UCLA Center for Health Policy Research

Half of apartment dwellers in Los Angeles report having been exposed to unwanted secondhand smoke in their homes in the last year, and 9 in 10 of them say they favor policies banning smoking from their buildings, a new study by researchers at the UCLA Center for Health Policy Research reveals.

Owners of multiunit housing properties in Los Angeles also expressed strong support, with 92% saying they favor smoke-free policies, according to the study, which surveyed more than 5,000 tenants and owners in some of the city’s most densely populated areas.

“We found that 1 in 2 tenants said that they were exposed to secondhand smoke and that there is a need to reduce that exposure in order to protect all tenants and children from harmful health effects,” said Peggy Toy, director of the Health DATA Program at the Center for Health Policy Research and lead author of the study.

Currently, that protection is hard to come by. There is no citywide policy in Los Angeles prohibiting tenants from smoking in privately owned apartments and condominiums. And in Los Angeles County, roughly 80% of cities allow smoking in these units. Around 80 million Americans live in multiunit housing and can be exposed to smoke in their homes.

The danger of exposure to secondhand smoke is well-documented. While tenants who smoke may believe they pose no threat to others, secondhand smoke from tobacco, marijuana and e-cigarettes can drift into other units through shared ventilation systems, walls, windows and common areas, endangering other tenants. Drifting secondhand smoke cannot be controlled and has been linked to over 40,000 annual deaths from heart disease and lung cancer combined, according to the U.S. Dept. of Health and Human Services.

For the study, nearly 5,000 survey responses were collected from household tenants in 12 Los Angeles City Council districts, with help from community partners who conducted surveys in English, Spanish and Korean. Approximately 200 surveys were conducted online and over the phone with private owners of multiunit buildings. The surveys covered topics such as tenants’ experiences with secondhand smoke in their homes, tenants’ and owners’ views on smoke-free policies, and the potential challenges of enforcing these policies.

In addition to widespread support for smoking restrictions, the study found higher-than-average rates of secondhand smoke exposure among vulnerable and minority tenants:

• 55% of tenants who live with someone with chronic a disease reported they had been exposed to secondhand smoke in their homes in the past year.
• 54% of tenants with children reported exposure to secondhand smoke.
• 54% of Latino tenants and 51% of black tenants said they had been exposed — more than any other races or ethnicities.

Private owners of multiunit buildings in Los Angeles have the authority to institute smoke-free policies, and many have. The study found that 3 in 5 tenants live in buildings with some form of smoking ban, whether in common areas or individual units. But these policies can be difficult to implement. If a tenant who smokes rented a unit before a smoke-free policy was in place, the owner cannot force them to stop. In the absence of a citywide prohibition, many landlords can only ask tenants to voluntarily refrain from smoking.

"We found that owners implemented voluntary smoke-free policies and supported them due to reasons like decreased maintenance costs and tenant health,” Toy said. “We found owners supportive of a citywide policy but concerned over accountability and enforcement that would hold owners liable if tenants violated the policy."

The study’s authors recommend policies to protect all residents from the health risks of secondhand smoke in their homes. These include establishing a single smoke-free policy requiring all multiunit housing properties in the city of Los Angeles to be 100% smoke-free to protect all tenants; identifying a policy-enforcement model that meets the needs of both tenants and owners; engaging and mobilizing community partners to ensure effective enforcement; and promoting access to resources that help people quit smoking in order to aid the compliance and enforcement processes.

“As more people are spending time at home due to the current COVID-19 pandemic, it is important that tenants feel safe about their surroundings and protected from exposure to unwanted environmental risks like secondhand smoke,” said Dr. Tony Kuo, director of the division of chronic disease and injury prevention at the Los Angeles County Department of Public Health. “We are hopeful that multiunit housing owners, tenants and community stakeholders can come to a solution that protects our communities from this danger in their homes.”

On Wednesday, May 20, the Center for Health Policy Research will host a webinar to discuss the study findings.

The UCLA Center for Health Policy Research is one of the nation's leading health policy research centers and the premier source of health policy information for California. The Center improves the public's health through high quality, objective, and evidence-based research and data that informs effective policy making. The Center is the home of the California Health Interview Survey (CHIS) and is part of the UCLA Fielding School of Public Health. For more information, visit www.healthpolicy.ucla.edu​.

A recent fact sheet by researchers at the UCLA Center for Health Policy Research and Claremont Graduate University shows that people who have complete housing amenities are more likely to have health insurance than those who are missing at least one amenity, both before and after the ACA’s implementation and independent of income. Missing amenities include housing that lacks a bathtub or shower, sink with a faucet, stove or range, or refrigerator.

“We found that people who may otherwise have access to no-cost insurance such as Medicaid are struggling to maintain basic necessities,” said Deborah Freund, lead author of the study and an economic sciences professor at Claremont Graduate University.

