Science
California Health and Human Services chief Dr. Mark Ghaly to step down
Dr. Mark Ghaly is stepping down as head of the California Health and Human Services Agency after an eventful tenure that included the eruption of the COVID-19 pandemic, Gov. Gavin Newsom announced Friday.
Newsom called Ghaly “a driving force for transformative changes to make healthcare more affordable and accessible,” whose leadership during the pandemic “saved countless lives and set the stage for our state’s strong recovery.” The governor’s office also credited Ghaly with reimagining Medi-Cal, the California Medicaid program; overhauling the state behavioral health system; and launching efforts to make crucial medications more affordable, among other initiatives.
Ghaly was appointed in 2019 to lead the state agency, which oversees a slew of California departments and offices that handle public health, mental health, assistance to people with developmental disabilities and a range of other health and social services.
Ghaly will stay at the agency through the end of the month. Newsom is appointing California Department of Social Services Director Kim Johnson to replace Ghaly in October. The Times talked to Ghaly this week about his tenure.
This conversation has been edited for length and clarity.
What were the three biggest challenges you faced at Health and Human Services, and what are the three biggest challenges facing your successor?
One of the big ones was navigating, under the governor’s leadership, this state through our COVID response — that obviously is a huge one. The second one, I think, is really addressing a comprehensive overhaul of our safety net …. And then the third piece has been, how do we make sure that for all Californians, we’re making progress to keep these basic necessities affordable, like healthcare … ?
The successor will certainly need to continue implementing the really thoughtful policy agenda that has stitched together … this real tapestry of programs and services that, when implemented successfully, I think really changed the arc of the lives of a lot of Californians, in particular the most vulnerable.
The focus on the principles of equity … I have no doubt that will continue to be a focal point. And then just on the last point, there’s a lot of pundits and detractors on the affordability agenda: Can we make thoughtful policy decisions and implement them to make things more affordable for Californians?
Having started a year before the pandemic, if you knew then what you know now, is there anything that you would do differently, in terms of the COVID response in California?
If you had told me that we had to successfully navigate California — the largest state in the nation — with one of the lowest end death rates from the disease, with a very thoughtful path to economic recovery, and while achieving that, build up and grow the California Health and Human Services Agency’s investment by nearly 50% over these six years, I would have said, ‘Sign me up for that job any day of the week. What a privilege.’
But of course, there are things that happened during the pandemic, that as it goes on and you think through it, you hope you may do something different in the future. And I would say No. 1 on the list for me … is how we supported young people with learning and school.
You’ll remember early on, the question about how to handle … schools as places where people become infected and go home and infect other vulnerable people — we were learning more about this sneaky airborne virus that mutated as it went along. And we made decisions in this state to have kids stay home, [to] really lean into virtual distance learning, and it stuck much longer than I think people had hoped …. And the governor put together a number of programs that supported their education in all sorts of forms.
But I think knowing what we know now about both the virus, the length of the pandemic — some of that information would have been helpful in those early days, weeks, months, around how we supported kids in schools.
During your time at the agency, we’ve seen some major changes in how California handles severe mental illness: the opening of CARE Court and Senate Bill 43, which broadened the definition of grave disability for involuntary treatment …. Do you think it is bringing about the change that was hoped for?
When I say the full transformation of the safety net, I can think of no better issue, single issue to focus on than behavioral health. Under Gov. Newsom’s leadership, we have changed from a focus on mental health to behavioral health, to include the very real need to focus on addiction and substance use disorders, its connection to things like housing instability and homelessness, its connection to incarceration.
When I came into this job, in my actual interview with the governor before I was appointed, we talked about how much we wanted to change the trajectory of people with serious mental health and behavioral health conditions, because in so many ways, the often ending place for individuals was jail, incarceration, prison ….
[With CARE Court] our goal was not just to get people in the line, but to get people in the front of the service line that so often are left outside to decompensate … until they do something that gets them arrested, and then suddenly we start to wrap around some of the care that they need, but often in the worst environment possible.
I do think the governor’s many programs that focus on behavioral health … when you take a step back and look at it all together, it’s essentially giving Californians and local government tools that they never had to be able to dream differently and put together a program that, I think, really gives us a credible shot to catch people much earlier in their trajectories with the challenges of behavioral health conditions, rather than what we so frequently do ….
