By Claudia Boyd-Barrett

The need for mental health services has surged during the COVID-19 pandemic, increasing pressure on California’s already beset mental health care system.

Yet one source of funding that could potentially help counties meet the demand for mental health care remains underused more than a year after the California Health Report first drew attention to the issue.

Counties can be reimbursed for providing mental health services to low-income residents through several state and federal programs. One is called Mental Health Medi-Cal Administrative Activities, or MH MAA, which provides funds for people enrolled in Medi-Cal, the state’s low-income health insurance program. 

More than a third of Californians are enrolled in Medi-Cal. Claiming more administrative funding could increase counties’ mental health budgets by millions of dollars, freeing up other money for direct mental health care, said Alex Briscoe, a former director of Alameda County’s health agency who now works as a consultant to counties interested in increasing their administrative claims. 

But very few counties participate in the program, state data shows, and those who do mostly claim only small amounts. 

Out of California’s 58 counties, only 15 claimed MH MAA funds for the 2019-20 fiscal year. Among those who did, most received a tiny fraction of the total statewide reimbursement of $41.7 million. A few, including Fresno, San Mateo and Santa Clara counties, did claim substantially more compared to four years ago, but most counties increased their reimbursements only modestly. Some, such as Sonoma, San Diego, Orange and Los Angeles counties — actually claimed less in 2019-20 than they did four years prior.

One notable exception is Alameda County, which has a history of maximizing MH MAA funding. The county, including the city of Berkeley, increased its claims from about $4 million in the 2016-17 fiscal year to over $24 million in 2019-20, accounting for more than half of statewide reimbursements last year. 

Each year, counties can opt to claim back some of the money they or their contractors spend on certain administrative work for mental health care by applying for the federal reimbursement. Counties can claim these funds for program administration, planning, referring people experiencing a mental health crisis to services, and helping people apply for Medi-Cal benefits.

Some county officials contacted by the California Health Report said that applying for the reimbursements is too complex and time consuming. They were also concerned about an increased risk of auditing from the state. Others considered the program inapplicable or irrelevant for their counties, because they can claim most of their administrative costs through another, simpler reimbursement program.

“Not only is it very burdensome to claim … but the state has tightened rules around claiming, increasing the burden around claiming and the audit risk,” said Jeffrey Nagel, Orange County’s deputy agency director of Behavioral Health Services, in an email. “There are other strategies to increase revenues that result in greater revenue with less administrative burden and less audit risk.”

Orange County’s strategies include claiming reimbursement for administrative costs as part of the county’s overall Medi-Cal mental health spending. This is an easier process that allows counties to claim up to 15 percent of the amount spent on mental health for administrative expenses (this increased to 30 percent during the pandemic). 

Riverside County has historically operated well under this 15 percent administrative claim maximum, which is why it hasn’t applied for MH MAA funds, said Thomas Peterson, county spokesperson. 

“Our understanding is that the MH MAA reimbursement program may be utilized when a county exceeds the administrative reimbursement cap and not all costs are eligible for reimbursement as a result,” Peterson wrote in an email.

Patrick Sutton, a long-time consultant on MH MAA funding who now works with Briscoe, said he’s looked at cost reports from across the state and most counties could take advantage of the program even if their immediate administrative costs don’t go above 15 percent. That’s because community-based organizations that contract with counties to provide mental health services are entitled to claim MH MAA money, he said. That requires time-keeping measures and staff training so that organizations can submit these claims through the county. It takes effort, but it’s doable, as Alameda County has demonstrated. 

“If the ultimate goal is to maximize your federal dollar, then it’s hard to imagine why many counties wouldn’t do mental health MAA,” he said. “I have yet to see a large county where it wouldn’t have been advantageous for them.”

Sutton and Briscoe worked with Los Angeles County in 2019 to increase its administrative reimbursement claims for the previous year. The county’s MH MAA claims soared to $15.6 million in the 2018-19 fiscal year, up from $5.4 million in 2017-18. However, last year, their claims dropped to $4 million. 

L.A. County did not respond to multiple requests for comment before the publication deadline. Sutton said the county had concerns about whether their timekeeping surveys met state and federal requirements, but he did not know the full story.

