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If you don’t have a child with autism, you might not know about Applied Behavioral Analysis. ABA is widely regarded as a necessary and effective treatment.

Now many poor children will lose access to this therapy under deals reached in Sacramento last week. Meanwhile, other kids — including those who become insured under the state’s new Obamacare marketplace — may well continue to have access to this therapy.

Here’s the background: under the Affordable Care Act, states can expand Medicaid, called Medi-Cal in California. People with incomes up to 138 percent of poverty will be eligible. Last week, as the legislature and the administration were wrapping up the state’s budget, the legislature was simultaneously moving forward on final bills to implement the Medi-Cal expansion.

Last Friday, after months of debate, legislators sent two final bills to the governor’s desk to approve the expansion. But for supporters of the expansion, this victory came at the cost — ABA therapy for kids on Medi-Cal was axed. Children’s advocates are frustrated.

“With ABA services not covered in Medi-Cal, it essentially means that low-income children are not provided the same comprehensive level of mental health benefits that we’ve mandated private plans cover,” said Mike Odeh, senior health policy associate at Children Now, an advocacy group based in Oakland.

Private insurers are currently required to cover ABA therapy under a law signed in 2011. But that law is scheduled to sunset in 2014. In an odd turn of fate, as legislators nixed ABA coverage for Medi-Cal last week they simultaneously moved a bill forward that would extend the mandate for private plans to continue to cover ABA therapy.

In short, if your children are on Medi-Cal, they will lose access to ABA while children receiving private insurance will apparently retain it — until 2019, if the proposed bill passes.

Families who had been receiving insurance through Healthy Families, California’s low-cost insurance specifically for children and pregnant women, have been fighting hard to keep access to ABA. Last fall, the state passed an emergency measure to provide ABA to children enrolled in the insurance program. When the state began moving Healthy Families children to Medi-Cal earlier this year, families were promised that benefits would be the same. Yet, some 500 children have lost or will soon lose their ABA benefits.

The emergency legislation “specifically documented that these children would likely face irreparable harm if they did not receive this treatment,” said Kristin Jacobson, President and Co-Founder of Autism Deserves Equal Coverage.

Families and advocates have been pushing the state to continue to cover this intensive therapy, which they say is necessary for many autistic children to build important developmental and social skills.

Without ABA “not only are you condemning [children] to a life where they are unable to function in society, you’re also burdening society with their care for their lifetime,” said Jacobson. She said the legislators’ move to take ABA coverage out of last week’s bills was “completely perplexing” and “inexplicable.”

Parents like Rachel Harris feel betrayed. Harris was told that her son’s treatments would continue despite the switch from Healthy Families to Medi-Cal. Harris’s 4-year-old son, Daniel, had just started receiving ABA for autism that he was diagnosed with at age 3.

In the short time Daniel had been receiving the therapy, he was already making big gains: making eye contact with people, asking questions, and he ran off less.

But when Daniel was moved to Medi-Cal on April 1, his ABA treatments ended. Harris said Daniel has begun to go backwards, biting his brother, climbing on top of the refrigerator and running off into a parking lot.

“I am trying to tend to my son and help him cope day to day,” Harris said in a press release. “It is nearly impossible without the ABA therapy on which we depended. We are devastated that the State has broken its promises to our son and our family.”

Half of the children enrolled in Healthy Families have already been switched over to Medi-Cal with the rest moving over in the coming months. With larger numbers of families expected to sign up for Medi-Cal later this year, more children with autism will not be able to access the care that they need.

Advocates are hoping to work with the legislature to get the therapy covered.

“There’s some urgency to it,” said Mike Odeh. “Some children that have already transitioned to Medi-Cal have lost those services but there’s still more transitions to come.”

At the state capital, Sen. Darrell Steinberg, (D-Sacramento), who has been pushing for autism coverage in both private insurance and Medi-Cal, said he will keep trying.

“Unfortunately, this year, there simply wasn’t enough room in the budget to fund ABA therapy in Medi-Cal for kids with autism spectrum disorder. I will not give up the fight, however,” Steinberg told California Healthline. “It’s at the top of my list to get done next year.”

