Mahmoud said his captors, foot soldiers of Syrian President Bashar Assad, tortured him and shot him in the leg.

“I was in jail for seven months. They let me go, but I was physically sick, and tired,” the 29-year-old refugee said, speaking inside a cheerful, modern medical clinic here with signs posted in English and Arabic. “I had infections, inflammation. I’m still trying to get treated for it all.”

Mahmoud, tall and friendly, agreed to be interviewed on the condition that only his first name be used for fear of retaliation against family back home. He settled in one of the largest Syrian refugee communities in the United States — a midsize California town near San Diego.

And by virtue of this influx of refugees, it has become a health care hub for a traumatized and physically ailing population.

On an old-fashioned Main Street, among Western-themed murals, thrift shops and halal markets, sits the bustling El Cajon Family Health Center, serving Mahmoud and other victims of the devastating civil war in Syria.

Syrian refugees struggle disproportionately with post-traumatic stress disorder, anxiety and depression because of their exposure to extreme violence and anxiety about relatives still in Syria, clinic staff and community volunteers say. Most who have fled spent years holed up in camps or apartments, with little access to routine medical care for war wounds or chronic conditions such as diabetes or heart disease.

Virtually all of the people who enter this country as part of the federal government’s refugee resettlement program qualify by income for Medicaid, the government-run health insurance program for low-income people (known as Medi-Cal in California).

Physicians and others who work with Syrian patients say that the refugees experience long waits and must often travel long distances to see specialists — challenges shared by many other low-income groups.

But access to medical interpreters is woefully insufficient, and refugees are often stymied by the paperwork and bureaucracy so unlike what they had back home. There, they were accustomed to walking in and seeing a doctor without having to wait, said Suzanne Akhras Sahloul, founder of the Syrian Community Network, a Chicago-based nonprofit that aids refugees.

Patients are often confused by Medicaid and the managed-care plans that provide it. They sometimes switch health plans inadvertently, which can lead to delays in care, El Cajon Family Health Center physicians and caseworkers said.

Of the 5.6 million people who since its civil conflict broke out in 2011, only a tiny fraction — — resettled in the U.S.

More Syrian refugees came to San Diego County than any other U.S. metro area — over 1,000 as of the first quarter of 2017, according to the State Department. And more than 80 percent of them live in El Cajon, where county service providers and resettlement agency offices abound, said Chris Williams, executive director of the Syrian Community Network-San Diego, a local branch of the aid organization.

Resettlement agencies, which work with the State Department to smooth entry into the U.S., generally help refugees sign up for Medicaid and get the care they need for their first three months in this country. After that, they are largely on their own to maintain coverage and get care.

“They will say, ‘Why do I need to visit the family doctor? Why can’t I go to the specialist?’” said Aileen Dehnel, a case manager at the El Cajon Family Health Center.

“Everywhere we go, people are helpful,” said Mahmoud, who now lives in Anaheim, Calif. “But the No. 1 challenge is the language.”

Relatively few trained interpreters in the area speak Arabic, and they are in high demand. In a communication vacuum, Mahmoud said, information gets passed from neighbor to neighbor, changing slightly with each telling, as in a game of telephone.

“We don’t know what’s going on,” he said.

Translators don’t always help, Mahmoud said. One time, he had to rush to the emergency room after a gallbladder attack, and an interpreter on the phone kept asking everyone to repeat themselves, blaming the difficulty on bad audio equipment. Mahmoud and his wife, Noura, became so frustrated that she used Google Translate to figure out what the nurses and doctors were saying. (Noura also spoke on the condition her last name not be used.)

Another refugee, 34-year-old Nisreen Tlaas, recalled having fainting spells after her arrival from Homs, Syria, in 2016. Two emergency rooms misdiagnosed her illness before the staff at a third hospital performed an MRI and saw an aneurysm in her brain.

She finally received lifesaving surgery — but only after a caseworker from the Syrian Community Network smoothed communications between a surgeon and a medical interpreter.

Dehnel, of the El Cajon Family Health Center, writes detailed instructions in Arabic for the patients she works with, and many pharmacies in El Cajon now print prescription labels in Arabic as well. But that’s not enough to make sure a diabetic patient gets his insulin or a pregnant woman takes her prenatal vitamins correctly, because many of the patients can’t read in any language, she said.

Language frustrations aside, the main challenge facing many Syrian refugees is psychological distress.

PTSD among Syrian refugees contributes to physical symptoms such as chronic pain, said Dr. Mai Duong, a family doctor at the El Cajon Family Health Center.

Some patients have seen relatives hurt or killed in fighting. Others don’t know if their friends and family are safe. Syria is among the countries affected by the Trump administration’s “travel ban,” and the administration also recently cracked down on refugee admissions in general.

Adjusting to life in the U.S. also can cause enormous anxiety. But many Syrian refugees resist asking for help for fear that authorities will swoop in.

“People always downplay their distress,” Duong said. “They worry that their kids will be taken from them.”

Mahmoud has tried talking to psychologists. But they haven’t been able to help him escape his dark thoughts.

“Our families are in a war zone right now,” he said. “I’m always in fear that my family will be killed.”

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Cuando puso la nevera sobre la mesa, la sala colmada de consultores en lactancia y defensores de la salud materno infantil del Inland Empire de California estalló en aplausos.

Soltes estaba donando su propia leche porque ya no la necesitaba. Su hijo, un niño pequeño, se había graduado recientemente en comida sólida, pero su congelador en casa todavía estaba lleno de leche bombeada.

“No sabía qué hacer con la leche”, dijo Soltes con mirada preocupada a dos jóvenes empleados del , un grupo sin fines de lucro en San José, California, que proporciona leche materna para niños frágiles en cuidados intensivos neonatales (NICU, en inglés).

Un número cada vez mayor de mujeres que producen más leche materna de la que necesitan la donan, o venden, para que otros la utilicen. Es una bendición para los bebés y madres que no pueden producir suficiente leche, pero también plantea cuestiones éticas y de salud pública controversiales.

Los médicos, los reguladores y otros se preguntan: ¿los bebés enfermos y prematuros deben tener acceso a esta leche antes que los sanos? ¿Las mujeres deberían recibir un pago por su leche, incluso si esto privara de la leche a sus propios bebés? ¿Deberían exigirse más controles para garantizar la seguridad de este suministro?

