The National  Memo Logo

Smart. Sharp. Funny. Fearless.

Monday, December 09, 2019 {{ new Date().getDay() }}

Hillary Clinton Meets With Health Care Workers

By Soumya Karlamangla, Los Angeles Times (TNS)

LOS ANGELES — Hillary Rodham Clinton brought her presidential campaign to Los Angeles on Thursday, telling home health care workers that she wants to improve their working conditions, training, and wages so more people can remain at home as they age.

Clinton met with eight women, all of whom had either worked in home health care or hired someone for care-giving, for a round table discussion at Los Angeles Trade Technical College.

It was a distinctly low-key event while most of the nation’s political spotlight focused on the first debate between Republican candidates, which took place in Cleveland. Nearly every candidate there took aim at Clinton, who is leading in polls for the Democratic nomination.

Many of the women at the round table described working for low wages, with no or very little sick time, no training, and no benefits. Clinton said she thinks the workers aren’t being valued enough.

“I’m hoping that this issue of care-giving will rise higher on the national agenda,” Clinton said.

Clinton said her mother lived with her for the last 10 years of her life, instead of in a nursing home. Though many people would prefer to stay at home, she said, they don’t have the resources to have that option, she said.

“We should be putting more money in the front-end to keep more people at home, to give more people a reason to live, and a reason to get up in the morning and a reason to have that smile on their face,” she said.

Kindalay Cummings-Akers, who works in Massachusetts, urged Clinton to improve conditions for these workers, saying, “2016 is coming, and somebody is going to be president.”

Clinton jumped in with, “Not just somebody!”

Lizabeth Bonilla, who works in Las Vegas, told Clinton that she’d been a home health care worker for more than 40 years. She said she finds her work gratifying, but that she isn’t paid enough.

“If I quit tomorrow, I have nothing to show for 42 years of life,” she said. She said that she recently started receiving food stamps.

Many of the workers told Clinton they make about $8 an hour.

“It’s just so wrong,” Clinton said. “There’s no other way to say it. It’s just so wrong.” She said that raising the minimum wage is a central part of her campaign’s economic agenda.

Susan Young, who works in Spokane, Wash., discussed successful efforts in her state to gain political support to raise workers’ wages and get them retirement plans.

“Most of us here at this table, we will work until we die,” she said.

Clinton said she wanted to figure out how more states can do what Washington did. She said that if more people use home health care workers, they can stay out of nursing homes, which saves Medicaid money.

“You’re actually doing a service that should be both recognized and respected, as well as provide the argument for greater financial benefits,” she said.

When Clinton referenced the savings, Young asked, “Do we always have to bring that up?”

“Yeah, I’m afraid you do,” Clinton said, and the crowd started laughing. “That’s OK, because you’ve got a good argument.”

Photo: Home care providers and consumers meet in Los Angeles with former Secretary of State and Democratic presidential candidate Hillary Clinton on Aug. 6, 2015, at Los Angeles Trade Technical College. (Barbara Davidson/Los Angeles Times/TNS)

For Those Here Illegally, Health Services In California Vary

By Soumya Karlamangla, Los Angeles Times (TNS)

LOS ANGELES — Margarita Vasquez lacked health insurance and couldn’t afford an eye operation that would save her from blindness. But under a Los Angeles County program that extends health care services to poor residents who entered the country illegally, the 64-year-old underwent surgery earlier this year and can now see clearly.

“It saved me,” she said.

An hour’s drive to the east, in the flatlands of the Inland Empire, Sujey Becerra wasn’t as fortunate.

She didn’t have the means to pay for a surgery to remove ovarian cysts and put off the procedure for months, until she began hemorrhaging and was rushed to a hospital emergency room. Scarring from the last-minute operation left her hurting, and without access to follow-up treatment.

“I’m in pain constantly — all night, all day,” she said.

For uninsured California immigrants such as Vasquez and Becerra, which side of a county line they live on can significantly affect the care available when they’re sick.

Under a Depression-era law, county governments are responsible for providing health care to poor residents. But the interpretations of that mandate vary across the state. Just 11 of California’s 58 counties provide some form of low-cost medical care to poor immigrants who’ve entered the country illegally.

