“We’re saying ‘time’s up,'” said , the chief medical officer for Covered California. “We’ve told health plans that by the end of 2019 we want networks to only include hospitals that have achieved that target.”

Here’s how hospitals will be measured: They must perform fewer unnecessary cesarean sections, prescribe fewer opioids and cut back on the use of imaging (X-rays, MRIs and CT scans) to diagnose and treat back pain. Research has shown these are problem areas in many hospitals — the procedures and pills have an important place, but have been overused to the point of causing patient harm, health care analysts said.

C-sections, in particular, have come under scrutiny .

Hospitals get paid more to perform a C-section than a vaginal delivery and C-sections usually take less time: 40 minutes for a scheduled procedure versus 24-hour on-call staffing for vaginal deliveries. Many women who don’t need a C-section  according to the data — and rates vary by hospital. Even in low-risk cases, several California hospitals are delivering 40 percent of babies by C-section, Lang said. At one hospital, it’s 78 percent.

“That means that when a woman goes to a hospital, it’s the culture of the hospital that really determines whether or not she gets a cesarean section, not so much her own health,” said Lang.

C-sections are major surgery. Doing them when they’re not needed exposes women to unnecessary risks: infection, hemorrhage, even death. Babies delivered by C-section are more likely to  and spend more time in the neonatal intensive care unit.

That’s not quality health care, Lang said, and that’s why Covered California is telling hospitals they need to reduce their C-section rates to 23.9 percent or lower, for low-risk births.

In this case, “low-risk” is defined as a healthy, first-time mom who has carried a single baby with its head down, all the way to full term — .

, the state health program for low-income residents, , the retirement program for state employees, and the , which represents self-insured employers, are also calling on hospitals to improve their quality measures. Together, these groups pay for the health care of 16 million Californians, or 40 percent of the state, which gives them substantial leverage with hospitals.

But only Covered California is telling hospitals that if they don’t play by the rules, they’ll be benched.

“It’s probably the boldest move we’ve seen in maternity care ever,” said Leah Binder, CEO of the , a Washington, D.C.-based nonprofit that rates hospitals on quality.

Expecting hospitals to meet external metrics for quality control is a recent phenomenon, and compliance is still largely voluntary, she said.

“Back in the ’80s and ’90s, nobody ever thought that hospitals should have to report to anyone on how they were doing,” she said. “There’s never been a culture of accountability.”

Covered California’s move is nationally significant, Binder said, given the consequences for hospitals, and the agency’s reach — 1.4 million people buy coverage through the marketplace — and they shop among plans offered by 11 state-approved insurance companies.

Insurers and business groups across the country are already keeping an eye on California’s effort, she said, to see how they might band together to demand similar change from the hospitals in their regions.

Overall, California’s hospitals are on board with the C-section goal. Of the 243 maternity hospitals in the state, 40 percent have met the target, Lang said, and another 40 percent have taken advantage of coaching and consulting to help educate doctors on how they can adjust their practices. They’re also finding they have to educate patients who request C-sections about the procedure’s risks.

“While many may prefer [the surgery], when having the full information about the risk that they may be putting themselves and their babies in, they elect not to move in that direction,” said Julie Morath, CEO of the , a subsidiary of the . Both groups support the C-section reduction goals as “the right thing to do,” she said.

The strategy has raised some concerns among mothers who hear about the 23.9 percent target and worry about rationing.

“We don’t just chase rates,” Morath said in response to that concern, “but rather look at what the clinical needs are and how to best respond to those. So if there is an indication for a cesarean section, the mother will receive a cesarean section.”

Still, not all hospitals will find it easy to comply. State data show there are about 40 hospitals that are still far off the target, including a cluster of hospitals in East Los Angeles that treat low-income, often uninsured, patients.

“If you have somebody who is on methamphetamines and is homeless and has not gotten any prenatal care, her chance of a C-section is way higher than someone who is not all those things,” said Dr. Malini Nijagal, an OB-GYN at Zuckerberg San Francisco General Hospital. “And so the problem is, how do you adjust for the patient population of a hospital?”

At Memorial Hospital of Gardena, the C-section rate is 45.2 percent. At East Los Angeles Doctors Hospital, the rate is 48.1 percent, according to publicly available state data listed on Ìý²¹²Ô»åÌý. Both hospitals are working diligently to lower the rates, according to Amie Boersma, director for communications for , which owns both hospitals.

She said the hospitals will meet the 23.9 percent benchmark and are committed to doing so for the sake of their patients. Being excluded from Covered California health plan networks, she added, would make it even more difficult for those patients to get care. They would either have to pay out-of-network fees to be seen there, or they would have to travel farther to another facility that was still in the network.

“We are in underserved, economically challenged urban neighborhoods and it is vitally important that we continue to provide appropriate, high-quality care for our communities,” Boersma said.

Health plans can request an exemption from Covered California’s contract rules (in order to keep noncomplying hospitals in their networks) — as long as they document their reasoning.

