California took a major step last month toward regulating dangerous “forever chemicals” in drinking water by proposing new health limits for two of the most pervasive contaminants.

On July 21, state environmental health officials recommended goals of one part per trillion and less — a minuscule amount 70 times smaller than the federal government’s non-binding guideline for drinking water nationwide.

Called “forever chemicals” because they persist in the environment, the contaminants are ubiquitous. Traces of two — perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) — are in the well water of 146 public water systems serving nearly 16 million Californians, a CalMatters analysis found last fall.

Long used to make non-stick and stain-proof coatings, firefighting foams and food packaging, the perfluorinated chemicals have been linked to kidney cancer and other serious health conditions in people drinking contaminated water. They often are found near airports, military bases and landfills.

The announcement sets in motion a multi-year process to develop enforceable state regulations to replace California’s guidelines.

State officials will seek public comments and outside scientific review of the proposed “public health goals” before they are finalized, which could take at least a year, said Sam Delson, a spokesperson for the state Office of Environmental Health Hazard Assessment.

After that, another agency, the state Water Resources Control Board, will develop enforceable standards. Those standards must under state law be set as close as possible to the health goal while considering what is economically and technically achievable. That process could take several years.

The health goals are based on concentrations that would pose “no significant health risk” to people, according to the report by the Office of Environmental Health Hazard Assessment. Attaining them would limit Californians’ risk to one case of cancer per one million people over a lifetime, based on studies of people and lab animals.

“We don’t consider a (public health goal) to be the boundary between safe and dangerous. It is a goal for negligible risk,” Delson said.

The proposed targets are 0.007 nanograms per liter of water for perfluorooctanoic acid (PFOA), which was used to manufacture Teflon, and 1 nanogram for perfluorooctanesulfonate (PFOS), which was formerly used to make Scotchgard.

A nanogram per liter is equivalent to a part per trillion — or one cup of a contaminant in a trillion cups of water.

“Keeping levels low will ensure that those who are most likely to experience adverse health outcomes, like children or people … who live in areas of high exposure, will be adequately protected,” said Jamie DeWitt, a professor of pharmacology and toxicology at East Carolina University, who studies the chemicals but was not involved in California’s analysis.

But cleaning up water to meet stringent standards for perfluorinated chemicals would be expensive. At military sites alone, the US Government Accountability Office estimates that investigating and cleaning up the contamination will cost far beyond the $3.2 billion that the Department of Defense spent in 2020 and expects to pay in 2021.

These chemicals are everywhere, in everyone

Nationwide, the drinking water of up to 80 million people is estimated to contain at least 10 nanograms per liter of the two chemicals combined, according to a study by the Environmental Working Group, an environmental group that focuses on toxic substances.

The chemicals are everywhere, in virtually everyone, in samples taken from pole to pole — they have accumulated not just in water, but also in soil and in human and animal bodies, beginning in the late 1940s, when 3M Co. developed a process to make them.

“They’ve shown toxicity in animals and in humans,” said Elaine Khan, chief of the Water Toxicology Section at the Office of Environmental Health Hazard Assessment. “It’s definitely something that we need to address in terms of protecting public health.”

Olga Naidenko, vice president for science investigations at the Environmental Working Group, said California’s analysis confirms that the chemicals pose health risks at levels lower than the parts per trillion dominating discussions at the national and international levels.

Philippe Grandjean, a renowned environmental health scientist at Harvard University, said the U.S. Environmental Protection Agency has been “exceedingly slow” enacting water standards for perfluorinated chemicals.” He said he hopes that California “will continue the effort to show the way to control or eliminate” them in the environment and in human bodies.

So far, there are no federal enforceable limits on any of the thousands of perfluorinated chemicals. Federal advisories set guidelines for PFOA and PFOS in drinking water of 70 parts per trillion, combined. The EPA announced plans in February to regulate the two chemicals, but standards are still likely years away.

In the absence of federal standards, a patchwork of recommendations and regulations have emerged across the country. Nine states have set guidelines ranging from 8 to 35 parts per trillion for PFOA and 10 to 40 for PFOS, according to an analysis published last year.

