Science
Tooth decay still plagues California kids nearly a decade after Medi-Cal promised change
Eight years after an independent state watchdog agency harshly criticized the state for failing to provide dental care to low-income children, California has failed to remedy the problem or fully implement the commission’s recommendations, according to a follow-up review published last week.
The Little Hoover Commission found that less than half of the children in Medi-Cal received an annual dental visit in 2022 — 3% higher than when the initial report was released in 2016, which implored the state to do more to ensure that children have access to needed care.
“California is still doing a miserable job,” said Pedro Nava, chair of the commission and a former member of the state Assembly. “We have failed generations of children. We and they deserve better.”
The 2016 report was one of the most scathing reports that the commission had generated in years, Nava said. It found that only 44.5% of children in the Medi-Cal program had a visit with a dentist in 2016, a key indicator of whether children are receiving the care they need to prevent painful dental decay, and recommended that the state increase the rate to 66%. Lawmakers responded with a law requiring the health department to set a target of at least 60% of children.
Last fall, after the publication of an L.A. Times story on high rates of dental disease among California children, the commission initiated a follow-up review of the state’s progress.
It found that the state had fallen far short of the goal; in 2022, the most recent data provided in the report, 47.6% of children with Medi-Cal visited a dentist, a 3-percentage-point increase from 2016.
“If you were an investor in a private company, and that was the best they could do, you’d sell your stock and invest it somewhere else,” Nava said. “It is a disappointment that low-income families with children have to shoulder the burden of this every day.”
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California has made some improvements since 2016, the report said, fully implementing one recommendation and partially implementing seven of the commission’s eight others.
The state health department, however, disputes those findings and said they have fully implemented all of the recommendations from the 2016 report. The percentage of kids going to the dentist had been increasing significantly, they said — up to 49.6% in 2019 — but the pandemic interrupted that growth.
“California, along with every other state in the nation, was profoundly impacted by the effects of the COVID-19 pandemic. Virtually every state within the U.S. decreased and had a recovery period that lasted at least two years to return to pre-COVID figures,” the Department of Health Care Services wrote in a statement provided to The Times.
Since 2016, the department has made a number of important changes, the department wrote, including expanding the use of tele-dentistry to reach members across the state, increasing provider networks and creating a public education and outreach media campaign for Medi-Cal patients and providers.
In 2023 the percentage of children who visited the dentist “recovered to 2019 levels. Even higher utilization is projected in 2024,” the health department said, although data have not been been released on this upward trend.
“I don’t think this response really questions the fact that they have not come close to reaching the recommendation set by the Legislature of 60% of kids getting in to see the dentist, let alone our rate of 66%,” said Ethan Rarick, executive director of the Little Hoover Commission. “Kids’ dental health is among the worst in the country, and much more needs to be done.”
California children have among the worst rates of dental disease in the nation. A national survey from 2020 to 2021 found that 14.8% of the state’s children ages 1 to 17 had decayed teeth or cavities in the last 12 months studied — ranking 47th out of 51 among all the states and the District of Columbia, with only Louisiana and Wyoming faring worse. “I don’t understand,” Nava said. “If you’re the fifth-largest economy in the world, you ought to be a leader in children’s health.”
Nationwide, more than half of children develop cavities by the age of 8, usually because of poor nutrition, bad hygiene habits or a lack of dental care.
The reality of dental disease can be devastating to children, causing pain and difficulty eating, sleeping and focusing in school, and low-income children of color are at greatest risk. L.A. County’s Smile Survey, which was conducted by the public health department, found that on any given day, more than 4,500 Los Angeles County kindergarten and third-grade children need urgent dental care, which means they may be experiencing mouth pain or a serious infection.
The state increased the payment rate for evaluating a child’s teeth, for example, from $15 to $45, and up to $100 if a dentist sees the same child two years in a row, according to the California Dental Assn. The reimbursement for a filling increased from $48 to $67.20. These rate increases were funded by Proposition 56, a 2016 tobacco tax that raised money for Medi-Cal payments, and by CalAIM, a state initiative to transform Medi-Cal. The Proposition 56 money was also used to fund county oral health plans and repay student loans for new dentists.
