Acute Confusion As Exchange Enrollment Gets Underway

November 2, 2017 by · Leave a Comment 

If the comments on Covered California’s Facebook page are any indication, you’re all suffering from acute health insurance confusion:

“I wanted to sign up again this year. … I’m hesitant now because of what Trump has done. Should I still consider?”

“Does the removal of subsidies mean we might lose our premium tax credits during the year?”

“So you’re telling me that [Trump’s] executive order didn’t do anything? I am so confused.”

Ask Emily is a series of columns answering consumers’ questions about California’s changing medical landscape.

I don’t blame you. Choosing a health plan will be doubly hard this year given President Donald Trump’s recent move to cut off federal payments for a key consumer subsidy, his administration’s decision to shorten exchange open-enrollment periods in most states to 45 days, Congress’ failed attempts to repeal Obamacare and the departure of some insurers from certain markets.

Let me ease your mind straightaway on three critical points:

  1. In California, open enrollment for individuals and families who buy their 2018 plans through Covered California and in the open market lasts three months, from Nov. 1 to Jan. 31.
  2. You won’t lose the tax credits that help you — and the vast majority of Covered California enrollees — afford your premiums, assuming you still qualify.
  3. The same goes for the cost-sharing subsidies that reduce out-of-pocket costs for some Covered California members, despite Trump’s decision to stop funding them.

But shopping will be challenging. Anthem Blue Cross is pulling out of a large swath of California’s individual market, on and off the exchange, forcing hundreds of thousands of consumers to find new plans. And in addition to regular, annual rate hikes — averaging 12.3 percent statewide — silver-level plans will bear an additional 12.4 percent average surcharge to make up for the loss of federal funding for the cost-sharing subsidies.1-ASK EMILYopen-enrollment-prices1

Remember, those are averages. Your actual premium will depend on several factors, including where you live, your income, what level of coverage you choose and which insurer you pick.

In an unexpected twist, some people may actually benefit from the surcharge because it could bring plans with more robust coverage within financial reach.

Before we get into all that, my most important piece of advice remains the same this year as before:

Don’t do this alone. Help from certified insurance agents and enrollment “navigators” is free. You can find local options by clicking on the “Find Help” tab on Covered California’s website,

Silver-Plan Surcharge

Nearly half of Covered California enrollees qualify for cost-sharing subsidies, which lower their copays, deductibles and coinsurance. The subsidies are paid directly to insurers, and are separate from the tax credits that reduce monthly premiums.

These discounts are available only to silver-plan enrollees whose annual income falls between 139 percent and 250 percent of the federal poverty level — about $34,200 to $61,500 for a family of four. That’s why Covered California added the 12.4 percent average surcharge only to silver plans amid Trump’s threats — and ultimate decision — to stop funding the subsidies.

Covered California estimates that 78 percent of subsidized consumers will pay the same as — or less than — this year, despite the surcharge, because their tax credits will rise with their premiums. About half of the remaining 22 percent will see increases of less than $25 per month.

“This is potentially good news for both insurers and consumers,” says Greg Fann, a senior consulting actuary based in Murrieta. “And bad news for taxpayers,” who are footing the bill for the increased tax credits.

Fann offers advice to consumers based on their income.

Covered California enrollees with incomes up to roughly 200 percent of the federal poverty level — or about $49,200 for a family of four — should probably remain in silver plans, he advises, because they qualify for significant cost-sharing reduction subsidies.

Policyholders who make between 200 and 400 percent of the federal poverty level (400 percent is about $98,400 for a family of four) should consider ditching silver plans and applying their higher tax credits to gold or platinum plans, he says. Tax credits are pegged to the cost of silver plans, which means that all subsidized enrollees will benefit from higher tax credits as silver premiums rise, regardless of which plan they ultimately purchase.

Gold and platinum plans are more expensive than silver plans, but they offer higher levels of coverage and lower out-of-pocket costs.

In some cases, “the gold may be cheaper than the silver,” Fann says.

You could also apply your increased tax credits to bronze plans, which have lower premiums and higher out-of-pocket costs. According to Covered California, three-quarters of enrollees can sign up for bronze coverage for less than $10 a month.

“I suspect a lot of people are going to downgrade their plans to high-deductible plans,” says Helena Ruffin, an insurance agent in Playa Vista.

Finally, there are about 65,000 Covered California enrollees with silver plans who don’t receive premium tax credits, says exchange spokeswoman Amy Palmer.

People in this group must pay the entire cost of their premiums.

“These are the ones in the middle class that are … getting hammered,” Ruffin says.

If you’re in this category, avoid the surcharge by buying a bronze, gold or platinum plan. Or, opt for a newly created silver plan sold off the exchange that won’t be subject to the surcharge — if you’re confident your income will remain above the threshold to qualify for premium tax credits.

“There may be better options off the exchange,” Palmer says. But if your income fluctuates, “it may be better to stay on the exchange so that you can receive tax credits if you become eligible,” she adds.

Health Plan Departures

Anthem will pull out of 16 of California’s 19 pricing regions, affecting about 300,000 policyholders who purchase from the individual market, both on and off the exchange.

Its departure will leave about 60,000 Covered California consumers with one option — Blue Shield of California. If you do not select a new plan by mid-November, Covered California will automatically enroll you in one. If you’re not satisfied with its decision, you can change it before the end of open enrollment, assuming you have a choice.

For those of you losing your insurer, you’ll want to know whether your existing providers are in any other Covered California plan networks.

Unfortunately, “the doctors networks are smaller and smaller all the time,” says Tom Freker, an insurance broker in Fountain Valley.

Covered California this year has debuted a revamped online directory that will allow you to search five doctors, hospitals or pediatric dentists at once.

It’s part of the agency’s “Shop and Compare” tool that allows you to enter your personal details to retrieve your plan choices and costs.

Because the directory is new, I urge you to cross-check with your plan and/or your provider.

Also, if you’re in the middle of treatment for a complex medical condition and lose your insurer, you may have options. A new state law will allow some seriously ill patients to continue seeing their current providers for a limited time.

Your new insurer may also be able to work with your existing provider to finish your treatment. Covered California advises you to call your new health plan to explain your situation.



Beyond The Shattered Lives And Bodies, Money Worries Weigh On Las Vegas Victims

November 2, 2017 by · Leave a Comment 

LAS VEGAS — Kurt Fowler and his wife, Trina, were celebrating their 18th wedding anniversary at a country music festival when the shooting started. Fowler, 41, knew he’d been hit in the ankle and couldn’t run. He hid under the stage until the gunfire ended.

“I knew my foot was completely useless,” said Fowler, a firefighter from Lake Havasu City, Ariz., and a father of three. He underwent surgery, spent nearly two weeks in the hospital and still may need another operation. He also will need rehabilitation and follow-up visits with a specialist.