La (FDA) no requiere pruebas para la leche humana donada. Un puñado de estados, incluyendo California y Nueva York, regulan los bancos de leche de la misma manera que lo hacen con los bancos de tejidos, exigiendo que se cumplan algunos estándares de seguridad, y muchos bancos de leche sin fines de lucro examinan a las donantes.

Sin embargo, la FDA por los sitios de comercio de leche en la web, advirtiendo a los consumidores que la leche que se les ofrece conlleva un mayor riesgo de contaminación por drogas o enfermedades, incluido el VIH. Además, la agencia insta a las madres a no alimentar a sus bebés con leche donada adquirida de otras personas o a través de Internet, también debido a estos riesgos.

Algunas empresas y expertos médicos se preguntan si incluso los bancos de leche establecidos –a los que la FDA elogió en 2010 por realizar exámenes voluntariamente– deberían hacer más para garantizar la seguridad. La doctora Jae Hong Kim, neonatóloga de la Universidad de California en San Diego, dijo que los esfuerzos de seguridad de los bancos de leche han funcionado bien hasta ahora, pero no están libres de errores. “El desafío es que, al extender las operaciones, aumenta la exposición al riesgo”, dijo.

Scott Elster, CEO de Prolacta Bioscience, una compañía que usa leche humana para fabricar productos fortificadores en su planta farmacéutica, dijo que aboga por un nivel de pruebas más riguroso.

“Creemos que toda la leche humana, ya sea que se distribuya comercialmente, por una red sin fines de lucro o de persona a persona, debe examinarse para detectar abuso de drogas, nicotina y otros adulterantes”, dijo.

Leche mágica

A principios de los años 70, apenas una quinta parte de los bebés estadounidenses eran amamantados. Hoy en día, por lo menos prueba la leche materna, según los Centros para el Control y Prevención de Enfermedades (CDC). Las ventajas para la salud están bien establecidas, especialmente para los bebés prematuros.

“La primera clase que tuve sobre leche humana quedé impresionada”, dijo Maryanne Perrin, nutricionista de la Universidad de Carolina del Norte en Greensboro. “Es el encuentro entre Harry Potter y Willy Wonka. Es una comida mágica”.

Algunos aficionados al amamantamiento se refieren a la leche humana como “oro líquido”. A veces, parece que todo el mundo la quiere, desde organizaciones sin fines de lucro, como el Mothers’ Milk Bank, hasta las empresas farmacéuticas de alta tecnología que se concentran en productos médicos “premium”, pasando por una vecina que podría querer un poco más de esta leche para complementar la dieta de su bebé.

Cada año se abren nuevos bancos de leche humana y se lanzan nuevas empresas centradas en la leche.

Nadie sabe exactamente cuánto de este exceso de leche es donado o vendido, pero el volumen está aumentando. Pauline Sakamoto, directora ejecutiva del Mothers’ Milk Bank y ex presidenta de la , una asociación de bancos de leche sin fines de lucro en Estados Unidos y Canadá, dijo que los bancos afiliados a su organización distribuyeron 4.4 millones de onzas de leche humana a hospitales el año pasado, frente a menos de la mitad de esa cantidad cinco años atrás. Cuando Sakamoto se convirtió en presidenta de la organización en 2014, tenía 18 bancos de leche. Ahora tiene más de 30 abiertos o en etapa de planificación.

¿Con o sin ganancias?

Los trabajadores del Mothers’ Milk Bank de San José viajaron casi 450 millas el año pasado para campañas de donación en la parte sur del estado, incluyendo la del Centro Médico Regional del Desierto en Palm Springs, donde aplaudieron a Soltes. El banco recolecta y pasteuriza la leche humana donada y la entrega a salas de cuidado intensivo prenatal de hospitales de California, a un costo.

Durante la semana, los trabajadores planearon llevar a cabo exámenes de riesgo en madres como Soltes, incluyendo análisis de sangre para el VIH y otras enfermedades. También planearon pedir a los médicos de las mujeres –y a los de sus bebés– que aprobaran las donaciones. El equipo esperaba recolectar 7,542 onzas de leche materna bombeada, suficiente para proporcionar más de 30,000 alimentaciones para bebés prematuros en cuidados intensivos.

“En este momento, tenemos un flujo constante de leche”, dijo Leah Carig, coordinadora de donantes en el banco de San José. “En el pasado, hemos tenido que incrementar los mensajes de correo electrónico que enviamos” para aumentar el suministro.

Las operaciones de leche materna con fines de lucro también se están expandiendo. La compañía de Elster, , almacena enormes congeladores llenos de leche humana.

Con sede en la Ciudad de la Industria, en California, Prolacta compra la leche de las mujeres a $1 la onza. La compañía la utiliza para hacer fortificantes que se agregan a la leche de una madre o donante para que los bebés prematuros reciban calorías, proteínas y minerales adicionales.

Los productos son caros, $200 a $300 para el suministro de un día. Pero reciben elogios de neonatólogos como Kim, porque pueden sustituir los fortificadores hechos de la leche de vaca, que, se sabe, aumentan el riesgo de enterocolitis necrotizante y de sepsis.

Más allá de las salas de neonatología y las puertas de la industria, los sitios informales en Internet, con nombres como y , también parecen . Un informe estimaba que el número de transacciones de leche en línea en los Estados Unidos subió de 22,000 en 2012 a 55,000 en 2015.

Algunas redes de distribución de leche son administradas por madres que venden su leche, mientras que otras la regalan.

Mandy Lindberg, miembro del consejo de administración de la , tiene experiencia con redes formales e informales de donación, y dijo que las mujeres a menudo optan por donar entre sí porque quieren ayudar a amigos o vecinos que no tienen suficiente leche para sus bebés.

“Es bueno ponerle rostro a un nombre”, explicó Lindberg.

Sin embargo, las investigaciones muestran que hay riesgo con la leche que cambia de manos en sitios de internet informales. En 2015, un equipo de investigadores que compró leche materna en el mercado abierto informó en la revista Pediatrics que alrededor del , lo que podría haber sido añadido por los vendedores para aumentar el volumen y por en, el costo. El mismo equipo había informado en 2013 que la leche comprada en internet frecuentemente estaba .

Kim Updegrove, directora ejecutiva de la organización sin fines de lucro , Texas, dice que la FDA debe regular el intercambio informal de leche, idealmente requiriendo que toda la leche pase por un banco de leche centrado en la distribución de acuerdo a la mayor necesidad médica. Esto, ella cree, ayudaría a que la práctica sea más segura y aseguraría que se les diera prioridad a los bebés más enfermos.

Updegrove y otros temen que, si el beneficio financiero se convirtiera en el factor dominante en la distribución de leche humana, los suministros podrían alejarse de los bebés en cuidados intensivos. Las madres pobres podrían vender su leche en lugar de darla a sus propios hijos, dijeron los críticos.

Las mujeres que participan en las redes de intercambio no siempre entienden la misión y las prácticas de los bancos de leche sin fines de lucro, informó Perrin con sus colegas en publicado en el Journal of Human Lactation. Sugirió que una mejor educación podría fomentar más donaciones para el uso en las salas de cuidados intensivos neonatales.

También dijo que, cuando comenzó su investigación, pensó en la leche humana como un “recurso escaso”. “Pero he hablado con mujeres que han compartido 9.600 onzas de leche. Algunas tienen congeladores llenos”, dijo. “Creo que es un problema de distribución, y no un problema de suministro”.

El concepto de almacenar la leche materna -de cualquier tipo- era nuevo para Soltes. La madre de La Quinta, California, dijo que cuando otros miembros de su grupo de lactancia materna tenían más leche de la que podían usar, no sabían qué hacer con ella. Ella aprendió acerca de la donación de leche a través de Google.

“Simplemente encontré este evento”, dijo. “Pensé, guau, prefiero hacer esto que tirarla a la basura”.

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She dropped it on a table, and the roomful of lactation consultants and maternal health advocates from California’s Inland Empire erupted in applause.

She was donating the milk because she didn’t need it anymore. Her son, a young toddler, had recently graduated to solid food, but her freezer at home was still packed with pumped milk.

“I didn’t know what to do with it,” a harried-looking Soltes told two young staffers from the , a nonprofit group in San Jose, Calif., that provides breast milk for fragile infants in neonatal intensive care units (NICUs).

Increasing numbers of women who produce more breast milk than they need are handing it over — or selling it — for others to use. It’s a boon to fragile infants and mothers who can’t produce enough milk, but it also poses challenging ethical and public health questions.

Physicians, regulators and others ask: Should sickly, premature babies get access to this milk before healthy ones? Should women be paid for their milk — even if it might lead some to deprive their own infants? Should greater safeguards be required to ensure the safety of the supply?

The does not require testing for donated human milk. A handful of states, including California and New York, regulate milk banks the way they do tissue banks, enforcing some safety standards, and many nonprofit milk banks screen donors.

But the FDA has expressed concern about milk-trading websites, that the milk offered there carries an increased risk of contamination by drugs or disease, including HIV. The agency further urges mothers not to feed their infants donated milk acquired from other individuals or over the internet, also because of such safety risks.

“The first class I had on human milk I was blown away,” said Maryanne Perrin, a nutrition scientist at the University of North Carolina-Greensboro. “It’s Harry Potter meets Willy Wonka. It’s a magical food.”

Some breast-feeding enthusiasts refer to human milk as “liquid gold.” At times, it seems as though everyone wants the stuff — from nonprofits like Mothers’ Milk Bank, to high-tech pharmaceutical companies that concentrate it into premium medical products, to your neighbor who might just want a bit more to supplement her baby’s diet.

Each year, new human milk banks open and new milk-focused companies are launched.

No one knows exactly how much of this excess milk is donated or sold, but the volume is increasing. Pauline Sakamoto, executive director of the Mothers’ Milk Bank and former president of the , an association of nonprofit milk banks in the U.S. and Canada, said her organization’s affiliated banks distributed about 4.4 million ounces of human milk to hospitals last year, up from less than half that amount as recently as five years ago. When Sakamoto became president of  the organization in 2014, it had 18 milk banks. Now it has more than 30 open or planned.

To Profit Or Not To Profit?

The Mothers’ Milk Bank workers from San Jose traveled nearly 450 miles last year for donation drives in the southern part of the state, including the one at the Desert Regional Medical Center in Palm Springs where they applauded Soltes. The bank collects and pasteurizes donated human milk and provides it at cost to NICUs throughout California.

Over the week, workers planned to conduct risk screenings, including blood testing for HIV and other diseases, on mothers like Soltes. They also planned to ask the women’s doctors — and their babies’ doctors — to approve the donations. The team expected to collect 7,542 ounces of pumped breast milk — enough to provide more than 30,000 feedings for premature infants in NICUs.

“Right now, we have a consistent flow of milk coming in,” said Leah Carig, donor coordinator at the San Jose-based bank. “In the past, we’ve had to put out [e-mail] blasts” to increase supply.

For-profit breast milk operations are expanding, too. Elster’s company, , stocks warehouse-like freezers full of human milk.

Based in City of Industry, Calif., it purchases the milk from women for $1 per ounce. The company uses it to make fortifiers that are added to a mother’s or donor’s milk to deliver extra calories, proteins and minerals to premature babies.

The products are expensive, at $200 to $300 for a one-day supply. But they win praise from NICU physicians like Kim, because they can replace fortifiers made of cow’s milk, which are known to increase the risk of necrotizing enterocolitis and sepsis.

Beyond the NICU and the gates of industry, informal internet-based sites, with names like Ìý²¹²Ô»å , also . One estimated that the number of online milk transactions in the U.S. soared from 22,000 in 2012 to 55,000 in 2015.

Some milk-sharing networks are run by mothers who sell their milk, while others give it away.

Mandy Lindberg, a board member of the , has experience with both formal and informal donation networks. She said that women often opt to donate among themselves because they want to help friends or neighbors who don’t have enough milk for their babies.

“It’s nice to put a face with the name,” Lindberg said.

Research shows there’s some risk with milk that changes hands on informal sites, however. In 2015, a team of researchers who purchased breast milk on the open market in the journal Pediatrics that about 10 percent of samples contained cow’s milk, which could have been added by the sellers to increase volume and thus the size of the payment. The same team had reported in 2013 that milk purchased online was by pathogenic bacteria.

Kim Updegrove, executive director of the nonprofit , in Texas, says the FDA should regulate informal milk-sharing, ideally requiring all milk to go through a milk bank focused on distributing it according to the greatest medical need. This, she believes, would help make the practice safer and ensure that the sickest babies were given priority.

Updegrove and others fear that if financial gain were to become the dominant factor in distribution of human milk, supplies could be siphoned away from the sickest NICU babies. Poor mothers might sell their milk instead of giving it to their own children, these critics said.