Briscoe said he’s in conversation with San Francisco and Sacramento counties about helping them claim MH MAA money, which they currently don’t. He has also urged the state Department of Health Care Services, which oversees Medi-Cal, to make the claiming process more accessible. A spokesperson for the San Francisco Department of Public Health said the county is conducting an analysis to determine whether to pursue the claiming procedure.

COVID-19 has also complicated county efforts to seek more funding, said Orange County’s Nagel.  

“While it may be possible to increase the MAA revenue source (with added costs of claiming, reporting and audit risk), we must also keep in mind that operations during 2020 had to be responsive to a global pandemic,” he wrote. “The COVID-19 pandemic strained the resources of staffing that would be necessary for training, tracking and reporting related to an increase in MAA claiming.”

To Briscoe, the budget pressures wrought by the pandemic make pursuing the funding even more important. In fact, he said he’s received calls from several counties asking for help obtaining the administrative funds. 

There’s a dire need for mental health services, and local governments must do everything in their power to meet it, Briscoe said.  A report by the Centers for Disease Control and Prevention in August found that symptoms for anxiety and depressive disorders among adults had increased between three and four-fold during the pandemic compared to 2019. Mental-health related emergency department visits among children have also soared.

“At the heart of it is a culture of public service,” he said.

Carol Sloan, a spokesperson for the state Health Care Services agency, meanwhile, said the department offers technical assistance to counties interested in the MH MAA program. Sloan said the state can’t change the application rules because it’s a federal program.

“While DHCS makes every attempt to remove unnecessary administrative burdens, the Department is required to comply with all statutes and regulations, which are prerequisites for counties to enroll in the program and receive federal funds,” Sloan wrote.

By Claudia Boyd-Barrett

The first time Cat Brooks sought help from the police to deal with her violent husband was also the last.

She was a 19-year-old college student, married to a man 10 years her senior. One night, after he beat her severely, her husband called police to their Las Vegas home. 

Brooks was bruised, scratched and bleeding, and assumed officers would take her side. But her unscathed husband insisted Brooks had attacked him, a victim-blaming tactic not uncommon among domestic abusers. The officers, all of whom were white like her husband, whisked Brooks, who is Black, to jail. They released her back to her abuser the following day.

“The message that (was) communicated to me was, ‘The police aren’t here to help me,’” said Brooks, now 45 and living in Oakland. “I never called them again.” 

Brooks’ experience isn’t unusual. A 2015 survey by the National Domestic Violence Hotline found that about 75 percent of survivors who called the police on their abusers later concluded that police involvement was unhelpful at best, and at worst made them feel less safe. 

A quarter of those surveyed said they were arrested or threatened with arrest when reporting partner abuse or sexual assault to police. About half of survivors never called the police at all, citing fear of discrimination by police, invasion of privacy, wanting to protect their children, not wanting their partner arrested, or concern that involving the authorities would exacerbate the violence. 

“[I am afraid] of making the situation worse,” one survivor who did not call police told the hotline. “They might arrest my abuser, and when he is out, he will hurt me like he has threatened.”

Another survivor who did call the police said, “I felt the police were buddy-buddy with my partner and ignored what I had to say and the reality of the situation. I was scared, and they ignored me.”

At 19, Brooks was severely beaten by her husband. When police intervened, Brooks was taken to jail rather than her husband.

Faced with findings and experiences like these, researchers and survivor advocates are increasingly searching for alternative ways to address domestic violence. More and more, they are beginning to question: If involving the police and criminal justice system isn’t a safe, reliable option for most survivors, why is it offered as the main pathway for seeking help? The conversation has gained new urgency amidst the rise of the Black Lives Matter movement and calls to reevaluate the scope of police funding and responsibilities.

“For decades, survivors have told us that it’s not safe for them to call law enforcement, that they don’t want to be ushered into a criminal justice system,” said Colsaria Henderson, board president for the California Partnership to End Domestic Violence. “What they want is the ability to be safe in their homes and in their families. They want the violence to stop.

“It’s really time that we re-center on what the survivors are telling us.”

