Abortion

After Election Win, California’s AG Turns to Investigating Hospital Algorithms for Racial Bias

SACRAMENTO, Calif. — California Attorney General Rob Bonta sailed to victory in the Nov. 8 election, riding his progressive record on reproductive rights, gun control, and social justice reform. As he charts a course for his next four years, the 50-year-old Democrat wants to target racial discrimination in health care, including through an investigation of software programs and decision-making tools used by hospitals to treat patients.

Bonta, the first Filipino American to serve as the state’s top prosecutor, asked 30 hospital CEOs in August for a list of the commercial software programs their facilities use to support clinical decisions, schedule operating rooms, and guide billing practices. In exchange, he offered them confidentiality. His goal, Bonta told KHN, is to identify algorithms that may direct more attention and resources to white patients than to minorities, widening racial disparities in health care access, quality, and outcomes.

“Unequal access to our health care system needs to be combated and reversed, not carried forward and propagated, and algorithms have the power to do either,” Bonta said.

It’s too early to know what Bonta will find, and his office will not name the hospitals involved. The California Hospital Association said in a statement that such bias “has absolutely no place in medical treatment provided to any patient in any care setting” and declined to comment further.

Advocates have high hopes for what Bonta will find — and for the next four years. “We expect to see a lot more from him in this full term,” said Ron Coleman Baeza, managing director of policy for the California Pan-Ethnic Health Network. “There is much more work to do.”

Last year, Gov. Gavin Newsom appointed Bonta as attorney general after Xavier Becerra left the position to join the Biden administration as secretary of the U.S. Department of Health and Human Services. In the Nov. 8 election, which won him his first full term, Bonta faced Republican challenger Nathan Hochman, a former federal prosecutor who campaigned on prosecuting violent criminals and pulling the deadly synthetic opioid fentanyl off the streets. In contrast, Bonta advocated for gun control and decriminalizing lower-level drug offenses, and in January advised law enforcement officials not to prosecute women for murder when a fetus dies, even if their drug use contributed to the death.

In unofficial results, Bonta had about 59% of the statewide vote, compared with 41% for Hochman.

Bonta, formerly a state legislator representing the East Bay, will be eligible to run for a second full term, which could allow him to serve for nearly 10 years.

His wife, Democratic state Assembly member Mia Bonta, was among the public officials who discussed their abortion experiences after a leaked draft of a U.S. Supreme Court opinion that was published in May revealed the justices would likely repeal Roe v. Wade. After they did, the attorney general threatened legal action against local jurisdictions that tried to adopt abortion bans.

Bonta called health care a right for all Californians and said he wanted to help people of color and low-income communities get more access to doctors and treatments, as well as better care. “It’s something I’ve been actively working on as an elected official my entire career, and even before that,” said Bonta, whose father helped organize health clinics for Central Valley farmworkers.

But health equity remains an elusive goal, even as it has become a catchphrase among advocates, researchers, politicians, and health care executives. And as with most aspects of the state’s mammoth health care system, progress comes slowly.

The Newsom administration, for example, will require managed-care plans that sign new Medicaid contracts to hire a chief equity officer and pledge to reduce health disparities, including in pediatric and maternal care. The state’s Medicaid program, known as Medi-Cal, serves nearly 15 million people — most of whom are people of color. But those changes won’t come until 2024, at the earliest.

State lawmakers are also trying to minimize racial discrimination through legislation. In 2019, for example, they passed a law that mandates implicit bias training for health care providers serving pregnant women. Black women are three times as likely to die from having a baby as white women.

In recent years, researchers started warning that racial discrimination was baked into the diagnostic algorithms that doctors use to guide their treatment decisions. One model predicted a lower rate of success for vaginal births among Black and Hispanic women who previously had a cesarean delivery than among white women, but failed to take into account patients’ marital status and insurance type, both of which can affect the success rate of a vaginal birth. Another, used by urologists, assigned Black patients coming into emergency rooms with “flank pain” a lower likelihood of having kidney stones than non-Black patients — even though the software’s developers failed to explain why.

Some researchers likened such medical algorithms to risk assessment tools used in the criminal justice system, which can lead to higher bail amounts and longer prison sentences for Black defendants. “If the underlying data reflect racist social structures, then their use in predictive tools cements racism into practice and policy,” they wrote in the New England Journal of Medicine in 2020.