The state has made it easier for dentists to enroll as Medi-Cal providers by simplifying the enrollment forms and putting them online, the report said. It also began a pilot program for telehealth to help bring care to healthcare deserts through the Dental Transformation Initiative.
Between the Medi-Cal payment rate and fewer administrative burdens, dentists appear to have taken note: 40% of all California dentists in the state now take Medi-Cal, a 34% increase since 2017, according to the dental association.
“The program had such a huge hole to dig out of, and COVID really derailed everything,” said Brianna Pittman-Spencer, senior director of government affairs at the California Dental Assn. “There have been improvements but obviously still a long way to go for the impact we want.”
Eileen Espejo, who leads the oral health project at Children Now, said she was pleased to see that the state had at least started to implement most of the recommendations, but that the numbers suggest the approach may not be working. “If we’re going to do better, it doesn’t seem like we should do more than the same,” she said.
In particular, she worries about children in far northern counties and those bordering Nevada, where dentists are hard to find. Twenty-one counties have five or fewer dental providers that take Medi-Cal, the report found. “How are we going to get providers to live in parts of the state where they aren’t yet?” she asked, adding that using more telehealth dentistry and allowing dental hygienists to provide more care could be part of the solution.
“Hopefully this report will light a fire and get more people engaged,” Espejo said. “I certainly think it opens the pathway for advocates to ask for more resources to help improve the program.”
This article is part of The Times’ early childhood education initiative, focusing on the learning and development of California children from birth to age 5. For more information about the initiative and its philanthropic funders, go to latimes.com/earlyed.
Science
Southern California mountain lions recommended for threatened status
The California Department of Fish and Wildlife has recommended granting threatened species status to roughly 1,400 mountain lions roaming the Central Coast and Southern California, pointing to grave threats posed by freeways, rat poison and fierce wildfires.
The determination, released Wednesday, is not the final say but signals a possibility that several clans of the iconic cougars will be listed under the California Endangered Species Act.
It’s a move that supporters say would give the vulnerable animals a chance at recovery, but detractors have argued would make it harder to get rid of lions that pose a safety risk to people and livestock.
The recommendation was “overdue,” Charlton Bonham, director of the state wildlife department, said during a California Fish and Game Commission meeting.
It arrives about six years after the Center for Biological Diversity and Mountain Lion Foundation petitioned the commission to consider listing a half-dozen isolated lion populations that have suffered from being hit by cars, poisoned by rodenticides and trapped by development.
The following year, in 2020 the Commission found the request might be warranted, giving the lions temporary endangered species protections as “candidates” for listing. It also prompted the state wildlife department to put together a report to inform the commission’s final decision.
The next step is for state wildlife commissioners to to vote on the protections, possibly in February.
Brendan Cummings, conservation director for Center for Biological Diversity, hailed the moment as “a good day, not just for mountain lions, but for Californians.”
If the commissioners adopt the recommendation, as he believes they will, then the “final listing of the species removes any uncertainty about the state’s commitment to conserving and recovering these ecologically important, charismatic and well-loved species that are so much a part of California.”
The report recommends listing lions “in an area largely coinciding” with what the petitioners requested, which includes the Santa Ana, San Gabriel, San Bernardino, Santa Monica, Santa Cruz and Tehachapi mountains.
It trims off portions along the northern and eastern borders of what was proposed, including agricultural lands in the Bay Area and a southeastern portion of desert — areas where state experts had no records of lions, according to Cummings.
Officials in the report note that most of the lion groups proposed for listing are contending with a lack of gene flow because urban barriers keep them from reaching one another.
In Southern California, lions have shown deformities from inbreeding, including kinked tails and malformed sperm. There’s an almost 1 in 4 chance, according to research, that mountain lions could become extinct in the Santa Monica and Santa Ana mountains within 50 years.