Using data from the American Community Survey from 2013 to 2018, researchers looked at the percentage of adults up to 64 years old who were uninsured based on whether they had all basic home necessities versus people who were missing at least one of those features. They found that those missing at least one basic home necessity and having incomes less than 100% of the Federal Poverty Level (FPL) had the highest uninsured rates in 2013 (33.5%) and 2018 (23%) compared with those who had all basic necessities (27.4% in 2013 and 17% in 2018). The same trend was true for people with income levels of 100-399% FPL and 400% FPL – though the differences were not drastically different in the highest income category.

“Future research should look more closely at housing as a social determinant of health, especially in relation to insurance coverage, as there may be important factors – lack of awareness of available resources, life burdens, and other budget priorities – uncovered that should be addressed to bridge the gap in needs and services for underserved communities,” Freund said.

This study was conducted jointly by the UCLA Center for Health Policy Research and the Claremont Graduate University with support from the A-Mark Foundation. This is in addition to a fact sheet on the link between education and insurance coverage, and will be part of a larger report examining several other factors.

In 2019, California lawmakers took steps to build upon the ACA by providing additional state subsidies for coverage in the individual market, including first-in-the-nation subsidies for middle income families above the federal subsidy cliff. California will also expand Medi-Cal coverage to low-income undocumented young adults, and institute a state individual mandate to replace the federal penalty that Congress eliminated.

Using CalSIM, a micro-simulation model that can be used to estimate the impact of various policies on health insurance coverage in California, the authors project that in the absence of these new policies, prices in the individual market would be higher and the number of uninsured in California would have climbed to 4.3 million by 2022. However, with these policies in place, they project that the number of uninsured would remain stable at 3.5 million. In addition to the 770,000 who would gain or retain coverage as a result of California’s policies, they project 750,000 would pay lower premiums as a result of a healthier mix of enrollees in the individual market and another 800,000 would receive state subsidies. Among them, 120,000 are projected to be middle income Californians not eligible for federal subsidies. 

Among the 3.5 million who are projected to remain uninsured, undocumented Californians remain the largest group. Low-income undocumented adults age 26 and older continue to be ineligible for full-scope Medi-Cal coverage. Affordability remains a major concern for the nearly  one million citizens or lawfully present immigrants projected to be eligible for Covered California but remain uninsured, most of whom have incomes in the subsidy eligible range. Californians who are low-income, Latino, or adults under 50 years of age are projected to be more likely to be uninsured.

“California’s lawmakers have taken important steps to build on the ACA, and we project 2.2 million Californians will benefit from these policies,” said Miranda Dietz, CalSIM project director at the UC Berkeley Labor Center and lead author of the report.

“Though millions of Californians will benefit from more affordable coverage thanks to these policies, 3.5 million will still be uninsured and many insured Californians will still struggle to afford coverage and care. Policy makers, including the new Healthy California for All Commission, have more work to do to make health coverage universal and affordable for all Californians,” said Gerald Kominski, senior fellow at the UCLA Center for Health Policy Research and co-author of the report.

The Center for Labor Research and Education (Labor Center) is a public service project of the Institute for Research on Labor and Employment (IRLE) at UC Berkeley. IRLE connects world-class research with policy to improve workers’ lives, communities, and society.

The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health policy information for California. The Center is the home of the California Health Interview Survey (CHIS) and is affiliated with the UCLA Fielding School of Public Health.

An evaluation by UCLA researchers has found that a California program launched in 2016 has been a positive step toward providing better-coordinated health care for people insured by Medicaid.

Initial findings from the ongoing analysis were published today by the UCLA Center for Health Policy Research. The researchers report that the state’s Whole Person Care program has been successful on several fronts so far, including the sharing of patients’ medical, behavioral health and social services data, which should enable providers to better collaborate to treat so-called “high-needs” patients.

That development is important in light of growing evidence that collaboration among medical, behavioral and social service providers can improve the health and well-being of people who frequently use health services — particularly those who are homeless or have mental health conditions. Nadereh Pourat, who led the evaluation and is the center’s associate director, said the lack of coordination among doctors, social workers and other health providers has been one of the system’s persistent and longstanding challenges.

Whole Person Care launched with 25 test programs covering 26 California counties; it is part of a California Department of Health Care Services effort to provide quality comprehensive care for people enrolled in Medicaid.

Among the researchers’ key findings:

• All 26 locations provided “active referrals” to medical care, behavioral health care and social services (meaning that workers made and attended appointments, and provided transportation assistance and follow-up).
• There were notable improvements in coordination and continuity of care because of the program.
• Data sharing capabilities improved. Seventeen pilots/centers (65%) had access to patients’ medical, behavioral health and social service data, and 15 of them (58%) had data-sharing agreements with all key partners. Also, 21 centers (81%) had access to patient data for frontline staff.
• Communication between the centers and patients was strong, with 23 centers (88%) reporting frequent, ongoing communication with enrollees.

The authors assessed the extent to which the program met criteria that they developed for evaluating the successful coordination of medical and behavioral health care.

“The program addresses challenges such as providing transportation to appointments or translation services for patients with complex needs, which can require organizations to work together in new ways,” said Emmeline Chuang, lead author of the paper and an associate professor at the UCLA Fielding School of Public Health. “We’ve identified elements of a framework that other organizations can use in considering how to successfully create their own programs and ultimately could influence policymakers and insurers to invest in the WPC approach to improve care for patients in California and beyond.”

