Over the last few years, California has been on the national front lines of closing health care access gaps through transforming Medi-Cal, its version of Medicaid.
Although California reached its lowest uninsured rate in 2022, health care access barriers still remain for many Californians, resulting in higher rates of illness and death — particularly for low-income individuals and people of color. In response, Department of Health Care Services (DHCS) staff went on a statewide tour to listen to Medi-Cal members who experienced health inequity firsthand, and use the feedback to re-design Medi-Cal.
At a Tuesday, June 18 Ethnic Media Services Briefing, a DHCS representative and two health care providers from a community-based organization that hosted one of the listening sessions discussed Medi-Cal’s transformation and the road ahead.
Medi-Cal and equity
“Who you are and where you live should not determine whether or how well you live,” said Pamela Riley, chief health equity officer and assistant deputy director of quality and population health management at DHCS.
“With nearly 15 million Californians enrolled, Medi-Cal has already taken significant steps to advance equity,” she continued, “our first step being to make Medi-Cal coverage available to all income-eligible people, regardless of age or immigration status” as of January 1, 2024.
Other historic measures include eliminating asset limits so only income is considered when determining Medi-Cal eligibility; establishing a Member Advisory Committee to give feedback on Medi-Cal programs; expanding language access so members can receive interpretation services in 18 languages; and creating new Community Supports that provide services well beyond the doctor’s office, like housing aid, home accessibility modifications, healthy meals and transportation to and from medical appointments.
“To listen to our members more directly to understand where our greatest health disparities lie and how we can improve them, DHCS also launched its three-phase Health Equity Roadmap Initiative,” said Riley.
For the first phase, begun in November 2023 and now complete, DHCS staff held 11 listening sessions hosted by community-based organizations statewide, to listen to hundreds of Medi-Cal members about the challenges that prevented them from getting the health care they need — particularly for members from communities of color, those with disabilities, those in rural areas and those with behavioral health issues like substance abuse disorder.
“We often heard from members that they wanted Medi-Cal to cover certain services which were already covered — like dental, vision or mental health care — which told us that our communication could be improved,” said Riley.
“They also wanted to feel respected and listened to in their native language,” she continued, so we have required all our health care facilities to have interpretation services available in threshold languages,” numbering 18 statewide as of 2021 — including Arabic, Chinese, Hindi, Hmong, Russian, Spanish and Vietnamese.
Alongside a report about listening tour feedback, to be released next year, “the second phase will involve using this feedback to identify common themes,” she added, while the third will outline specific steps to make Medi-Cal more accessible on the ground.
Closing health access gaps on the ground
“In my 22 years here, there has never been anything like this. This is historic,” said Debbie Toth, president and CEO of Choice in Aging, one of the listening session hosts.
“DHCS reached out to us about talking with patients at our Bedford Center in Antioch” — which primarily provides Alzheimer’s day health care and transition care out of/from nursing facilities — “because you could see the social determinants of health at play. We have elderly adults, but also younger low-income participants who may be in their 50s, yet their physical health is like somebody in their 80s,” she explained. “They may be unhoused, or have substance use or mental health support needs.”
“Our biggest challenge was that we’re working with a population with a lot of cognitive impairments, like mid-to-late-stage dementia, who can’t always express what they need directly,” Toth continued, “so Michael, our program director, broke the participants into small tables while also engaging their caregivers as to what everyone’s needs were for easier health care and language access.”
“Another challenge is that we’d always like to enroll more people, but we’re the only adult day health care center in the area,” added Michael Whalen, program director of The Bedford Center. “As many of our at-home caregivers themselves can be quite elderly, we had a unique opportunity to coordinate solving the challenges both they and their patients faced.”
“Another big challenge is financial,” said Toth. “We have the DHCS Health Equity Roadmap, we have the California Master Plan for Aging, these policy frameworks set up to support people in their communities … but if we have a recession, a change in administration, if we can’t pay livable wages, we lose the infrastructure like we are already, with the massive closures of adult day health care centers.”
As of June 2024, California has less than 300 adult day health facilities — compared to 365 before the Great Recession, when the statewide closures began.
“Our greatest marker of success is keeping people out of skilled nursing facilities who don’t want to be there,” Toth said. “Our current de facto long-term care system is warehousing folks as they age or become disabled … and what’s so incredible is the community focus that DHCS has, rather than an institutional focus. They’re not just giving out questionnaires to clinics, but actually learning from the community whether their needs are being met.”
“As an example of the humility needed in asking these questions … When I started at Choice in Aging, there were Russian, Farsi, and English programs, but no Spanish program for the needs of our Spanish-speaking community members — so I made one, and quickly discovered that they did not want it,” she continued. “There were people from El Salvador, Mexico, Argentina, Spain, and their message was: ‘Just because we share a language, we don’t necessarily share a combined interest.’”
“It was a lesson to be learned … that our needs aren’t necessarily based on one characteristic we share,” Toth added. “It’s important to ask with humility what everyone’s needs really are, and then adapt — which is how DHCS is leading Medi-Cal right now.”
