Opponents have deployed a novel strategy to shut them down: using environmental regulations to sue over needle waste.

This article was published on Wednesday, October 6, 2021 in Kaiser Health News.

By Rachel Bluth  

SANTA CRUZ, Calif. — For more than 30 years, public health officials and nonprofits in California have provided clean hypodermic needles to people who use them to inject drugs.

For nearly that entire time, opponents have accused the free needle programs of promoting drug use and homelessness.

But recently, opponents have deployed a novel strategy to shut them down: using environmental regulations to sue over needle waste. They argue that contaminated needles pollute parks and waterways — and their lawsuits have succeeded across the state.

A bill signed Monday by Democratic Gov. Gavin Newsom will thwart that tactic.

Environmental challenges have already forced free needle programs in Orange County, Chico and Eureka to close or modify their operations.

The new law comes at a critical moment for a program in Santa Cruz. A final court ruling that could determine the fate of the program is expected within days, and it's not clear how the law will affect the judge's decision.

"We're in the midst of an opioid crisis," said Assembly member Joaquin Arambula (D-Fresno), a physician who wrote the bill Newsom signed, AB 1344. "We need all the tools that we have available for us to address this crisis head-on."

Despite the legislative victory, lawsuits to challenge needle programs on other grounds are still possible, and local ordinances banning needle exchanges have flourished across California.

Under the new law, which takes effect Jan. 1, opponents of free needle programs will no longer be able to sue over violations of the California Environmental Quality Act, known as CEQA.

CEQA requires projects that need approval from a public agency or receive public funding to be assessed for their potential environmental impacts. This requirement applies to major construction projects, like reservoirs and freeway overpasses, and localized ones such as affordable housing. CEQA is enforced by lawsuits and has been invoked over the years to stop or slow unpopular proposals, like homeless shelters.

California allows licensed physicians to give clean needles to patients without authorization. Free needle programs run by local governments or community groups must be approved by the state, a county or city.

These programs, which allow people to dispose of used "rigs" and get new ones, attempt to reduce the spread of HIV and hepatitis C, which can spread among drug users who share needles, and decrease infections among users. Some are true "exchanges" that require people to turn in a used needle to get a new one. Others allow people to take what they need without returning them.

In the past few years, opponents have started focusing on the programs' environmental impacts because some needles end up on the ground or in creeks and rivers.

Walt McNeill, a lawyer in Nevada City, California, challenged nonprofit-run needle programs in Chico, Eureka and Santa Cruz on behalf of local officials, former law enforcement officers and community groups.

McNeill said his clients aren't opposed to needle programs in general, just ones they believe are run irresponsibly. "You have no idea where the needles are going, and no way of recovering needles effectively," he said.

The trend in environmental challenges began a few years ago when the only needle program in Orange County shut down following a CEQA lawsuit. In 2020, a program created to address needle pollution in Chico closed after it settled a CEQA lawsuit, then later reopened on a smaller scale under a physician's authority. Also in 2020, Eureka officials wouldn't reauthorize a needle program after McNeill challenged it on environmental grounds.

Last year, McNeill sued one of two free needle programs in Santa Cruz County. Run by the Harm Reduction Coalition of Santa Cruz County, it operates out of a van and serves up to 75 people each Sunday on the same street corner in an industrial part of town. The complaint alleged the program "spread tens of thousands of used and unused hypodermic needle 'litter'" throughout the community and has led to "environmental degradation of the creeks, streams, rivers and beaches."

A superior court judge in Sacramento is expected to hand down her ruling soon. McNeill said he's confident the judge will side with his clients despite the new law because of other flaws in the program. If she disagrees, he said, he may file another suit on other grounds.

"No matter how you slice it, the program will be deauthorized," he said.

But Denise Elerick, founder of the coalition, said she believes her program will survive. She said arguments about needle litter mask anti-homeless sentiment.

"They say it's about the environment but it's not. They want people to die and disappear," she said.