Women involved in sharing networks don’t always understand the mission and practices of nonprofit milk banks, Perrin reported with colleagues in a that appeared in the Journal of Human Lactation. Better education might encourage more to donate for NICU use, she suggested.

She said that when she started her research, she thought of human milk as a “scarce resource.” “But I’ve talked to women who have shared 9,600 ounces of milk. Some have freezers full,” she said. “I think it’s a distribution problem, and not a supply problem.”

The entire concept of breast milk banking — of any type — was new to Soltes. The La Quinta, Calif., mother said that when other members of her breast-feeding group had more milk than they could use, they didn’t know what to do with it. She learned about the milk drive by doing a Google search online.

“I just happened to find this event,” she said. “I thought, wow — I’d rather do this than throw it all out.”

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Her staff worried that a repeal of the Affordable Care Act, long promised by Republicans, would obliterate their jobs. Patients fretted it would jeopardize their care.

Nearly a third of the clinic’s 25,000 patients were newcomers, many of them recently covered through the expansion of Medi-Cal ushered in by the Affordable Care Act. Thanks to the expansion, Valley Community Healthcare had been growing rapidly, opening one new site, adding on to others, and offering patients new dental and mental health services.

What would happen if this new source of financial support were taken away?

Wilson didn’t have an answer that day, and she still doesn’t. But she’s hanging on to a cautious hope. “Pretty much that whole first week was getting a grip and assuring people: We’ve been here 46 years and we’re not going anywhere,” she said. “We’ve fought the fight before, and we’ll do it again.”

In the absence of details about the impact and timing of a possible ACA repeal, Wilson’s brand of determination is all community clinics can count on for now.

Republicans, newly empowered by Donald Trump’s ascendance to the White House, have made clear they plan to repeal large parts of the landmark health care law in short order. The timing of any replacement is still uncertain, though political pressure has been growing recently for any void left by a repeal to be quickly filled with a new plan.  For the time being, however, consumers are unlikely to see big changes in their health care.

Community clinics are key providers of primary care services for the poor. CaliforniaHealth+ Advocates, which represents the state’s clinics, estimates that they serve 6.2 million Californians — an increase of more than a million in less than five years. Today, more than 3.5 million community clinic patients are covered by Medi-Cal, California’s version of Medicaid, the federal health insurance program for people with low incomes.

More than half of patients who signed up for Medi-Cal after the advent of the ACA have gotten their primary care at community clinics, according to a December 2015 by the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

Historically supported by Democrats and Republicans alike, community clinics worked hard to implement Obamacare reforms, and they benefited as a result. Many, like Valley Community Healthcare, helped enroll patients and expanded their services, taking advantage of special ACA funding that enabled them to improve their facilities and systems of care.

The has played out nationwide at many of 1,400 federally backed community health centers — a type of community clinic — according to two studies published recently in the journal .

, which used data from 2012 to 2015 to track visits to community health centers, showed that in states that adopted the Medicaid expansion, the centers saw more patient visits, including those for mental health treatment,Ìý²¹²Ô»å lower rates of uninsured patients — a financial boon for clinics that typically operate on thin margins.

The second  which examined data from 2011 to 2014, found that in the Medicaid expansion states, patients were more likely to receive asthma treatment when it was needed, have their body mass index assessed, get pap smears and keep their blood pressure relatively stable.

Proponents of the health reform law in California had hoped the expansion of community clinics would provide primary care for more patients, thus reducing expensive emergency room visits at safety-net hospitals.

“Health centers have been the poster child of positively embracing the ACA. They’ve gone along with everything,” said Blue Shield of California Foundation CEO Peter Long, whose organization supports the clinics. But without clarity about where funding will come from in the future, or how much of it there will be, it’s possible that clinics will “go into hunker-down mode,” he added. That could mean limiting hours, reinstating waiting lists for new patients and cutting promising new programs.

Implementing Obamacare “put a lot of stress on their systems,” Long said. “To unwind it would be equally hard.”

Wilson and other clinic CEOs say they’re trying to anticipate worst-case scenarios and plan accordingly, but that’s hard when Congress hasn’t specified what changes it is planning, or when to expect them.

“Right now it’s all crystal ball gazing,” said Steven Wallace, associate director of the UCLA Center for Health Policy Research. “‘Repeal and replace’ is a great slogan, but ‘replace’ is really hard to figure out.”

Community clinic leaders say they’re focusing on several . First is a potential rollback of the ACA’s Medicaid expansion program, which extended new coverage to about 20 million people in the U.S., including more than 5 million in California, said Carmela Castellano-Garcia, CEO of CaliforniaHealth+ Advocates.

Some also worry that shifting Medicaid to a block grant system, an idea President Trump has endorsed, would result in cuts to services; or that Congress could decline to reauthorize “330 funding” — an additional $5 billion community clinics receive each year from the federal government. That stream of federal dollars is set to expire in September 2017.

That funding, in addition to payments from the Medi-Cal expansion, allowed the Los Angeles Christian Health Centers to add medical, mental health, dental and case management staff and open two new sites.

The clinic, headquartered on Skid Row in downtown Los Angeles, also launched a fundraising campaign to revamp and enlarge its flagship facility. But CEO Dr. Lisa Abdishoo now worries that some financial assumptions made in planning the expansion may no longer apply now that Trump has been sworn in. “We’re trying not to panic, but now we have to question the sustainability of some of the growth,” she said.

Health care advocates have advised community clinics that they may need to “look at 2009 levels” to plan for post-ACA operations, Abdishoo said. That year, Los Angeles Christian Health Centers served 6,600 patients a year, compared to 10,000 today.

Jane Garcia, CEO of La Clínica De La Raza, a 32-site clinic network in Alameda, Contra Costa and Solano Counties, said her organization could lose ground on hard-fought cost reductions if people’s insurance is taken away and they revert to their old behavior of seeking care only when they are very sick.

“Patients who don’t have coverage hesitate to come in and see the doctor, and they hesitate to seek preventive care,” Garcia said. “That’s the kind of thing that was starting to have an impact on bending the curve on cost reduction.”

ACA-related grants allowed La Clínica’s health centers to improve case management and collaborate more effectively with partners such as Sutter Health, which also saved money by reducing the number of patients seeking primary care in emergency rooms. La Clínica would probably have to cut such administrative efforts were the ACA repealed, Garcia said.

Pamela Richardson, a 60-year-old patient of Valley Community Healthcare who suffers from an iron absorption disorder called hereditary hemochromatosis, was unable to get health insurance before Obamacare prohibited insurers from excluding people with preexisting medical conditions. The clinic helped her sign up for coverage through the Medi-Cal expansion.

