Tagged California

Juul Hires Leading Teen Addiction Researcher As Medical Director

Juul Labs, the nation’s leading manufacturer of e-cigarettes, has hired as its medical director a prominent University of California researcher known for his work on the dangers nicotine poses for the adolescent brain.

The company said the hire will support its efforts to stem a teen vaping craze the Food and Drug Administration has labeled an epidemic. But critics see a cynical tactic taken straight from the Big Tobacco playbook.

Dr. Mark Rubinstein, a pediatrician and formerly a leading researcher with UC San Francisco’s Center for Tobacco Control Research and Education, took up the post of executive medical officer at Juul last week, a move first reported by Politico. Rubinstein has done signature research on teen addiction and how nicotine, which is present in high levels in e-cigarettes, affects adolescents. He has spoken openly of the potential risks of vaping for children.

In a statement, Juul said Rubinstein would oversee research on underage use of vapor products, guide the company’s youth prevention programs and policy positions, and help form links with the public health community. The company declined to make Rubinstein available for an interview. It says the move is part of its effort to reduce teen vaping while it continues to provide an alternative to smoking for adults.

Colleagues of Rubinstein, however, said they were disturbed by the move and skeptical of Juul’s motivations. At the heart of their concerns is whether Juul is willing to lose the giant base of teen users who have helped fuel the company’s meteoric rise and hefty market share.

Stanford University professor Bonnie Halpern-Felsher, who researches teen vaping and writes curriculum on teen prevention, helped train Rubinstein at UCSF. She said she was both incensed and disappointed when she heard about his move.

“Even if you believe in harm reduction,” she said, “to go work for a tobacco company … to me goes against everything that anybody doing control should believe in.” She said she is particularly concerned that a specialist on the effects of nicotine in adolescents has gone to work for the industry. Last year, Altria, one of the world’s largest cigarette makers, bought 35% of Juul for $12.8 billion.

Stanton Glantz, director of the Center for Tobacco Control Research and Education, concurred, saying he was “shocked and depressed” by Rubinstein’s decision to leave UCSF for Juul. He sees Juul’s early social media campaigns as evidence the company has intentionally marketed to teens. Research supports this claim, though the company denies it and has shut down its Facebook and Instagram presence.

Not everyone shares their skepticism. Dr. Neal Benowitz, a UCSF professor who has studied addiction and smoking cessation for decades, frequently published with Rubinstein. He said he is hopeful that e-cigarettes can help people quit smoking and wants them to remain on the market while more research is done. He was shocked by the job change but said that if anyone can help figure out strategies to reduce youth vaping, it’s Rubinstein.

Rubinstein’s hire comes as Juul works to gather evidence to submit to the FDA that its devices offer more public benefit than risk. If it fails to convince the agency, Juul could be prohibited from selling most of its products.

Under the Trump administration, the FDA, which has oversight of all tobacco products, originally gave e-cigarette manufacturers until 2022 to file applications for approval for their devices, but a federal judge recently advanced the deadline to 2020. Juul has been wooing prominent researchers in the lead-up to the deadline, but with limited success amid concerns about the company’s goals.

“Part of Juul’s strategy is to create credibility and buy influence by hiring everybody who would take their money. We shouldn’t be fooled: Juul created the youth e-cigarette epidemic and refuses to take responsibility for it,” said Vince Willmore, spokesman for the Campaign for Tobacco-Free Kids.

Some believe it will be a tall order for the companies to show that e-cigarettes are a net benefit, given what is known about the risks of teen vaping and how few studies there have been on their long-term efficacy to help people quit smoking. Others see the FDA’s relatively lenient approach to the industry so far as a sign it may take a more favorable view of the products.

The FDA last year labeled teen vaping an “epidemic,” noting federal survey data showed nearly 1 in 5 high school students had tried vaping in 2018. While not as harmful as older tobacco products, e-cigarettes contain high doses of nicotine and a variety of carcinogenic chemicals, according to Rubinstein’s research. When it comes to vaping, Juul is by far the biggest seller in the U.S., capturing an estimated 70% of the e-cigarette market.