Bonta is seeking the hospital industry’s cooperation in his algorithm investigation by framing racial and ethnic disparities as injustices that require intervention. He said he believes that his inquiry is the first of its kind and that it falls under the California Department of Justice’s responsibility to protect civil rights and consumers. “We have a lot of depth,” he said of his 4,500-employee agency.

Coleman Baeza and other advocates for health care consumers said the attorney general should also monitor nonprofit hospital mergers to ensure that health care facilities don’t reduce beds in underserved communities and crack down on predatory medical lending, particularly in dental care.

“They violate existing consumer protections, and that falls squarely within the AG’s jurisdiction,” said Linda Nguy, a senior policy advocate for the Western Center on Law and Poverty.

Nguy urged Bonta to go after underperforming health plans when they fail to contract with enough providers so patients can get timely appointments, even though the California Department of Managed Health Care is the state’s main health insurance regulator.

“During covid, the health plans were essentially given a pause on reporting of their timely access. But that pause is over, and the plans have to meet these requirements,” Nguy said. “He can ask for that utilization data.”

Bonta remains circumspect on a particular issue related to race.

His office has been facilitating California’s reparations task force, which issued a nearly 500-page preliminary report this year that noted that Black Californians had shorter life expectancies and poorer health outcomes than other groups. In surveys of hospitals across the country, Black patients with heart disease “receive older, cheaper, and more conservative treatments” than white patients, the report said.

The task force could recommend cash compensation for Black Californians who can establish ties to enslaved ancestors, but Bonta hasn’t endorsed that plan. The final report is due in July.

“If we can move the needle, then we should,” Bonta said. “There are a whole set of different possible solutions, pathways to get there.”

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

Mark Kreidler:

@MarkKreidler

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Abortion

Patient Mistrust and Poor Access Hamper Federal Efforts to Overhaul Family Planning

JACKSON, Miss. — Two years ago, after an emergency cesarean section at a Mississippi hospital, Sherika Trader was denied a tubal ligation. Trader, now 33, was told that to have her tubes tied, she had to have a second child or a husband’s permission, even though she wasn’t married.

Jasymin Shepherd had heavy menstrual cycles because of a birth control pill prescribed after the birth of her son 13 years ago. The symptoms continued even after she stopped taking the medication. Last year, a doctor in Jackson responded by offering Shepherd, 33, a hysterectomy, which she didn’t want.

The experiences left the women feeling as though providers acted like “robots,” or, worse, they felt stereotyped. Black women already face major barriers to accessing health care, including provider shortages and racial bias rooted in the medical system.

But with contraceptive care, which deals with deeply personal patient preferences, they must also contend with providers who dismiss their concerns. Decisions about whether — or when — to have a baby and how to prevent pregnancy are not as standardized as care for other conditions. Yet providers hand out prescriptions or recommendations while disregarding a patient’s specific circumstances, Shepherd said.

Late last year, the White House made new recommendations for a federal program that provides funding for free contraceptives, wellness exams, and certain cancer screenings. Health officials want to regain the trust of patients like Trader and Shepherd, who feel as though their doctors don’t always listen to them. The goal of the Title X program, which distributes grants to states and other groups for family planning, is to let patients dictate the care they want, said Jessica Marcella, who is the deputy assistant secretary for population affairs at the U.S. Department of Health and Human Services and oversees the Title X program.

“Our belief, and that of the family planning field, is that it is essential that you respect the interests, needs, and values of a client,” she said. Providers shouldn’t force patients to take a birth control method because it’s more effective, she said, or deny them a particular method because they think a patient might want more kids.

“What we don’t want is a provider to create trauma or do unintentional harm,” Marcella said.

In Mississippi, efforts to implement that approach have started with a change in who gets to administer the Title X funds, taking that responsibility from the state and giving it to a four-year-old Jackson-based nonprofit named Converge. The Biden administration’s decision this year to give Converge the $4.5 million grant marks the first time in four decades that Mississippi’s health department hasn’t won the federal family-planning grant.

Converge doesn’t offer family planning services. Instead, the group provides funding to a network of clinics statewide, organizes provider training, helps clinics navigate technology challenges, and keeps them stocked with supplies. For example, when a provider was having trouble printing out a survey that patients took about their contraception preferences, Converge co-founder and co-director Jamie Bardwell shipped the clinic a wireless printer.

