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3/28/2019
  
Ninez A. Ponce, PhD, MPP

Ninez Ponce​ is the director of the UCLA Center for Health Policy Research and principal investigator of the California Health Interview Survey. Ponce organized events in Sacramento and Los Angeles for the recent E. Richard Brown Symposium on Universal Health Care, which she discusses in this brief interview.​

What was the impetus behind the universal health care symposium?

​​E. Richard Brown, who founded the UCLA Center for Health Policy Research 25 years ago, waged a lifelong battle for a health system that would provide universal health care and believed that the smart design of such a system be informed by good data and sound research evidence. To this end, Dr. Brown launched the California Health Interview Survey — a population health survey that has tracked the state’s report card on health coverage since 2001.    

Rick’s widow, Marianne Brown, approached me a few years ago to honor Rick. Honoring Rick’s legacy on health policy in California, this symposium’s topic is so timely — universal health care in California. Rick would be thrilled that we presented a program of esteemed international and California speakers, moderators and other participants to outline possible system designs, policy proposals that inform discussions currently taking place in the legislature and governor’s office on universal coverage. ​​

You had the E. Richard Brown Symposium in two different locations. Did you have different goals for each?

​​Yes. In Sacramento, our goal was to inform the decisionmakers at the state policy level — legislators, regulators, chief administrators and their staff. We are grateful Dr. Richard Pan, chair of the Senate Committee on Health, for sponsoring our briefing​ at the Capitol. At a kick-off reception for the event, we were honored by the presence of Insurance Commissioner Ricardo Lara and Assemblymember Jim Wood, the chair of Assembly Health Committee.  

In Los Angeles, our goal was to bring the world to the UCLA community. With our speakers — Joseph Kutzin from the World Health Organization (WHO), Geneva; Raisa Deber from University of Toronto; and Tsung-Mei Cheng from Princeton University, who is an expert on the Taiwan system — our UCLA students learned about different models and paths to universal coverage from around the world. After the presentations, students had the opportunity to engage in small-group roundtable discussions with faculty and our invited speakers.​

This symposium launched the 25th anniversary of the Center — what other events are on tap?
We will continue the conversation by producing a report from the E. Richard Brown Symposium with key insights and recommendations for a research agenda to ensure implementation of universal coverage, and we will host a series of seminars throughout the year, starting with a spring seminar. Then we’ll culminate with a gala celebration in late fall. ​
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1/31/2019
  
Janet C. Frank, DrPH

Janet Frank is a faculty associate and lead author of a new study on the need for a more robust and well-trained workforce to serve the behavioral health needs of California’s older adults. In this brief interview, she discusses the need for geriatric behavioral health training and models that have addressed the recruitment and retention for the public behavioral health workforce that serves California’s older adults.

Explain a little more why behavioral health training needs to be specialized for older adult behavioral health services?

​There are several important differences about serving older adults with behavioral health needs. First, most older adults, about 80 percent, have one or more chronic medical conditions, along with their behavioral health issues. This makes their care more complicated. Clinicians need to be able to take an integrated approach to their care and understand the challenges of providing services to people with complex medical needs. One example of this is managing medications. Older adults metabolize medications more slowly than younger people, so they stay in their systems longer. So the geriatric approach to medication dosage is “start low and go slow” to avoid toxicity and other adverse events associated with medication mismanagement.  

Your study reports that the public behavioral health workforce is understaffed and inadequately trained for the challenges of caring for older adults.  What models or ideas address these issues?

​There are a number of good models that counties have developed to address the specialized needs of older adult behavioral health care. In Los Angeles County, the Geriatric Evaluation Networks Encompassing Services Intervention Support (GENESIS) Program deploys an interprofessional geriatric team to provide assessment and treatment to older adults. GENESIS includes geriatric psychiatry residents from UCLA for a six-month rotation.

Another great training model is in San Diego County. The Geriatric Certificate Program is an intensive six-month certificate training with a culminating project and continuing education with the academy based at San Diego State University. There is an application process and selection for the positions for clinician case managers who will be clinic-based. This is believed to be the only such intensive education for persons who focus on service to older adults. This is at the level of a college course and provides an incentivized job role to account for older adult case load.

In Monterey County, the Senior Peer Counseling Program (SPC) provides no-cost mental health intervention and emotional support to older adults suffering from depression, anxiety, grief, loss, adjustment to chronic illness, and other stressors that can occur in the later life. Peer counselors, trained and supervised by mental health professionals, provide short-term one-on-one counseling that may be home-based, office-based, or at long term-care facilities.

You talk about many problems in training and retaining workers in behavioral health. Is there any way to make geriatrics training sexier, so more people will go into the field?

Since colleges and universities typically do not require gerontology or geriatrics courses within the “helping professions” that comprise the behavioral health workforce (e.g., psychiatrists, psychologists, social workers, counselors), there is not exposure to this content unless the student takes elective courses. Only between 1 and 4 percent of behavioral health professional take geriatrics electives during their graduate work. Due to ageism, the cost and time for advanced training and lack of programmatic and salary incentives, there is not much “up side” for going into geriatrics, and specifically geriatric behavioral health.

I’m afraid there isn’t a way to make geriatrics “sexier,” however we can urge our state planners and policy makers to set up course requirements and hiring/salary incentive programs to encourage people to choose this specialization. After all, 1 in 5 Californians will be older adults by the next decade we are already late in our preparation to serve their needs.  

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/janetfrank.jpg"
10/31/2018
  
Tara Becker, PhD

​Tara Becker is a CHIS senior public administration analyst and author of a new policy brief that analyzes the latest health insurance trends in California. In this interview, Becker discusses changes in employer-sponsored insurance (ESI) and the effects of actual and potential federal policy changes regarding elements of the ACA.

ESI enrollment hit a low of 48.2 percent in 2016. But this year the rate rebounded to 51.2 percent. Meanwhile, Medi-Cal's steadily-rising enrollment rate declined from 33 percent in 2016 to 29 percent in 2017. What does that suggest to you?

​Enrollment in employer-sponsored insurance coverage improved as the economy continued to improve. During this period, more Californians entered the labor force and fewer were unemployed. These changes lead to an increase in the rate of employer-provided coverage both because Californians are more likely to be working, and in a tight labor market, employers are more likely to offer health insurance coverage to attract and retain employees.

The individual mandate feature of the ACA will be eliminated in January. What effect will that have on insurance rates?

The purpose of the individual mandate was to encourage younger and healthier people to purchase insurance so that the pool of Californians with health insurance coverage would have lower average health care costs. This in turn would lower health insurance premiums and make health insurance more affordable for those who have higher medical costs.

Without this incentive to purchase health insurance coverage, many younger and healthier people might opt out of purchasing insurance because their expected medical costs are lower than the cost of insurance coverage. This may reduce the pool of insured Californians primarily to those who are older and less healthy, meaning the average medical costs incurred by each individual in the pool will increase, leading to higher health insurance premiums. This may discourage even more young healthy Californians from purchasing coverage, further increasing the average costs for those who remain insured, and in an extreme case, leading to an insurance market death spiral.
 
In the long-term, this will make health coverage more expensive for these younger and healthier Californians when they do need to purchase health insurance in the future.
Although Medi-Cal enrollment dropped in 2017, 29 percent of nonelderly Californians are covered by the state health program for low-income and disabled Californians. Which groups stand to lose most if the federal government tightens Medi-Cal funding?

​Low-income Californians are the most likely to lose coverage if changes to Medi-Cal are made. In 2017, more than 60 percent of nonelderly Californians with family incomes below 139 percent of the federal poverty guidelines (FPG) were insured through Medi-Cal, as were more than 40 percent of those with family incomes between 139 percent and 200 percent FPG. Because more than 40 percent of Latinos and 30 percent of African-Americans are covered through Medi-Cal, the uninsured rate will likely rise for these groups if Medi-Cal eligibility is restricted.

Regionally, any restrictions on Medi-Cal eligibility would hit the San Joaquin Valley the hardest, because more than 40 percent of residents in this region are enrolled in the program. Both Los Angeles County (34 percent enrolled) and the Northern and Sierra counties (31 percent enrolled) also experience high rates of Medi-Cal enrollment and would likely experience an increase in the number of uninsured.
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9/27/2018
  
Susan H. Babey, PhD

Susan H. Babey is co-director of the Center’s Chronic Disease Program and lead author of new studies on child/teen physical activity and adult walking. In this brief interview, Babey discusses why many children are sedentary, why adults should put in even more steps walking, and other benefits of physical activity.

Your study found that only 1 in 3 kids and 1 in 5 teens get the recommended hour a day of physical exercise. What factors influence their avoidance of sweat?

A lot of factors influence how much physical activity kids get. Many kids live in neighborhoods without sidewalks and without access to safe parks or bicycle trails and paths near their homes. Our study found that kids who lived near parks got more exercise. Concerns about safety can be a barrier to physical activity. We found that 15 percent of children and adolescents live in neighborhoods that they or their parents consider unsafe. Those children and adolescents were less physically active.

In addition, between school, homework, and other activities, kids have a lot competing for their time. Video games, TV, phones and other technology offer a tempting diversion ― one that can encourage significant amounts of sedentary behavior during kids’ free time if parents don’t set limits. 
In comparison, the adult recommendation for walking is just 150 minutes a week. Are we letting adults off too easily?

​Physical activity guidelines recommend that adults get at least 150 minutes of moderate activity each week. Walking is the most common form of physical activity among adults and it is one that many adults are able to maintain throughout their life. The recommendation of 150 minutes of moderate activity is associated with substantial health benefits including lower rates of heart disease, high blood pressure, stroke, type 2 diabetes, and colon and breast cancer as well as helping to prevent weight gain.

However, the guidelines also emphasize that even greater health benefits are associated with 300 minutes of physical activity per week, and this amount is more in line with the recommendations for kids. Our study found that only one-third of California adults meet the physical activity recommendations by walking for at least 150 minutes per week. However, our data only included information about walking (not other kinds of physical activity). More of the adults in our study would have met recommendations if other types of activity were included. Nationally, about half of adults meet physical activity guidelines.
Are there other reasons beyond being physically fit to pull ourselves away from sedentary activities like binge-watching TV shows and exercise instead?