(William West/AFP/Getty Images)

In a unanimous decision, the U.S. Supreme Court ruled Thursday morning that human genes are not patentable.

The case centered around Myriad Genetics, the holder of patents on two genes, BRCA1 and BRCA2. Some mutations of these genes are associated with an increased risk of breast and ovarian cancer. For women with a strong family history of these cancers, the only place they could be tested was Myriad Genetics, which sometimes charged more than $3,000 for the test.

Breast Cancer Action, an advocacy group based in San Francisco, was a plaintiff in the case, and executive director Karuna Jaggar sounded jubilant in a phone call Thursday morning.

“From our perspective, these patents never should have been granted in the first place,” Jaggar said. “There’s no question that DNA is a product of nature, and so it’s very affirming to see the court rule in our favor.”

BRCA1 and 2 mutations became international news when actress Angelina Jolie revealed that she’d had a preventive double mastectomy after testing showed that she had a specific mutation that put her at very high risk of developing breast cancer.

Breast Cancer Action has long argued against the high cost of the test, and said that the patent gave an unfair monopoly to Myriad Genetics, which is located in Salt Lake City. With the court’s ruling, Jaggar believes that more companies will be able to offer a test to women.

“They’ll have access to new tests at lower costs and will have access to second opinions,” Jaggar said. “Currently Myriad offers the one and only test. It has not been peer reviewed; it has not been scientifically validated. New labs will now be able to offer new tests using new methodologies.”

In a statement Myriad Genetics played down the magnitude of the decision, pointing to its 500 other valid patent claims as well as the BRCA test. The court upheld patent claims on what’s known as synthetic DNA or “cDNA.” Synthetic DNA is man-made, not a “product of nature,” and is still patentable.

“We believe the Court appropriately upheld our claims on cDNA,” Myriad’s CEO Peter Meldrum said in a release, “ensuring strong intellectual property protection for our BRACAnalysis test moving forward.”

But Breast Cancer Action insists the Supreme Court’s decision opens the door to new options for women who worry about inherited risk of breast cancer. “Laboratories can conduct genetic testing without using cDNA and this means that Myriad no longer holds a monopoly on the BRCA genes,” Jaggar said in a release this morning.

Roughly 5 to 10 percent of women carry a BRCA1 or 2 mutation, according to the National Cancer Institute. Not all mutations are harmful, but some can be devastating. Angelina Jolie said that she had a mutation that put her at an 87 percent risk of breast cancer.

Learn More:

Read the decision: Association for Molecular Pathology v. Myriad Genetics, Inc.

(seliaymiwell/flickr)

After years of devastating cuts to the health and human services budget, this year’s small surplus brought restoration of some programs.

Mental health programs will get a one-time boost of $140 million. The adult dental program, Denti-Cal, cut back in 2009 and leaving tooth extraction as just about the only service being covered, has been restored, albeit partially. Benefits won’t start until next May.

But lost in the deal was a proposal to provide some therapies to 500 children with autism. Those children had lost some services when the state moved them from Healthy Families and to Medi-Cal.

Then there’s the issue of funding to county health programs. Counties bear the cost for providing health care to the uninsured. Gov. Brown has been arguing since he introduced his budget in January that counties will gain federal money in January under the full implementation of the Affordable Care Act and so the state could reduce its own health funding to counties. But counties have fought that idea, saying that there would still be plenty of uninsured people after Jan. 1 — and that now is not the time to cut the safety net.

While we’re still waiting for final language, the legislature seems to have agreed with the governor’s numbers, and it appears $300 million in county health funding cuts are coming.

Alex Briscoe, Director of Alameda County’s Health Care Services Agency, called it a “money grab” that will “threaten the stability of local safety nets.”

Briscoe says the cuts presume that safety net providers are adequately funded right now, a presumption he called “offensive.”

“The state has overestimated savings it will achieve, underestimated the burden of the residually uninsured and put forward a proposal that is divorced form the reality of local safety nets,” he said.

The budget deal also leaves in place a 10 percent cut in Medi-Cal provider rates — cuts that were approved by the legislature in 2011 and then held up in a long court challenge. The appeals process was exhausted last month, and the cuts will likely move forward this summer.