Once Richardson was covered, she got long-delayed primary care, which revealed that she had “scary high” blood pressure and a lump in one breast (which proved benign). “When you don’t have insurance you don’t get breast exams. You don’t have pap smears,” she said. “I wish people had a little more patience with Obamacare. Once you get what’s wrong with you under control, the cost would come down.”

Wilson, Castellano-Garcia and others said they plan to make precisely that case — that community clinics represent a good value — once state and federal officials begin mulling an ACA replacement in earnest.

A in the American Journal of Public Health showed that Medicaid spending was 24 percent lower for patients who received a majority of their primary care from federally qualified health centers — a type of community clinic — than for patients who got care in other settings. The savings extended across all services, the study’s authors reported.

In rural Shasta County, where a majority voted for Trump, one in three people has Medi-Cal coverage. Dean Germano, CEO of Shasta Community Health in Redding, said he has already launched conversations with staffers of Republican U.S. Rep. Doug LaMalfa, whom he considers “a friend of the health centers.”

“Our mission is to make people like him realize what [repeal] will mean for people on the ground,” Germano said. “If the system goes through a major shock, what would happen to jobs? It would have a major impact on rural communities.”

Another clinic CEO, Kim Wyard of Northeast Valley Health Corporation in San Fernando, said she takes heart because Congress will have to do something to replace what it is taking away. Just blowing everything up isn’t an option, she said.

“We need a safety net, and if more patients are uninsured, we’ll need it more,” Wyard said. “We’re cost-effective,” she added. “Our new president wrote ‘The Art of the Deal.’ He likes a deal. I don’t think there’s a better deal than health centers.”

Shefali Luthra contributed to this report.

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Había recibido malas noticias del equipo del Riverside University Health System Medical Center: sus dolores abdominales agudos y la dificultad para comer, previamente mal diagnosticados en otro hospital como gastritis, eran causados efectivamente por un cáncer metastásico. El tumor estaba creciendo. David, de 45 años, no se iba a recuperar.

Maldonado acercó una silla para ella y otra para el doctor Faheem Jukaku, especialista en cuidados paliativos, y los dos se sentaron al nivel de los ojos de David. Señalando a una imagen de resonancia magnética del abdomen de David, Jukaku le explicó en inglés cómo los cirujanos intentarían aliviar los síntomas al día siguiente. Maldonado tradujo las palabras de Jukaku al español, modulando su tono de voz para que coincidieran con las del médico. David escuchó, luciendo resignado, pero agradecido de que algo de alivio pudiera estar en camino.

Ocasionalmente, le hizo una pregunta en español sobre el procedimiento, la que Maldonado tradujo para Jukaku. Consultado sobre su primer mal diagnóstico, movió sus ojos.

David, mecánico y padre de tres adolescentes, entiende algo de inglés. Pero dijo que la ayuda de Maldonado había sido crucial para decidir sobre su nuevo curso de tratamiento. Gracias a Maldonado, dijo en español mientras ella traducía, “no tengo ningún malentendido. Estoy más en paz”.

Los intérpretes ayudan rutinariamente a las personas que hablan un inglés limitado —cerca del 9 por ciento de la población de los Estados Unidos, y un porcentaje que crece— a entender lo que está pasando en el hospital. Se convierten en más indispensables en los días en los que los pacientes están muriendo. Pero especialistas dicen que los intérpretes necesitan entrenamiento adicional para capturar los matices del lenguaje en torno a la muerte.

Muchos doctores y enfermeras necesitan la asistencia de los intérpretes no sólo para superar barreras del lenguaje, sino también para navegar diferencias culturales. Las oportunidades para la falta de comunicación con los pacientes abundan. Las palabras no siempre significan lo mismo en todos los idiomas.

El personal médico, de por sí nervioso por anunciar malas noticias, puede hablar muy rápido, decir mucho o demasiado poco. Pueden no darse cuenta que los pacientes no están comprendiendo que el equipo ya no puede salvar sus vidas.

“Ahí es cuando se vuelve interesante”, dijo Maldonado. “¿El médico entiende que el paciente no está entendiendo?”.

En Riverside y algunos otros hospitales, los intérpretes han completado un entrenamiento especial y trabajan en estrecha colaboración con los equipos de cuidados paliativos, para ayudar a los pacientes y a sus familias a decidir cuándo ha llegado el momento de detener un tratamiento para curar una enfermedad y comenzar a enfocarse en confort y calidad de vida.

El cuidado paliativo es inusual entre las especialidades médicas, dijo el doctor Neil Wenger, internista quien es jefe del comité de ética del UCLA Medical Center. En vez de curar o eliminar la enfermedad, su propósito es manejar los síntomas para los pacientes que no se espera que se recuperen.

Los médicos y las enfermeras hablan extensamente con los pacientes que están muriendo y con sus familias sobre sus deseos, colaborando con trabajadores sociales, capellanes y trabajadores de cuidados paliativos. Bajo ninguna circunstancia, el cambio clínico de curar la enfermedad a tratar los síntomas puede ser difícil para médicos y pacientes.

La planificación de cuidado por adelantado (advance care planning) —un proceso utilizado para ayudar a los pacientes a entender su prognosis y explorar preferencias para la atención futura— es más una psicoterapia que una consulta médica de rutina, dijo Wenger.

“Esto no es un conjunto sencillo de preguntas”, dijo. “Usted hace una pregunta, y la siguiente pregunta depende de la respuesta. Es muy fácil usar las palabras equivocadas y asustar a la persona, y descolocarla. Es una conversación peligrosa”.

Cuando hay una brecha en el idioma o la cultura, agregó Wenger, la interacción se vuelve aún más difícil. Ambas partes pueden dejar de reconocer matices importantes, tales como el lenguaje corporal y las variaciones en el significado de las palabras.

Wenger dijo que él encuentra difícil hablar con pacientes sobre cuidados paliativos a través de un intérprete porque, en su experiencia, cambios inesperados en la conversación y emociones difíciles pueden perderse en la traducción .

Otros dicen que los intérpretes son clave para ayudar a los pacientes a entender el sentido del cuidado paliativo, y que sólo necesitan entrenamiento adicional para hacerlo bien.