​Physical activity has a lot of benefits beyond improved physical fitness for both kids and adults. In addition to physical health benefits, more physical activity is linked to improved cognitive function and sleep quality as well as reduced risk for depression and dementia for adults. For kids, more physical activity is linked with increased mental alertness and higher academic achievement, as well as lower levels of stress and depression.

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8/30/2018
  
D. Imelda Padilla-Frausto, PhD, MPH

D. Imelda Padilla-Frausto is a Center research scientist and co-author of a fact sheet on rent burden shouldered by low-income seniors in California. In this brief interview, Padilla-Frausto discusses the concept of rent burden and poverty, regional rent and senior budgets, and the image of  “worry-free” retirement living.

Your study says that more than three-quarters of low-income senior renters are rent burdened (pay 30 percent or more of their income on rent). How did this happen? 

​Many low-income older Californians live on a fixed income year after year. But rental housing costs in California rise dramatically every year, creating an ever-growing gap between older adults’ income and rental housing costs. As this gap widens, more adults become rent burdened. Housing tends to be the biggest expense in older adults’ budget as documented by the California Elder Economic Security ™ Index (Elder Index), and low-income, older Californian renters are the most vulnerable.

In fact, California ranks third in the nation for having one of the largest gaps between renters’ wages and the cost of rental housing. This large gap is for wage earners so we can assume it is much worse for those on fixed-incomes like older adults.

How can the rent burden for seniors be higher in Sacramento than in San Francisco? And what can be done about it?

​This difference is most likely due to rent-control policies that exist in San Francisco but not in Sacramento. For this data, rent burden is calculated using current spending on rent. So, while the cost to a new renter for a one-bedroom apartment in San Francisco is more than twice that for a comparable unit in Sacramento, the long tenure of older renters in San Francisco’s rent-controlled units likely reduces the actual rents paid by most seniors.

There are a few things that can be done to decrease the number of rent-burdened older adults, such as adopting more local rent-control policies for older adults in particular and building more affordable housing for seniors. Another unique approach would be to subsidize low-income older renters like the pilot project in Santa Monica called Preserve Our Diversity. This program provides rental assistance to their long-term residents over the age of 65 who would otherwise be displaced from the city due to their inability to pay their rent. The Santa Monica Housing Council used the Elder Index for Los Angeles City to identify the income an older adult needs to pay for basic living expenses.

There's a general image that older adults retire and live comfortably in senior communities. What is the reality?

​For some fortunate older adults, this may be true, but for many older adults, the happily-ever-after ending of the “golden years” is complete fiction. Recent data from the Elder Index shows over one-quarter of older adults do not have enough income to cover basic living expenses, and there are particular groups of older adults who are disproportionally impacted.

For instance, older renters fare the worst compared to those who own their homes, regardless if they have a mortgage or not. Older Latinos, blacks and Asians are more likely to be economically insecure than their white counterparts. Older women are more likely to have less income to meet their basic living expenses than older men, but there is still one-quarter of older men who are economically insecure. Similarly, older Californians age 75 and over tend to be more vulnerable to economic insecurity than those age 65 through 74, but still one-quarter of the younger age group face economic challenges.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/DImeldaPadillaFrausto.jpgIn Progress
7/25/2018
  
Ninez A. Ponce, PhD, MPP

​Ninez Ponce, CHIS principal investigator and professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health, became Center Director July 1. In a brief interview, Ponce discusses the path that led her to the Center, the roots of health inequality, and more.

How did you begin your career and end up at the Center?

​I was a volunteer for the Berkeley Free Clinic. The Berkeley Free Clinic experience made me think about the importance of health care as a right and not a privilege. I was also very interested in public health policy, because … I thought that fixing the health care system and health populations required multiple sectors and not just the medical sector.

I worked in Thailand with a relief organization looking at development and child nutrition. When I came back to the United States and graduated, I started working on immigrant health, a transnational link between domestic and international health. I got very passionate about data disaggregation particularly for the Asian American and the Native Hawaiian Pacific Islander community and then began advocacy work in that I was very moved by making a difference in public health.

One day, I got a note from Dr. E Richard Brown. It felt like that was a big pivot in my career that planted the seed in wanting to be an academic, do better data collection, better evidence for public health, and that was the beginning of my career in public health that was based here at the Center.

What do you see as the emerging public health trend in the future?

​I think it’s happening now. There is recognition that the population’s health problems as well as the inequities that occur in health are not produced solely by the health care system. Some of these problems are beyond the clinical walls and that they may have been generated in not just what the individual has been exposed to in their lifetime but it could have been generational disadvantages ― this notion of institutional racism and structural disadvantages. 

I think what’s emerging is that trying to come up with a wider system of care that collaborates in addressing needs for patients with complex clinical problems and complex social problems.

What would you be doing if you could go back and pick another line of work to go into?

​​I would be an architect, because I like structure and how design influences how people gather, live, and get together. I would want to design homes that are efficient and aesthetically pleasing that can solve our homelessness problem here. There is also a part of me, the data part of me, which wishes I were a computer scientist. I want to gather all the freely available data that is out there and come up with much humanized stories and public health insights.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/ninezponce.jpgIn Progress
5/23/2018
  
Brian M. Wells, MS
Brian Wells is the data quality and survey methodology manager of the California Health Interview Survey. In this brief interview, Wells provides insight into what’s notable and new about the Adult Health Profiles and the Race and Ethnicity Health Profiles. s and the Race and Ethnicity Health Profiles.

 

What are Health Profiles?

The Health Profiles serve as a quick and easy resource to look at health behaviors, insurance enrollment, and other key health factors within the state using data from the California Health Interview Survey (CHIS). The Adult Health Profiles provide this at regional and county levels, as well as the sub-county level for Los Angeles and San Diego Counties. The brand new Race and Ethnicity Health Profiles allow policymakers, media and everyday citizens to see those important health and health care factors for each of the major race groups within the state, as well as for Latino and Asian ethnic groups.

What is one of the most interesting findings this cycle?

Seeing the full, if uneven, impact of the Affordable Care Act and how it has affected various groups within the state is most interesting to me.

According to the CHIS data, the adult uninsured rate across the state has dropped from 27 percent in 2011-12 down to nearly 17 percent in 2015-16. African-Americans in the state are seeing a record low uninsured rate with only 14 percent uninsured. Latinos had the largest drop in uninsured during this time, but still represent the largest uninsured group within the state with 26 percent still uninsured in 2015-16.

This illustrates the great strides we’ve made especially with expanding Medi-Cal enrollment, but also suggests we have a long way to go to help correct the health care disparities within our state.

You’ve changed the format of the Race and Ethnicity Health Profiles to a dashboard. Will I still be able to print out my queries the way I could with the previous format (pdf)?

This feature is currently under development, but you'll be able to download reports soon. There is a tab in the dashboard where you will be able to download the report as a pdf with all of the key tables and graphs from the dashboard, or you can download the report as a csv (or comma delimited) file which makes it easy for media and researchers to have the health estimates easily accessible for reporting or making their own graphics.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/brianwells.jpgIn Progress
4/26/2018
  
Joelle Wolstein, PhD, MPP, MA

​Joelle Wolstein is a research scientist at the Center and co-author of a new fact sheet on the upswing in kids’ consumption of sugary beverages. In this brief interview, Wolstein discusses the recent trend and factors that may contribute to it.

Consumption of sugary beverages among children dropped in half between 2003 and 2009, from 49 percent to 26 percent. What prompted the uptick after this steady decline?

There are a number of factors that could be contributing to this reversal. Consumers have become more aware of the sugar in soda and drink less of it as a result. However, people may be replacing soda with drinks they consider to be “healthier” — like flavored waters, iced teas, or sports drinks — that actually contain quite a bit of sugar although less than soda.

Marketing could be influencing the trend as well. Beverage industry giants seem to be responding to the downward shift in soda consumption by acquiring “healthier” drink companies and targeting consumers from both ends — campaigning for higher sales of both sodas (through marketing ploys like Share A Coke®) and “healthier” — but still sugary — drinks at the same time.
Are some communities more vulnerable than others?

​Without a doubt! Our data show that low-income children and children of color consume higher quantities of sugary drinks than their higher-income and white counterparts, respectively. Communities of color are exposed to more advertising for sugary drinks than other communities. Additionally, compared to higher-income neighborhoods, low-income neighborhoods have a higher density of fast food restaurants and convenience stores, where sugary drinks are readily available. People who see more ads for sugary drinks and go to places that sell them are likely to consume them more often.

You have a young daughter. As she grows up, how will you keep soda and sugary beverages out of her diet given the influence of marketing and peer pressure?

​My daughter is only 2 years old so it’s been relatively easy to limit her exposure to sugar and other unhealthy foods up to this point. I know that when she goes to school in the near future, and as she becomes exposed to different foods and begins to make her own choices, that will quickly change.

Regardless, there are a number of things I can do as a parent. First, I can limit the drink options at home to healthy ones, like water and milk. I can also educate her about why her regular beverage of choice should be water and why sugary drinks should be consumed in moderation, if at all. Finally, I believe it’s my responsibility as a parent to model healthy behaviors for her, whether they’re related to food, physical activity, body image, etc. Hopefully the efforts made by individual households, paired with those of health advocacy groups and government agencies, will drive a shift in social norms when it comes to exposing children to unhealthy foods and beverages.
https://healthpolicy.ucla.edu/PublishingImages/Members%20Images/joellewolstein-jan2015.jpgIn Progress
3/18/2018
  
AJ Scheitler, EdD

​AJ Scheitler is the Center coordinator of stakeholder relations and lead author of new findings on three main types of barriers women with breast cancer face in California. In this brief interview, Scheitler discusses a pending state bill on breast cancer care time limits, barriers to accessing care, and gaps in awareness of patient rights.

How would the proposed bill, SB-945, help low-income women who have breast cancer?

​Currently, a woman who enrolls in the Breast and Cervical Cancer Treatment Program (BCCTP) has a limit of 18 months of treatment for breast cancer and 24 months for cervical cancer. No woman who needs more [time] to complete her breast cancer care program should be told she’s now on her own. The bill would eliminate the prescribed time limits and instead provide coverage throughout treatment, whether that is 12 months or 20 months.

