TAG: "Health policy"

Study examines how Obama executive actions could aid California immigrants


Hundreds of thousands could gain health insurance, but many will remain uncovered.

Between 360,000 and 500,000 immigrants living in California would become eligible for Medi-Cal if they receive temporary protection from deportation and permission to work as a result of recent executive actions by President Barack Obama. Up to 57 percent of immigrants in California who are eligible under the executive actions are low-income and lack private health insurance, according to a study by UC Berkeley’s Center for Labor Research and Education and the UCLA Center for Health Policy Research.

In November, Obama announced the expansion of the Deferred Action for Childhood Arrivals program, or DACA, which was established in 2012, and the creation of Deferred Action for Parents of U.S. Citizens and Lawful Permanent Residents, or DAPA. Applications continue for the original DACA program. Application processes for the new programs have been placed on hold under a court order, but immigration policy experts predict that the new programs will ultimately be implemented.

Although immigrants approved under the DACA and DAPA programs are not eligible for health coverage options under the Affordable Care Act, they are eligible for Medi-Cal under California state policy if they are in families earning less than a certain amount.

“We have left behind millions of undocumented workers and students who are excluded from health coverage options under the Affordable Care Act,” said Laurel Lucia, a policy analyst at the UC Berkeley Labor Center and lead author of the brief. “California is leading among states by providing comprehensive health care services to low-income residents granted DACA and DAPA, which is an important step toward closing the state’s largest eligibility gap.”

The researchers estimated that 66 percent of DACA- and DAPA-eligible adults are working.

“The only way we can improve overall health and efficiencies in expenditures is by providing important preventive and primary care services to everyone, not just those lucky enough to afford coverage,” said Nadereh Pourat, director of research at the UCLA Center for Health Policy Research and co-author of the brief. “Insurance coverage is the essential requirement for getting care when it is needed, and most undocumented working in low-income jobs fall through the cracks.”

New cost per person likely to be low

The researchers found that Californians eligible for DACA and DAPA are relatively young: 92 percent are under the age of 45, which would likely mean that their insurance premiums would be lower than the current statewide average.

Providing comprehensive coverage would also build upon federal and state funds already spent. Previous research by the authors found that 60 percent of the cost per adult of comprehensive Medi-Cal coverage is already paid for by the federal and state government through restricted scope Medi-Cal, which covers emergency and pregnancy-related services.

Many undocumented will remain uncovered

Even after expanded DACA and DAPA are implemented, many undocumented Californians would be expected to remain uninsured because they are not eligible for the programs, face barriers in signing up for deferred action or enrolling in Medi-Cal, or are not income-eligible for Medi-Cal.

This brief comes as the California Legislature considers the Health for All Act, or Senate Bill 4, proposed by state Sen. Ricardo Lara. The bill would expand eligibility for comprehensive Medi-Cal to all low-income Californians, regardless of their immigration status, and broaden undocumented Californians’ options for purchasing private insurance.

The health coverage and demographic estimates use data from the 2013 Current Population Survey, conducted by the U.S. Bureau of Labor Statistics and Census Bureau. The estimates are applied to the Pew Research Center’s estimate that 1.25 million Californians are potentially eligible for DACA and DAPA.

“This report gives us an important new insight on how many people are still locked out of health coverage. Now that we’ve seen these numbers, we can all work together to make sure everyone gets enrolled,” said Daniel Zingale, a senior vice president at The California Endowment, which funded the research. “People shouldn’t suffer or die because of their immigration status. The president’s executive action brings us a step closer to securing a healthier future for everyone, but even still, there will be others who are locked out of affordable coverage, and California needs to finish the job.”

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Los Angeles Times: Medi-Cal rolls could swell under Obama’s deportation relief plan

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UCLA launches first-of-its-kind study of U.S. transgender population


Information collected could be used to help craft better policy.

Ilan Meyer, UCLA

By Lauren Jow, UCLA

Researchers at the Williams Institute at UCLA School of Law, Columbia University and The Fenway Institute at Fenway Health are launching a first-of-its-kind study of the transgender population in the United States that they expect will create a more accurate and detailed picture of the issues faced by transgender individuals.

The study, which is being led by Ilan Meyer, Williams Senior Scholar of Public Policy at the Williams Institute, will provide researchers and policymakers with unbiased estimates about the demographics, health outcomes and health care needs of the transgender population by relying on a randomly selected sample of the U.S. population. The study, titled “TransPop: U.S. Transgender Population Health Survey,” also will provide insights into the methodology of surveying transgender people.

“With awareness about transgender people growing in the public and among researchers and policymakers, there are new opportunities to establish policies that address the needs of transgender people in the United States,” said Meyer, the study’s principal investigator. “Timely and accurate data about the transgender population is crucial for designing evidence-based public health and policy interventions.”