Decades of research shows that needle giveaways aren't a major source of pollution, and that people who get needles from an exchange are more likely to dispose of them properly than those who don't.

A 2019 study by Santa Cruz County's Health Services Agency found that for every 10 needles that ended up on the ground or in a river, 1,000 made it into a sharps container, used to collect used needles, or an official disposal point. The report concluded that reducing needle litter would require more syringe programs and disposal sites, not fewer.

The Santa Cruz program, which began in 2018, gives out as many syringes as people request.

In addition to offering nine sizes of syringes, the program gives out sharps containers, ranging in capacity from a quarter gallon to 8 gallons, which can be returned, picked up or left at disposal kiosks around town.

On one Sunday in August, 56 people stopped by the van and 51 sharps containers were distributed. The coalition would not disclose how many needles it typically gives away.

The clients also gathered supplies to protect them from staph infections, COVID and other dangers: condoms, hand sanitizer, masks, alcohol pads, drug-testing strips to ferret out fentanyl, and medication to reverse overdoses. The program even offered clean pipes to encourage that drugs be smoked — rather than injected — and reduce the spread of COVID from sharing pipes.

Many who line up each week live in nearby parks and alongside creeks that are the focus of opponents' environmental concerns. They said they have a vested interest in keeping the environment clean.

"Just because we're drug addicts doesn't mean we don't take care of ourselves," said one woman, 35. (In order to observe how the program works, KHN agreed not to name the people procuring supplies.) "Yeah, I live in a tent, but my tent is clean. I try to take care of other people and I take care of myself."

The new law comes too late for programs like Chico's, because the city has since passed an ordinance banning syringe exchanges. Similar bans have been adopted in Anaheim, Oroville, Butte County, Yuba City and elsewhere in the past few years.

Ryan Coonerty, a Santa Cruz County supervisor, said the county likely won't adopt a ban, though he's disappointed by Newsom's decision. He believes the nonprofit needle program in Santa Cruz contributes to needle pollution more than the county-run program, which requires people to turn in used needles to get fresh ones.

"We will continue to struggle with needle litter and, unfortunately, not get any help from the state to stop needles from going into the ocean, parks and beaches," he said.

But the Centers for Disease Control and Prevention and other public health agencies say one-for-one programs limit the ways people can safely dispose of sharps, forcing them to hang onto their needles until the next needle exchange. That's not realistic, according to the people who lined up to get needles from the Santa Cruz program.

"A lot of us are homeless," said one 40-year-old woman, "and we can only stay someplace for so long."

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

Rachel Bluth: rbluth@kff.org, @RachelHBluth

The COVID-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults.

This article was published on Tuesday, October 5, 2021 in Kaiser Health News.

By Helen Santoro   

GUNNISON, Colo. — For the past eight years, my wife, Ky Hamilton, has undergone gender-affirming hormone therapy. As a transgender woman, she injects Depo-Estradiol liquid estrogen into her thigh once a week. This drug has allowed her to physically transition as a woman, and each vial, which lasts around five weeks, was completely covered by insurance.  

That was until she lost her job in April 2020 and we switched to a subsidized private health insurance plan in Colorado's Affordable Care Act marketplace. We discovered that our new insurance from Anthem doesn't cover Depo-Estradiol and it would cost $125 out-of-pocket per vial. With both of us — and our four pets — depending heavily on Ky's weekly $649 unemployment check, such medical expenses proved difficult. And as of Sept. 6, those unemployment checks ran out.

"I'm absolutely stressed. I don't know what to do," Ky said in August as we tried to find a solution.

Because of Ky's physical transition as a transgender woman, her body doesn't make the testosterone it once used to. So, without the medication, she would essentially go through menopause. A decline in estrogen levels can also cause transgender women to lose the physical transitions they've achieved, resulting in gender dysphoria, which is psychological distress from the mismatch between their biological sex and their gender identity.

