Texas Water: Past, Present and Future
Sep 21, 2017 | 34 views | 0 0 comments | 0 0 recommendations | email to a friend | print

Texas Water: Past, Present and Future

Authors: Carlos Rubinstein, Herman Settemeyer, and Megan Ingram 

Persistent droughts and damaging floods are, regrettably, part of the Texas experience.  As much as they have affected our lives, landscape and economy, these weather events have also informed legislative and regulatory changes. In many instances, when it comes to water planning and management, Texas has gotten it right. But not always.

While policymakers will rightly be focused on the consequences of receiving too much water, we also have to remember that Texas is a land of extremes. Even now, some regions of the state are already in the initial phase of a drought.  That means that policymakers shouldn't forget the importance of water policy and markets.

In 1997, on the heels of yet one more drought, the Texas legislature responded with Senate Bill 1 — a comprehensive water planning directive that created the regional and state water planning processes we know and use today. We find this twentieth anniversary an appropriate time to reflect on our state and the way its water laws have been implemented since the enactment of Senate Bill 1 with a focus on a key goal of the landmark legislation — the establishment of water markets.

Water is a most fundamental natural resource: vital to all life, to our growing economy, to human welfare, and to the environment. SB1 envisioned market based voluntary transactions as a critical means of allocating water resources to meet future demand.

With very few exceptions, such voluntary market based transfers of water have not occurred.

Of equal concern is that as noted in the latest 2017 State Water Plan, a significant number of water management strategies (86 percent), critical to meeting our future needs, remain only as concepts on paper. This highlights the difference between planning and implementation.

To Texas’ credit and pride, we do have what many believe to be a national model when it comes to water planning coupled with attractive funding available from the state. This has in part incentivized the development of some projects, but not the creation of a water market.

As Texans, we very much value our property rights. In Texas water is a private property either by land ownership (groundwater) or by the issuance of a surface water rights.

Yet regulatory impediments have hindered our ability to move water from where it is to where it is needed.

Whether it is due to conflicting interests and regulations by Groundwater Conservation Districts or to legislative requirements that devalue water such as the “junior water rights provision” when it comes to interbasin transfers — water markets have been suppressed.

The lack of established water markets also limits our ability to properly value water. Water in Texas is, as most would agree, undervalued. And this goes beyond the purchase and use price for water; it also negatively impacts discussions on and valuation of area of origin impacts, economic benefit on receiving basin, and impacts to our environment bays and estuaries.

As other states have successfully experienced, competitive markets for Texas’ water will foster the development of a water supply to meet current and future demands while also promoting conservation.

There is a need for a new omnibus water bill to reform state regulations that now impede the proper valuation and trade of water.

Carlos Rubinstein is principal member of RSAH2O, an environmental consulting firm. Herman Settemeyer is a partner at RSAH2O. Megan Ingram is a policy analyst with the Armstrong Center for Energy & the Enviro

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JUDITH GRAHAM, Kaiser Health News



Caregivers Draw Support By Mapping Their Relationships
by JUDITH GRAHAM, Kaiser Health News
Sep 21, 2017 | 47 views | 0 0 comments | 3 3 recommendations | email to a friend | print

Caregivers Draw Support By Mapping Their Relationships

DENVER — Every time Jacque Pearson tried to devise a plan to move her 81-year-old dad, who has Alzheimer’s, from his home in Boise, Idaho, to hers in Denver, she felt stuck. Then, two weeks ago, she had a breakthrough.

It happened at an AARP-sponsored session in which Pearson created a “CareMap” — a hand-drawn picture showing all the people she cares for as well as the people surrounding those individuals and her own sources of support.

On one side of the paper, Pearson sketched out her father’s situation. There were three friends from Alcoholics Anonymous and his longtime doctor — the people he relies on most. There were three sisters and two sons in Arizona, not very involved. And there she was, the primary caregiver, far, far away.

As she peered at the drawing later that evening, Pearson saw what she had to do. “I’m going to contact each of his Alcoholics Anonymous friends and his doctor and ask them to convince my father to come to Colorado,” she told me when I called a week later.

How could a quick sketch of stick figures (representing the people in her father’s life), triangles (representing his medical providers), arrows (representing relationships between people) and box-like houses (where she and her father live) have this kind of impact?

CareMaps are an intriguing new tool created by the Atlas of Caregiving, an ambitious project that hopes to gather comprehensive data about family caregivers. The project’s pilot study examined 14 families in the San Francisco Bay Area who wore miniature cameras and sensors, kept a log of their activities and participated in extensive in-person interviews.

One of the goals was to understand what Rajiv Mehta, the project’s founder, calls the “ecosystem of family caregiving, the relationships that surround caregivers and that shape their experiences.”

One family caregiver might be at odds with her siblings but have a close group of friends she can turn to for emotional support as she cares for a disabled husband, for example. Another might be divorced but have a son living at home who can help with practical responsibilities as he cares for his mother with Parkinson’s disease, who moved in a year ago. Yet another couple in their 60s, both struggling with serious illness, may rely primarily on their three children, all living nearby, but have few friends.