Kate O’Malley, oficial de programas senior en la California Health Care Foundation, dijo que comenzó a pensar sobre los intérpretes cuando la fundación, con sede en Oakland, California, financió nuevos programas de cuidados paliativos en hospitales de la red de seguridad a través del estado. Halló que un vasto número de pacientes no hablaban inglés como primera lengua.

En Los Angeles County-USC Medical Center, por ejemplo, 68 por ciento de los pacientes de cuidados paliativos en el 2011 hablaban un primer idioma que no era inglés. En el

San Francisco General Hospital, ese número era el 45 por ciento; en el Riverside County Medical Center, 33 por ciento.

“Uno de los principios fundamentales de los cuidados paliativos es tener discusiones sobre los objetivos de la atención”, dijo O’Malley. Así que cuando los pacientes hablan un idioma diferente, “¿cómo se puede hacer eso?” Su equipo encontró que los proveedores de cuidados paliativos a veces traían intérpretes para ayudar, pero que muchos de ellos no tenían el conocimiento, la formación, o el vocabulario para transmitir conceptos claves.

Piense en la idea de cuidados paliativos, los servicios de cuidados paliativos integrales disponibles para los pacientes en sus últimos meses, a menudo en el hogar. Para las personas de México, la palabra en español equivalente es hospicio, “que evoca la imagen del peor hogar para adultos mayores que usted pudiera imaginar”, dijo la doctora Anne Kinderman, quien dirige el servicio de cuidados paliativos en el Zuckerberg San Francisco General Hospital. “Si entro a la habitación y digo, ‘estoy aquí para hablarle sobre una gran cosa llamada hospicio’, hay una desconexión cognitiva”, dijo.

Los intérpretes tienen que aprender cómo zanjar la brecha. “Usted tiene que saber cómo presentar (la palabra hospicio) en español”, dijo Viviana Marquez, supervisora del departamento de idiomas y servicios culturales en Riverside, y la jefa de Maldonado. “No es cuestión de encontrar una palabra equivalente, porque no hay. Tiene que entrar en una explicación más profunda”. Sin ese tipo de comunicación clara, muchas familias latinas nunca entienden que hospicio no es un lugar sino más bien un conjunto de servicios adicionales enfocado en el confort, disponible en el hogar, que los parientes usualmente no pueden proveer por sí mismos, dijo

Beverly Treumann, intérprete médica en Los Angeles quien ahora trabaja como jefa de control de calidad para la Health Care Interpreter Network, una cooperativa con sede en Emeryville, California, que permite a los hospitales miembros compartir intérpretes a través de videoconferencias.

Treumann dijo que una vez entrenó a un intérprete que había rechazado cuidados paliativos para su propia madre a causa de un malentendido. “Esta intérprete estaba destrozada”, dijo Treumann. “La familia se hizo cargo de la madre, pero sin los servicios adicionales que podría proporcionar el cuidado paliativo. La madre sufrió porque el concepto no se explicó adecuadamente”.

Las diferencias culturales también pueden generar otros malentendidos, dijo Kinderman. Familias de distintas partes del mundo toman decisiones de atención de salud en grupo.

Para ellos, puede ser difícil de comprender un concepto de cuidados paliativos, como un representante del cuidado de salud —una persona que toma las decisiones médicas cuando el paciente esté incapacitado. Con la esperanza de evitar todos estos campos minados, la

California Health Care Foundation reclutó a Kinderman y a otros expertos para ayudar a desarrollar un curriculum de cuidados paliativos para intérpretes.

El curriculum introduce el concepto de cuidados paliativos, definiendo términos y ofreciendo vocabulario para ayudar a los intérpretes a trasmitir con precisión las ideas principales. Anima a los intérpretes a alertar a los médicos cuando se sospecha que un paciente y su familia no entienden lo que se les dice. También incluye materiales para ayudar a los intérpretes a lidiar con sus propias emociones complejas durante los encuentros de cuidados paliativos.

Marquez dijo que los intérpretes de los 10 centros médicos de Riverside medical han completado alguna versión del curriculum, que se enseña en persona o por internet. Para Maldonado, quien ha estado interpretando por cerca de cinco años, trabajar con pacientes de cuidados paliativos se ha convertido en una pasión.

Ella asiste a las reuniones semanales del equipo de cuidados paliativos, trabajando estrechamente con el personal y los pacientes. Si Maldonado está cerca cuando surge una conversación difícil, ella es la primera persona que Marquez envía para interpretar. Si Maldonado u otro intérprete que se siente cómodo con el trabajo en cuidados paliativos no está disponible, dijo Jukaku, “tratamos de posponer la charla”.

El año pasado, Maldonado dictó un curso de entrenamiento en cuidados paliativos para intérpretes. La sesión, realizada en el Moreno Valley hospital, atrajo a  cerca de 50 participantes del sur de California. Los participantes querían hablar sobre terminología y “trauma indirecto”, la carga emocional que acarrea interpretar para pacientes en cuidados paliativos.

Compartieron técnicas de autoprotección. Marquez recomendó usar la tercera persona en lugar de la primera persona habitual: en vez de traducir directamente las palabras del médico y decir, “yo recomiendo”, una intérprete debe crear una distancia emocional en momentos difíciles diciendo “su médico recomienda”.

Maldonado dijo que ella también tiene problema algunas veces para contener sus emociones cuando las familias están angustiadas o tienen problemas para aceptar que un paciente puede morir pronto. “Más tarde en el día digo, “oh Dios mío… ¿puedo descargar mi emoción? Tengo que hacerlo”.

Pero Maldonado también señaló que la emoción cruda de las familias significa que ella está haciendo bien su trabajo. “Cuando conseguimos lágrimas y reacciones”, dijo, “sabemos que hemos entregado el mensaje”.

Esta historia fue producida por Kaiser Health News, que publica , un servicio de la . La cobertura de KHN de temas del final de la vida y enfermedades graves es apoyada por .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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He had received distressing news from the team at the Riverside University Health System Medical Center: His sharp abdominal pains and difficulty eating, previously diagnosed at another hospital as gastritis, were actually caused by metastatic cancer. The tumor was growing. David, 45, was not going to recover.

Maldonado pulled up a chair for herself and another for palliative care specialist Dr. Faheem Jukaku, and the two sat at David’s eye level. Pointing to an MRI image of David’s abdomen, Jukaku explained in English how surgeons would attempt to ease his symptoms the next day. Maldonado translated Jukaku’s words into Spanish, modulating her tone of voice to match the doctor’s delivery.

