Health & Human Services – Page 11 – Public Policy Institute of California

Video: Feinstein on Her Role in a New World

Senator Dianne Feinstein was clear about the challenges ahead for a California Democrat in contentious times.

“Here we are: outnumbered, outvoted, in the West, fairly liberal,” she said.

Speaking before an energetic capacity crowd in San Francisco, Feinstein said her office had received more than a million phone calls about Trump’s cabinet nominees. She described her approach to them: careful evaluation, rather than blanket opposition—an approach too conciliatory for some sign-carrying audience members. Feinstein said that in her role on the Senate Judiciary Committee, she needed to work with the administration officials in charge of national security and felt she could work with Trump appointees James Mattis, defense secretary; John Kelley, secretary of homeland security; and Mike Pompeo, CIA director. But she opposed other nominees because they lacked credentials for the job or they aren’t right for the county, she said. Nevertheless, they went on to win approval.

“The key for me is to figure out how we can begin to win some of these battles.”

Asked about Trump’s nominee to the Supreme Court, Neil Gorsuch, Feinstein wouldn’t say how she would vote. She said she will be particularly interested in his views on gun laws and on women’s reproductive rights.

Feinstein’s visit was greeted by dozens of protesters who marched outside, upset that she had not hosted a traditional town hall. Inside, Feinstein touched on a range of issues from climate change to immigration to health care, in a wide-ranging conversation with Mark Baldassare, PPIC president and CEO. His questions included a number that PPIC solicited online in advance of the event.

Moving up the Health Career Ladder

Upward mobility is inextricably tied to educational attainment in today’s economy. How do California’s educational institutions foster upward mobility for their students when developing their programs of study? One way community colleges across the country are working to do so is through the development of training pathways that allow students to “stack” multiple credentials. The idea is that students can earn certificates or degrees sequentially and move up a career ladder—upward mobility in action. For example, a student who completes a certificate in medical assisting can return to complete additional training and earn a degree in registered nursing—an occupation that offers large wage returns.

Despite the promise of “stackable credentials,” our analysis of students enrolled in health programs at California’s community colleges finds that among those who earn one credential, most don’t go on to get another. We followed the 85,000 students who earned their first health degree between 2000 and 2009. Only 13 percent completed a second health credential within six years. This isn’t terribly surprising since about half of health students in California’s community colleges initially earned an associate degree—the highest level award that is offered. Many associate degrees in health lead to well-paying jobs such as registered nurse or dental hygienist. But even among students who earned a shorter-term, lower-return credential, only 20 percent returned to earn another health credential.

However, the evidence suggests that students who do stack multiple health credentials see sizable economic returns eventually (see figure). Median earnings are similar across the two groups of students before starting their health training programs and while they are in school. The wage trajectories diverge, however, after degree completion. Students completing a single award—most often an associate degree—earn more than $15,000 per quarter just one year after finishing their health degree. In comparison, those completing multiple awards—a shorter-term, lower-return certificate is the most prevalent first degree—earn only $8,000 a year out. This difference narrows considerably over a five year period when students completing a second health credential see a larger gradient in their earnings.

Currently, most students who “stack” health credentials ultimately attain an associate degree in nursing—one of the highest value awards offered in the community college system. It’s plausible to imagine building pathways that allow students to meaningfully stack credentials to other high-value, in-demand careers. But to do so, colleges must carefully align program curricula to ensure that skills gained along the way are sequential or complementary, while at the same time making sure that each credential has standalone value in the labor market. This is not an easy task but one our community college system is currently focused on, given state and federal investment in growing career pathways.

At the same time, community colleges are investing in ways to support students as they explore pathways to well-paying careers. All of these efforts, taken together, hold promise for increasing the number of students who improve their economic standing through engagement with training pathways available through California’s community colleges.

Learn more

Read the report Health Training Pathways at California’s Community Colleges
Visit the PPIC Higher Education Center

Video: An Early Look at Views of President Trump

The January PPIC Statewide Survey asked Californians for to assess their new leaders in Washington and found that just a third of Californians, or 30%, approve of the way President Trump is doing his job. Californians gave Congress a similar rating.

Dean Bonner, associate survey director, presented these and other key findings at a briefing in Sacramento. The survey also examined contentious issues that are the focus of national debate.

