Tagged California

Pacientes sin nombre: cuando el personal del hospital tiene que ser detective

El hombre de 50 años con la cabeza rapada y los ojos marrones no reaccionó cuando los paramédicos lo llevaron a la sala de emergencias. Sus bolsillos estaban vacíos: ni billetera, ni teléfono, ni un solo trozo de papel que pudiera revelar su identidad a las enfermeras y médicos que estaban tratando de salvarle la vida. Su cuerpo no tenía cicatrices ni tatuajes distintivos.

Casi dos años después de ser atropellado por un automóvil en el ajetreado bulevar de Santa Mónica, en enero de 2017, y de que lo transportaran a Los Ángeles County + USC Medical Center con una lesión cerebral devastadora, nadie había venido a buscarlo o lo había reportado como desaparecido. El hombre murió en el hospital, todavía sin nombre.

El personal del hospital a veces debe actuar como detective cuando un paciente sin identificación llega para recibir atención. Establecer la identidad ayuda a evitar los riesgos que pueden conllevar realizar tratamientos sin conocer el historial médico del paciente. Y se esfuerzan por encontrar parientes cercanos para ayudar a tomar decisiones médicas.

“Buscamos a alguien que pueda tomar decisiones, una persona que pueda ayudarnos”, dijo Jan Crary, trabajadora social clínica supervisora ​​en L.A. County + USC: con frecuencia convocan a su equipo para identificar a pacientes sin nombre.

El hospital también necesita un nombre para cobrar el pago de un seguro privado o programas de salud del gobierno como Medicaid o Medicare.

Pero las leyes federales de privacidad pueden hacer que descubrir la identidad de un paciente sea un desafío para el personal de los hospitales de todo el país.

En L.A. County + USC, los trabajadores sociales revisan las pertenencias y la ropa del paciente, sus teléfonos celulares si no tienen contraseña, buscando nombres y números de familiares y amigos, y revisan recibos o pedazos de papel arrugados en busca de cualquier rastro de la identidad del paciente. Hacen preguntas a los paramédicos que lo trajeron o a los operadores del 911 que atendieron la llamada.

También toman nota de los tatuajes y piercings, e incluso intentan rastrear los registros dentales. Es más difícil chequear las huellas dactilares, porque eso se hace a través de la aplicación de la ley, que se involucrará solo si el caso tiene un costado criminal, dijo Crary.

A menudo, los pacientes no identificados son peatones o ciclistas que dejaron sus identificaciones en casa y fueron arrollados por vehículos, agregó Crary. También pueden ser personas con deterioro cognitivo grave, como Alzheimer, pacientes en estado psicótico o usuarios de drogas que sufrieron una sobredosis. Los pacientes más difíciles de identificar son aquellos que están socialmente aislados, incluidas las personas sin hogar, cuyas admisiones en hospitales han aumentado considerablemente en los últimos años.

Lenh Vuong, trabajadora clínica social de Los Angeles County+USC Medical Center, visita a un paciente que ingresó sin nombre y que recientemente fue identificado. ((Heidi de Marco/KHN))

En los últimos tres años, el número de pacientes que llegaron sin identificación a L.A. County + USC aumentó de 1.131 en 2016 a 1.176 en 2018, según datos proporcionados por el hospital.

Si un paciente permanece sin identificar por mucho tiempo, el personal del hospital inventará una identificación, generalmente comenzando con la letra “M” o “F” para el género, seguido de un número y un nombre al azar, dijo Crary.

Otros hospitales recurren a tácticas similares para facilitar la facturación y el tratamiento. En Nevada, los hospitales tienen un sistema electrónico que asigna a los pacientes no identificados un “alias de trauma”, dijo Christopher Lake, director ejecutivo de resiliencia comunitaria en la Asociación de Hospitales de Nevada.

El tiroteo en un concierto de Las Vegas en octubre de 2017 representó un desafío para los hospitales locales que intentaron identificar a las víctimas. La mayoría de los asistentes al concierto llevaban muñequeras con chips escaneables que contenían sus nombres y números de tarjetas de crédito para poder comprar cerveza y recuerdos. En la noche del tiroteo, el último día de un evento de tres días, muchos se sentían tan cómodos con las pulseras que no llevaban carteras ni billeteras.

Esa noche, más de 800 personas resultaron heridas y fueron trasladadas a numerosos hospitales, ninguno de los cuales estaba equipado con dispositivos para escanear las pulseras. El personal de los hospitales trabajó para identificar a los pacientes por sus tatuajes, cicatrices u otras características distintivas, y por fotografías en las redes sociales, dijo Lake. Pero fue una batalla, especialmente para los hospitales más pequeños, agregó.

Jan Crary, trabajadora social clínica supervisora ​​en L.A. County + USC, lidera un equipo que muchas veces tiene que jugar el papel de detective cuando no se puede identificar a un paciente.((Heidi de Marco/KHN))

La Ley federal de responsabilidad y portabilidad del seguro de salud (HIPAA, por sus siglas en inglés), destinada a garantizar la privacidad de los datos médicos personales, a veces puede hacer que la identificación sea más ardua porque es posible que un hospital no quiera divulgar información sobre pacientes no identificados a personas que indagan sobre personas desaparecidas.

En 2016, un hombre con Alzheimer fue ingresado en un hospital de Nueva York a través de la emergencia como paciente no identificado y se le asignó el nombre de “Trauma XXX”.

La policía y miembros de la familia preguntaron por él en el hospital varias veces, pero le decían que no estaba allí. Después de una semana, durante la cual cientos de amigos, familiares y agentes de la ley buscaron al hombre, un médico que trabajaba en el hospital vio una noticia sobre él en la televisión y se dio cuenta que era el paciente no identificado.

Más tarde, los funcionarios del hospital le dijeron al hijo de este hombre que, debido a que no había preguntado explícitamente por “Trauma XXX”, no pudieron darle información que pudiera haberlo ayudado a identificar a su padre.