The late P-22 — a celebrity mountain lion that inhabited Griffith Park – personified the tribulations facing his kind. Rat poison and car collisions battered him from the inside out. He was captured and euthanized in late 2022, deemed too sick to return to the wild because of injuries and infection.
For some species, protections come in the form of stopping chainsaws or bulldozers. But imperiled lions, Cummings said, need their habitats stitched together in the form of wildlife crossings — such as the gargantuan one being built over the 101 Freeway in Agoura Hills. He added that developments that could restrict their movement should get more scrutiny under the proposed protections.
Critics of the effort to list lion populations have said that it will stymie residential and commercial projects.
California is home to roughly 4,170 mountain lions, according to the recent report, but not all are equal in their struggle.
Many lion populations, particularly in northwest coastal forests, are hearty and healthy.
Protections are not being sought for those cats. Some, in fact, would like to see their numbers reduced amid some high-profile conflicts.
Bonham, the director of the state Department of Fish and Wildlife, spoke to concerns about public safety at the recent meeting, alluding to the tragic death of young man who was mauled by a cougar last year in Northern California.
“These are really delicate issues and the conversation I know in the coming years is going to have to grapple with all that,” said Bonham, who will be stepping down this month after nearly 15 years in his role.
California’s lions already enjoy certain protections. In 1990, voters approved a measure that designated them a “specially protected species” and banned hunting them for sport.
Science
California’s last nuclear plant clears major hurdle to power on
California environmental regulators on Thursday struck a landmark deal with Pacific Gas & Electric to extend the life of the state’s last remaining nuclear power plant in exchange for thousands of acres of new land conservation in San Luis Obispo County.
PG&E’s agreement with the California Coastal Commission is a key hurdle for the Diablo Canyon nuclear plant to remain online until at least 2030. The plant was slated to close this year, largely due to concerns over seismic safety, but state officials pushed to delay it — saying the plant remains essential for the reliable operation of California’s electrical grid. Diablo Canyon provides nearly 9% of the electricity generated in the state, making it the state’s single largest source.
The Coastal Commission voted 9-3 to approve the plan, settling the fate of some 12,000 acres that surround the power plant as a means of compensation for environmental harm caused by its continued operation.
Nuclear power does not emit greenhouse gases. But Diablo Canyon uses an estimated 2.5 billion gallons of ocean water each day to absorb heat in a process known as “once-through cooling,” which kills an estimated two billion or more marine organisms each year.
Some stakeholders in the region celebrated the conservation deal, while others were disappointed by the decision to trade land for marine impacts — including a Native tribe that had hoped the land would be returned to them. Diablo Canyon sits along one of the most rugged and ecologically rich stretches of the California coast.
Under the agreement, PG&E will immediately transfer a 4,500-acre parcel on the north side of the property known as the “North Ranch” into a conservation easement and pursue transfer of its ownership to a public agency such as the California Department of Parks and Recreation, a nonprofit land conservation organization or tribe. A purchase by State Parks would result in a more than 50% expansion of the existing Montaña de Oro State Park.
PG&E will also offer a 2,200-acre parcel on the southern part of the property known as “Wild Cherry Canyon” for purchase by a government agency, nonprofit land conservation organization or tribe. In addition, the utility will provide $10 million to plan and manage roughly 25 miles of new public access trails across the entire property.
“It’s going to be something that changes lives on the Central Coast in perpetuity,” Commissioner Christopher Lopez said at the meeting. “This matters to generations that have yet to exist on this planet … this is going to be a place that so many people mark in their minds as a place that transforms their lives as they visit and recreate and love it in a way most of us can’t even imagine today.”
Critically, the plan could see Diablo Canyon remain operational much longer than the five years dictated by Thursday’s agreement. While the state Legislature only authorized the plant to operate through 2030, PG&E’s federal license renewal would cover 20 years of operations, potentially keeping it online until 2045.