Your study says more than 29,000 women in the state will be diagnosed with breast cancer. Why do so few doctors treat women with the disease?

​This barrier is not exclusive to the number of physicians and treatment centers in California. Certainly, the challenge of finding providers varies by insurance status and the size of the available network. However, multiple other factors can complicate access, such as geography or language. While an obvious example of a barrier is an immigrant living in a rural area seeking a doctor that can speak Tagalog, it can be just as difficult for a woman in Los Angeles who depends on public transportation to find conveniently located breast cancer providers.

Aren’t some of the issues identified in your study, such as rights to interpreters for limited-English proficient patients and/or the ability to keep a current provider if insurance status changes already covered by state law?

​Yes, unfortunately, we did identify some barriers that seemingly should not be given current state laws. The fact that we heard that language barriers still stop women from getting timely care demonstrates a gap in services. This includes the timely availability of an interpreter when a patient has an appointment or during other interactions, like scheduling appointments or receiving pre-appointment instructions.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/AJScheitler.jpgIn Progress
2/27/2018
  
Paul Dourgnon, PhD, M.Sc.

​Paul Dourgnon, Center faculty associate, discussed in the Center's Feb. 21 seminar how immigrants are served by California's health safety net. In this brief interview, Dourgnon discusses undocumented immigrants' obstacles to health services in California, the role of safety-net health centers in providing care to them, and the impact of a hostile political environment.

What is the biggest obstacle for immigrants in need of health services in California?

​Fear of ''the system'' is certainly a factor in immigrants avoiding health care. Existing research has identified that fear of being deported creates a ''chilling effect'' in various settings, within and outside the health system. However, from what we observed as well as from what former studies have shown, lack of insurance coverage is clearly the biggest obstacle to undocumented immigrants accessing care in California, and should be addressed as a major element in tackling inequalities in access to healthcare and, eventually, health inequalities.

What are safety-net clinics and others doing well where immigrants are concerned and where do they need to improve?

​County safety nets have a number of strengths. First, they are resilient. They are nimble and can adjust to changes in federal or state policies as well as changes in eligibility and funding. They are also committed to coverage expansion in most cases. These elements give safety-net health centers the capacity to remain innovative and to remain focused on providing more and better coverage to low-income and uninsured Californians, who in large part are undocumented immigrants.

Limitations stem from the very nature of counties as administrative entities, because some counties have the size and capacity to offer services, while smaller counties can’t undertake such programs. The result is that there is inequality between counties. So county-level efforts to expand coverage may take more time and not level the playing field.

Has stepped-up enforcement by Immigration Customs Enforcement (ICE) and other law enforcement and the general political climate in the U.S. affected how care is provided through the safety-net?

​The federal government's attitude in general, which is seen as hostile toward undocumented immigrants and also toward universal coverage, seems to have strengthened cohesion of California stakeholders and advocates for undocumented immigrants' health coverage, and many see California as a stronghold for their policy hopes. Our qualitative study showed that many advocates consider the situation an opportunity to develop alternative policies towards more, not less, coverage.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/pauldourgnon.jpgIn Progress
1/24/2018
  
Kathryn G. Kietzman, PhD, MSW

​Kathryn Kietzman is a research scientist at the Center and lead author of a new study about the need for mental health services specifically for older adults. In this brief interview, she discusses generational differences in mental health needs, need among the homeless population, and workforce challenges to providing care.

Your study focuses on older adults' mental health needs versus adults under 60 in the public health system. But you say even within the "elder" group there are generational differences in need?  

​There is great diversity across the groups that represent the broad expanse of the 60+ population. Each generation has experienced a unique set of cultural, political, and economic factors that shape how they interact with each other and which may influence societal attitudes about mental illness. For instance, the baby boomer generation – those born between 1946 and 1964 – may be especially prone to substance use and addiction disorders which sometimes emerge in response to an unmet need for mental health services. 

While some of the ''younger'' older adults in this category may see mental health services as a normal part of health care, some older baby boomers may experience significant stigma around help-seeking in general, a reluctance which may only be heightened when the help-seeking is specific to mental health issues.

Meanwhile, members of the ''oldest-old'' population, those who are 85+ years of age, are at greater risk than their younger cohorts of developing cognitive disorders like Alzheimer's. The onset of dementia and related disorders further complicates the treatment of serious mental illness – both from the standpoint of clinical care and from the standpoint of health care service delivery and financing.

Mental health among the homeless population is often in the news, including the number of older homeless in need. But how do you find them to get them those services?

​Many of the homeless have mental health conditions and, unfortunately, older adults represent a sizeable and growing proportion of the homeless. Last year's count of homeless in Los Angeles revealed that 25 percent of the homeless population are 55 years of age and older. Within this group of older adults, more than one-third have serious mental illness and close to 20 percent have substance use disorders.

Sadly, older adults in general tend to be more "invisible'" members of our society, and homeless older adults may be even less visible. Among the 12,000 plus homeless older adults in Los Angeles County in 2017, only 2,200 (less than 20 percent) were considered "'sheltered'" homeless. Without an address, older homeless are even less likely to be able to apply for and access the supportive health and social care services that they likely need, especially as they are more likely to be living with multiple chronic conditions.

Indeed, their point of entry to health care, most typically the ER, may be the best place to identify and conduct outreach with homeless older adults. Mobile outreach services provide another productive strategy, often in the form of interdisciplinary professional teams that canvas places where the older homeless may congregate – at shelters, food banks, and soup kitchens. In addition, law enforcement and emergency medical personnel are among the most likely to regularly encounter the homeless of all ages. These first responders need special training to more effectively identify and screen older adults, to assess their needs, and get them to appropriate services.

Your study focuses on the public health system lacking adequate mental health services for older adults, but does the private health system do a better job?

​Whether through public or private mental health care delivery systems, it is increasingly difficult to find and access the direct services of a psychiatrist, and those specializing in geriatrics are even fewer and farther in between! The longstanding and common denominator across the public and private systems of mental health care for older adults is workforce shortages and, more specifically, the lack of providers who are trained in geriatrics. The shortages in geriatric specialties traverses the full range of health provider types  including psychiatrists, primary care physicians, psychologists, and social workers – and dramatically affects the capacity of both public and private mental health delivery systems to identify and effectively respond to the unmet mental health needs of the older adult population. 

Part of the problem may be linked to provider incentives in the form of Medicare reimbursement rates, which tend to be low, and which are used by many of the 65+ and/or disabled population to pay for mental health services. Another systemic issue is related to the workforce pipeline – the current shortages in the geriatric profession are certainly the product of the quality and intensiveness of training and curricula required of a broad range of health care professionals, much of which results in clinicians who are woefully unprepared to care for the aging population in general and even less prepared to care for those who are aging with mental illness.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/kathrynkietzman2012.jpgIn Progress
12/13/2017
  
Gerald F. Kominski, PhD

​In this brief interview, Center Director Gerald Kominski discusses what to expect if the House and Senate agree upon a tax plan that axes the individual mandate, how California can protect its achievements, and whether 2018 will bring any relief.

Given the likelihood that the individual mandate might be repealed as part of the GOP tax bill, what will the Center focus on in the coming year?

​We are currently in discussion with several groups in California to model the effects of the mandate repeal, as well as other policy options that California might explore to minimize the damage being done by the President and Republicans in Congress to the Affordable Care Act (ACA).

What can California do to protect itself from what's happening in Washington, D.C.?

​Unfortunately, until there is a change in one or both houses of Congress, it appears Republicans will continue to pursue their "death by a thousand cuts" approach to destabilizing the ACA. Nevertheless, California can explore options to stabilize the individual market, both within and outside Covered California, to keep health insurance affordable to Californians who don't have employment-based coverage. Some of those options would require increased state funding, so the cost of maintaining affordable access without additional federal support will be a challenge.

What is possible in terms of positive health policy developments in 2018?

​Whatever happens, the UCLA Center for Health Policy Research will be there to measure, report and keep policymakers accountable for their decisions and to ensure that all voices are heard on health.  We will continue to be champions of health equity. We will also provide the data and policy analysis to document the serious consequences of reversing the substantial progress we've made in recent years to make health care more accessible to all Californians.

http://healthpolicy.ucla.edu/about/PublishingImages/GKominskiHeadShot.JPGIn Progress
11/29/2017
  
Xiao Chen, PhD

​Xiao Chen is the associate director and senior statistician of the Center's Health Economics Evaluation Research (HEER) Program. She is a co-evaluator of nutrition and obesity prevention programs in Metropolitan and South Los Angeles.

In this brief interview, Chen discusses the methodology and challenges in evaluating the multifaceted Nutrition Education and Obesity Prevention (NEOP-LA) Program.

What are the challenges in evaluating a program like NEOP-LA?

​Three important factors come to my mind. One of the goals of this evaluation is to assess the long-term effect of NEOP-LA. Lack of longitudinal data makes it very difficult to estimate or predict what would happen 10 or 20 years ahead. It is also important to take into account the impact family members and coworkers have on a person's health behavior. This social network component is usually not directly observed. Last but not least is that NEOP is not a single intervention program; it has multiple components built-in. We would like to be able to compare the impact of these different components.

Why an agent-based model for this particular evaluation project?

​An agent-based model is a type of simulation model and it allows researchers to simulate relationships, interactions among individuals and to synthesize information from different sources, such as individual data, program data and literature review. The idea is to construct computational models that will mimic the real world and allow researchers to test different hypotheses and scenarios. 

In a simulation model, we can easily formulate and test a hypothesis related to time, such as how long it takes for an intervention to have a long-term effect. We are able to model a scenario with only a single intervention and also model multiple interventions simultaneously.

Why are you only studying adults?

​NEOP-LA programs touch both children and adults. Nevertheless, many of the programs have been targeted more to adults. We created a cohort of individuals and will follow them in the simulation model over many years. In our simulation system, we need to account for population change, such as birth, death and migration. To focus only on adults makes our model more manageable and the results easier to understand.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/xiaochen-sep2015.jpgIn Progress
10/31/2017
  
Bianca D.M. Wilson

Jody Herman and ​Bianca D.M. Wilson, both at the Williams Institute, are co-authors of a policy brief about the newly released CHIS data on transgender adults in California.
In this brief interview, they discuss the high rates of suicidal thoughts and attempts among transgender adults, the need to enforce policies that protect the population, and the importance of CHIS accurately measuring gender orientation, and how its current and future data will inform better research and policies in the future.

