This week at CBPP, we focused on state budgets and taxes, the federal budget and taxes, the safety net, health care, Social Security, and the economy.
Better funding for schools leads to better long-term outcomes for students, a careful study concludes. That’s a timely and important message. As our new report shows, public investment in K-12 schools — crucial for communities to thrive and the economy to offer broad opportunity — has fallen dramatically in a number of states over the last decade.
Earlier this year, Dr. Joaquin Arambula, an emergency room physician from Selma, became the first Latino physician to serve in the State Assembly after being elected to represent the state’s 31st District — a central California agricultural region where the population is nearly 70 percent Latino.
Arambula said he ran for office partly because of the rapidly growing influx of Spanish-speaking patients in his emergency department. He sought reinforcements, “but there aren’t enough doctors with the cultural competency and understanding of the Latino community” to serve this growing population, Arambula said.
“This is something that needs to change,” he said.
Arambula and members of the Latino Physicians of California, a professional group that seeks to boost the number of Latino doctors in the state, spoke to reporters last week about the need for more representation of Latinos in the medical field.Use Our Content This story can be republished for free (details).
Latinos make up about 40 percent of the population in California — outnumbering any other ethnic-racial group, and they’re expected to constitute a majority of the state’s population by 2050. But only about 5 percent of all physicians in the state are Latino, according to the California Health Care Foundation. Latinos also represent 8 percent of nurses and about 4 percent of pharmacists, the group of physicians noted. (California Healthline is an editorially independent publication of the California Health Care Foundation.)
Adding to the need, more than one-third of Latino physicians plan to retire within the next 10 years, according to a new survey of the LPOC’s physician members.
This is especially pressing when Latinos make up a small percentage of students graduating from medical schools, said Dr. Jose Arevalo, chair of the Latino physicians group.
According to the Association of American Medical Colleges, 7 percent of medical school graduates in California identified as Latino in 2015.
“If we are going to properly serve our current and future patient base, we must begin to develop a true pipeline to bring in Latino physicians and health professionals to meet this growing need,” Arevalo said.
Arevalo and colleagues also pointed to a 2015 UCLA national study that showed a decline in the number of Latino physicians. In 1980, for example, there were an estimated 135 Latino doctors for every 100,000 Latinos in the U.S. By 2010, that ratio dropped to 105 per every 100,000.
Silvia Diego, a family doctor in Modesto, said Latino doctors simply are better equipped to serve the needs of Latino patients. Understanding the language and culture results in better health outcomes, she said.
“Latinos are very family-centric, we take care of our old, we learn traditional home remedies,” Diego said. “It’s difficult to establish a patient-doctor relationship if [doctors] don’t understand or dismiss cultural values.”
Interpreters can help patients understand doctors’ orders, Diego said, but that doesn’t help close gaps in patient-doctor relationships.
“And then we wonder,” she added, “why there are large health disparities among Latinos.”
She and her colleagues agreed: Most Latino patients, especially those who only speak Spanish, will seek the Latino doctors in their communities.
“But the few of us cannot take the many of them,” she said.
The problem is exacerbated in areas, such as the Central Valley, where the Latino population is known to struggle with chronic conditions, such as diabetes and obesity.
But the passage of the Medical DREAMER Opportunity Act in California may help more Latinos become doctors. The legislation, signed by Gov. Jerry Brown in September, allows students without papers pursuing medical professions to apply for state scholarships and loan forgiveness programs. The law goes into effect next year.
Medical education is expensive but is even more so for students in the country illegally because they are barred from receiving federal financial aid.
Dr. Catherine Lucey, vice dean for education at the University of California, San Francisco School of Medicine, said there are not enough scholarship opportunities for medical students in general. “Students are daunted with anticipated debt,” Lucey said, “and this does influence career decisions.”
This may be an even greater concern for first-generation students, who often are responsible for supporting their families financially.
UCSF’s School of Medicine, Lucey said, is pushing to diversify its student body with the help of pipeline medical education programs as well as through a more holistic approach to admissions. This encompasses taking into account more than just test scores but also the ability to communicate in a second language and a student’s environment. Currently Latinos make up about 20 percent of UCSF’s medical students, Lucey said.
“More diversity means health care quality is better, team science is better,” she said. “The medical education profession believes this.”
Nurse practitioner Kim Hamm talked in soothing tones to her 14-year-old patient as she inserted a form of long-acting contraception beneath the skin of the girl’s upper arm.
“This is the numbing medicine, so you’re going to feel me touch you here,” she said, taking the teen’s arm. “Little stick, one, two three, ouch. And then a little bit of burn.”