Jamie Bardwell (left) and Danielle Lampton co-founded Converge, a nonprofit that administers federal family-planning funds in Mississippi through a grant it won earlier this year.(Nico Hopkins)

But across the South, the attempt to change the culture of family planning care faces old and new obstacles. Some are deeply rooted in the medical system, such as the bias long faced by Black women and other women of color. In addition, contraception care is limited in the conservative South, and the Supreme Court’s June decision to overturn Roe v. Wade has led to the curtailing of abortion access across much of the region.

Black women often feel disrespected and dismissed by their providers, said Kelsey Holt, an associate professor of family and community medicine at the University of California-San Francisco. She co-authored a 2022 study in the journal Contraception in which dozens of Black women in Mississippi were interviewed about their experiences getting contraceptives.

Women told researchers that they struggled to get appointments, faced long wait times, and had to put up with condescending behavior. Many of the women said providers didn’t inform them about alternatives to the contraceptive Depo-Provera, a progestin shot administered once every three months, despite the known side effects and the availability of other, more appropriate options.

Trying to undo decades of such damage — and overhaul how providers deliver family planning care — became even more difficult after the Supreme Court decision and the closure of abortion clinics across the South. Suddenly, women in Mississippi, Alabama, and about a dozen other states could no longer get abortions.

“A major service has been cut off,” said Usha Ranji, associate director for women’s health policy at KFF. Title X funds cannot be used — and have never been used — to pay for abortions. But, she said, clinics can no longer present abortion as an option, hampering their ability to provide comprehensive counseling, a key requirement of the Title X program.

Many Mississippians can’t afford to travel across state lines to terminate an unwanted pregnancy. In 2020, 84% of Title X clients in the U.S. had incomes at or below 200% of the federal poverty level, and 39% were uninsured. Even women in Mississippi with the means to travel will face hurdles in nearby states, like Georgia and Florida, where abortion is not fully banned but access has been scaled back.

Even before the Supreme Court decision, access to family planning care in Mississippi came with hurdles and judgment.

In 2017, when Mia, who didn’t want her last name used for fear of legal and social repercussions, became pregnant for the second time, she called the local health department in Hattiesburg for advice on obtaining an abortion. She had a daughter and wasn’t financially or mentally prepared to have another child. The health department contact sent Mia to a faith-based, anti-abortion center.

“I felt judged,” Mia said about the call. Eventually, she terminated the pregnancy in Jackson, about 90 miles away, at the state’s sole abortion clinic, which closed in July. “Ultimately, I did what was best for me,” said Mia, who went on to have a son several years after the abortion.

The loss of abortion care in Mississippi puts more pressure on family planning providers to win the trust of their patients, said Danielle Lampton, who also co-founded Converge. Patient-centered care is the “bedrock of what we do,” Lampton said.

Both Trader and Shepherd serve on Converge’s patient experience council and receive occasional stipends for providing their perspectives to the nonprofit.

Providers shouldn’t force or pressure low-income patients to use long-term contraception, such as an intrauterine device, to safeguard against pregnancy, said Dr. Christine Dehlendorf, a family physician and researcher at UCSF, who is advising Converge.

Wyconda Thomas, a family nurse practitioner, opened a clinic four years ago in Gunnison, Mississippi, a town of only a few hundred people. Thomas lets patients’ life circumstances, their history, and their needs determine what type of contraception she prescribes.(Haleigh Brooke Thomas McGee)

Pressuring Black women to use IUDs, implants, and other long-term contraception is reminiscent of a history in which Black women were sterilized against their consent, she said. Even today, studies show that providers are more likely to pressure women of color to limit the size of their families and recommend IUDs to them. These women also have a harder time getting a provider to remove the devices and getting insurance to cover the removal cost, Dehlendorf said.

Too often, Wyconda Thomas, a family nurse practitioner near the Arkansas border, meets patients who are skeptical of birth control because of a bad experience. Many of her patients continued Depo-Provera shots even after they gained an unsafe amount of weight — a known side effect — because they weren’t offered other options.

Even if patients come in for another reason, Thomas talks to them about family planning “every chance I get,” she said. Four years ago, Thomas opened the Healthy Living Family Medical Center in Gunnison, a 300-person town that is 80% Black. The clinic receives Title X funds through Converge. Still, Thomas doesn’t force contraception on patients — she respects their decision to forgo a pill, patch, or implant.

But Title X funds help Thomas stock a variety of contraception methods so patients don’t have to worry about driving to a separate pharmacy.

“My job for them is to get them to understand that there are more methods and there’s no method at all,” Thomas said. “And that’s a whole visit by itself.”