Solid majorities of Californians favor state action—independent of the federal government—to protect the rights of undocumented immigrants and to address global warming.
About half of Californians have favorable opinions of the Affordable Care Act, and a slight majority oppose repealing it.
Most Californians—across political parties—say the government should not interfere with a woman’s access to abortion.

The survey also looked at views of Governor Brown’s job performance and his proposed budget. The governor job approval rating is at a record-high 66%. But his budget proposal and his plan to fund maintenance of the state’s roads, highways, and bridges fares less well. Just under half of residents support his budget plan and 41 percent support his transportation proposal.

Learn more

Read the January PPIC Statewide Survey
Learn more about the PPIC Statewide Survey

Video: Strengthening Pathways to Health Careers

Health programs at California’s community colleges hold particular promise for helping students enter in-demand careers and addressing the state’s workforce needs, new PPIC research shows. These career technical education (CTE) programs, also known as vocational education, attract a large and diverse set of students. The state’s community colleges offer a broad range of programs—including nursing, respiratory therapy, medical and dental assisting, and health IT—that are linked to growing job opportunities in health services, a generally well-paying industry for Californians without a bachelor’s degree.

PPIC researchers presented two reports on the topic in Sacramento. Among the key findings summarized by report coauthor Shannon McConville: many students who have earned career tech credentials in health care have seen sizeable wage gains, and completion rates in these programs are relatively high. More than 70 percent of students who begin a program either obtain a degree or transfer to a four-year college within six years, while only about half of the overall CTE student population obtains a credential within six years.

But there is room for improvement. Completion rates vary substantially across health programs, ranging from 93% in dental hygienist programs to 44% in emergency medical services. And there are racial and ethnic achievement gaps across programs.

After the research presentation, an expert panel took up the topic. Anette Smith-Dohring, manager for workforce development at Sutter Health, underscored the need to diversify the health care workforce.

“We want our front-line health care providers to reflect the communities we serve because those are our patients,” she said. “We want them to come from [the] communities we serve—we don’t want to import health care providers.”

Linda Collins, executive director of the Career Ladders Project, which has worked with community colleges, said it is important both to expand career awareness of the range of allied health professions and to improve science proficiency in middle and high school. If a student has “a basic grounding in math and science from the high school level, that will allow a student to take almost any allied health occupation program and be successful,” she said.

All of the speakers provided examples of small-scale programs in community colleges that have improved student success rates—and expressed frustration that the funding has not been consistent enough to expand them.

Linda Zorn, statewide director of the California Community Colleges Health Workforce Initiative, summed up: “Programs that provide structure and clarity about what students need to take, and integrate both proactive and embedded student supports in the instructional experience, are critical.”

Learn more

Read Career Technical Education in Health: An Overview of Student Success at California’s Community Colleges
Read Health Training Pathways at California’s Community Colleges
Visit the PPIC Higher Education Center

Medi-Cal and the Fall Election

Lost in the sound and fury of the national election are the results of four statewide ballot initiatives that aimed to bolster financing of the Medi-Cal program. Medi-Cal is California’s version of Medicaid, which pays for the health care of low-income families, many elderly who live in nursing homes, and—with the passage of the Affordable Care Act—single low-income adults. The state spends nearly $19 billion annually from the General Fund (and $87 billion from all sources) to provide medical coverage for 13.5 million Californians through Medi-Cal.

Three of the four initiatives passed on November 8, providing up to $3 billion in additional funds for Medi-Cal each year. But it will take a while for Californians to see the concrete outcomes of their votes. And, as is often the case with initiatives, the impact of these measures will depend on questions that have yet to be answered. The three measures that passed include:

Proposition 52: This initiative permanently extends the fees hospitals pay to the state, which the state then uses to get federal matching funds to support Medi-Cal. This translates to about $1 billion in state General Fund savings annually – providing this system continues to be allowed under federal law. There wasn’t much doubt that the state would seek to extend these fees past the sunset date of January 1, 2018, since they reduce pressure on the General Fund. But the initiative makes it more difficult for the legislature to modify the hospital fee program.
Proposition 55: Extending the tax on high-income earners will generate between $4 billion and $9 billion each year to pay for K–12 education and community colleges, Medi-Cal, and other budget priorities. For Medi-Cal, this is expected to provide up to $2 billion annually starting in 2018. But the amount may vary significantly from year to year for several reasons. First, K–12 education gets first call on the new revenue. In addition, the amount of new revenue will be affected by the volatility in what high-income taxpayers earn. Thus, the governor and legislature will have to learn to cope with an undependable funding source for Medi-Cal.
Proposition 56: Higher tobacco taxes will generate up to $1 billion for Medi-Cal in 2017–18. Revenue from tobacco taxes has generally fallen each year as the number of smokers in California has declined, and the new tax may accelerate that trend. While building these funds into the Medi-Cal budget may strengthen the program now, the state’s General Fund could face increasing pressure in the future if this source of funding declines. The state legislature and governor will determine how to use these funds as part of budget discussions next spring.