Unfortunately, Ky's experience is shared by many other transgender Americans. The COVID-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults, who reported at higher rates than non-LGBTQ adults that they lost their jobs during the crisis. Consequently, enrollment surged in ACA plans and Medicaid, the state-federal health program for low-income people. Yet many of those plans don't fully cover gender-affirming care, partly because of conservative policies and lack of scientific research on how crucial this care is for transgender patients.

According to a survey by Out2Enroll, a national initiative to connect LGBTQ people with ACA coverage, 46% of the 1,386 silver marketplace plans polled cover all or some medically necessary treatment for gender dysphoria. However, 7% have trans-specific exclusions, 14% have some exclusions, and 33% don't specify.

"It's this whack-a-mole situation where plans for the most part do not have blanket exclusions, but where people are still having difficulty getting specific procedures, medications, etc., covered," said Kellan Baker, executive director of the Whitman-Walker Institute, a nonprofit that focuses on LGBTQ research, policy and education.

Twenty-three states and Washington, D.C., include gender-affirming care in their Medicaid plans. But 10 states exclude such coverage entirely. In 2019, an estimated 152,000 transgender adults were enrolled in Medicaid, a number that has likely grown during the pandemic.

Yet even in states such as California that require their Medicaid programs to cover gender-affirming care, patients still struggle to get injectable estrogen, said Dr. Amy Weimer, an internist who founded the UCLA Gender Health Program. While California Medicaid, or Medi-Cal, covers Depo-Estradiol, doctors must request treatment authorizations to prove their patients need the drug. Weiner said those are rarely approved.

Such "prior authorizations" are an issue across Medicaid and ACA plans for medications including injectable estrogen and testosterone, which is used by transgender men, Baker said.

The lack of easy coverage may reflect the fact that injectable estrogen, which provides the high doses of the hormone needed for transgender women to physically transition, isn't commonly used by non-trans women undergoing hormone therapy to treat menopause or other issues, Weimer said.

It also may be because cheaper options, including daily estrogen pills, exist, but these increase the risk of blood clots. Estrogen patches release the hormone through the skin but can cause skin reactions, and many people struggle to absorb enough estrogen, Weimer said. Consequently, many of Weimer's patients wear up to four patches at a time, but Medi-Cal limits the number of patches patients can get monthly.

While such insurance gaps have existed for long before the pandemic, the current crisis seems to have amplified the matter, according to Weimer.

The ACA prohibits discrimination based on race, color, national origin, age, disability and sex in health programs and activities that receive federal financial assistance. The Trump administration significantly narrowed the power of that provision, including eliminating health insurance protections for transgender people.

However, in June 2020, before the Trump regulations could take effect, the Supreme Court ruled in Bostock v. Clayton County, Georgia, that employment discrimination based on sex includes sexual orientation and gender identity.

This landmark decision has served as a crucial tool to address LGBTQ discrimination in many aspects of life, including healthcare. As of July, for example, Alaska Medicaid can no longer exclude gender-affirming treatment after Swan Being, a transgender woman, won a class-action lawsuit that relied in part on the Bostock decision.

The Biden administration announced in May that the U.S. Department of Health and Human Services Office for Civil Rights will include gender identity and sexual orientation in its enforcement of the ACA's anti-discrimination provision. The next month, Veterans Affairs health benefits were expanded to include gender confirmation surgery.

But for now, the pressure is still on patients like Ky to fight for their health benefits.

Anthem spokesperson Tony Felts said Depo-Estradiol is not on the list of covered drugs for its ACA plans, though many of its private employer-sponsored plans cover it.

Because we had one of those ACA plans, Ky had to be persistent. After four months of emails and phone calls — and just before unemployment ran out — Anthem finally authorized her Depo-Estradiol. That brings her out-of-pocket cost to $60 per vial for the next year. It's still expensive for us right now, but we'll find a way to make it work.

"The reality is that trans people are more likely to be in poverty and don't have the time or knowledge to spend four months fighting to get their estradiol like I did," Ky said.

Black women are about 1.6 times as likely as whites to give birth more than three weeks before the due date.

