Mr. James was cold. An internal body temperature of 84.2 degrees Fahrenheit qualifies as severe hypothermia. When I first met him in the Emergency Department, his grey hair was poking out from under a warming blanket. Warm fluids were running through an IV into his veins and through a catheter into his bladder. He responded incoherently when I asked his name. His 67-year-old brain and body had frozen.
I ordered a battery of blood tests searching for the cause of Mr. James’ hypothermia. As I’d been taught in medical school, I considered infection, hypothyroidism, adrenal insufficiency, and carbon monoxide intoxication. All the tests came back normal.
It turns out Mr. James was cold from sleeping outside. Someone stole his blankets and the temperature dropped, a simple formula for hypothermia. He’d had three identical hospital admissions in the last year, each of which involved the same process: We warmed him up, gave him a few hot meals and a warm bed for the night, and then discharged him to the street with a taxi voucher to a homeless shelter. He walked out of the hospital and right back into the cold.
Discharged to the Street
As a resident, or doctor in training, one of my key roles is coordinating discharges from the hospital. Every time I sign a discharge order, I must select the patient’s destination from a dropdown menu of options including home and other levels of care such as skilled nursing facility. “Street” is not an option and yet this is where patients like Mr. James end up.
Treating and Streeting Vulnerable Patients - Inhumane and Ineffective
By: John Landefeld, MD MS
Healing is hard work for patients and clinicians, and leaving the hospital can be just the beginning of a long and complicated recovery process. As a physician, I care for many marginally-housed or homeless patients who struggle with managing antibiotics, wound care, physical therapy, or necessary follow-up appointments after they leave the hospital. Yet most hospitals discharge patients as soon as they are ‘medically clear’: when the wound is stitched, burn is treated, or heart stabilized after cardiac arrest. Homeless patients who still need care are often discharged to the streets or to waiting lines at shelters. A recent survey by the SF Homeless Coalition found that more than half of shelters reported hospitals routinely dropped off discharged patients who were still wearing hospital gowns, had open wounds, or injuries that were not fully treated. Some patients even had IV’s in their arms! Many of these people were confused, still in crisis, or in need of counseling.
The painful experience of my recent patient, Mr. “F”, illustrates this disturbing and increasingly common situation. Mr. “F”, a San Francisco native, is homeless. Due in part to the harsh reality of his life on the street, he developed a severe skin infection that required hospitalization, where I first met and cared for him. After several days, he no longer required IV antibiotics and had stabilized, but still needed several more days of oral antibiotics. To the health care system the hospital had done its job, and he was to be discharged in an all-too-familiar manner for many of our marginally-housed patients; dropped off to a line waiting for a jam-packed shelter, hoping to secure an open bed for the night.
Updated on January 8, 2018 to include recommendations made by Maternal and Child Health Access
We are excited to announce, in a joint statement with Asian Americans Advancing Justice-Los Angeles and Justice in Aging, that beginning January 1, 2018, adults with full-scope Medi-Cal have many dental benefits restored through Denti-Cal. This includes all pregnant women, regardless of immigration status, who are eligible for pregnancy-related Medi-Cal with full benefits.
The full restoration provides an important opportunity to educate California residents, especially Medi-Cal beneficiaries, about the additional dental benefits to ensure that beneficiaries are able to seek needed dental services.
Here are the major dental services available to adults through Medi-Cal, as of January 1, 2018. However, Denti-Cal continues to have a cap of $1,800 for covered services per year, although some services do not count towards the $1,800 cap and additional services can be covered if shown to be medically necessary. Adults with full-scope Medi-Cal can expect to receive a letter in the mail notifying them of these new benefits.
Tomorrow kicks-off the fifth year of open enrollment for coverage under the Affordable Care Act (ACA). In past years, the beginning of open enrollment coincided with a groundswell of digital, TV, radio, and in-person outreach. Instead, a few weeks ago the Trump administration announced a 90 percent cut in funds for open enrollment advertising and a 40 percent cut in grants for navigators who provide in-person enrollment assistance. We know that applying and selecting a health plan is a big decision for people. And this year—with all the attempts to repeal the ACA, cuts to subsidies paid to insurers, shorter enrollment period in many states, and the many insurers that have left ACA exchanges—the confusion is at an all-time high. CPEHN has created a fact sheet with some frequently asked questions that we've heard. Check it out here!