The fourth initiative affecting the Medi-Cal program, Proposition 61, failed to garner a majority of votes. Perhaps not surprisingly, more questions were raised about the impact of this initiative than the other three. Proposition 61 prohibited the state from paying more for prescription drugs than the federal US Department of Veterans Affairs, which typically pays the lowest prices of any public or private entity. The measure’s intent was to reduce the cost of prescription drugs in California, but the fiscal analysis by the Legislative Analyst’s Office suggested that the savings were uncertain.

While the new funds for Medi-Cal will be welcome, it remains to be seen whether they will provide reliable support for the program. Plus, there are questions about how the new president and Congress will alter the Affordable Care Act and how that will affect the state’s program. For instance, the law allowed California to extend Medi-Cal coverage to single low-income adults. In the 2016–17 state budget, coverage for this group cost about $15 billion annually, with the federal government picking up 95% of the tab. If the federal government significantly reduces or eliminates this enhanced funding rate, the $3 billion in new revenues generated by the three initiatives will not be enough to operate California’s expanded Medi-Cal program without other fiscal support.

Income and Inequality Vary Widely Across California

Income inequality has been growing for decades and—despite the recovery from the Great Recession—remains historically high. Today, the low end of the income spectrum (the 10th percentile) in California is 19% lower than what it was in 1980, and the upper end of the spectrum (90th percentile) is 40% higher, according to our new report. As a result of these trends, the ratio of high to low incomes—a key measure of income inequality—is nearly twice the size it was three decades ago.

In Los Angeles County, high-income families have 15 times more income than low-income families.

Both income and income inequality vary substantially across California. Looking at after-tax family incomes, we find that, in 2014, the Bay Area had the highest incomes. However, the gap between high and low incomes was biggest in Los Angeles County, the Central Valley, and northern parts of the state—places where low incomes tend to be particularly low. For example, in Los Angeles County, high-income families have 15 times more income than low-income families. At the other end, the Inland Empire and Orange County have the lowest income inequality.

Why does the gap between families across the income spectrum matter? In part because low-income families may have insufficient resources to meet their basic needs. If family incomes are widely spread (inequality is high) but even families at the low end of the economic spectrum are able to attain a sufficient level of well-being (poverty is low), income inequality may not be a big problem. But that is not the case: one in five Californians live in poverty.

Inequality itself may also raise concerns for a host of social, cultural, and political reasons. One economic consequence of inequality is that the greater spread of incomes may inhibit upward mobility. Recent research finds a correlation between income inequality in a region and the upward mobility of its children. Low-income children who grew up in areas with higher income inequality have, on average, lower incomes as adults than otherwise similar children who grew up in regions with less income inequality. In this and other ways, the consequences of growing income inequality may play out over generations, highlighting the need for policies that take this long-range view into account.

Source: Based on California Poverty Measure data, 2012–2013 (Bohn and Danielson 2016).
Notes: Dollar amounts are rounded to the nearest $1,000. Income shown includes cash from work and retirement sources net of federal and state income and payroll taxes; low-income tax credits are not included. Dollar amounts adjusted to represent a family of four. The inequality ratio shown is calculated as the ratio of the 90th percentile of income to the 10th percentile of income; higher numbers indicate greater income inequality. Regions defined as follows. Northern: Butte, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Tehama, and Trinity Counties; Sacramento area: El Dorado, Placer, Sacramento, Sutter, Yolo, and Yuba Counties; Bay Area: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano, and Sonoma Counties; Central Valley and Sierra: Alpine, Amador, Calaveras, Fresno, Inyo, Kern, Kings, Madera, Mariposa, Merced, Mono, San Joaquin, Stanislaus, Tulare, and Tuolumne Counties; Central Coast: Monterey, San Benito, San Luis Obispo, Santa Barbara, and Ventura Counties; Inland Empire: Imperial, Riverside, and San Bernardino Counties. Los Angeles, Orange, and San Diego Counties are shown separately.

