TAG: "Health policy"

California children with health insurance, regular dental care show big gains


UCLA research shows significant increases over past decade, but disparities persist.

Photo by Elena Zhukova

By Venetia Lai, UCLA

An impressive 3 in 4 California children ages 2 to 5 had a regular dental checkup in 2012, including those from poorer households, according to a new policy brief by the UCLA Center for Health Policy Research.

A decade earlier, just half the children in low-income households made an annual visit to the dentist, along with 60 percent of those from higher-income households.

The findings are part of a comprehensive new study that tracked young children’s health in California from 2003 to 2012. The study found gains in many areas, including health insurance coverage and dental care, but showed a drop in preschool participation, perhaps because of the associated costs.

“These are really encouraging trends for the health and well-being of children in California,” said Sue Holtby of the Public Health Institute, who is lead author of the study. “But some beneficial services remain out of reach for low-income families. The challenge for policymakers is to continue to improve access to, and quality of, the care children receive.”

Using data from 10 years of California Health Interview Survey from 2003 to 2012, the report assessed trends in the health of young children in areas linked to health and school readiness. The report focused on Latino, white, Asian and African-American children ages 5 and younger. According to CHIS, more than 3 million children in that age range lived in the state in 2012.

The safety net expands

Much of the time period covered by the study took place during the recession from 2008 to 2012, when many families lost access to employer-funded health coverage. As more low-income families gained health coverage through two public programs — Medi-Cal and Healthy Families —  ––the share of children ages 5 and younger who had private health insurance plummeted, from 57 percent in 2003 to 44 percent in 2011–12. The change meant a bigger share of young children relied on public coverage: 1 in 2 overall, compared to 1 in 3 a decade earlier.

The dramatic improvements in dental care for young children during the time period may be attributable, in part, to expanded public support.  Specifically, the study notes that a $7 million grant from First 5 California, which funded the study, provided preventive dental health training and education for dental and medical providers at Women, Infants and Children and Head Start programs from 2004 to 2008, the same time period in which annual child dental visits increased. In addition, Medi-Cal and Healthy Families promoted greater awareness of dental benefits.

More parents reading to their children

Another bright spot: More families participated in activities that promote social skills and brain development in young children. The percentage of parents who sang or played music with their child every day rose from 64 percent in 2003 to 68 percent in 2011–12, and those who took their children out on an excursion increased from 32 percent to 37 percent. The biggest jump was in the share of parents who read to their children daily: from 53 percent in 2003 to 62 percent a decade later.

However, the report found the proportion of 3- and 4-year-olds going to preschool at least 10 hours a week dropped over the decade, from 37 percent to 30 percent.

“Parents have gotten the message that there’s a lot they can do for their children’s development at home,” said Elaine Zahnd, a faculty associate at the Center for Health Policy Research and co-author of the study. “But there is more work to do to help parents who want their children to go to preschool.”

Other findings from the report:

  • More young children had access to health care. Access to health care improved for poor children as the decade progressed: the rate of uninsured poor children dropped from 13 percent in 2003 to 8.9 percent in 2012.
  • There are disparities in the sources of medical care. In 2012, far more young Latino children (40 percent) obtained care at community clinics or public hospitals compared to white (14.6 percent) and Asian (20.1 percent) children. However, the share of white children who visited a private doctor’s office or an HMO declined 5.3 points over the decade to 82 percent.
  • Almost all young children (97 percent) had a usual source of medical care in 2012, with two-thirds being treated by private practice doctors and HMOs and the rest at community clinics and hospitals.

“Parents are getting coverage for their children, but can they access health care for their children when they need it?” asked David Grant, director of the California Health Interview Survey and co-author of the report. “As more children rely on the safety net, policymakers must ensure that the clinics and public hospitals that serve them are adequately funded.”

The report found noteworthy improvements in young children’s health over the decade — especially in closing the income gap in dental and health care. But authors say continued monitoring and further research are needed to understand what prompted negative changes in private insurance coverage and preschool enrollment.

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Japanese Americans’ healthier golden years could be model for other seniors


‘Japanese Americans provide a window into our future.’