A raíz de esa confusión, el Centro de Información para Personas Desaparecidas del estado de Nueva York elaboró ​​un conjunto de pautas para los administradores de hospitales que reciben solicitudes de información sobre personas desaparecidas de la policía o miembros de la familia.

Estas pautas incluyen aproximadamente dos docenas de pasos que deben seguir los hospitales, que incluyen la notificación a la recepción, la introducción de descripciones físicas detalladas en una base de datos, tomar muestras de ADN y el seguimiento de correos electrónicos y faxes sobre personas desaparecidas.

Las pautas de California estipulan que, si un paciente no está identificado y tiene incapacidades cognitivas, “el hospital puede revelar solo la información mínima necesaria que sea directamente relevante para ubicar a los familiares del paciente, si esto es por el mejor interés del paciente”.

En L.A. County + USC, la mayoría de los pacientes sin nombre se identifican rápidamente: o bien recuperan el conocimiento o, como en la mayoría de los casos, amigos o familiares llaman para preguntar por ellos, dijo Crary.

Aun así, el hospital no siempre tiene éxito. De 2016 hasta 2018, 10 personas sin nombre permanecieron sin identificar durante sus estadías en L.A. County + USC. Algunos murieron en el hospital; y otros fueron a hogares de adultos mayores con nombres inventados.

Pero Crary dijo que ella y su equipo agotan todas las vías en busca de una identidad.

Una vez, un hombre mayor, no identificado y de aspecto distinguido, con una barba recortada con pulcritud, fue llevado a la sala de urgencias delirando, con lo que luego se diagnosticó como encefalitis, y con incapacidad para hablar.

Siguiendo la corazonada de que este hombre tan distinguido debía tener a alguien que lo estaba buscando, Crary consultó con las estaciones de policía en el área. Lo que descubrió es que el hombre era buscado en varios estados por agresión sexual.

“Es un caso que nunca olvidaré”, agregó Crary. “La verdad es que estoy más feliz cuando podemos identificar a un paciente y ubicar a la familia para tener una hermosa reunificación, en vez de encontrar a un criminal”.

As ER Wait Times Grow, More Patients Leave Against Medical Advice

Emergency room patients increasingly leave California hospitals against medical advice, and experts say crowded ERs are likely to blame.

About 352,000 California ER visits in 2017 ended when patients left after seeing a doctor but before their medical care was complete. That’s up by 57%, or 128,000 incidents, from 2012, according to data from the Office of Statewide Health Planning and Development.

Another 322,000 would-be patients left the emergency room without seeing a doctor, up from 315,000 such episodes in 2012.

Several hospital administrators said overcrowding is a likely culprit for the trend. California emergency room trips grew by almost 20%, or 2.4 million, from 2012 to 2017.

Moreover, ER wait times also increased for many during that time period: In 2017, the median ER wait time for patients before admission as inpatients to California hospitals was 336 minutes — or more than 5½ hours. That is up 15 minutes from 2012, according to the federal Centers for Medicare & Medicaid Services. The median wait time for those discharged without admission to the hospital dropped 12 minutes over that period, but still clocked in at more than 2½ hours in 2017.

California wait times remain higher than the national average. In 2017, the median length of a stay in the ER before inpatient admission nationwide was 80 minutes shorter than the median stay in California. Four states — Maryland, New York, New Jersey and Delaware — had even longer median wait times.

The growth in patients leaving California ERs prematurely was faster than the growth in overall ER encounters. About 2.4% of ER trips in 2017 ended with patients leaving the ER against medical advice or abruptly discontinuing care after seeing a doctor, compared with 1.8% in 2012.

“Most patients are sick but not critically ill,” said Dr. Steven Polevoi, medical director of the emergency department at UCSF Helen Diller Medical Center at Parnassus Heights. “Emergency care doesn’t equal fast care all of the time.”

When a patient leaves the ER after seeing a doctor but before the doctor clears them to leave, the Office of Statewide Health Planning and Development classifies that encounter as “leaving against medical advice or discontinued care.” The definition includes encounters in which a doctor carefully explains the risks to the patient and has the patient sign a form, but also instances in which the patient simply discontinues care and bolts out the door.

Patients leaving the emergency room too soon “are deliberately putting themselves at more risk for morbidity and even mortality,” Polevoi said — a point echoed by other physicians.

Dr. Veronica Vasquez-Montez, emergency room medical director at Good Samaritan Hospital in Los Angeles, said she sometimes finds herself having “tough conversations” with sick patients intent on leaving the ER, often citing pressing responsibilities.

“If you die from this,” she tells them, “you are good to no one you are caring for.”

One of her recent patients was at high risk for a major stroke but insisted he needed to leave the ER to take care of his pet.

“Guess what he came back for? A major stroke,” said Vasquez-Montez, also a clinical assistant professor at the University of Southern California’s Keck School of Medicine.

Compared with all ER patients, those leaving against medical advice were more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal, the government insurance program for the poor, state figures show. They were also more likely to complain primarily of non-specific symptoms such as chest pain or a cough.

Fresno, Shasta, Yuba, Kern, San Bernardino and Tulare counties had the highest proportion of ER encounters in 2017 that ended with patients leaving against medical advice or abruptly discontinuing care. Each of those counties recorded more than 4% of ER patients leaving too soon, state figures show.

From 2012 to 2017, the number of emergency room encounters in Fresno County increased by almost 95,000, or 37%. At Fresno’s Community Regional Medical Center, about 9% of ER encounters ended with a patient leaving too soon, more than three times the statewide rate.

Community Regional Medical Center is one of the busiest hospitals in the state. It recently instituted a “Provider at Triage” program that puts caregivers in the lobby area with patients, said Dr. Jeffrey Thomas, the hospital’s chief medical and quality officer. The hospital’s internal data now show fewer than 2% of patients leaving against medical advice or abruptly discontinuing care.

“When patients bring themselves into the ED, they are seen in about 5 minutes by a qualified registered nurse and, on average, are seen by a provider within 30 minutes of arrival,” Thomas said in a statement.