Anti-tobacco activists contend Juul increasingly is drawing on the tactics of tobacco companies to push back against regulation of its products. They point to a recent Juul campaign to overturn restrictions on e-cigarettes and flavored tobacco in San Francisco, where the company is based.

Last month, a Juul-backed ballot proposal gathered enough signatures to make the city’s November ballot. The bill’s supporters claim it would strengthen regulations around adolescent access to tobacco products, while ensuring the devices are available to those who want to quit smoking. Opponents, including the city’s former attorney, say the measure would take away local control and peel back existing bans on flavored tobacco products and the sale of e-cigarettes until they are approved by the FDA.

“To us, Juul is Big Tobacco 2.0,” said John Schachter of the Campaign for Tobacco-Free Kids, asserting the company is using deceptive legislation to maintain the sale of its products.

Benowitz of UCSF disagreed with the comparison, saying he sees a big difference between Juul, whose products show legitimate potential to help people addicted to cigarettes, and the tobacco companies that predate it.

One question at the core of the concerns over Rubinstein’s move is whether research and prevention should come from within the industry. An internal research program is problematic, said David Michaels, a professor at George Washington University who has studied corporate attacks on the science underpinning environmental protection. “I understand why scientists are concerned about a program like this, and I think they should be,” he said.

E-cigarette manufacturers, not taxpayers, should fund research of their products, Michaels said, but the research must be completely independent of the company. Tobacco companies have long used scientists to manufacture uncertainty and defend products that have harmed public health, he said, and the research they produce in-house will always be called into question.


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

Employers Urged To Find New Ways To Address Workers’ Mental Health

In the middle of a work project at a global corporate consulting firm, Katherine Switz was gripped with a debilitating bout of anxiety. Her body froze, her heart raced, her chest tightened, and her mind went blank, which made it nearly impossible for her to concentrate on a computer screen and do her work.

The anxiety lasted three months, likely related to her bipolar disorder. During that time, she felt unable to ask for help from her employers or co-workers, afraid that her poor performance would get her fired or passed over for promotion.

“I didn’t know how to ask for help. I didn’t know what to do,” said Switz, 48, who was working as an associate business consultant in Washington, D.C., when the episode occurred.

While a diagnosis of cancer might garner sympathy at work and a casserole to take home to the family, an admission of a psychotic disorder might elicit judgment, fear and avoidance among co-workers. And even if such illnesses are not talked about much, 1 in 5 adults in the U.S. have a mental health disorder, and 1 in 22 adults live with a serious mental illness, such as schizophrenia, major depression or bipolar disorder, according to the National Institute of Mental Health.

The American Disabilities Act of 1990 prohibits discrimination against people with disabilities, which includes certain mental health conditions, and requires employers to provide reasonable accommodations to help them get their jobs done. Some employers also offer mental health support for employees through employee assistance programs, known as EAPs, which provide services such as short-term counseling and referrals to treatment for substance use.

Even with those federal protections and existing employer programs, some employees can be reluctant to ask for help at work. An estimated 8 in 10 workers with a mental health condition don’t get treatment because of the shame and stigma associated with it, according to the National Alliance on Mental Illness.

As a result, the pressure is growing on employers to adopt better strategies for dealing with mental health.

California has taken notice and last year passed legislation that makes it the first state to establish voluntary standards for workplace mental health.

Under the law, the state will create guidelines to help companies strengthen access to mental health care for their employees and reduce the stigma associated with it.

The measure aims to normalize workplace mental health in the same ways that employers already promote physical health, so that an employee having severe mental health symptoms feels comfortable taking medical leave, for example, just as a person with cancer might during periods of treatment and recovery.

The law was inspired by the California nonprofit group One Mind at Work. The organization had developed a charter of mental health principles to guide companies. But because the law doesn’t have any regulatory teeth, some companies may not see how investing in mental health will make them more competitive in the marketplace.

One Mind at Work offers an online calculator tool to estimate how much money they’re losing by not addressing mental health. The estimated annual loss of earnings tied to mental health conditions is at least $190 billion nationwide because of absenteeism and lost productivity.