Fowler has a Blue Cross Blue Shield PPO through his job, but he said he doesn’t know how much he will have to pay out of his own pocket for the care he is receiving. In an era of higher deductibles and limited choice of in-network doctors, however, he knows he could face significant medical bills.

His insurance card says his individual deductible is $5,000 and his coinsurance 20 percent. He said he didn’t know how much his health plan would cover for out-of-state care.

“Medical expenses are astronomical these days,” Fowler said from his bed at Sunrise Hospital & Medical Center here. “It’s a mountain that just doesn’t seem like it’s gonna be climbable, but we are gonna do our best.”

As hundreds of survivors struggle to recover emotionally and physically from the Oct. 1 attack, they are beginning to come to terms with the financial toll of the violence perpetrated against them. Even those who are insured could face untold costs in a city they were only visiting.

Michael Caster, from Indio, Calif., was shot as he ran from the Route 91 Harvest festival in Las Vegas. Now, he is paralyzed from the waist down. Fowler’s mom, Patricia, was also at the festival and said she fears how expensive his medical care may be. But she said, “Whatever expenses come down the road, we’ll handle it somehow.” (Anna Gorman/KHN)

Michael Caster, from Indio, Calif., was shot as he ran from the Route 91 Harvest festival in Las Vegas. Now, he is paralyzed from the waist down. Fowler’s mom, Patricia, was also at the festival and said she fears how expensive his medical care may be. But she said, “Whatever expenses come down the road, we’ll handle it somehow.” (Anna Gorman/KHN)

The total costs of medical care alone could reach into the tens of millions of dollars, said Garen Wintemute, who researches gun violence at the University of California-Davis. And that is just the beginning. Many survivors will be out of work for months, if they are able to return at all.

“We really don’t have a good handle on the intangible costs of something like this … the ripple effects on family and friends and neighborhoods when a large number of people have been shot,” Wintemute said.


More than 100,000 people are shot every year in the U.S., according to the Centers for Disease Control and Prevention. That generates about $2.8 billion per year in emergency room and inpatient charges alone, according to a recent study in Health Affairs. The average emergency room bill for an individual gunshot victim is $5,254 and the average inpatient charge is $95,887, according to the study.

The U.S. senators representing Nevada, Dean Heller and Catherine Cortez Masto, wrote a letter to America’s Health Insurance Plans, an industry trade group, and CEO Scott Serota of Blue Cross Blue Shield requesting help with out-of-network bills, copayments and deductibles for the Las Vegas shooting victims. Many of the people who were shot had traveled from other states, including California, Iowa and Tennessee.

California and some states protect consumers from such bills, but Nevada is not one of them, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. But Corlette said most insurers allow patients to request exceptions based on the circumstances. “In this situation, I imagine most insurers are going to want to be compassionate and work something out,” she said.

The victims and their families aren’t the only ones who will be affected financially by the mass shooting. Taxpayers, too, pick up much of the tab for the health care costs associated with gun violence because many patients are covered by Medicaid and Medicare, two government insurance programs.

And hospitals will also be on the hook for some of the care for patients who don’t have insurance. Hospitals in Las Vegas quickly mobilized to treat the hundreds of victims who were streaming in that night, and they don’t know yet how much of the care will be reimbursed.

At Sunrise Hospital & Medical Center, staff treated more than 200 patients. Sunrise plans to file insurance claims and will “be extremely sensitive to the financial status” of patients when considering their out-of-pocket portions, a spokeswoman said.

Valley Hospital Medical Center is encouraging patients to complete paperwork for a state program called Nevada Victims of Violent Crime, which would pay their balances. And Dignity Health’s St. Rose Dominican said it will bill insurers and accept donations but will not require payment from victims.

California victims can also get help with medical expenses and income loss from the California Victim Compensation Board.

Mary Moreland gets an update on her daughter from neurosurgeon Keith Blum at Sunrise Hospital & Medical Center. Moreland’s daughter, Tina Frost, was shot in the eye and was in a medically induced coma for two weeks. Frost has insurance through her job as an accountant in San Diego, but her mother said she knows it won’t cover everything. (Anna Gorman/KHN)

Mary Moreland gets an update on her daughter from neurosurgeon Keith Blum at Sunrise Hospital & Medical Center. Moreland’s daughter, Tina Frost, was shot in the eye and was in a medically induced coma for two weeks. Frost has insurance through her job as an accountant in San Diego, but her mother said she knows it won’t cover everything. (Anna Gorman/KHN)

In addition, a GoFundMe account started by a Clark County commissioner has raised more than $11.3 million thus far. And many survivors have individual GoFundMe accounts.

Kurt Fowler’s GoFundMe page has raised more than $41,000. Fowler said he doesn’t have disability insurance so he will rely on the funds to help cover his expenses while he is recovering and missing work.

Michael Caster, 41, who lives in Indio, Calif., has a GoFundMe account that has raised over $27,000 so far. He’s paralyzed from the waist down after a bullet lodged in his spine.

At Sunrise Hospital, doctors drained the blood from Caster’s lungs and removed some of the bullet fragments. Sitting in a hospital bed 11 days after the shooting, Caster said he didn’t know how much of his care would be covered by his health insurance.

He works in human resources at a California hospital and has a job-sponsored policy with Anthem Blue Cross. “I’ve never really dealt with injury,” he said. “I don’t want to be stuck with a bunch of bills.”

His bills could rise further: That day, he was scheduled to be flown to a rehabilitation center in Colorado for people with spinal cord injuries.

Mary Moreland, whose daughter Tina Frost was shot during the country music festival, said that at first she didn’t understand why so many families were setting up fundraisers. Then, the severe financial strain the shooting would take started to dawn on her.

Now, Moreland said she’s grateful for the $583,000-plus raised as of Sunday through GoFundMe.


Frost, a resident of San Diego, had emergency brain surgery the night of the shooting. A bullet had pierced her eye and exploded in her brain. As she lay in ICU earlier this month, her mother said small improvements were major milestones. “Today she squeezed my hands,” Moreland said.

The next night, Frost came out of a medically induced coma and was later flown to Johns Hopkins Hospital in Baltimore, near her mother’s home. Over the next weeks and months, she will need multiple operations and a slew of specialists, including neurosurgeons, plastic surgeons, occupational therapists and mental health counselors.

Moreland said she cannot even begin to imagine what her daughter’s care will cost. Frost has Blue Cross insurance through her job at Ernst & Young in San Diego, but Moreland said she doesn’t know what the deductible and copayments are.