When a sick patient is about to leave the emergency room, doctors should determine why he or she wants to go, make sure the patient is capable of making a sound decision, involve friends and family, explain the course of treatment and, if nothing works, arrange for speedy follow-up care, said Dr. Jay Brenner, emergency department medical director at Upstate University Hospital-Community Campus in New York and co-author of several studies about patients leaving against medical advice.

“When someone requests to leave,” Brenner said, “it needs to be a priority that ranks just below a cardiac arrest.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Newsom Changes Course On Plan To Pay For Immigrant Health Coverage

Gov. Gavin Newsom’s administration Friday reversed course on his plan to divert public health dollars from several counties to help provide health coverage to young adults who are in the country illegally.

The administration heeded the alarm sounded by Sacramento, Placer, Santa Barbara and Stanislaus counties, which had warned that the governor’s plan would compromise their ability to cope with surging rates of sexually transmitted diseases and, in some cases, measles outbreaks.

“The Administration has subsequently reevaluated this proposal due to the potential negative impacts to public health activities in these counties,” Vivek Viswanathan, chief deputy director of the state Department of Finance, wrote in a letter Friday to the chairs of the state Assembly and Senate Budget Committees.

Sacramento County, for example, estimates it would have lost roughly $7.5 million  that goes toward operating its STD clinic and paying communicable disease investigators. It warned that without the money, it would have to close the STD clinic and cut its own health services for undocumented immigrants of all ages.

“The public health dollars being restored make a big difference particularly at a time we have measles,” Dr. Peter Beilenson, Sacramento County Health Services Director, told California Healthline Friday. “We’re thrilled. It’s a great thing for the patients that we’re serving.”

This year, there have been 44 confirmed cases of measles in California as of May 8, three of them in Sacramento County. Public health officials also are struggling to address record rates of sexually transmitted diseases, with more than 300,000 cases of gonorrhea, chlamydia and syphilis reported in California in 2017.

On Thursday, when Newsom unveiled his revised budget — one that still included the plan to divert money from the four counties — he announced it would cost less to cover young adult unauthorized immigrants next year than previously estimated.

Because the state would have to delay the implementation date by six months to address IT issues, he said, it would cost $98 million to cover them in 2019-20, a significant drop from his original forecast of $260 million. The number of people expected to enroll also has dropped from 138,000 to 106,000.

The lower cost estimate means the administration won’t need to divert money from those four counties. What it does need, it will take from a special state budget reserve fund, said Department of Finance spokesman H.D. Palmer.

Newsom still plans to divert state money from 35 mostly small and rural counties, funds that currently pay for health services for uninsured residents, including undocumented immigrants, Palmer said.

Those counties participate in something called the County Medical Services Program, which has a $300 million budget surplus, Newsom noted at his budget briefing Thursday.

“That’s more than enough to address their issues,” Newsom said.

He also noted that his budget includes $40 million to combat infectious diseases.

Legislators are crafting their own budget proposals and have held dozens of hearings examining Newsom’s plan. The governor and lawmakers have until June 15 to negotiate a final budget, so it’s not yet clear which proposals will be included.

Placer County, which has reported three measles cases this year, praised Newsom’s change of heart.

“I appreciate the governor listening to some of the potential impacts it could have on public health and realizing that, in this time in California, we need to be making investments,” said Jeff Brown, director of Placer County’s Health and Human Services Department.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

‘John Doe’ Patients Sometimes Force Hospital Staff To Play Detective

The 50-something man with a shaved head and brown eyes was unresponsive when the paramedics wheeled him into the emergency room. His pockets were empty: no wallet, no cellphone, not a single scrap of paper that might reveal his identity to the nurses and doctors working to save his life. His body lacked any distinguishing scars or tattoos.

Almost two years after he was hit by a car on busy Santa Monica Boulevard in January 2017 and transported to Los Angeles County+USC Medical Center with a devastating brain injury, no one had come looking for him or reported him missing. The man died in the hospital, still a John Doe.

Hospital staffs sometimes must play detective when an unidentified patient arrives for care. Establishing identity helps avoid the treatment risks that come with not knowing a patient’s medical history. And they strive to find next of kin to help make medical decisions.

“We’re looking for a surrogate decision-maker, a person who can help us,” said Jan Crary, supervising clinical social worker at L.A. County+USC, whose team is frequently called on to identify unidentified patients.

The hospital also needs a name to collect payment from private insurance or government health programs such as Medicaid or Medicare.

But federal privacy laws can make uncovering a patient’s identity challenging for staff members at hospitals nationwide.

At L.A. County+USC, social workers pick through personal bags and clothing, scroll through cellphones that are not password-protected for names and numbers of family or friends, and scour receipts or crumpled pieces of paper for any trace of a patient’s identity. They quiz the paramedics who brought in the patient or the dispatchers who took the call.

They also make note of any tattoos and piercings, and even try to track down dental records. It’s more difficult to check fingerprints, because that’s done through law enforcement, which will get involved only if the case has a criminal aspect, Crary said.

Unidentified patients are often pedestrians or cyclists who left their IDs at home and were struck by vehicles, said Crary. They might also be people with severe cognitive impairment, such as Alzheimer’s, patients in a psychotic state or drug users who have overdosed. The hardest patients to identify are ones who are socially isolated, including homeless people — whose admissions to hospitals have grown sharply in recent years.

In the past three years, the number of patients who arrived unidentified at L.A. County+USC ticked up from 1,131 in 2016 to 1,176 in 2018, according to data provided by the hospital.

If a patient remains unidentified for too long, the staff at the hospital will make up an ID, usually beginning with the letter “M” or “F” for gender, followed by a number and a random name, Crary said.

Jan Crary, supervising clinical social worker at Los Angeles County+USC Medical Center, leads a team who increasingly must play detective when patients cannot be identified.((Heidi de Marco/KHN))

Other hospitals resort to similar tactics to ease billing and treatment. In Nevada, hospitals have an electronic system that assigns unidentified patients a “trauma alias,” said Christopher Lake, executive director of community resilience at the Nevada Hospital Association.