This article was published on Tuesday, October 5, 2021 in Kaiser Health News.

By Anna Maria Barry-Jester  

The tipping point for Dr. Paula Braveman came when a longtime patient of hers at a community clinic in San Francisco's Mission District slipped past the front desk and knocked on her office door to say goodbye. He wouldn't be coming to the clinic anymore, he told her, because he could no longer afford it.  

It was a decisive moment for Braveman, who decided she wanted not only to heal ailing patients but also to advocate for policies that would help them be healthier when they arrived at her clinic. In the nearly four decades since, Braveman has dedicated herself to studying the "social determinants of health" — how the spaces where we live, work, play and learn, and the relationships we have in those places, influence how healthy we are.

As director of the Center on Social Disparities in Health at the University of California-San Francisco, Braveman has studied the link between neighborhood wealth and children's health, and how access to insurance influences prenatal care. A longtime advocate of translating research into policy, she has collaborated on major health initiatives with the health department in San Francisco, the federal Centers for Disease Control and Prevention and the World Health Organization.

Braveman has a particular interest in maternal and infant health. Her latest research reviews what's known about the persistent gap in preterm birth rates between Black and white women in the United States. Black women are about 1.6 times as likely as whites to give birth more than three weeks before the due date. That statistic bears alarming and costly health consequences, as infants born prematurely are at higher risk for breathing, heart and brain abnormalities, among other complications.

Braveman co-authored the review with a group of experts convened by the March of Dimes that included geneticists, clinicians, epidemiologists, biomedical experts and neurologists. They examined more than two dozen suspected causes of preterm births — including quality of prenatal care, environmental toxics, chronic stress, poverty and obesity — and determined that racism, directly or indirectly, best explained the racial disparities in preterm birth rates.

(Note: In the review, the authors make extensive use of the terms "upstream" and "downstream" to describe what determines people's health. A downstream risk is the condition or factor most directly responsible for a health outcome, while an upstream factor is what causes or fuels the downstream risk — and often what needs to change to prevent someone from becoming sick. For example, a person living near drinking water polluted with toxic chemicals might get sick from drinking the water. The downstream fix would be telling individuals to use filters. The upstream solution would be to stop the dumping of toxic chemicals.)

KHN spoke with Braveman about the study and its findings. The excerpts have been edited for length and style.

Q: You have been studying the issue of preterm birth and racial disparities for so long. Were there any findings from this review that surprised you?

The process of systematically going through all of the risk factors that are written about in the literature and then seeing how the story of racism was an upstream determinant for virtually all of them. That was kind of astounding.

The other thing that was very impressive: When we looked at the idea that genetic factors could be the cause of the Black-white disparity in preterm birth. The genetics experts in the group, and there were three or four of them, concluded from the evidence that genetic factors might influence the disparity in preterm birth, but at most the effect would be very small, very small indeed. This could not account for the greater rate of preterm birth among Black women compared to white women.

Q: You were looking to identify not just what causes preterm birth, but also to explain racial differences in rates of preterm birth. Are there examples of factors that can influence preterm birth that don't explain racial disparities?

It does look like there are genetic components to preterm birth, but they don't explain the Black-white disparity in preterm birth. Another example is having an early elective C-section. That's one of the problems contributing to avoidable preterm birth, but it doesn't look like that's really contributing to the Black-white disparity in preterm birth.

Q: You and your colleagues listed exactly one upstream cause of preterm birth: racism. How would you characterize the certainty that racism is a decisive upstream cause of higher rates of preterm birth among Black women?

It makes me think of this saying: A randomized clinical trial wouldn't be necessary to give certainty about the importance of having a parachute on if you jump from a plane. To me, at this point, it is close to that.

Going through that paper — and we worked on that paper over a three- or four-year period, and so there was a lot of time to think about it — I don't see how the evidence that we have could be explained otherwise.

Q: What did you learn about how a mother's broader lifetime experience of racism might affect birth outcomes versus what she experienced within the medical establishment during pregnancy?