California has some of the lowest Medicaid reimbursement rates in the nation, advocates say.

Protesters are calling on the governor to restore $1 billion in health care funding. (seliaymiwell/flickr)

Thousands of doctors, dentists, patients, health care professionals and other protesters are expected to gather Tuesday outside the Capitol Building to support the idea of reversing a 10 percent Medi-Cal provider rate cut. Organizers say it will be the largest health care protest in Sacramento history.

“We have people hopping on buses in Oceanside at 4 in the morning to get here,” said Molly Weedn, director of media relations for the California Medical Association. “People are coming from all over the state, and we’ve seen support from both sides in the Legislature. All of this [support] shows that the public doesn’t want Medi-Cal to be cut, so that’s why we’re doing this.”

It has been a tough couple of weeks for proponents of reversing the rate cut made in 2011 and not yet implemented because of court battles.

On May 24, the Ninth Circuit federal appeals court ruled the Medi-Cal cut to be legal, and lifted the injunctions on its implementation. That means the lawsuits to reverse the reduction now have only legal recourse, and that’s an appeal to the U.S. Supreme Court.

Two bills moving through the legislature are seeking to stop the cuts.

The day before the court ruled, a bill to reverse the Medi-Cal reduction, SB 640 was put on suspense file in the Senate Committee on Appropriations. Until that day, the bill had bipartisan, unanimous support in committee voting.

The companion piece of legislation to SB 640 was AB 900. It passed committee and the Assembly floor, but only after the scope was narrowed to reverse cuts exclusively for certain skilled nursing facilities.

“The legislation is certainly an important piece,” Weedn said, “but this is something that can ultimately be fixed in the budget. We think it’s unique, this coalition coming together, because we’ve all independently fought against these Medi-Cal cuts for years, and now we’re together. That coalition and the bipartisan support [in the Legislature] is pretty remarkable.”

Weedn said she expects 5,000 to 7,000 people to show up on the Capitol lawns, and that’s a conservative estimate, she said. “We’ve never had a group that size rallying around a health care issue in Sacramento,” she said. The event will run most of the day.

According to Jan Emerson-Shea, vice president of external affairs for the California Hospital Association, legislation may have stalled but there is a real possibility that the Medi-Cal reduction could be reversed in budget negotiations over the next few weeks.

“The situation is still very fluid,” Emerson-Shea said. “There is still a lot of negotiations and discussion that will play out over the next few weeks.”

Legislators are keenly aware of the problem with the provider cuts, she said.

“The event just cements the issue in legislators’ minds as a high priority,” Emerson-Shea said.

(Marnette Federis/KQED)

Collene Kraut says she never misses a chance to tell her 3-year-old daughter to eat vegetables and fruits. So when a farmers’ market launched in March, a block away from her home near San Diego, Kraut was eager to go.

“I don’t like it when people give my kid bad things to eat,” said Kraut. “I just want her to be healthy.”

Kraut receives funds from SNAP (formerly called food stamps), and she learned that she could use those funds at this new market. But Kraut learned about another new program while she was there, one that would help her stretch her dollars further. It’s called Fresh Fund, a grant-funded program which provides matching dollars specifically to purchase produce.

“I brought some [greens] back for my dad, and he was eating it plain without salad dressing, he said it was good,” she recounts.

The Fresh Fund program helps families such as Kraut’s to stretch their food budgets so they have more room to shop for healthier food. The program’s goal is to help low-income families buy accessible, affordable, nutritious produce. Offering matching dollars for produce appears to influence people’s diets.

“People come out and try things they may not be used to, and they understand this produce tastes so much better than what they can get at the corner store,” said Troy McKinney, coordinator of Fresh Fund.

At the El Cajon Farmers’ Market, eligible families may collect up to $30 over a two months. At another market, in San Diego’s City Heights neighborhood, people get up to $90 over three months.

Organizers acknowledge that there are some limitations to the program because participants only have a two or three-month period to be part of it. The goal is that once families try out the farmers’ market they will keep coming back.