David listened — seeming resigned, but grateful that some relief might be on the way. Occasionally he’d ask a question in Spanish about the procedure, which Maldonado translated back to Jukaku. Asked about his earlier misdiagnosis, he rolled his eyes.

David, a mechanic and father of three teenagers, understands some English. But he said Maldonado’s help had been crucial to deciding on his new course of treatment. Thanks to her, he said in Spanish as she translated, “I don’t have any misunderstandings. I’m more at peace.”

Interpreters routinely help people who speak limited English — close to 9 percent of the U.S. population, and growing — understand what’s happening in the hospital. They become even more indispensable during . But specialists say interpreters need extra training to capture the nuances of language around death.

Many doctors and nurses need the assistance of interpreters not only to overcome language barriers but also to navigate cultural differences. Opportunities for miscommunication with patients abound. Words don’t always mean the same thing in every language.

Medical staff, already nervous about , may speak too quickly, saying too much or too little. They may not realize patients aren’t comprehending that the team can no longer save their lives.

“That’s when it gets interesting,” Maldonado said. “Does the doctor understand that the patient isn’t understanding?”

At Riverside and some other hospitals, interpreters have completed special training and work closely with palliative care teams to help patients and their families decide when the time has come to stop trying to cure a disease and start focusing on comfort and quality of life.

Palliative care is unusual among medical specialties, said Dr. Neil Wenger, an internist who is chair of the ethics committee at the UCLA Medical Center. Rather than curing or eliminating disease, its purpose is to manage symptoms for patients who are not expected to recover.

Physicians and nurses talk at length with dying patients and their families about their wishes, collaborating with social workers, chaplains and hospice workers. Under any circumstances, the clinical shift from curing disease to treating symptoms can be difficult for doctors and patients. Advance care planning — a process used to help patients understand their prognoses and explore preferences for future care — is more like psychotherapy than a routine medical consult, Wenger said.

“This is not a straightforward set of questions,” he said. “You ask a question, and the next question is dependent on the response. It’s very easy to use the wrong words and startle the person and put them off. It’s a dangerous conversation.”

When there’s a language or culture gap, Wenger added, the interaction becomes much more difficult. Both sides can fail to recognize important nuances, such as body language and variations in the meaning of words.

Wenger said that he finds it hard to speak with patients about palliative care through an interpreter because, in his experience, unexpected turns in the conversation and difficult emotions can literally get lost in translation.

Others say that interpreters are key for helping patients make sense of palliative care — that they just need extra training to be good at it.

Kate O’Malley, a senior program officer at the California Health Care Foundation, said she started thinking about interpreters when the Oakland, Calif.-based foundation funded new programs in safety net hospitals throughout the state. It found that vast numbers of patients did not speak English as their primary language.

At Los Angeles County-USC Medical Center, for instance, 68 percent of palliative care patients in 2011 spoke a first language other than English. At San Francisco General Hospital, that number was 45 percent; at Riverside County Medical Center, 33 percent.

“One of the key tenets of palliative care is to have goals-of-care discussions,” O’Malley said. So when patients speak a different language, “How do you do that?” Her team found that palliative care providers sometimes brought in interpreters to assist, but that many of them didn’t have the knowledge, training, or vocabulary to convey key concepts.

Take the idea of, the comprehensive palliative care services available to patients in their last months, often at home. For people from Mexico, the Spanish equivalent hospicio “conjures up the image of the worst nursing home you could ever imagine, where people are disabled and left for dead,” said Dr. Anne Kinderman, who runs the palliative care service at Zuckerberg San Francisco General Hospital. “If I come into the room and say, ‘I’m here to tell you about this great thing called hospicio,’ there’s a cognitive disconnect,” she said.

Interpreters have to learn how to bridge that gap. “You have to know how to present [hospice] in Spanish,” said Viviana Marquez, supervisor of the department of language and cultural services at Riverside, and Maldonado’s boss. “It’s not a matter of finding an equivalent word, because there is none. You have to get into a deeper explanation.”

Without that kind of clear communication, many Latino families never understand that hospice isn’t a place but rather a suite of comfort-focused extra services, available at home, that relatives usually can’t provide on their own, said Beverly Treumann, a medical interpreter in Los Angeles who now works as head of quality assurance for the Health Care Interpreter Network, an Emeryville, Calif.-based cooperative that lets member hospitals share interpreters through videoconferencing.

Treumann said she once trained an interpreter who had refused hospice for her own mother because of such a misunderstanding. “This interpreter, she was heartbroken,” Treumann said. “The family took care of the mother — but without the extras that hospice could provide. The mother suffered because the concept wasn’t explained adequately.”

Cultural differences can breed other misunderstandings too, Kinderman said. Families from many parts of the world approach health care decisions as a group. That can make a palliative care concept like a health care proxy — a person who makes medical decisions when a patient becomes incapacitated — hard for them to grasp.

Hoping to bypass all these potential minefields, the California Health Care Foundation recruited Kinderman and other experts to help develop a palliative care curriculum for interpreters.

It introduces the palliative care concept, defining terms and providing vocabulary to help interpreters accurately convey key ideas. It encourages interpreters to alert physicians when they suspect a patient and his family don’t understand what they are told. It also includes materials to help interpreters deal with their own complicated emotions during palliative care encounters.

Marquez said that all 10 of the Riverside medical center’s interpreters have completed some version of the curriculum, which is taught in person or .

For Maldonado, who has been interpreting for about five years, working with palliative care patients has become a passion.

She attends the palliative care team’s weekly meetings, working closely with staff and patients. If Maldonado is around when a difficult conversation arises, she’s the first person Marquez sends to interpret. If Maldonado or another interpreter who is comfortable with palliative care work is not available, Jukaku said, “we try to postpone the talk.”

Last year, Maldonado taught a palliative care training course for interpreters. The session, held at the Moreno Valley hospital, attracted around 50 participants from throughout Southern California.

The participants wanted to talk about terminology and “vicarious trauma” — the emotional toll that interpreting for palliative care patients can take. They shared self-protection techniques. Marquez recommended using the third-person voice instead of the customary first person: rather than directly translating the doctor’s words and saying “I recommend,” an interpreter might create emotional distance for herself in difficult moments by saying, “your doctor recommends.”

Maldonado said she, too, has trouble sometimes containing her feelings when families are distraught or have trouble accepting that a patient may soon die. “Later in the day I say, ‘Oh my God … can I vent?’ I have to vent.”

But Maldonado also noted that raw emotion from the families means she is doing her job well.