Yesterday, the GOP took the first step towards slashing health care from millions of people to fund a trillion dollar tax break for the wealthy. The House voted 216 to 212 to pass the Senate’s federal budget resolution with all 14 House Republicans from California supporting the plan despite a provision that will result in higher taxes on middle income earners in the state. That provision prompted 20 Republicans, primarily from New York and New Jersey to vote against their own party’s resolution. This latest vote clears the way for reconciliation, which replaces the Senate’s 60 vote threshold with a simple majority of 51 votes.
While yesterday's vote is disappointing, it is unfortunately not surprising. Despite the harm it will cause to their own constituents, California’s Congressional GOP delegation has voted again and again for massive cuts to Medicaid and this vote is no different. The latest tax proposal is actually a double whammy for Californians who will see their taxes increase due to the elimination of the state and local tax deduction (SALT) at the same time while their health care is threatened. In 2015, more than 6 million California taxpayers claimed the SALT deduction, which was worth $112.5 billion.
Proposed GOP Cuts to our Care The GOP’s health care attack list is long. Here are some of the ways the GOP budget will use health care to pay for a $1.5 trillion tax cut for the rich:
Medi-Cal, Medicare and Children’s Health Care Slashed
Over the past two days, California’s “Assembly Select Committee on Health Care Delivery Systems and Universal Coverage” heard testimony from key policy experts summarizing the state’s current health care delivery system and universal coverage systems around the world. Sarah de Guia, the California Pan Ethnic Health Network’s Executive Director issued this statement:
“California is closer to achieving universal coverage than ever before. Thanks to the Affordable Care Act (ACA), nearly 14 million Californians are enrolled in Medi-Cal and able to access preventive services, primary care, mental health, substance use treatment, and oral health care. Another 1.3 million Californians receive health care coverage including financial assistance through Covered California, our state’s ACA marketplace. More than 5 million Californians who were previously uninsured now have access to care thanks to the Affordable Care Act.
While we have made progress, our work is not done. 3 million Californians, a majority of whom are people of color and low-income, still lack health care coverage. In addition, stark disparities in health outcomes remain. For example, Black and Latino communities are more likely to have diabetes and to report poor mental health than White communities. CPEHN remains committed to achieving universal coverage and eliminating health disparities. We look forward to working with the Legislature to explore all options to achieve universal coverage and to make meaningful strides towards eliminating disparities in access to care and health outcomes in our state.”
The California Pan-Ethnic Health Network (CPEHN) is a statewide multicultural advocacy organization that works to improve the health of communities of color. Visit www.cpehn.org for more information.
October 15th marked the last day for Governor Brown to sign or veto bills passed during this legislative session. Of the 977 bills sent to his desk, Brown signed 859 bills and vetoed 118. CPEHN is proud to have 3 of our 4 sponsored bills among the bills signed:
CPEHN staff were tremendously saddened yesterday to learn of Brandon Harrison’s death. Last year, Brandon served as one of our powerful speakers at the Youth Leaders Plenary during CPEHN’s biennial conference. Kimberly Chen, CPEHN’s Government Affairs Manager, had the unique privilege of facilitating that conversation. Kim writes:
Brandon Harrison was one of several promising youth leaders I got to interview at last year’s CPEHN conference in Los Angeles. Brandon talked about the important work he was doing collecting data about youth homicides in Stockton and his work challenging policymakers including the Chief of Probation to adopt more restorative justice policies. He captivated the stage with charm and candor.
From the way he took control of the microphone to his fresh suit complete with a purple bowtie, Brandon had a mission and purpose – to share his story—and made sure we heard him. He was reflective about the cards stacked against him, yet insightful about the role he hoped to play as a leader for his community.
On Thursday, October 5, House Republicans took their first major step toward bankrolling tax cuts for the wealthy through devastating cuts to Medicaid and Medicare. In passing its budget resolution, the House promises to inflict $1.5 trillion cuts to Medicaid and $497 million to Medicare.
The House passed the budget resolution on a 219-206 vote.
While 19 Republicans joined Democrats to oppose the resolution, all California Republicans voted in favor of the proposal, which would lead to deep deficits in Medi-Cal, jeopardizing care for millions of beneficiaries.
The proposed cuts pave the way for the Republican tax reform plan that aims tax breaks largely at the wealthy. Middle and upper income families would see only modest gains while low income families will see safety net programs in health care and food assistance torn apart.