Before the Affordable Care Act (ACA) was enacted nearly six years ago, American health care was like a car speeding precariously toward the edge of a cliff. Health costs and insurance premiums were steadily climbing. Safety-net institutions were staggering under the weight of demand for uncompensated care. Health insurance companies routinely denied coverage to people with pre-existing health conditions. Nearly 50 million Americans were uninsured, and millions of others who carried health plan membership cards had threadbare benefits that left them one accident or illness from financial disaster. While the ACA was certainly not a panacea for all that ails American health care, it’s fair to say that it sparked important health policy changes that steered the health care system away from the cliff.
Here in California millions of people gained protection from medical bankruptcy for themselves and their families. Eligibility expansions enabled by the law have begun to benefit overlooked and underserved communities. Since implementation began two years ago, more than 2 million Californians enrolled in Medi-Cal, and 1.3 million people purchased subsidized private health plans through Covered California just this year. And Governor Jerry Brown recently signed into law the Health for All Kids Act, allowing up to 250,000 undocumented children in the state to be transitioned into comprehensive Medi-Cal coverage. In this new health care model, insurers must issue coverage to anyone regardless of medical condition, buyers of coverage are eligible for tax credits to help pay monthly premiums, and there must be parity between mental health and physical health services.
While expanded coverage is essential to improving the health of Californians, it will not by itself solve the state’s myriad health care challenges. Consider the network of safety-net providers who care for a disproportionate number of low-income patients. To help control costs and ensure patient access, the state has assigned 3.2 million Medi-Cal enrollees to managed care plans since 2013. Community clinics stepped up to care for most of these people — and in some regions of the state, a growing proportion of them have complex chronic conditions. Safety-net clinics face staff and provider shortages, while lacking the infrastructure and capital needed to meet increased demand for care. Research presented at a CHCF Sacramento briefing last week showed that clinics need funding, technical assistance, and payment incentives to be able to provide high-quality, efficient, and affordable care.
The challenges facing these clinics and providers mirror broader problems across California’s health care landscape. Many consumers lack access to specialty care. Providers and payers are working to offer effective models integrating behavioral and physical health care. And the drive for value and greater patient autonomy is gaining steam. Because of these challenges, CHCF is more focused than ever on how low-income Californians can get timely access to high-quality care they need, when they need it, and at a price they can afford.
CHCF Initiatives in the Year Ahead
In the behavioral health arena, providers, health systems, payers, and policymakers are increasingly realizing the importance of thinking about mental health needs along with medical needs, not in separate silos. We have a long way to go in achieving integration across the delivery system, but CHCF is committed to whole-person care as a way to improve outcomes and use resources wisely.
Over the last 10 years, opioid-related overdose deaths have quadrupled, and CHCF is joining national efforts to reduce the risk that comes with overprescribing painkillers. There is new energy among stakeholders to address the problem head-on, to promote better and safer treatment of chronic pain, and to increase access to life-saving and effective treatments for addiction.
One key focal point for CHCF is reversing the rising rate of cesarean sections. In the past decade, the US cesarean birth rate has increased by 50%. Many surgical deliveries are unwarranted, as evidenced by striking rate variation among hospitals. Unnecessary cesareans can harm both mother and baby. As CHCF-sponsored research has shown, changing this dynamic means changing practice patterns for health care providers. That presents challenges, but unprecedented momentum from stakeholders has encouraged us to stay focused on the issue. CHCF plans to harness this momentum by funding projects with stakeholders committed to reducing, over the next five years, the state’s cesarean-section rate for low-risk women to 23.9%, the target adopted as a federal Healthy People 2020 goal.
We will continue our work to educate the public about choosing options for end-of-life care that reflect each individual’s personal values and wishes, to expand access to palliative care services outside of big cities, and to accelerate the public release of state health care data.
The CHCF Health Innovation Fund will continue to pursue opportunities for trailblazing mission investing in support of disruptive technologies that provide services and improve access to care for low-income populations. One example is PipelineRx, a telepharmacy company that offers safety-net and rural hospitals access to remote pharmacy consultations to improve efficiency and reduce errors.
The Next Half-Century of Medi-Cal
As Medi-Cal celebrates its 50th anniversary in 2016, CHCF will be looking to the next half-century of this critical program. We are working with partners to develop a long-term statewide vision for ongoing and sustainable delivery system reform in Medi-Cal. We will share the results of this work in early 2016 to foster discussion and action.
We know more Californians than ever are insured, but at what cost to individuals and families? We will conduct foundational research to better understand the affordability of the health care coverage options currently available.
Because of existing capacity problems in the safety net, many low-income Californians can’t get the care they need, when and where they need it, whether or not they have insurance. CHCF will be investing in telehealth strategies as part of our ongoing work to expand timely access to care in the safety net.
Finally, we believe data and analysis can help improve the quality of decisionmaking. The CHCF Health Care Almanac series tracks the state’s changing health care environment with objective information on health care costs, coverage, quality, and delivery. These reports have for many years assisted policymakers, industry leaders, journalists, and others. In 2016 CHCF will update the Almanac, including the reports on Medi-Cal, the uninsured, and the physician supply, and we’ll introduce new ones on behavioral health, maternity care, and other subjects. In addition, look for updates to our regional market reports, which highlight variations in affordability, access, and quality of care in seven major California markets.
These projects and initiatives demand energy, focus, and commitment. Working with health plans, providers, and other funders, CHCF in 2016 is determined to chart pathways to health care 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.