To date, most of what researchers know about the transgender population comes from studies that do not use random selection methods, Meyer said. While those studies have provided valuable information about transgender lives, they may not accurately represent the population.

Goals for the study include:

  • To describe basic demographic parameters of the U.S. transgender population including race/ethnicity, gender identity, age, place of residence, education, employment and income.
  • To describe basic health outcomes and health behaviors, including general health status, mental health, smoking, history of suicide attempts, disability, quality of life and health care access (including insurance coverage).
  • To describe experiences of transgender people with interpersonal and institutional discrimination, including experiences in healthcare, employment, housing and law enforcement.
  • To describe transgender identity history and transition-related experiences, including access to gender-affirming mental health services, hormone treatment and surgery, when relevant.

The findings from the study will show how various groups of transgender people differ and to what degree. That level of detail could highlight concerns that were previously underreported and help service providers develop more targeted programs.

The researchers will use a survey of 350,000 U.S. adults, conducted by Gallup, a global survey organization that delivers analytics and advice. Gallup survey participants will be screened during a one-year period, and those who identify as transgender will be invited to participate in the TransPop study. The researchers estimate that 300-500 transgender-identified individuals will participate.

In addition to Meyer, TransPop investigators are Jody Herman, scholar of public policy at the Williams Institute; Dr. Walter Bockting, professor of medical psychology and co-director of the LGBT Health Initiative at Columbia University; and Sari Reisner, research fellow, department of epidemiology at Harvard T.H. Chan School of Public Health and research scientist at The Fenway Institute at Fenway Health. The study is affiliated with UCLA’s California Center for Population Research.

The study is supported by the NIH Office of Social and Behavioral Science and is part of “Generations,” a larger five-year study funded by a federal grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (1R01HD078526) to the Williams Institute.

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Insuring undocumented residents could help solve multiple health care issues


UCLA health policy care analysis finds four key problem areas for Latinos under ACA.

Alex Ortega, UCLA

By Mark Wheeler, UCLA

Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.

Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.

Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:

  • The consequences of not covering undocumented residents.
  • The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.
  • The heavier demand on public and private health care systems serving newly insured Latinos.
  • The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.

“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”

Insurance for the undocumented

Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.

For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.

For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.

In addition, previous research has shown that undocumented people often delay seeking care for medical problems.

“That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients,” Ortega said.

Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.

“Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems,” Ortega said.

The growing Latino population in non-ACA Medicaid expansion states

A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.

As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.

“It’s estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law — the undocumented and those who have been in the U.S. less than five years,” Ortega said. “Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate.”

New demands on community clinics and health centers

Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.

But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.

“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”

Need for diversity in health care workforce

Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers — Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.

The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.

The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.

“That, of course, is the goal — to see improvements in the overall health for everyone,” Ortega said.

Other authors of the study were Arturo Vargas Bustamante of UCLA and Hector Rodriguez of UC Berkeley. Funding was provided by the National Heart, Lung, and Blood Institute (P50 HL105188).

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‘Sugar Papers’ reveal industry role in 1970s dental program


Sugar industry worked closely with NIH on research agenda on preventing tooth decay.

By Kristen Bole, UC San Francisco

A newly discovered cache of industry documents reveals that the sugar industry worked closely with the National Institutes of Health in the 1960s and ‘70s to develop a federal research program focused on approaches other than sugar reduction to prevent tooth decay in American children.

An analysis of those papers by researchers at UC San Francisco appears today (March 10) in the open-source scientific journal, PLoS Medicine.

The archive of 319 industry documents, which were uncovered in a public collection at the University of Illinois, revealed that a sugar industry trade organization representing 30 international members had accepted the fact that sugar caused tooth decay as early as 1950, and adopted a strategy aimed at identifying alternative approaches to reducing tooth decay.

Meanwhile, the National Institutes of Health had come to the conclusion in 1969 that focusing on reducing consumption of sucrose, “while theoretically possible,” was not practical as a public health measure.

Thus aligned, the sugar industry trade organization and the NIH worked in parallel and ultimately together on developing alternative research approaches, with a substantial portion of the trade organization’s own research priorities — 78 percent — directly incorporated into the 1971 National Caries Program’s first request for research proposals from scientists.

“The dental community has always known that preventing tooth decay required restricting sugar intake,” said first author Cristin Kearns, D.D.S., M.B.A., a UCSF postdoctoral scholar who discovered the archives. “It was disappointing to learn that the policies we are debating today could have been addressed more than 40 years ago.”