Learn more

Read the report Income Inequality and the Safety Net in California

Video: 3 Cities Address Economic Challenges

When Uber officials announced the company was moving to Oakland, there was a wave of fear and anger that well-paid tech workers would push longtime residents out of the city. Fresno, with its high concentration of poverty, struggles to attract the kind of private investment that caused angst in Oakland. In South Gate, housing is relatively affordable, which should be good news. But there are few homes for residents to buy because most are rentals owned by outside investors.

These stories, told by leaders of these communities at a recent PPIC event, were different. But common across the agendas of all three leaders was an emphasis on education as a key part of the solutions they are working on to address income inequality and poverty.

Jorge Morales, councilmember and former mayor of South Gate, said business owners told him that city residents didn’t have the education needed to get jobs beyond the entry level. Now, thanks to a partnership with the Los Angeles Community College District, a new campus will open in South Gate. The focus will be on jobs that become careers, Morales said.

“One of the mistakes we made as policy makers is that when manufacturing jobs started to leave, we all got excited about the revenue—about the sales taxes size—and we started building shopping centers everywhere.””What did that do? That provided the jobs that didn’t provide a living for folks.”

Ashley Swearingen, mayor of Fresno, said that missing the dot com boom of the late 1990s was a wake-up call for her city.

“We were not as a city and a region prepared to ride that wave of expansion,” she said. “That tidal wave of prosperity hit the state, but not a drop hit the ground in the places I was living and working.” The city partnered with Fresno State University to “undo and redo everything about our community” from its public systems to its civic environment, and entrepreneurship education is woven through school curriculums beginning in elementary school.

Libby Schaaf, mayor of Oakland, said she is most passionate about a program she is raising money to start, the Oakland Promise. She said that among this year’s ninth-graders, only 10% will have a college degree by the time they are 23 years old. The Oakland Promise is a “cradle-to-career strategy to triple that number in 10 years.” Each baby born into poverty will get a $500 college savings account, and parents will get another $500 in direct support for home visits and literacy training. Every kindergartener will receive a $100 college savings account. Students will be connected with internships, mentors, peer support groups, and help with financing college.

“You have got to intervene at every moment, from birth until college completion,” she said.

Schaaf says she has raised $23 million for the program and needs $15 million more.

Learn more

Read the PPIC report Income Inequality and the Safety Net in California

Public Preschools Support Education, Work

As policymakers discuss California’s system of early childhood care and education, it is useful to look more closely at the families who use it—or might like to. Public preschools—enrolling four-year-olds and some three-year-olds—hold promise for improving school readiness and later life outcomes, particularly for low-income students who may not otherwise have access to high-quality preschool experiences. At the same time, publicly provided early education also serves a second goal: supporting work among low-income parents.

Full- or part-time work is typical among California’s low-income families with preschool-aged children. For a family of three, low-income means living on $37,167 a year – which is 185% of the federal poverty line, a threshold used to designate economic disadvantage in the K-12 education context. Among all such families, just 11% report no adults working in the past year. Lack of work is much more common in single-parent families (34%) than in families with two or more adults (6%). Research shows that access to subsidized child care raises employment among single mothers, suggesting that the larger percentage of single-adult families reporting no work reflects in part a lack of viable childcare options.

Most low-income preschool age children live in families with two adults (64%). Far fewer of these families than single-parent families report no work (7%); the share with both adults working full-time, year round is only 8%. The remaining 85% of low-income families with preschool-aged children and two adults rely on a combination of full-time and part-time work. In about a quarter of two-parent families, no adult has full-time work. This complexity reflects multiple factors—including opportunities for employment and family choices about care for young children.

In the context of a policy discussion about preschool, why are these patterns important? Working parents will be more likely to enroll their children in programs that align well with their work schedules. Non-working parents are more likely to seek work if they have reliable child care. Given that employment is a central piece of the financial picture for most California families, whether low-income or not, it is critical that policymakers keep the dual purposes of early care and education in mind as they consider ways to improve the system of public preschool in California.