“We’re hoping that in that short period of time, they’ll come out here …  they’ll try the produce, and they’ll choose to budget farmers’ market produce” into their regular shopping McKinney explained.

The International Rescue Committee, which provides services to refugees resettling in the United States, launched both the farmers’ markets and Fresh Fund as a way to expand access to healthier food for low-income families.

In 2008, IRC opened the market in City Heights, a low-income neighborhood and home to a large population of refugees from Southeast Asia, Africa and other parts of the world.

IRC staffers said the farmers’ market was a way to address challenges often faced by low to moderate-income families when it comes to eating healthy.

“Families don’t have to fall into the trap of buying calorie-rich but nutrient-deficient, cheap food,” said Ralph Achenbach, IRC’s Food and Farming Marketing Coordinator.

Refugees also find it difficult to cook native dishes without access to fruits and vegetables they traditionally use, said Achenbach. At the City Heights Farmers’ Market, some of the vendors include refugees who are trained by IRC to grow and sell produce found in their home countries.

“Some of the African farmers are growing African amaranth or cassava, or things you don’t necessarily find in other farmer’s market,” said Achenbach.

McKinney said El Cajon was chosen as the site for the newest farmers’ market because many of IRC’s clients, including Iraqi refugees, have resettled in the area.

“We want to make sure that our clients and the community, have access to this quality produce, which we think is really the highest quality produce you can buy in San Diego or in any other neighborhood,” said McKinney.

Mayce Kadhum is from Iraq and recently moved to El Cajon in the beginning of 2013. She said she appreciates the produce available at the farmers’ market because she is unable to plant her own vegetables.

“Someone told me to plant something,” Kadhum said. “The problem is, I don’t have enough space in my flat. This is the problem.”

Fresh Fund organizers said they have seen the program improve the lives of participants.

Of participants surveyed, more than 95 percent said they have increased or greatly increased both the amount and variety of fruits and vegetables they eat.

Angelina Jolie’s decision to have a double mastectomy after genetic testing has prompted a discussion about which other tests should be covered. (Gage Skidmore/Flickr)

When it comes to inherited genetic mutations that increase the risk of breast cancer, BRCA1 and BRCA2 get nearly all the attention.

Inherited mutations in these genes cause from 5 to 10 percent of breast cancers as well as up to 15 percent of ovarian cancers, according to the National Cancer Institute.

There are other, rarer genetic mutations that also predispose women to breast cancer.

When Angelie Jolie said earlier this month that she’d tested positive for a particularly harmful BRCA1 mutation and had a double mastectomy to substantially reduce her risk of getting breast cancer, she didn’t mention her insurance coverage.

But many health insurance plans routinely cover genetic counseling and testing if a woman has a family history of breast or ovarian cancer. This is particularly true when there’s a pattern of early breast cancer, with diagnoses of family members in their 40s, long before the mid-60s when most women develop the disease.

Under President Obama’s Affordable Care Act, health plans that weren’t grandfathered must cover genetic counseling and testing in such women without requiring them to pay anything out of pocket for it.

Counseling can cost several hundred dollars, and the genetic test costs roughly $3,000. (The high cost is in part because one company, Myriad Genetics, holds the patent on the BRCA1 and BRCA2 genes. That patent has been challenged and is currently under review by the U.S. Supreme Court.)

But other genes besides BRCA1 and BRCA2 might have mutations that predispose a woman to breast cancer. Even though women may test negative for BRCA1 and BRCA2 mutations, some women’s history clearly indicates a familial link.

“These women come from families where breast cancer has been marching through the family in young women, with women in their 40s being diagnosed with breast cancer,” said Stephen Edge, the medical director of the breast center at Roswell Park Cancer Institute in Buffalo, N.Y.

These women may well have inherited other genetic mutations, probably related to complex interactions with other genes, that haven’t yet been identified, said Edge.

In such cases, even without a positive genetic test, insurers generally don’t quibble about covering treatment such as a prophylactic double mastectomy if that’s what the woman decides she wants to do, he said.

But sometimes a woman’s family history will indicate the possibility that she has a different, rarer inherited mutation that increases the likelihood of developing breast and other cancers.