Should that happen, the utility would need to make additional land concessions, including expanding an existing conservation area on the southern part of the property known as the “South Ranch” to 2,500 acres. The plan also includes rights of first refusal for a government agency or a land conservation group to purchase the entirety of the South Ranch, 5,000 acres, along with Wild Cherry Canyon — after 2030.
Pelicans along the concrete breakwater at Pacific Gas and Electric’s Diablo Canyon Power Plant
(Brian van der Brug/Los Angeles Times)
Many stakeholders were frustrated by the carve-out for the South Ranch, but still saw the agreement as an overall victory for Californians.
“It is a once in a lifetime opportunity,” Sen. John Laird (D-Santa Cruz) said in a phone call ahead of Thursday’s vote. “I have not been out there where it has not been breathtakingly beautiful, where it is not this incredible, unique location, where you’re not seeing, for much of it, a human structure anywhere. It is just one of those last unique opportunities to protect very special land near the California coast.”
Others, however, described the deal as disappointing and inadequate.
That includes many of the region’s Native Americans who said they felt sidelined by the agreement. The deal does not preclude tribal groups from purchasing the land in the future, but it doesn’t guarantee that or give them priority.
The yak titʸu titʸu yak tiłhini Northern Chumash Tribe of San Luis Obispo County and Region, which met with the Coastal Commission several times in the lead-up to Thursday’s vote, had hoped to see the land returned to them.
Scott Lanthrop is a member of the tribe’s board and has worked on the issue for several years.
“The sad part is our group is not being recognized as the ultimate conservationist,” he told The Times. “Any normal person, if you ask the question, would you rather have a tribal group that is totally connected to earth and wind and water, or would you like to have some state agency or gigantic NGO manage this land, I think the answer would be, ‘Hey, you probably should give it back to the tribe.’”
Tribe chair Mona Tucker said she fears that free public access to the land could end up harming it instead of helping it, as the Coastal Commission intends.
“In my mind, I’m not understanding how taking the land … is mitigation for marine life,” Tucker said. “It doesn’t change anything as far as impacts to the water. It changes a lot as far as impacts to the land.”
Montaña de Oro State Park.
(Christopher Reynolds / Los Angeles Times)
The deal has been complicated by jurisdictional questions, including who can determine what happens to the land. While PG&E owns the North Ranch parcel that could be transferred to State Parks, the South Ranch and Wild Cherry Canyon are owned by its subsidiary, Eureka Energy Company.
What’s more, the California Public Utilities Commission, which regulates utilities such as PG&E, has a Tribal Land Transfer Policy that calls for investor-owned power companies to transfer land they no longer want to Native American tribes.
In the case of Diablo Canyon, the Coastal Commission became the decision maker because it has the job of compensating for environmental harm from the facility’s continued operation. Since the commission determined Diablo’s use of ocean water can’t be avoided, it looked at land conservation as the next best method.
This “out-of-kind” trade-off is a rare, but not unheard of way of making up for the loss of marine life. It’s an approach that is “feasible and more likely to succeed” than several other methods considered, according to the commission’s staff report.
“This plan supports the continued operation of a major source of reliable electricity for California, and is in alignment with our state’s clean energy goals and focus on coastal protection,” Paula Gerfen, Diablo Canyon’s senior vice president and chief nuclear officer, said in a statement.
But Assemblymember Dawn Addis (D-Morro Bay) said the deal was “not the best we can do” — particularly because the fate of the South Ranch now depends on the plant staying in operation beyond 2030.
“I believe the time really is now for the immediate full conservation of the 12,000 [acres], and to bring accountability and trust back for the voters of San Luis Obispo County,” Addis said during the meeting.
There are also concerns about the safety of continuing to operate a nuclear plant in California, with its radioactive waste stored in concrete casks on the site. Diablo Canyon is subject to ground shaking and earthquake hazards, including from the nearby Hosgri Fault and the Shorline Fault, about 2.5 miles and 1 mile from the facility, respectively.
PG&E says the plant has been built to withstand hazards. It completed a seismic hazard assessment in 2024, and determined Diablo Canyon is safe to continue operation through 2030. The Coastal Commission, however, found if the plant operates longer, it would warrant further seismic study.