The deadly mass shooting at a Las Vegas concert in October 2017 presented a challenge for local hospitals who sought to identify the victims. Most concertgoers were wearing wristbands with scannable chips that contained their names and credit card numbers so they could buy beer and souvenirs. On the night of the shooting, the final day of a three-day event, many patrons were so comfortable with the wristbands that they carried no wallets or purses.

More than 800 people were injured that night and rushed to numerous hospitals, none of which were equipped with the devices to scan the wristbands. Staff at the hospitals worked to identify patients by their tattoos, scars or other distinguishing features, as well as photographs on social media, said Lake. But it was a struggle, especially for smaller hospitals, he said.

The Health Insurance Portability and Accountability Act (HIPAA), a federal law intended to ensure the privacy of personal medical data, can sometimes make an identification more arduous because a hospital may not want to release information on unidentified patients to people inquiring about missing persons.

In 2016, a man with Alzheimer’s disease was admitted to a New York hospital through the emergency department as an unidentified patient and assigned the name “Trauma XXX.”

Police and family members inquired about him at the hospital several times but were told he was not there. After a week — during which hundreds of friends, family members and law enforcement officials searched for the man — a doctor who worked at the hospital saw a news story about him on television and realized he was the unidentified patient.

Hospital officials later told the man’s son that because he had not explicitly asked for “Trauma XXX,” they could not give him information that might have helped him identify his father.

Prompted by that mix-up, the New York State Missing Persons Clearinghouse drafted a set of guidelines for hospital administrators who receive information requests about missing persons from police or family members. The guidelines include about two dozen steps for hospitals to follow, including notifying the front desk, entering detailed physical descriptions into a database, taking DNA samples and monitoring emails and faxes about missing persons.

California guidelines stipulate that if a patient is unidentified and cognitively incapacitated, “the hospital may disclose only the minimum necessary information that is directly relevant to locating a patient’s next-of-kin, if doing so is in the best interest of the patient.”

Lenh Vuong, a clinical social worker at Los Angeles County+USC Medical Center, checks on a former John Doe patient who was recently identified. (Heidi de Marco/KHN)

Maria Torres visits Felipe Luna, her brother. Luna ended up at Los Angeles County+USC Medical Center after he was hit by a car and suffered head injuries. “The only thing he had on him was a bank card and a receipt,” Torres says. “I think that was a good thing he had that in his pocket, but that’s not an ID.” (Heidi de Marco/KHN)

At L.A. County+USC, most John Does are quickly identified: They either regain consciousness or, as in a majority of cases, friends or relatives call asking about them, Crary said.

Still, the hospital does not always succeed. From 2016 to 2018, 10 John and Jane Does remained unidentified during their stays at L.A. County+USC. Some died at the hospital; others went to nursing homes with made-up names.

But Crary said she and her team pursue every avenue in search of an identity.

Once, an unidentified and distinguished-looking older man with a neatly trimmed beard was rushed into the emergency room, delirious with what was later diagnosed as encephalitis and unable to speak.

Acting on a gut instinct that the well-groomed man must have a loved one who had reported him missing, Crary checked with police stations in the area. She learned instead that this John Doe was wanted in several states for sexual assault.

“He was done in by a mosquito,” Crary mused.

“It is a case that I will never forget,” she added. “The truth is that I am more elated when we are able to identify a patient and locate family for a beautiful reunification rather than finding a felon.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

State Bans Pesticide Linked To Developmental Problems

California will ban the use of a widely used pesticide in the face of “mounting evidence” that it causes developmental problems in children, state officials announced Wednesday.

Several studies have linked prenatal exposure of chlorpyrifos to lower birth weights, lower IQs, attention deficit hyperactivity disorder and autism symptoms in children.

The chemical is mostly used on crops — including citrus, almonds and grapes — but is also applied on golf courses and in other non-agricultural settings.

The ban “is needed to prevent the significant harm this pesticide causes children, farm workers and vulnerable communities,” Jared Blumenfeld, secretary of the California Environmental Protection Agency (CalEPA), said in a statement.

California’s ban comes as federal regulators fight to keep the chemical on the market.

Almost two decades ago, the U.S. Environmental Protection Agency, which regulates pesticides at the federal level, prohibited the sale of chlorpyrifos for residential use.

But under the Trump administration, the agency rejected a proposal to ban its use altogether, ignoring the recommendations of its own scientists. It continues to defend the use of chlorpyrifos in court.

Some states aren’t waiting for the federal government to act, California Healthline reported last month. The New York legislature last week sent a proposed ban to Democratic Gov. Andrew Cuomo for consideration. A bill in the California legislature to ban chlorpyrifos was pending at the time of the CalEPA’s announcement. Oregon and Connecticut lawmakers also are considering bans.

Hawaii was the first state to enact a state ban last year.

“Because the science is pretty clear that this a dangerous chemical, it’s long past time to get it off the market,” said Virginia Ruiz, director of occupational and environmental health at the Washington, D.C.-based nonprofit Farmworker Justice. “There’s momentum now, and people and policymakers are becoming better educated about chlorpyrifos.”

Chlorpyrifos can be inhaled during application and as it drifts into nearby areas or ingested as residue on food. People also can be exposed through drinking water if their wells have been contaminated by it.

Globally, several companies make chlorpyrifos products. In the U.S., the most recognized brand names are Dursban and Lorsban, manufactured by Corteva Agriscience, formerly known as Dow AgroSciences.

Corteva Agriscience did not respond to requests for comment.

California citrus growers are among the groups that oppose the ban. They worry that eliminating chlorpyrifos could result in disease outbreaks among their fruit trees.

Casey Creamer, president of California Citrus Mutual, pointed to the Asian citrus psyllid, a tiny insect that feeds on citrus leaves that can transmit a disease known as Huanglongbing, or citrus greening, as one risk.

