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Diabetes Costs Medi-Cal Billions, Prevention Is Complicated

The waiting room at the Effort Clinic in downtown Sacramento is like any other doctor's waiting room. The difference is, many people here can't see another doctor. They're poor, undocumented or medically indigent.

"We believe in providing a really dignified presence for our clients," said Jonathan Porteus, CEO of The Effort. He says about 60% of the clinics' patients are on Medi-Cal, the state's health plan for the poor. The clinic is seeing more people with diabetes younger, and needing more complicated care.

Porteus said, "We have a lot of patients who are getting more and more complicated. Because it's a progressive chronic condition so people get sicker as a result. And then they have all these secondary issues. It's a financial burden because those secondary issues involve extensive specialty treatment."

About 4 million Californians have diabetes, though many don't know it yet. The rates are higher in disadvantaged groups. About half a million people in Medi-Cal have the disease, and their care costs the system more than cancer or congestive heart failure.

"The state of California has a significant budget crisis," said Norman Williams who is with the California Department of Health Care Services. "Medi-Cal is the second largest general fund expenditure, [and] must be part of the solution."

About 40% of the people with diabetes on Medi-Cal are Latinos. That roughly corresponds to the Latino population in the state. Chad Silva is with Latino Coalition for a Healthy California. He says the high rate of diabetes among Latinos is related to income and environment. So a strategy to control the disease cannot rely only on education about healthy choices. "There's a certain percentage of the population where that is effective because they just aren't aware. I also think that there's a good, significant portion of the population that is aware but that choice just isn't available. So therefore the issue isn't necessarily education but also investment and opening up opportunities for healthy eating," said Silva.

Silva says the state can help by establishing nutrition guidelines and allocating funds towards prevention. But he says change won't be meaningful unless food businesses are more accountable for what they sell and how they advertise. "There are examples in other areas where people are responsible for the products they create and should be responsible for the products they create and the after effects thereof."

"Public health agencies really can't control many of the things that are most influential in determining peoples' health outcomes in California," said Dr. Linda Rudolph of the California Department of Public Health. Rudolph says it's clear the environment has great power to determine health. She leads the Health in All Policies Task Force, which brings 18 state agencies into the fight against obesity. She compares this effort to the fight against tobacco. "Twenty years ago, nobody would've blinked if I had picked up a cigarette and started smoking right here. And if I picked up a cigarette right now, you would all probably be quite shocked. We did that by educating the public, by countering the advertising of the tobacco industry, by creating financial incentives for people that encouraged them to think twice about buying cigarettes."

The difference is, nobody has to smoke, but we all have to eat. Jonathan Porteus of The Effort says clinics like his can be more involved in the fight against diabetes if they have an incentive. "I'd rather do routine care rather than have young people walking in with a chronic disease. I mean, that's pretty shocking. So maybe I'm sort of the mechanic who would rather do oil changes than fix cars that have been driven with empty radiators for a long time," said Porteus.

The good news is, recent data shows childhood obesity levels have declined slightly in California, but that is not true in all parts of the state.

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