Tagged California

Medicare Open Enrollment Is Complicated. Here’s How to Get Good Advice.

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”

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

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Consejos para inscribirse bien en Medicare durante la complicada inscripción abierta

Puede que hayas visto al actor Danny Glover o a Joe Namath, la leyenda de la NFL de 77 años, en comerciales de TV animándote a que llames a un número 800 para obtener fabulosos beneficios extra de Medicare.

Hay muchos otros anuncios de Medicare, algunos de ellos con un fondo rojo, blanco y azul para sugerir que son oficiales; aunque si te acercas a la pantalla del televisor, podrás ver que la letra chica dice que no están respaldados por ninguna agencia del gobierno.

En realidad, son agentes de seguros de salud compitiendo agresivamente por un pedazo de un mercado lucrativo.

A esto es a lo que ha llegado el período de inscripción anual de Medicare. Los beneficiarios —personas de 65 años o más, o con discapacidades a largo plazo— tienen hasta el 7 de diciembre para participar, cambiar o dejar los planes de salud o de medicamentos, que entran en vigencia el 1 de enero.

Al cambiar de plan, se podría ahorrar dinero o conseguir beneficios que normalmente no ofrece el programa federal.

A pesar de toda su complejidad y de sus opciones casi infinitas, Medicare se reduce fundamentalmente a dos alternativas: la clásica tarifa por servicio del Medicare Tradicional o el enfoque de atención administrada de Medicare Advantage.

La elección correcta para cada uno depende de los recursos financieros y del estado de salud, así como de los futuros escenarios de atención médica que a menudo son difíciles de pronosticar.

Los costos y beneficios entre la multitud de planes de Medicare que compiten entre sí varían, y el laberinto de normas y otros detalles puede resultar abrumador.

De hecho, la sobrecarga de información explica, en parte, porqué la mayoría de las más de 60 millones de personas que tienen Medicare, incluidos más de 6 millones en California, no hacen comparaciones ni se cambian a planes más adecuados.

“LLevo haciendo esto 33 años y mi cabeza todavía da vueltas”, dijo Jill Selby, vicepresidenta de iniciativas estratégicas y desarrollo de productos de SCAN, una organización sin fines de lucro de Long Beach que es una de las mayores proveedoras de cuidados administrados de Medicare de California, conocida como Medicare Advantage. “Definitivamente es un curso universitario”.

Esta es la razón por la que los medios de comunicación y los buzones de los correos electrónicos se abarrotan con publicidad de gente que se ofrece a ayudarle a aprobar “el curso”.

Muchos promocionan Medicare Advantage, que es administrado por aseguradoras de salud privadas. Puede que se ahorre dinero, pero no necesariamente, y las investigaciones sugieren que, en algunos casos, le cuesta al gobierno más que administrar el Medicare tradicional.

Pero el marketing no es necesariamente un signo de mala fe. Los agentes de seguros autorizados buscan la buena comisión que reciben cuando contratan a alguien, pero también pueden proporcionar información valiosa sobre los desconcertantes matices de Medicare.

Los conocedores de la industria y los expertos coinciden en que la mayoría de las personas no debería navegar solas por Medicare. “Es demasiado complicado”, asegura Mark Diel, director ejecutivo de California Coverage and Health Initiatives, una asociación estatal de organizaciones de alcance local y de inscripción en el cuidado de la salud.

Pero si la decisión es consultar con un agente de seguros, hay que mantenerse alerta. Pídeles a personas de confianza que te recomienden agentes, o visita eHealth o cualquier otra agencia en línea establecida. Pon a prueba al agente que elijas haciéndole preguntas por teléfono.

“Tenga cuidado si siente que el agente de seguros lo está presionando para que tome una decisión”, advierte Andrew Shea, vicepresidente de marketing de eHealth. Y si tienes dudas, busca una segunda opinión, aconseja Shea.

También puedes hablar con un consejero de Medicare a través de uno de los Programas Estatales de Asistencia de Seguros de Salud (SHIP), presentes en todos los estados. Encuentra el SHIP de su estado en www.shiptacenter.org.

Vale la pena leer Medicare & You, un manual completo. Descárgalo en el sitio web oficial de Medicare, www.medicare.gov.

El sitio web ofrece una inmersión profunda en todos los aspectos de Medicare. Si escribes tu código postal, puedes ver y comparar todos los planes de Medicare Advantage, los planes de seguro suplementario, conocidos como Medigap, y los planes de medicamentos (Parte D).

El sitio también te muestra las calificaciones de calidad de los planes, en una escala de cinco estrellas. Y los costos de tus medicamentos en cada plan. Explora el sitio web antes de hablar con un agente de seguros.

California Coverage y Health Initiatives puede remitirte a agentes de seguros autorizados que te proporcionarán asesoramiento local y asistencia para la inscripción. Llama al 833-720-2244. Sus miembros se especializan en ayudar a quienes son elegibles tanto para Medicare como para Medicaid, el programa de seguro de salud para personas de bajos ingresos.

Los llamados elegibles duales —casi 1.5 millones en California y cerca de 12 millones en todo el país— obtienen beneficios adicionales, y en algunos casos no tienen que pagar la prima médica mensual de Medicare (Parte B), que será de $148.50 en 2021 para la mayoría de los beneficiarios, pero más alta para las personas que superan ciertos umbrales de ingresos.