The prevalence of suicide ideation and attempts among transgender people seems quite high. What do you make of that?

​True, the suicide ideation rate among transgender people in this study is high and alarming.  Unfortunately, it reflects what over a dozen surveys of transgender adults in the United States and other countries have also found.
Research shows that several factors appear to be related to suicide ideation and attempts among transgender people:  stress related to experiences of anti-transgender bias, delaying health care due to discrimination, and not receiving medically necessary gender affirming health care.  These factors are also interrelated.

These high rates of suicide ideation and attempts tell us that interventions are needed to help a severely marginalized group in the population. And the known factors associated with suicidality tell us that these interventions should focus on preventing violence and discrimination against transgender people and increasing access to culturally competent care and gender-affirming care.

These alarming data also tell us that we need to understand more about the lives of those who are not experiencing suicidal ideation or attempts. This would help us learn about existing sources for resiliency.

California policies — including the new Gender Recognition Act― seem to help promote the health and well-being of transgender people. However, the study found significant health disparities in this population. Why do you think this is?

​California has put a number of protective public policies in place. Writing and passing good policies are a critical first step, but we then need to make sure those policies operate the way we expect.
These data point to a need to better understand how well the policies are being implemented and enforced to ensure these laws and regulations are bringing about positive effects. We also know that while public policies are one important piece of the puzzle to ending discrimination, more is needed.

We must develop interventions that target the ways families and communities treat transgender children, youth and adults to reduce anti-transgender rejection and violence.

This is the first population-based data collected on transgender people in California. What do you hope to learn as the CHIS survey continues and larger samples are collected?

​This was the first time the commonly recommended two-step method for assessing gender identity was used in a state-wide representative survey.  Our survey asked respondents for their sex assigned at birth and how they currently describe themselves (male, female or transgender). This two-step approach allowed us to include a larger range of transgender people in our analysis without needing them to self-identify as transgender. We expect that the success of using this approach in CHIS, the largest state health survey in the U.S., makes it more likely that other surveys conducted at national, state and county levels will also adopt this approach. 

Using reliable and valid measures of gender identity that are inclusive of transgender people leads to more accurate information about the health and well-being of people in the U.S. This first round of data collection gave us representative information about the health and health care access of transgender adults in California. As more data are collected over the years, we will be able to examine whether transgender and cisgender people differ in other areas of health, such as insurance coverage, disease rates, and poverty.

Also important, a larger sample size will make it possible to assess whether there are important intragroup differences among transgender adults.  For example, are their racial differences among transgender people that are relevant to discussions about health inequities? Do transgender people in Los Angeles and the Bay Area — counties known to have greater amounts of political, social and cultural resources for transgender people compared to some other parts of California — have different health outcomes and health access than those outside of these counties?

Answering questions like these will help health services and advocates consider how to best design and target future interventions, and use their resources more effectively.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/biancawilson.jpgIn Progress
9/27/2017
  
Kate McBride

​Kate McBride is a graduate student researcher at the Center and lead author of a new policy brief on medically fragile Angelenos who rejected a new managed care health plan, Cal MediConnect. In this brief interview, McBride discusses the high rate of opt-outs for the program, the tug between care and cost, and how Cal MediConnect can keep people in their existing care networks.

Why did these consumers reject the program in such a big way? Just 19 percent stayed enrolled, and 58 percent went through the trouble of opting out.

​Being able to maintain continuity of care was the highest priority for dual-eligible consumers. Participants in our study who anticipated that enrollment in Cal MediConnect (CMC) would lead to a disruption in their care, either through the loss of their doctor or preferred health services, were more likely to opt out or dis-enroll from the program. 

These participants emphasized the importance of keeping their relationships with their current health care providers (primary care and/or specialists) and services or products (pharmacies, durable medical equipment suppliers). Although all dual-eligible beneficiaries enrolled in CMC can continue to see their present doctors and receive existing services for up to a year in order to ease the transition, many were either unaware of this option, or unwilling to undergo the process of choosing a new provider within the CMC network, but who would be unfamiliar with their complex medical history.

CMC's status as a managed care plan was also seen as a disadvantage among participants who believed that managed care plans typically provide fewer choices. These individuals voiced concerns that the network of doctors and specialists in managed care plans is limited compared to FFS Medicare, and that managed care plans impose more restrictions on services and benefits.

The program was started to address gaps in health care services. Does the program actually provide better coverage for this group of vulnerable consumers?

​Dual-eligible consumers are faced with the challenge of navigating two different health delivery programs that have different requirements and provide different health care services, which contributes to the existing fragmented and uncoordinated care for this population. The purpose of integrating Medicare and Medicaid for dual-eligible consumers was to create a more unified system of accessing and utilizing health care benefits and services, with the goal of improving quality of care and reducing costs. CMC is responsible for delivery and coordination of medical, behavioral health, long-term services and supports. All services are administered through CMC health plans, which offer supplemental benefits, such as care coordination, medical and non-medical transportation, and vision and dental benefits.

While consumers in our study agreed there were numerous advantages to having extra benefits and services with Cal MediConnect, including lower out-of-pocket costs, access to specialists and specialty services became more difficult to obtain under their new CMC plans due to authorization requirements.

Ultimately, the decision to opt out or dis-enroll involved weighing the extra benefits of CMC ― such as transportation, dental, and vision services ― versus the loss of primary care doctors and specialists. For these participants, remaining with their trusted doctors who had extensive knowledge of their medical history was the most important factor in their decision-making process, even though the decision left them with more limited services.

Dual-eligible consumers are very concerned about losing their trusted network of providers. What could Cal MediConnect and other similar programs do better to address this?

​Several states are currently testing new models of care delivery for dual-eligible beneficiaries to better manage high-risk, high-cost patients.

For example, Washington state is currently testing an integrative managed fee-for- service (MFFS) model for dual-eligibles, known as the Washington Health Homes Program. In contrast to the CMC model in California, Washington state is building upon its existing Medicaid Health Homes to target dual-eligible beneficiaries with chronic health conditions. Beneficiaries are free to choose whether to receive these new services, and continue to have access to the same Medicare and Medicaid services and benefits, resulting in no disruption in care. The program has been extremely successful to date, and has reduced inpatient hospital admission, emergency room visits, inpatient psychiatric admissions, and the need for nursing home admissions.

Maintaining continuity of care and avoiding disruption to ongoing services were the main priorities for virtually all consumers in our study. Rather than disrupt the existing care networks of vulnerable health care consumers, California and other states with similar programs should consider implementing a coordinating agency to streamline existing health care services for consumers, or develop other management strategies to coordinate Medicare and Medicaid benefits, while offering supplemental services and referrals to community supports and services.

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8/22/2017
  
Nadereh Pourat, PhD

​Nadereh Pourat is director of the Center's Health Economics and Evaluation Research (HEER) Program and lead author of an evaluation of L.A. County's Parks After Dark (PAD) program. In this brief interview, Pourat discusses the origin and evolution of the after-dark program, what makes it different, and whether it improved community-police interaction.

The Parks After Dark program started in 2010 as an intervention to keep at-risk teens busy and out of trouble. Has its evolution over the past seven years made it more effective?

​The program has been effective in advancing a number of its goals, such as addressing needs of a broader community by providing safe spaces for sports and recreation, and increasing perceptions of safety at parks. The spread of the program in many new parks speaks to the importance of this type of publicly funded programming in many areas of Los Angeles County. The success of the program is in part attributable to the County's recognition of the importance of such programming and dedicating funding and resources to the program.

"Let's go to the park" is a retro idea in an age where most people interact through electronic devices. What makes the program work?

​That is exactly the point. The lack of safety in public spaces, such as parks, contributes to kids and adults staying at home with their electronics instead of venturing out. Low-resource communities find it harder to join a gym or take the kids to the movies or to fun, paid activities. What has made the program successful is the opportunity to get out, exercise, and have fun with your family.

Did the L.A. County Sheriff's Department see a difference in how they were viewed by the communities with PAD program, and vice versa?

​In interviews with Sheriff's Deputies, they were acutely aware of the opportunity they had to interact with community members and building trust-based relationships. They were interested in showing kids and young adults what they do on a daily basis by bringing their mobile command centers to some parks and giving children tours. The PAD participants were particularly interested in seeing the deputies getting out of their cars and walking and interacting with people as a way of changing the perceptions of law enforcement.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/naderehpourat2013.jpgIn Progress
7/31/2017
  
Maria-Elena Young, PhD, MPH

Maria-Elena Young is a graduate student researcher at the Center and lead author of a new policy brief about how federally qualified health centers, also called community health centers (CHCs), formed partnerships to expand coverage to the uninsured. CHCs are the main providers of health care to 25 million low-income and uninsured people in the U.S. In this brief interview, Young discusses how partnerships increased CHCs' capacity to serve patients and how ongoing attempts to repeal and replace the ACA may undermine these efforts.

Community health centers gained under the Affordable Care Act. What do they face if the current administration repeals the ACA? How will forming partnerships help?

A Congressional Budget Office report estimated that 19 million Americans would lose their Medicaid coverage by 2026 if the ACA's Medicaid expansion is repealed. Nationally, most CHC patients are insured through Medicaid — including the Medicaid expansion — and the revenue from insured patients allows CHCs to serve those who still lack insurance. So, the loss of Medicaid funding under an ACA repeal is a major threat to CHCs and the people that they serve.

Partnerships could never fill in the gap, but our findings suggest that CHCs and their partners are a key line of defense for protecting safety net services in the health care system. For example, as highlighted by the advocacy work being done in New York State, CHCs around the country are active in making the case for health care funding and speaking up for their patients. We also saw that non-CHC partners, from hospitals to foundations to local government, recognized the value of funding and supporting infrastructure for CHC-led primary care services.