Hamm works at the Gaston County Teen Wellness Center, in Gastonia, N.C., which provides counseling, education and medical care. The teenager had already talked through her birth control options with another health care provider and chosen the implant — a flexible rod, about the size of a matchstick, that slowly releases low levels of hormones to prevent pregnancy.
“You’re going to feel tons of pressure here,” Hamm says, using a small device to insert the implant. “That’s it!”
And, in terms of preventing pregnancy, that will be it for the teen for the next several years.
Long-acting reversible contraception methods — including implant rods and intrauterine devices, or IUDs — are safe forms of birth control, and 99 percent effective, say specialists in reproductive medicine.They are endorsed by the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists as a good line of defense against teen pregnancy.This story is part of a partnership that includes WFAE, NPR and Kaiser Health News. It can be republished for free. (details)
But in the U.S., these long-acting, reversible devices are still not as frequently used by young women as elsewhere. They can be expensive, and problems with older versions of the devices — issues that have since been resolved — hurt their reputation. Only about 10 percent of American women use the devices, says Megan Kavanaugh a senior research scientist at the Guttmacher Institute, which studies reproductive issues.
“Some of the other developed countries that we look at are in the high teens, maybe low 20s in terms of percentage of use,” she said.
Kavanaugh said better provider training and patient education should lead to higher usage of the long-term devices in the United States.
That’s exactly what is happening in Gaston County, N.C., where clinics have seen usage rates climb to nearly 30 percent among teens. Since 2009, all providers in Gaston County clinics have been trained to insert the devices. The county uses federal funding to help cover the cost for the uninsured, which can be roughly $1,000 for an IUD.
Colorado is also subsidizing the cost of long-acting, reversible contraceptive methods, said Jody Camp of Colorado’s public health department, and has seen higher usage and subsequent drops in teen pregnancy and abortion.
“While we are not claiming full responsibility for all the decreases in these public health indicators, we do believe that our LARC investment made a huge impact on those,” Camp said.
Recently, the federal Department of Health and Human Services has started encouraging all states to make the methods more accessible through Medicaid, government insurance that covers many low-income women. The government is asking doctors to talk to their patients about long-acting reversible contraception and allowing higher reimbursement rates for the devices.
By using effective contraception to space out their children, teens and other young women can help reduce the risk of delivering a premature or low-birth-weight baby, research shows. And preventing unplanned pregnancies can be “essential to a woman’s long-term physical and emotional well-being,” according to HHS.
There are versions of the implants that can be left in place to prevent pregnancy for five or 10 years at a stretch. But women can also choose to get them removed whenever they want, and restore their fertility. Kie’Ja Phillips is from Gastonia and 19-years-old. She had the three-year implant in her arm before heading to college last year.
“I do not want to have children until I’m done getting my education,” she said. “I want to be able to provide for my children and give them a stable household — financially and emotionally and physically.”
Phillips also teaches her friends and other teens about their options. She says a lot of them know about the contraceptive pill, but very few about IUDs or implants.
“They have a lot of misconceptions and myths about it,” she said. “Like, ‘how am I supposed to get it out?’ You go to a doctor to get it out. You don’t take it out yourself. It’s just things like that — common misconceptions that people have.”
Last year, nearly 30 percent of teens who got contraception at the Gaston County clinics chose the long-acting kind.
Gaston County Medical Director Dr. Velma Taormina says the increased use of long-term contraception is a key reason the county’s teen pregnancy rate has been dropping faster than the state as a whole. Gaston County has also largely erased the disparity between African-Americans and whites in teen pregnancy rates.
“We feel very strongly that this is making a huge impact here,” Dr. Taormina said.
Medicaid in the state next-door — South Carolina — has also seen an increase in the use of these long-acting reversible contraceptives. In 2012, the state implemented a new way of paying hospitals so medical providers could offer and insert long-acting reversible contraception right after a woman gives birth, which the nation’s leading obstetrician’s group says can be a “particularly favorable time.”
Staff with the Palmetto Health-University of South Carolina School of Medicine in Columbia demonstrated the procedure to health care providers recently in its SimCOACH, which is basically a truck outfitted, for training purposes, with two hospital rooms and high-tech mannequins that can simulate a variety of birth outcomes. Palmetto Health drives the coach around the state to teach hospital staff about a variety of procedures and topics, including contraception.
“The IUD is inserted 10 minutes after delivery of the placenta when a patient has had a vaginal delivery,” Dr. Judy Burgis said.
B.Z. Giese is director of the South Carolina Birth Outcomes Initiative, a project within the state’s department of health and human services. Giese says the choice to have an IUD or implant inserted is always completely up to the woman, and only after she’s consulted with a health care provider. But the reason obstetricians within her program started offering it immediately after birth is simple: About half of women on Medicaid who gave birth weren’t showing up to their postpartum visit.