“The impacts are potentially significant,” he said. If farmers “don’t have the tools to effectively manage the psyllid, people are going to switch out or stop growing citrus.”

Implementing the ban in California could take up to two years as the state wades through the administrative process and tries to find safer options, CalEPA said in its announcement.

On Thursday, Democratic Gov. Gavin Newsom is expected to propose $5.7 million as part of his 2019-20 budget to support the transition to “safer, more sustainable alternatives,” the announcement said.

The agency added that its decision to ban chlorpyrifos “follows mounting evidence … that the pesticide causes serious health effects in children and other sensitive populations,” even at low levels of exposure.

The California Farm Bureau Federation warned that food may get pricier as a result of the ban, leaving state residents more dependent on produce grown in states with less stringent regulations.

“Protecting our food supply, rural economy and the many jobs that depend on California agriculture will require state agencies to be open-minded and realistic in evaluating ways to fight pests and plant diseases,” said Jamie Johansson, the federation’s president.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

A Plan To Cover Immigrants Would Divert Public Health Dollars

California Gov. Gavin Newsom wants the state to provide health coverage to low-income young adults who are in the country illegally, but his plan would siphon public health dollars from several counties battling surging rates of sexually transmitted diseases and, in some cases, measles outbreaks.

Public health officials describe the proposed reallocation of state dollars as a well-meaning initiative that nonetheless would have “dire consequences” to core public health services.

There have been 764 confirmed cases of measles this year through May 3 in 23 states, including California, the highest number since 1994, the Centers for Disease Control and Prevention reported Monday. State public health officials also are struggling to address record rates of sexually transmitted diseases, with more than 300,000 cases of gonorrhea, chlamydia and syphilis reported in 2017.

The reallocation of state money “would exacerbate our already limited capacity to respond to outbreaks and public health emergencies,” said Jeff Brown, director of Placer County’s Health and Human Services Department, which has responded to three measles cases so far this year.

California already allows eligible immigrant children up to age 19 to participate in Medi-Cal, the state’s Medicaid program for low-income residents, regardless of their immigration status. The current budget sets aside $365.2 million to pay for the coverage.

In his 2019-20 budget plan, Newsom proposes expanding eligibility to unauthorized young adult immigrants from age 19 through 25.

His office estimates it would cost nearly $260 million to cover them in 2019-20. While state and federal governments usually share Medicaid costs, California would have to bear the full cost of covering this population.

To help pay for it, Newsom proposes to redirect about $63 million in state funds from 39 counties, arguing they would no longer need to provide health benefits to low-income young adults covered by the state.

“As the state takes on responsibility for providing health care to undocumented adults, counties’ costs and responsibilities on indigent health care are expected to decrease,” Jenny Nguyen, a budget analyst at the state Department of Finance, told lawmakers at a recent legislative hearing.

Under the governor’s 2019-20 budget plan, which requires legislative approval, 35 mostly small and rural counties expect to lose about $45 million in state money that funds health services for uninsured residents, including undocumented immigrants. Those counties — which participate in something called the County Medical Services Program — aren’t expected to feel an immediate financial impact because the program has a budget surplus.

But four counties — Placer, Sacramento, Santa Barbara and Stanislaus — would take big and immediate hits to their public health budgets, officials say.

The amount of money the governor wants to divert from them to cover unauthorized immigrants under Medi-Cal is far more than the counties now spend on comprehensive health services for those immigrants, local health officials said.

“The idea that these dollars would be offset is just not accurate,” said Mary Ann Lee, managing director of Stanislaus County Health Services Agency, who described the governor’s budget proposal as “alarming.”

For example, Stanislaus County estimates it would lose $2.5 million under the governor’s budget plan. When officials studied the population served by their health centers, they found only 18 individuals were young adults who might not have legal immigration status. The total cost to provide care to them: just $1,700 a year.

Sacramento County, which reported a 300% increase in syphilis cases in the past four years, would have to shutter its newly opened STD clinic if the county loses an estimated $7.5 million in state funding, Dr. Peter Beilenson, the county Health Services Director, told lawmakers.

And while Sacramento County provides primary health care to an estimated 4,000 undocumented immigrant adults, just 100 are ages 19 to 25, and they are the least expensive to cover, Beilenson said.

“We agree with the idea behind this, increasing coverage for [those who are] undocumented,” Beilenson said. But losing those funds would force the county to close its STD clinic and terminate some communicable disease investigators “at a time when we now have measles cases in the region and we don’t want to be shutting those services down.”

The 40 confirmed cases of measles reported in California as of May 1 include three in Sacramento County.

As a result of the reduced funding, Sacramento County also would have to slash health services to its unauthorized immigrant residents — the very people Newsom aims to help — by an estimated 75%, Beilenson added.

Whether lawmakers will approve the governor’s proposal is unclear.

Several already have expressed concern, including state Assemblywoman Eloise Reyes (D-Grand Terrace), who said, “I think it is clear that this would be terrible for those counties.”

Officials with the Department of Finance told lawmakers at the hearing that they were aware of counties’ concerns but that the “governor’s budget stands as it is.”

The governor is scheduled to release a revised budget proposal by May 14, before the legislature votes on it this summer.

“I hope there will be some reconsideration,” said state Sen. Richard Pan (D-Sacramento), chairman of the Senate Health Committee. “There’s a disconnect there.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Meth Vs. Opioids: America Has Two Drug Epidemics, But Focuses On One

Kim had been wine tasting with a friend in Sonoma, Calif. They got into an argument in the car that night and Kim thought someone was following them. She was utterly convinced. And she had to get away.

“I jumped out of the car and started running, and I literally ran a mile. I went through water, went up a tree,” she said. “I was literally running for my life.”

Kim was soaking wet when she walked into a woman’s house, woke her from bed and asked for help. When the woman went to call the police, Kim left and found another woman’s empty guesthouse to sleep in — Goldilocks-style.