“Being realistic, knowing what I know about costs of health care, it’s scary,” Moreland said. “But she’s alive. She’s not one of the 58 other people.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Anna Gorman:, @AnnaGorman

Imagining A Single-Payer Health System In California

October 5, 2017 by · Leave a Comment 

With the crumbling of the latest GOP plan to repeal and replace the Affordable Care Act, many Americans seem more willing to discuss what a single-payer system might look like and whether it is desirable — or even possible.

U.S. Sen. Bernie Sanders (I-Vt.) recently introduced a Medicare-for-All Act, which would gradually expand the government-financed system to the general population while eliminating private insurance companies and consumer cost sharing, such as copays and deductibles. Although the bill is backed by 16 Democratic senators, including California’s Kamala Harris, observers predict it has no chance of moving through a Republican-controlled Congress.

California lawmakers took a fresh look at single-payer health care this year through SB562, a proposal to create one government-financed program that covers all Californians. That bill stalled, but debate will continue this fall in legislative hearings. A grass-roots campaign is underway to put a plan to finance such a system before voters.

“It is time to have those discussions [as] to how we actually get everyone covered, and get them covered in a way that they can afford to pay for care when they need it,” said Jen Flory, policy advocate with Western Center on Law & Poverty, a group that supported the single-payer bill in concept.

But Rob Lapsley, president of the California Business Roundtable, expressed concerns about the enormous costs of building such as system, saying “the numbers matter.” He said a government-financed health care system for all cannot be allowed to endanger funding for other public services — like education and public safety — which ensure a high quality of life in California.

Flory and Lapsley were among the consumer advocates and industry players who last week sat side by side in Sacramento to debate the merits and challenges of universal health care coverage, whether through a single payer or other means.

The discussion occurred during a conference in Sacramento last week called “Health Care In Crisis,” organized by Capitol Weekly and the USC Sol Price School of Public Policy. California Healthline/Kaiser Health News Sacramento correspondent Pauline Bartolone moderated the discussion.

Other panelists included Dr. Paul Song, co-chair of the Campaign for a Healthy California, a coalition that formed to support California’s single-payer effort, and Mark Sektnan, president of the Association of California Insurance Companies.


California Healthline is produced by Kaiser Health News, delivering expanded coverage of health policy news in California and original reporting that highlights the state’s outsized influence on the nation’s health care system.

Tips On Finding Nursing Home Bed When On Medi-Cal

October 5, 2017 by · Leave a Comment 

Most everyone agrees it can be very difficult — next to impossible, really — for Medi-Cal enrollees to snag a spot in a nursing home, especially if they’re transferring from their homes or assisted living facilities rather than going straight from the hospital.Senior man taking cough syrup while reclining on hospital bed

Not everyone agrees on the reasons, however.

“There’s massive, systemic Medi-Cal discrimination,” says Pat McGinnis, executive director of California Advocates for Nursing Home Reform. She believes some nursing homes illegally turn away enrollees because they don’t want to accept Medi-Cal’s lower reimbursement rates.

“If they can get more money with private pay or Medicare, they would rather accept one of them,” she says.

Deborah Pacyna, director of public affairs for the California Association of Health Facilities, which represents most of the state’s standalone nursing homes, says it’s illegal for nursing homes to discriminate based on payment type. She blames access problems on the state’s rapidly aging population.

“Projections are that we will run out of nursing home beds by 2020,” Pacyna says. “That is putting even more pressure on the Medi-Cal population.”

No matter what you believe, the situation amounts to a crisis for Californians who desperately need a nursing home and are covered by Medi-Cal, the state’s version of the federal Medicaid program for low-income residents, says Susan Geffen of Hermosa Beach, an elder law attorney, gerontologist and author of the book “Take That Nursing Home and Shove It!”

If you think low-income doesn’t mean you, think again. Many middle-class Californians need Medi-Cal to help pay for their long-term care because they run out of money paying the bills on their own, she says.

Despite the access challenges many Medi-Cal enrollees face, about two-thirds of California’s nursing home residents rely on the program to cover all or part of their costs.

The state Department of Health Care Services (DHCS), which oversees Medi-Cal, says that nearly 90 percent of California’s 1,400 nursing homes accept its enrollees. The department is the only entity I interviewed that “is not aware of Medi-Cal members who are having difficulty finding a nursing home that will accept them.”

Today, I’m offering some advice if you or a loved one needs a nursing home for a long-term stay. It will be easier if you’re already in the hospital, which I realize is cold comfort.

Finding a bed if you’re not in the hospital — especially a bed in your community — might mean you’ll have to pay out of your own pocket initially. Or it might require some creative maneuvering, like working with your doctor to get you admitted to a hospital. Even then, “a hope and a prayer” might be necessary, says Derrell Kelch, executive director of the California Association of Area Agencies on Aging.


If You’re Coming From the Hospital

More than 90 percent of nursing home admissions last year came directly from hospitals, according to data from the Office of Statewide Health Planning and Development.

If you or a loved one is in the hospital and may not be able to return home afterward, “start working with the hospital discharge planner immediately” and ask for a list of nearby nursing homes, Kelch advises.

If you have fee-for-service Medi-Cal, you will require prior authorization, and the request must be made by the hospital or the nursing home, says DHCS spokeswoman Carol Sloan. If you’re in a Medi-Cal managed care plan, it will help determine where you go, she says.

You may want to visit the facility first before committing your loved one to it, Pacyna suggests. Also check out Nursing Home Compare on the Medicare website for quality ratings.

Medicare, the publicly funded health insurance program for older Americans, is often the first payer when you move into a nursing home. Under certain conditions, it will cover you for a limited time — up to 100 days.

The traditional form of Medicare will pay 100 percent for the first 20 days, after which you will owe $164.50 a day for up to 80 additional days. But you can qualify for this coverage only if you enter a Medicare-approved nursing facility within 30 days of an inpatient hospital stay that lasted at least three days. Beware: “Observation” care in the hospital won’t count as an inpatient stay.

Medicare does not cover long-term nursing home stays.

So, once you are in the nursing home, don’t wait to apply for Medi-Cal if you’re not already enrolled in it, Geffen says. Medi-Cal can help cover your Medicare copays, if you’re eligible, and then take over when your Medicare coverage ends, she says.

“They can’t just discharge somebody [from a nursing home] because they’re going on Medi-Cal,” McGinnis says.

If the nursing home balks and says it can’t keep you after you’ve switched to Medi-Cal, you can seek help from McGinnis’ organization ( or 800-474-1116) or another advocacy group, including legal services organizations or your local Long-Term Care Ombudsman, she says.

Be sure to let the facility know that you know it can’t discriminate against Medi-Cal enrollees, McGinnis adds.

If You’re Coming From the Community

Just because a small percentage of patients admitted to nursing homes last year came from their homes or assisted living facilities doesn’t mean people aren’t trying, says Mike Connors, an advocate for McGinnis’ group.