By Venetia Lai, UCLA

Nearly 1 in 4 Japanese Americans are 65 and older — nearly twice the proportion of seniors in the overall U.S. population. The facts that they are likelier to live longer than other Americans and are healthier when they age make Japanese Americans an important subject of research by health policy experts — and could provide clues about how all Americans can age, according to a new study by the UCLA Center for Health Policy Research.

Using California Health Interview Survey data from 2003 to 2012, the study found that elderly Japanese Americans had lower risks for nine of 15 health indicators than other Asian and other racial and ethnic groups in California. Older Japanese Americans, however, did have higher rates of arthritis and hypertension than seniors in other racial and ethnic groups.

“Japanese Americans provide a window into our future,” said Ying-Ying Meng, lead author of the study and co-director of the center’s Chronic Disease Program. “They show us one vision of how our nation can age and can help us prepare for the enormous generational shift ahead.”

The report, which was funded by Keiro Senior HealthCare, examines three categories of Japanese in California: Those who identify as being “only” Japanese — typically with parents who both were Japanese; those who identify as being mixed race; and those who identified as being Japanese in some way.

Among the findings:

Japanese only

  • 2 in 5 have hypertension, compared with 1 in 5 Asians in California overall and 1 in 3 Californians.
  • 2 in 5 have arthritis, compared with 1 in 5 or fewer among Chinese, Korean and South Asians in the state.
  • About 9 percent have diabetes — higher than the 7 percent target set for all Californians by Let’s Get Healthy California, a state-backed initiative that sets health goals, but comparable to the prevalence among all California adults and Asians in the state overall.

Mixed race

  • 1 in 5 eat fast food four or more times a week, compared with 1 in 10 Japanese only.
  • About 8 percent have hypertension — significantly lower than the figure among the Japanese-only cohort (22 percent). The study’s authors say the disparity may be a result of the multiracial group being younger overall.

Any Japanese identification

  • About 1 in 3 reported binge drinking — significantly more than those in Chinese or Vietnamese communities (both fewer than 1 in 5).
  • About 9 percent have diabetes, the same as among the Japanese-only group.
  • About 14 percent are obese, nearly double the 6 percent rate among the Chinese community but close to the Let’s Get Healthy California goal of 11 percent, and much lower than the rate for Latinos (30 percent) and African-Americans (35 percent).
  • They are much less likely to self-report fair or poor overall health than all other Asian groups in California, except for South Asians.
  • Rates of serious psychological distress are low, although the authors say Japanese-American families might not report mental health needs because of stigma.
  • Japanese seniors had a much lower prevalence of falls, about 8 percent, than Latinos (15 percent) and whites (14 percent).

Japanese-only residents, in large part the older generation, have some health behaviors and health outcomes that outshine their racially mixed grandchildren.

“In diet, for instance, the older Japanese population and new immigrants from Japan eat traditional foods — such as fish, miso soup and produce — while the younger, racially mixed generation is more fueled by fast food,” Meng said.

About 20 percent of California’s Japanese population identifies as multiracial, according to CHIS data from 2007 to 2012. Among Japanese Americans ages 18 to 34, about 57 percent identify as multiracial, and only 14 percent identify as Japanese only.

Tailored community outreach needed

To address health issues such as binge drinking and hypertension among California’s Japanese-Americans, the authors suggest culturally appropriate interventions tailored to subgroups, community-based prevention programs in non–health care settings, and more study of Japanese health and health behaviors.

“The approaching wave of aging baby boomers will place more demands on families and communities and significantly affect public health, social services and health care systems across the country,” said Dianne Kujubu Belli, chief administrative officer of Keiro Senior HealthCare. “Not only does this report guide Keiro and other Japanese-serving organizations to establish priorities in programming, but researchers and policymakers can study Japanese-Americans’ better health and take steps to promote healthy lifestyles and dietary habits for all future seniors.”

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States’ policies put health of undocumented immigrants at risk


Ohio rules create greatest health risk for undocumented residents; California the fewest.

By Gwendolyn Driscoll, UCLA

California scored the highest in a new ranking of U.S. states’ public policies and laws that support the health and well-being of undocumented immigrants.