Si eliges el Medicare tradicional, considera un suplemento de Medigap si puedes pagarlo. Sin él, serás responsable del 20% de los costos de tu médico y de servicios ambulatorios, así como un elevado deducible de hospital, sin un límite a lo que pagas de tu propio bolsillo. Si necesitas medicamentos recetados, probablemente convendrá un plan de la Parte D.

Por su parte, Medicare Advantage es una ventanilla única. Por lo general, incluye un beneficio de medicamentos además de otros beneficios de Medicare, con un costo compartido para servicios y recetas que varía de un plan a otro. Los planes de Medicare Advantage suelen tener primas bajas o nulas, aparte de la prima de la Parte B que la mayoría de las personas paga en cualquiera de las dos versiones de Medicare. Y cada vez más ofrecen servicios adicionales, incluyendo visión, dental, transporte, entrega de comidas e incluso cobertura en el extranjero.

Pero ten cuidado con los riesgos.

Sí, la ruta tradicional de Medicare suele ser más cara al principio si deseas estar totalmente cubierto. Eso se debe a que pagas una prima mensual por una póliza Medigap, que puede costar $200 o más. Añade a eso la prima de la Parte D, estimada en un promedio de $41 al mes en 2021, según KFF. (KHN es un programa editorialmente independiente de KFF.)

Sin embargo, las pólizas Medigap a menudo te protegerán contra grandes facturas médicas si necesitas muchos cuidados.

En algunos casos, Medicare Advantage podría terminar siendo más caro si te enferma o lesionas gravemente, porque los copagos pueden sumar rápidamente. Por lo general, tienen un límite máximo cada año, pero aun así pueden costarte miles de dólares. Los planes Advantage también suelen tener redes de proveedores más limitadas, y los beneficios adicionales que ofrecen pueden estar sujetos a restricciones.

Más de un tercio de los beneficiarios de Medicare a nivel nacional están inscritos en los planes Advantage. En California, alrededor del 40%.

El principal atractivo del Medicare tradicional es que no tiene las reglas y restricciones de la atención médica administrada.

El doctor Mark Kalish, un psiquiatra retirado de San Diego, dijo que optó por el tradicional pago por servicio con Medigap y la Parte D porque no quería un plan en que tuviera que “pedir permiso”.

“Tengo 69 años, así que los ataques al corazón ocurren; el cáncer ocurre. Quiero poder elegir mi propio médico e ir a donde quiera”, señala Kalish. “Me ha ido bien en la vida, así que el dinero no es un problema para mí”.

Ten en cuenta que si no te inscribes en un plan Medigap durante el período de inscripción abierta de seis meses, que comienza cuando te inscribes en la Parte B de Medicare, se te podría negar la cobertura de una condición preexistente si intentas comprar una más tarde.

Hay algunas excepciones a esto en la ley federal, y cuatro estados —Nueva York, Massachusetts, Maine, Connecticut— exigen el acceso continuo o anual a la cobertura Medigap sin importar el estado de salud.

Asegúrate de entender las reglas y excepciones que aplican en tu caso.

De hecho, esa es una excelente regla general para todos los beneficiarios de Medicare. Lee y habla con los agentes de seguros y los consejeros de Medicare. Habla con amigos, familiares, tu médico, tu plan y otros planes de salud.

Cuando se trata de Medicare, dijo Erin Trish, directora adjunta del Centro Schaeffer de Política y Economía de la Salud de la Universidad del Sur de California, “se necesita de una comunidad”.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

California Law Banning Toxic Chemicals in Cosmetics Will Transform Industry

A toxic chemical ban signed into law in California will change the composition of cosmetics, shampoos, hair straighteners and other personal care products used by consumers across the country, industry officials and activists say.

The ban, signed by Gov. Gavin Newsom at the end of September, covers 24 chemicals, including mercury, formaldehyde and several types of per- and polyfluoroalkyl substances, known as PFAS. All the chemicals are carcinogenic or otherwise toxic — and advocates argue they have no place in beauty products.

When the law takes effect in 2025, it will mark the first major action to remove toxic substances from beauty products in almost a century. Federal regulation of cosmetics has not been updated meaningfully since 1938, and only 11 ingredients in personal care products are regulated by the Food and Drug Administration. By contrast, the European Union bans more than 1,600 cosmetic substances and ingredients from cosmetics.

The California law, passed by wide margins in both houses of the legislature, “is a milestone for cosmetic safety in the United States,” said Emily Rusch, executive director of the California Public Interest Research Group, which was heavily involved in shaping the bill.

The Personal Care Products Council, which represents big companies like Amway and Chanel, was hesitant but eventually supported the bill and worked directly with legislators on its final form. The industry’s buy-in will help give the California law national repercussions.

“If you’re doing business in the United States, you’re doing business in California,” said Mike Thompson, senior vice president for government affairs at the council. “I would assume that this would really, in many ways, set up a new standard.”

Breast Cancer Prevention Partners, another activist group, advocated strongly for the measure because many of the banned chemicals have been linked to breast cancer, said Janet Nudelman, the group’s director of program and policy.

For salon workers like Kristi Ramsburg, the bill could offer the peace of mind that comes from knowing her workplace is freer of toxics. Over the 20 years she’s worked as a hairdresser in Wilmington, North Carolina, Ramsburg has done hundreds of straightening jobs on her clients’ naturally frizzy hair. Performing the procedure known as a Brazilian Blowout three to four times a week exposed her to harsh and dangerous/toxic products including formaldehyde and phthalates.