Indigenous and LGTBQ perspectives

Immigrant victims of domestic violence can face additional hurdles. Some avoid calling the police out of fear that they or their family members will be deported, said Dulce Vargas, who coordinates a domestic violence intervention and prevention program for the Mixteco/Indígena Community Organizing Project in Oxnard, which serves Ventura County’s indigenous immigrant population. Survivors and their children may also be reliant financially on their abusers and have no family in the country they can turn to for support. If an abusive partner is arrested or deported, survivors worry they’ll be left destitute, Vargas explained. Additionally, police officers rarely speak indigenous languages or understand the cultural dynamics within the community, which further deters survivors from calling.

Mistrust of law enforcement is also pervasive within the LGBTQ community, said Terra Russell-Slavin, deputy director of policy and community building at the Los Angeles LGBT Center. That’s partly because the legal system historically criminalized gay and transgender people. LGBTQ survivors are still subject to higher rates of wrongful arrest, Russell-Slavin said.

“Much of the (police) assumption and assessment is based on (traditional) gender roles, and that just doesn’t hold true for LGBT survivors,” she said. “That can lead to survivors being deemed perpetrators because maybe they’re more masculine presenting or they’re relying on size differentials and other factors.”

Survivors of sexual violence sometimes also find police intervention ineffective. After suffering a sexual assault seven years ago, Laura Heraldez, 41, of Bakersfield sought help at a hospital, where the staff called the police. But when officers arrived, they dismissed her story, according to Heraldez, and refused to authorize a rape kit because she had been drinking. 

“They told me that I was drunk, that I was not raped,” she said. “It caused me to numb everything and not get the help I needed. I didn’t seek therapy. I got absolutely no help. I was in complete denial of what happened to me, because you get told something and you start believing it.” 

Laura Heraldez sits in Jastro Park in Bakersfield.

‘We’ve informally done it for centuries’

The search for more effective interventions has become even more important during the COVID-19 pandemic. Reports of domestic violence have soared while survivors are confined at home with their abusers, and families face additional economic and emotional pressures. 

So far, there is no broad agreement on the best or most effective alternative solutions to address domestic violence, but some ideas are coming into focus. They include creating trained networks of community volunteers to intervene in domestic disputes, engaging survivors and their partners in restorative justice proceedings removed from the criminal legal system, and establishing programs that encourage men to embrace healthy definitions of masculinity.  

Brooks, who is now executive director of Justice Teams Network, a coalition of organizations dedicated to eradicating state violence, is a leader in the effort to identify alternatives. Over the past year, her organization has been working on a toolkit that lays out principles and strategies communities can use to create their own responses to inter-partner abuse. The work is based on conversations with community members and organizations around the country who are working to address domestic violence and police overreach, mainly in communities of color, she said. It also draws from a program she helped launch this summer in Oakland called Mental Health First, that offers a hotline people can call instead of 911 for help de-escalating psychiatric crises.

Statistics show people of color are more likely than white people to be incarcerated and face police violence.  One study estimated that Black men are 2.5 times more likely to be killed by law enforcement than white men. Women of color and those living in poverty also face disproportionate rates of criminalization and are more likely than white women to be criminalized and punished for surviving violence, according to a report from PolicyLink.

While the toolkit is still a work in progress, Brooks said there are some main principles that can help inform the dialogue around solutions. First, advocates agree that responses should be localized to individual communities or even neighborhood blocks, be culturally sensitive, and have broad community oversight. 

Such responses should also allow survivors to make decisions about how they want the violence addressed, and incorporate interventions that help the entire family (including children and the perpetrator). Although law enforcement should be a last resort, there must be a plan for when calling police is appropriate to ensure safety, she added. Brooks said she envisions small crisis intervention teams run out of churches, mosques or community centers, likely staffed by volunteers and funded through local philanthropy. 

One solution might be similar to the Mental Health First hotline in Oakland, which responds to mental health crises, including those involving domestic violence. A survivor or person concerned about a domestic violence incident would call a hotline staffed by trained volunteers such as doctors, nurses, mental health professionals and community members. A team of volunteers would then respond in-person to the incident, work to deescalate the situation and connect the parties involved with community resources such as shelters, mental health treatment or financial assistance.  

Colsaria Henderson, board president for the California Partnership to End Domestic Violence, in Newark, Calif.