“When we get the tears and the reactions,” she said, “we know we’ve rendered the message.”

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As of early August, 15 weeks later, the licensing board still had not reviewed her file and could not tell her when it would. Russo called the agency, often, to ask about the status of her application. It was hard to get a staff member on the phone. When she did, she said, “Every time I got a different story.”

State officials claim that hiring new nurses is a crucial workforce concern for California, yet at least 2,000 recent nursing graduates like Russo remain in licensing limbo, with their applications taking as long as 24 weeks for the to process.

Experienced nurses from other states who apply for California licenses also wait months for the go-ahead to work.

Even as labor experts worry the U.S. won’t to care for an aging population, license delays have plagued nursing boards across the nation in recent years — in ,   and, more recently, , where thousands were reportedly as of early August.

The current delay in California comes on the heels of a related slowdown in 2014 and is a major inconvenience for the nurses who want jobs and a hassle for the hospitals that want to hire them. And critics say at least some of the problem stems from the flawed $96 million implementation of a computer system called which, as its name suggests, was intended to streamline professional licensing.

Patricia McFarland, CEO of the Association of California Nurse Leaders, an advocacy group, described the computer system as poorly conceived and inefficiently deployed, citing it as a significant contributing factor in the delays. Moreover, she said, the licensing board doesn’t have a big enough staff to handle the volume of license applications it receives.

“We can’t license our graduates,” McFarland lamented. “Nurses want to retire, they want to train the next generation. We have hospitals investing in residency programs and they can’t start the new nurses they want to hire. At the end of the day, who’s suffering? Our nurse graduates and our patients.”

Veronica Harms, a spokeswoman for the nursing board and for the that oversees it, said the department had resolved early glitches with the new computer system. But she acknowledged that the system is still labor-intensive and time consuming, and she agreed more staff is needed to speed the licensing process.

Harms said that the board’s new executive officer, Joseph Morris, who started July 10, “has acknowledged the backlog of applications and is determined to work with [the department] in finding long-term solutions.”

The nursing board is responsible for licensing the state’s more than 417,000 registered nurses, or RNs. It conducts background checks, verifies educational bona fides and authorizes nurse graduates to take the National Council Licensure Examination, or NCLEX, which candidates must pass to get their nursing license. In fiscal year 2015-2016, the board issued 23,743 licenses, more than half to new nurses.

This year’s delays are not the first at the board, which suffered a slowdown in 2014 after it and nine other state licensing agencies adopted the “off-the-shelf” BreEZe system. Once launched, the system malfunctioned, upending workflow and creating more tasks for staff.

A February 2015 on the system by the California State Auditor concluded that the consumer affairs department “failed to adequately plan, staff and manage the project for developing BreEZe.” The audit recommended that the nursing board analyze its application process to determine its need for additional resources.

But McFarland, of the nurse leaders’ association, said the state audit was a “game of dodge ball” in which the consumer affairs department and state IT leaders refused to accept responsibility for a real fix.

The audit showed that most of the 10 state boards that implemented BreEze in 2014 were “generally dissatisfied” with it. All 10 were unhappy with the system’s reporting capability, and eight of them said the system actually made their operations less efficient.

Today, BreEZe is used by 18 state boards, bureaus and committees, including the Medical Board of California, the Dental Board and the Board of Behavioral sciences.

The nursing board reports on its website which applications it is currently reviewing — but only by dates received, not by name. Applicants cannot click to find out where their individual applications stand in the process or how much longer they should expect to wait. And the website warns that “contacting the Board for application status while within these timeframes may cause processing delays.”

As of Aug. 8, the board was processing applications filed between March 16 and March 31, according to the . Nursing graduates said it seems to have been working on March applications for some time.

On July 27, Russo asked if showing up in person might help expedite her case. The worker on the phone said she didn’t think so.

“I’d drive eight hours up to Sacramento if it meant I could move this forward even one week faster,” Russo said. Promising offers come and go, she said, but she can’t start a job until she has her license.

She said she had to withdraw or cancel interviews with a subsidiary of Rady Children’s Hospital-San Diego and the Center for Discovery La Jolla, a residential treatment facility.

Other nursing grads are also feeling confused and frustrated as their job searches get mired in the state’s licensing logjam.

Lara Golden, who recently earned a Master of Nursing degree from the University of Virginia, applied for her California license on April 13. She had postal receipts, but when she called the board in June they couldn’t find her paperwork. So she flew from Virginia to California to submit a second set of fingerprints in person. Seven weeks and many phone calls later, Golden is still uncertain when her application will be reviewed.

Fremont resident Angel Li received her bachelor’s degree in nursing from Washington State University in Spokane in May. She submitted an application to the nursing board on March 15. After hearing nothing for 12 weeks she, too, started calling the agency.

“I kept waiting and waiting and calling back, which is not an easy task,” she said. “Sometimes they just hang up due to the high call volume.”

In May, Li said she had a promising interview for a pediatrics position at a Southern California hospital. The manager wanted to hire her, but said she couldn’t move ahead until Li had a license.

Golden is supposed to start a residency program at a UC hospital but fears she won’t have her license in time.

“I have people calling me crying,” said Kathy Harren, regional chief nursing officer at Providence Health and Services, Southern California. “We have positions for them, but we can’t let them in without licenses in hand.”

Nancy Blake, critical care services director at Children’s Hospital Los Angeles, said that as of Aug. 9, 22 nurses out of the 57 her hospital has hired for its nursing residency program, which starts September 26, still had not been cleared by the nursing board to take the licensing exam. Under normal circumstances, only two or three candidates would not yet have taken the test by this point in the summer, she said.

Blake, who hit roadblocks while renewing her own license earlier this year, worries that young nurses will get discouraged — and that hospital staffing will suffer. “A lot of the boomers are retiring,” she said. “I believe we’re on the cusp of a nursing shortage.”

A by the state nursing board acknowledged as much, reporting that nearly half of California’s nurses were over 50 and that many younger nurses were having trouble getting work. It is “essential that recently graduated RNs find employment opportunities so they are prepared to take on the roles of retiring RNs,” the report urged.

Susan Odegaard Turner, founder of , a consultancy in Thousand Oaks, said California now has more of the newly trained nurses it needs but still has not solved the problem.

“We got more nurses. But now they can’t get their license,” Turner said. “This is a different kind of shortage. We’ve produced them, but they’re not working.”

This story was produced by , which publishes , a service of the .

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