She experienced “sore throats, dizziness. My vision changed, definitely,” she said. “You’d be almost crying at first.”

Studies dating to the early 1900s show that inhaling even small quantities of formaldehyde can lead to pneumonia or swelling of the liver. It’s been classified as a carcinogen, according to the FDA.

Ramsburg believes her exposure severely damaged her health. Over six years, she had surgeries to remove her gallbladder, ovaries and appendix. After her liver swelled dangerously, she suspected, based on medical consults and studies she read, that the formaldehyde she had been breathing for decades was to blame.

“I was just inundated with toxins constantly. I literally almost died,” she said.

Horror stories like Ramsburg’s are what motivated legislators, as well as the cosmetic industry, to support the California law.

Federal legislation that would have given the FDA more power to control or recall products containing the 11 federally regulated ingredients failed to gain traction in either chamber in recent sessions, despite the support of celebrities like Kourtney Kardashian.

Advocates say the inadequacies in federal regulation have been apparent for years. Current law does not require cosmetics to be reviewed and approved by the FDA before being sold to consumers. And the agency can take post-marketing action only if a cosmetic’s ingredients were found to be tampered with or its labeling is wrong or misleading.

The FDA couldn’t even intervene when asbestos was found in cosmetics sold at the youth-oriented Claire’s and Justice stores. In a 2019 letter, then-FDA Commissioner Scott Gottlieb wrote that his hands were tied because “there are currently no legal requirements for any cosmetic manufacturer marketing products to American consumers to test their products for safety.” No action was taken.

FDA scientists moved to ban formaldehyde from hair straighteners as early as 2016, according to internal agency emails, but weren’t successful. A 2019 study by government investigators found that using hair straighteners was linked with a higher risk of breast cancer, which rose with increased use. The study also found that using permanent hair dye was linked with an increased breast cancer risk.

After the federal legislation stalled, advocates changed their focus to California. The Golden State’s liberal leanings made it a likely place to pass a bill, while its status as the world’s fifth-largest economy meant any new law would have national impact. That has previously been the case, as when California set its own limits on car emissions or demanded nutrition labels for restaurant menus.

“It plays that pivotal role nationwide and has such a large economy, and so much of the cosmetic industry has a huge base here,” said Rusch, of the California Public Interest Research Group. “This type of landmark legislation has the effect essentially of setting a national standard. That was our intent.”

The Personal Care Products Council was open to the ban since the chemicals on the list — after some pruning during negotiations on the bill — include only those already prohibited in the European Union.

“You don’t want a patchwork of rules, either around the country or around the world. You want consistency,” Thompson said. “A lot of our companies may be already there, because they’re designing products for the European Union. … It’s just simpler for them to put out one product versus two.”

In recent years, growing consumer demand for transparency in beauty products has led to the development of a “clean cosmetics industry” whose products make up about 13% of high-end sales, double the percentage four years ago, according to the market research company NPD Group.

Drug and department stores have also increasingly moved toward “clean” products. CVS in 2019 removed parabens, phthalates and chemicals that contain or can give off formaldehyde from its store-brand products.

Advocates argue that the state law will force all companies to provide transparency and consistency about what, exactly, is in the products consumers put on their hair and faces.

“In order to ensure and give assurance to the public that the worst of the worst stuff is out of cosmetics, we felt we really needed to standardize and to put that into statute,” Rusch said.

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March 2020 (Heidi de Marco/KHN)
November 2020: Cars wait at the corner of Hollywood and Highland, a bustling intersection that was deserted in March. Some shops on Hollywood Boulevard are open to the public, but many remain shuttered. (Heidi de Marco/KHN)

On a Monday afternoon in March, four days after Gov. Gavin Newsom issued the nation’s first statewide stay-at-home order to slow the spread of the coronavirus, some of Southern California’s most famous landmarks were deserted and few cars traveled the region’s notoriously congested freeways.

Eight months later, businesses are open, traffic is back — and COVID-19 cases in the state are surging. 

“This is simply the fastest increase California has seen since the beginning of this pandemic,” Newsom said in a press conference Monday, when he announced a major rollback of the state’s reopening process, saying the state’s daily case numbers had doubled in the previous 10 days.

That same day, California Healthline’s Heidi de Marco returned to the landmarks she photographed in March. This time, it took her nearly two days — Monday and Tuesday — to document them because of traffic.

The biggest change was the greater number of vehicles on the road. Foot traffic had also stepped up, but most pedestrians and shoppers were wearing masks and not gathering in large numbers.

It turns out that activities such as strolling along the beach and window-shopping are not the primary way the disease is spreading in Los Angeles County. Public health officials there blame the surge on an increase in social gatherings, such as private dinners and sports-watching parties with people from multiple households, and the virus is spreading mostly among adults ages 18 to 29. In a bid to slow the virus, county public health director Barbara Ferrer announced additional restrictions on businesses, effective Friday. Among them, outdoor dining and drinking at restaurants and breweries will be limited to 50% of capacity, and outdoor gatherings can include only 15 people from no more than three households, including the host’s household.