Pourat, who also directs the research center’s Health Economics and Evaluation Research Program, said, “The data highlighted the value of continued investment in developing needed structure for care coordination, focusing on patient-centered practices that engage vulnerable patients and leveraging resources and partnerships to address limited availability of permanent housing. The program breaks down some of the barriers in our fragmented health care system and could pave the way for future models of care.”

The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health policy information for California. The Center improves the public’s health through high-quality, objective, and evidence-based research and data that informs effective policymaking. The Center is the home of the California Health Interview Survey (CHIS) and is part of the UCLA Fielding School of Public Health. For more information, visit www.healthpolicy.ucla.edu.

The symposium featured a trio of international health policy experts--Tsung-Mei Cheng, Princeton University, discussed Taiwan's system; Raisa Deber, University of Toronto, spoke about Canda's regional models; and Joseph Kutzin, World Health Organization, covered a number of systems in developing and moderate-income countries.

► Watch the Sacramento webcast of the E. Richard Brown Symposium on universal heath care

The experts stressed the benefits of universal care models and measured outcomes against the current multi-payer model of health care in the United States. As an example, Kutzin presented data that showed that while the U.S. had 4 percent of the world's population in 2016, it accounted for 43 percent of world health expenditures.

“Everyone should be able to have access to good-quality health services, without fear of the financial consequences for themselves, their families, their businesses and their jobs,” Kutzin said.

Approximately 130 people, including legislative staff, media and students, attended either the panel presentation and discussion at the state Capitol building in Sacramento March 1 or the workshop at UCLA on March 2. More than 500 people viewed the live webcast from Sacramento (recording available here). The office of State Senator Richard Pan (D-Sacramento) helped organize the Sacramento event.

At a reception that kicked off the symposium, California Insurance Commission Ricardo Lara decried that high health care costs forces Californians to choose between losing homes or savings to care for loved ones and thanked the Center for its research to help inform the state on facts about public health systems.

“Your work is critical to getting us to a place where we can have the data, we can have the facts of how the public enormously benefits,” Lara said. “We're California. We lead. We don't wait for the rest of the country.”

Assemblymember Jim Wood (D-Santa Rosa)  called the Center’s research a “driving force in how we can get to the ultimate goal to get health coverage for everyone in California.”

Center Director Ninez Ponce presented Marianne Brown, widow of UCLA Center for Health Policy Research founder E. Richard Brown, with a resolution from State Senator Ben Allen (D-Santa Monica) honoring her for a lifetime of work improving the health of Californians.

At the UCLA event Saturday, David Carlisle, president and CEO of Charles Drew University of Medicine and Science, said the symposium’s namesake, E. “Rick” Brown, “taught me everything I know about health policy.” Carlisle said Brown converted him from treating one patient at a time to treating a population. “He was always a guiding light that informed my work.”

Other Center staff participating in the symposium included Director Ninez Ponce; Associate directors Steven P. Wallace and Nadereh Pourat; Senior Fellow Gerald Kominski; and Faculty associates Jack Needleman, Michael Rodriguez and Mark Peterson.

The symposium launched the 25th anniversary of the UCLA Center for Health Policy Research, founded by E."Rick" Brown in 1994. Brown spent his life advocating strongly for a care-for-all system that would ensure health services for every Californian.

Ninez Ponce said a goal of the symposium is to "honor Rick in a way that gets action; honors Rick in a way that all the presentations are not just 'feel good,' but that they get used."

• Tsung-Mei Cheng. Woodrow Wilson School of Public and International Affairs, Princeton University 
• Raisa Deber, Institute of Health Policy, Management and Evaluation, University of Toronto [See Deber slide presentation]
• Joseph Kutzin, World Health Organization Coordinator & Lead of Health Financing Team [See Kutzin slide presentation]
• Q&A: Ritu Sadana

5. Break

6. Working Lunch – students move between 7-10 tables lead by guest speakers, faculty. Facilitators: Steve Wallace, Michael Rodriguez, Ninez Ponce, Mark Peterson. Lunch will be provided.

a. Financial/Economic Considerations

b. Health System Design

c. Workforce Concerns

d. Public Health and Policy

a. Have students react to the recommendations

On Oct. 10, the federal government proposed changes to the “public charge” rule, which is used to determine whether certain immigrants can obtain “green cards” and sponsor the immigration of family members. If the proposed changes are enacted, using public benefits to help meet basic needs ― including food and health care ― will count against immigrants who are working toward permanent residency in the U.S.

Immigration policy experts say the rule change will result in a “chilling” effect of fear and confusion, keeping individuals and families from using essential programs ― even if they are not actually subject to the “public charge” rule.

The resulting loss of federally funded public benefits will have a broad ripple effect throughout the economy, affecting health care providers, businesses, and workers in health care, food-related industries and other sectors.

There is a 60-day public comment period for the proposed rule.

On Nov. 7, Ninez A. Ponce, director of the UCLA Center for Health Policy Research; Laurel Lucia; director of the health care program at the UC Berkeley Center for Labor Research and Education; and Tia Shimada, director of programs at California Food Policy Advocates, will preview a forthcoming report and share estimates of the health and economic impact the rule change will have on California, its regions, and its racial and ethnic groups.

The research is supported by the California Health Care Foundation and The California Endowment.

To attend in person: Please RSVP at https://bit.ly/2EfNbyQ

To attend online: goo.gl/6Vp8eB (No RSVP needed)

• The percentage of residents under 65 who were enrolled during 2014-15: Fresno County had the highest proportion, 49 percent; Marin County the lowest, 10 percent.
• The percentage point change in enrollment from 2012 to 2014-2015: San Joaquin County had the highest increase, 22 percent; Madera and Yolo counties the largest declines, each down 5 percent.
• Per capita expenditures in 2015: Humboldt County had highest expense, $387 per capita; Yuba County the lowest, $79 per capita.
• The percent change in public health expenditures per capita from 2012 to 2015: Riverside County had largest increase at 39 percent; Yuba County the biggest decline, down 12 percent.

• Mental health and wellness. Park therapy workers provided residents with mental health screenings, led mental health discussion groups and offered other services in accessible, approachable ways, such as using a mental health mobile game truck to reduce stigma about and create a relaxed environment for conversations on the topic.
• Probation enrichment program. Deputy probation officers at the parks worked with neighborhood youth, offering access to educational resources, job training and placement, and field trips to cultural events outside the community.
• Intervention workers. Through a partnership with the City of Los Angeles Office of Gang Reduction and Youth Development, community intervention workers resolved potential conflicts, encouraged at-risk youth to avoid joining gangs, and connected current gang members with community resources and services.

When Parks After Dark was launched at three parks in 2010, it primarily focused on improving safety and reducing gang-related crime at the parks. With investments from Los Angeles County departments of public health and probation, and from other key partners, the program evolved into a key prevention and intervention strategy that encompasses safety, health, social cohesion and community well-being. In 2017, residents made nearly 200,000 nighttime visits to the 23 parks participating in the program.

As in previous years, concerts and movie nights remain Parks After Dark’s most popular offerings, according to the UCLA report. Deputy sheriffs continue to build positive relationships with residents through participation in Parks After Dark activities, face-to-face conversations, and foot patrols of the parks. In 2017, the evening park program employed about 50 youth and young adults — including teens for whom the experience was their first job — and more than 300 youth volunteered at the evening park programs.

“The community has discovered that there’s a safe place right in their backyard that they can go to at night with family and friends,” said Tatevik Magakyan, the parks department’s Parks After Dark coordinator. “When people feel safe, they are more willing to come out the parks to exercise, socialize and access needed services. It should be our priority to sustain programs – like Parks After Dark — that help high-need communities thrive.”

The report recommends that Parks After Dark expand by providing additional programs at the parks already in the program; that the program uses parks as hubs to link at-risk youth with more social services through strategic partnerships; and identify a sustainable funding source for the program.

The program was implemented in partnership with the Los Angeles County Board of Supervisors; several county agencies, including the Chief Executive Office, Los Angeles County Department of Public Health, Los Angeles County Sheriff’s Department, Los Angeles County Probation Department, Los Angeles County Department of Mental Health; and local community-based organizations.

​Dr. Ninez Ponce, a UCLA professor and passionate advocate on behalf of evidence-based health policies that represent and serve the nation’s increasingly diverse population, has been appointed the new director of the UCLA Center for Health Policy Research at the Jonathan and Karin Fielding School of Public Health, starting July 1.

She will succeed Dr. Gerald (Jerry) Kominski, a professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health and a distinguished health policy analyst and health economist who has advocated on behalf of coverage for the underserved throughout his 30-year career at UCLA.

Ponce, also a professor in the UCLA Fielding School of Public Health's Department of Health Policy and Management, is internationally recognized as a disparities researcher. She is also a noted expert in survey-based research and helped develop the California Health Interview Survey (CHIS), the nation’s largest state health survey.

“The UCLA Center for Health Policy Research is a cornerstone of policy in California and our data collection methods are a model for how to understand a rapidly changing nation,” said Ponce. “It will be an honor to lead this renowned research center at a crucial time in our country’s ongoing conversation about race, equity, and access to health care.”

Kominski was appointed director in January 2012 and served as an associate director for 18 years prior to that. He will continue to research critical issues in health policy as a senior fellow at the Center and in his continuing role as a professor in the UCLA Fielding School of Public Health.

“My commitment to social justice began in the 1960s, when I was inspired by the civil rights movement and Dr. King to fight for a more equal and just society,” Kominski said. “The Center embodies those ideals that inspired me so early in my life. But now it’s time to ‘pass the torch‘ to a new generation of leaders in the fight for social equality.”