While tooth decay is largely preventable, it remains the leading chronic disease among U.S. children, according to the Centers for Disease Control and Prevention. The CDC estimates that more than half of American children and teens have cavities in their adult teeth, and 15.6 percent of children age 6 to 19 have untreated tooth decay, which can lead to tooth loss, infections and abscesses.

Kearns discovered the papers in a collection that was left to the University of Illinois library by the late Roger Adams, a professor emeritus of organic chemistry who served on the Sugar Research Foundation (SRF) and the scientific advisory board of the International Sugar Research Foundation (ISRF), which became the World Sugar Research Organization.

They include 1,551 pages of correspondence among sugar industry executives, meeting minutes and other relevant reports from between 1959 and 1971. Kearns and UCSF co-authors Stanton A. Glantz, Ph.D., and Laura A. Schmidt, Ph.D., analyzed the papers against documents from the National Institute of Dental Research (NIDR) to explore how the sugar industry may have influenced the research policies of the 1971 National Caries (Tooth Decay) Program.

The analysis showed that in the late 1960s and early 1970s, the sugar industry funded research in collaboration with allied food industries on enzymes to break up dental plaque and a vaccine against tooth decay. It also shows they cultivated relationships with the NIDR and that a sugar industry expert panel overlapped by all but one member with the NIDR panel that influenced the priorities for the NIH tooth decay program. The majority of the research priorities and initial projects largely failed to produce results on a large scale, the authors found.

“These tactics are strikingly similar to what we saw in the tobacco industry in the same era,” said Glantz, whose similar discovery in the 1990s of tobacco industry papers led to massive settlements between the industry and every U.S. state, and to the Department of Justice’s successful prosecution of the major tobacco companies and their research organizations under the Racketeer Influenced and Corrupt Organizations Act. The Legacy Tobacco Documents Library at UCSF now contains 14 million of those documents.

“Our findings are a wake-up call for government officials charged with protecting the public health, as well as public health advocates, to understand that the sugar industry, like the tobacco industry, seeks to protect profits over public health,” Glantz added.

While the authors recognize that the Adams papers provide a narrow window into the activities of one sugar industry trade association, they noted that the sugar industry’s current position remains that public health should focus on fluoride toothpaste, dental sealants and other ways to reduce the harm of sugar, rather than reducing consumption. They concluded that industry opposition to current policy proposals — including the World Health Organization’s newly released guidelines to reduce added sugar to less than 10 percent of daily caloric intake — should not be allowed to block this prudent public health standard.

“There is robust evidence now linking excess sugar consumption with heart disease, diabetes and liver disease, in addition to tooth decay,” said Schmidt, who also is principal investigator on the UCSF-led SugarScience initiative. “Times have definitely changed since that era, but this is a stark lesson in what can happen if we are not careful about maintaining scientific integrity.”

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Are we closing the gender gap?


UCLA report reveals marked inequalities in legal rights for women and girls around world.

The report found that although all but seven countries have made primary education tuition-free, 40 charge tuition before the end of secondary school. (Photo courtesy of UCLA's World Policy Analysis Center)

By Carla Denly, UCLA

On March 9, the United Nations will convene to evaluate the global community’s progress on gender equality in the 20 years since 189 countries adopted the Beijing Declaration and Platform for Action. The U.N. session will continue through March 20.

Closing the Gender Gap,” a new report by UCLA’s World Policy Analysis Center (World), reveals that more than 170 countries have legal barriers preventing women and girls from experiencing the same rights, protections and liberties as men and boys.

World’s new report and accompanying online resource bank take a heightened approach to global accountability and transparency by detailing the rights, laws and policies pertaining to gender equality in 197 countries and Beijing Platform signatories. The resource bank includes quantitatively analyzable data, policy briefs, mobile-friendly interactive maps, infographics, fact sheets and more.

Analysis by World shows that in most countries, gender inequality continues to be embedded in national constitutions, laws and policies:

  • More than 150 countries lack protections critical to ensuring women’s economic participation.
  • Sixty-one countries provide girls with less legal protection from early marriage than they do for boys.
  • Ninety-two countries guarantee paid leave to mothers of infants, but not to fathers, perpetuating inequalities in the burden of caregiving and limiting equal opportunities at work.

The U.S. is not immune from these concerns — here, for example, mothers are not ensured paid leave to care for their newborn children, making the U.S. the world’s only high-income country not to provide such a guarantee. And while more than 80 percent of countries in the world have a constitutional guarantee of gender equality, the U.S. does not.

Yet the report findings indicate that progress is possible. More than 95 percent of the 56 new national constitutions adopted around the world in the past 20 years legally guarantee gender equality. Good legislation and policies exist in all regions and at all country income levels.