For example, Li-Fraumeni syndrome, caused by a mutation on the TP53 gene, is often associated with an increased risk of breast cancer and sarcomas, cancers of the bones or connective tissues, said Mary Daly, chair of the department of clinical genetics at Fox Chase Cancer Center in Philadelphia. Likewise, Cowden syndrome, associated with a mutation on the PTEN gene, increases the risk of breast and thyroid tumors.

Even though genetic tests are available for these rarer breast cancer syndromes, “they often aren’t covered by insurance,” she said.

Joe Raedle/Getty Images)

The state’s health insurance exchange, Covered California, announced Thursday morning the plans and premiums that will be available to millions of Californians.

And what everyone wants to know is: how much will it cost. Experts had warned of “rate shock,” that premiums might skyrocket for all kinds of reasons. That has not happened.

Covered California says that individuals will pay an average premium of $321 per month for a “silver” plan. (More on silver plans below.) Many people will be eligible for subsidies to reduce that cost further.

Across the state, people who had been working toward this day seemed to heave a collective sigh of relief.

“This is a home run for consumers in every region of California,” said Peter Lee, executive director of Covered California, in a release to reporters. “Californians should be proud of how not only health plans in this state, but doctors, medical groups and hospitals have stepped up — creating a market that will allow millions of consumers to enroll in affordably priced products.”

The plans on the exchange are required to offer a standard set of comprehensive benefits. It’s hard to compare premiums next year to what’s in place this year, since there is no standard set of benefits at present. Covered California chose as the best comparison the average premium for a small business plan. The rates in Covered California range from 2 percent above to 29 percent below that benchmark.

“It’s nice to have a good news day in California,” said Daniel Zingale, senior vice president of The California Endowment. “It turns out there’s power in numbers when it comes to … health plans.”

13 Plans Selected for the Insurance Exchange

The selected plans and premiums are still subject to review by state regulators. Covered California has picked 13 plans, including Anthem Blue Cross, Blue Shield of California, Health Net and Kaiser as well as many regional plans and some country-sponsored health plans. Those include Alameda Alliance for Health, Chinese Community Health Plan, Contra Costa Health Services, L.A. Care Health Plan, Molina Helathcare, Sharp Health Paln, Valley Health Plan, Ventura County Health Care Plan and Western Health Advantage.  You can look up your own region and see what plans and premiums you can choose from.

The “silver” plan mentioned above is in the middle. It has the same standard set of benefits as the other plans, and has a $2,000 annual deductible. Still, preventive care and some other services are outside the deductible — people would pay only a co-pay when they see the doctor.

When setting an individual’s premium, insurance plans in the exchange may look at only three factors: age, where you live and family size. Insurance companies may no longer use your health condition or your health history to set premiums. People may no longer be turned down for pre-existing conditions.

Subsidies are available for people making from 138 to 400 percent of the federal poverty level – or about $15,500 to $45,000 for an individual or about $31,000 to $92,000 for a family of four.

Breakdown on Premiums, Before and After Subsidy

Covered California provided tables of average rates for a 21-year-old and a 40-year-old single person. For the 21-year-old buying the most affordable silver plan, the premium is $216 per month. But depending on income, the 21-year-old may get a subsidy, making the price that person would pay range from $44 per month to $216 per month.

The premium for a 40-year-old buying the most affordable silver plan will be $276. But depending on the subsidy, that 40-year-old will pay from $40 to the full $276.

Starting this fall, people will be able to go online and look up plans and rates across the board for themselves or their families.

“Everything will be quite standardized and literally charted out,” said Betsy Imholz, special projects director for Consumers Union. “So you can look across lines and compare plans.”

On average, people in the larger metropolitan areas in California will be able to choose from among five different plans. Covered California says that even in rural areas where options have typically been sparse, people will have two or three health plans to choose from.

“We were particularly concerned about Californians in rural parts of the state,” Zingale said. “So it’s a relief to see that they will have doctors, hospitals and health benefits available in those areas.”