“We want to show tangible economic proof that improving mental health in the workplace is good for business,” said One Mind at Work co-founder Garen Staglin, who is also a private equity investor.

The approach is working.

Sutter Health, Bank of America, Walgreens, Levi Strauss & Co. and the state of California are among the employers that have signed onto One Mind’s charter and have begun to include strategies to address mental wellness.

Some companies provide health coaches, mental health awareness training for managers and peer support groups in the workplace, hoping to build an atmosphere of understanding, so people feel comfortable talking about their conditions and asking for help. Some even have on-site meditation services and wellness centers to help employees access mental health resources, such as free counseling sessions, financial counseling and mobile apps that teach stress-management techniques.

San Francisco-based Levi Strauss & Co. has recently given employees access to counseling immediately after emergencies at work. And Sutter Health is creating an online mental health awareness course for all employees that will highlight what it is like to live with a mental illness.

Another way companies have been working to support employees is by pressuring their insurers to offer a more robust array of mental health benefits.

“Employers can often feel that they’re at the mercy of health plans. But employers have the power of the pocketbook,” said Angela Kimball, acting CEO of the National Alliance on Mental Health. “They have an enormous ability to change the market by simply demanding better.”

Switz now lives in Seattle and is executive director of the Stability Network, a nonprofit organization she founded to reduce mental health stigma in the workplace. The network is made up of a group of educated professionals who speak publicly about what it is like living and working with mental illness.

During Switz’s three-month bout with anxiety, she got a poor performance review and nearly lost her job. She was given three months to turn things around.

She was assigned to a more focused project that made it easier to manage her anxiety, plus the symptoms began to wane on their own, allowing her to perform like her old high-functioning self.

She said she knows that other people with mental conditions aren’t as fortunate as she was and get fired because they don’t get the help they need.

“People need to ask for accommodations to get better at times,” she said. “And that, I think, is a scary thing for people.”


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

As Temperatures Climb, A New Push To Keep Workers Safe

Last month, on a day that was sweltering even by Phoenix standards, Filiberto Lares knew he wasn’t well. An airline caterer, he said he had spent hours moving between the scalding tarmac and a truck with no air conditioning. Lares, 51, was dehydrated and fell ill with a fever that would keep him out of work for four unpaid days. It wasn’t the first time this had happened.

“Honestly, I never imagined I would live a situation like this in the United States, especially not in an industry as valued as the airlines,” he said in Spanish.

It’s a scene that plays out on airport tarmacs, in farm fields and on construction sites across the country: workers falling ill after laboring in hot or humid conditions for long hours without enough water and rest. Over the past decade, more than 350 workers nationwide have died from heat-related illness, according to data compiled by the U.S. Bureau of Labor Statistics. Tens of thousands have had heat-related illnesses serious enough that they missed at least one day of work.

For years, labor leaders have called on the federal government to create national regulations laying out steps employers must take to keep workers safe when it’s hot. On Wednesday, U.S. Reps. Judy Chu (D-Calif.) and Raúl Grijalva (D-Ariz.) introduced legislation that for the first time would require the Occupational Safety and Health Administration to create heat-related workplace standards.

Currently, just three states have heat-related labor standards: California and Washington, which protect outdoor workers; and Minnesota, which protects indoor workers. California’s regulations — developed more than a decade ago in response to a spate of farmworker deaths — are broadly considered the gold standard, and experts said the state’s experience is instructive in terms of what it would take for a national law to prevent thousands of injuries that occur each year.

“[Heat] is not an inconvenience or a nuisance,” said Marc Schenker, a professor at the University of California-Davis who researches the health effects of farm work. “It’s very real, with consequences that can range from minor to fatal.”

On the federal level, heat-related stress is regulated only by the general standard that employers must create safe working conditions. In the absence of specific regulations, that standard is difficult to enforce. In Lares’ case, he said his employer has a policy on the books that calls for a 10-minute break every two hours when temperatures rise above 95 degrees, and that trucks without air conditioning should not count as shade. But raising questions about enforcement with managers earned him only citations, he said, and his union had to step in to keep him from being fired.