How could these webs of relationships — people who are caring for each other and who are cared for, in turn, by others — be portrayed? Interviewers started drawing them quickly as family members were speaking. Symbols were assigned to people, pets, health care professionals, facilities and households.

Over time, refinements were added. Bidirectional arrows, for example, could show support flowing between people in both directions and the amount of assistance being provided (multiple times a day, daily, weekly or occasionally). Instructions for drawing CareMaps — anyone can give it a try — are available on the Atlas of Caregiving website.

At conferences, Mehta displayed some CareMaps and was surprised by the interest they generated. Somehow, seeing these pictures helped social workers, psychologists and other professionals understand what caregivers were experiencing in a different way.

In California, the Santa Barbara Foundation launched a series of caregiving workshops last year, using the CareMaps tool. Carol Levine, who directs the United Hospital Fund’s Families and Health Care Project and advises the Atlas of Caregiving, attended some of those sessions and was struck by how many participants seemed to have “aha moments.”

“There’s something visceral about making these pictures — it seems to open people’s vision to a broader view of what they were doing as caregivers,” she said.

Phylene Wiggins, director of the community caregiving initiative at the Santa Barbara Foundation, recalled leading a group at one of the workshops. “After people drew their CareMaps, we started going around the table and talking about their maps, and it was so heartbreaking,” she remembered. “One by one, each caregiver said ‘I am so alone.’ ‘I am so alone.’ ‘I am so alone.’” Encouraging those kinds of conversations and discovering ways to address that social isolation are among the foundation’s priorities, she said.

Cynthia McNulty, a social worker at Family Service Agency in Santa Barbara County, said her agency is using CareMaps in individual and group counseling sessions as a conversation opener. “Many of the people we work with, especially Latinos, don’t even acknowledge themselves as caregivers,” she said. “This is a useful way to shed light on the responsibilities they’ve taken on and needs that might not be met.”

“There’s no stigma attached: You’re just drawing a picture, not complaining,” she said.

AARP is testing CareMaps in six cities this year — Charleston, S.C.; Denver; Houston; Los Angeles; Phoenix; and Tulsa, Okla. It may roll out workshops more widely next year, depending on feedback. And the Atlas of Caregiving is preparing a web-based version, set to debut by year‘s end or early next year, Mehta confirmed.

In Denver, Alice Jordan, 69, is the primary caregiver for her partner, Vickie, 64, who has multiple sclerosis. When she drew her CareMap recently, Jordan saw that almost nobody was supporting Vickie other than her brother Bob, the only one of four siblings who checks in to see how she’s doing.

“MS isn’t a warm-and-fuzzy type of illness,” Jordan said, when I contacted her after attending one of the AARP sessions. “I’m going to call Bob and tell him how much we both appreciate him.”

For her part, Jordan initially felt that the circle of people who care for her would be empty. “When we started doing the diagram, it was like, ‘Bloody hell, I don’t have anybody,’” she said. But she found herself drawing Steve, a neighbor, who helps out when she goes out of town; Mary, a former colleague whom she walks with once a week; Onna, one of her sons whom she has lunch with regularly; Irene, a friend with Parkinson’s disease who’s always ready to talk; and her church, a source of comfort and connection.

“It made me realize I had more support than I thought,” Jordan said. And for that, she added, she’s very grateful.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation and coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

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LAURIE UDESKY, Kaiser Health News



Open Your Mouth And Say Goo-Goo: Dentists Treating Ever-Younger Patients
by LAURIE UDESKY, Kaiser Health News
Sep 21, 2017 | 67 views | 0 0 comments | 3 3 recommendations | email to a friend | print

Open Your Mouth And Say Goo-Goo: Dentists Treating Ever-Younger Patients

Allen Barron scrunches up his tiny face and wails as his mother gently tips him backward onto the lap of Jean Calvo, a pediatric dental resident at the University of California-San Francisco.

Allen’s crying may be distressing, but his wide-open mouth allows Calvo to begin the exam. She counts his baby teeth and checks for dental decay.

“Nothing I am going to do will hurt him,” Calvo tells Allen’s mother, Maritza Barron, who is holding her son’s hands.

To some, the 20-month-old toddler may seem far too young for a dental exam. In fact, he’s on the late side, according to leading dental and pediatric professional associations.

To stave off a lifetime of dental problems and make sure parents learn how to prevent children’s tooth decay, babies should have their first exam when they get their first tooth, or no later than their 1st birthday, according to guidelines from the American Academy of Pediatric Dentistry.

However, many dentists are uncomfortable treating babies, and that has created a significant gap in dental care for infants and toddlers of all backgrounds, experts say. The shortfall is hard to quantify because professional organizations, such as the American Dental Association, do not survey their members on whether they care for infants.

