Over half a century, the Medicare and Medicaid programs have transformed, modernized, and reorganized American health care. Likewise, the Affordable Care Act (ACA) has brought about important health policy changes that will reverberate for decades to come — and many of the changes have special importance for the health of California’s Latino community.
Eligibility expansions enabled by the law have benefited populations long overlooked and underserved. Since implementation began two years ago, more than 2 million Californians have signed up with Medi-Cal, and now almost half of its 12.4 million enrollees are Latino. Covered California enrolled 1.3 million people this year; nearly 300,000 were Latino. And last month Governor Jerry Brown signed into law the Health for All Kids Act, which will enable up to 250,000 undocumented children in the state — most of them Latino — to transition into comprehensive Medi-Cal coverage.
While California is moving in the right direction in providing access to care for this population, much remains to be done. In clinics and offices, we witness many Latinos who struggle to obtain adequate medical care. Language issues, transportation challenges, and lack of cultural sensitivity are significant barriers. And many don’t seek care because of immigration status, forgoing necessary treatment until they are forced to go to an emergency room.
CHCF is pursuing research to deepen our understanding of the barriers Latinos face in getting care and also supporting strategies to address them. Solving these problems may require changes to public policy, greater efficiencies by plans and providers, and leadership from private foundations.
Latinos Reach Critical Mass in California
In 2015, California’s Latino population reached critical mass. As of June, 15 million called California home — representing 38% of the population and the state’s largest ethnic or racial group. California officials project that number will grow to 24 million by 2050, accounting for nearly half the state population. Latinos own hundreds of thousands of California businesses, contribute 20% of the state’s tax revenue, and have a growing presence — in the halls of government and in the voting booth. To protect the economic future of the nation’s largest state, it is imperative that California devise ways to make the health care system more inclusive by recognizing and meeting the needs of Latinos, especially those in low-income families.
This year, Medi-Cal will spend more than $90 billion on care. This prodigious purchasing power gives it a unique opportunity to influence the best ways to deploy health care dollars, ensuring better health outcomes for enrollees and improving the overall health care system. This involves collaborating with private payers and safety-net providers to promote safe, timely care based on sound science and organized around the needs of patients.
The task is to provide affordable, easily understood care options that are accessible at convenient times and locations. Families stay healthier when they can find care that matches their needs, their preferences, and their schedules. CHCF is working hard to stimulate policy dialogue that fosters the creation of those options.
Improved access to coverage and care is critical. One in three California Latinos is poor or near the poverty line, a risk factor for inadequate access to coverage and care. For those who have taken advantage of ACA eligibility expansion, it’s not enough to be covered if unaffordable copays and deductibles prevent people from seeking care.
Latino Uninsured Rate Stands at 20%
Twenty percent of Latinos in the state remained uninsured in 2014. Latinos represent 37% of Californians projected to be eligible for subsidized Covered California plans, but only 28% of 2015 members were Latino. After outreach problems in the Latino community in year one of ACA implementation, Covered California revised its strategy. Latino enrollment was more successful in year two. Still, most of the nearly 1 million Latinos projected to be eligible for Covered California have not signed up.
One key lesson learned from the Covered California experience: Latinos prefer individual, face-to-face assistance from certified enrollment counselors and other assisters. It’s important that California invest in this capacity to get Latinos enrolled. Many Latino adults who are newly eligible for Medi-Cal remain unenrolled, and others who were eligible for Medi-Cal before the ACA was implemented have yet to take advantage of coverage opportunities.
CHCF is pursuing research to understand how best to target the unenrolled and is supporting groups working to reduce enrollment barriers. The median age of California Latinos is 29 years, compared with 45 for the non-Hispanic white population, and this means Latino families are key targets of outreach campaigns for enrollment and selection of appropriate providers. We are encouraging collaboration among groups developing resources for promotores de salud in their communities to reach vulnerable, low-income, and underserved Latinos. Promotores are trusted, trained peers who guide clients to the most appropriate health plan and help them enroll.
Medi-Cal Prepares for Undocumented Immigrant Children
Governor Brown’s 2016 budget includes funding to expand full-scope Medi-Cal coverage to children otherwise eligible except for immigration status. The Department of Health Care Services is starting to focus on the details. As implementation is mapped out, it is essential that state officials, health plans, providers, and parents have sensible coordination and clear communication to avoid interruptions in coverage and to prevent needless disruptions in relationships with providers. CHCF has formulated suggestions about how to limit such disruptions.
It’s also vital that all newly eligible children be targeted with outreach and enrollment efforts that are linguistically and culturally appropriate. That means addressing families’ fears about immigration status and misperceptions that Medi-Cal enrollment may jeopardize future citizenship applications. We need strong collaboration among the state, the county social services eligibility offices, community-based organizations, and application assisters.
Finally, CHCF is working on finding ways to make greater use of email, phone, and video visits to add convenient alternatives to face-to-face care — many of which are commonly available to patients of large, integrated systems. Expanding this capacity in safety-net clinics, whose patient population is 68% Latino, may not be easy, but we must try.
CHCF is redoubling its efforts to support the testing and evaluation of innovative approaches to improving care. We are commissioning research and analysis that policymakers, clinical leaders, payers, consumers, and the media depend on to better understand California’s complex health care system.
Following the path to equity in access, coverage, and care is not only the right choice for California, it will lead us to a sound, manageable, and sustainable delivery system that works for all Californians.
Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also cochaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco. It was the first time a local government in the US attempted to provide health care for all of its constituents.
In February 2018, Sandra was appointed by Governor Jerry Brown to the Covered California board of directors. She also serves on the Betty Irene Moore School of Nursing Advisory Council at UC Davis and on the UC Regents Health Services Committee. Sandra is an assistant clinical professor at the UCSF School of Medicine. She practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016.
Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.