“We were missing a lot of moms who did not come back,” Giese says. “And, actually, the next time the doctor saw them, they came back pregnant with another child.”
Ana Walker, an 18-year-old in Columbia, S.C., chose to have an implant that lasts three years inserted in her arm. Walker got the implant after giving birth to her daughter Bella. She said she likes that she won’t have to remember to take a pill every day.
“Right when I heard about it, I went for it,” she says.
Breanna Martin, who is 20 and also lives in Columbia, recently chose an IUD after she had her baby. Martin said the device puts her in control of her fertility.
“That’s the wonderful thing about it,” she said. “If I want to wait five years, I’m protected for five years. And if I want to have kids sooner, then I can get it taken out.”
Giese calls getting the device after childbirth a win-win for the baby and the mom. “It is a cost savings,” she said. “It is a convenience for the mom. The satisfaction rate of the moms that we know leaving the hospital is extremely high.”
Now, she says, at some hospitals in South Carolina, around a third of new mothers leave with an IUD or implant in place. That number, Giese says, was basically zero just a few years back.
AUSTIN — Peggy Wall, a family nurse practitioner at a local community health center, treats many women in their 40s, who already have a family and find themselves confronting an accidental pregnancy.
Many, she says, wish they had taken preventive steps after their last child was born and could be good candidates for getting an intrauterine device in the delivery room, immediately after giving birth. Until recently, that sort of IUD access has been difficult to come by.
“Some of them have chaotic lives — or they think they won’t be insured,” she said. “We try to help them.”
Soon, she said, that should become easier.
Health officials are trying to rebuild the state’s women’s health program, a complicated project launched after Texas in 2011 cut funds for family planning that had been going to Planned Parenthood and other clinics affiliated — even loosely — with abortion providers. As part of the new program, the state is trying to bolster low-income women’s access to birth control to curb unintended pregnancies.
Nationally, about half of pregnancies are unintended. And Texas is one of nearly two dozen states changing their Medicaid programs, the federal-state insurance plan for low-income people, to pay hospitals for inserting an IUD or contraceptive implant in the delivery room. In the past, most Medicaid program generally offered a set payment for labor and delivery and didn’t include an option for payment for the IUD insertion.
States hope to keep women healthier, especially since doctors advise spacing pregnancies at least 18 months apart. They’re betting the upfront investment will pay off.This KHN story also ran in The Texas Tribune. It can be republished for free (details).
So far, 20 states plus the District of Columbia are promoting the option, while others such as Oregon, Pennsylvania and Tennessee are considering it. The federal Centers for Medicare & Medicaid Services this spring began urging states to adopt the payment practice. The Centers for Disease Control and Prevention has singled out immediate post-partum insertion of long acting birth control as key in curbing unintended pregnancy. Organizations such as the American College of Obstetricians and Gynecologists (ACOG) and the Association for State and Territorial Health Officers are also on board.
“It just makes so much sense — from a patient-care standpoint, and from a dollars standpoint,” said Melissa Gerber, president of AccessMatters, a Pennsylvania-based organization advocating for the change there.
Only recently have IUDs, which are reversible and 99 percent effective, come into vogue among public health experts. But the high price tag has kept many people from using the devices, which can cost nearly $1,000 up-front even though hormonal ones last for up to six years. Many patients and doctors also remain skittish because of residual fear after the Dalkon Shield caused health problems for many women in the 1970s. That’s one of the reasons why many doctors never learned to insert the devices or counsel patients about them, even though current versions of the device don’t bring those same health risks.
Younger OB-GYNs are more likely to be familiar with IUDs, but even they often aren’t fluent in the post-labor procedure, which is done as soon as 10 minutes after delivery. It isn’t difficult, experts said, but is different.
Until recently, doctors usually waited to discuss an IUD or implant until a woman’s first postnatal checkup, six weeks after delivery. But between 10 percent and 40 percent of women never show up for this exam. In Travis County, which includes Austin, it’s more like 60 percent for women on Medicaid, estimated Dr. Ted Held, director of reproductive health at People’s Community Clinic. That is why the delivery room option is viewed by many as an opportunity.
But for this approach to have an impact, local governments, hospitals and doctors all need to make extra effort. That means training doctors, adapting hospital infrastructures and ensuring patients get proper counseling — so that they get the contraception treatment only if they want it, and can have a device removed if they change their mind.
And no one yet knows how to make that all happen, experts said.
“This is too fresh. Too new. Everyone is trying to figure it out,” said Dr. Stephanie Teal, a professor of obstetrics and gynecology at the University of Colorado, in Aurora, who helped lead that state’s efforts.