There were many ways that experiencing racial discrimination would affect a woman's pregnancy, but one major way would be through pathways and biological mechanisms involved in stress, and stress physiology. In neuroscience, what's been clear is that a chronic stressor seems to be more damaging to health than an acute stressor.

So it doesn't make much sense to be looking only during pregnancy. But that's where most of that research has been done: stress during pregnancy and racial discrimination, and its role in birth outcomes. Very few studies have looked at experiences of racial discrimination across the life course.

My colleagues and I have published a paper where we asked African American women about their experiences of racism and we didn't even define what we meant. Women did not talk a lot about the experiences of racism during pregnancy from their medical providers; they talked about the lifetime experience, and particularly experiences going back to childhood. And they talked about having to worry, and constant vigilance, so that even if they're not experiencing an incident, their antennae have to be out to be prepared in case an incident does occur.

Putting all of it together with what we know about stress physiology, I would put my money on the lifetime experiences being so much more important than experiences during pregnancy. There isn't enough known about preterm birth, but from what is known, inflammation is involved, immune dysfunction, and that's what stress leads to. The neuroscientists have shown us that chronic stress produces inflammation and immune system dysfunction.

Q: What policies do you think are most important at this stage for reducing preterm birth for Black women?

I wish I could just say one policy or two policies, but I think it does get back to the need to dismantle racism in our society. In all of its manifestations. That's unfortunate, not to be able to say, "Oh, here, I have this magic bullet. And if you just go with that, that will solve the problem."

If you take the conclusions of this study seriously, you say, well, policies to just go after these downstream factors are not going to work. It's up to the upstream investment in trying to achieve a more equitable and less racist society. Ultimately, I think that's the take-home, and it's a tall, tall order.

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

Anna Maria Barry-Jester: annab@kff.org, @annabarryjester

Allcove offers standalone health and wellness sites to those ages 12 to 25, often on a walk-in basis, at minimal or no cost.

This article was published on Monday, October 4, 2021 in Kaiser Health News.

By Mark Kreidler  

Phebe Cox grew up in what might seem an unlikely mental health danger zone for a kid: tony Palo Alto, California, in the heart of Silicon Valley. But behind its façade of family success and wealth, she said, is an environment of crushing pressure on students to perform. By 2016, when Cox was in middle school, Palo Alto had a teen suicide rate four times the national average.

Cox's family lived by the railroad tracks where many of the suicides occurred. She got counseling. But that option, she told KHN, is not always easily available to teens in crisis — and she and her peers regarded school mental health services as their last choice because of concerns about either confidentiality or anonymity.

A new program, designed largely by the people who use it, provides an alternative. Called Allcove, it offers standalone health and wellness sites to those ages 12 to 25, often on a walk-in basis, at minimal or no cost. Although Allcove is built to support a wide range of physical, emotional and social needs, its overarching goal is to deal with mental health challenges before they develop into deeper problems.

Allcove is yet in its infancy, with two sites just opened in the Bay Area and five more in the pipeline around California. It's modeled on a 15-year-old program in Australia, Headspace, which has 130 such clinics. Headspace has inspired programs in other countries as well, including Jigsaw in Ireland and Foundry in Canada. All of them, including Allcove, also offer online and phone services.

Allcove's core values resonate with Cox, now 19 and a student at Pitzer College in Claremont, California, and one of dozens of young people who have offered advice on the program's structure and services.

"Right away, I knew it was going to be a big thing," Cox said. "I felt pretty helpless as a young teenager, but Allcove is all about the students and the students' needs."

About half of all lifetime mental illness begins by age 14, and 75% before age 25, according to researchers. Yet access to mental healthcare in the U.S. is lacking. According to the National Alliance on Mental Illness, some 30 million adults and children with mental health conditions go without treatment, and 129 million people live in areas with shortages of mental health professionals. A 2017 survey found that Californians were five times more likely to go outside their private insurance network for mental health office visits than for medical or surgical needs.