County-to-county differences in such care have existed for decades. But President Barack Obama’s overhaul of the health care system is focusing new attention on the disparities and complicating choices for local officials as they consider what, if any, health care they should provide to Californians who remain uninsured.

“Everything is getting shaken up,” said Catherine Teare, senior program officer for health reform at the California HealthCare Foundation, noting that the Affordable Care Act altered how the state’s health care system is funded and operates.

With health insurance coverage expanded to millions more Californians, people living here illegally _ who are barred from signing up for Obamacare _ now make up the single biggest group of uninsured state residents. A quarter of that population has private insurance coverage through their job or that of a family member, researchers say. But that leaves close to 1.5 million uninsured.

Now, advocates for the poor are urging state and county officials to wade back into discussions about politically sensitive and potentially costly options for improving health care for those living here illegally.

This month, the state Senate passed a bill, with most Republicans opposed, that would provide health care to hundreds of thousands of children younger than 19 who are here illegally.

Some have sharply criticized efforts to expand such coverage. “They seem to stay up late in Sacramento thinking up new benefits and services to provide to illegal aliens, even as they’re cutting back services to everybody else,” said Ira Mehlman, a spokesman for the Federation for American Immigration Reform.

At the county government level, a key change that accompanied Obamacare is complicating the same debate. When the state expanded the number of people eligible for Medi-Cal, its health program for the poor, it took back hundreds of millions of dollars in funding from local public health agencies.

That has put a squeeze on counties that chose to serve residents in the country illegally and made it more difficult financially for other jurisdictions to consider adding such programs.

Poor immigrants who aren’t eligible for free or subsidized insurance plans offered by the state can go to emergency rooms and community free clinics, but generally don’t have access to specialists or surgery. For just a portion of emergency room visits and pregnancy care involving those living here illegally, the state pays an estimated $1.4 billion annually.

Some experts argue that leaving large numbers of residents uninsured and relying on emergency rooms as a last-resort form of health care will undercut savings anticipated under Obamacare. UCLA health policy professor Steven Wallace noted the federal health system overhaul is based on an expectation that easy access to regular, preventive care will keep patients healthy and reduce overall medical costs.

According to projections from the University of California, Berkeley and UCLA people in the country illegally will continue to make up about half the roughly 3
million Californians lacking insurance four years from now.

“That’s the next big group to go after,” Wallace said.

Proponents of increased coverage point out that in recent years Californians have shown a willingness to extend privileges to those living here illegally, including driver’s licenses and lower-cost, in-state tuition at the state’s public colleges and universities.

One recent survey conducted for the Public Policy Institute of California found that 80 percent of Californians favored a path to citizenship for those living here illegally, including 66 percent of Republicans.

With more elected officials voicing support for expanded medical coverage for those residents, the big question has become: Whose financial responsibility is it?
State officials are considering picking up as least some of the cost.

But counties are required under a 1933 state law to “relieve and support all incompetent poor, indigent persons.” That requirement has been open to interpretation when it comes to health care for those in the country illegally. Among the 11 counties that provide low-cost medical care to such immigrants, some limit treatment to seriously ill patients or children.

The remaining 47 counties do not consider these immigrants to be covered by the state mandate.

(Karlamangla’s reporting on the remaining uninsured was undertaken as a California Health Journalism Fellow at USC’s Annenberg School of Journalism.)

(c)2015 Los Angeles Times. Distributed by Tribune Content Agency, LLC.

Photo: Sujey Becerra, an uninsured immigrant living in San Bernardino County, Calif., was unable to pay for the removal of ovarian cysts and now lives in constant pain after emergency surgery. She’s shown with her sons, Alexandre, 10, left, and Gonzalo Cervantes, 16. (Irfan Khan/Los Angeles Times/TNS)

Out From Behind The Counter, Pharmacists Bring Their Own Take To Health Care

By Soumya Karlamangla, Los Angeles Times (TNS)

LOS ANGELES — Jose Alvarez clutches a red drawstring bag as he hobbles into a small office. He leans his crutches against the wall and takes a seat in the corner. His seven pill bottles, of varying heights, create a miniature skyline of orange and white.

A heavyset man with a scraggly beard, Alvarez has diabetes, high blood pressure, and asthma. He’s here at this clinic in East Los Angeles for his two p.m. appointment with Sangeeta Salvi.