The report, by the UCLA Center for Health Policy Research and the UCLA Blum Center on Poverty and Health in Latin America, with support from the UC Global Health Institute, also found that Ohio had policies that were more exclusionary than those of any other state.

The report focuses on state policies as of 2014 in nine categories across five areas: public health and welfare, higher education, labor and employment, access to driver licensing and government ID card programs, and enforcement of the federal Secure Communities program — all of which influence the health of immigrants and their families.

The researchers rated each state’s policies as “inclusive” (supporting health and well-being) or “exclusive” (harming health and well-being). Scores, which ranged from +1 to -1 for each category, were then tallied for an overall rating for each state. The average total score was -2.5 points.

California scored a total of +9; liberal-leaning New York scored +1. Only six other states and Washington, D.C., had overall scores greater than 0. Other surprises: Texas, frequently in the news for its conservative policies, scored +2 overall, making it one of the five most inclusive states. And Florida, which has a large population of recent immigrants, earned a -3. In all, 41 states were in negative territory.

See the results in a sortable, state-by-state list.

States with the top five and bottom six overall scores:

Top 5
1. California +9
2. Illinois +7
3. Washington +4
4. (tie) Colorado +2
4. (tie) Texas  +2

Bottom 6
51. Ohio -7
50. (tie) Alabama -6
50. (tie) Arizona -6
50. (tie) Indiana -6
50. (tie) Mississippi -6
50. (tie) West Virginia -6

“It is frustrating that so many states have policies that ignore or exclude a group of people who work hard and contribute so much to our society,” said Steven P. Wallace, associate director of the UCLA Center for Health Policy Research and co-author of the report. “The neglect or outright discrimination of the undocumented does not just hurt workers and their families; it hurts the communities that rely on them for the basic labor that makes our society function.”

Policies affect millions

The states’ public policies — and how each responds to flexibility in federal laws — affect the estimated 11.2 million undocumented immigrants living in the country, according to the report. The policies evaluated in the study also affect about 4 million U.S.-born children who live in “mixed-status” families, in which at least one parent is undocumented.

Laws in Arizona — including its immigration status check provision — and in other states have attracted federal court challenges and much media attention. Yet many state laws that can either promote or complicate the health of undocumented immigrants receive little attention.

Examples of beneficial or harmful policy outcomes, by program area:

Public health and welfare. Some states offer child health insurance or similar benefits regardless of immigration status, and some offer full Medicaid to pregnant undocumented women, but many do not. Most states determine eligibility for food stamps (now known as Supplemental Nutrition Assistance Program, or SNAP) by factoring in the family’s income and the number of all family members, regardless of their immigration status. But five states, including Arizona and Ohio, calculate eligibility for assistance using the income of all family members, but determine “family size” based only on those who are citizens or lawful permanent residents. This makes it more difficult for families with undocumented members to qualify.

Higher education. Twenty states, including California, Illinois, Florida, New York and Texas, allow undocumented students who attended secondary school in the state to pay in-state tuition for colleges and universities. Five of those, including California and Texas, also offer scholarship funding for those students. The rest require undocumented college students to pay out-of-state tuition, even if they attended K-12 in-state. Among the most exclusive is Georgia, which bars undocumented students from attending many of its public colleges and universities — even if they graduated from high schools in the state.

Labor and employment. Ten states’ workers’ compensation laws classify undocumented workers as “employees,” which qualifies them for workers’ compensation if they are injured on the job. But many states encourage public and private employers making hiring decisions to use the federal employment tool, E-verify, to check if an immigrant is authorized to work. Twenty states require state agencies, state contractors and/or private employers to use E-Verify; only two — California and Illinois — limit its use.

Access to driver’s licenses and government IDs. While some undocumented people can obtain identifications cards from their consular offices, cities such as Chicago, Oakland and San Francisco offer municipal IDs, which allow more access to public and private services. As of 2014, six states — California, Colorado, Illinois, Oregon, Utah and Washington — have laws that provide driver’s licenses to undocumented residents. But a federal law, REAL ID, puts restrictions on states that grant driver’s licenses or other IDs to the undocumented. Half of the states have passed resolutions or statute opposing the law.