I think we’re going to see these programs really pay off as they become more deeply seated [and] we work through some of the obvious operational challenges.
California has been expanding Medi-Cal, its Medicaid program, to cover many more people, but there’s been concern from healthcare providers that it doesn’t pay them adequately, which results in a shortage of providers willing to accept Medi-Cal patients. How should California fix that problem?
A: I often tell the governor, ‘Look, there’s four basic things when you talk about health services. You think about benefits, you think about access, you think about quality, you think about eligibility.’ And I think the governor has addressed all of those areas ….
We made pretty big investments in some of what I’ll call the bread-and-butter rates in Medicaid, bringing them either to 100% or close to 100% of what Medicare pays in this part of the country. Because of some budget challenges, we had to back off some other planned investments for this coming year, but as that budget starts to hopefully turn around … I know those will be an ongoing place of focus.
Mind you, Medicaid has a lot of different ways for providers and plans to receive payment …. I think as you look at that in totality, the opportunities to recruit providers to take care of the Medicaid population is stronger than it was when Gov. Newsom took office six years ago.
That all said, this has to be an ongoing sort of balance and conversation about how we continue to support this program, because one in three Californians now depend on Medicaid. So many kids — more than 33%, closer to 50% of kids — are dependent on Medicaid. When you have that vital a safety net program, we must continue to keep our eye on all four of those elements: quality, access, eligibility and benefits.
Earlier this year, the Office of Health Care Affordability announced a target of 3% annual growth in healthcare spending, to be phased in over time. How do you anticipate that healthcare providers will reach that target, given the kinds of pressures that have ramped up costs in the past — things like labor costs and inflation?
I think it’s going to require some real movement away from our traditional views on how you operate healthcare. We’re going to really have to make some decisions about moving more things upstream — promoting prioritizing things like preventative care and primary care, helping support other access points for people where access is challenging, and frankly speaking, really looking at some of the benefits of each of the different entities in the whole healthcare delivery system ….
We don’t expect everyone in California to always be there. There will be some conditions that legitimately push the markets in a different direction.
But as a whole, if we don’t chase a target that is both aggressive and achievable, that affordability problem that so many Californians face won’t just not get better — it is likely to get worse.
Reporters who cover the Capitol have raised concerns about interviews like this becoming rare. I know for me, personally, it’s been unusual to get anyone from the Department of Public Health on the phone. Why aren’t these departments routinely speaking directly to the media, instead of sending written statements?
Frankly, it is less about a lack of interest in speaking directly to the media — often, the interviews allow directors and leaders to very clearly convey nuance and important points.
My experience has been, so often the questions that reporters want answers to have some ability to be answered very clearly in a written form. And so we’ve used that frequently — not to sort of hide behind something or avoid the live interview — but because it seems and has been adequate in many of those conversations or requests.
One of the things I know you’ve been working on lately is this state plan on services for Californians with developmental disabilities. In California, these services have long been coordinated through a system of nonprofits called regional centers, which contract with the state. Do you believe that system is working for Californians and their families, and if not, what do you think needs to change?
One of the most important themes that got amplified during COVID was this notion of building trust through transparency …. And in my time and experience, I have heard loud and clear [from consumers and their families] that this system is not as transparent as it can be or that it should be, and I agree with that.
So part of the work of this new strategic plan … is recognizing that Gov. Newsom did something unprecedented. He took a rate study from before he came into office and implemented it …. We’re on a trajectory to fully implement that soon [Ghaly is referring to increases in rates paid to regional center vendors that provide services to people with disabilities] …. To say it plainly, we — given the level of investment — should become a lot more of a system that’s able to say “yes” to consumers, rather than “no” or delay.
Science
Doctor surrenders license after allegations that he sexually abused patients and employees
A longtime internist who founded a chain of Southern California clinics has surrendered his medical license after an accusation from the state medical board that he sexually assaulted three patients, two of whom worked for his clinics.