The more momentum there is to make CHCs integral to the overall health care system, the more support, funding and political will there is to ensure that CHCs and their patients are not thrown under the bus to fund tax breaks for the wealthy.

Instead of competing, your policy brief talks about how some community health centers found success by sharing and collaborating with other CHCs, hospitals and governments. What are some main results?

​Community health centers are mission-driven, which means that they seek partnerships that are not only good financially for their organizations, but that will have the most beneficial impact for the people that they serve. While our results show that CHCs were incentivized to partner with others to support their organizational well-being, they were also driven by their mission of making health care available to everyone. We heard over and over again how important it was to find partners that share the same mission to serve the underserved. To make this happen, it was critical to have the opportunities — and the resources — to build relationships with like-minded organizations.

That said, however, CHCs often have limited budgets for relationship building, so partnerships with non-CHCs, such as hospitals or health departments, were the most successful and most easily facilitated when potential partners had a common challenge that benefited from a team approach. CHCs spent time and resources educating potential partners. Our findings are a reminder that individuals and organizations in other parts of the health care system could support building CHC partnerships.

If the ACA is left in place, what is the outlook for CHCs? Can the federal government still cut funding?

​If the ACA is left in place, we may see more states expand Medicaid. This would benefit both CHCs and their patients, whether insured or uninsured. The remaining uninsured would have better access to primary care and any needed specialty care. Also by increasing insurance revenue, CHCs can direct resources towards other aspects of their work, such as preventative services or quality improvement, instead of having only enough funding to cover the costs of care for the uninsured. Furthermore, it means more opportunities to expand partnerships. The flexibility in both staffing and financial resources is essential to give CHCs the organizational capacity to develop the innovative types of partnerships that we examined in our policy brief.

The other scenario is that the ACA remains in place but is undermined in order to wreck the program.  If that happens, CHCs will be more crucial than ever to handle the overflow of patients needing care.

Regardless of what happens, CHCs receive funding from the Community Health Center Fund that needs reauthorization from Congress. CHCs have historically had bipartisan support, but CHCs and their partners will continue to have to work to ensure that this funding is maintained.

They have to make the case that their services are critical regardless of what health coverage system we have in place.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/mariaelenayoung.jpgIn Progress
6/28/2017
  
Nadereh Pourat, PhD

​Nadereh Pourat is the Center's director of research and author of the new policy brief that summarizes the evaluation of a pilot program that aimed to improve health care delivery at a group of California's safety-net hospitals. In this brief interview, Pourat discusses what prompted the program, how the evaluation of hospitals was conducted, and how the hospital systems achieved success through the program.

DSRIP was born out of a frustration with the rate of innovation and reform in public hospitals. What were the reasons for this? 

​In California, the majority of public hospitals are owned and operated by counties. They frequently face resource limitations and high demand from uninsured patients who cannot pay for their care and disabled and elderly Medicaid patients with poor health. Most of the resources go to providing care for the patients and there are limitations on how much effort can go towards innovations, improving quality of care, or improving patient experiences. Overtime these organizations have lagged behind many private hospitals with more resources. The improvements taken on by hospitals under DSRIP are essential for the ability of these organizations to keep up and remain competitive.

Participating California public hospitals met 97 percent of their milestones. That seems almost too good to be true. How was the program so successful over so many categories?

​The hospitals had five years to plan, implement and improve their outcomes. They had time to achieve their goals. The goals ranged from more easy to achieve to more complex and this variation was also helpful. Most importantly, the hospitals had a mix of optional and required milestones. When possible, they chose projects that were consistent with their prior goals, which were not previously implemented due to lack of resources.

DSRIP was a $3.3 billion program involving 17 public hospitals serving millions of patients. How did you evaluate such a large, complex project with so many different kinds of interventions?

​These evaluations require significant effort and an army of analysts. Some components were evaluated primarily using multiple hospital reports, in-depth surveys, and lengthy interviews. Others further involved analyses of large, confidential, and statewide datasets. We leveraged available data from another Medicaid Waiver evaluation ― the Low Income Health Program ― for one set of analyses, and we analyzed California hospital discharge data for another set of analyzes. We engaged experts in questionnaire design, quality of care assessment, and HIV care. We consulted with various other experts and worked closely with DHCS and CMS to complete the evaluation.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/naderehpourat2013.jpgIn Progress
5/31/2017
  
William McCarthy

​William McCarthy, adjunct professor at the UCLA Fielding School of Public Health, and Susan Babey, co-director of the Center'sChronic Disease Program, coordinated a recent national roundtable of leading experts on sugar in foods and will present findings from that meeting at today's Center Health Policy Seminar. In this brief interview, McCarthy discusses what might come out of the meeting, some of the surprising findings, and how we can cut back our excess sugar intake.

What was the purpose of bringing so many experts together in one room to discuss added sugar in foods? 

​The impetus for this expert roundtable came from Kaiser Permanente's Health Policy Institute in collaboration with the American Heart Association. The American Heart Association has made decreasing Americans' excess added sugar intake a core part of their 2020 Impact Goals because of the increasingly strong research linking excess sugar intake to negative cardiometabolic outcomes. Kaiser Permanente's clinicians are increasingly aware of the need to get their patients to limit their daily intake of added sugars and would benefit from guidance about the latest consensus science concerning effective clinical approaches to reducing daily added sugar consumption.

Because Kaiser Permanente recognizes that there is more to reducing population level excess sugar intake than clinician interventions, they were open to the expert roundtable addressing the full range of public health and clinical approaches to intervention, as well as some focus on putative mechanisms by which excess added sugar is thought to harm cardiometabolic functioning.

Kaiser Permanente contracted with the UCLA Center for Health Policy Research to identify leading researchers who could speak to the full range of research on added sugars and to convene the roundtable on a day when most of the identified researchers could make it for a face-to-face meeting.

The end product was expected to be a state-of-the-art view of what is known about the linkages between added sugar intake and cardiometabolic outcomes, and about the range of strategies that have been tested for their effectiveness in reducing patients' excess added sugar intake.

Were there any surprises coming out of the meeting? What did you hear that you had not heard before? 

​A common assumption among psychologists treating obese patients is that many of them are "addicted" to consuming excess added sugar, implying a level of physiological compulsiveness that could only be remedied by limiting the patient's exposure to sugary foods.

Our UCLA colleague Emeran Mayer, MD, PhD, author of the Brain-Gut Connection, challenged this notion of physiological compulsion by noting that one of the surprising benefits of gastric bypass surgery is a marked reduction in appetite for sugary foods. How does constricting the stomach and shortening the usable small intestine ― actions that are limited to the gut ― have such a profound effect on how the appetite and reward systems in the brain respond to sugar intake? If "addiction" is so easily remedied at the level of the gut, we may need to rethink compulsive consumption of added sugar as an addiction.
USDA data show Americans consumed 12 teaspoons of refined cane/beet sugar a day in 2015 ― that's 91 cups a year. How can consumers break up with sugar, or at least, cut back?

​Although experts differ on the recommended daily limit, added sugar consumption is a normal part of eating. The American Heart Association recommends limiting added sugars to no more than 5 percent of daily calories; the American Dietary Guidelines for Americans recommends a limit of 10 percent daily. On a 2000 kcal/day diet, that translates to a daily limit of 13 teaspoons of total added sugars.

But added sugars include high fructose corn syrup and other caloric sweeteners in addition to refined cane/beet sugar. According to the USDA, Americans consumed 22 teaspoons of total added sugars in 2015, which is 9 teaspoons more than recommended. Because added sugar is ubiquitous in processed foods ― over 70 percent of processed foods have added sugar ― the short answer to the question of what practical steps to take to reduce added sugar consumption is to limit the daily consumption of processed foods.

But the alternative to processed foods ― namely minimally processed, fresh fruits, vegetables, and whole grains which almost all Americans know they should be eating more of ― don't taste as good as most processed foods. Ten thousand years ago our hominid forebears had no problem consuming 14 daily servings of fruits and vegetables (and avoiding consumption of processed foods) whereas we moderns fall shy of even just five combined fruit and vegetable servings per day. We will not solve the excess added sugar challenge if we don't solve the problem of how to get Americans to eat more minimally processed fruits, vegetables, and whole grain foods. 
 
Epidemiological data show that seniors, the highly educated and chronic exercisers are more successful at eating recommended amounts of minimally processed fruits and vegetables than the young, those with less than high school education and non-exercisers. Some combination of experience, knowledgeable and persistent experimentation with different food choices, and adherence to daily aerobic physical activity seem to contribute to the solution.
http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/WilliamJMcCarthy_crop.jpgIn Progress
4/26/2017
  
Haleigh Mager-Mardeusz

​Haleigh Mager-Mardeusz is a co-author of the new policy brief on how GOP changes to Medicaid could affect health care for tens of millions of low-income Americans. In this brief interview, she discusses why Republicans favor "capped" financing, the political risk of undoing the ACA, and the likelihood of Medicaid caps being enacted.

Do Republican efforts to put a "cap" on Medicaid spending reflect a fair concern about spiraling costs of coverage for health care in general and Medicaid in particular?

​Both Democrats and Republicans are right to be concerned about health care cost growth. Health care costs continue to consume our gross domestic product and federal budget. The United States spends about twice per capita on health care compared to other high-income countries, but continues to rank lower in health system outcome measures. Capping federal Medicaid expenditures will limit health care as a percentage of the federal budget, but it will also push this financing burden onto states, low-income individuals and safety net providers.
 
Medicaid is already an extremely efficient program because of its low provider reimbursement rates and administrative costs. Per enrollee costs are considerably lower for Medicaid than private insurance, when similar coverage groups are compared.
 
One estimate found that adults covered under the Medicaid program cost about 22 percent less than if they were covered by a private plan. Between 1987 and 2014, per enrollee cost growth for Medicaid was also much lower when compared with private insurers. Further, Medicaid expansion states have seen savings from fewer payments to hospitals for uncompensated care.
 
While health care cost containment methods should continue to be explored, capping federal Medicaid spending will likely not curb overall health care cost growth. And it will be at the expense of our country's most vulnerable residents.

Might it be politically uncomfortable for some Republicans to backtrack on Medicaid after expanding it in their states given that it now serves many of their core constituents?

​With the passage of the Affordable Care Act (ACA), 14 million people have gained Medicaid health insurance, among which 4.5 million reside in Republican governed states. Among the 32 states that expanded their Medicaid programs, 11 were headed by Republican governors. Repeal and replace of the ACA has been continuously cited as a central priority for the GOP under the Trump Administration.
 
However with recent efforts focusing on capping funding for Medicaid, including the most recent effort -- the American Health Care Act (AHCA) -- the Republican Party has faced widespread opposition within its own party. Republican states that have expanded their Medicaid programs have seen positive changes for their constituents. For example, Ohio concluded that expanding their Medicaid program led to experiencing the lowest rate of uninsured working-age adults in the state's history.
 
A repeal of Medicaid expansion provisions would have profound impacts on states' abilities to continue to cover current beneficiaries and services, which would affect the health and well-being of their constituents. There is therefore a resistance from Republican states that have expanded their Medicaid programs and from within the party, which is one reason that the AHCA failed to pass.
 
There is disagreement within the party on what should be included in health reform. For example, other GOP proposals have included provisions allowing for states to maintain parts of the ACA up to their discretion. Furthermore, the Republican Party has become more reliant on an older, white, lower-income voter base, who are a large population cohort that have benefited greatly from Medicaid expansion.

What are the chances that Republicans will be able to pass any kind of Medicaid reform during the Trump administration?

​Block granting the Medicaid program has long been a priority for the GOP. President Reagan proposed this reform in 1981, Speaker Newt Gingrich in 1995 and President George W. Bush in 2003. Speaker Paul Ryan has included this in his legislative agenda for years and has introduced numerous Medicaid block grant reform proposals.
 
While Republicans have long been promoting this financing reform, efforts have failed thus far. Instead, Medicaid has cut its ties as a welfare-linked program and transformed to become the nation's largest health public health insurance program. Today, Medicaid covers about 1 in 5 people (over 70 million).
 
While the recent AHCA efforts have been thwarted, there is still a very real chance that the GOP will come back to health reform, especially if their tax reform efforts fail. Medicaid reform would easily meet budget reconciliation criteria, and some conservative think tanks have recommended taking a more incremental approach to dismantling the ACA and safety net.
 
Recently, President Donald Trump restated his pledge and commitment to health reform. House Freedom Caucus members even predict that a new health bill will pass the House within the next few weeks. But recent polling in Louisiana shows how popular the Medicaid expansion has been: More than half of Louisiana residents have an unfavorable view of the ACA, while almost 75 percent approve of the state's Medicaid expansion.
 
As expansion states continue to report decreased uninsurance rates, improved access to care for residents, and better financial stability for state budgets, changing the Medicaid program and taking away coverage will become harder and harder to do.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/HaleighMager-Mardeusz.jpgIn Progress
3/29/2017
  
Petra Rasmussen, MPH

Petra Rasmussen is a Ph.D. student in Health Policy and Management at the UCLA Fielding School of Public Health and the co-author of a new Center study on how the American Health Care Act would have affected Californians. In this brief interview, Rasmussen talks about how the fight over health reform is not over, why Americans are confused about the existing law, and whether California could go single-payer. 

Is the battle to "repeal and replace" the ACA over?

​The Republican failure to pass the American Health Care Act (AHCA) and repeal and replace parts of the Affordable Care Act (ACA) is a victory for health reform. The bill was defeated because it would have caused tremendous damage to Americans across the country.

However, just because the AHCA is gone for now does not mean that the fight is over. The Trump administration has already begun to make fundamental changes to the ACA outside of legislation, and the consequences of these actions are already being seen in the reduced enrollment numbers in the law's health insurance exchanges.

In his first week as Secretary of Health and Human Services, Tom Price introduced proposed rule changes that would weaken the patient protections in the ACA and make it harder for people to enroll in coverage. This set of proposed rules is likely just the first of many that the administration will put forward to undermine the law. Furthermore, the Trump administration and the Republican-controlled Congress can still return to repealing the ACA at a later date.

The policy ideas that were included in the AHCA are ones that Republicans have been touting for many years, and they won't go away with just one bill's defeat. Understanding these ideas and the very real impact they could have on Americans is a key challenge for researchers and policymakers moving forward.

Why is the ACA so unpopular among conservative voters?

T​here's been a lot of misinformation about the law and what it provides. Some people are even under the incorrect belief that the ACA they like and use is different from the "Obamacare" that they hate!

This is in part because the ACA is a complicated law to understand. The Kaiser Family Foundation's Health Tracking Poll has consistently found that people support the separate policies included in the ACA, but are not as supportive of the law as a whole, and many have misconceptions about what is included in the legislation. The same poll has also shown that most Americans support the Medicaid program and very few want to see a reduction in its funding.

We all know that the ACA provisions protecting young people and people with pre-existing conditions are popular across the political spectrum. And the move by the Freedom Caucus to try to eliminate essential health benefits was politically risky. All of this goes to show that Republican lawmakers aren't paying attention to the majority of their constituents or looking out for their best interest when they push forward with attempts to destabilize or repeal the ACA.

Do you think a single-payer system in California is possible? Would the federal government allow it, and how could it be funded?

​If there's any state that could be successful with its own single payer system, California is it. The diversity and size of the state, its high-quality health care system, and the largely progressive political leaning of residents make the possibility of a single-payer system very real.

California State Senator Ricardo Lara introduced a bill in mid-February to create such a system in the state. And California has explored this option before with the legislature passing single-payer legislation in 2006 and 2008. These bills were eventually vetoed by then-Governor Schwarzenegger. Lawmakers have learned a lot from these previous attempts and could have an even better shot at success at the state level under Governor Jerry Brown.

However, there are challenges. The federal government would need to approve any changes to Medicaid and Medicare that would incorporate them into the state's single-payer system. While the Trump administration has voiced support for greater state flexibility in Medicaid, it is unclear if the current administration would approve a waiver to allow federal funding for the program to go towards a system many ideologues regard as tantamount to socialism. And if future legislation looks to alter the funding structure for Medicaid like the AHCA did, it is possible that federal funding could be cut, increasing the cost to California.

Furthermore, it is unlikely that the current federal government would allow the state to include the Medicare population in any plan to switch to a single-payer system. This would leave the state with a two-tiered system ― one for residents 65 years of age and older, and another for the under-65 population.

However, Californians have shown a willingness to increase taxes in order to pay for important programs that improve the well-being of the state's most vulnerable. There are also alternative funding streams that could be tapped, including taxes on recreational marijuana. The state should definitely move forward with exploring the potential costs and benefits of a single-payer system.

http://healthpolicy.ucla.edu/PublishingImages/Members%20Images/petrarasmussen.jpgIn Progress
2/28/2017
  
Jack Needleman, PhD

Jack Needleman is chair of the Department of Health Policy and Management at the UCLA Fielding School of Public Health and a faculty associate at the Center. He was a panelist at the Feb. 15 Grand Rounds seminar on how repeal of the ACA would affect safety net providers and moderated the Jan. 25 Paul Torrens Health Forum on planning for changes to the ACA.

In this brief interview, Needleman discusses the likelihood of Medicaid converting to block grants, how reduced funding may put pressure on California's already rock-bottom provider payments, and what it will take to get politicians to take notice.

Beyond repeal of ACA subsidies and the Medicaid expansion program, you and the other panelists brought up another scenario: The federal government converting Medicaid, known as Medi-Cal in California, to a block grant system. Why should we care?

​We should definitely care whether Medicaid is made a block grant. Currently, the costs of Medicaid are split between the federal and state government. The state bears only a portion of the costs of expanding the population covered, expanding services, increasing payment rates, or cost increases due to medical inflation. And decisions reflect this. The program is also sensitive to economic downturns, when the population eligible for Medicaid can increase, and the costs associated with the growth of the Medicaid population are only partly borne by the state with the federal government also sharing in those costs. 

While there are several ways in which a block grant might be implemented, there are two key features of virtually all proposals. One is limiting the growth of the block grant to a fixed percentage each year, which most observers expect will be less than the actual inflation of medical expenses, so the state would bear an increasing share of the total costs of the program over time. The second is making the block grant insensitive to changes in economic conditions or to the growth of the number of eligible, requiring states to absorb these additional costs, reduce eligibility or lower payment rates for services.

One of your fellow panelists said California's Medi-Cal reimbursement fees to doctors were fourth-lowest in the country. What will happen to those fees under a block grant program?

​The federal requirements for state Medicaid programs allow substantial variation in payment rates and some variation in eligibility standards and services offered. California, like many states, chose to structure its Medicaid program to maximize eligibility and covered services, and limit state expenditures by establishing low fees for physicians and other services. 

Under a block grant, to the extent that California had to absorb increases in the costs of the program below the rate of medical inflation, it would confront hard choices about increasing the amount of state funds going to the program, cutting eligibility or benefits, or cutting payment rates. Historically, payment rates would come under the most pressure, and eligible services would be next on the cutting block.

These changes would likely reduce the level of participation of providers in the program, reducing access to both primary and specialty services. This would increase the demand on safety net providers such as federally qualified health centers, and while care at safety net providers is often found to be good, higher demand coupled with level or reduced payment could threaten access or quality.

A recent story reports some Republican-leaning counties in California have a high share of Medi-Cal recipients, and cutting off Medi-Cal to those areas would be too politically risky. Is putting representatives on notice the key to averting block grants?

​The politics of Medicaid are complex. The Republican members of Congress and the Senate who have advocated for repeal and replacement are not in agreement about what a replacement program would look like. Many Republican members of Congress from California and elsewhere are from conservative but low-income areas, such as the Central Valley, which have benefited from Medicaid expansion.

Political science theories that try to explain the behavior of Congress members tend to emphasize the dual loyalty of Congress members to congressional leadership (which can provide rewards for members such as leadership positions and power within the legislature, campaign funds and consideration of member-sponsored legislation) and to constituents, motivated by the desire for re-election and fear of an electorate mobilized over specific issues. Electorate mobilization is often weak as low-information individuals may not become involved. But a highly salient issue, one whose profile has been elevated by demonstrations, news coverage and engagement of local organizations in lobbying and electioneering, which can heavily influence an election.