Secure Communities. This enforcement program required that local police share information with federal immigration authorities, and it has contributed to the deportation of roughly 400,000 people per year, according to Pew Research. This has separated families and put stress on immigrants’ finances and health, the authors write. California, Connecticut and Colorado have adopted policies that prevent some undocumented immigrants charged with low-level, nonviolent offenses from being turned over to federal immigration authorities. Secure Communities was replaced by the Priority Enforcement Program, which does not require local law enforcement agencies to share information gathered in an arrest with the federal government.

Even high-scoring states can improve

Even the states that earned positive scores have room for improvement. The authors recommend actions all states can take to create a better environment for undocumented immigrants:

• Strengthen laws that secure undocumented immigrants’ rights in the five areas reviewed in the report.
• Buffer federal laws that restrict undocumented immigrants’ rights or access to resources.
• Focus on passing laws that are inclusive, rather than laws that explicitly exclude residents based on their legal status.
• More closely examine public policies for their ultimate impact on undocumented immigrants’ health.

“State and national lawmakers must recognize the value undocumented immigrants have in our country,” said Dr. Michael Rodriguez, co-author of the report, of the Blum Center and a faculty associate at the UCLA Center for Health Policy Research. “States must understand the critical role their policies play in promoting or hindering the well-being of undocumented immigrants who are an important part of the economic, political and social fabric of our nation.”

A report launch seminar with the authors, “The Healthiest (and Most Unhealthy) States to Be an Undocumented Immigrant: A Review of State Health Policies,” will be held from 12-1 p.m. today (April 16) at 10960 Wilshire Boulevard, Suite 1550, Los Angeles.

A special plenary session, “No Federal Immigration Reform? What States Can Do to Improve the Health of Undocumented Workers,” will be held from 11:30 a.m.-12:15 p.m. Saturday, April 18, during UC Global Health Day at UCLA, Covel Commons, 200 De Neve Drive, Los Angeles. Registration for UC Global Health Day is required for admission. Onsite: general $75, student $50.

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Unnecessary preoperative testing still done on cataract patients


UCSF researchers find testing based on provider behavior, not patient traits.

By Scott Maier, UC San Francisco

Although routine preoperative testing is not indicated for patients undergoing cataract surgery, researchers at UC San Francisco have found that it is still a common occurrence and is driven primarily by provider practice patterns rather than patient characteristics.

Their study appears in the April 16 issue of the New England Journal of Medicine.

“Our study shows that routine preoperative testing still occurs in Medicare patients undergoing cataract surgery, even though it is one of the safest procedures out there,” said lead author Catherine Chen, M.D., M.P.H., resident physician in the Department of Anesthesia and Perioperative Care at UCSF. “The major professional societies have agreed for more than a decade that routine testing doesn’t improve outcomes from surgery.”

According to the study background, cataract surgery is the most common elective surgery among Medicare beneficiaries, with 1.7 million surgeries annually. The average surgery is just 18 minutes long, and virtually all are performed in an outpatient setting with eye drops for anesthesia.

Chen and her colleagues analyzed a cohort of Medicare beneficiaries undergoing cataract surgery in 2011 to determine the frequency and cost of preoperative testing and office visits in the month before surgery.

Among nearly 441,000 patients studied, 53 percent had at least one preoperative test, and 52 percent had a preoperative office visit in the month before surgery. Testing and office visit expenses were $4.8 million (42 percent) and $12.4 million (78 percent) higher, respectively, than the average monthly expenditures during the preceding 11 months.

However, the researchers found testing varied widely among ophthalmologists and seemed to have little to do with patient characteristics. Although most ophthalmologists did not appear to do additional testing during the preoperative month, a small group of ophthalmologists accounted for more than 84 percent of the excess tests performed.

“The ophthalmologist who operated on the patient was a stronger predictor of whether patients were tested than any other variable we looked at, which implies that it doesn’t matter whether a patient is sick or healthy,” Chen said. “There are certain doctors who will always order tests in their patients just because that patient is having surgery, even though studies have shown that these tests don’t make a difference since cataract surgery itself is so low risk.”