“I was in denial for a very long time,” Alvarez, 42, says about his diabetes. Now he comes in every three weeks to discuss his medications, diet and exercise with Salvi.

Despite the white coat slung over the back of her chair, Salvi isn’t a physician, but a pharmacist.

She’s one of a growing number moving out from behind grocery store pharmacy counters across the country and seeing patients in new ways, part of a push to reduce health care costs, address social issues that impede people’s health, and ease a national shortage of primary care physicians.

Steven Chen, a University of Southern California clinical pharmacy professor, runs this pilot initiative at ten clinics belonging to AltaMed, a nonprofit clinic network that serves largely low-income populations in L.A. and Orange counties.

In a health care system that often seems impersonal and intimidating, pharmacists can act as a much-needed sympathetic ear and source of advice, spending extra time with patients.

“That’s the reason why we’ve been very successful,” Chen says, “because someone is taking the time to sit with the patient.”
Team-based medical care, in which multiple health care professionals work together to treat a patient, is a central feature of the Affordable Care Act. But as different workers collaborate, there’s concern that pharmacists could overstep their bounds.

“Every member of the team is critical but not interchangeable,” says Reid Blackwelder, board chair of the American Academy of Family Physicians.

Pharmacists’ role is fundamentally different from doctors’; whereas doctors try to diagnose a root problem, pharmacists just try to make the symptoms better. Pharmacists are best trained to determine appropriate uses and dosages of medications to help patients with their problems.

Nearly 90 percent of patients with chronic illnesses take medication as the first line of treatment. In the United States, between a third and a half of patients don’t take their medicines properly, which — along with poor prescribing and diagnoses — costs the health care industry as much as $290 billion a year, according to the New England Health Care Institute.

On average, clinical pharmacists in the USC program find ten drug-related problems per patient — things such as taking the wrong dosage or missing a needed medicine.

But they also act as a sort of medical counselor, helping patients with a range of issues, including diet, exercise and stresses of all kinds. Many pharmacists taking part in the USC initiative — funded by a $12-million federal grant — also call insurance companies and drug manufacturers to make sure patients can get needed medications.

“Our patients need that,” says Rosie Jadidian, director of pharmaceutical services for Community Clinic Association of Los Angeles County. “They’re waiting on bus schedules, and their lives are organized in different ways. They need that one-stop shopping.”
Sitting face-to-face in her cramped office, their knees almost touching, Salvi and Alvarez review the medicines he’s taking.

Three times a day. Eight milligrams. Before meals. When I wake up.

Pharmacists at AltaMed clinics are paired with patients they can help most: those with chronic illnesses.

When Salvi first started treating Alvarez, she realized he was using only a quick-relief inhaler, not one for long-term control.

Now that he’s taking the preventive inhaler regularly, Alvarez, who lives in Boyle Heights, says he hasn’t experienced much shortness of breath.

“It’s only been a month and a half, two months, and I’ve noticed a difference,” he says.

Salvi says the fast-paced work of clinical pharmacy was more appealing than working behind a counter.

“We’re directly involved in their care,” says Salvi, who’s been treating patients at AltaMed clinics for two years. “We develop a strong relationship.”

Patients usually see their pharmacists once a month, while they see their primary care doctors a few times a year. And pharmacist visits are typically longer, lasting up to an hour.

Alvarez has had diabetes for more than ten years. He lost his job as a chef last year because of a foot ulcer that made it impossible for him to stand all day in the kitchen. After he lost a toe in January, he decided to start trying to keep his diabetes under control.

After consulting her notes, Salvi asks Alvarez whether he’s still eating eggs and two pieces of wheat toast for breakfast. He says he’s reduced it to one slice.

“I used to drink a two-liter Coke by myself at lunch,” he says. Now, he has half a 23-ounce Arizona iced tea with his midday meal, but he’s working to cut that out too, he says.
Salvi tells him that breaking a habit cold turkey is always difficult. “Remember to take baby steps,” she says.
Clinical pharmacists are part of a burgeoning number of recent medical interventions that aim to increase access to medical care. Across the country, patients can see a nurse or a pharmacist at new retail clinics, urgent-care clinics, and kiosks. Some patients can also now talk to a health care professional on video chat.

“It’s probably exhilarating and also a little overwhelming,” says Dr. Ateev Mehrotra, a Harvard Medical School professor who studies innovations in health care delivery.