Measuring the nation’s diversity
Ponce led pioneering efforts in multicultural survey research, including some of the first scientific techniques to accurately measure race and ethnicity, cultural assimilation, generational status, and discrimination. As the Principal Investigator for the Center’s California Health Interview Survey (CHIS), she led efforts to expand the survey’s already-comprehensive understanding of race and ethnicity, including adapting the survey into Chinese (Cantonese and Mandarin), Korean, Vietnamese, and Tagalog (along with Spanish and English), and implementing Asian ethnic oversamples.  Under her leadership, CHIS became a national and increasingly global model of how to collect health information about many little-studied racial, ethnic, indigenous, and sexual minority groups. That data has made the Center’s research pivotal on many national issues, from single-payer health care, to the health of the undocumented, to gay marriage.

“Ninez Ponce is uniquely qualified to serve as the next director of the Center,” said Kominski. “She is a committed advocate for the underserved, and her leadership of CHIS makes her the perfect person to continue the Center’s core mission, begun by Rick Brown, of fighting for universal access to health care in California, the nation, and the world.”

Since joining the Center at its founding in 1994, Kominski helped build the Center into one of the nation’s leading think tanks, known in particular for its evidence-based research on the uninsured before and after the passage of the Affordable Care Act, as well as for its large-scale evaluations of state and federal health programs. During the past 8 years, he has led the Center’s efforts, in collaboration with UC Berkeley, to develop complex predictive modeling of enrollment and other factors affecting implementation of the Affordable Care Act. He is widely recognized as a strong and effective public defender of that landmark legislation in the media and in his many speaking appearances.

“It is an enormous pleasure to appoint Ninez Ponce as the new director of the Center,” said Dr. Jody Heymann, dean of the UCLA Fielding School of Public Health, which serves as the Center’s organizational home. “Ninez’s outstanding leadership in advancing our understanding of health disparities, and in moving from developing the best evidence base to public policy which changes lives represents public health at its most transformative. She will be following in the footsteps of a truly extraordinary leader who has contributed immensely to increasing access to health across the country: Jerry Kominski.  We are deeply indebted to him for his leadership of the Center and the endless energy he brings to ensuring all Americans have access to health care.”

The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health policy information for California. The Center improves the public’s health through high-quality, objective, and evidence-based research and data that informs effective policymaking. The Center is the home of the California Health Interview Survey (CHIS) and is part of the UCLA Fielding School of Public Health. For more information, visit www.healthpolicy.ucla.edu.

A new UCLA study finds that 27 percent, or 796,000, of California’s youth, ages 12 to 17, report they are viewed by others as gender nonconforming at school.

The study also assessed differences in mental health among gender nonconforming youth and gender conforming youth in the state, and found no significant difference in the rates of lifetime suicidal thoughts and suicide attempts between gender nonconforming youth and their gender conforming peers. However, gender nonconforming youth were more than twice as likely to have experienced psychological distress in the past year.

“The data show that more than one in four California youth express their gender in ways that go against the dominant stereotypes,” said lead author Bianca D.M. Wilson, the Rabbi Barbara Zacky Senior Scholar of Public Policy at The Williams Institute. “However, the heightened psychological distress we see among gender nonconforming youth indicates that we must continue to educate parents, schools and communities on the mental health needs of these young people and reduce known risk factors, such as bullying and bias.”

The study, released by The Williams Institute at UCLA School of Law and the UCLA Center for Health Policy Research, analyzed data collected from nearly 1,600 California households in the 2015-2016 California Health Interview Survey. It is the first time this survey has included questions about gender expression among teens.

Gender nonconforming refers to people whose behaviors and appearance defy the dominant cultural and societal stereotypes of their gender. The health interview survey measured gender expression by asking adolescents how they thought people at school viewed their physical expressions of femininity and masculinity. Youth who reported that people at school saw them as equally masculine and feminine were categorized as “androgynous.” Girls who thought they were seen as mostly or very masculine and boys who thought they were seen as mostly or very feminine were categorized as “highly gender nonconforming.”

Key findings of the study include:

• 27 percent, or 796,000, of California’s youth, ages 12 to 17, report they are viewed by others as gender nonconforming at school, including 6.2 percent who are highly gender nonconforming and 20.8 percent who are androgynous.

• Highly gender nonconforming, androgynous and gender conforming youth do not statistically differ in rates of lifetime suicidal thoughts and suicide attempts.

• As a group, both highly gender nonconforming and androgynous youth reported higher levels of psychological distress compared to their gender-conforming peers.

The finding that gender nonconforming youth in California do not have higher rates of suicide differs from the findings of some previous research. The study co-authors suggest that the variation in findings may be due to sample-size limitations of this study or possibly to the state’s supportive policies for gender nonconforming people. California is one of several states that expressly prohibit bullying and discrimination against gender nonconforming people in schools and public accommodations, among other arenas.

“It’s possible California’s policy environment has made it safer for adolescents to be gender nonconforming,” said Tara Becker, a co-author and statistician for the health survey, which is conducted by the UCLA Center for Health Policy Research. “But given events at the national level, we should by no means relax our stance. California can and should strive to be an ongoing model of acceptance and inclusion.”

The Williams Institute, a think tank on sexual orientation and gender identity law and public policy, is dedicated to conducting rigorous, independent research with real-world relevance.

The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health policy information for California. The Center improves the public’s health through high-quality, objective, and evidence-based research and data that informs effective policymaking. The Center is the home of the California Health Interview Survey (CHIS) and is part of the UCLA Fielding School of Public Health. For more information, visit www.healthpolicy.ucla.edu.