Some organizations have also attempted to resolve domestic violence disputes through a process called restorative or transformative justice. The process varies, but in general it involves a mediated discussion between the survivor, perpetrator and community members. They discuss the violence and its impact then agree on a safety and reparations plan — including ongoing accountability for the perpetrator. 

Alternative approaches to handling domestic violence have long existed informally in communities of color, where mistrust of law enforcement runs deep, said Henderson. They are people or groups that survivors turn to for help, such as local pastors, attorneys, friends, relatives or even hair stylists, she said. 

“We’ve informally done it for centuries,” said Henderson. “But it didn’t have a dedicated number to call. It didn’t have a true, regular avenue to flourish.”

Optimizing these alternatives and making them widely available will require funding for pilot projects in different communities, she and others agreed. But Anita Raj, director of the Center on Gender Equity and Health at the UC San Diego School of Medicine, said significant investment from government at all levels is needed to fund these projects, but budgets are slow to shift in that direction.

One attempt at the state level to fund alternative responses to domestic violence was vetoed by Gov. Gavin Newsom in September. Assembly bill 2054 would have provided grants of at least $250,000 to help community-based organizations establish pilot programs that address emergency situations such as domestic violence without involving the police. In his veto letter, Newsom disagreed with the bill’s proposal to house the pilot program under the California Office of Emergency Services. Instead, he wanted it assigned to the Board of State and Community Corrections. But supporters of the bill felt this was antithetical to its purpose, arguing that alternatives should be separate from the criminal legal system. 

It’s important to acknowledge that some survivors do find police help effective and they want access to law enforcement, Russell-Slavin said. Police intervention is one tool for addressing domestic violence, Russell-Slavin explained, but may not be the best tool for every situation.

A society that has allowed violence and racism to flourish

Whatever solutions eventually emerge, most advocates agree they need to involve the perpetrators of domestic violence. Statistically, most often, that means men, although women and nonbinary people can be abusive too. An estimated one in four women and one in 10 men in the U.S. experience sexual or physical violence or stalking by an intimate partner in their lifetimes, according to the National Coalition Against Domestic Violence, although incidents are likely underreported. African Americans, Native Americans and multiracial people are at highest risk for domestic violence, according to a report by the Blue Shield of California Foundation. 

Marc Philpart is principal coordinator of the Alliance for Boys and Men of Color at PolicyLink, a national network of community-based organizations seeking policies that better support the wellbeing of boys and men of color, and their families. That includes policy shifts in responses to inter-partner violence. The organization argues, domestic violence should be treated as a public health problem arising from societal norms and structures that have allowed violence, racism and misogyny to flourish. Embroiling perpetrators in the criminal legal system only exacerbates that violence, Philpart said. Men need a chance to learn new patterns of behavior, heal from their own traumatic experiences, and become positive agents of change in their relationships and communities, he said. 

Marc Philpart, principal coordinator of the Alliance for Boys and Men of Color at PolicyLink, stands outside the Critical Resistance offices in the Temescal neighborhood of Oakland.

“We’ve found ourselves in this situation where men aren’t involved in solution making and in safety planning and in stabilizing relationships,” said Philpart. “That one-sided approach has done nothing but deepen male involvement in the carceral state and in the criminal legal system and it also has led to significantly more destabilization in families and hasn’t helped to break the cycle of violence in a way that has been productive.”

Currently, the only widely funded education programs targeting perpetrators of domestic violence are so-called “batterer intervention programs.” These programs are typically overseen by county probation departments, and men attend because they’re required to by court order. 

The forced nature of the programs and the association with the legal system mean that men who attend feel stigmatized, Philpart said. There is little evidence that these programs work to change men’s behavior or keep victims safe, and it’s been shown that many men fail to complete the program because there is so little accountability.

To reach more men, programs like these should be overseen by agencies like public health departments, not probation agencies, said Philpart. They should be promoted as open to anyone who wants to participate, not just those convicted of a crime. And they need to reflect the culture of the community they’re serving, Philpart added.