But not everyone was delighted. Jay Nelson is a 33-year-old attorney who lives with his wife and three children in Oakland. Nelson does not have employer-based insurance, although his firm is looking into options. He has been unable to afford insurance for his family. Nelson said he was disappointed the premiums were not cheaper.

“We’re exactly in that income level that is essentially uninsurable,” he said. “We make too much money to qualify for any help, but we don’t make enough money to pay for this … comfortably.”

Bacchi acknowledged that while the Covered California premiums are generally “positive news,” that’s not the case for everyone. “The reality is that there are some people who will pay more than they currently pay. That’s because the Affordable Care Act requires increased benefits and it also imposes less cost sharing on the enrollee through deductibles and co-pays.”

Plans and premiums for Covered California’s small business exchange are expected to be announced in June, and a major education and outreach campaign will launch this summer.

Learn More:

Listen to a discussion of the new plans and premiums on KQED’s Forum:

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Where you live matters. And in health care, it matters in all sorts of ways you might not think of immediately. If you’re having elective surgery, one of the major factors determining what kind of treatment you will receive depends on where you live, according to new research released Tuesday.

In health policy, “elective” does not necessarily mean cosmetic surgery. Treatments for early stage cancers are considered “elective” because there are a range of options. The California Healthcare Foundation (CHCF) has been following this issue in its “All Over the Map” project. Previously, the foundation has examined variation in heart procedures, joint replacement and c-sections. Tuesday the foundation added a detailed look at geographic variation in treatments for three more conditions: breast cancer, prostate cancer, and back and neck pain.

PIcking out eyebrow-raising numbers was no problem:

• Men in Indio (Riverside County) receive brachytherapy, known commonly as radiation seeds, to treat prostate cancer at almost five times the statewide average.
• Women in Healdsburg (Sonoma County) receive lumpectomy without radiation for early stage breast cancer at 270 percent of the statewide average.
• People in Brawley (Imperial County) are nearly three times as likely to receive cervical fusion, where two vertebrae in the neck are fused together, for neck problems compared to statewide.

Low rates are easy to find, too. To name just one: women in Lancaster, northeast of Los Angeles, with early stage breast cancer receive lumpectomy with radiation at just 26 percent of the statewide average.

The question is why. Maribeth Shannon with the foundation says the variation is “just puzzling to us.” She stressed that the statewide average is not necessarily the “right” rate, but the state average is an estimate that’s easy to use as a benchmark.

In its analysis, the foundation accounted and adjusted for a host of patient characteristics that might skew the numbers. Still, the broad variation is there. Shannon pointed out that it would be “unusual” that patients would differ so significantly in what treatments they wanted, simply according to where they lived.

“It’s much more likely,” Shannon said, “that physicians practicing in that area tend to rely on that course of treatment over others. … It does seem to be more the physician preference than the patient preference.”

Professor Renee Hsia at UC San Francisco was not involved in the study. She agreed that physician preference matters, counter to what patients might think.

“A lot of patients out there think you go to one doctor and they will prescribe the same treatment,” no matter where you live, Hsia said, “because you go to medical school and there’s one answer.” Tuesday’s release shows there’s “a lot of variability.”

“The way your peers practice … in your group or in your hospital affects the way you practice also,” Hsia said. “I wouldn’t say it’s peer pressure, but it’s adapting to your current environment.”

Patients should be “good consumers”

Jeff Belkora, a UCSF professor of health policy says that physician preference for certain treatments needs to be “trumped” by what individual patients need. He called for patients to be good consumers and challenge their physicians. “We want to work with our physicians,” Belkora said. “We want to trust them. At the same time … any given doctor is different than any given patient, so we need to make them understand what we want and what we need.”

If you’re thinking that’s a tall order in the face of a challenging diagnosis, patients should remember that they likely have more time to weigh options than they might think. Belkora says patients need to make their diagnosis and treatment decisions into a “project.”

Elizabeth Becker of Piedmont did exactly that. She was diagnosed with DCIS, a very early stage non-invasive breast cancer, a year ago. She spent weeks researching her treatment options. The more she found out about the specific biology of her specific type of cancer, the closer she came to a decision. While DCIS is unlikely to recur as invasive cancer, in Becker’s case, if the cancer recurred, it was likely to be aggressive. Becker ultimately chose a mastectomy.