March 2020 (Heidi de Marco/KHN)
November 2020: The TCL Chinese Theatre shops are open for business in Hollywood, but the theater itself is closed. (Heidi de Marco/KHN)
March 2020: Pedro Castro used to book about 20 bus tour tickets on Hollywood Boulevard per day, he said, but ticket sales fell dramatically right after the shutdown. (Heidi de Marco/KHN)
November 2020: The Hollywoodland Experience shop is empty Monday afternoon. The tour guide stationed outside the store, who didn’t want to be photographed or named, said business is steady but not nearly as heavy as before the pandemic. (Heidi de Marco/KHN)
March 2020 (Heidi de Marco/KHN)
November 2020: The Hollywood Freeway started to get busy at about 3:30 p.m. Monday and cars were moving fast. It was bumper-to-bumper by 5:30 p.m., hitting peak gridlock later than in pre-pandemic days — but still much busier than in March. (Heidi de Marco/KHN)
March 2020 (Heidi de Marco/KHN)
November 2020: Some shops on Olvera Street remain closed, but most restaurants are open and offer outside seating for customers. (Heidi de Marco/KHN)
March 2020: Ricardo Gaytan, a cook at Cielito Lindo on Olvera Street, said he feared that with only a few customers a day, the restaurant could close completely. (Heidi de Marco/KHN)
November 2020: Gaytan now wears a mask while working and stands behind a plexiglass barrier when taking orders. The restaurant has remained open during the pandemic, he said, and business is steady. He said he has had to deal with only a few customers who didn’t want to wear a mask. (Heidi de Marco/KHN)
March 2020 (Heidi de Marco/KHN)
November 2020: People wander through the Rodeo Drive Walk of Style in Beverly Hills, which is again open to the public. Most people wore masks as they visited the stores that were open. (Heidi de Marco/KHN)

November 2020: The city of Santa Monica has closed its famous pier to cars. (Heidi de Marco/KHN) November 2020: People are allowed to walk onto the pier as long as they wear a face covering.(Heidi de Marco/KHN) November 2020: Despite the haze, a handful of people work out at Muscle Beach in Santa Monica on Tuesday afternoon. (Heidi de Marco/KHN) November 2020: Beachgoers said they didn’t feel the need to wear a mask since they were outside, and because wearing a mask makes it harder to breathe while working out.(Heidi de Marco/KHN)

March 2020 (Heidi de Marco/KHN)
November 2020: There weren’t many customers at Randy’s Donuts in Inglewood on Tuesday, but the shop is hiring. (Heidi de Marco/KHN)

KHN correspondent Anna Almendrala contributed to this report.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN on the Air This Week

KHN Midwest correspondent Lauren Weber discussed COVID-19 surges in Wisconsin with Wisconsin Public Radio’s “Central Time” on Nov. 13.

California Healthline correspondent Angela Hart and editor Emily Bazar discussed how the Supreme Court case about the Affordable Care Act could affect California with the CalMatters and Capital Public Radio’s “California State of Mind” podcast.

KHN chief Washington correspondent Julie Rovner discussed open enrollment for ACA marketplace plans with Maine Public Radio’s “Maine Calling” on Monday.

KHN Midwest correspondent Cara Anthony discussed protections against race-based hair discrimination with KTVU Fox 2 on Tuesday.

KHN senior correspondent Liz Szabo discussed COVID vaccine candidates with Newsy on Tuesday.

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Push Is On in US to Figure Out South Asians’ High Heart Risks

For years, Sharad Acharya’s frequent hikes in the mountains outside Denver would leave him short of breath. But a real wake-up call came three years ago when he suddenly struggled to breathe while walking through an airport.

An electrocardiogram revealed that Acharya, a Nepali American from Broomfield, Colorado, had an irregular heartbeat on top of the high blood pressure he already knew about. He had to immediately undergo triple bypass surgery and get seven stents.

Acharya, now 54, thought of his late father and his many uncles who have had heart problems.

“It’s part of my genetics, for sure,” he said.

South Asian Americans — people with roots in Nepal, India, Pakistan, Sri Lanka, Bangladesh, Bhutan and the Maldives — have a disproportionately higher risk of heart disease and other cardiovascular ailments. Worldwide, South Asians account for 60% of all heart disease cases, even though — at 2 billion people — they make up only a quarter of the planet’s population.

In the United States, there’s increasing attention on these risks for Americans of South Asian descent, a growing population of about 5.4 million. Health care professionals attribute the problem to a mix of genetic, cultural and lifestyle influences — but researchers are advocating for more resources to fully understand it.

Rep. Pramila Jayapal (D-Wash.) is sponsoring legislation that would direct $5 million over the next five years toward research into heart disease among South Asian Americans and raising awareness of the issue. The bill passed the U.S. House in September and is up for consideration in the Senate.

The issue could gain more attention after Sen. Kamala Harris (D-Calif.) becomes the nation’s first vice president with South Asian lineage. Harris’ mother, Shyamala Gopalan, moved from India to the U.S. in 1958 to attend graduate school. Gopalan, a breast cancer researcher, died in 2009 of colon cancer.

A 2018 study for the American Heart Association found South Asian Americans are more likely to die of coronary heart disease than other Asian Americans and non-Hispanic white Americans. The study pointed to their high incidences of diabetes and prediabetes as risk factors, as well as high waist-to-hip ratios. People of South Asian descent have a higher tendency to gain visceral fat in the abdomen, which is associated with insulin resistance. They also were found to be less physically active than other ethnic groups in the U.S.