Dr. Mohammad Rasekhi signed an agreement to give up his medical license last month, weeks after the Medical Board of California filed an accusation against him detailing allegations that Rasekhi sexually abused three women while they were under his care.
Rasekhi denies all the allegations, his attorney Peter Osinoff said this week. He chose to waive his rights to a hearing and retire from medicine, a decision Osinoff said his client had been considering for some time.
“For him to spend his retirement money litigating over a license he no longer uses is not a good use of money,” Osinoff said. The surrender took effect Dec. 2.
Rasekhi was the founder and chief medical officer of Southern California Medical Center, a group of general practice clinics with locations in El Monte, Van Nuys, Pico Rivera, Woodland Hills, Pomona and Long Beach.
Sheila Busheri, co-founder of Southern California Medical Center and Rasekhi’s spouse, declined to comment.
In a document filed Oct. 3, the state medical board accused Rasekhi of sexual exploitation and gross negligence in his treatment of three patients.
The first became a primary care patient of Rasekhi’s around 2005, when she was 12 years old. In 2016, she accepted a job at SCMC while still seeing Rasekhi for her medical care.
Soon after, Rasekhi began making sexually suggestive comments to her at work, the document states. These progressed to unwanted sexual contact the woman endured for fear of losing her job, according to the complaint. The abuse continued until she went on medical leave in 2020.
The medical board reviewed records of the woman’s doctor appointments with Rasekhi. According to her chart, Rasekhi performed breast exams on the patient during visits for seemingly unrelated complaints such as back pain and hair loss, the accusation states.
“Respondent denied performing breast exams during those visits and conceded that the medical record does not accurately reflect the details about the visit or the examinations actually performed,” the complaint states.
A second patient began seeing Rasekhi in 2016 at the age of 62. In September 2017, the complaint states, Rasekhi arrived unannounced at the patient’s home.
“After entering Patient 2’s home and without Patient 2’s consent and over Patient 2’s protests, Respondent made sexual advances towards, and had sexual contact with, Patient 2,” the complaint said.
A third patient was employed at SCMC from 2007 to 2017, and became a patient of Rasekhi’s in 2015. Rasekhi made frequent suggestive comments at work that escalated into advances and sexual contact that continued until her resignation, the complaint stated.
A woman whose employment dates matched those of the third patient settled with Rasekhi, Busheri and SCMC for $3.5 million in 2019, according to a report in the Daily Journal.
Science
Avocados, salmon, strawberry yogurt: Which of these meets FDA's new definition of a “healthy” food?
In an effort to improve American diets, the U.S. Food and Drug Administration Thursday released a new definition of what it means for a food to qualify as “healthy.”
Products like fruit-flavored yogurt, fortified white bread and sweetened energy bars will no longer be allowed to label themselves as healthy if they exceed certain limits on saturated fat, sodium and added sugars.
At the same time, foods like salmon, almonds and even water will qualify as healthy for the first time.
The new definition reflects the advice offered in the Dietary Guidelines for Americans, which are produced by the Department of Agriculture and the Department of Health and Human Services. The hope is that consumers who consider health claims on packaged foods while filling their grocery carts will be steered toward a more nutritious eating pattern, the FDA said.
There’s no question that Americans can use some help with their diets. For example, less than half of U.S. adults eat a piece of fruit on any given day, and only 12% consume the recommended 1.5 to 2 cups of fruit per day, according to national surveys conducted by the Centers for Disease Control and Prevention. Americans are even further off the mark with vegetables, with only 10% meeting the target of 2 to 3 cups per day.
On the other hand, 90% of us eat too much sodium, 75% eat too much saturated fat and 63% eat too many added sugars, the FDA said.
The new definition of healthy foods aims to turn that around by excluding foods with excess sodium, saturated fat and added sugars even if they also contain valuable nutrients like protein and whole grains.
The specific limits vary depending on food groups. The limits will also depend on whether a product is an individual food (like cheese), a “mixed product” (like trail mix) or a complete meal (like a frozen dinner).
For instance, in order for a dairy product such as yogurt to qualify as healthy, a single 2/3-cup serving can’t have more than 5% of the recommended daily amount of added sugars, 10% of the recommended daily amount of sodium or 10% of the recommended daily amount of saturated fat.