“But then I woke up and stole her car,” said Kim, who is 47 and now in recovery. (KHN is using her first name only because she has used illicit drugs.) Kim had been high on Xanax and methamphetamine. “I was crazy. Meth causes people to act completely insane.”

While public health officials have focused on the opioid epidemic in recent years, another epidemic has been brewing quietly, but vigorously, behind the scenes. Methamphetamine use is surging in parts of the U.S., particularly the West, leaving first responders and addiction treatment providers struggling to handle a rising need.

Across the country, overdose deaths involving meth more than quadrupled from 2011 to 2017. Admissions to treatment facilities for meth are up 17%. Hospitalizations related to meth jumped by about 245% from 2008 to 2015. And throughout the West and Midwest, 70% of local law enforcement agencies say meth is their biggest drug threat.

But policymakers in Washington, D.C., haven’t kept up, continuing to direct the bulk of funding and attention to opioids, said Steve Shoptaw, an addiction psychologist at UCLA in Los Angeles, where he hears one story after another about meth destroying people’s lives.

“But when you’re in D.C., where people are making decisions about how to deploy resources, those stories are very much muffled by the much louder story about the opioid epidemic,” he said.

Even within drug treatment circles, there’s a divide. Opioid addiction advocates are afraid their efforts to gain acceptance for measures like needle-exchange programs and safe injection sites will be threatened if meth advocates demand too much.

“The bottom line is, as Americans, we have just so much tolerance to deal with addiction,” Shoptaw said. “And if the opioid users have taken that tolerance, then there’s no more.”

So, lawmakers in San Francisco are trying to get a grip on the toll meth is taking on their city’s public health system on their own. The mayor recently established a task force to combat the epidemic.

“It’s something we really have to interrupt,” said Rafael Mandelman, a San Francisco district supervisor who will co-chair the task force. “Over time, this does lasting damage to people’s brains. If they do not have an underlying medical condition at the start, by the end, they will.”

Since 2011, emergency room visits related to meth in San Francisco have jumped 600% to 1,965 visits in 2016, the last year for which ER data is available. Admissions to the hospital are up 400% to 193, according to city public health data. And at San Francisco General Hospital, of 7,000 annual psychiatric emergency visits last year, 47% were people who were not necessarily mentally ill — they were high on meth.

“They can look so similar to someone that’s experiencing chronic schizophrenia,” said Dr. Anton Nigusse Bland, medical director of psychiatric emergency services at San Francisco General. “It’s almost indistinguishable in that moment.”

They have methamphetamine-induced psychosis.

“They’re often paranoid, they’re thinking someone might be trying to harm them,” he said. “Their perceptions are all off.”

If the person is extremely agitated, doctors might administer a sedative or even an antipsychotic medicine. Otherwise, the treatment is just waiting 12 to 16 hours for the meth to wear off. No more psychosis.

“Their thoughts are more organized, they’re able to maintain adequate clothing. They’re eating, they’re communicating,” Nigusse Bland said. “The improvement in the person is rather dramatic because it happens so quickly.”

Trends In Drug Use Come In Waves

The trend in rising stimulant use is nationwide: cocaine on the East Coast, meth on the West Coast, said Dr. Daniel Ciccarone, a professor of medicine and substance use researcher at the University of California-San Francisco.

“It is an epidemic wave that’s coming, that’s already here,” he said. “But it hasn’t fully reached our public consciousness.”

Drug preferences are generational, Ciccarone said. They change with the hairstyles and clothing choices, like bell-bottoms or leg warmers. It was heroin in the 1970s, cocaine and crack in the ’80s. Then opiate pills. Then methamphetamine. Then heroin. And now meth again.

“The culture creates this notion of let’s go up, let’s not go down,” Ciccarone said. “New people coming into drug use are saying, ‘Whoa, I don’t really want to do that. I hear it’s deadly.’”

Kim has been with meth through two waves. When she got into speed in the 1990s, she was hanging out with bikers, going to clubs in San Francisco.

“Now what I see, in any neighborhood, you can find it. It’s not the same as it used to be where it was kind of taboo,” Kim said. “It’s more socially accepted now.”

Dying From Meth

A hint about who uses meth now comes from the data on deaths.

Meth is not as lethal as opioids: 47,600 people died of opioid-related overdoses in 2017 compared with 10,333 deaths involving meth. But the death rate for meth has been rising. Meth-related deaths in San Francisco doubled since 2011, another indication that more people are using meth and that today’s supply is very potent, said the UCSF’s Ciccarone.

Another hypothesis to explain the growth in meth-related overdoses is that meth users are aging. Most meth deaths are from a brain hemorrhage or a heart attack, which would be unusual for a 20-year-old.

“Because your tissue is so healthy at that age,” said Dr. Phillip Coffin, a physician and the director of substance use research at the San Francisco Department of Public Health. “Whereas when you’re 55 years old and using methamphetamine, you might be at higher risk for bursting a vessel and bleeding and dying from that.”

Another explanation for the rising death rate is that meth has become contaminated. And that affects everyone, old and young. Last year, three young people in San Francisco died after smoking meth together. It turns out the meth had fentanyl in it. The synthetic opioid has been causing waves of heroin overdoses across the country, but now it’s showing up mixed into cocaine and meth.

Most researchers believe the contamination happens accidentally, when a dealer uses the same equipment to bag fentanyl and later meth, Ciccarone said.

A meth overdose alert from the Drug Overdose Prevention and Education Project.(April Dembosky/KQED)

Relapses Are Common

Over her two decades of meth use, Kim has been through drug treatment more than a dozen times. Relapse is part of recovery, and among meth users, 60% will start using again within a year of finishing treatment. Unlike opioids, there are no medication treatments for meth addiction, which makes it particularly hard to treat.

In April, Kim completed a six-month residential treatment program for women in San Francisco called the Epiphany Center. She came directly from jail, after serving time for her housewarming-and-car-theft spree in Sonoma. She said that in the first 30 days all she could do was try to clear the chaos from her mind.

“You have to get used to sitting with yourself, which is essential for life, is to get along with your own self,” she said.