“People think that children are afraid of dentists, but really it’s that dentists are afraid of children,” said Pamela Alston, who is a dentist and dental director of the Oakland-based Eastmont Wellness Center, a publicly funded clinic that is part of the county-run Alameda Health System.

Hoping to narrow the gap in care, the public health agencies of San Francisco and Alameda counties are launching pilot programs to train dentists to treat babies. About 70 dentists will learn over the next three years how to coax infants into cooperating and help parents guard against tooth decay. The first training session in Alameda County is scheduled for early November; San Francisco will begin its training in January. The American Dental Association was not aware of any similar programs in other states.

The guidelines calling for earlier dental visits stemmed from a growing awareness that cavity-causing bacteria can be passed from parents to babies, through shared utensils, for example. Giving babies bottles of fruit juice or sugar water also can cause cavities. Decay in baby teeth has been linked to adult tooth decay.

“By the time children are age 3, they are often so far down the road that prevention is no longer an option,” said Ray Stewart, a pediatric dental professor at UCSF, who has treated infants for more than 15 years and is among the professionals enlisted by Alameda and San Francisco to train the dentists.

Communicating directly with children during dental exams can help reduce their stress, Stewart says. (Robert Durell for Kaiser Health News)

Dentists don’t regard exams of very young children as a means of boosting their income, said Alicia Malaby, spokeswoman for the California Dental Association. “Denti-Cal reimbursements are below actual costs for many procedures,” she said. Rather, they want to help “improve community health outcomes.”

Low-income children, who are more at risk of dental decay and have less access to care than their affluent peers, present the greatest need for early oral exams, dental professionals say.

A portion of the revenue from California’s new tobacco tax will be earmarked to help very young children from low-income families get the dental care they need. The money will be used to give dentists a 40 percent increase on top of the standard reimbursement for services to Denti-Cal patients, including oral exams of children age 3 and under. Denti-Cal provides dental care to beneficiaries of Medi-Cal, California’s version of Medicaid.

Alameda County will offer dentists an extra $20, on top of that statewide increase for appointments with Denti-Cal-covered children that include a thorough exam of the baby’s mouth, a fluoride varnish if needed, a talk with parents about prevention and a demonstration of how to brush their baby’s teeth.

The Alameda and San Francisco training programs, funded by grants from Medi-Cal, could be replicated throughout California if they are successful, according to the Department of Health Care Services.

Maritza Barron came to UCSF after her own dentist — despite the best of intentions — was unable to examine her baby’s mouth. “He tried to say ‘open up’ to him but he wouldn’t do it,” Barron said of the failed attempt, which left her son in tears.

Alston, the Oakland dentist, once faced similar challenges treating very young children, but she has since undergone a transformation. She blames dentists’ wariness of young patients on a lack of experience. When she graduated from dental school in 1982, she said, she had no training that prepared her to work with children younger than 6.

“I didn’t feel like I could manage their behavior,” Alston said.

Over time, however, it became increasingly clear to her that she wasn’t seeing children early enough.

Almost all of the kids who came to her for their first dental visit at age 6 had mouths riddled with tooth decay, Alston said. She had to refer them to specialists for treatment that required sedation. She kept lowering the minimum age for a first visit in her practice, then left it at age 3 for a long time.

But even 3-year-olds were coming in with cavities. Ultimately, she learned how to treat infants and toddlers through a program run by Alameda County’s public health department — not unlike the training to be offered by the new pilot programs.

Today, Alston is passionate about treating very young children and has lined up pediatricians to refer infants to her. And she has revised her guidance on when kids should get their first oral exam, advising parents to bring their children in when their first tooth starts to erupt.

She also trains dental students to examine infants. An important trick she teaches them is how to avoid being bitten: “Put your finger behind the last tooth!”

Communicating directly with children during dental exams can help reduce their stress, saod both Alston and Stewart, the UCSF dental professor.

At a recent visit to UCSF’s Pediatric Dentistry Faculty Clinic, 18-month-old Sebastian King scrutinized the dental mirror Stewart handed to him.

“That’s what I’m going to put in your mouth to look at your teeth!” Stewart told him exuberantly.

He asked the young boy to show him where his mouth was. Sebastian smiled with delight as Stewart handed him a blue exam glove he’d blown up into a balloon, and the young boy remained calm throughout the exam.

Helping parents understand their role is also critical, dentists say.

In addition to advising parents not to share eating utensils with their children, Stewart urges them not to let their kids fall asleep with a bottle of milk and to limit their consumption of fruit juice. He also says they should wipe their infants’ gums and teeth with a cloth after feeding them to remove residue that can cause cavities.

That’s the message Calvo, the dental resident, gave to Barron, whose baby sat happily on his mother’s lap after his exam. The boy had cavities because he had been falling asleep with his bottle.

Barron said she recognized that weaning Allen from the bottle at night would be a challenge.

But “it’s really logical,” she told Calvo, adding that she was determined to give it a try.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN’s coverage of children’s health care issues is supported in part by a grant from The Heising-Simons Foundation.

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