The first release of transgender data from the California Health Interview Survey, the nation’s largest state survey, reveals the demographic characteristics of transgender adults in the state — such as population size, racial makeup and marital status — as well as sobering disparities in their health status. For example, one in five transgender adults in California has attempted suicide — a rate six times that of the state’s adult cisgender population.

The health data used in a new policy brief by The Williams Institute and the UCLA Center for Health Policy Research are among hundreds of new California Health Interview Survey (CHIS) estimates released today. Included are updated statistics on health insurance that show the number of uninsured Californians at record lows in 2016, primarily as a result of Medi-Cal expansion under the Affordable Care Act. A webinar on findings from the policy brief and the survey is today from noon to 1 p.m.

The policy brief on gender identity, which uses pooled 2015-2016 California Health Interview Survey data for greater stability, reports that 92,000 transgender adults between the ages of 18 and 70 make up 0.35 percent of California’s adult non-institutionalized population. According to the report, transgender adults have general health status, insurance and health access similar to cisgender adults, or adults who identify with their sex assigned at birth.

However, 22 percent of transgender adults have ever attempted suicide, compared to 4 percent of cisgender adults. Transgender adults are about three times more likely to have had lifetime suicidal thoughts, 34 percent to 10 percent, and nearly four times more likely to have experienced serious psychological distress in the past year, 33 percent compared to 9 percent, according to the brief. They are significantly more likely to report having a disability due to a physical, mental or emotional condition, 60 percent to 27 percent. They are more likely to delay or not get needed doctor-prescribed medicine compared to cisgender adults, 32 percent compared to 11 percent, according to the brief.

“In many ways, transgender adults in California are similar in characteristics and experiences to cisgender adults,” said Jody Herman, Scholar of Public Policy at the Williams Institute and lead author of the brief. “Yet, this study points out that there’s still much that needs to be done in California to address health disparities for the transgender population.”

Diverse survey participants
Because it reflects California’s diversity, CHIS is used nationally and even internationally for its wealth of data on many under-surveyed racial, ethnic and gender minority groups. In 2016, 21,269 California households participated in the survey, and 21,444 responded in 2015. Those who were surveyed answered questions on health topics such as mental, dental and physical health issues; insurance coverage; internet usage; and baby bottle-feeding practices.

Trends and new topics
The proportion of uninsured Californians from birth to age 64 declined from 15.5 percent in 2013 — the year before the Affordable Care Act was expanded — to 9.5 percent in 2015 and to 8.5 percent, or 2.8 million people, in 2016. Residents who are undocumented make up 37.4 percent of those who are uninsured and ineligible for Medi-Cal, the public program for low-income and disabled Californians.

“More than 60 percent of the uninsured are Latino,” said Ninez Ponce, principal investigator for CHIS and associate director of the Center. “They have remained at the bottom of the health care pyramid.”

Although the proportion of nonelderly Latinos who were uninsured was cut almost in half, from 21.4 percent in 2013 to 12.3 percent in 2016, they remain more likely to be uninsured than members of other racial groups and account for the highest percentage of the state’s overall uninsured population, according to the survey.

Continuing uncertainties over federal funding of health programs cast a pall on gains in health insurance coverage, particularly for the one in three Californians covered by Medi-Cal. Fresno, Siskiyou, Tehama and Tulare, all rural counties, had among the highest growth in post-Affordable Care Act adult Medi-Cal enrollment — from 25.7 to 29.4 percent, according to the survey estimates. The state’s safety-net health program now covers 33.3 percent to 45 percent of the population in those counties.

“Many children and adults newly insured by the ACA’s expansion of Medi-Cal are at risk of losing health care if health program funding is cut back or allowed to languish,” said Todd Hughes, director of CHIS. “Rural communities will suffer significantly.”

Other noteworthy 2016 health data and trends on Californians:

Transgender demographics: California’s transgender adults ages 18 to 70 are more likely to be white compared with cisgender adults, 65 percent to 39 percent, respectively, and less likely to be Latino, 13 percent to 38 percent. When asked how they currently describe themselves, 7 percent of transgender adults said male, 32 percent female, 46 percent as transgender and 15 percent as a different gender identity.

Disparities in medical care discrimination. African-American adults have the highest rate of reporting medical care discrimination due to race or ethnicity, 14.2 percent. Rates for other racial groups: whites, 2.6 percent; Asians, 5 percent; Latinos, 6.4 percent; other and multiple races, 8.7 percent. However, whites and multiple-race respondents had the highest rates of medical discrimination based on mental health, sexual orientation or gender identity, 4.5 percent and 5.1 percent, respectively.

Marriage inching down. The proportion of married adults dropped below the halfway mark in 2015 to 48.4 percent and hit 47.4 percent in 2016. The share of never-married singles is increasing gradually, reaching 27.7 percent in 2016.

Fewer married couples with children. The proportion of married adults with children has gradually declined to 22.7 percent in 2016, a 9-percentage-point drop since 2005. The proportion of married couples without children remains fairly constant at 25.8 percent. In 2016, 4.7 percent of women ages 18 to 44 said they were pregnant.