The San Jose-based National Compadres Network has offered programs like this for years, although they are run by community-based organizations rather than local governments. The nonprofit has developed a concept called “men’s circles” where men come together to assess their own misguided ideas about manhood; explore those within the context of their experiences with systemic racism, oppression and childhood trauma; and develop a new understanding of what it means to be honorable based on their cultural heritage. The circles mostly serve men of color — largely those who are Latinx, Native American and Black. They also welcome people who are gay, lesbian, bisexual, queer/questioning and transgender. Some of the participants are referred by probation departments, but the programs welcome all men or people who identify as male who are seeking to be better fathers, partners, brothers, grandfathers and community members and to improve their relationships, said Jerry Tello, who founded the nonprofit.

Jerry Tello, founder of the National Compadres Network, sits in the garden of the Los Angeles chapter of the network.

Dozens of men’s circles exist in California and across the country. The Compadres Network also offers nonviolence programs that target specific groups of men and boys, such as fathers, teenagers and gang members. Additionally, they run circles for women and mothers on how to improve family relationships and raise healthy boys. 

“Really this is a process and a movement and a re-grounding of manhood, a re-grounding of what it means to develop in a healthy way,” Tello said.

Mixteco/Indígena Community Organizing Project also runs a domestic violence intervention and prevention program for both men and women. Living With Love is a series of workshops held in Spanish and the indigenous language Mixteco, that focuses on how to have healthy relationships, the impact of domestic violence on families and children and what to do if someone is experiencing domestic violence. The program, which is funded by the California Department of Public Health, encourages participants to explore the reasons for their own violent behavior, such as childhood trauma, said Vargas, the coordinator. Promotional materials for the program emphasize healthy relationships and self-care, rather than domestic violence specifically, which she said reduces stigma and encourages more people to participate.

Dulce Vargas, coordinator of a domestic violence intervention and prevention program for the Mixteco/Indígena Community Organizing Project (MICOP), photographed at the MICOP offices in Oxnard.

To make interventions like this more widely available, the Alliance for Boys and Men of Color recommended in a policy paper last year that California create a statewide office focused on violence prevention and intervention, increase violence prevention programs and services in schools, and increase funding for community-based solutions to end domestic violence. 

Brooks left her abusive husband in 1994, but she wonders what difference the alternative intervention strategies now being proposed would have made for both her and her ex-partner if they’d had access to them. 

“I could have gotten the help I needed, the healing I needed,” she said. “Maybe he could have too.” 

This story was produced in partnership with Resolve Magazine and YES! Magazine.

By Denzel Tongue 

Photo by iStock/Marcos Elihu Castillo Ramirez

For Sarah Dar, the success of California’s Health4All Campaign is a “life-or-death issue” for the state’s undocumented seniors.  If the expansion to cover undocumented seniors is legislated, it would be the first time in California’s history, says the public benefits director at California Immigrant Policy Center.  

While President Barack Obama’s 2010 health reform bill, the Affordable Care Act, greatly expanded insurance access, it excluded undocumented immigrants across the country. This likely contributed to COVID-19’s disproportionate impact on undocumented Californians—an example of how institutional inequity can have life-altering consequences.

Health equity and immigrant rights advocates have been urging California leaders to broaden health coverage for nearly a decade. Health4All began in earnest in 2013 when advocates first introduced legislation designed to expand Medi-Cal coverage to undocumented immigrants in California. Medi-Cal is California’s low-income health insurance program. Then in 2015, Gov. Jerry Brown signed SB 75 into law, expanding Medi-Cal access to undocumented children under 18 in the Golden State. And in 2019, Gov. Gavin Newsom expanded Medi-Cal coverage further to young adults up to age 25, regardless of immigration status.

But that hasn’t helped older adults like Pedro Montes Vargas, a former farmworker. Montes Vargas, 76, has been in California’s Central Valley since 1975. He worked in the fields as a repairman for decades, fixing irrigation systems and farm equipment, along with other related tasks. In recent years, Montes Vargas has been forced to slow down because of his age and health challenges. He has high blood pressure, diabetes, and high cholesterol, which have made it difficult for him to use his hands and continue to work.

Montes Vargas, who shared his story through an interpreter, now relies primarily on recycling to gain a modicum of income to support himself and his elderly wife. Because he is undocumented, he doesn’t qualify for Medi-Cal. He receives limited medical care from a local community clinic but is often unwilling to go because he has to pay out of pocket. Montes Vargas has already accumulated medical debt and receives regular calls from debt collectors. 