“Citizens need and deserve to know their rights and how their country fares when compared to others,” said Dr. Jody Heymann, founding director of the World Policy Analysis Center and dean of the UCLA Fielding School of Public Health. “Only by getting data into the hands of citizens and leaders alike on what effective steps have been taken — and what haven’t — can we close the gender gap in our global community.”

The study examined whether laws treat women and men equally, and whether concrete steps have been taken to reduce inequality. Among the findings:

Constitutions

  • Constitutional guarantees are nearly universal in newly passed constitutions. More than 95 percent of the 56 constitutions that have been adopted since 1995 include guarantees for gender equality, compared with just 79 percent enacted before then. These protections of equality provide a foundation to challenge discriminatory laws.
  • Thirty-two constitutions still do not explicitly guarantee gender equality.
  • Eleven constitutions allow customary or religious law to supersede constitutional protections of gender equality, potentially jeopardizing equal rights for women.
  • Despite constitutional guarantees, discriminatory laws remain in place in many countries around the world.

Families and marriage

  • Only 56 constitutions guarantee equality within marriage and there has been little change in the level of protection over the past 20 years.
  • Legislation also lags behind in this area. Sixty-one countries allow girls to be legally married younger than boys.
  • Inequalities in the law contribute to more girls being married young than boys: Nearly five times more girls than boys are married before the age of 18.
  • While large gaps remain, many countries have strengthened child marriage legislation since Beijing. Among 105 low- and middle-income countries, the percentage of countries that allow girls to be married before age 18 with parental consent fell from to 56 percent in 2013 from 80 percent in 1995.

Families and work

  • One hundred and eighty-eight countries guarantee paid leave for new mothers (the U.S. does not), but only 96 countries provide paid leave for new fathers. This legal inequality reinforces social norms that women are responsible for care and limits women’s economic opportunities, contributing to lower employment rates and wages for women.
  • Caregiving doesn’t end at infancy. Eighty-one countries provide no leave that can be used to meet children’s health needs and five other countries place the burden of meeting children’s health needs solely on women. In 143 countries, no leave can be used to meet children’s educational needs and two other countries place the burden of meeting children’s educational needs solely on women.
  • As the global population ages, leave to care for adult family members is increasingly important. Ninety-seven countries do not provide any leave to meet adult family members’ health needs. This gap disproportionately affects women who carry far more of the elder caregiving globally.
  • Countries that do guarantee paid leave for men and women exist in every region and income level.

Education

  • All but seven countries have made primary education tuition-free, but 40 countries continue to charge tuition before the end of secondary school.
  • When cost is a barrier, girls are more likely to be kept out of schools than boys. Unsurprisingly, the regions with the largest gaps in secondary enrolment for boys and girls are also those that are most likely to charge tuition.
  • Among those countries with available expenditure data, 43 percent that charge tuition before the completion of secondary school spend less than 4 percent of their gross domestic product on education.

Economy and work

  • Only 64 countries constitutionally guarantee women protection from discrimination at work or guarantee equal pay for equal work.
  • Only 40 countries have legislative protections from gender discrimination in hiring and pay.
  • Of constitutions adopted in the past 20 years, 38 percent guarantee protection from discrimination at work, compared to only 12 percent of those that existed previously.

World’s findings provide an opportunity to examine countries’ progress in closing the gender gap, especially in critical areas that impact the daily lives of women and girls — access to quality education and the ability to remain in school, protection from child marriage, equal rights in employment, and policies that ensure health at work and at home.

“When the status of women and girls improves, population health improves and the economic strength of companies and countries increases. Entire families, communities, and countries are lifted up,” Heymann said.

The Maternal and Child Health Equity research program at McGill University helped develop longitudinal data on child marriage, breastfeeding breaks and maternal leave for the study.

The Bill & Melinda Gates Foundation provided grant support for this work to improve the quantity and quality of comparative policy data available in partnership with the Bill, Hillary & Chelsea Clinton Foundation’s No Ceilings Initiative.

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Undocumented farmworkers use Medicaid half as often as documented farmworkers


UC Davis study finds that greatest predictor of farmworker use of Medicaid is having children.

J. Paul Leigh, UC Davis

By Karen Finney, UC Davis

Undocumented farmworkers are half as likely as those who are documented to use Medicaid, the federal health insurance program available to low-income individuals and families, according to a new study from UC Davis Health System. The research also shows that the greatest predictor of farmworker use of Medicaid, which provides coverage for prenatal, pediatric and emergency care regardless of documentation status, was having children.

“Undocumented agricultural workers are using Medicaid at about half the rate of documented immigrants and citizens, and they appear to be using it in accordance with the law,” said J. Paul Leigh, senior author of the study, professor of public health sciences and researcher with the Center for Healthcare Policy and Research. “There’s a perception that undocumented farmworkers are overusing Medicaid resources, but our findings indicate the opposite.”

