. A core provisionstipulates that regions throughoutCalifornia will have to prepare what’scalled a “Sustainable Communities Strategy”(SCS) as part of the regional transportationplan they’re already requiredto prepare every four or five years. To cutback automobile use, these plans can callfor policies that create more “humanscale”communities: neighborhoodswhere residences, businesses, and officesare located near each other and are accessibleby public transit, walking, andbiking. The plans can also help reducesocial and health inequities by investingdollars into building access to transportationin low-income neighborhoods.What’s the biggest incentive for communitiesto change their developmentpatterns? Money will flow to those thatcomply with their regional SCS. TheState of California will distribute $17million a year to fund transportationprojects that are consistent with the SCS.The SCS planning process offers aprime opportunity to speak out aboutthe importance of these strategies forpublic health. Metropolitan PlanningOrganizations (MPOs) oversee the processin each region, setting timelines andopportunities for input.That’s where you come in.California residents can join or startregional advocacy groups to participatein the proposal process. Advocacygroups can comment on draft SCS proposalsand press for healthier, more equitableland use and transportationplanning.Residents also can educate transportationcommissioners and other communityleaders about the health effectsof transportation and land use decisions,urging them to prioritize strategies thatcreate more walkable, transit-orientedneighborhoods – and holding them accountablefor their decisions.With SB 375 planning deep in theworks, now is the time to push for strategiesthat will improve California residents’health and wellbeing for decadesinto the future. CHRPilar Lorenzana-Campo is a senior associatein planning and development at PublicHealth Law & Policy, a research and trainingcenter based in Oakland.healthycal. org July 2012 California Health Report 31

Policy and PerspectivesDANIEL WEINTRAUBCalifornia’s HeartbeatWhere’s the love for the Cal State system?Like parents with more thanone child, Californians say theylove their higher educationsystems equally. But everyoneknows that the University of Californiais really the favorite, with its collectionof beautiful seaside campuses and college-townenclaves, high-powered academics,world-renowned researchlabs and nationally ranked athleticpowerhouses.The California State University(CSU) system? Not so much. Thisscrappy array of 23 campuses is the underappreciatedyounger sibling always striving to winmore affection, usually to no avail.For all the glitz of the University of California, the CSUis the state’s indispensable workhorse of higher education.It’s an engine for growing and sustaining the middleclass, a ladder of opportunity that has allowed thechildren of low-income families to move into the economicmainstream.It certainly delivered for me. I was just the second ofeight children in my family to graduate from college.While we were already in the middle class, my parents’divorce had left my mom and my brothers clinging precariouslyto that status. I graduated from high school nearthe top of my class and had decent SAT scores, yet I neverconsidered applying to the University of California, becausethere was no way my family could have afforded it.So it was on to the local school, San Diego State. There,despite the low fees—it cost me less than $500 a year toattend—I had to work three jobs to make ends meet. Ilived with two or three other guys in shabby apartmentson “Montezuma Mesa” near the campus, spending onesemester sleeping in a closet under a staircase to save afew bucks.After four and a half years, I got a degree in economics,a minor in journalism and a ton of practical experience atthe college daily. I was able to go directly from San DiegoState to a job as a reporter with the Los Angeles Times anda career in newspapers and online journalism.That sort of professional education is the bread andbutter of the CSU system. Its campuses award the lion’sshare of professional degrees in the state, including 95percent of degrees in hospitality and tourism, 76 percentin agriculture, 69 percent in criminal justice and 53 percentin the fast-growing sector of business and professionalservices. The CSU is also the state’s single largest producerof nurses and engineers. Forty-six outof every 100 Californians who earnedan undergraduate degree in this statelast year got it from a CSU school.Increasingly, those graduates are minorities.Latino undergraduate enrollmentat the CSU has increased by 68percent over the past decade, to 113,000out of a total undergrad enrollment of367,000. Within the next year or two,Latinos will probably pass whites to becomethe largest ethnic group in thesystem. The CSU, in other words, looksa lot like the rest of California.The CSU’s pursuit of its mission has not been helpedby the deep budget cuts it has suffered over the past fewyears as the state’s economy and tax revenues havestagnated. California is spending a staggering half a billionless in general tax dollars on the CSU this year thanit did 10 years ago, despite a 15 percent increase in undergraduateenrollment. The system will almost certainlyhave to limit admissions in the coming year tomake ends meet.And as the taxpayer contribution has declined, studentsand their families are making up much of the differencewith higher fees. Long gone are the days when feesamounted to a few bucks per month. Today, it costs about$5,300 to attend the CSU for a year, plus all of the othercosts of living.Even that higher price is still less than the national averagefor public universities, and after financial aid, fulltimestudents at the CSU pay an average of about $2,000per year. That’s not cheap, but it’s within reach of mostfamilies and probably still a bargain for the money, especiallyif the system can maintain the quality of its programsthrough tough times.California, which faces a shortage of professional workers,will increasingly depend on immigrants and the childrenof immigrants to drive economic growth andprosperity in the years ahead. The CSU system, if it is preserved,will be the key player in training the generation ofstudents who, when they graduate, will be paying thetaxes that help sustain the quality of life for the state’s risingtide of aging baby boomers. CHRDaniel Weintraub graduated from San Diego State Universityin 1982. He has been writing about California public policyand politics since then and currently edits the CaliforniaHealth Report at www.healthycal.org.32 California Health Report July 2012 healthycal. org

A program of theStay Up to Date onChildren’sIssuesFind, customize, andshare data on morethan 400 measuresof child health andwell being. Dataare available forevery legislativedistrict, city, county,and school districtin California. Visitwww.kidsdata.org.Students Eligible toReceive Free or ReducedPrice School Meals: 2011No Data25.5% to

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