Pedro Montes Vargas. Photo from Central Valley Immigrant Integration Collaborative (CVIIC).

California has hundreds of thousands of other immigrants like Montes Vargas. If the state expanded Medi-Cal to all undocumented immigrants, they would be eligible to receive potentially life-saving health care.

Undocumented immigrants make up the single largest group of uninsured people in the state. Projections show that, if nothing changes, by 2022, undocumented Californians will comprise roughly 38% of California’s uninsured population. The lack of access to health care has likely contributed to higher mortality rates in occupations that undocumented Californians tend to hold, especially during the COVID-19 pandemic. For example, agricultural workers died at a 55% higher rate during the pandemic compared to pre-pandemic times. Mortality rates among California’s construction laborers and cooks soared by 49 and 60%  respectively. In comparison, Californians in general ages 18 to 65 experienced a 22% increase in mortality between March and October 2020. 

Undocumented immigrants have been instrumental in keeping California running during the pandemic. Not only do we rely on their work, but also their contributions to the economy and tax system. In 2018, undocumented Californians paid an estimated $3.7 billion in state and local taxes, and $7 billion in federal taxes. Ironically, some of their tax dollars fund Medi-Cal, the very program they’re excluded from. 

Health4All coalition members are now calling for the state to expand full Medi-Cal coverage to undocumented elders like Montes Vargas. They see this as the next critical step toward eventually expanding coverage to all undocumented adults.

Newsom included funding for undocumented seniors ages 65 and older in his January budget proposal for fiscal year 2020-21, but state leaders failed to include the expansion in the final budget, citing the economic downturn created by the COVID-19 pandemic. 

Beginning in 2018, I served as a campaign coordinator for the Health4All campaign for two years. I saw firsthand how determined residents in the Inland Empire were to find health care for their elderly relatives and neighbors. I remember community members from TODEC Legal Center passionately advocating for immediate coverage of undocumented elders in their community during a legislative visit to state Sen. Richard Roth’s office. After years of organizing and storytelling, their work was so powerful that it led Roth to agree to co-sponsor the senate bill for Health4All Seniors in 2019. Moments like these remind me that the stakes of organizing for health equity are not theoretical—they are life-altering.

Newsom has shown a willingness to lead on the defining issues of our era. He’s taken concrete steps to make health care more affordable and accessible. It’s time for the governor to prioritize expanding health care to one of our state’s most vulnerable groups. 

The momentum is present, the economic rationale is clear, and the moral reasons are indisputable. It is now up to our state leaders to decide whether or not community elders who have sacrificed their working lives to support California’s economy deserve to live and age with dignity.

This story was produced in partnership with Yes! Magazine.

By Laurine Lassalle • Jan 21, 2020

Photo credit: iStock. 

When President Barack Obama enacted the Affordable Care Act a nearly decade ago, the broad aim was to improve health care access. One of the pieces of that legislation: requiring doctors to use electronic health records. 

Electronic health records, which include health histories, prescriptions and test results, are now commonplace—but not everyone has access to them.

Apple users are the only ones who can access their health records on their phones. CommonHealth, a new app for Android users, wants to change that and tackle health disparities in the process.

“Android users tend to earn lower incomes, so medical centers using the Apple app are cutting out (a large fraction of patients),” said Ida Sim, a professor of medicine at UC San Francisco, where she leads the team piloting the app. 

Sim and UCSF colleagues collaborated with Cornell Tech, the nonprofit Commons Project, and two other nonprofits to develop CommonHealth, which will be available to download for free in the coming months. 

The app will allow patients with Android phones to safely store their health records on their devices and tell them how other apps are treating their stored health information. Experts also say it’s a step toward addressing the health-information access gap between Android and Apple users, because it will make medical records universally available—no matter the users’ smartphone brand. 

Apple launched Apple Health Records two years ago, in January 2018, as part of the Apple Health app. The app allows users to access their immunization records, prescriptions, test results, documented allergies and other health information collected through their doctor’s patient portal. 

The Office of the National Coordinator Health Information Technology reportedthat from January to May 2018, about 60 percent of the people who were offered access to online medical records viewed their records at least once on their smartphone or tablet.