The National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention, has recommendations for addressing workplace heat stress — but no mechanism for enforcement. The principles are fairly simple: Provide sufficient shade and rest when it’s hot (what’s considered hot depends on how hard the work is), as well as enough water to drink.

Because the majority of heat-related illnesses occur during the first few days on the job, employers should let workers acclimate and train them to spot signs of heat stress, according to the recommendations. That might have prevented the death of Miguel Angel Guzman Chavez, who died of heat stroke while picking tomatoes in Georgia last year just days after arriving in the United States.

California developed its heat standards in 2005, after 10 laborers, including four farmworkers, died from excessive heat exposure in a matter of months. The legislation requires water, rest and shade for outdoor workers, as well as education. At first, the state did little to enforce the law, said Leydy Rangel, a spokeswoman for the United Farm Workers Foundation. It wasn’t until several more farmworkers died, including a pregnant teen, and multiple lawsuits were filed that state regulators stepped up oversight, she said.

In 2015, the UFW received more than 50 complaints about heat-related violations and another farmworker, a father of three, died picking citrus. Complaints have steadily decreased since, though compliance remains an issue, Rangel said. Still, over the past two years, there have been no heat-related deaths among agricultural workers, according to state data.

Farmworker Vicente Reyes said he has seen just how much the statewide regulations have improved working conditions. He has worked the fields around Bakersfield since he was 11 and remembers that people used to hide if they were feeling sick or dizzy, afraid they would be sent away without pay. Now 19, and working and going to college full time, he said workers are told every morning they should rest if they need it and reminded throughout the day. They also are given shade and water.

There’s still room for improvement, he said, like having better access to cleaner bathrooms, but the difference is dramatic. “You used to see people dying,” he said. “Now, they are being more cautious.”

Despite improvements in California, home to the nation’s largest agricultural workforce, heat remains the leading threat to farmworker health. Across the country, other industries are hit hard as well, including construction, landscaping and postal delivery. For the population at large, heat is the leading weather risk, causing more deaths than hurricanes, tornadoes or flooding. The threat is expected to grow as the planet warms and heat waves become more intense and less predictable.

Florida, a top seller of ferns, citrus and tomatoes, offers a prime example of the dangers. Last year, temperatures soared above the thresholds considered safe for very heavy labor by NIOSH on more than 70% of days from May through September, in every Florida county, according to a report by Public Citizen, a nonprofit consumer advocacy group.

In 2015, Emory University researchers did a study involving Florida farmworkers, who were asked to ingest small devices, the size of a vitamin, that could track core body temperature. They found that 4 in 5 workers experienced body temperatures that exceeded the recommended limit of 100.4 degrees Fahrenheit on at least one of the three days they were monitored. And nearly 85% of the workers reported symptoms of heat-related illness, including dizziness, confusion, fainting, nausea and headaches.

“People focus on the deaths because they are so tragic and dramatic,” said Jeannie Economos, environmental health coordinator for the Farmworker Association of Florida and a collaborator on both the Public Citizen and Emory University studies. “But you don’t have to just wait for somebody to die to be concerned about heat. The heat is so debilitating in so many other ways.”

In the absence of federal standards, some employers have been implementing changes on their own with dramatic results.

A decade ago, the city of Waco, Texas, wanted to do something about the costly illnesses outdoor employees were experiencing due to heat. The central Texas city regularly experiences temperatures above 100 degrees. Workers paving roads or grooming city parks were falling ill, said Dr. Ronda McCarthy, city medical director at the time.

From 2011 to 2017, McCarthy’s team trained employees on prevention and screened workers for diseases such as diabetes or hypertension that might put them at increased risk for heat-related illness. Some people found to be susceptible had their duties adjusted until they got other health issues under control.

But the biggest changes came from working with managers to provide more breaks and ensure adequate water supplies, and to start the riskiest jobs earlier in the day when it was cooler, or swap out the hardest tasks more frequently.

By 2016, heat-related illnesses had essentially been cut to zero and median worker compensation costs were cut in half.

In 2005, congresswoman Chu was a member of the California State Assembly and championed the legislation that worker advocates now hold up as a model. That legislation, combined with the recommendations from NIOSH and practices used by the military, form the backbone of the minimum standards proposed in the new federal bill.