In conducting the study, which is published online in the Journal of Occupational and Environmental Medicine, Leigh analyzed records from the U.S. Department of Labor’s National Agricultural Workers Survey (NAWS) on 41,324 farmworkers from 1993 through 2009, about half of whom were migrants working without residency, citizenship or visas.

Because the NAWS database is the only nationally representative sample of undocumented workers, it is a rare source of information on demographics and income at both individual and household levels for this often elusive group. Given that almost 50 percent of Medicaid recipients are children, the data on households rather than individual adults was particularly relevant to the current study.

Leigh found that undocumented farmworker heads of household were 52 percent less likely to use Medicaid than their documented counterparts: 22.6 percent of documented farmworker heads of household and only 12.2 percent of undocumented farmworker heads of household reported that one or more family members received Medicaid services over two-year intervals during the 16-year study period.

The odds of receiving Medicaid benefits for documented heads of household with one child were 6.57 times greater than that of documented heads of household with no children. One-child undocumented heads of household were 8.4 times more likely to utilize Medicaid than childless documented heads of household.

“Simply having children is the best determinant of Medicaid use,” said Leigh. “Use by undocumented, unmarried males appears to be extremely rare.”

The seemingly disproportionate effect of children on undocumented versus documented heads of household may be explained by access to non-government health insurance options, according to Leigh. Documented workers are much more likely than undocumented workers to have employer-sponsored health insurance, which families typically prefer over Medicaid. Undocumented heads of household, even those with children who are U.S. citizens, rarely have that choice.

“Undocumented workers don’t have any other place to go for health insurance,” Leigh said. “As soon as they have a child in the family, undocumented workers are much more likely to use Medicaid.”

Higher income, either for individuals or families, was associated with lower odds of Medicaid use for both documented and undocumented heads of household. There were also variations by region, with California having the highest odds of Medicaid use.

This is one in a series of studies of health care utilization prepared by Leigh, an expert in economics and occupational illnesses. Next in the pipeline is a study of those who use food stamps and the U.S. Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants and Children, which provides supplemental foods, health care referrals, and nutrition education for low-income women and young children who are deemed at nutritional risk.

“Medicaid Use by Documented and Undocumented Farm Workers” was co-authored by Yoon-Kyung Chung of the Korea Energy Economics Institute in Seoul and Ph.D. graduate of the UC Davis Department of Economics. It was supported by the National Institute for Occupational Safety and Health (grant number 2U54OH007550-11). The study is available online.

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California breast density law slow to have an impact


UC Davis research demonstrates need for more physician education.

Jonathan Hargreaves, UC Davis

By Dorsey Griffith, UC Davis

Ten months after California legislators enacted a controversial law mandating that radiologists notify women if they have dense breast tissue, UC Davis researchers have found that half of primary care physicians are still unfamiliar with the law and many don’t feel comfortable answering breast density-related questions from patients. The findings, to be published in the March print edition of Journal of the American College of Radiology, suggest that if the law is going to have any significant impact on patient care, primary care providers need more education about breast density and secondary imaging options.

“Overall, the impact of the breast density legislation probably is not significant if  primary care physicians are not educated or aware of it,” said lead author Kathleen Khong, a UC Davis radiologist and staff physician. “We should put some emphasis on educating the primary care physicians so that when they get questions from patients, they can be comfortable in addressing the issues.”

The California law, which took effect in April 2013, requires that patients whose breast density is defined as “heterogeneously dense” or “extremely dense” (about 50 percent of women), receive the following notification:

“Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer. This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.”

The researchers point out that breast density has long been a required part of any radiological report following mammography, but unless a patient asks to see the report, the information is shared only with the patient’s providers. Led by patient advocates, the legislation is intended to increase awareness of dense breasts and encourage patients to discuss the clinical issues with their doctors. According to published research, 28 states have passed, rejected or considered dense-breast notification legislation since 2009.

But the UC Davis study demonstrated that while women and their doctors are receiving the notifications, many of those physicians are unclear about what to do with the information. As a consequence, the researchers said, it appears that relatively few patients with dense breasts are asking questions about their breast density and its implications.

The UC Davis study surveyed 77 physicians about the new law.  Roughly half (49 percent) reported no knowledge of the legislation and only 32 percent of respondents noted an increase in patient levels of concern about breast density compared to prior years. In addition, a majority of primary care physicians were only “somewhat comfortable” (55 percent) or “not comfortable” (12 percent) with breast-density questions from their patients.