Elaine Khoong, an associate professor at UCSF and primary care research fellow at Zuckerberg San Francisco General Hospital, said that most of her patients express interest in accessing their health information online. But she said that even with apps for both Apple and Android users, there will still be barriers in the way. 

“Our patient population is overwhelmingly a lot of patients with limited health literacy, who are low-income insured on Medicaid, racial-ethnic minority groups, and there’s a certain number of limited English proficient patients as well,” she said. 

Khoong, who is conducting patient interviews on usability, testing and perceptions about CommonHealth, said she is preparing to test the app with Spanish and Chinese speaking patients in the future. 

Accessing test results requires some level of health knowledge to understand what their results mean, said Adrian Aguilera, associate professor at UC Berkeley’s School of Social Welfare who conducts research on mobile health technology. This can discourage “patients from looking at their electronic health records,” Aguilera said. 

Studies have shown that the smartphone market is almost equally divided between Apple and Android, but iPhone users are more likely to earn higher incomes than Android users. 

A 2013 Pew Research Center study showed that 40 percent of cellphone owners who earned $75,000 or more annually had an iPhone, while 31 percent had an Android. Only 13 percent of those who earned less than $30,000 owned an iPhone, compared with 28 percent at this income level who owned an Android. 

Because Android phones are cheaper, they are the only brand available through the “Obama phone” or Lifeline Assistant program, which gives free smartphones to low-income Americans.

Moreover, while Hispanics and non-Hispanic whites were as likely to own an Android as an iPhone, 42 percent of African American cellphone owners said they had an Android.

Apple phones, said Khoong, serve “a really specific segment of the population.” 

About 400 health care centers in the United States already use Apple Health Records—and the number keeps growing. Apple and the US Department of Veterans Affairs, the largest medical system in the country, which provides service to more than 9 million veterans throughout more than 1,000 facilities, announced last month that veterans can now access their health records on their iPhones. But those who have an Android will still have to wait for CommonHealth. 

For some, apps that allow medical information to be stored on phones, whether Apple or Android, raise privacy and security concerns, especially whether the tech giants can see and use this medical information. Recent data breaches make those personal data even more vulnerable. 

JP Pollack, co-founder of the Commons Project and a CommonHealth project collaborator, said that the CommonHealth app would ask third-party apps to disclose their policies. The app will evaluate and inform users about their safety to help them make their own decisions. CommonHealth will also use encryption to secure health records. 

But “once the data goes to another application, you no longer have control over it,” Pollak said. “It could be sold anywhere.” 

That’s because the Health Insurance Portability and Accountability Act (HIPAA), which makes health care providers and insurers keep medical information private, doesn’t protect a patient’s information once it is stored on their phone.  

Pollak said that patients, privacy experts, researchers and developers would work together during a workshop in February to finalize the CommonHealth app and address final issues regarding data privacy and information sharing.

By Anne Daugherty • Nov 28, 2019

Addison Rose Vincent, center, leads a workshop for transgender and gender-nonconforming teens near Big Bear Lake in San Bernardino County. Vincent is part of a statewide research initiative called Reimagine Lab, which deploys strategies from the product design world to identify the root causes of family violence. Photo courtesy of Margot Anderson.

Addison Rose Vincent set a transgender pride flag and cans of paint on a table overlooking Big Bear Lake in San Bernardino County last July.

Vincent, an LGBTQ+ activist, was leading a workshop for transgender and gender-nonconforming teens. LGBTQ+ is a term that encompasses marginalized sexual identities and gender identities. 

The idea was to help these youth develop a sense of identity in a creative, inclusive and gender-affirming space. The teens, who sat nervously at the table, were painting family portraits on pride flags. 

For many of the participants, the exercise was also a way to begin healing from the trauma of domestic abuse.

Vincent, who is 27 and lives in Los Angeles, had designed the workshop as part of a statewide research initiative called Reimagine Lab, which deploys strategies from the product design world to identify the root causes of family violence and find new ways to prevent it. Vincent, who identifies as transgender and uses they/them pronouns, is an educator, LGBTQ+ activist and community organizer. 

Beside the lake on that hot summer day, a 14-year-old shared a story about how he was rejected by his parents for being transgender. Vincent listened. The teen told them how his grandparents, who had taken him in, had both died last year. 