“That is flexibility that we asked for to ensure that we maintain adequate access to providers,” said Charles Bacchi, CEO of the , a trade group for insurers. “Any major changes to health plan networks must be filed with regulators. And health plans have to ensure that patients continue to receive services in a timely manner.”

So far, the prospect of exclusion, plus the coaching for hospitals on how to reduce the rates, have functioned as an effective motivator. By 2020, Covered California’s Lang predicted, all hospitals will either have met the target or be on their way.

“It’s a quality improvement project,” Lang said, “but with a deadline.”

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

“Growing up in Appalachia, you look forward to getting your first firearm,” he said, “probably more so than your first car.”

His grandfather taught him to hunt squirrels and quail. Zimmerman, who lives in Elizabethton, Tenn., said pretty much everyone he knows has a gun. It’s just part of the culture.

“When I went into the military, that culture was reinforced,” he said. “Your weapon is almost another appendage. It’s part of who you are.”

Zimmerman served as a medic in the Army in the late 1990s and early 2000s, with stints in Bosnia, Africa and the Middle East. Since he came home, he’s struggled with PTSD and depression. It reached a crisis point a few years ago, when his best friend — the guy who had saved his life in a combat zone — killed himself. Zimmerman decided his time was up, too.

“I decided that I would have one more birthday with my daughter, one more Christmas with my daughter,” he said. “I had devised my own exit strategy for 16 February 2013.”

But then he bumped into a woman who used to ride the same school bus when they were kids. His exit date came and went. They’re married now.

Zimmerman still gets depressed, but now he’s a peer counselor at the in Johnson City, Tenn. He also travels to conferences all over the country, sharing his story with therapists and with other vets, encouraging them to ask for help when they need it.

Even today, he explains at these conferences, if he’s not doing well, he disassembles his guns and stores them separately from ammunition, so he can’t make any rash decisions. And if things get really bad, Zimmerman has a special arrangement with a few friends.

“I call them and say, ‘Look, I’m feeling like it’s not safe for me to have firearms in my home. Can you store them for me for a couple days till I feel like I’m OK to have them back?’ “

Suicide is often an impulsive act. Nearly half the people who survive an attempt say the time between their first thought of suicide and the attempt itself was less than 10 minutes. But the method can mean the difference between life and death: People who take pills have time to change their minds, or may still be alive when discovered. .

Almost 70 percent of do so with a gun, which prompted President Barack Obama to order the VA to talk to vets about gun safety and storage options like the ones Zimmerman uses.

But here’s the trouble: Most therapists aren’t gun people. They don’t know how to talk about guns and so they don’t.

“One obvious reason for that is that no one has taught them how,” explained , a psychologist and National Deputy Director in the Office for Suicide Prevention in the U.S. Department of Veterans Affairs.

McCarthy was invited to speak recently at a suicide prevention conference in San Francisco, aimed at therapists who work with vets.

“How many of you would say you feel really comfortable having a conversation with any of the people you work with about limiting access to all lethal means?” she asked the roomful of therapists.

Hardly anyone raised their hand.

“OK, so that’s why we’re here today,” she said.

Researchers recommend starting with a field trip to a shooting range. There, therapists can learn about different kinds of firearms, as well as gun locks, and get an introduction to gun culture.

When counseling vets, therapists have to ask more questions and be less directive, McCarthy said.

“We often conceive of ourselves as experts — as people who impart information to clients,” she said. But with vets, “it may take time to build trust. Telling them what to do the first time you’ve met them is probably not going to be a very effective approach.”

McCarthy presented a case study at the conference: A 28-year old, unmarried Army veteran who fought in Iraq told his VA psychiatrist that he had an argument with his girlfriend last week. He drove to an empty parking lot and sat with his loaded handgun in his lap, intending to kill himself.

He didn’t do it. A week later, the man told his psychiatrist things were still tense with his girlfriend. But he didn’t want to talk about suicide or storing his gun.

McCarthy asked the clinicians in the audience what they would do next, if they were this man’s psychiatrist.

“Why did he not do it? That would be my question,” one therapist said.

“I would want to see this individual again, within the same week,” said another. “I believe in strong intervention.”

Jay Zimmerman, the former army medic and peer counselor, stood up and explained his different perspective.

“Chances are the reason he’s not talking to you is because he’s afraid he’s going to lose his gun that he carries pretty much all the time,” Zimmerman said. “My buddies are the same way. We all carry — all the time.”

A lot of veterans would sometimes rather confide in a fellow vet than someone in a white coat, Zimmerman said. And that was an unusual takeaway for the professional counselors: Sometimes their role is not to intervene at all, but to be a facilitator. To make sure vets have someone to talk to outside the therapy office.

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

“I literally pulled over the car and was like ‘What’s going on?’” Stabile remembered. “I was having a panic attack.”

Another ad showed two men in bed, looking nervous, with the question “Trust Him?”

“As a gay man, you really have to fight against this idea that you’re constantly in danger,” said Stabile, who came of age during the height of the AIDS epidemic in the 1980s. “Fear and stigma actually works against people getting tested.”