The activism, demonstrations and engagement in town halls play a double role of increasing public knowledge and challenging elected officials. The political risks of cutting Medi-Cal will only become substantial if elected officials become concerned that a significant proportion of their electorate will vote on this issue.

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1/31/2017
  
AJ Scheitler, EdD

​AJ Scheitler is the Center's coordinator of stakeholder relations and co-author of a new study on barriers to breast cancer care that was the topic of a Jan. 12 legislative briefing in Sacramento. In this brief interview, Scheitler discusses the gap between passing a health law and making sure it is used and how care involves more than just medical treatment.

What was a major finding from the report that surprised you?

One notable barrier we found is that many women seeking care for breast cancer face a weak system of support during and after their medical treatment: Where can they find a wig after chemotherapy or get fitted for a prosthetic bra after breast removal? Can they get transportation to the various doctors who are treating them? Can they afford to miss time at work needed for treatments and recovery? They need more than just the medicine.

Some doctor's offices provide information on how to handle all the things they have to deal with outside of actual treatment for the disease; some don't. It's a hit-and-miss system and is a big detriment to the patient. For women who have limited English proficiency, these barriers are even more complicated.

 Because of language barriers, some women can't understand what the doctor is telling them during diagnosis and treatment. Didn't California just pass a law that sets aside funding for medical translation services?

​That question came up during the legislative briefing: Although we're lucky to have a law in California that mandates funding for medical translation services for Medi-Cal patients (AB 635) many physicians — and patients — don't know the law or that funds exist. So, the doctors may not provide those services and the patients don't know to ask for them.

There needs to be more outreach to educate both. Further, language services are needed outside the examination room. Patients must be able to understand medication instructions, dietary and physical therapy recommendations, and reminders for follow-up appointments.

The study was based on interviews with organizations that work with breast cancer patients. Why weren't the patients themselves interviewed?

​We had one breast cancer survivor, Veronica Vera, at the legislative briefing, and her story helped "put a face" on what these women endure to receive care for breast cancer.

But for the report, we needed to maximize efficiency. We were able to get many more examples of the kind of barriers women faced by interviewing organizational representatives who talk and work with hundreds of survivors. These representatives ― including breast health educators, on-site clinic workers, patient navigators, and individuals involved with support groups ― have listened to women's questions and challenges for years. So I think the patients' experiences and frustrations with roadblocks to care came through in the report.

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12/14/2016
  
Todd Hughes

Todd Hughes is the director of the California Health Interview Survey (CHIS), the nation's largest state health survey, which released new 2015 data today. In this brief interview, Hughes discusses new topics, such as gender identity and telemedicine, and the role of cell phones and computers in CHIS data gathering.

What new questions and innovations are in the 2015 CHIS?

​CHIS always tries to be responsive to the latest research questions and health challenges. Important new topics in the survey include whether Californians have experienced discrimination based on race or ethnicity ― allowing researchers and others to see for the first time whether bias is a factor in how people access and receive health care.  We're also releasing new indicators on topics of emerging importance, such as telemedicine, which is receiving care from a doctor or health professional through a video or telephone conversation.

According to CHIS, 1 in 10 people used some form of telemedicine in 2015, a sizable percentage for such a new field and one that is likely to grow. In an era when it's hard for people to travel to a doctor, such as in rural areas with few providers or get an in-person appointment to see a doctor in a timely manner, telemedicine may be the only way some people get access to health care.

We're also releasing preliminary results of highly-anticipated data on adult gender identity and teen gender expression ― the first time we've ever collected these data. Even more data on these topics will be released in early 2017 when we publish an article on CHIS transgender data in the American Journal of Public Health in partnership with The Williams Institute at the UCLA School of Law.

As exciting as all our new topics are, CHIS is tremendously valuable for the many questions it asks again and again, allowing researchers to trend health and health care over time.

How many indicators are being released by CHIS and why are some being held back?

​We are releasing more than 200 indicators with CHIS 2015 ― the most ever released at one time by CHIS.  It's a big year! However, there are always questions that are held for later release. These are usually few and include open-ended question, like health insurance plan name, industry and occupation. We want to take special care and ensure we accurately capture the intent of the participant. Data for these additional questions will be released in early 2017.

What proportion of respondents do you reach by cell phone? Will CHIS eventually move to an online survey?

​The design of CHIS has evolved to better reflect changes in the population and the increasing number of households that only have telephone service through mobile devices. In 2013-2014, we reached about 80 percent of respondents through land lines and 20 percent by cell phone. In 2015, we changed our sample design to contact roughly half of our survey respondents by cell phone. 

Telephone surveys still allow us to reach a broad set of Californians, despite a changing culture with fewer people answering incoming phone calls. However, many surveys are moving to designs that involve asking people to respond by mail or Internet. These surveys may experience higher cooperation rates and can be conducted less expensively than telephone surveys, but there are some disadvantages as well. CHIS makes special efforts to conduct interviews in a large set of languages other than English to reflect California's diverse population, and this would be more challenging in a mail or Internet survey.

Someday, an approach that involves a blend of different approaches may make sense, and we will begin next year to examine these approaches in more detail.

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11/22/2016
  
Gerald F. Kominski, PhD

​Gerald Kominski is the director of the UCLA Center for Health Policy Research, which recently partnered with Prevention Magazine on a survey of attitudes toward health insurance in the U.S. In this brief interview, he discusses survey results ― showing 9 in 10 respondents are satisfied with their health plans ― and what can be done to rein in costs outside of the ACA as the incoming administration discusses how to "repeal and replace" the law.

What does the survey reveal in terms of feelings about the Affordable Care Act?

​There's been a lot of misinformation about how people feel about the Affordable Care Act (ACA). The survey we conducted shows that people are satisfied or even very satisfied with their coverage and want to keep their current health plan. 

There are concerns about costs ― but the overwhelming message seems to be that Americans do not perceive their health care system in need of a radical change along the lines of what is being proposed by the incoming administration.

Does the survey reveal concerns about cost?

Yes, and affordability has been an ongoing concern of Obamacare. But affordability will be a concern no matter what plan is in place because health care spending isn't effectively controlled by insurance companies, and the incentives for providers to control spending are weak or nonexistent. Everyone wants health care to be cheaper, but don't want to give up anything to keep spending under control. You know the saying, having your cake and eating it too!

Further, Obamacare would be much MORE affordable if important stronger penalties for remaining uninsured had been enacted, and if more generous subsidies were available even higher up the income ladder. Or, if federal reinsurance of high-cost patients was a permanent program rather than a temporary program that phased out this year just in time for the Presidential election, which once again brings more negative attention to the ACA.

Outside the ACA, what can be done to rein in costs?

This is this issue that still hasn't been faced by U.S. policymakers or the general public. In fact, we are in massive denial about real solutions.

We can either have broad, unlimited access to every innovation, regardless of cost; low copayments and deductibles; freedom for doctors, hospitals and pharma to bill whatever the market will bear; and accept that this is the price we have to pay for unregulated markets while we also complain about the high cost of insurance and health care. Or, we can recognize that unlimited health care might be too expensive, that providers don't face real price competition in most markets because they have monopoly power, and that insurance needs to have incentives to identify and pay for value rather than volume.

Repealing Obamacare, and creating Medicaid block grants Medicare vouchers are just convenient mechanisms for limiting federal government expenditures; these policies do nothing to rein in costs. But for the immediate future, national policy is going to focus exclusively on cutting federal health spending, not controlling overall health costs.

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10/26/2016
  
Maria-Elena Young, PhD, MPH

​Maria-Elena Young is a doctoral candidate in the UCLA Fielding School of Public Health's Department of Community Health Sciences and a co-author of a new study on the role of community health centers (CHC) in a post-ACA landscape. In this brief interview, Young discusses who uses community health centers, the state of CHC funding, and why staffing is difficult.

Who is seeking care at community health centers in the ACA era? Did the centers lose patients after the law passed, as some experts predicted?

​We found that community health centers (CHCs) serve a very diverse mix of patients ― both uninsured and insured. Our study focused on CHCs in immigrant communities and we certainly found that significant portions of the uninsured are ineligible for insurance due to their legal status.

However, we also found that CHCs are serving many other populations who are still uninsured due to a wide range of barriers to insurance. In Texas and Georgia, there are still many adults who cannot get Medicaid. Across all four states, vulnerable populations, such as the homeless or migrant farm workers, continue to seek care at CHCs. Finally, CHCs are providing care to individuals who have insurance through the insurance exchanges, but just can't afford the co-pays or deductibles. But thanks to the ACA, the majority of patients now have insurance.

Contrary to what many anticipated, CHC directors reported that very few of their newly insured, long-term patients left for different providers. In fact, a common characteristic across their diverse patient populations was that most people were long-time patients of the CHCs and, regardless of their insurance status, continued to seek care at these organizations. Given the choice between a community health center and a new provider, many people stuck with what they knew.

Federal funding has been an important part of the equation but may be reduced in the future. How will CHCs replace this source of funding and what happens if they don't?

​One of the major findings of this research was the importance ― and future uncertainty ― of the federal core funding for CHCs. All of the CHC directors that we spoke with emphasized that their mission was to serve everyone who needed care ― particularly the remaining uninsured. Federal funding makes it possible for them to achieve that mission. All are working to bring in more diverse revenue ― either from patients insured through Medicaid or the Marketplace or private grants. This will help, but likely could never make up the difference if federal funding were cut.

Several directors told us that a cut to or loss of their federal funding would lead to as much as a third or a half reduction in the number of patients they can serve. Some said their organization could not continue without it. The loss of federal funding will jeopardize the ability of CHCs to meet their mission.
Staffing is a chronic challenge at CHCs.  Where are the needs most acute?

​The majority of the CHC directors we spoke with struggled to recruit and fund both clinical and non-clinical positions. On the clinical side, CHCs have a hard time offering competitive salaries. On the administrative side, it is difficult to fund the care coordination and administrative staff that perform crucial, but non-reimbursable services. An additional challenge ― but also a key priority ― was to recruit staff who have a commitment to working with the underserved and uninsured populations.