Kim, who has four children, is hopeful that this round of treatment will stick. She is living in transitional housing now, has a job and has been accepted to a program at the University of California-Berkeley to finish her college degree.

“I’ve gone through 12 different programs and it’s been for my children, for my mom, for the courts. I’ve never come to be there for myself,” Kim said. “So it’s like I’ve come to a place where it has to be for me.”

This story is part of a partnership that includes KQED, NPR and Kaiser Health News.

The Long And Winding Road To Mental Health Care For Your Kid

For several months last spring and summer, my teen daughter, Caroline, experienced near-daily bouts of depression and debilitating panic attacks. During those episodes, she became extremely agitated, sobbing uncontrollably and aggressively rebuffing my attempts to comfort or reason with her.

My daughter was in a dark place, and I was worried.

But I have excellent health insurance, and I thought that would help me find a good therapist.

I dutifully dialed everyone on my health plan’s list. Some of them even called me back — only to say they weren’t taking new patients, or couldn’t see Caroline for three months, or didn’t have the training to match her symptoms.

I ultimately found a great therapist who isn’t in my health plan’s network — and after many months of weekly sessions, Caroline is doing much better.

I’m luckier than most parents, because my health plan covers a significant portion of Caroline’s out-of-network therapy. I pay only $45 per session, while some parents shell out north of $200 every week.

Think about how perverse this is. Mental health professionals say that with children, early intervention is crucial to avoid more severe and costly problems later on. Yet even parents with good insurance struggle to find care for their children.

The U.S. faces a growing shortage of mental health professionals trained to work with young people — at a time when depression and anxiety are on the rise. Suicide was the No. 2 cause of death for children and young adults from age 10 to 24 in 2017, after accidents.

There is only one practicing child and adolescent psychiatrist in the U.S. for about every 1,800 children who need one, according to data from the American Academy of Child & Adolescent Psychiatry.

Not only is it hard to get appointments with psychiatrists and therapists, but the ones who are available often don’t accept insurance.

“This country currently lacks the capacity to provide the mental health support that young people need,” says Dr. Steven Adelsheim, director of the Stanford University psychiatry department’s Center for Youth Mental Health and Wellbeing.

Alison Bloeser, a Seal Beach, Calif., mom, has struggled for nearly a decade to find effective care for her now 15-year old son’s obsessive-compulsive disorder and attention deficit hyperactivity disorder, known as ADHD. In that time, Bloeser says, she has taken him to over 20 therapists and had him on medication — spending more than $20,000 along the way.

“We have a growing number of young people in this country crying out for help at a young age,” Bloeser says. “Why are we not addressing that full force?”

There’s no one-size-fits-all solution because people’s financial and personal situations vary widely.

So let me begin with tips for all parents, even those with skimpy insurance or none at all. A good place to start is the pediatrician’s office — whether it’s a private practice or a low-cost community clinic.

“When your children reach adolescence, you should be asking their pediatricians to screen for both anxiety and depression,” advises Dr. Bhavana Arora, chief medical officer of the Children’s Hospital Los Angeles Health Network. A number of pediatricians in her program are becoming increasingly comfortable treating mild to moderate mental health problems in their offices, Arora says.

If your finances are constrained, try a community health clinic that offers mental health services regardless of a family’s ability to pay.

For instance, Los Angeles-based AltaMed (www.altamed.org) has 12 clinics in L.A. and Orange counties where children and teens with mild to moderate mental health disorders can get short-term therapy. Medi-Cal picks up the tab for most of those kids. For kids not on Medi-Cal, the clinics charge on a sliding scale.

One way to find a community clinic near you is to search https://findahealthcenter.hrsa.gov/.

Your child’s school is another place to seek help.

Caroline’s high school has a mental health counselor whom she visits when she is anxious or feeling blue. She always feels better afterward. If your kid’s school doesn’t have a mental health counselor, nurses and regular school counselors will likely know of outside options. Talk to them.

Faith-based organizations are increasingly engaged in mental health care. Saddleback Church, with numerous locations around Southern California, offers support groups and counseling. Jewish Family Service agencies nationwide provide counseling on a sliding scale. Muslims can try the Khalil Center, which has branches in Chicago, L.A., the San Francisco Bay Area, New York and Toronto.

If you, like me, have insurance and find a good therapist who is not in your network, try to make it work — if you can possibly afford it.

Start by checking whether you have coverage for out-of-network providers. If not, or if it’s not enough, ask if your health plan is willing to treat the therapist as an in-network provider just for your child — an arrangement known as a single-case agreement.

The therapist likely will have to agree to a lower payment.

For many parents, the most productive thing is meeting others who are experiencing similar problems.

“Grassroots support groups, finding other parents going through what they’re going through, is the launch pad of everything,” says Debra Ann Afarian, coordinator of the Orange County, Calif., chapter of Children and Adults With Attention-Deficit/Hyperactivity Disorder.

If you need help and peer support, check with the National Alliance on Mental Illness. It offers a six-week course, “NAMI Basics,” which educates parents and puts them in touch with others in the same boat. Go to www.nami.org to find the chapter in your area.

Janis Thereault, of Santa Ana, Calif., whose adult son lives at home and has obsessive-compulsive disorder, searched the website of the International OCD Foundation (www.iocdf.org), which has affiliates around the country, and found local therapists specializing in the illness. They directed her to a support group.

After her son refused therapy for months, Thereault and her husband, Brian, followed the advice of one of the therapists: They told their son if he did not agree to counseling, they would evict him from the house. Members of the support group, some of whom had made similar decisions, offered them a sympathetic ear.

“It’s not an easy thing for us to do as parents,” Thereault says.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Sweetgreen Makes Healthful Fast Food — But Can You Afford It?

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Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.

Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.Credit Jason Henry for The New York Times

Healthful, fast and affordable food is the holy grail of the public health and nutrition community. A popular restaurant chain shows just how much of a challenge that is.