“It’s just extraordinarily difficult,” he says. “People end up waiting for months. … They get sick and get hospitalized.”

To find a facility that is certified for Medi-Cal, go to the state Department of Public Health’s database at You might need to target larger nursing homes that have higher turnover, McGinnis says.

If it’s financially possible, consider starting out as a private-pay client.

Instead of getting rid of all of your money ahead of time to become eligible for Medi-Cal long-term care coverage, Geffen suggests keeping some in reserve so you can gain entry as a cash customer.

Then, once you’re a resident and run out of money, “they’re not allowed to kick you out,” Kelch says.

Geffen also knows of people who have gone to the hospital in the hope of getting admitted, so they can be discharged directly into a nursing home. “Some people have had to go to extraordinary feats in order to get into a nursing home on Medi-Cal,” she says.

You can also consult with your doctor to devise a plan. If she agrees that you need to be in a facility, request documentation that you can take to the nursing home as proof, Pacyna says. Or, “if you’re ill, it may be appropriate to be admitted to the hospital,” Connors says.

I wish there were more support for individuals and families struggling through this.

Placement services, such as A Place for Mom, can help you find a nursing home with openings. You can also talk to an elder law attorney.

You can even ask your county social services department for help, says Benson Nadell, director of the San Francisco Long-Term Care Ombudsman program. “People cannot navigate this complex system on their own,” he says.


Feds Give Calif. Poor Marks On Monitoring Foster Children

September 28, 2017 by · Leave a Comment 

The federal government has given California bad marks on monitoring the well-being of children in foster care.

State officials were slow to investigate complaints of abuse or neglect, failed to notify investigators of serious sexual abuse allegations and didn’t follow up to ensure cases were resolved, according to an audit released late Monday by the U.S. Department of Health and Human Services’ Office of Inspector General.

In some cases, investigations took more than a year to complete, according to the report. It said these problems arose either because officials didn’t follow procedures or because they had not been properly trained to handle complaints. An audit released in May by the inspector general revealed similar deficiencies in the foster care agency of Texas.

Michael Weston, a spokesman for the California Department of Social Services, said his agency agreed with the report’s findings, which were provided to the agency earlier, and either has implemented or is working on the changes recommended by federal auditors. The auditors noted that the agency has re-hired former employees to support investigations of complaints and has created dashboards for managers to better track the progress of investigations.

The state agency oversees about 60,000 children under 18 who are in foster care. Federal auditors reviewed 100 cases selected from among the nearly 6,200 complaint investigations completed by the state agency between 2013 and 2015.

California’s child welfare system has been scrutinized in recent years as media reports have highlighted the overuse of powerful psychiatric drugs and the dubious arrests of foster children in temporary shelters around the state. The state has been criticized previously for lagging on investigations of abuse and neglect. California’s privatization of some foster care, leaving independent agencies to recruit and oversee foster families, also has raised concerns.

Child welfare experts say that it’s important to investigate reports of abuse or neglect in foster homes quickly and thoroughly because the consequences for vulnerable children can be severe, even fatal. A 4-year-old Sacramento girl was killed in her foster home in 2010, apparently burned by a Molotov cocktail. She previously had been injured while in foster care, according to media reports.

The state agency’s official goal is to investigate all cases within 90 days. But the federal audit found that in some cases, no investigative actions were logged for up to 15 months, suggesting that no one was working on them. In addition, investigators either did not visit or could not provide proof that they had visited the foster family home, group home or foster care agency cited in the complaint within the 10 days required by law.

“The failure to complete investigations in a timely manner — noted in 78 of 100 complaints — is the most egregious finding in the report,” Bill Grimm, senior attorney at the National Center for Youth Law, wrote in an email.

Grimm said the agency’s existing goal of investigating abuse or neglect complaints within 90 days “should be unacceptable” because the goal is only 30 days for children who are not in foster care.

If investigations aren’t completed promptly, children who have been maltreated often move on to other foster care placements “and critical information is lost,” he said.

Stacy Castle, chairwoman of the Child Abuse Council of Santa Clara County, said she and her colleagues have long worried about how complaints of child abuse against all children — including foster children — were logged and investigated by the state. But she said a new manager at the California Department of Social Services earlier this year improved the situation by adding staff to the complaint hotline and extending its hours.

“There’s been a significant turnaround in a lot of these” issues raised by the audit, Castle said.

Has California Hit The Brakes In Regulating Breath-Robbing Big Rigs?

July 27, 2017 by · Leave a Comment 

OAKLAND, Calif. — James Lockett sits on his bed and opens the drawer of his nightstand, revealing a stash of asthma inhalers: purple disc-shaped ones he uses twice a day to manage his symptoms and others for full-blown attacks.

Lockett, 70, says he never leaves home without an emergency inhaler.

His senior housing complex in East Oakland is less than a mile from Interstate 880, a major corridor for freight trucks shuttling to and from the Port of Oakland. On the way to factories and warehouses, the trucks often roll through streets near homes, schools and libraries.

The diesel-fueled big rigs are a major source of air pollution, spewing soot and other pollutants that can cause or aggravate respiratory conditions such as asthma and bronchitis.

Just walking while talking on his cellphone can leave him short of breath, Lockett said. “The [asthma] triggers here, without my medications, it would be terrible.”

California has cleaned up its diesel fleet significantly in recent years by phasing out older trucks and requiring operators to install the latest pollution-control equipment. But local air district officials and environmental advocates say more needs to be done and that the emissions goal should be close to zero.

Efforts to get there are stalled, they say, in part because of a provision in the $52 billion road improvement law signed in April by Gov. Jerry Brown. That provision exempts most diesel trucks on the road from future emissions reduction requirements for many years.

Regulators and environmentalists warn that, without further reductions in emissions, many residents who live near major truck routes or the port remain at high risk of cancer, heart problems, asthma and other lung diseases, especially children and seniors.

Asthma is a critical problem in Oakland for these two groups. Among other indicators, the rate of emergency room visits for asthma among seniors (age 65 and older) in East Oakland, where Lockett lives, is nearly three times higher than it is statewide, and the rate in West Oakland is nearly two times higher, according to state and county data.

Austin Carter, 13, learns how to properly use an inhaler during his visit at the Breathmobile clinic in Oakland in May. (Heidi de Marco/California Healthline)

Similarly, children in these neighborhoods go to the emergency room for asthma at more than double the rate of their peers statewide, according to 2016 data. In the heart of West Oakland, near the port, nearly 21 percent of children have been diagnosed with asthma, according to 2014 data from the California Health Interview Survey. That’s well above the statewide average of 15 percent.