“I felt powerful,” she said, referring to the process of deciding as well as the options and choices she had. She also credited her doctor who held open-ended conversations with her. Becker said another doctor she had seen seemed to want to “teach me about breast cancer and then tell me my (treatment) option.” She was unimpressed.

Belkora says there are resources available for people facing treatment decisions. The first stop is research at reputable sites such as the American Cancer Society or the National Cancer Institute for those with a cancer diagnosis, he says.

The Informed Medical Decisions Foundation has decision aids for a wide variety of conditions, from cancers to back pain to heart disease. Health libraries at medical centers can also be a good resource.

But it’s easy to imagine that handling this “project” and doing all this research is a tall order for anyone staring down a diagnosis, let alone the most vulnerable among us, people who are low income, with little education, people who have limited English skills.

While Shannon said the foundation’s goal is in part to encourage patients to be more proactive, she also said the greater transparency could be an effective way to let “physicians know that they seem to be outliers,” she said. “that they seem to be prescribing a particular course of treatment much more often or less often than their peers across the state do.”

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At first glance, you might not think that cuts to public transportation might affect someone’s health. But Devilla Ervin understands the impact firsthand. The 23-year-old lives in West Oakland and a few years ago worked the graveyard shift at McDonald’s.

“I got off work at 4 a.m. and there was no bus service,” he describes. “And so I was walking in my community of West Oakland, with shootings and violence, 45 minutes to an hour to get home.”

Yet, in addition to the threat of violence, Ervin also described a sense of social isolation that he’s felt as a result of recent cuts to bus service in his area.

“It’s not good for physical and mental health,” he says. “It wasn’t good for my spiritual health too, because I couldn’t get to church. A lot of the bus cuts were around International Boulevard where my church is.”

Access to public transportation is what policy types call a “social determinant of health” or SDOH. Health is about much more than health care, than simply seeing a doctor.

Now, in a new study, the Alameda County Public Health Department documents the link Ervin has experienced between health and access to reliable public transportation.

In the report, Getting on Board for Health, health department representatives surveyed transit-dependent riders in Alameda County. The Bay Area as a whole has experienced an 8 percent cut to bus service between 2006 and 2011.

“We found among the transit dependent riders we surveyed, more than 8 in 10 say they have more difficulty getting to their jobs, social activities, school or doctors office,” says study co-author Rebecca Flournoy. “And we know this is problem from public health” studies (for example, this one).

Flournoy, the deputy director for planning policy and health equity at the Alameda County Public Health Department says the health impacts include cumulative effects of stress and social isolation, as well as missed doctors care.

And Devilla Ervin is not alone. There are about 2 million Bay Area residents who do not have a car and are transit dependent.

The survey included 477 transit-dependent riders in Alameda County. Nearly two-thirds reported longer wait times as a result of service cuts, one-third said they had longer commutes, and about one in ten said they didn’t see friends or family as frequently. About 6 percent — mostly seniors and people with disabilities — reported less access to health care appointments.

Sheela Gunn-Cushman, a member of the Disability Action Network of Hayward, is blind and relies on buses to get around. She says there’s a clear link for her between health and transit.

“When the buses don’t run, neither do we. That means we can’t work, play, socialize things like that. And we can’t get jobs and keep jobs and and go to doctors appointments and be human,” says Gunn-Cushman.

“A lot of these residents really build their daily lives around where, when and if public transportation is available,” says study co-author Flournoy.

While other transportation studies have explored public transit health impacts in terms of physical activity, traffic safety, and air quality this is one of the first of its kind to focus on health benefits from improving transportation access.

The county health agency released the report now in hopes of influencing the draft Plan Bay Area which will go before the Metropolitan Transportation Commission (MTC) for a vote in July. The long-term plan helps determine the allocation of $289 billion in regional transportation spending over the next 27 years.

One option for the MTC’s plan includes maintaining public transportation funding at current levels. The Alameda report advocates for a different option called the “Equity, Environment and Jobs” alternative. This approach would invest more funding into services, including bus transit around the region.