Learn more
Just the Facts: Public Preschools in California
Just the Facts: Californians and Early Childhood Education
Just the Facts: Child Poverty in California

Video: County Jails and the ACA

A majority of inmates in California’s jail system are likely to be eligible for Medi-Cal, and providing health care coverage for them could have multiple benefits. These are the key findings of a new PPIC report, Expanding Health Coverage in California: County Jails as Enrollment Sites.

Coauthor Shannon McConville presented the report to a Sacramento audience last week. She noted that the 4 million state residents who are still uninsured will probably be the toughest to reach. The legislature has allocated money to target these Californians and increase enrollment in health coverage under the Affordable Care Act (ACA).

At the same time, counties—which have gained new responsibilities for low-level criminal offenders—have new incentives to help inmates successfully transition back into the community and avoid further contact with the criminal justice system.

“Health coverage, newly available under the ACA, could be part of a more comprehensive reentry strategy,” McConville said.

Managed care plans are also increasingly focused on better integrating physical health and behavioral health, providing more mental health and substance abuse treatment—services needed by the jail population.

These policy changes add up to an opportunity to leverage federal and state Medi-Cal resources to improve both public health and safety. Enrolling inmates could improve health care in the jail system, lower county corrections costs, and reduce recidivism.

McConville said the work to achieve these goals is just beginning. Counties are still adjusting to their new responsibilities. As a first step, they will need to identify effective enrollment strategies that improve reentry and reduce recidivism.

Closing California’s Health Insurance Gap

California has made great strides toward closing the health insurance coverage gap under the Affordable Care Act (ACA). In 2014, the state reduced the share of the population that was uninsured by 5 percentage points, or about 2 million people. Early evidence suggests the state made additional gains in 2015, but more than 3 million California residents continue to lack health insurance and many are eligible for free or subsidized coverage. Reaching them may have benefits beyond meeting the state’s health coverage goals, including the potential to improve public safety and public health.

The characteristics of the remaining uninsured are striking. Younger men (those under age 45) make up less than one-fifth of California’s adult population but represent more than one-third of the uninsured. When we examine other characteristics of Californians who continue to lack coverage, we find the highest uninsured rates among those facing high levels of disadvantage. Uninsured rates among adults with low levels of income, education, or employment are above 30 percent. And when we focus more closely on young men with high levels of disadvantage, uninsured rates are well above 50 percent.

Because highly disadvantaged young men are detached from educational and labor market institutions, they are likely to be among the hardest to reach through traditional sites of enrollment. They are also disproportionately represented among people who are arrested and incarcerated in county jails and state prisons.

In our study of a subset of California counties, we find that more than three-fourths of individuals booked into jail are men under age 45. Within the counties under study, nearly half a million individuals flowed through the jail system in 2014. Given the substantial overlap in the characteristics of the uninsured and the characteristics of individuals who have contact with the criminal justice system, county jails may provide an opportunity to target a share of the remaining uninsured.

Enrolling county correctional populations in health coverage may also support efforts to improve reentry outcomes under Public Safety Realignment by reducing the likelihood of recidivism. Specifically, chemical dependency treatment and outpatient mental health programs have been associated with reductions in repeat arrests and fewer total arrests.

Many county jail systems are engaged in some form of enrollment assistance. However, approaches and resources vary across the state. Counties may take a “front door” approach, offering enrollment screening to the large group of individuals being booked into jail. Or they may take a “back door” approach, offering enrollment assistance to a much smaller group of individuals nearing the end of their sentences, as part of reentry planning. When resources are limited—and they almost certainly are—counties face trade-offs between providing some form of assistance to a large population and providing in-depth assistance to a smaller group.

This variation across counties creates an opportunity to identify best practices in providing enrollment assistance. Further, we can help counties that successfully enroll a substantial share of their correctional populations to evaluate the effects of enrollment on recidivism. This kind of research can inform efforts to make the most cost-effective use of criminal justice resources.

Chart Source: American Community Survey, Public Use Microdata Sample, 2014.
Chart Note: Insurance coverage is measured at the time of the survey. Results shown are for all California adults ages 18–64. Income levels are presented as poverty rates based on federal poverty level (FPL) thresholds related to income eligibility cutoffs for health insurance coverage programs including Medi-Cal (under 138% FPL), premium and copayment subsidies available for coverage purchased through Covered California (138%–250% FPL), and premium subsidies only for coverage purchased through Covered California (250%–400% FPL).