One of the nation’s largest undertakings to understand these risks is the Mediators of Atherosclerosis in South Asians Living in America study, which began in 2006. The MASALA researchers, from institutions such as Northwestern University and the University of California-San Francisco, have examined more than 1,100 South Asian American men and women ages 40-79 to better understand the prevalence and outcomes of cardiovascular disease. They stress that high blood pressure and diabetes are common in the community, even for people at normal weights.

That’s why, said Dr. Alka Kanaya, MASALA’s principal investigator and a professor at UCSF, South Asians cannot rely on traditional body mass index metrics, because BMI numbers considered normal could provide false reassurance to those who might still be at risk.

Kanaya recommends cardiac CT scans, which she said help identify high-risk patients, those who need to make more aggressive lifestyle changes and those who may need preventive medication.

Another risk factor, this one cultural, is diet. Some South Asian Americans are vegetarians, though it’s often a grain-heavy diet reliant on rice and flatbread. The AHA study found risks in such diets, which are high in refined carbohydrates and saturated fat.

“We have to understand the cultural nuances [with] an Indian vegetarian diet,” said Dr. Ronesh Sinha, author of “The South Asian Health Solution” and an internal medicine physician. “That means something totally different than … a Westerner who’s going to be consuming a lot of plant-based protein and tofu, eating lots of salads and things that typical South Asians don’t.”

But getting South Asians to change their eating habits can be challenging, because their culture expresses hospitality and love through food, according to Arnab Mukherjea, an associate professor of health sciences at California State University-East Bay. “One of the things South Asians tend to take a lot of pride in is transmitting cultural values and norms knowledge to the next generation,” Mukherjea said.

Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains.(Eli Imadali for KHN)

The intergenerational transmission goes both ways, according to MASALA researchers. Adult, second-generation South Asian Americans might be the key to helping those in the first generation who are resistant to change adopt healthier habits, according to Kanaya.

In the San Francisco Bay Area, El Camino Hospital’s South Asian Heart Center is one of the nation’s leading centers for educating the community. Its three locations are not far from Silicon Valley tech giants, which employ many South Asian Americans.

The center’s medical director, Dr. César Molina, said the center treats many relatively young patients of South Asian descent without typical risk factors for cardiovascular disease.

“It was like the typical 44-year-old engineer with a spouse and two kids showing up with a heart attack,” he said.

The South Asian Health Center helps patients make lifestyle changes through meditation, exercise, diet and sleep. The nearby Palo Alto Medical Foundation’s Prevention and Awareness for South Asians program and the Stanford South Asian Translational Heart Initiative provide medical support for the community. Even patients in the later stages of heart disease can be helped by lifestyle changes, Sinha said.

Dr. Kevin Shah, a University of Utah cardiologist who co-authored the AHA study, said people with diabetes, hypertension and obesity are also at higher risk of COVID-19 complications so should now especially work to improve their cardiovascular health and fitness.

In Colorado, Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains.

“Nowadays, I feel very, very good,” he said. “I’m hiking a lot.”

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California States

As Broad Shutdowns Return, Weary Californians Ask ‘Is This the Best We Can Do?’

SANTA CRUZ, Calif. — For Tom Davis, being told by the state this week that he must close his Pacific Edge Climbing Gym for the third time in six months is beyond frustrating. The first time the rock-climbing gym and fitness center shut down, co-owners Davis and Diane Russell took out a government loan to pay employees. The second time, they were forced to lay everyone off — themselves included. Now, as they face another surge of COVID cases across California, he fears he may lose the business for good.

California’s ping-ponging approach to managing the virus — twice reopening large portions of the service-sector economy only to shut them again — doesn’t seem just or reasonable, Davis said. As of Tuesday evening, he was planning to defy the order, keeping the gym open but with additional restrictions on capacity.

“The government is essentially saying, ‘We’re just picking you to personally go bankrupt and all the people who work with you,’” said Davis. “Nobody can afford to live in Santa Cruz on unemployment.”

It’s a grim time in the pandemic. California has surpassed 1 million cases of COVID-19 and 94% of Californians — more than 37.7 million people — live in a county considered to have “widespread” infection. Santa Cruz is one of 41 California counties now under the most restrictive orders in the state’s four-tiered COVID blueprint for determining which businesses can stay open amid the pandemic, and under what proscriptions.

(Blueprint for a Safer Economy/COVID19.ca.gov)

Until Monday, Santa Cruz was in the red tier — the second-most restrictive — meaning Pacific Edge could be open at 10% capacity. Now, its owners are being told to close entirely.

For business owners and workers, a backward slide on the blueprint represents yet another financial setback in a bleak year, leaving some residents angry, exasperated and wondering if this is really the best the state can do.

It’s a question reverberating nationwide as every state experiences a deadly rise in COVID cases and a growing number of hospitals say they are simply out of beds. Among states, California is performing relatively well, ranking 39th in cases per capita and 32nd in deaths, according to a New York Times tracker.

But even here, the virus is too pervasive in its spread — and the public health infrastructure too enfeebled — to make the reopening of businesses and schools an easy proposition. Some experts say that during a pandemic, when the virus is everywhere, the push and pull California businesses are enduring may be what success looks like in much of the U.S. for months to come.

“The yo-yo nature of this is a feature of the pandemic,” said Dr. Ashish Jha, dean of the School of Public Health at Brown University. “And in fact, when I look at really successful countries like South Korea, Taiwan and New Zealand, they all have a yo-yo feeling to them.”