Khong said their survey results were surprising, but acknowledged that many primary care physicians may not feel they have sufficient training to make a clinical recommendation for a particular type of secondary screening. In fact, the study also found that 75 percent of respondents would like more education about the breast-density law and its implications for primary care.

“They are eager to learn and want to help their patients and be part of something positive as a result of this,” Khong said.

Jonathan Hargreaves, assistant professor of clinical radiology and a study co-author, said, for example,  that if a patient has dense breasts she should have a risk assessment, which takes into account her family history of breast cancer, biopsy history and other factors to determine whether a supplemental screening is warranted. Once  complete, the physician should then discuss the potential benefits and risks of supplemental imaging in determining the most appropriate approach for the patient. The use of ancillary screening in addition to mammography is a complex subject and still the subject of considerable debate, explained Hargreaves.

Tomosynthesis, known as 3-D mammography, is one supplemental test that breast radiologists generally agree provides a slight benefit for women with dense breasts over a standard mammogram and can be scheduled for the next annual mammographic screening appointment after receiving a notification. Breast magnetic resonance imaging (MRI) is another secondary imaging option, Hargreaves said, but is generally only used for screening in women who have a very strong family history of breast cancer or have a known high-risk gene, such as BRCA.

“The law has raised a lot of awareness about breast density,” Hargreaves said. “That being said, mammography screening is the primary thing patients need to do, and beyond that, the real benefits of other screening techniques are still the subject of ongoing medical debate.”

Khong and Hargreaves hope to validate their findings by expanding their research to include primary care physicians from other major university health care systems in California.

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Kids of melanoma survivors need better protection from sun’s harmful rays


UCLA study is first to include Latinos, whom have often been left out of skin cancer prevention research.

Credit: Sean Brenner, UCLA

By Reggie Kumar, UCLA

UCLA researchers have found that children of melanoma survivors are not comprehensively adhering to sun protection recommendations, despite them being at an increased risk for developing the disease as adults.

In the study led by Beth Glenn, associate director of the UCLA Jonsson Comprehensive Cancer Center’s Healthy and At-Risk Populations Research Program, researchers asked parents about their attitudes toward melanoma prevention, how at risk for melanoma they believed their child to be, and their current use of sun protection strategies for their child. They found that about three-quarters of parents relied on sunscreen to protect their child against sun exposure, but less than a third of parents reported that their child wore a hat or sunglasses or attempted to seek shade when exposed to the sun.

Additionally, Glenn said, 43 percent of parents surveyed reported that their child experienced a sunburn in the past year. This is concerning because sunburns are a major risk factor for melanoma.

The UCLA researchers used the California Cancer Registry (which tracks all cases of cancer across the state) to identify and survey 300 melanoma survivors with children ages 17 and younger during a three-year period. The study targeted both non-Latino white melanoma survivors and for the first time Latino melanoma survivors as well.

Latinos have often been left out of skin cancer prevention research due to a common misconception that sun protection is not important for this group.

“Sunburns were common among the children in our study despite their elevated risk for skin cancer. Also, children of Latino survivors were just as likely as children of non-Latino white survivors to have experienced a recent sunburn, which highlights the importance of including this group in our work,” said Glenn, associate professor of Health Policy and Management in the UCLA Fielding School of Public Health.

The survey results will be used to apply for additional funding to develop an intervention program that combines a text message reminder system with educational materials and activities for parents and children. The intervention program is designed to help melanoma survivors more effectively monitor and properly protect their child against UV radiation.

“Protecting kids against the sun’s harmful rays at an early age is vitally important. Our goal is to develop an intervention that will help parents protect their children today and help children develop sun safe habits that will reduce their risk for skin cancer in the future,” said Glenn.

The study will be published online Jan. 13 in the journal Cancer Epidemiology, Biomarkers & Prevention.

The research was supported in part by the National Cancer Institute.

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Trending: Full-time employment with no health benefits


In 2012, nearly half of uninsured Californians were in families with a full-time worker.

By Venetia Lai, UCLA

Almost half of the 6.9 million Californians who lacked insurance in 2012 were in a family with a full-time worker, according to a new report from the UCLA Center for Health Policy Research.

The State of Health Insurance in California report also found that the number of adult workers with job-based health insurance declined between 2009 and 2012. Full-time workers saw a drop of 2.9 percentage points to 63.6 percent and part-time workers dropped 2.2 points to 39.6 percent.

The report is based on data from the 2011-12 California Health Interview Survey, which is the nation’s largest state-based health survey and one of the largest health surveys in the United States. Because the data were collected just before full implementation of health care reform, the latest State of Health Insurance in California report will serve as a baseline to gauge the effects of the Affordable Care Act.