A mobile asthma clinic called a Breathmobile regularly parks at elementary schools near the port, and Darryl Carter makes good use of it for son Austin, 13. During a recent visit, he recalled a terrifying attack eight years ago that sent Austin to the hospital. Since then, the boy’s been back to the hospital three or four times — not ideal, but the Breathmobile visits have made a difference.

Asthma has multiple causes and triggers, including poor housing conditions, a family history of the disease, certain weather conditions and exposure to cigarette smoke. Poverty, lack of access to health care and little knowledge of preventive care all can contribute to high rates of emergency visits, said Dr. Washington Burns, administrative director of the Breathmobile in Northern California.

However, “there’s often more asthma around corridors with trucks and cars than in areas where there aren’t,” Washington said.

Diesel trucks account for 2 percent of vehicles but emit 30 percent of key smog-forming nitrogen oxides and 65 percent of the soot attributable to motor vehicles, according to the state Air Resources Board (ARB).

A ‘Dirty Deal’?

In 2015, the Oakland City Council began diverting trucks from streets with homes, schools or senior centers. But some community activists say enforcement of these local ordinances has not been strong enough.

The provision in the state’s new law exempts all but the oldest or highest-mileage trucks from any new emission reduction rules the state might impose. The exemption lasts 18 years from the time they meet current emissions standards or until they have traveled 800,000 miles.

It’s unclear exactly how the exemption will affect local air districts and ports that want to cut emissions further. Environmentalists say these agencies may face resistance and risk being sued by the trucking industry if they forge ahead with more aggressive plans.

Critics say the governor agreed to the last-minute exemption to gain the trucking industry’s support for higher diesel and gas taxes that, along with vehicle fees, are expected to raise $5.2 billion annually over 10 years to repair roads and bridges and to expand public transit.

Bill Magavern, policy director for the Sacramento-based Coalition for Clean Air, said improving infrastructure is laudable but should not come at the cost of clean air.

“There’s a lot to like in that bill, and we hated to oppose it,” but there was a “dirty deal” thrown in at the last minute, Magavern said.

Gov. Brown’s office referred questions on the truckers’ amendment to the ARB, the state’s clean-air agency.

The ARB said it can provide incentives to further reduce emissions without imposing additional requirements. And the new law, it said, will strengthen enforcement of existing rules.

Under the law, “truck operators can be denied [Department of Motor Vehicles] registration if they’re not meeting the current rules,” board spokesman David Clegern said. “Diesel pollution will be reduced by bringing 300,000 more trucks into compliance.”

Local air managers in Southern California say greater enforcement of current rules is important, but it won’t sufficiently accelerate turnover of the truck fleet. And that’s crucial to helping Southern California meet federal clean-air standards, said Philip Fine, deputy executive officer of planning and rule development with the South Coast Air Quality Management District.

The problem for local air districts and ports is that when it comes to directly regulating mobile sources of pollution like diesel trucks, the state is the boss. It approves local district plans, and the local districts more or less oversee the ports. So the most effective way to reduce trucker emissions is to set stringent policy at the state level, as California has aggressively done in the past.

Emissions Way Down

But truckers say the state has imposed enough requirements. Chris Shimoda, vice president of government affairs for the California Trucking Association, said diesel emissions from trucks in California ports have fallen dramatically in recent years.

“This is attributable to the current $1 billion annually being invested by truckers in the cleanest available technology throughout the state,” Shimoda said.

He also said that being exempted from any future state emissions-reduction requirements reassures the trucking industry that it will recoup the investment it is making in new engines to meet current state standards.

Under existing state rules, owners of heavy-duty trucks must have 2010 or newer-model engines by 2023.

Those rules have dramatically improved air quality. A study by the Bay Area Air Quality Management District, among others, found that from 2009 to 2013 emissions of black carbon from trucks at the Port of Oakland dropped by 76 percent and nitrogen oxides by 53 percent.

People living near ports like the one in Oakland have benefited from the state’s efforts to clean up the truck fleet — by phasing out older models and requiring operators to install the latest pollution-control equipment. (Heidi de Marco/California Healthline)

Critics: More Progress Needed

Still, ports throughout the state rely mostly on diesel to power vessels, yard equipment, trains and trucks. Ports in Southern California remain the single-largest fixed source of smog-forming pollution in the region. And the Port of Oakland is the largest fixed emitter of diesel pollution in the Bay Area, local air managers say.

That’s why local districts were alarmed by the governor’s concession to the trucking industry, said Tom Addison, legislative and policy adviser for the Bay Area air district.

It “gives the trucking industry a get-out-of-jail-free card,” said David Pettit, senior attorney with the Natural Resources Defense Council. “It bars any kind of state regulations that might require truckers to move to a different kind of truck — natural gas-powered, electric or hydrogen fuels — when those become available in the market.”

Last month, the mayors of Los Angeles and Long Beach set ambitious goals for the ports to transition to zero-emission truck and yard equipment over the next 20 years. The mayors affirmed that the ports’ 2017 clean-air blueprint, which is expected to be released Wednesday, will include further emissions reductions from ships and the development of a zero-emissions truck pilot program.

But the new state law calls into question whether those plans — and others in coming years — will be enforceable.

If the ports in Southern California announced that in five years they’re going to have an all zero-emissions fleet, Pettit said, “they’d be sued [by the trucking association] in a heartbeat.”

Updated 4:30 p.m.: Includes entire text of original story published by California Healthline.

Calif. Officials Sound Alarm, Envisioning $114B Hit To Medi-Cal Under U.S. Senate Bill

June 29, 2017 by · Leave a Comment 

California risks losing $114.6 billion in federal funds within a decade for its Medicaid program under the Senate health care bill, a decline that would require the state to completely dismantle and rebuild the public insurance program that now serves one-third of the state, health leaders said Wednesday.

The reductions in the nation’s largest Medicaid program would start at $3 billion in 2020 and would escalate to $30.3 billion annually by 2027, according to an analysis released by the state departments of finance and health care services.

“It is not Medicaid reform,” Jennifer Kent, director of the state Department of Health Care Services, said in an interview. “It is not entitlement reform. It is simply a huge funding reduction in the Medicaid program. We are deeply concerned what that means for the long-term viability of the program as it stands today.”

Los Angeles County Supervisor Hilda Solis and other county leaders pledged to fight Republican efforts to overturn Obamacare. “The bill ends Medi-Cal as we know it,” Solis said during a press conference Tuesday in downtown Los Angeles. “We are not going to give up.” (Anna Gorman/California Healthline)

Los Angeles County Supervisor Hilda Solis and other county leaders pledged to fight Republican efforts to overturn Obamacare. “The bill ends Medi-Cal as we know it,” Solis said during a press conference Tuesday in downtown Los Angeles. “We are not going to give up.” (Anna Gorman/California Healthline)

Medicaid covers a staggering 13.5 million low-income Californians — children, people with disabilities, nursing home residents and others. About 3.8 million of them, many of whom are chronically ill, became eligible for coverage under the Affordable Care Act, informally known as Obamacare.