Experts say a crucial factor in being able to reopen safely is getting cases low enough that time-tested public health tools like quarantines and contact tracing can work. Most U.S. hot spots, including broad swaths of California, have never achieved those low levels.

In California, Gov. Gavin Newsom, like many other governors, is trying to thread the needle, to keep cases to a minimum while also allowing many businesses to remain open. It’s a sensitive equation, said Dr. Aimee Sisson, public health officer for Yolo County.

“It’s really hard to dial in the balances of getting our economy going again, which is important for public health, and maintaining our health, which is important for the economy.”

And while California is doing better than many other states, said Cameron Kaiser, the health officer for Riverside County, it’s certainly not cause for celebration. “At this point we’re clearly doing better, but our trends are not good either. When you’re talking about the relative impact of different tragedies, I’m not sure you’d call that a success.”

Even as it frustrates some residents, California’s tiered reopening system has won praise nationally. The system draws on three COVID metrics to guide restrictions: new cases per population; the share of people tested for the coronavirus who are positive; and, in larger counties, an equity measure to ensure cases are low across the county, including in high-risk communities. Under revised guidelines released this week, county tier assignments can change from week to week — and more than once a week if data indicates a county is losing ground.

“We think it’s a best practice nationally and globally,” said Dr. Tom Frieden, a former director of the Centers for Disease Control and Prevention. “This is not about closure — this is about adjusting what is open when.”

Still, the state blueprint isn’t perfect, health officers say. In its early stages, there were inconsistencies around which businesses could stay open. For example, nail salons were treated differently from hair salons, though the exposure conditions are fairly similar. The state has taken feedback, said Sisson, and tried to make improvements.

And perhaps the biggest weakness is how little data exists to determine which businesses present the greatest risks for exposure and transmission, said Sisson and other health officers. While restaurants and bars are broadly considered high-risk because people remove their masks while eating and drinking, not much is known about viral spread at places like gyms and movie theaters, where it’s possible to reduce occupancy and wear masks.

That’s part of what frustrates Davis in Santa Cruz. Pacific Edge has reduced occupancy to just 30 people in the sprawling old factory building and instituted a range of protective measures. “Compare that to Costco. I honestly believe we are just as safe if not safer than other businesses,” Davis said.

Measuring California’s success in navigating the pandemic depends on what your goal is, said Marm Kilpatrick, an infectious disease researcher at the University of California-Santa Cruz who has been advising local government and businesses, including Pacific Edge, on reopening. The state has prioritized both keeping businesses open and keeping cases down, which means neither can be done perfectly.

Still, he’s not sure the whiplash of openings and closings is the best the state can do. He worries the tiered system may inadvertently send the wrong signals: Again and again, public health officials have watched in dismay as residents whose counties move into less-restrictive tiers revert to socializing in large groups and shedding basic safety protocols like masks and social distancing — followed by a dangerous upsurge in infections and hospitalizations.

Dr. Mark Ghaly, the state’s Health and Human Services secretary, has acknowledged as much, stressing that cases are linked to both social gatherings and businesses. Ultimately, he said on Monday, the state is taking a “dual approach” that includes changes to business practices, and asking individuals to be disciplined in wearing masks outside the home, regularly sanitizing hands, staying 6 feet apart, and socializing outdoors and in small gatherings.

Meanwhile, the holiday season looms. The most recent spike in cases directly correlates to Halloween, several health officers said, just as previous spikes were linked to Memorial Day, the Fourth of July and Labor Day. With Thanksgiving, Christmas and New Year’s on the horizon, officials wonder whether they might have to recommend a farther-reaching stay-at-home order to keep cases under control.

“I’m very worried about Thanksgiving,” said Dr. Chris Farnitano, health officer for Contra Costa County. “The tradition of so many families is to get together with their extended families, and that means gatherings with groups of people, and that’s where the virus wants to spread.”

In addition, Farnitano said, given the realities of commerce and travel, what happens in other states affects California. “Having other states with the same restrictions would help California,” he said.

What’s really needed, several public health officials said, is a coordinated national message and strategy.

“I’m hoping we’re gonna have the new president come in and take the reins very firmly,” said Steffanie Strathdee, associate dean of global health at UC-San Diego. “He has the right people around him advising him. But, by then, winter will be half over and we’re going to be facing 400,000 deaths. Digging ourselves out of that mess is going to take awhile.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Lo que los doctores no aprenden: a detectar el racismo en la atención médica

Betial Asmerom, estudiante de medicina de cuarto año en la Universidad de California-San Diego (UCSD), nunca había demostrado interés en ser doctora.

En su adolescencia, ayudó a sus padres, inmigrantes de Eritrea que hablaban poco inglés, a navegar el sistema de atención de salud en Oakland. Veía a médicos que eran irrespetuosos con su familia y que no se preocupaban por el tratamiento de la cirrosis, la hipertensión y la diabetes de su madre.

“Todas esas experiencias hicieron que no me gustaran los médicos”, dijo Asmerom.

“En mi comunidad siempre se decía: ‘Sólo ve al médico si estás a punto de morir’”.

Pero eso cambió cuando tomó un curso en la universidad sobre disparidades en salud. Se dio cuenta que otras comunidades de color sufrían lo mismo que su familia y amigos eritreos. Asmerom pensó que, como médica, podía ayudar a cambiar las cosas.