A key development for continuing Diablo Canyon’s operation came in 2022 with Senate Bill 846, which delayed closure by up to five additional years. At the time, California was plagued by rolling blackouts driven extreme heat waves, and state officials were growing wary about taking such a major source of power offline.
But California has made great gains in the last several years — including massive investments in solar energy and battery storage — and some questioned whether the facility is still needed at all.
Others said conserving thousands of acres of land still won’t make up for the harms to the ocean.
“It is unmitigatable,” said David Weisman, executive director of the nonprofit Alliance for Nuclear Responsibility. He noted that the Coastal Commission’s staff report says it would take about 99 years to balance the loss of marine life with the benefits provided by 4,500 acres of land conservation. Twenty more years of operation would take about 305 years to strike that same balance.
But some pointed out that neither the commission nor fisheries data find Diablo’s operations cause declines in marine life. Ocean harm may be overestimated, said Seaver Wang, an oceanographer and the climate and energy director at the Breakthrough Institute, a Berkeley-based research center.
In California’s push to transition to clean energy, every option comes with downsides, Wang said. In the case of nuclear power — which produces no greenhouse gas emissions — it’s all part of the trade off, he said.
“There’s no such thing as impacts-free energy,” he said.
The Coastal Commission’s vote is one of the last remaining obstacles to keeping the plant online. PG&E will also need a final nod from the Regional Water Quality Control Board, which decides on a pollution discharge permit in February.
The federal Nuclear Regulatory Commission will also have to sign off on Diablo’s extension.
Science
In search for autism’s causes, look at genes, not vaccines, researchers say
Earlier this year, Health and Human Services Secretary Robert F. Kennedy Jr. pledged that the search for autism’s cause — a question that has kept researchers busy for the better part of six decades — would be over in just five months.
“By September, we will know what has caused the autism epidemic, and we’ll be able to eliminate those exposures,” Kennedy told President Trump during a Cabinet meeting in April.
That ambitious deadline has come and gone. But researchers and advocates say that Kennedy’s continued fixation on autism’s origins — and his frequent, inaccurate claims that childhood vaccines are somehow involved — is built on fundamental misunderstandings of the complex neurodevelopmental condition.
Even after more than half a century of research, no one yet knows exactly why some people have autistic traits and others do not, or why autism spectrum disorder looks so different across the people who have it. But a few key themes have emerged.
Researchers believe that autism is most likely the result of a complex set of interactions between genes and the environment that unfold while a child is in the womb. It can be passed down through families, or originate with a spontaneous gene mutation.
Environmental influences may indeed play a role in some autism cases, but their effect is heavily influenced by a person’s genes. There is no evidence for a single trigger that causes autism, and certainly not one a child encounters after birth: not a vaccine, a parenting style or a post-circumcision Tylenol.
“The real reason why it’s complicated, the more fundamental one, is that there’s not a single cause,” said Irva Hertz-Picciotto, a professor of public health science and director of the Environmental Health Sciences Center at UC Davis. “It’s not a single cause from one person to the next, and not a single cause within any one person.”
Kennedy, an attorney who has no medical or scientific training, has called research into autism’s genetics a “dead end.” Autism researchers counter that it’s the only logical place to start.
“If we know nothing else, we know that autism is primarily genetic,” said Joe Buxbaum, a molecular neuroscientist who directs the Seaver Autism Center for Research and Treatment at the Icahn School of Medicine at Mount Sinai. “And you don’t have to actually have the exact genes [identified] to know that something is genetic.”
Some neurodevelopment disorders arise from a difference in a single gene or chromosome. People with Down syndrome have an extra copy of chromosome 21, for example, and Fragile X syndrome results when the FMR1 gene isn’t expressed.
Autism in most cases is polygenetic, which means that multiple genes are involved, with each contributing a little bit to the overall picture.
Researchers have found hundreds of genes that could be associated with autism; there may be many more among the roughly 20,000 in the human genome.
In the meantime, the strongest evidence that autism is genetic comes from studies of twins and other sibling groups, Buxbaum and other researchers said.
The rate of autism in the U.S. general population is about 2.8%, according to a study published last year in the journal Pediatrics. Among children with at least one autistic sibling, it’s 20.2% — about seven times higher than the general population, the study found.
Twin studies reinforce the point. Both identical and fraternal twins develop in the same womb and are usually raised in similar circumstances in the same household. The difference is genetic: identical twins share 100% of their genetic information, while fraternal twins share about 50% (the same as nontwin siblings).
If one fraternal twin is autistic, the chance that the other twin is also autistic is about 20%, or about the same as it would be for a nontwin sibling.
But if one in a pair of identical twins is autistic, the chance that the other twin is also autistic is significantly higher. Studies have pegged the identical twin concurrence rate anywhere from 60% to 90%, though the intensity of the twins’ autistic traits may differ significantly.
Molecular genetic studies, which look at the genetic information shared between siblings and other blood relatives, have found similar rates of genetic influence on autism, said Dr. John Constantino, a professor of pediatrics, psychiatry and behavioral sciences at the Emory University School of Medicine and chief of behavioral and mental health at Children’s Healthcare of Atlanta.
Together, he said, “those studies have indicated that a vast share of the causation of autism can be traced to the effects of genetic influences. That is a fact.”
Buxbaum compares the heritability of autism to the heritability of height, another polygenic trait.
“There’s not one gene that’s making you taller or shorter,” Buxbaum said. Hundreds of genes play a role in where you land on the height distribution curve. A lot of those genes run in families — it’s not unusual for very tall people, for example, to have very tall relatives.
But parents pass on a random mix of their genes to their children, and height distribution across a group of same-sex siblings can vary widely. Genetic mutations can change the picture. Marfan syndrome, a condition caused by mutations in the FBN1 gene, typically makes people grow taller than average. Hundreds of genetic mutations are associated with dwarfism, which causes shorter stature.
Then once a child is born, external factors such as malnutrition or disease can affect the likelihood that they reach their full height potential.
So genes are important. But the environment — which in developmental science means pretty much anything that isn’t genetics, including parental age, nutrition, air pollution and viruses — can play a major role in how those genes are expressed.
“Genetics does not operate in a vacuum, and at the same time, the impact of the environment on people is going to depend on a person’s individual genetics,” said Brian K. Lee, a professor of epidemiology and biostatistics at Drexel University who studies the genetics of developmental disorders.
Unlike the childhood circumstances that can affect height, the environmental exposures associated with autism for the most part take place in utero.
Researchers have identified multiple factors linked to increased risks of the disorder, including older parental age, infant prematurity and parental exposure to air pollution and industrial solvents.
Investigations into some of these linkages were among the more than 50 autism-related studies whose funding Kennedy has cut since taking office, a ProPublica investigation found. In contrast, no credible study has found links between vaccines and autism — and there have been many.
One move from the Department of Health and Human Services has been met with cautious optimism: even as Kennedy slashed funding to other research projects, the department in September announced a $50-million initiative to explore the interactions of genes and environmental factors in autism, which has been divided among 13 different research groups at U.S. universities, including UCLA and UC San Diego.
The department’s selection of well-established, legitimate research teams was met with relief by many autism scientists.
But many say they fear that such decisions will be an anomaly under Kennedy, who has repeatedly rejected facts that don’t conform to his preferred hypotheses, elevated shoddy science and muddied public health messaging on autism with inaccurate information.
Disagreements are an essential part of scientific inquiry. But the productive ones take place in a universe of shared facts and build on established evidence.
And when determining how to spend limited resources, researchers say, making evidence-based decisions is vital.
“There are two aspects of these decisions: Is it a reasonable expenditure based on what we already know? And if you spend money here, will you be taking money away from HHS that people are in desperate need of?” Constantino said. “If you’re going to be spending money, you want to do that in a way that is not discarding what we already know.”
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