Public Citizen has rallied dozens of organizations in support of the legislation, saying climate change poses an urgent crisis for outdoor workers.

“As temperatures continue to rise, the problem is going to get worse,” said Shanna Devine, the organization’s worker health and safety advocate. “In some places, we’re going to lose the ability to work outside.”


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

Calif. Lawmakers Pass Bills To Stabilize Utilities After Wildfires, But Critics Call Law ‘A Reward For Monstrous Behavior’

The legislation is complicated and was quickly shepherded through the California Legislature with fears of the utility companies going bankrupt if something wasn’t done. The bill will provide investor-owned utilities with at least $21 billion to pay for damage from blazes linked to their equipment beginning this summer. Utility customers will be required to pay $10.5 billion to the so-called wildfire fund. Meanwhile, new data show the town of Paradise lost over 90% of its population since a wildfire killed 85 people last year.

Listen: Young Undocumented Californians Cheer Promise Of Health Benefits

Medicaid provides health care to low-income people. And California is set to be the first state to offer it to immigrants younger than 26 living there without legal permission. Starting in January, California will expand eligibility to include undocumented people ages 19 through 25. The change allows them to apply for full health coverage under Medi-Cal, the state’s version of Medicaid. It’s part of a bigger plan to eventually get everyone in the state covered. California is making the move at a time when other states and the Trump administration are trying to restrict who gets health benefits.

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

Hospitals Block ‘Surprise Billing’ Measure In California

Citing fierce pushback from hospitals, California lawmakers sidelined a bill Wednesday that would have protected some patients from surprise medical bills by limiting how much hospitals could charge them for emergency care.

The legislation, which contributed to the intense national conversation about surprise medical billing, was scheduled to be debated Wednesday in the state Senate Health Committee.

Instead, the bill’s author pulled it from consideration, vowing to bring it back next year.

“We are going after a practice that has generated billions of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu (D-San Francisco). “This certainly does not mean we’re done.”

Chiu said he and his team would keep working on amendments to the bill that address the concerns of hospitals while maintaining protections for patients.

Hospitals focused their opposition on a provision of the bill that would have limited what they can charge insurers for out-of-network emergency services, criticizing it as an unnecessary form of rate setting.

“Balance billing,” better known as surprise billing, occurs when a patient receives care from a doctor or hospital — or another provider — outside of her insurance plan’s network, and then the doctor or hospital bills the patient for the amount insurance didn’t cover. These bills can soar into the tens of thousands of dollars.

In the absence of federal laws, many states have tried to formulate solutions to balance billing, but health policy experts suggest this issue would be best addressed by the federal government.

Congress is discussing different approaches but not without facing fierce opposition and lobbying from two influential groups: health insurers and providers, including doctors and hospitals.

Last week, the Senate Health, Education, Labor and Pensions Committee passed the Lower Health Care Costs Act, which would require insurers to pay providers no more than the median in-network rate in a geographic region for emergency and nonemergency care. But the American Hospital Association deemed the payment arrangement unworkable.

Getting buy-in from hospitals and other providers will not be easy.

“The system exists in a way that allows a subset of providers to stay out-of-network and charge very high rates,” said Christen Linke Young, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy. “They’re basically exploiting the system.”

Chiu’s bill would have prohibited out-of-network hospitals from sending surprise bills to privately insured emergency patients. Instead, hospitals would have to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.

The bill also would have limited the amount hospitals could charge insurers for each service, and the amounts would have varied by region.

That’s the part hospitals opposed.

“We’ve said from the beginning that we are supportive of protecting patients. Unfortunately, the proponents of the bill inserted a completely unrelated provision regarding rate setting,” said Jan Emerson-Shea, a spokeswoman for the California Hospital Association.

Emerson-Shea said that if the state sets prices, health plans would have little incentive to negotiate contracts with hospitals. If this provision were removed, the hospital association would support Chiu’s bill, she said.

“That provision doesn’t need to be in the bill if the bill is really about protecting patients,” she said.