Hace tiempo que profesores y activistas estudiantiles de todo el país les piden a las escuelas de medicina que aumenten el número de estudiantes e instructores de comunidades poco representadas, para mejorar el tratamiento y fomentar la inclusión.

Pero para identificar las raíces del racismo y sus efectos en el sistema de salud, dicen, se deben hacer cambios fundamentales en los planes de estudio.

Asmerom es una de las muchas voces que piden una sólida educación antirracista. Exigen que las escuelas eliminen el uso de la raza como herramienta de diagnóstico, que reconozcan cómo el racismo sistémico perjudica a los pacientes, y que tengan en cuenta parte de la historia racista de la medicina.

Este activismo no es algo nuevo. White Coats for Black Lives (WC4BL), una organización dirigida por estudiantes que lucha contra el racismo en la medicina surgió a raíz de las protestas de Black Lives Matter en 2014.

Pero después del asesinato de George Floyd en Minneapolis, en mayo, las escuelas de medicina y las organizaciones médicas están bajo más presión para tomar medidas concretas.

Dejar de usar la raza como herramienta de diagnóstico

Durante muchos años, se ha enseñado a los estudiantes de medicina que las diferencias genéticas entre las razas tenían un efecto en la salud. Pero en los últimos años, estudios han encontrado que la raza no refleja eso de manera confiable.

El Instituto Nacional de Investigación del Genoma Humano observa muy poca variación genética entre las razas, y más diferencias entre las personas dentro de cada raza. Por eso, más médicos aceptan que la raza no es una diferencia biológica intrínseca, sino una construcción social.

Pero la doctora Brooke Cunningham, médica y socióloga en la Escuela de Medicina de la Universidad de Minnesota, señaló que en una idea difícil de abandonar. Forma parte de la manera en que los médicos diagnostican y miden las enfermedades, explicó.

Algunos médicos afirman que es útil tener en cuenta la raza cuando se trata a los pacientes; otros sostienen que conduce a prejuicios y a una atención deficiente.

Esas opiniones han llevado a una variedad de creencias falsas, como que los negros tienen la piel más gruesa, que su sangre se coagula más rápido que la de los blancos o que sienten menos dolor.

Cuando la raza interviene en los cálculos médicos, puede conducir a tratamientos menos eficaces y perpetuar las desigualdades basadas en la raza.

Uno de estos cálculos estima la función renal (eGFR, o la tasa estimada de filtración glomerular). El eGFR puede limitar el acceso de los pacientes negros a la atención médica porque el número utilizado para denotar la raza negra en la fórmula proporciona un resultado que sugiere que los riñones funcionan mejor de lo que lo hacen, según informaron recientemente los investigadores en el New England Journal of Medicine.

Entre otra docena de ejemplos que citan está una fórmula que los obstetras usan para determinar la probabilidad de un parto vaginal exitoso después de una cesárea, lo cual pone en desventaja a las pacientes negras no hispanas e hispanas, y un ajuste para medir la capacidad pulmonar usando un espirómetro, lo cual puede causar estimaciones inexactas de la función pulmonar para pacientes con asma o enfermedad pulmonar obstructiva crónica.

A la luz de estas investigaciones, los estudiantes de medicina piden a las escuelas que se replanteen los planes de estudio que tratan la raza como un factor de riesgo de enfermedad.

Briana Christophers, estudiante de segundo año en el Weill Cornell Medical College de Nueva York, dijo que no tiene sentido que la raza haga a alguien más propenso a las enfermedades, aunque los factores económicos y sociales jueguen un papel importante.

Naomi Nkinsi, estudiante de tercer año de la Escuela de Medicina de la Universidad de Washington en Seattle (UW Medicine), recordó haber asistido a una conferencia —junto a otras cuatro estudiantes negras en la sala— y haber oído que los negros son más propensos a enfermedades.

“Lo sentí muy personal”, expresó Nkinsi. “Ese es mi cuerpo, esos son mis padres, esos son mis hermanos. Ahora, cada vez que vaya a un consultorio, sentiré que no sólo no me consideran una persona completa, sino que soy físicamente diferente a todos los demás pacientes sólo porque tengo más melanina en la piel”.

Nkinsi ayudó en una exitosa campaña para excluir la raza del cálculo del eGFR en la UW Medicine, uniéndose a un pequeño número de otros sistemas de salud. Ella dijo que el logro, anunciado oficialmente a finales de mayo, se debió en gran parte a los incansables esfuerzos de los estudiantes negros.

Reconocer los efectos adversos del racismo en la salud

El Liaison Committee on Medical Education (LCME), órgano oficial de acreditación de las facultades de medicina de los Estados Unidos y Canadá, dice que se debe enseñar a los estudiantes a reconocer los prejuicios “en ellos mismos, en los demás y en el proceso de prestación de servicios de atención de la salud”.

Pero el LCME no exige explícitamente a las instituciones acreditadas que enseñen sobre el racismo sistémico en la medicina.

Esto es lo que los estudiantes y algunos profesores quieren cambiar.

El doctor David Acosta, jefe de diversidad e inclusión de la Asociación Americana de Escuelas de Medicina (AAMC, en inglés), reportó que cerca del 80% de las facultades ofrecen un curso obligatorio o electivo sobre disparidades en salud. Pero explicó que hay pocos datos sobre cuántas escuelas enseñan a los estudiantes a reconocer y combatir el racismo.