Those limits translate to 2.5 grams of added sugars, 230 milligrams of sodium and 2 grams of saturated fat. A single serving of Chobani strawberry Greek yogurt would miss the mark because it contains 9 grams of added sugars. So would Chobani’s “less sugar” variety, which has 5 grams of added sugars.
Sugar, salt and fat are only part of the new criteria. To meet the new definition of healthy, foods must contain a minimum amount of protein, whole grains, fruit, vegetables or fat-free or low-fat dairy, the FDA said.
Whole foods like eggs, beans, seafood and nuts will automatically qualify as healthy if they are sold with no added ingredients (except for water). That makes foods like avocados, olive oil and higher-fat fish like salmon eligible to be labeled as healthy for the first time. Fruits, vegetables and fish can make the cut if they are fresh, frozen or canned, making them accessible to people on a range of budgets, the agency said.
However, products like fortified breads, cereals, fruit snacks, granola bars and fruit punch will lose the label unless they are reformulated to meet the new definition.
Nancy Brown, chief executive of the American Heart Assn., said the new definition was long overdue and hopes it will improve Americans’ diets by motivating food manufacturers to create healthier products. However, she added that it would be more meaningful to require products to carry a nutrition label on the front of their packages, which she believes would make it easier for consumers to identify and select healthier options.
The previous definition of healthy foods, which was issued in 1994, focused more on total fat and cholesterol. Since then, nutrition scientists have recognized that not all fats should be treated the same, and that unsaturated fats found in nuts, seeds, fish and certain vegetable oils can lower disease risk.
The old definition also required foods to provide at least 10% of the recommended daily amount of vitamin A, vitamin C, calcium, iron, protein or fiber. The FDA said it is shifting its focus from specific nutrients to larger food groups in order to help consumers build a healthy dietary pattern.
Poor diet is a risk factor for many of the leading causes of death in the U.S., including heart disease, stroke, diabetes and some types of cancer.
Food manufacturers will have three years to conform to the new definition, the FDA said, though those that meet the new criteria don’t have to wait that long to start using the “healthy” label.
Science
I'm a woman in my 40s. Why do I feel terrible every time I have a drink?
This summer an old high school friend of mine decided to quit drinking entirely. She didn’t want to, but she felt she had no choice.
“All of a sudden my body decided that alcohol is poison,” she told me recently over a bitter grapefruit mocktail at an Italian restaurant. “I can have as little as one drink, and I have a hangover.”
Like me, my high school friend was never a heavy drinker. She enjoyed having a glass of wine with dinner and a craft cocktail or two at a bar or restaurant with friends. If she had several drinks in a night she would expect to feel sluggish in the morning, but one or two was never a problem. Then, sometime in her mid-40s, her ability to tolerate alcohol plummeted.
“It’s that feeling of regret,” she said when I asked her about her post-drinking symptoms. “Headache, fatigue, I don’t know how to name that feeling in your stomach.”
The last time she had a margarita she felt so terrible that she ended up canceling her plans the following evening.
It’s a story I’ve been hearing from a growing number of my female friends since we entered our mid-40s a few years ago. Molly finds drinking wreaks havoc with her digestive system and her sleep. Alexis loads up on water and Motrin even if all she’s had was a half-glass of wine. Naama, who still makes the world’s most delicious batch cocktails, stopped drinking a few years ago after getting the sweats and a splitting headache halfway through a vodka soda.
I’ve experienced it as well. After even one drink, I find myself waking up at 3 in the morning with a dull ache in my stomach, wishing I’d made a different choice. Now, each opportunity to grab a beer at a barbecue, enjoy a cocktail at a restaurant or sip a glass of wine at a dinner party requires a cost-benefit analysis: How much do I want a drink now versus but how much am I willing to pay for it later?
To understand why my friends and I are finding alcohol more difficult to tolerate as we age, I reached out to George F. Koob, director of the National Institute on Alcohol Abuse and Alcoholism.
Koob pointed to studies that show that women are more sensitive to the toxic effects of alcohol — developing alcohol-related liver disease and high blood pressure due to drinking at higher rates than men — but added that scientists are still working out why that seems to be the case.