Allcove meets some of that head-on by providing fully staffed safe spaces for teens and young adults to discuss and deal with their health, both mental and physical, along with substance misuse issues and educational support. California law allows those 12 and older to get outpatient mental health or counseling services without a guardian's consent.

Allcove's sites in Palo Alto and San Jose are filled with vibrant colors and plenty of open space, the result of input by a youth advisory group that numbers a dozen or more members and changes out about once a year. Inside Allcove, clients can access group or individual care, ask a doctor about a problem, and even get help preparing for college.

Unlike the Australian program, Allcove has no ongoing funding source yet. Allcove is "a really big lift, and we [at the state level] want to say, 'How can we help you?'" said Toby Ewing, executive director of the California Mental Health Services Oversight and Accountability Commission, which administers the fund that seeded the first two sites with $15 million.

Funding eventually may come from a combination of state, private and nonprofit sources, as well as Medi-Cal reimbursements, said Dr. Steven Adelsheim, a psychiatrist who directs Stanford University's Center for Youth Mental Health and Wellbeing.

Adelsheim previously spent nearly 30 years in New Mexico, helping that state build a network of school-based health centers. His experience convinced him that many students were likely to avoid mental health services at school. They were reluctant, he said, to discuss such issues with their own counselors, who might be the same people writing the students' letters of recommendation for college and might unwittingly breach privacy.

That realization led Adelsheim in 2014 to get exploratory funding from the Robert Wood Johnson Foundation to create Allcove. (KHN, which produces California Healthline, also receives funding support from the foundation.) "There is a crying need in the U.S. to reach kids with early intervention and help," Adelsheim said.

The idea struck a chord with Santa Clara County officials, who'd seen Palo Alto lashed by teen suicide clusters during the 2009-10 and 2014-15 school years. "The saddest part of the story is that a teen didn't reach out earlier, didn't have the opportunity to get help when and where they needed it," County Supervisor Joe Simitian said in announcing Allcove's opening in June. "The appeal of the Allcove model is it's designed to engage young people who are struggling, long before they hit a crisis point."

When Cox moved from middle school to Palo Alto's Henry M. Gunn High School, her therapist told her about Adelsheim's project and suggested Cox apply to be part of Allcove's youth council. One of Cox's contributions was to suggest weekday hours extending at least to 7 p.m., "because young adults are doing things and on the move all day. It's the evenings — and even the weekends — when we're dealing with things or feeling more helpless. For a lot of my friends, at night is when things can get overwhelming."

Both Foundry, the Canadian program, and Allcove address physical health as well. Steve Mathias, CEO of Foundry, said his program's emphasis is "on health and wellness, not just mental health, which is a part of wellness." Said Adelsheim, "Sometimes a kid may come in with a physical complaint, and only after a few visits is the mental suffering brought out into the open." When that happens, Allcove can make a "warm handoff" to a mental health specialist on-site.

The most significant difference between Headspace and Allcove may be funding. Headspace is part of the Australian government's mental health initiative, and thus budgeted. Allcove is essentially building on the fly, and its long-term ability to grow will depend on money.

California's Proposition 63, written in 2004 by then-Assembly member Darrell Steinberg (now the mayor of Sacramento), levies a 1% tax on personal incomes over $1 million to fund community mental health services. This year, the tax may yield $2.4 billion, Ewing said. Most of that goes to existing programs, but about 5% each year — more than $100 million in 2021 — feeds an innovation fund to encourage new approaches to mental health.

Santa Clara County got $15 million from that fund to launch Allcove. The state also has helped fund Allcove sites, in Sacramento, San Mateo and Orange counties, and two in Los Angeles County.

"We've made a $30 million-plus investment in this model," Ewing said. "We are assuming that it's going to be successful."

Success, say Adelsheim and Cox, would mean the establishment of hundreds of Allcove centers up and down the state, readily available to young people. The hope is that, if it catches on, Allcove could become a well-known brand for young Californians — and, eventually, others around the country.

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

Mark Kreidler: @MarkKreidler