California would face the biggest losses of any state, according to a report issued Wednesday by the consulting firm Avalere Health. Federal funding would drop by 26 percent over 10 years, the report said. Many states, including Alabama, Georgia, Texas and Florida, would face a drop of less than 10 percent.

The Senate bill to repeal and replace the ACA would be a “massive and significant fiscal shift” of responsibility from the federal government to states, according to the analysis. It would force difficult decisions about who and what to cover and how much to pay doctors, hospitals and clinics, the report said.

In addition to expanding its Medicaid population early and vigorously under Obamacare, the state began covering undocumented immigrant children last year. California’s program, known as Medi-Cal, also provides dental care and other services that are optional under federal Medicaid rules.

The state’s Medicaid director, Mari Cantwell, said Republican proposals present a fundamental problem that can’t be solved by making cuts around the edges.

“Nothing is safe — no population, no services,” Cantwell said. “It is really disheartening and honestly horrifying to think about the world under this Senate bill and what it would mean.”

The losses are more than what was predicted under the House bill. The analysis said that’s because the cost shift increases over time under the Senate proposal.

Ken Bascom, 62, was diagnosed with kidney cancer after becoming eligible for Medi-Cal in 2014. Bascom is now cancer-free but said that without insurance, “more likely than not, I would’ve been dead.” (Anna Gorman/California Healthline)

GOP leaders in Congress have been trying to repeal the ACA for seven years, deeming it disastrous public policy that costs too much and leaves consumers with rising premiums and too few choices for care.

The Senate bill would overhaul Obamacare in several ways. Besides revamping the Medicaid program, it would dramatically change the system of tax credits used to help low-income Americans get health coverage. The Congressional Budget Office concluded that the bill would cut the federal deficit by $321 billion over the next decade while leaving 22 million more Americans without health insurance.

Unable to lock down the support he needs in the Senate, Majority Leader Mitch McConnell on Tuesday postponed a vote on the bill until after the July Fourth holiday. Its fate remains uncertain as senators head back to their districts for a weeklong recess.

Under the legislation, the federal government would pay a fixed amount to states for Medicaid expenditures, a per capita rate, instead of paying for a share of all expenses incurred.

State health leaders predict that the state’s costs would outpace the federal government’s allocation, meaning California would have to come up with an additional $37.3 billion between 2020 and 2027.

“Whether it’s drugs or cost of living going up or new technologies in health care, there are costs we can’t control,” Cantwell said. “And if you have a trend factor that doesn’t really reflect the reality of what health care looks like, the state is always going to be in a place of not being able to bring the costs within that target.”

The proposed financial caps would have a “devastating and chilling effect” on spending in the Medicaid program and would pinch providers further, the analysis said. California already ranks near the bottom for how much it pays Medicaid providers.

The Senate’s overhaul of Obamacare would also force hospitals and clinics serving the poor and uninsured to live within the new financial limits, leading to “uncompensated care in the hundreds of millions, if not billions annually,” according to the analysis.

In addition, the Senate bill would phase out funding for the expansion of Medicaid, which enabled 3.8 million single, childless adults and others in the state to qualify. Under the Affordable Care Act, the federal government pledged to pay for 90 percent of their costs. But the Senate bill would reduce that to 50 percent beginning in 2024.

Without the promised federal funds, California would have to spend five times more than previously estimated to continue covering those newly eligible. By 2027, the cumulative cost to California would be $74.1 billion, according to the analysis.

California leaders vowed Tuesday to fight the bill, known as the Better Care Reconciliation Act. “Simply stated, this is a terrible bill and we must defeat it,” said Democratic Sen. Dianne Feinstein in a call with reporters.

Sen. Kamala Harris, also a Democrat, added that the most vulnerable populations are the ones who have most to lose: children, people with disabilities, seniors. “This bill is nothing short of a disaster, and it’s no wonder they did it in secret because they have nothing to be proud of,” said Harris, who aims to kill the bill before it hits the Senate floor.

The fallout would be particularly bad in Los Angeles County, home to 1 of every 20 Medicaid recipients in the nation, county officials said Tuesday.

“L.A. County will be ground zero for the plan’s deadly consequences,” said county Supervisor Sheila Kuehl during a press conference. “This is not just about money. … This is about the people who count on us for health care.”

During the conference, several Los Angeles County residents and union members held up signs that read “Healthcare is a Human Right” and, in Spanish, “SALUD para todos,” or “Health for everyone.”

Ken Bascom, 62, who lives in Venice, Calif., and attended the gathering, said he lost his job and his employer-based insurance during the recession. Soon after Bascom became eligible for Medi-Cal in 2014, he was diagnosed with kidney cancer. Now cancer-free, Bascom said he often thinks about what would have happened if he hadn’t been able to get health care.

“More likely than not, I would’ve been dead,” said Bascom, who gets care at Venice Family Clinic. “It’s very scary.”

Also in attendance was Steven Martin, 27, who said he depends on insurance he got through Obamacare to pay for his leukemia treatment. Martin, who has private insurance through Covered California, the state’s exchange, said his medication costs tens of thousands of dollars each year.

“Without insurance, I’m not going to have access to my medication,” he said.

Los Angeles County Health Agency Director Mitch Katz said the ACA made a “huge difference” in the county — dramatically cutting the uninsured rate, reducing wait times at emergency rooms and helping connect patients to primary care doctors.

“The emergency rooms themselves often had two- and three-day waits,” he said. “Because of the ACA, that is no longer the case. … The emergency room now is back to what is should be — for emergencies.”

Katz said he feared all of that would change if the Republicans succeed in overhauling the health law.

Ana Ibarra contributed to this report.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Lots Of Boos In California For Senate Health Bill

June 28, 2017 by · Leave a Comment 

California politicians, medical providers and consumer advocates served up harsh critiques of the newly unveiled Senate health care bill Thursday, arguing that the proposed legislation could make coverage inaccessible for poor residents while cutting taxes on the rich.

“This bill is not a health care bill,” said Ed Hernandez, a Democrat and chair of the state Senate Health Committee. “This is a tax bill that will benefit the most wealthy individuals at the expense of those who need health care the most — the working poor and seniors.”

Democratic Gov. Jerry Brown said in a tweet that the bill had the same “stench” as the bill that passed the House last month. “Millions will lose health care coverage, while millionaires profit,” he wrote. “The American people deserve better.”