“In this study, we found that the excess testing occurred primarily among a small number of physicians who are readily identifiable using claims data,” said senior author R. Adams Dudley, M.D., M.B.A., director of the Center for Healthcare Value at The Philip R. Lee Institute for Health Policy Studies at UCSF. “This study hopefully will encourage these physicians to examine their practice and make a change, but it also demonstrates that payers like Medicare could use their own data to figure out which doctors they need to talk to about this.”

Chen is careful to point out it is not necessarily the ophthalmologist alone who is driving testing.

“We can’t tell which doctor – the ophthalmologist, the anesthesiologist or the primary care provider – actually ordered the tests,” Chen said. “Ophthalmologists usually work closely with anesthesiologists and primary care physicians to evaluate their patients before surgery. That being said, our study is important because it shows that claims data can be used to eliminate wasteful spending without negatively impacting the quality of care provided to Medicare patients.”

Other UCSF contributors to the New England Journal of Medicine study were Grace Lin, M.D., M.A.S., assistant professor of general internal medicine; Naomi Bardach, M.D., M.A.S., assistant professor of pediatrics; W. John Boscardin, Ph.D., professor of epidemiology and biostatistics; and Adrian Gelb, M.D., Ch.B., professor, Mervyn Maze, M.B., Ch.B., professor, and Michael Gropper, M.D., Ph.D., professor and interim chair, anesthesia and perioperative care. Theodore Clay, M.S., statistician at Clay Software & Statistics, also contributed.

Funding was provided by the Foundation for Anesthesia Education and Research and The Grove Foundation.

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Income inequality affects who get an underutilized test for breast cancer


UCLA-led study shows that economic factors may influence adoption of new technologies.

The study, led by UCLA’s Ninez Ponce, found that communities with greater gaps between high-income individuals and low-income individuals also had larger gaps in testing. (Photo by Shweta Saraswat, UCLA)

By Venetia Lai, UCLA

Wealthier women who live in communities with the greatest income divide between rich and poor had better access to a new genetic test that can determine the most effective form of treatment for early-stage breast cancer, according to a new study (link is password-protected) by the UCLA Center for Health Policy Research, Harvard Medical School’s Brigham and Women’s Hospital and Aetna. The study, published in the April issue of the journal Health Affairs, also indicated that only a small minority of women with breast cancer received the test at all.

“Our study shows that even among women who have insurance, where they live and how income is distributed in their community were closely linked to their chance of getting access to an effective innovation in the early years of its diffusion,” said Ninez Ponce, associate director of the UCLA Center for Health Policy Research and lead author of the study.

The Gene Expression Profiling test is an early example of a “precision medicine” genomic test that estimates a patient’s risk of having a recurrence of a disease. According to current medical evidence, a woman with early-stage, estrogen-receptor–positive, lymph-node–negative breast cancer with a low-risk GEP test score may not benefit from adding chemotherapy to her treatment plan, while a woman with a high-risk score would benefit and should consider including chemotherapy in her treatment. More than 100,000 women are diagnosed with this type of breast cancer every year.

The study is based on a survey of 1,847 women between the ages of 35 of 64 who were insured through an Aetna health plan and were newly diagnosed with breast cancer in 2006 and 2007. Of those, 235 (12.7 percent) had the GEP test.

The study found that the greater the gap between high-income individuals and low-income individuals within a community, the larger the gap in testing. In communities where there was greater equality in income — whether poorer or wealthier — the adoption and use of the tests was slower than in communities with unequal income levels.

“Income inequality is at an all-time high right now,” said Dr. Jennifer Haas, a co-author of the study and associate professor at Harvard Medical School’s Brigham and Women’s Hospital. “That it should have a bearing on who gets an innovative test and who doesn’t could lead to more social disparities in cancer care.”

The authors point to the need for more research to address the socioeconomic and other barriers that may prevent women from accessing GEP and other medical innovations.

The TRANSPERS Center for Translational and Policy Research on Personalized Medicine, the National Institutes of Health, Harvard Catalyst, the Harvard Clinical and Translational Science Center, and the National Research Service Award Primary Care Research Fellowship and Aetna supported this study.

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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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