“Health care reform filled a huge and growing gap in job-based insurance,” said Shana Alex Charles, lead author of the study and director of the Health Insurance Program at the Center for Health Policy Research. “Sadly, health insurance is no longer a guarantee provided by many employers.”

Latinos still in the medical “shadows”

According to the report, Latinos had the lowest rate of job-based health coverage — 33.9 percent, compared to 63.3 percent of whites — and the highest rate of not having insurance, 28.4 percent.

Although nearly a third of low-income adult Latinos had Medi-Cal, 1 in 4 still lacked a usual source of care, the report noted, and 17.2 percent of adult Latinos covered by job-based insurance didn’t see a doctor in 2011-12, a much higher rate than either non-Latino whites or African Americans.

“This report shows us where we were, and it wasn’t a good place,” said Gerald Kominski, director of the Center for Health Policy Research and co-author of the study. “From here on out we can accurately measure how California’s health improves under reform.”

Young adults gain job-based coverage in ACA reform

In an early example of the benefits of health care reform, the study found that adults ages 19-26 were the only age group that gained health coverage from 2009 to 2012, with job-based coverage for them jumping to from 23.2 percent to 27.1 percent. That was an increase of 254,000 people. This age group also experienced the largest drop in the rate of people without insurance; this rate went from 28.9 percent in 2009 to 26 percent in 2012.

But for older adults, the percentage of those covered by job-based insurance plummeted. In the 40- to 54-year-old age group, more than half a million people  lost job-based coverage — a drop from 49 percent in 2009 to 45.4 in 2012.

“With job-based coverage shrinking year after year and nearly a third of California’s Latino community without health coverage, California was poised and ready for the implementation of the Affordable Care Act,” said Robert Ross, president and CEO of The California Endowment, which co-funded the report along with the California Wellness Foundation. “I’m confident we’ll see improvements in health coverage rates when the 2014 enrollment numbers are crunched.”

High-deductible plans create “underinsurance”

Among people with insurance, high deductibles played a big role in whether people put off having medical procedures. Californians with high-deductible plans that they purchased directly from an insurance company delayed or went without needed medical care at a rate double that of those without high-deductible plans, 16.1 percent versus 6.6 percent.

While the share of workers carrying individually purchased insurance is small — about 5 percent of full-time workers and 9.5 percent of part-time workers — the burden falls on many who are small business owners, according to the report.

“These data underscore the importance of Covered California’s Small Business Health Options Program,” said Judy Belk, president and CEO of the California Wellness Foundation. “It makes getting health insurance much more affordable for small businesses. People should not have to put their health at risk because insurance premiums are too high.”

Other findings include:

White, middle class and uninsured. Among whites with a family income higher than 400 percent of the federal poverty level (about $92,200 for a family of four in 2012), 1 in 4 went without insurance all or part of the year.

Public health insurance programs protect millions. One-fifth of Californians under age 65 in 2012 — 6.4 million people — were insured by Medi-Cal and the Healthy Families programs. That included nearly 2.6 million low-income children ages 0-11. This represented an 8-percentage-point jump from 2009 — the biggest increase of any age group — to 40.3 percent covered. This increase underscores the importance of public health insurance programs in maintaining the health of children. Nearly 70 percent of children covered by Medi-Cal are Latino.

With the release of the report, policy analysts and health advocates have a tool to measure the extent to which ACA reforms changed health access and health outcomes among the state’s residents in 2014.

“While the clear early success of the ACA in enrolling young adults in private coverage is promising, our data show that even the insured have delays in care, problems affording deductibles, and other access barriers that we hope will be addressed,” Charles said.

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Higher-earning docs make more money by ordering more procedures per patient


UCLA findings suggest that the practice may not be in patients’ best interest.

By Kim Irwin, UCLA

In results they characterized as “very surprising,” UCLA researchers found for the first time that higher-earning clinicians make more money by ordering more procedures and services per patient rather than by seeing more patients, which may not be in patients’ best interest.

The researchers, from UCLA’s Department of Urology and the Veterans Health Administration, examined the amount Medicare was billed and the amount paid to clinicians. They reviewed data from Medicare Part B payments during 2012.

“Medicare spending is the biggest factor, crowding out investment in all other social priorities,” said Dr. Jonathan Bergman, the research letter’s first author and an assistant professor of urology and family medicine at the David Geffen School of Medicine at UCLA.

“With clinicians making more not by seeing more unique patients, but by providing more services per person, additional research needs to be done to determine if these additional services are contributing to improved quality of care,” Bergman said. “These findings suggest that the current health care reimbursement model — fee-for-service — may not be creating the correct incentives for clinicians to keep their patients healthy. Fee-for-service may not be the most reasonable way to reimburse physicians.”

The research letter was published in the journal JAMA Internal Medicine.