Colorado was among the first to change its Medicaid reimbursement for this procedure, and its experience shows the switch’s potential. In three years, the state recovered the investment more than six times over.
Still, getting health care providers trained in the process is important. Data is limited, but surveys in Colorado suggests doctors and midwives responsible for delivery often aren’t comfortable performing the immediate postpartum procedure. Similar findings have been documented in Massachusetts.
“There is definitely going to be a need for training,” said Dr. Michelle Moniz, an assistant professor of obstetrics and gynecology at the University of Michigan, who has researched the subject.
Texas has created a training toolkit that hospitals can use to educate their medical staffs. ACOG is sending doctors around the country to do the same. But without such instruction — particularly when it comes to sensitive, thorough counseling about the device’s benefits, without pressing it upon patients — the post-delivery IUD cannot be a clinical option, Held said.
But many hospitals — especially rural ones — don’t have the time or resources to take this on, noted Dr. Daniel Grossman, an obstetrician-gynecologist at the University of California, San Francisco, who researches reproductive health. Smaller facilities without medical residency programs may struggle in building a critical mass of knowledgeable doctors. Buying IUDs upfront and keeping them on hand can pose a financial burden, even if Medicaid dollars will eventually come through.
“These devices aren’t inexpensive. They have to be purchased in advance, they need to be stocked, they need to be easily accessible,” said Lisa Waddell, the chief program officer of community health and prevention at the state health officers’ association, who has worked extensively with states to bolster IUD access.
Meanwhile, Catholic hospitals, which typically treat a significant number of low-income patients, don’t provide birth control in house. For states making IUDs quick and convenient, Teal said, that poses a hurdle.
“Catholic hospitals do put up barriers — that’s the elephant in the room,” she said.
And the timing of discussing IUD implants is also an issue. Ideally, doctors said, this decision-making process should begin early in pregnancy. But efforts to encourage that dialogue highlight gaps in low-income women’s access to prenatal care.
Federal data suggests maybe 15 percent of women get inadequate prenatal care, and 6 percent get none at all. Those women will not have had IUD counseling, and there isn’t time during delivery, Waddell noted.
Follow-up care also can be of concern if women later want to get pregnant and need the device removed, or have other complications that require medical attention. They may lose access to care thanks to income switches or other life changes, and many are no longer eligible for Medicaid after their pregnancy is over.
But still, advocates see promise. In South Carolina, which made the switch in 2012, in-hospital insertions of IUDs and implants increased by more than 100 percent between the 2013 and 2015 fiscal years, according to data tracked by the state health officers’ association. Delaware saw 271 insertions between March 2015, when it made this adjustment, and this past August.
Research suggests Texas will see a similar kind of demand, Held said.
“It’s not hard to find a story where a patient hasn’t gotten served,” Held said. “We want to make sure that access is broad — and that all women have access to this.”
Researchers have discovered a piece in the puzzle of how the Zika virus spreads in human cells and neutralizes the body’s defenses.
A study by scientists at the University of California, San Diego School of Medicine answered a fundamental question posed by biologists: What happens when the virus enters a human cell?
Zika infections lead to modifications in the genetic material of both the virus itself and humans’ immune systems, influencing the virus’ spread and the body’s immune response, according to the researchers. Their study was published Thursday in Cell Host & Microbe.This KHN story also ran in USA Today. It can be republished for free (details).
While humans’ genetic material is made up of DNA and RNA, some viruses’ genomes — including Zika and HIV — are comprised only of RNA. In humans, RNA carries genetic information from DNA to create new cells.
Researchers found that when the Zika virus infected a human cell, the cell modified viral RNA to get rid of the infection. But that adaptation triggered human enzymes that may have impacted the cell’s protective shield. The Zika infection also induced modifications on human RNA, according to the study.
Changing viral RNA let the virus “hide in plain sight,” said Tariq Rana, the lead author of the study and a professor of pediatrics at UC San Diego.KHN Zika Coverage Click Here To Read More Of KHN’s Zika Coverage
That discovery probably won’t help find a vaccine for Zika, but it could contribute to the discovery of drugs to prevent birth defects in some babies born to women who contracted the virus while pregnant, said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston. He was not involved in the study.
It might also help scientists develop drugs in the future that can specifically target and stop Zika from changing RNA, Rana said.
And understanding how Zika changes RNA opens the door to studying when fetuses are harmed during pregnancies and what potential risk factors may be, said Amesh Adalja, a senior associate at the Center for Health Security, part of the University of Pittsburgh Medical Center.
The research may be a key to understanding how Zika causes so much damage to a developing fetus, said Adalja, who was also not part of the study.
“What you’re seeing with Zika is science progressing at breakneck speed to discover mysteries about this virus that no one paid attention to for decades and decades,” Adalja said.