The 142-page Senate bill, released Thursday morning, would overhaul the Affordable Care Act and repeal the taxes that pay for many of the law’s benefits. The proposed legislation also would significantly reduce funding for Medicaid, the program for people with low incomes, and phase out the ACA’s massive expansion of it.

It would limit eligibility for tax subsidies to purchase insurance in the state and federal exchanges and allow insurers to charge elderly people up to five times more than younger consumers, compared with three times under the ACA.

The Senate bill is substantially similar to the one passed by the House last month, but it differs in some key respects. The Senate measure proposes a slower timeline for the phaseout of the Medicaid expansion and it completely eliminates the requirement that individuals be insured rather than just charging consumers for lapses in coverage, as the House bill does. It would also cut federal spending on Medicaid more deeply than the House bill over the long term.

The two bills also handle premium subsidies differently: The House version would base them solely on age while the Senate proposal factors in age, income and geography.

About one-third of California’s residents — 13.5 million people — are on Medicaid, known as Medi-Cal in the state. About 3.8 million of them have gained coverage since the Affordable Care Act, also known as Obamacare, took effect in 2014. Another 1.3 million have health coverage through Covered California, the insurance marketplace.

Cory Dobbs stands in front of the Cares Community Health clinic in Sacramento. He has HIV and cancer. “For some of us it’s life or death,” he said. (Kellen Browning/California Healthline)

Under the Senate bill, insurance companies would have to accept all people regardless of their preexisting conditions. However, the measure would allow states to do away with the minimum “essential benefits” that are required under Obamacare, such as hospital visits and mental health benefits. Some health experts believe insurers could use that as a back door for excluding people with histories of illness, simply by selling policies that don’t include coverage they need.

That worries people like Cory Dobbs, a checker at a Grocery Outlet supermarket, who has HIV and cancer.

“For some of us it’s life or death,” said Dobbs, 42, a Medi-Cal patient who goes to Cares Community Health clinic in Sacramento. “Some of us really will possibly pass because of this bill. It’s just the truth.”

Critics of the Affordable Care Act argue that the federal government needs to rein in costs and that states should take more responsibility for providing health care. For example, states could divert funding from other parts of their budgets if they wanted to continue with the Medicaid expansion, said Lanhee Chen, a health policy expert at the Hoover Institution.

“I tend to push back on the notion that the alternative of Obamacare will result in people dropping coverage,” he said of the Republican push to repeal the law. “This is not just a question of what the federal government does with Medicaid financing, but what the state can do if the financing changes become law.”

But Sarah de Guia, executive director of the advocacy group California Pan-Ethnic Health Network, said the Golden State has set the bar high in terms of providing coverage under the ACA and that the Republicans’ efforts threaten that coverage.

“California is obviously a leader,” she said. “But with the potential cuts … it is inevitable that the state would have to make some really tough decisions.”

In the Medi-Cal program, that could mean cutting benefits, shrinking eligibility or reducing reimbursements for providers, which are already among the lowest in the nation. That has caused anxiety among staff at community clinics, safety-net hospitals and nursing homes.

“Community clinics will continue and they will try to stay open, but it is like pulling the rug out from under us,” said Deena Lahn, vice president of policy and advocacy for the San Francisco Community Clinic Consortium. “Medicaid is now the financial underpinning for our work.”

Dr. Jay Lee, chief medical officer of the Los Angeles-based Venice Family Clinic, spent Thursday at a “white coat” rally of physicians in Washington, D.C., in opposition to the GOP’s efforts to “repeal and replace” Obamacare.

The Senate bill “basically guts Medicaid” and makes it harder for physicians to do their jobs, Lee said. “I might as well write my [prescription] scripts in invisible ink if patients can’t pay for the medications.”

In the individual insurance market, tens of thousands of people who receive federal subsidies would no longer qualify for the help because of a provision in the Senate bill that reduces the income thresholds for eligibility.

Officials with Covered California, the state’s marketplace, said the bill could have a wide-ranging impact on enrollees. “At first blush, it would not only provide far skimpier health coverage than what’s offered today, but millions of people would have no coverage at all,” the exchange’s executive director, Peter V. Lee, said in a written statement.

Some consumers support a rollback of the ACA. Sarah Foster, 83, opposes both the Senate and House health proposals, but for a different reason: She does not think either go far enough toward a full repeal of Obamacare.

Foster, a Sacramento resident who is on Medicare and Medi-Cal, said she never had trouble finding a doctor before the ACA. She said that, after it passed, it seemed many physicians went into specialized care because of the “red tape” associated with the law.

Now, she said, she lacks a primary care physician. “So now I’m running around trying to find an internal [medicine] person.”

Safety-net hospitals, which also have benefited under the ACA, fear the impact of a Republican overhaul. California’s public hospitals could be out more than $2 billion a year if the Medicaid expansion is repealed, according to the California Association of Public Hospitals and Health Systems.

The bill is a “futile effort to save money,” the group’s president and CEO, Erica Murray, said in a statement. “Simply refusing to spend money on health care does not reduce the cost of it, or the need.”

Dr. Matthew Hickey, 30, a University of California-San Francisco medical resident who works at San Francisco General Hospital, that city’s safety-net hospital, said he was concerned the bill is going to “dramatically reduce both coverage and the quality of coverage.”

He added: “The Medicaid cuts in particular are quite concerning. Many of the patients I take care of and who got care through the Medicaid expansion won’t be able to see me.”


California Healthline Senior Editor Barbara Feder Ostrov contributed to this report. This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.


State Senate’s Health Chairman Vows To Defend California Coverage Gains

November 22, 2016 by · Leave a Comment 

A key state health care figure vowed Thursday to defend the coverage gains California has seen under the Affordable Care Act in the face of widely expected efforts by President-elect Donald Trump to overturn much of the health reform law.

“I want to assure you, your staff and Californians that we stand ready to fight to keep what is working in this state,” Sen. Ed Hernandez (D-West Covina), chairman of the Senate Health Committee, told the board members of Covered California, the state’s health insurance exchange, in their first public meeting since Trump was elected on Nov. 8.

“What we have is too important to lose,” said Hernandez, an optometrist. He cited examples of people who had come into his optometry office for the first time because of their newly gained health coverage.

Any rollback in coverage, Hernandez said, would hurt millions of Americans.

California’s rate of uninsurance has been cut roughly in half since 2014, when federally subsidized health plans sold through the exchange first took effect and eligibility for Medicaid, the health care program for low-income individuals, was expanded. Both are key features of the Affordable Care Act, also known as Obamacare.

Health advocates who addressed the board Thursday sent the same message as Hernandez, expressing support for the ongoing efforts of the exchange to sign Californians up for coverage in the fourth annual open enrollment period, which started Nov. 1 and ends Jan. 31.

Covered California officials said that Trump’s plan to “repeal and replace” the Affordable Care Act has created confusion among enrollees but that people are still signing up.