Chiu disagrees. Protecting patients from high costs and capping what insurers pay hospitals are “inextricably related,” Chiu said.

If this provision were removed, patients might still face high costs in the form of rising insurance premiums as insurers try to recoup their costs, Chiu said.

“It is useless to protect patients from receiving a bill on the front end if hospitals can turn around and price gouge consumers on the back end. It’s like closing your front door and leaving the back door wide open,” he said.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive nonemergency care.

But millions remain vulnerable to surprise bills, largely because California’s protections don’t cover all insurance plans.

Chiu’s bill was designed to close some of the loopholes. “It is disappointing it couldn’t get done this year” because more Californians will get hit with exorbitant balance bills in the meantime, he said.

The measure was prompted by the peculiar billing practices at Zuckerberg San Francisco General Hospital, located in his district.

Unlike most large hospitals, San Francisco General does not contract with private insurers. An investigation by Vox found that the hospital considered patients with private insurance out-of-network for emergency care and was slapping many of them with whopping bills. The hospital has since announced it has stopped balance billing patients.


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

With ACA’s Future In Peril, California Reins In Rising Health Insurance Premiums

Premiums on California’s health insurance exchange will rise by an average of 0.8% next year, the lowest increase in the agency’s history, state officials announced Tuesday.

Covered California Executive Director Peter Lee credited two new statewide initiatives for keeping the proposed rate hikes low: Next year, California will be the first state in the country to offer state-funded tax credits to middle-class enrollees, which will be paid for in part by a new tax penalty on Californians who don’t have health insurance.

“It shows what happens when a state says, ‘Protect the Affordable Care Act and build on it to make the system work for all Californians,’” Lee said.

Covered California estimates that the state-based tax credits, in conjunction with the new state tax penalty, will result in 229,000 newly insured Californians.

The average rate hike for 2020 is far lower than this year’s average increase of nearly 9% — and the five-year average increase of 8.4%. Covered California began offering health plans in 2014 to individuals and families who purchase their own insurance as part of the state’s implementation of the Affordable Care Act.

Most Covered California enrollees receive financial assistance based on their incomes.

California’s announcement of 2020 Obamacare rates comes at a precarious moment for the federal health law: Oral arguments were set to start Tuesday in a landmark lawsuit filed by a group of Republican attorneys general who want the entire health law overturned. The 5th Circuit Court of Appeals in New Orleans heard oral arguments in the case, known as Texas v. United States. California Attorney General Xavier Becerra is leading a group of Democratic attorneys general in defending the Affordable Care Act.

The Trump administration, through the Department of Justice, has declined to defend the law. Depending on what happens at the appeals court, the health law could reach the U.S. Supreme Court before the 2020 presidential election.

The Trump administration has taken other steps to hobble Obamacare, including shortening the annual open-enrollment period for the federally run health insurance exchange, healthcare.gov, and drastically slashing funding for enrollment outreach efforts. Administration officials have said that a replacement plan for Obamacare will be unveiled soon.

In addition to California, some other states have reported low rate increases or decreases for 2020. Washington state last month announced an average 0.96% increase for next year. Maryland announced an average 2.9% rate reduction for 2020. But some exchanges may continue to see more significant increases. Earlier this year, for example, New York proposed an 8.4% rate increase.

Matthew Fiedler, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy, said California’s “relatively subdued” rate increase shows that insurers expect the state’s new health insurance requirement and tax credits to help bring healthier people into the market — and are responding with lower premiums for consumers.

However, Fiedler said, “everything California is doing depends on the Affordable Care Act remaining in place.” Few if any states would be able to spend enough to make up for the elimination of federal tax credits that help some income-eligible people purchase health insurance, he said.

Lee said the 11 health insurers participating in Covered California would return next year, and Anthem Blue Cross, a national plan, will expand its offerings in the state. Anthem’s expansion comes after it pulled out of some regions in 2018. The insurer will expand into the Central Coast, parts of the Central Valley, Los Angeles County and the Inland Empire, Lee said.

Nearly all Californians will have a choice of at least two insurers, Lee said.

California is divided into 19 pricing regions, and not all 11 plans participating in the exchange next year will be offered in each region. In some regions, the rate increase will be higher than the statewide average. In others, it will be lower.