“This is a new area of research,” he said.
While Koob wasn’t aware of studies that looked specifically at how a woman’s ability to metabolize alcohol changes in middle age, he said any changes may be due in part to the natural and inevitable fact that our lean muscle mass decreases and our body fat increases as we get older.
“You might drink the same amount of alcohol that you used to drink, but now that one drink is more like having one and a half or two drinks, because the alcohol is hanging out in the bloodstream.”
— George F. Koob, director of the National Institute on Alcohol Abuse and Alcoholism
Alcohol is drawn to water, Koob explained, and lean muscle mass has a higher percentage of water than fat does. Lean muscle mass, then, gives alcohol more space to dissipate throughout the body, making for less of it in the bloodstream, and a lower blood alcohol concentration. But as we age and lose lean muscle mass and gain fat, a higher concentration of alcohol winds up in our bloodstream. That makes for worse hangovers and extended recovery time.
“You might drink the same amount of alcohol that you used to drink, but now that one drink is more like having one and a half or two drinks, because the alcohol is hanging out in the bloodstream,” he said.
If it makes you feel any better, men also lose lean muscle mass and gain fat as they age, but men’s bodies have a higher concentration of water (55% to 65%) compared with women (45% to 50%) to begin with, so the effects may not be as obvious as they are for us.
Koob supports finding alternatives to drinking — “If you feel better when you don’t drink, then listen to your body,” he said. If you are going to drink, he offered that eating a snack beforehand can slow down the body’s absorption of alcohol and help blunt the irritation to the stomach that can cause the icky feeling I know so well. He also advised against using ibuprofen immediately after drinking, because it can also irritate the stomach. Drinking extra water will help dilute the alcohol, but ultimately, it’s the amount of alcohol you drink that will affect how you feel, not how much water you drink.
Because my friends and I are also firmly in the perimenopausal phase of our lives, I called up Dr. Monica Christmas, associate professor of obstetrics and gynecology at the University of Chicago and associate medical director of the Menopause Society, to see if our new challenges with alcohol might be related to hormonal changes as well.
The answer was a resounding yes.
She explained that alcohol triggers or exacerbates many of the symptoms of both menopause and “the menopause transition,” which can begin seven to 10 years before a woman’s period actually stops.
For example, 40% of women report mood instability during the menopause transition, which can include increased anxiety, depression, or not being motivated to do the things they once did.
“Alcohol exacerbates those things,” Dr. Christmas said. “So if you’re already experiencing mood instability, you’re only going to feel that much worse when you drink alcohol.”
I haven’t noticed my anxiety skyrocketing after having a drink or two, but my high school friend said that sounded familiar.
“There was an evil loop I was in, where I was like, I’m really anxious, maybe I’ll have another drink,” she said. “My husband was like, how’s that working out for you?”
To be clear, not all my friends feel this way. Some who have always consumed alcohol more regularly looked at me quizzically when I asked if they find it harder to drink these days. It’s possible they have developed a physiological tolerance to alcohol or may just be more used to hangovers, said MacKenzie Peltier, an assistant professor of psychiatry at Yale School of Medicine who studies sex differences in alcohol abuse disorders. It might also be that their experiences of the menopausal transition or aging are different. “But that’s complete speculation,” she said.
As for the rest of my friend group, we’re all handling this frankly unwelcome change in different ways. My high school friend has become a mocktail connoisseur. Molly hasn’t cut out alcohol completely, but she does do dry months to give her body a break. Alexis recently decided not to drink during the week anymore, but weekends are still up for debate. Naama is always on the hunt for a fancy nonalcoholic drink with low sugar content to sip at celebratory occasions.
“The only time I miss it is when we’re out with friends and the only option is Diet Coke,” she said. “And God forbid if that option is only Diet Pepsi. Then I’m really screwed.”
As for me, I’m trying to minimize the temptation to consume alcohol. Not only are pre-dinner cocktails expensive from a financial standpoint, they’re costly from a health perspective, too.
I do still love to have a drink at my Italian social club, however, and if that means a couple of rough nights a month in order to enjoy an Aperol Spritz or two — for me, that’s a trade-off I’m willing to make.
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