It began when three Georgetown University students were frustrated that they could not find a healthy fast-food restaurant near their campus. With money raised from family and friends, they started their own, renting a small storefront on M Street in Georgetown. The result was Sweetgreen, a restaurant that offered organic salads, wraps and frozen yogurt. Pretty soon, the daily line of lunchtime customers stretched out the door and around the corner.

Ten years later, the line is still there, but Sweetgreen has grown into a nationwide salad chain, with more than 40 locations. Sweetgreen is part of a small but growing breed of farm-to-table fast-food chains – like Chopt Creative Salad Company on the East Coast and Tender Greens in California – that are giving fast-food restaurants a plant-based makeover. Their mission: to fix fast food, which has long been fattening and heavily processed.

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At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.

At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.Credit Jason Henry for The New York Times

Sweetgreen’s owners say their goal is to offer customers foods made with nutritious, sustainable and locally grown ingredients. The company has decentralized its food sourcing and production. Fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site. They don’t sell soda or use refined sugar.
Sweetgreen expects to open another 20 stores in major cities around the country this year, and eventually to expand to places where experts say healthy, delicious fast food is needed most — low-income neighborhoods.

But while the chain has proven there is a big appetite for more healthful fast food, the goal of taking this concept to poor areas may be a distant reality. The company and other chains like it operate almost exclusively in affluent communities, far from the low-income food deserts where obesity is rampant and farmers’ markets and healthy food stores are scarce. And with salads that typically cost between $9 and $14, some question whether a healthful fast-food chain like Sweetgreen can ever be affordable for average Americans.

Maegan George, a Columbia University student who lives near a Sweetgreen, calculated that for the price of one Sweetgreen salad, she could buy the same ingredients in bulk at a local market and make several similar salads at home.

“I’m a first-generation student and I’m on full financial aid,” she said. “Sweetgreen is delicious and I enjoy it. But there’s no way I could afford to eat there on a regular basis.”

Jackie Hajdenberg, another Columbia student, wrote about the restaurant for the campus newspaper, The Spectator, earlier this year, lamenting that on a per calorie basis, a salad at Sweetgreen was three times the price of a Big Mac at McDonald’s.

“Sweetgreen has not only made it easier for people to make healthy decisions – it has also illustrated the unequal socioeconomic landscape of the world in which we live,” she wrote.

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Salad options at Sweetgreen change often, depending on what is available at local farms.

Salad options at Sweetgreen change often, depending on what is available at local farms.Credit Jason Henry for The New York Times

Sweetgreen says it prices its food so that it can compensate its suppliers and employees fairly, and that it expects nutritious fast food to become more affordable as the healthy food movement grows. Nicolas Jammet, a co-founder of Sweetgreen, said the company wants to serve lower-income customers, and has long-term plans to expand to low-income communities.

To get there, he said, the company will have to overcome hurdles involving its supply chain, the minimum wage and greater nutrition awareness and education among the public. For the past six years the company has been running a nutrition education program in schools that teaches children about healthier eating and locally grown food.

“It’s a long-term goal for us to be part of this larger systematic change that needs to happen,” he said. “But there are so many parts of this problem that need to be addressed.”

Mr. Jammet notes that the company was among the first to show that fast-food chains don’t need profits from soda and sugary drinks to succeed. He believes chains like Sweetgreen have caused a ripple effect throughout the fast-food industry.

In January, for example, Chick-fil-A unveiled a new kale, broccolini and nut “superfood” salad, responding to customer demands for “new tastes and healthier ways to eat in our restaurants.” McDonald’s is experimenting with kale salads, and Wendy’s is testing a spinach, chicken and quinoa salad.

“Companies like McDonald’s have more power to change the way that people eat than we do,” Mr. Jammet said. “We don’t see these companies as the enemy. We just have to force change on them.”

Public health experts say that such changes cannot come soon enough. A University of Toronto study recently showed that people have a higher risk of developing diabetes if they live in “food swamps” – an area with three or more fast-food restaurants and no healthy dining options.

Another study published in JAMA in June found that the percentage of Americans eating an unhealthy diet — high in sugar, refined grains, soft drinks and processed foods and low in fruits and vegetables — was on the decline, but the improvements in diet were much smaller for lower-income Americans.

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Customers wait in line at Sweetgreen in Berkeley, Calif.

Customers wait in line at Sweetgreen in Berkeley, Calif.Credit Jason Henry for The New York Times

Overall about twice as many people from poor households have poor diets compared to those at higher income levels.
Why is traditional fast food so cheap? One reason is the underlying infrastructure of the industry. Many of the ingredients, like the soy that’s turned into oil for deep fryers, or the the corn that’s fed to animals and used to make high-fructose corn syrup, begin with crops that are heavily subsidized by the government. To make their food economical, many traditional fast-food chains mass-produce their food in large factories, often stripping it of fiber and other nutrients that decrease its shelf life, while adding salt, sugar and other flavorings and preservatives.

Then they freeze and ship the processed components, like burger patties, bread, pickles and sauce, to their restaurants. There they are reheated and assembled, often with minimal effort, ensuring that a Big Mac in Seattle looks and tastes the same as a Big Mac in Charlotte, N.C.

By comparison, every Sweetgreen location has a chalkboard that lists the farms where its organic arugula, peaches, yogurt or blueberries are produced. As a result, the menus vary by location and by season. In Boston, Sweetgreen stores use New England Hubbard squash. In Los Angeles, the menu features a different variety of squash grown locally in California.

Those differences mean fresher, more nutritious ingredients, but ultimately costlier food for customers — one of the obstacles that Sweetgreen and other chains like it will have to overcome if they hope to make their food more accessible to all income brackets.
Marion Nestle, a professor of nutrition, food studies and public health at New York University and the author of “Food Politics,’’ says restaurants like Sweetgreen offer an encouraging, but imperfect, model for making fast food more healthful.

“What’s not to like?” she asks. “The cost, maybe, but for people who can afford it the quality is worth it. Next step: Moving the concept into low-income areas.”

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