The challenges in achieving the right staffing levels play out differently in each area. The needs are most certainly most acute in regions with high provider salaries (such as large metro areas) or provider shortages (such as rural areas with smaller workforces). But the challenges are also felt by CHCs that are smaller or have less flexibility in their funding, as they have less capacity to make adjustments to meet staffing needs. 

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9/27/2016
  
Peggy Toy, MA

Peggy Toy is project director of the Center's Healthy Aging Partnerships in Preventative Initiative (HAPPI) which awarded $140,000 in grants to eight community groups to increase use of preventive services -- such as flu shots and cancer screenings -- among underserved  adults age 50 and over in South Los Angeles. In this brief interview, Toy discusses the urgent need behind the awarding of these grants, the community groups and their focus, and the fears and mistrust that will need to be overcome.

Why is this project important?

​The population of adults ages 50-64 years doubled in the last 10 years in South Los Angeles (LA).  Elder care, especially in low-income, underserved areas, is becoming an urgent challenge.  In South LA, older African-Americans and Latinos are at higher risk for having heart-related disease, certain cancers and chronic respiratory illnesses than the overall county population. The flu shot immunization rate is 10 points lower than the state average ―  less than 50 percent of residents age 50 and over get a flu shot each year in our project area. And the death rate in this area related to flu and pneumonia is 10 points higher than Los Angeles County generally.

Who received the grants and who will benefit from them?

A majority of the grantees are partnering with clinics in South LA to specifically encourage African-Americans and Latinos over 50 to get mammograms, colon cancer screenings and cholesterol and other tests to check for early signs of disease and help them take steps to reduce premature disability and death.  Our goal is to connect at least 300 older residents to preventive services and to spread awareness about the importance of preventive services to many more. 

The grant winners' projects were guided by the Center study, Bringing It to the Community: Successful Programs That Increase the Use of Clinical Preventive Services by Vulnerable Older Populations, which reviewed different preventive care programs across the nation  in various communities using local, community-based approaches found to be effective in increasing the use of clinical preventive services. 
 
Our aim is to do the same thing here in South LA ― identify what works best for these communities by the community itself.  Community-driven approaches foster solutions that can be embraced and sustained over time.  

How will the organizations facilitate access for those who need clinical preventive care services? For instance, a recent study using California Health Interview Survey data reports African-Americans have a skeptical attitude toward flu shot effectiveness

Attitudes ― or misconceptions ― about preventive services can be a significant barrier to preventive care, along with lack of access. Among some African-Americans, there is a suspicion that the care they do receive is inferior to the care provided to other communities. Among Latinos, especially the undocumented, there may be a reluctance to seek care due to fears of deportation.

Unfortunately, one does not have to look very far into this country's history such as the Tuskegee experiment and the treatment of undocumented persons to understand some of the reluctance. There are also issues about insufficient information, barriers to follow up, and concerns about what to do with the results. 
 
Our grantees are local organizations with a history of service to African-Americans and Latinos, and a level of trust to effectively address those concerns. They will use workshops lead by community representatives who themselves have benefited from preventive care.  They will also engage local clinics, members of the Southside Coalition of Community Health Centers, to provide preventive services where people live. Some of the grantees will conduct education events to encourage participants to go to their own provider to get the service.
 
And some of the projects will be able to deliver the services in non-clinical settings, like churches and housing complexes, which will be important and reassuring for those who are reluctant to seek help from hospitals and clinics.

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8/31/2016
  
Gerald F. Kominski, PhD

Gerald Kominski is the director of the UCLA Center for Health Policy Research and co-author of a new policy brief on the share of taxpayer dollars that are spent on health care expenditures. In this brief interview, Kominski discusses how tax exemptions for employer-sponsored health insurance premiums benefit the rich more than the poor, why California's share of Medicaid spending is 10 percentage points higher than the national average, and why a streamlined single-payer system might be preferable to the nation's current "crazy patchwork" of health care financing.

California spends money on health care in a variety of ways, including through tax exemptions for employer-sponsored health insurance premiums. Can you explain how this works ? or does not work?

​The premiums that employers and workers pay for employer-sponsored health insurance (ESI) are exempt from taxation. These "foregone" taxes deduct $10.9 billion annually from the state coffers that could be spent on state programs like Medi-Cal and Healthy Families. Nationally, ESI tax subsidies are the third-largest health care program after Medicare and Medicaid, according to the National Bureau of Economic Research. And the ESI exclusion doesn't help low-wage workers much -- it benefits those with the highest incomes who have the most generous health plans. More than anything, the tax exempt status of ESI seems like an inefficient way to finance employer-based insurance.

California's share of Medicaid spending is 10 percentage points higher than the national average (27% versus 17%). Why is this?

​Almost 33% of the population in California is enrolled in Medicaid, which is notably higher than average enrollment across the U.S.  California has done a much better job at enrollment and has embraced the Medicaid expansion under the ACA. The major disadvantage of having a higher share of public spending in California for both Medicaid and total health spending is that there are fewer funds provided by private insurers. This creates pressure on providers to compete more intensely for a smaller share of privately insured patients, because they are generally the most profitable.

When providers select patients based on their profitability, we find greater disparities in access at a time when we are trying to reduce and eliminate disparities by expanding public insurance programs. This isn't a problem California can solve on its own, unless the state applies for a federal waiver to develop a single-payer system that puts everyone on equal footing.

Does the current system of multiple health care programs and health-related tax incentives make sense?

Despite the great successes of the ACA nationally and in California, our findings focus attention once again on the crazy patchwork of health care financing we have in the U.S. I believe that Sen. Sanders's campaign pledge of Medicare for All resonated with so many because it acknowledged a simple truth that most people understand intuitively; namely, that not only should everyone have health insurance, we shouldn't have significantly different health care options for the poor, for seniors, and for the working population. Far from creating "one size fits all" as critics also complain, it is possible to design a single-payer system in the U.S. that provides multiple options, subject to minimum benefit requirements that guarantee a floor for everyone. 

Now that we have health insurance exchanges as a result of the ACA, maybe ACA 2.0 should find a way to move ESI, Medicare Part C, and Medicaid eligible populations into those exchanges so that insurers are required to compete for all categories of insurance, not just those they find most profitable.

Or, if insurers like Aetna don't really want to sell health insurance, it might be time to pull the plug on this grand 87-year "experiment" with trying to make private insurance markets work, and finally admit once and for all, that in this sector of the economy, government really is the best choice for financing everyone's health care.

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6/29/2016
  
Nadereh Pourat, PhD

​Nadereh Pourat, Center director of research, is co-author of a new policy brief about a project in Los Angeles aimed at improving oral health among children younger than six years of age. In this brief interview, Pourat discusses primary teeth, child-wary dentists, and dental insurance.

Why is it important to examine a child's baby teeth when they fall out naturally anyway?

​Primary teeth are more vulnerable to cavities because the hard exterior of the tooth is thinner. Most people don't realize that cavities are caused by bacteria feeding on sugar and that these bacteria are contagious. The first step is to educate parents to avoid passing the bacteria to their young children, the second step is to make sure these bacteria are kept in check, and the third is to address problems early. Healthy habits such as not sharing utensils, brushing with toothpaste and reducing sugar in the diet can guarantee healthy permanent teeth.

Having an examination is essential to promote these healthy habits and reduce the chance of getting cavities during the rest of children's lives.

In your policy brief, the UCLA-First 5 LA 21st Century Dental Homes Project launched many strategies to improve access to care and quality ― including training for medical and dental providers on how to deal with kids. Was there a dentist "fear factor"?

​Most dentists are trained to deal with adult patients, but a child may not be instantly cooperative about opening his or her mouth so a stranger can look in it ― there will be resistance. Examining a child younger than six years old requires a child-centric approach by a comfortable, confident dentist. Delivering oral care to very young children also requires different techniques, such as having the child held in the parent's arms, since a child is unlikely to be able to sit in a chair on his or her own.

Is having insurance enough to ensure children receive basic preventive dental care?

​That's something we touch on in the policy brief. Simply having insurance is probably enough to get you in the door to receive prevention such as fluoride varnish or cleaning. However, providers need to go further and manage children that are at high risk for cavities.

For example, the provider has to assess the risk by asking parents about frequency of sugary drinks and foods, brushing regularly and with fluoride toothpaste, and sending the kids to bed with a bottle of milk. Risk assessment should be covered by insurance so that providers will take the time to do it. We know that there are many children that don't receive risk assessment and risk-based care. This project shows several ways we can address this significant problem for all young children.

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5/19/2016
  
Cindy L. Cain, PhD

Cindy L. Cain is a Center faculty associate and author of a Center policy brief on California's new law that allows a terminally ill patient with six months left to live to take a lethal dose of medication to hasten death. In this brief interview, Cain discusses lack of awareness about the law, problems having an end-of-life talk with a doctor, and more.

 

How are Californians being made aware that their terminally ill loved ones have the option to use a physician-prescribed medication to hasten death starting in June?

I think most Californians do not know that this option will be available starting in June. However, many Californians will remember stories about Brittany Maynard, a young woman dying from brain cancer who moved to Oregon to take advantage of the Death with Dignity Act. These kinds of mass media conversations may have increased awareness of the debates surrounding aid in dying.

Now that the law is going into effect, we need more intentional public campaigns to raise awareness about what the law permits, what it does not permit, and how one can get more information.

Is the burden on the terminally ill patient and his or her family to ask a physician about end-of-life options?

The burden is on the patient to bring up aid in dying as an option at the end of life. If a patient asks their attending physician for a comprehensive list of end-of-life options, the physician may tell them about aid in dying as one of those options. However, because the law permits physicians to opt out of participating in aid in dying, physicians do not have to give information about aid in dying if they are opposed to it on moral or ethical grounds.

This means that patients who want this information may have to change physicians if their current physician is opposed. Ultimately, patients will have to be much more proactive to receive information on this option, compared to other options at end of life.

Three states have enacted or allowed aid in dying in the last six years. Is it a signal of a national trend?

There is a growing national interest in talking about end-of-life issues and quality of life. Several states are now considering legal actions that would make aid in dying possible. As more people learn about California's End of Life Option Act, I expect that there will be more public interest in having this option. 

 

 

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