Last year, California developed thresholds of 10 parts per trillion for PFOA and 40 parts per trillion for PFOS. These are just guidelines, although a state law empowers regulators to require that water providers either clean up contaminated supplies, shut down tainted wells or notify customers.

CalMatters’ analysis in November 2020 found that nearly 200 drinking water wells, or 15% of those tested, have exceeded the new thresholds in at least one round of testing over the prior year.

The new public health goals don’t change anything for now, said Darrin Polhemus, deputy director of the water board’s drinking water division. “This is the very, very, very first step of the regulatory process,” he said.

But some water providers may want to enforce them, or at least start developing plans to remove the chemicals from their water or blend supplies to dilute them.

“These are really important chemicals to address,” Khan said, “because they are forever chemicals, and they stay around for a very, very long time.”

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AURORA — Fatumo Osman, a 65-year-old Somali refugee who speaks limited English, was in a bind. She made too much money at a meal prep service job so she no longer qualified for Medicaid. But knee pain kept her from working, so her income had dropped. She could reapply for Medicaid, get her knee fixed and return to work, at which point she’d lose that safety-net health coverage. Her first step was getting a note from a doctor so she wouldn’t lose her job.

So, Osman came to Mango House, a clinic in Aurora, that caters primarily to refugees and turns no one away, regardless of their ability to pay. Dr. P.J. Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. reject as too low.

Dr. P.J. Parmar started Mango House 10 years ago to provide health care to refugees in Aurora. But the center goes beyond standard primary care with an entire ecosystem at the site of dentistry, after-school programs, English classes, legal help, nine stores and six restaurants owned and run by refugees. “This is what I call a medical home,” Parmar says. (Ross Taylor for KHN)

Ross Taylor/KHN

The clinic is just one part of a broader refugee ecosystem that Parmar has built. Mango House provides food and clothing assistance, after-school programs, English classes, legal help — and Parmar even leads a Boy Scout troop there. He leases space to nine stores and six restaurants, all owned and run by refugees. Mango House hosts a dozen religious groups, plus community meetings, weddings and other celebrations. When Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he can easily grab one of his tenants.

“This is what I call a medical home,” Parmar said.

Although it’s not part of the formal U.S. refugee resettlement program, Mango House is in many ways emblematic of refugee health care in the U.S. It’s a less-than-lucrative field of medicine that often relies on individual physicians willing to eke out a living caring for an underserved and under-resourced population.

Parmar finds creative ways, often flouting norms or skirting rules, to fit his patients’ needs. As a result, Mango House looks nothing like the rest of the U.S. health care system and, at times, draws the ire of the medical establishment.

Health care for older immigrants sees momentum among states

“How do you deliver the quality of care necessary, and that they deserve, while still keeping the lights on? It’s a struggle for sure,” said Jim Sutton, executive director of the Society of Refugee Healthcare Providers. “It’s these heroes, these champions out there, these cowboys that are taking this on.”

Osman brought her son, Jabarti Yussef, 33, to interpret for her. They have been coming to Mango House for 10 years and said that Parmar opens doors for them when they have trouble accessing care.

“If we ask for an appointment to get Medicaid, P.J. makes the call,” Yussef said. “If we call, we’re on hold for an hour, and then it hangs up. If we go to the ER, it’s a three-hour wait. Here, the majority of people walk in and sit for 30 minutes. It’s good for the community.”

As for Osman’s knee pain, Yussef asked Parmar, could they pay cash to get an MRI at the hospital?

“I can almost guarantee it’s arthritis,” Parmar replied. “You could do an X-ray. That will cost $100. An MRI will cost $500. And if it shows a bigger problem, what are you going to do? It will cost you $100,000.”

Parmar said he would connect them with someone who could help Osman enroll in Medicaid but that it’s an imperfect solution. “Most orthopedists don’t take Medicaid,” Parmar said. Older immigrants need to have worked the equivalent of 10 years in the U.S. to qualify for Medicare.

Medicaid, which covers low-income people, generally pays primary health care providers a third less than Medicare, which covers seniors and the disabled. And both pay even less than commercial insurance plans. Some doctors paint Medicaid patients as more difficult and less likely to follow instructions, show up on time or speak English.

Parmar said he realized back in medical school that few doctors were motivated to treat Medicaid patients. If he limited his practice to just Medicaid, he said dryly, he’d have guaranteed customers and no competition.

So how does he survive on Medicaid rates? By keeping his overhead low. There are no appointments, so no costs for a receptionist or scheduling software.

He said his patients often like that they can drop in anytime and be seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in their native countries.

Because he takes only Medicaid, he knows how to bill the program and doesn’t have to hire billing specialists to deal with 10 insurance companies.

It’s also more cost-efficient for the health system. Many of his patients would otherwise go to the emergency room, sometimes avoiding care altogether until their problems get much worse and more expensive to fix.

“Really none of our innovations are new or unique; we just put them together in a unique way to help low-income folks, while making money,” Parmar said. “And then, instead of taking that money home, I put it back into the refugee community.”

The son of Indian immigrants, Parmar, 46, was born in Canada but grew up in Chicago and moved to Colorado after college in 1999, where he did his medical training at the University of Colorado School of Medicine. He opened Mango House 10 years ago, buying a building and renting out space to refugees to cover the cost. Two years ago, he expanded into a vacant J.C. Penney building across the street.

“There’s a good three-, four-year dip in the red here, intentionally, as we move from there to here,” Parmar said. “But that red is going to go away soon.”

The covid pandemic has helped shore up his finances, as federal incentives and payment increases boosted revenue and allowed him to pay down his debt faster.

Parmar must navigate a host of obstacles while working to overcome financial and language barriers. A Muslim Somali woman needs dental care but is uncomfortable seeing a male dentist. A Nepalese woman needs a prescription refill, but she lives in Denver and so has been assigned by Medicaid to the safety-net hospital, Denver Health. Parmar won’t get paid but sees her anyway. Another patient brings paperwork showing he’s being sued by a local health system for a year-old emergency room bill he has no way to pay. A Nepalese man with psoriasis doesn’t want creams or ointments; good medicine, he believes, comes through a needle.

“A lot of this is, basically, geriatrics,” Parmar said. “You have to add 20 years to get their age in refugee years.”

When one patient turns away momentarily, Parmar discreetly throws away her bottle of meloxicam, a strong anti-inflammatory he said she shouldn’t be taking because of her kidney problems. He began stocking over-the-counter medications after realizing his patients got overwhelmed amid 200 varieties of cough and cold medicines at the drugstore. Some couldn’t find what he told them to get, even after he printed flyers showing pictures of the products.

Parmar’s creative solutions, however, often rub many in health care the wrong way. Some balk at his use of family members or others as informal interpreters. Best practices call for the use of trained interpreters who understand medicine and patient privacy rules. But billing for interpretation isn’t possible, so hospitals and clinics must pay interpreters themselves. And that’s beyond the capabilities of most refugee clinics, unless they’re affiliated with a larger health system that can absorb those costs.

“It’s a good thing to have the standards, but it’s another thing altogether to implement them,” said Dr. Pat Walker, an expert on refugee health at the University of Minnesota.

When Mango House began providing covid vaccines, residents of more affluent areas of town started showing up. Parmar tried to limit vaccinations only to those patients living in the immediate area, checking ZIP codes on their IDs. The state stepped in to say he could neither require IDs nor turn away any patients, regardless of his refugee-focused mission.

During a recent lull at the clinic, Parmar took stock of that day’s inventory of patients. Six were assigned to Denver Health, one patient’s Medicaid coverage had expired, and two had high-deductible commercial plans. Chances are he wouldn’t get paid for seeing any of them. Of the 25 patients he had seen that day, 14 had Medicaid coverage that Parmar could bill.

“We see the rest of them anyway,” he said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Georgia Gov. Brian Kemp sought to shift blame to President Joe Biden for Georgia’s poor vaccination rate Thursday as COVID-19 infections and hospitalizations continued to sprint upward. The Republican, speaking to reporters, blamed the Democratic president for not doing enough to push the Food and Drug Administration to upgrade its emergency authorization for the vaccines to a permanent authorization. Kemp said urging people to use masks again is a “mixed message” that could discourage vaccination.

Read the full article:
Associated Press 

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