Un plan de estudios antirracista debería explorar formas de mitigar o eliminar el daño del racismo, indicó Rachel Hardeman, profesora de políticas de salud de la Universidad de Minnesota.

“Hay que pensar en cómo penetra esto en el aprendizaje de la educación médica”, dijo. Los cursos que profundizan en el racismo sistémico deben ser obligatorios, añadió Hardeman.

Edwin Lindo, profesor en la Escuela de Medicina de la Universidad de Washington, dijo que se debería adoptar un modelo interdisciplinario, permitiendo a sociólogos o historiadores dar conferencias sobre cómo el racismo perjudica la salud.

Acosta dijo que la AAMC ha organizado un comité de expertos para desarrollar un plan de estudios contra el racismo para cada nivel de la educación médica. Esperan hacer público su trabajo este mes y hablar con el LCME sobre el desarrollo e implementación de estándares.

“Nuestra próxima tarea es cómo persuadir e influenciar al LCME para que piense en añadir cursos de capacitación antirracista”, dijo Acosta.

Reconocer el racismo en el pasado y el presente de la educación médica

Los activistas quieren que sus instituciones reconozcan sus propios pasos en falso, así como el racismo que ha acompañado a los logros médicos del pasado.

Dereck Paul, estudiante de medicina en la Universidad de California-San Francisco, dijo que quiere que en todas las facultades se incluyan conferencias sobre personas como Henrietta Lacks, la mujer negra que se estaba muriendo de cáncer cuando le extrajeron células sin su consentimiento, que se utilizaron para desarrollar líneas celulares que han sido fundamentales en la investigación médica.

Asmerom puntualizó que quiere que la facultad reconozca el pasado racista de la medicina en las clases. Citó un curso introductorio de anatomía en su escuela que no señaló que en el pasado, cuando los científicos trataban de estudiar el cuerpo humano, los negros y otros grupos habían sido maltratados. “Es como, OK, ¿pero no vas a contar que sacaron de sus tumbas cuerpos de negros para usarlos en el laboratorio de anatomía?” preguntó.

Aunque a Asmerom le alegra ver que su facultad escucha las reivindicaciones estudiantiles, siente que los administradores deben reconocer sus errores del pasado reciente.

“Alguien tiene que admitir cómo se perpetuó el racismo anti-negro en esta institución”, dijo Asmerom.

Asmerom, una de las líderes de la Coalición Antirracista de la UCSD, aseguró que la administración ha respondido favorablemente hasta ahora a las demandas de la coalición de invertir tiempo y dinero en iniciativas antirracistas. Y se siente cautelosamente esperanzada.

“No me atrevo a aguantar la respiración hasta que vea cambios reales”, concluyó.

Related Topics

California Noticias En Español Public Health Race and Health

What Doctors Aren’t Always Taught: How to Spot Racism in Health Care

Betial Asmerom, a fourth-year medical student at the University of California-San Diego, didn’t have the slightest interest in becoming a doctor when she was growing up.

As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the health care system in Oakland, California. She saw physicians who were disrespectful to her family and uncaring about treatment for her mother’s cirrhosis, hypertension and diabetes.

“All of those experiences actually made me really dislike physicians,” Asmerom said. “Particularly in my community, the saying is, ‘You only go to the doctor if you’re about to die.’”

But that changed when she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too. Asmerom came to believe that as a doctor she could help turn things around.

Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism’s roots and its effects in the health system, they say, fundamental changes must be made in medical school curriculums.

Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine’s racist history.

This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests. But now, as with countless other U.S. institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action.

Debunking Race as a Diagnostic Tool

For many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very little genetic variation among races, and more differences among people within each race. Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.

Dr. Brooke Cunningham, a physician and sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It’s baked into the way doctors diagnose and measure illness, she said. Some physicians claim it is useful to take race into account when treating patients; others argue it leads to bias and poor care.

Those views have led to a variety of false beliefs, including that Black people have thicker skin, their blood coagulates more quickly than white people’s or they feel less pain.

When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate). The eGFR can limit Black patients’ access to care because the number used to denote Black race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.

In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.

Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.

“It was very personal,” Nkinsi said. “That’s my body, that’s my parents, that’s my siblings. Every time I go into a doctor’s office now, I’ll be reminded that they’re not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin.”

Nkinsi helped in a successful campaign to exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students’ tireless efforts.

Acknowledging Racism’s Adverse Effects on Health

The Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S. and Canada, said faculty must teach students to recognize bias “in themselves, in others, and in the health care delivery process.” But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.

This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities. But little data exists on how many schools teach students how to recognize and fight racism, he said.

An anti-racist curriculum should explore ways to mitigate or eliminate racism’s harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.

“It’s thinking about how do you infuse this across all of the learning in medical education, so that it’s not this sort of drop in the bucket, like, one-time thing,” she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.

Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.

Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.

“Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there,” Acosta said.

Recognizing Racism in Medical Education’s Past and Present

Activists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements. Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.

Asmerom said she wants to see faculty acknowledge medicine’s racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. “It’s like, OK, but you’re not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?” she said.

While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. “There needs to be an admission of how you perpetuated anti-Black racism at this institution,” Asmerom said.

Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition’s demands to pour time and money into anti-racist initiatives. She’s cautiously hopeful.

“But I’m not going to hold my breath until I see actual changes,” she said.

Related Topics

California Public Health Race and Health

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


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.


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.


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.


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.”