What consumers ultimately pay depends on where they live, their income, how much coverage they want and their choice of insurer.

The health exchange is expected to release proposed rates by region on July 17; state regulators must approve them.

Open enrollment for 2020 is expected to start in October. State lawmakers are weighing whether to extend the enrollment period to Jan. 31. Open enrollment for 2019 coverage ended on Jan. 15.

The 2017 Republican tax bill eliminated the federal tax penalty for not having insurance, which took effect this year. But California lawmakers recently agreed to implement a state-level insurance requirement and tax penalty, joining Massachusetts, New Jersey, Vermont and the District of Columbia.

The new individual mandate for Californians starts in 2020. The penalty for not having insurance will mirror the one under the Affordable Care Act, which was $695 per adult (and $347.50 per child under 18) or 2.5% of annual household income, whichever is greater. That can amount to thousands of dollars a year.

The revenue from the penalty, plus other state funds, will help pay for state-based tax credits for roughly 922,000 people who purchase insurance through Covered California. As part of the 2019-20 state budget signed by Gov. Gavin Newsom last month, the state will pledge $1.45 billion over the next three years for this effort.

Under the deal, California will become the first state to offer financial aid to middle-income enrollees who make between 400% and 600% of the federal poverty level — many of whom have been struggling to pay their premiums. That’s between about $50,000 and $75,000 a year for an individual and between about $103,000 and $154,500 for a family of four.

Under the Affordable Care Act, people who purchase plans through Covered California and other health insurance exchanges are eligible for federal tax credits only if they make between 138% and 400% of the federal poverty level. People who earn more than 400% of the federal poverty level get no federal aid.

The majority of the state-based financial aid would go to roughly 235,000 of these middle-income people. The average household tax credit in this category would be $172 per month, according to Covered California.

Some state financial aid will also go to 663,000 low-income enrollees who already qualify for federal tax credits. The average household tax credit for those who make between 200% and 400% of the federal poverty level — roughly between $25,000 and $50,000 for an individual and $51,500 and $103,000 for a family of four — would be $15 a month, Covered California estimated.

About 1.4 million state residents purchased health plans through the exchange this year, according to Covered California. In January, the agency announced that new enrollment fell by nearly a quarter, with 295,980 new sign-ups, compared with 388,344 last year. Plan renewals, on the other hand, increased by about 7.5%.

The decrease in new enrollment was steeper than expected for 2019 — and the agency blamed it primarily on the elimination of the federal tax penalty for not having insurance.

An analysis by the Kaiser Family Foundation earlier this year showed that older adults who earn just above the income cutoff, and live in rural areas, have an especially hard time affording their premiums. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

In California, older residents of far northern counties — such as Shasta and Modoc — and the Central Coast counties of Monterey and San Benito are among those who spend the highest percentage of their incomes on premiums, the analysis found.


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

New Hampshire Pumps Brakes On Medicaid Work Requirements After 17,000 Found To Be Non-Compliant In First Month

Gov. Chris Sununu is delaying the penalties tied into the legislation for 120 days as the state continues its outreach efforts to make people aware of the requirements. “Making sure we get this right is just absolutely paramount,” said Sununu. “So the idea of giving ourselves another 120 days to move forward on this and get the implementation where we need it to be, it’s not just fair to the system, but it’s fair to those individuals.” New Hampshire is just the latest state to struggle with the implementation of the work requirements.

Medi-Cal Enrollment Among Immigrant Kids Stalls, Then Falls. Is Fear To Blame?

As California prepares to expand Medicaid coverage to young adults living in the state illegally, the number of undocumented immigrant children in the program is slowly declining, new state data show.

Unauthorized immigrant children have been eligible for Medi-Cal, the state’s Medicaid program for low-income residents, since May 2016, and their enrollment peaked nearly a year later at 134,374, according to data from the state Department of Health Care Services.

Since then, enrollment has stayed mostly flat or fallen. Last February, the latest month for which data are available, 127,845 undocumented immigrant children through age 18 were enrolled in Medi-Cal, down about 5% from the April 2017 peak.