Teen facts. In 2016, 22.5 percent of teens ages 12 to 17 said they had tried an alcoholic beverage, a 14-percentage-point decline since 2003. About 1 in 10 teens have used an e-cigarette; 15.5 percent reported they have had sex; and 23 percent described themselves as obese.

Overall adult health status. Nearly four in five adult Californians report being in good/very good/excellent health. But measuring by race shows disparities: While 85.9 percent of whites reported they were in good-to-excellent health, 69.9 percent of Latinos and 77.5 percent of African-Americans said the same. Latinos make up the largest racial/ethnic group in the state, 39.2 percent, according to the state Department of Finance.

Dental health. Nearly 71 percent of adults report they have excellent/very good/good teeth, and 61 percent have dental insurance. Two percent said they don’t have their own teeth. Among all children, nearly 70 percent had a dental check within the past 6 months in 2016, a 9-percentage-point increase compared to 2013. The number who had never been to a dentist was 12.5 percent — an almost 7-percentage-point decline over the same time period.

Housing crunch. Homeownership has steadily declined statewide over the past decade, from 62 percent in 2007 to 55.2 percent in 2016, although it varies from county to county. In San Francisco County, the rate is 38.6 percent and in Los Angeles County, it is 48.7 percent. Of adult survey respondents under 30, nearly half — 48.9 percent — still live with their parents.

Six years of annual information — 2011 to 2016 — are now available to the public for free through the center’s easy-to-use web tool AskCHIS, which allows users to customize their queries.

The 2016 survey spans 16 broad topic categories, including: general health; health conditions (such as chronic conditions like diabetes, asthma, high blood pressure and obesity); mental health; dental health; health behaviors (such as diet, activity, alcohol and cigarette use, sexual behaviors); neighborhood and housing (such as social cohesion); health insurance coverage and child and adolescent health insurance; access to health care; employment (status, hours, industry and occupation); child care; respondents’ characteristics (such as race, sexual orientation, gender identity and gender expression, and citizenship).

Read the transgender report: Demographic and Health Characteristics of Transgender Adults in California: Findings from the 2015-201 California Health Interview Survey

Find 2016 California Health Interview Survey data: AskCHIS.com

Read the insurance policy note: Number of Uninsured in California Remained at Record Low in 2016

The California Health Interview Survey is conducted by the UCLA Center for Health Policy Research in collaboration with the California Department of Public Health and the California Department of Health Care Services and is supported by several public and private funders committed to improving the health of Californians.

• Have people help review and disseminate the health care information. Current consumers and their families can help make sure future informational materials are in simple, understandable language and translated into multiple languages and formats — print, in-person talks and web-based materials. Also, consumers’ families, doctors, community advocates and others could be trained as health information navigators for those with limited health literacy, similar to Covered California’s Navigator Program.
• Avoid disruption of a someone’s existing network of health care. Losing access to trusted health providers is the biggest concern of consumers who are eligible for both Medicare and Medi-Cal. State policymakers and planners could propose a new model that coordinates care across existing programs. Then consumers could choose to keep their existing Medicare and Medi-Cal providers if they wish but also access new program services they lack. Washington State’s managed fee-for-service program is an example of this type of model.
• Recognize and respond to consumer diversity. Language proficiency, education, immigration status and other factors complicate decision-making about new health care plans. Community organizations must identify and address the different needs and challenges facing these people in L.A. County and help them through the decision-making process

​A Los Angeles County recreational program created stronger ties within communities, improved relations between the community and law enforcement officers, and decreased crime, according to a report by the UCLA Center for Health Policy Research. The study also found that the program, called Parks After Dark, saved millions of dollars in policing and health care costs.

The program was intended to make specific Los Angeles County parks safer through positive community engagement by the Los Angeles County Sheriff’s Department, while providing wider access to free recreation, health and wellness programs. The effort, which was launched in 2010 as an anti-gang initiative by the county’s Department of Parks and Recreation, has focused on neighborhoods with high levels of gang activity and crime.

The program provides recreational sports, classes on healthy eating and exercise, computer courses, concerts and movies, as well as health care and social services — including registration for the CalFresh food stamps program, mammograms, mental health assessments and other health screenings — on Thursday, Friday and Saturday evenings from June through August.

Parks After Dark expanded from three parks in its first year to 23 this summer, including in unincorporated communities of South Los Angeles, East Los Angeles, Altadena, La Puente, Sylmar, Val Verde, Lake Los Angeles and Whittier.

The UCLA report found that about 95 percent of people who participated in Parks After Dark programs in 2016 said they felt the program improved their community’s relationship with the deputy sheriffs, and of participants who described their own neighborhoods as ''unsafe,'' 7 in 10 said they felt safe while they attended park programs. About 95 percent said it helped improve their relationships with neighbors.

''The evaluation revealed evidence of multiple benefits,'' said Nadereh Pourat, director of the Health Economics and Evaluation Research Program at the center and the report’s lead author. “The data show the program achieved its goals of promoting healthy behavior and safer communities.''

The program’s budget for 2016 was $2.3 million, but the UCLA report estimates that by reducing crime, it saved the county about $5.87 million in law enforcement costs last year. The researchers also estimated that wellness programs, including Zumba and other physical activity classes, ultimately saved the participants and the county more than $500,000 in health care expenditures.

In 2016, Parks After Dark programs received about 178,000 visits, according to the report.

''Families who are involved in the evening park programs want PAD to continue, and they say these programs have brought their families — and the community — together,'' said Faith Parducho, special assistant at the Department of Parks and Recreation.

The report includes recommendations for strengthening Parks After Dark, such as finding ways to encourage participants to be physically active year-round, identifying a sustainable source of funding and encouraging deputy sheriffs to increase their engagement with residents throughout the year to further build trust — especially through more organized activities with teens.

The program was implemented in partnership with the Los Angeles County Board of Supervisors;  several county agencies, including the chief executive’s office, department of public health, sheriff’s department and probation department; and local community-based organizations.

Read the policy brief: Parks After Dark: Evaluation Brief

Read the related interview: Three Questions for the Expert

The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health policy information for California. The Center improves the public’s health through high-quality, objective, and evidence-based research and data that informs effective policymaking. The Center is the home of the California Health Interview Survey (CHIS) and is part of the UCLA Fielding School of Public Health. For more information, visit www.healthpolicy.ucla.edu.

​Allowing podiatrists to give diabetic patients regular foot health screenings — which are usually done by primary care doctors — could save limbs, lives and money, according to a new policy brief from the UCLA Center for Health Policy Research.

As many as 1 in 4 diabetic Californians develop damaging toe, foot and leg ulcers which could lead to amputation and elevated risk of death, according to the study. The cost of treatment statewide reached $565 million in 2014.

Using admissions data from the California Office of Statewide Health Planning and Development, authors of the study found that podiatry services provided to diabetic patients could have saved between $29 million and $97 million in 2014, even given the limited number of diabetics who received foot screenings — between 11 percent and 30 percent of patients, depending on age.

Role of podiatrist
A medical doctor who provides podiatric services to a Medi-Cal patient is reimbursed for treatments, which could include screening for foot health or treating wounds that could lead to infection. But a podiatrist who performs the same services in his or her office to that patient is typically denied reimbursement because his or her services are considered "optional."

"Foot screening should not be optional, unless you consider lower limbs optional," said Jonathan Labovitz, Medical Director of the Foot & Ankle Center at Western University of Health Sciences and lead author of the report. "An amputation does not just result in a reduced quality of life but in a significantly increased risk of death."

Foot ulcers are one of the most common complications of diabetes. Treatment for advanced cases involves hospitalization and amputation, making management of foot ulcers extremely expensive — about $17 billion a year nationwide, according to figures cited in the report. More than 80 percent of toe, foot or leg amputations among diabetic patients are preceded by foot ulcers, and as many as three-quarters of those amputees die within five years, according to the report.

It costs between $7,500 and $20,600 each time a diabetic foot ulcer is treated, according to the American Podiatric Medical Association (APMA). In comparison, the APMA says a limb amputation resulting from a foot ulcer costs $70,400 and as much as a half-million dollars over a patient's lifetime. The study's authors estimate that California would save between $7.5 and $16.9 million for Medi-Cal patients alone by providing foot screening and preventing amputation.

California Health Interview Survey data cited in the study estimates diabetes rates among California residents rose from 8.4 percent in 2011 to 8.9 percent in 2014. Among seniors, the rates were even higher: from 18.6 percent to 20.6 percent, possibly presaging a rise in diabetes-related complications — and costs.

"Getting diabetic patients checked regularly before foot problems escalate significantly brings down health care costs," said Gerald Kominski, Center director and co-author of the report. "Diabetes is not going away and California is aging. From a policy perspective, podiatric foot screenings are key to combatting the economic toll of this disease."

Read the policy brief: Podiatric Services Could Reduce the Cost of Treating Diabetes Complications in California by up to $97 Million

The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health policy information for California. The Center improves the public’s health through high-quality, objective, and evidence-based research and data that informs effective policymaking. The Center is the home of the California Health Interview Survey (CHIS) and is part of the UCLA Fielding School of Public Health. For more information, visit www.healthpolicy.ucla.edu.

• Urban areas: Three-quarters of young families are urban residents, and half of those are Latino parents; about 30 percent are non-citizens; and about a quarter are enrolled in Medi-Cal and/or WIC.
• Rural areas: Ten percent of young families live in rural areas. They have the highest proportion of U.S.-born parents -- 66 percent with at least one parent born in the U.S. Rural areas also have a higher proportion of young White families. These areas also have the highest level of feeling safe in their neighborhoods "all of the time" at 55 percent.
• Suburbs: Less than 15 percent of young families live in the suburbs. Suburban parents have the highest educational attainment — 72 percent report more than 12 years of education. The area has higher proportions of White and Asian young families, and higher incomes — 70 percent are at or above 200 percent of FPL — compared to 51 percent of urban families and 46 percent of rural families.