In the first two weeks of open enrollment, 44,885 new people have enrolled in health insurance through Covered California, according to numbers provided by the board. That’s down from about 50,000 in the same period last year.

But Peter V. Lee, the exchange’s executive director, noted that Covered California did not run ads at the beginning of this enrollment period because it didn’t want to compete with the election campaign. He said the new numbers are in line with Covered California’s projection of approximately 400,000 new exchange enrollees next year.

This week, the Centers for Medicare and Medicaid Services announced that more than 1 million people had selected plans on, the federal exchange website, during the first 12 days of open enrollment. Of those, 250,000 were new to the exchange. The number of people who selected plans was up 53,000 from the same period last year, according to CMS.

Covered California is the largest state-run marketplace. It has 1.4 million members, nearly 90 percent of whom receive federal tax subsidies to help pay their premiums.

Consumer advocates who spoke at the board meeting expressed optimism that California would maintain its status as a leader in health care reform, though many are also changing the conversation to focus on what parts of the Affordable Care Act might be kept.

It is unclear how far Trump will go in dismantling the health law. He conceded last week that he would like to keep some aspects of it — in particular, allowing young adults to stay on their parents’ health plans and banning insurance companies from refusing to cover people with preexisting medical conditions.

Health experts who addressed the Covered California board made it clear that everything is up in the air: The only thing they’d be willing to bet on is that the Republican replacement for the health reform law won’t be called Obamacare

Ian Morrison, a health care consultant and futurist, told board members that the Republicans’ sweep of the White House and Congress will probably mean a less regulated insurance market, the end of mandates to buy insurance, smaller federal subsidies for the uninsured and greater state control over Medicaid — which also means less federal funding for the program.

Both Trump and House Speaker Paul Ryan (R-Wis.) have endorsed the idea of transforming Medicaid into a block grant program, in which states would get fixed allotments from the federal government and would be responsible for any health spending above those amounts.

“When you hear the term block grant, that is code for less money,” Morrison said. “No one talks about block grants and more money.”

The overarching question, Morrison said, is this: Will health coverage for 20 million people be significantly eroded?

He also said he found it hard to understand how guaranteed coverage for people with preexisting conditions could be kept if buying insurance was no longer a requirement for all. The authors of the health reform law believed that a lot of young, healthy people needed to be in the insurance pool in order to ensure that the sick ones didn’t drive up the cost of premiums.

John Bertko, Covered California’s chief actuary, said people should be looking to 2018, since any changes in 2017 are highly unlikely.

“I suspect with the big rate increases, 2017 is going to be a good year for plans that are in exchanges,” Bertko said. He said that was “a bit ironic” given the cloud now hanging over Obamacare.

In A Diverse State, California’s Latino Doctors Push For More Of Their Own

October 27, 2016 by · Leave a Comment 

California Healthline – Earlier this year, Dr. Joaquin Arambula, an emergency room physician from Selma, became the first Latino physician to serve in the State Assembly after being elected to represent the state’s 31st District — a central California agricultural region where the population is nearly 70 percent Latino.

Arambula said he ran for office partly because of the rapidly growing influx of Spanish-speaking patients in his emergency department. He sought reinforcements, “but there aren’t enough doctors with the cultural competency and understanding of the Latino community” to serve this growing population, Arambula said.

“This is something that needs to change,” he said.

Arambula and members of the Latino Physicians of California, a professional group that seeks to boost the number of Latino doctors in the state, spoke to reporters Friday about the need for more representation of Latinos in the medical field.

Latinos make up about 40 percent of the population in California — outnumbering any other ethnic-racial group, and they’re expected to constitute majority of the state’s population by 2050 a majority of the state’s population by 2050. But only about 5 percent of all physicians in the state are Latino, according to the California Health Care Foundation. (California Healthline is an editorially independent publication of the California Health Care Foundation.) Latinos also represent 8 percent of nurses and about 4 percent of pharmacists, the group of physicians noted.

Adding to the need, more than one-third of Latino physicians plan to retire within the next 10 years, according to a new survey of the LPOC’s physician members.

This is especially pressing when Latinos make up a small percentage of students graduating from medical schools, said Dr. Jose Arevalo, chair of the Latino physicians group.

According to the Association of American Medical Colleges, 7 percent of medical school graduates in California identified as Latino in 2015.

“If we are going to properly serve our current and future patient base, we must begin to develop a true pipeline to bring in Latino physicians and health professionals to meet this growing need,” Arevalo said.

Arevalo and colleagues also pointed to a 2015 UCLA national study that showed a decline in the proportion of Latino physicians relative to the overall Latino population. In 1980, for example, there were an estimated 135 Latino doctors for every 100,000 Latinos in the U.S. By 2010, that ratio dropped to 105 per every 100,000.

Silvia Diego, a family doctor in Modesto, said Latino doctors simply are better equipped to serve the needs of Latino patients. Understanding the language and culture results in better health outcomes, she said.

“Latinos are very family-centric, we take care of our old, we learn traditional home remedies,” Diego said. “It’s difficult to establish a patient-doctor relationship if [doctors] don’t understand or dismiss cultural values.”

Interpreters can help patients understand doctors’ orders, Diego said, but that doesn’t help close gaps in patient-doctor relationships.

“And then we wonder,” she added, “why there are large health disparities among Latinos.”

She and her colleagues agreed: Most Latino patients, especially those who only speak Spanish, will seek the Latino doctors in their communities.

“But the few of us cannot take the many of them,” she said.

The problem is exacerbated in areas, such as the Central Valley, where the Latino population is known to struggle with chronic conditions, such as diabetes and obesity.

But the passage of the Medical DREAMER Opportunity Act in California may help more Latinos become doctors. The legislation, signed by Gov. Jerry Brown in September, allows students without papers pursuing medical professions to apply for state scholarships and loan forgiveness programs. The law goes into effect next year.

Medical education is expensive but is even more so for students in the country illegally because they are barred from receiving federal financial aid.

Dr. Catherine Lucey, vice dean for education at the University of California, San Francisco School of Medicine, said there are not enough scholarship opportunities for medical students in general. “Students are daunted with anticipated debt,” Lucey said, “and this does influence career decisions.”

This may be an even greater concern for first-generation students, who often are responsible for supporting their families financially.

UCSF’s School of Medicine, Lucey said, is pushing to diversify its student body with the help of pipeline medical education programs as well as through a more holistic approach to admissions. This encompasses taking into account more than just test scores but also the ability to communicate in a second language and a student’s environment. Currently Latinos make up about 20 percent of UCSF’s medical students, Lucey said.

“More diversity means health care quality is better, team science is better,” she said. “The medical education profession believes this.”

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