This drop mirrors statewide and national trends for all children enrolled in Medicaid and the Children’s Health Insurance Program, a separate public program that some states use to cover low-income children.

From December 2017 to December 2018, overall child enrollment in both programs dropped 2.2% nationally and 3% in California, according to a recent report from Georgetown University’s Health Policy Institute.

Some experts attribute the enrollment drop among all children to a strong economy because more people have jobs — and access to employer-sponsored health insurance. But Medicaid researchers say there are likely other factors at play for immigrant children.

The decline in their enrollment is more likely due to a shift in migration patterns and rising fear among their families in response to anti-immigrant rhetoric and federal crackdowns on unauthorized immigrants, said Edwin Park, a health policy research professor at Georgetown University.

“It’s likely the overall hostile environment for immigrant families is playing a critical role in enrollment,” Park said. “You should have seen a continued ramp-up” in sign-ups because the program is still relatively new. California along with Illinois, Massachusetts, New York, Oregon and Washington, plus the District of Columbia, provide public health coverage for undocumented immigrant children.

Last year, California allocated $365.2 million to cover these children. Even though Medicaid is a joint state-federal program, California must pay for the expanded benefits for unauthorized immigrants itself.

Starting next year, as part of the 2019-20 state budget signed last month by Gov. Gavin Newsom, the state will expand Medi-Cal coverage to young adult unauthorized immigrants ages 19 through 25. Officials estimate 90,000 young adults will join in the first year.

President Donald Trump criticized California’s move and threatened to “stop it.”

“The Democrats want to treat the illegals with health care and with other things, better than they treat the citizens of our country,” Trump said on July 1.

The state Department of Health Care Services, which administers Medi-Cal, said undocumented immigrant children might be leaving the program because they age out of eligibility when they turn 19 or move out of state.

Randy Capps, director of research at the Washington, D.C.-based Migration Policy Institute, said a shift in immigration patterns into and out of California could also affect their enrollment.

The number of people coming into the country illegally is down, especially from Mexico, according to a Pew Research Center report released in June. That is notable in California, where Mexican nationals make up the majority of the state’s undocumented immigrant population.

The report estimates there were 4.9 million unauthorized immigrants from Mexico in the U.S. in 2017, down from 6.9 million in 2007.

“All data suggest a downward trend on illegal immigration, especially of Mexican origin,” Capps said.

In California, “with the recent economic boom, that may be accelerating because the cost of living is escalating astronomically,” he said. “Housing is becoming prohibitively expensive for undocumented immigrants in large parts of the state.”

Although there have been an increasing number of Central American migrants trying to enter the U.S. at the southern border this year, most are claiming asylum and are not considered undocumented immigrants.

As a result, most of those children wouldn’t qualify for Medi-Cal under this program, explained Gabrielle Lessard, a staff attorney with the National Immigration Law Center.

But the rhetoric surrounding the Central American refugees has been heated, and Trump has made tough talk on immigration a centerpiece of his presidency.

Last month, Trump warned of “massive” deportation raids that would have targeted about 2,000 families — but they were postponed after he gave members of Congress time to make changes to asylum laws. He said the raids might begin this week.

His administration also has pursued policies targeting immigrants. For instance, last fall, the federal government introduced its “public charge” proposal, which would consider immigrants’ use of public benefit programs including Medi-Cal, CalFresh and Section 8 housing vouchers as a reason to deny lawful permanent residency — or green card status.

That proposed rule has not taken effect, and it’s not clear whether it will. If implemented, the policy would mostly affect legal immigrants, but it could also affect undocumented immigrants should they become eligible to seek legal status in the future.

In response, unauthorized immigrant families have been forgoing care, missing doctors’ appointments and asking whether they should disenroll from Medicaid coverage, health centers across California and the country have reported.

Lessard suspects that unauthorized immigrants could be pulling their children out of Medi-Cal or simply not renewing their coverage.

“This community has been so terrorized by the administration that people are afraid to show up to their appointments at health centers,” she said. “So the prospect of giving your information to the government, even though it’s the state government, is really terrifying to a lot of people.”


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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