But the teen found hope in his grandparents’ story. His elders had immigrated to the U.S. and became successful, despite many challenges, the teen shared. 

“If they could do that back then,” he told Vincent, “I think I can make it, too.” 

Applying ‘Human-Centered Design’ to Domestic Violence

Vincent is one of Reimagine Lab’s 16 Californian fellows, who come from diverse personal and professional backgrounds. The fellows have spent the last year researching new ideas and developing prototypes to prevent multi-generational cycles of family violence. 

Reimagine Lab applies principles of “human-centered design” to domestic violence. The design theory—which yielded the first Apple mouse, for example—champions the end users, or in this case, domestic violence survivors and perpetrators, focusing on their needs and ensuring solutions are appropriate for them. 

The lab’s fellows formed five teams—each using a different approach to domestic violence prevention. Vincent is part of the History Reimagined team, along with Ana Rosa Najera, a licensed clinical social worker, and Devika Shankar, who supervises the STOP Domestic Violence Program at the Los Angeles LGBT Center. The team’s approach was inspired by a 2001 study by Emory University researchers Marshall Duke and Robyn Fivush, who found that youth who knew more about their family histories were more resilient and had higher self-esteem, greater family cohesiveness and a lower incidence of behavior problems.

In addition to the Big Bear Lake summer camp activity, the group held workshops in September for students at a middle school in Los Angeles. At an Indigenous Pride L.A. celebration in October, the team staffed a booth for transgender Native American teens. The teens painted their family trees on tiles, which they then placed together with others to form a larger community tree.

“The idea was that the kids needed to know their roots,” Vincent said, “before they could spread their branches.”

Not all of History Reimagined activities have gone according to plan. Initially the team underestimated the importance of earning the students’ trust—many weren’t comfortable speaking about sensitive topics until they had a chance to know the team better. As a result, Vincent and his group have opted to include teambuilding exercises up front. Teens have been more comfortable after that, and have shared their family and community stories through dance, poetry, public speaking and acting. 

Developing Resilience 

A Centers for Disease Control and Prevention report published in 2017 found nearly 33 percent of women and 27 percent of men in California will experience intimate partner violence, sexual violence or stalking in their lifetimes. The National Coalition Against Domestic Violence reports that one in 15 American children are exposed to intimate partner violence, and 90 percent of them directly witness the violence.

Transgender and gender nonconforming populations experience domestic violence at higher rates. The 2015 U.S. Transgender survey found that 54 percent of respondents had experienced some form of intimate partner violence, including acts involving coercive control and physical harm. Nearly a quarter of those responding experienced severe physical violence by an intimate partner, compared to 18 percent of the general population.

Violence among transgender people of color was even more prevalent. While 47 percent of all respondents reported experiencing sexual assault at some point in their lifetimes, 53 percent of African Americans and 63 percent of Native Americans had experienced sexual assault. 

Cases of domestic violence among LGBTQ+ youth are often unacknowledged, underreported or misreported, according to the 2006 Lesbian, Gay, Bisexual and Transgender Domestic Violence in the U.S. study. Youth are less likely to use or respond to domestic violence terminology, which has traditionally just described abuse between heterosexual people. First responders and therapists can also express bias and misunderstanding, keeping LGBTQ+ community members from accessing emergency services.

Reimagine Lab is funded by Gobee Group, an innovation design organization, and the Blue Shield of California Foundation.

Reimagine Lab fellows from around the state gathered in Oakland earlier this month to pitch their project prototypes at a demo day event. They hoped to secure funding to continue piloting their design concepts. More than 40 community members, sector leaders, catalysts and funders from California’s domestic violence arena were on hand to hear from the teams. Teams are meeting with potential funders and the lab will soon share the ideas publicly to ensure that others in the field hear about them.

History Reimagined mapped out a three-year budget for a school curriculum project, along with a transition strategy that includes lobbying state legislators, working with AmeriCorps and requesting federal funding. The team continues to pilot the program in southern Californian schools—and ultimately hopes to expand it across the state.

Vincent, whose activism stems in part from their own experience coming out as transgender, wants to help stop the intergenerational cycle of domestic abuse that affects LGBTQ+ youth.

Vincent remains hopeful the “curriculum will help these kids not only address some of this trauma,” but also develop resilience.