Renuka Rayasam:
rrayasam@kff.org,
@renurayasam

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Courts

Voluntarios electorales quieren que los latinos sepan que votar es bueno para su salud

HUNTINGTON PARK, California. – Jonathan Flores pasó un sábado soleado de fines de octubre tocando a las puertas de los votantes registrados en esta ciudad de clase trabajadora, predominantemente latina, en el sureste del condado de Los Ángeles.

La mayoría de las personas no estaban en casa o no abrían la puerta. Algunos de los que sí atendieron expresaron fuertes opiniones sobre Joe Biden y Donald Trump, y se interesaron por las iniciativas a favor del aborto y del aire limpio que estarán en la boleta electoral de California el 8 de noviembre.

Un joven rechazó a Flores y dijo que dudaba de que su voto fuera contado.

Al igual que los otros voluntarios enviados ese día por AltaMed, una gran cadena de clínicas comunitarias, Flores tenía puesta una gorra de béisbol negra y una camiseta con las leyendas: “My vote. Mi health”; y, abajo, en español, “Mi voto. Mi salud”.

Su misión era instar a los residentes a votar, incluso si nunca lo habían hecho, para que pudieran estar representados de manera justa en el ayuntamiento, en Sacramento y más allá.

“Siento que he visto comunidades –personas que se parecen a mí, a mis padres–, que luchan mucho”, dijo Flores, de 31 años, cuya madre y padre nacieron en México y ahora viven en el Valle Central.  “Entonces, llegar a ellos, al centro de esos problemas, es básicamente lo que me llevó a hacer esto”.

En los últimos años, las instituciones de atención de salud a lo largo de todo Estados Unidos han realizado esfuerzos para promover el voto, inspiradas por la creciente creencia de que votar mejora la salud de las personas y las comunidades.

La American Medical Association respalda esta idea. En esta elección, AltaMed, con un departamento de compromiso cívico activo, se ha enfocado en más de un cuarto de millón de votantes registrados en los condados de Los Ángeles y Orange, la mayoría de ellos en comunidades latinas. Ha ofrecido espacios para votar por adelantado en una docena de clínicas, y planea movilizar voluntarios hasta el día de las elecciones.

“Nuestros problemas a menudo se desencadenan, o se exacerban, por factores de nuestra vida diaria, el aire que respiramos, el lugar donde vivimos, los alimentos que comemos”, dijo Aliya Bhatia, directora ejecutiva de Vot-ER, una organización sin fines de lucro que trabaja con 700 hospitales y clínicas en todo el país, incluido AltaMed, para alentar a los pacientes y al personal a votar. “El trabajo de Vot-ER ayuda a los pacientes a ser parte de un proceso, de avanzar, para dar forma a esas políticas que afectan nuestra salud”.

Votar puede ser un desafío en las comunidades latinas a pesar de su potencial como fuerza electoral. La población latina se ha cuadruplicado en las últimas cuatro décadas y ahora comprende el 19% de la población de los Estados Unidos. En California, los latinos representan más del 39% de la población, superando a los blancos no hispanos, y convirtiéndolos en el grupo étnico o racial más grande del estado.

Sin embargo, la participación electoral entre los latinos continúa a la zaga de otros grupos. Su participación en las elecciones de 2020 estuvo más de 14 puntos porcentuales por debajo de la población total en edad de votar del estado, según datos del Center for Inclusive Democracy de la Escuela de Políticas Públicas Sol Price de la Universidad del Sur de California. […]

California

Election Canvassers Want Latinos to Know Voting Is Good for Their Health

HUNTINGTON PARK, Calif. — Jonathan Flores spent a sunny Saturday in late October knocking on the doors of registered voters in this predominantly Latino working-class town in southeastern Los Angeles County. Most people weren’t home or didn’t come to the door. Some of those who did expressed strong opinions about Joe Biden and Donald Trump and took an interest in abortion rights and clean-air initiatives on the California ballot for the Nov. 8 election. One young man gave Flores the brush-off, saying he doubted his vote would be counted.

Like the other canvassers sent out that day by AltaMed Health Services Corp., a large chain of community clinics, Flores sported a black baseball cap and a T-shirt emblazoned with “My Vote. My Health.” Underneath, it read the same in Spanish, “Mi Voto. Mi Salud.” His mission was to urge residents to cast their ballots, even if they had never voted, so they could be fairly represented in city hall, Sacramento, and beyond.