Because these innovations often take care out of the hands of doctors, many of them also help with the shortage of providers across the country that worsened with the expansion of health insurance under the Affordable Care Act.

The nationwide shortfall of primary care doctors is expected to grow to about 45,000 by 2020. Almost a quarter of Californians already live in a primary care shortage area, according to state data.

A California law went into effect last year that allows pharmacists to bill for medical care — seen as a step toward solidifying their expanded roles outside pharmacies. Congress is considering a similar bill, but critics say that an already costly health care system can’t afford to pay another provider.

Early data from the AltaMed initiative shows that bringing in a clinical pharmacist saves money overall by reducing hospitalizations and other expensive medical treatments, but initially increases costs both to pay the pharmacists and to provide more medicines.

Historically, that’s made clinical pharmacists a hard sell because clinics haven’t been financially responsible if a patient ends up in the hospital, so there is little incentive to pay for the extra service. That’s slowly changing with the Affordable Care Act, as payment models shift so providers are rewarded if patients stay healthy, and penalized if they don’t.

At AltaMed clinics, pharmacists’ schedules are almost always booked.

Salvi takes Alvarez’s blood pressure one last time. With a smile, she tells him she thinks they’ve covered everything for the day.

She tentatively schedules him an appointment in three weeks, because he’s not sure when he’ll be free next month.

“I’m sure we’ll be calling you anyways,” Salvi says. “You know how we are.”

Photo: Allen J. Schaben via Los Angeles Times/TNS

California Study Finds It Cheaper For Students To Buy Insurance Than Go Without

By Soumya Karlamangla, Los Angeles Times (TNS)

LOS ANGELES — As this year’s deadline for Obamacare fast approaches, California State University officials are trying to show students that buying health insurance makes financial sense.

A new analysis from the CSU Health Insurance Education Project found that half the approximately 445,000 students in the CSU system are able to purchase health insurance for less than they would have to pay in fines for remaining uncovered.

Walter Zelman, project director and chairman of the Cal State L.A. Public Health Department, said the numbers challenge the idea that the cost of health insurance — often cited as the main reason people don’t sign up — is unaffordable.

“It’s pretty striking that half our students, they shouldn’t even be thinking about this. It’s so obvious,” Zelman said. “It’s a no-brainer.”

When Congress approved the Affordable Care Act, lawmakers required almost everyone starting in 2014 to have health insurance, or pay a fine.

Sunday is the deadline to sign up for insurance for 2015 through Covered California, the state’s insurance exchange. Although 1.2 million people have either signed up for new policies or renewed existing Covered California plans, the exchange is still thousands away from its goal of enrolling 1.7 million by the end of the sign-up period.

Zelman said he hopes the Cal State data will show that health insurance won’t stretch students’ pocketbooks. Healthy young people have long been a focus of enrollment efforts, with some officials worrying that if not enough signed up, insurance companies would be left with too many sick and expensive customers, which would eventually cause carriers to raise premiums.

The CSU analysis looked at the cost of the cheapest insurance plan offered through Covered California and found that approximately 50 percent of CSU students can purchase health insurance for less than $325, the fine for the 2015 tax year.

The analysis found that all financially independent CSU students with annual incomes of $18,000 or less and all four-person families with an income less of $45,000 or less can purchase insurance for less than the fine.

Approximately 75 percent of these students are eligible for Medi-Cal, the state’s free low-income health program that was expanded under the Affordable Care Act. The remainder are eligible for subsidized plans through Covered California.

At the six campuses in the L.A. region — San Bernardino, Los Angeles, Northridge, Pomona, Dominguez Hills and Long Beach — the lowest monthly premium available to a 21-year-old who makes $18,000 annually or less is about $26 a month.

The premiums were much lower at the other CSU campuses across the state; at those 17 campuses, that same student can get a plan with a monthly premium of $5 or less.

Last year, Obamacare enrollment among CSU students exceeded expectations, with 60,000 signing up and the numbers of uninsured dropping by 60 percent. Roughly 10 percent remained without health insurance at the beginning of this year’s open enrollment.

Zelman said he thinks there’s greater awareness about health insurance availability on campus this year, and that demand for enrollment assistance has been increasing as the Sunday deadline approaches.

AFP Photo/Robyn Beck