Bergman, who also is a urologist and bioethicist at the VA Greater Los Angeles Healthcare System, believes the review of Medicare data is important because of its potential impact on public policy.

“Our findings suggest a weakness in fee-for-service medicine,” he said. “Perhaps it would make more sense to reimburse clinicians for providing high-quality care, or for treating more patients. There probably shouldn’t be such wide variation in services for patients being treated for the same conditions.”

Further research will need to be done to assess if treatment outcomes differ between those who had more services ordered and those who had fewer. This may also show a clearer view of how to best target resources to maximize value for patients, Bergman said.

Going forward, Bergman and his team will look at alternative payment models, such as those used at Veterans Affairs facilities and in “safety net” hospitals, to see if they make more sense than fee-for-service plans.

The research letter reported: “The goals of payment reform are currently unrealized, as evidenced in these data. Physicians take an oath to care for patients using ‘appropriate means and appropriate ends,’ focusing on what is best for the patient, and this centuries-old oath still resonates with graduates of medical school classes. Rather than react to externalities imposed by payers, clinicians can lead the movement toward a high-value, patient-centered care. We are uniquely empowered to ensure that all individuals access the procedures they need, and are not exposed to those they don’t.”

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Social, behavioral data provide key info for electronic health records


IOM report details 12 social and behavioral factors that should be included in EHRs.

If social and behavioral data were included in electronic medial recorders if could help nurses and physicians have a better picture of the patient's health. (Photo by Cindy Chew)

By Juliana Bunim, UC San Francisco

Social and behavioral data provide crucial information about factors that influence health and effectiveness of treatment and should be incorporated into patient electronic health records (EHR), according to a new report from the Institute of Medicine (IOM).

The IOM committee, co-chaired by Nancy Adler, Ph.D., vice chair of the Department of Psychiatry at UC San Francisco and William Stead, M.D., of Vanderbilt University, was created in 2013 to conduct a two-phase study, first to identify the social and behavioral areas that most strongly determine health, and then to evaluate the measures that can most effectively be used in EHRs. Kirsten Bibbins-Domingo, M.D., of the UCSF Department of Medicine, also served on the committee.

The committee reviewed the evidence linking social conditions and health behaviors to health, which suggests that health behaviors such as alcohol use, and social conditions such as financial resource strain account for more than half of all premature deaths in the United States. They evaluated more than 70 relevant domains and subdomains, 17 of which were judged to be most valuable for inclusion in electronic health records.

“Having access to information about health-related aspects of a patient’s life in the electronic health record can enable clinicians to make more accurate diagnoses and engage more effectively with the patient in making treatment choices,” said Adler. “The information can also help health systems understand the needs of the populations they serve and design more effective services.”

The second phase of the report, published Nov. 13, details 12 social and behavioral factors that should be included in electronic health records.

The new report, Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2, recommends that providers use their EHRs to capture patients’ census information including race, ethnicity and address, in addition to tracking alcohol use, tobacco use and exposure, physical activity, educational attainment, social connections, depression, stress, financial resource strain, neighborhood and community compositional characteristics, and exposure to violence.

“When analyzed along with genomic and clinical data, standardized social and behavior information in EHRs can enable new discoveries regarding the etiology and progress of disease,” said Adler. “It can also point to the effectiveness of specific treatments for patients with different psychosocial and biological profiles.”

Read phase one of the report here.

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Many seniors who fall repeatedly don’t seek medical attention


Study finds health care workers also often fail to counsel seniors on preventing future falls.

More than half a million older Californians — 12.6 percent of the state’s senior population — fall more than once a year, but nearly 60 percent of them fail to seek medical attention afterward, according to a new study by the UCLA Center for Health Policy Research.

The study also found that among those who did seek treatment, 40 percent did not receive counseling from a medical provider about how to prevent future falls.

Falls are the leading injury-related cause of death and need for medical care among Californians age 65 and older, according to the study. In 2012, more than 1,800 seniors died after falling and seniors’ fall-related injuries resulted in more than 72,000 hospitalizations.

“There is a cost in terms of both lives and resources when doctors fail to talk to seniors who have already fallen about how to prevent future falls,” said Steven Wallace, associate director of the Center for Health Policy Research and author of the study.

Using data from the 2011–12 California Health Interview Survey, the study found older seniors are twice as likely as younger seniors to have multiple falls: nearly 1 in 5 people 85 and older reported that they fell more than once a year, compared with 1 in 10 of those aged 65 to 74. Nearly a quarter of seniors who have suffered a stroke, and almost 20 percent of those with any disability, had multiple falls. Twenty-six percent of seniors with moderate mental impairment had multiple falls, as did 38 percent with severe mental impairment.

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