“I feel like I’ve seen communities — people who look like me, like my parents — struggle through so much,” said Flores, 31, whose mother and father were born in Mexico and now live in the Central Valley. “So reaching out to them at the core of those issues is basically what got me doing this.”

Health care institutions across the United States have mounted get-out-the-vote efforts in recent years, inspired by a growing belief that voting improves the health of individuals and communities. The American Medical Association has endorsed that idea. AltaMed, with an active civic engagement department, has targeted more than a quarter-million registered voters in Los Angeles and Orange counties this election, most of them in Latino communities. It has offered early voting at a dozen clinics and plans to send canvassers out right up until Election Day.

“Our problems are often triggered — or exacerbated — by factors in our daily lives, whether it’s the air we breathe, where we live, the food we eat,” said Aliya Bhatia, executive director of Vot-ER, a nonprofit organization that works with 700 hospitals and clinics around the U.S., including AltaMed, to encourage patients and staff members to vote. “Vot-ER’s work helps patients be part of a process of going upstream to shape those policies that impact our health.”

Getting out the vote can be challenging in Latino communities despite their potential as an electoral force. The Latino population has quadrupled in the last four decades and now constitutes 19% of the U.S. population. In California, Latinos account for over 39% of the population, exceeding the share of non-Hispanic whites and making them the state’s largest ethnic or racial group.

However, voter participation among Latinos continues to trail other groups. Their turnout in the 2020 election was more than 14 percentage points below that of the state’s eligible voter population, according to data from the Center for Inclusive Democracy at the University of Southern California’s Sol Price School of Public Policy.

Researchers and Latino advocacy groups cite various factors that inhibit Latino voting, including feelings of cultural and linguistic marginalization, a mistrust of government, a disproportionately high poverty rate, and a younger-than-average population. Another key factor, they said, is a lack of outreach by political campaigns and other election organizations.

In a recent poll by the Latino Community Foundation, 71% of California Latino residents said they had not been contacted by a political party, campaign, or other organization this year.

“It makes a difference in whether they are actually going to turn out to vote,” said Mindy Romero, director of the Center for Inclusive Democracy.

In neighboring Los Angeles, mayoral candidate Rick Caruso, a billionaire developer, has made a strong effort to court Latinos, which could play a decisive role in his race to lead a city where they account for nearly half the population. After trailing by a double-digit margin early on, Caruso has pulled even with his opponent, U.S. Rep. Karen Bass, according to a recent poll published by the Southern California News Group.

Notably, 43.7% of Latino voters said they would back Caruso, compared with 29.4% for Bass.

“He is meeting us where we are, at our businesses, where we shop, where we eat. He is telling us he sees us and he hears us,” said Nilza Serrano, president of the Avance Democratic Club, a Latino organization in L.A. County that has drawn scrutiny over its endorsement of Caruso. “I think our community is fed up and a little exhausted from not being heard.” […]

Audio

Knoxville’s Black Community Endured Deeply Rooted Racism. Now There Is Medical Debt.

KNOXVILLE, Tenn. — When Dr. H.M. Green opened his new medical office building on East Vine Avenue in 1922, Black residents of this city on the Tennessee River could be seen only in the basement of Knoxville General Hospital. They were barred from the city’s other three medical centers.

Green, one of America’s leading Black physicians, spent his life working to end health inequities like this. He installed an X-ray machine, an operating room, and a private infirmary in his building to serve Black patients. On the first floor was a pharmacy.

Today the Green Medical Arts Building has been replaced by a tangle of freeways that were built after the city’s Black business district was bulldozed in a midcentury urban renewal project.

But the health gaps Green labored to narrow still divide this community. And if segregation is less apparent in medical offices today, its legacy lives on in crushing medical debt that disproportionately burdens this city’s Black community.

In and around Knoxville, residents of predominantly Black neighborhoods are more than twice as likely as those in largely white neighborhoods to owe money for medical bills, Urban Institute credit bureau data shows, one of the widest racial disparities in the country.

That tracks with a disturbing national trend. Health care debt in the U.S. now affects more than 100 million people, a KHN-NPR investigation found. But the toll has been especially high on Black communities: 56% of Black adults owe money for a medical or dental bill, compared with 37% of white adults, according to a nationwide KFF poll conducted for this project.

The explanation for that startling disparity is deeply rooted. Decades of discrimination in housing, employment, and health care blocked generations of Black families from building wealth — savings and assets that are increasingly critical to accessing America’s high-priced medical system. […]