Stabile said he sees the same heavy-handed, moralistic attitude behind , the state ballot initiative that would require adult film performers to use condoms on porn sets. If they don’t, and state regulators fail to enforce the mandate in a timely manner, any Californian can sue the film producer.

“Its success depends on stigma around sex, stigma around porn,” said Stabile, who now works for the .

The man behind Proposition 60 — and all those billboards — is Michael Weinstein, president of the , and a long-time maverick in gay activist circles.

The nonprofit runs pharmacies and provides HIV care in 13 states and 37 countries, and gave away 38.5 million condoms last year. It’s putting $4.5 million from its pharmacy sales into backing the Proposition 60 condom mandate. (It also put $14.7 million behind , Weinstein’s initiative aimed at lowering drug prices.)

Weinstein said he’s steadfastly promoting condoms when other groups seem to have forgotten them.

“It’s unfashionable,” he said. “I was on a panel discussion and one of the guys said ‘You’re acting like our mother telling us to wear galoshes.’ And my reaction was ‘Yeah, somebody needs to do that!’ I mean, I’m not trying to win a popularity contest. Obviously.”

For Weinstein, Proposition 60 primarily is about protecting adult film workers against sexually transmitted diseases at a time when California’s infection rates are at a 20-year high. But it’s also another large-scale condom campaign.

“A lot of people get their sex education through these films and I think it’s sending a bad message,” Weinstein said. “I don’t want young people to be educated that the only kind of sex that’s hot is unsafe sex.”

Controversial Figure

Weinstein has long taken controversial positions, but he’s often landed on the right side of history. In the 1980s, he fought lawmakers in California who wanted to quarantine AIDS patients. When nurses were afraid touch patients, leaving them languishing in the hallways of county hospitals, he helped set up one of the first AIDS hospices, where people could die with dignity and compassion. And when the life-saving antiretroviral drugs known as the AIDS cocktail came out, Weinstein risked bankruptcy to provide the drugs to uninsured patients.

“We decided we had a moral obligation to give them and we paid for them and those people lived,” he said.

One of Weinstein’s more recent and most unpopular stances is on , the daily medicine that . Many activists consider it a gift from God. Weinstein calls it a party drug.

“It’s often taken in conjunction with crystal meth and other party drugs,” he said. “It’s really a get out of jail free card.”

Weinstein argues PrEP gives people a free pass to not use condoms and be reckless, driving a rise in other STDs, which bear out. But other public health groups say PrEP will reduce HIV transmission and save lives, which the studies also support.

“It’s not helpful to have one of the largest HIV organizations in the world trivializing it or downplaying its importance,” said Courtney Mulhern-Pearson, director of state and local affairs at the 

Her group, along with , opposes Proposition 60, in part, because it ignores PrEP. Mulhern-Pearson said Weinstein’s singular focus on condoms is outdated and unrealistic.

“Condom fatigue is real,” she said. “And I think that all of us are probably not realistic and not forthcoming about our condom use.”

History And Opposition

Weinstein has been fighting to mandate condoms in adult films for years. While federal and state worker safety laws technically already require producers to protect performers against STDs with condoms, the law is largely ignored and poorly enforced. Weinstein has been pushing California’s Division of Occupational Safety and Health for years to refine and clarify regulations, . He’s backed local measures in Los Angeles County to require condoms, which , but enforcement has, again, been minimal.

At every turn, the adult film industry has opposed condom mandates. They say it will force them to make products that won’t sell, driving the business underground or out of state.

In mid-October, more than a hundred adult film performers rallied outside Weinstein’s office in Los Angeles to protest Proposition 60. They chanted slogans like “Our Bodies, Our Choice!” and carried signs that read “Where is Weinstein?”

They say they prefer to rely on the industry’s bi-monthly testing protocol over condoms. Performer Ela Darling says condoms don’t work on porn sets — they’re uncomfortable and cause friction rashes.

“The sex you have on camera isn’t like the sex you have at home,” she said. “It’s like Olympic-level, athletic sex.”

She’s frustrated that Weinstein is ignoring their concerns.

“He will not hear us, he will not speak to us, but he’s happy speaking for us,” she said. “And that’s the problem.”

Weinstein defends his refusal to meet with the adult film industry.

“I’m not going to put myself in a position of debating people where all they do is call me names,” he said.

It’s true. Weinstein’s critics have called him bombastic, a bully. They compare him to Donald Trump. They post tweets that refer to him as the Condom Nazi.

“In case they haven’t noticed, I’m Jewish and I’m gay, OK,” he said. “It makes my skin curl.”

Weinstein said he’s never liked the limelight. He’s had to develop a thick skin to stay in this business, to stand up for what he believes is the moral thing to do, for what he believes is his responsibility toward young generations.

But it’s clear that the criticism bothers him.

“He’s been hurt,” said Sharon Raphael, an old friend and fellow activist. “I know that it hurts him.”

But, she added, everyone knows he’s a force to be reckoned with.

“When most people would be down and out, strike three, he’d get up again,” she said. “He never gives up. Ever.”

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .