This is a special moment for people in the business of ensuring that low-income Californians get the health care they need when they need it. Although it’s now more than five years old, the Affordable Care Act continues to reverberate across the health care system — especially in California, which went further than any other state in embracing opportunities created by the law. As a result, millions of people in our state have for the first time gained health insurance membership cards. This should aid in reducing social inequality by giving more Californians health and financial security, while strengthening California’s burgeoning economy.
But this opportunity also brings challenges. The sudden and remarkable growth in the insured population has created a new burden for health care providers who are struggling to keep pace with the demand for care. CHCF-supported studies have documented that within the Medi-Cal program, which serves more than 12 million low-income Californians, many of whom have disabilities or complex, chronic health conditions, there are not enough primary care doctors to adequately meet their patients’ needs.
In the drive to ease inequalities in health care, access to coverage in the form of a health plan ID card is necessary but often not sufficient. Coverage doesn’t guarantee timely access to the care and providers patients need, leaving work to be done in care expansion.
The California health policy community, state health agencies, insurance companies, local health plans, and the media have never been more focused on this question than they are right now. So too are primary care providers on the front lines — community health centers, county health systems, integrated delivery systems, and solo practitioners in urban and rural areas. And the same is true for us at the California Health Care Foundation (CHCF).
CHCF recently restructured its programs to ensure that we devote our resources to help California reach the goal of expanded access to appropriate, high-quality, affordable health care. We want to help policymakers understand the manifold obstacles to achieving this goal and to foster practical, attainable systemwide reforms to get us there. CHCF aims to improve access by ensuring that low-income Californians have access to coverage they can understand, use, and afford, and by expanding the capacity of safety-net providers to provide care through payment and delivery system reforms.
While CHCF believes firmly in taking a holistic approach to the challenge, each strand in the primary care braid must be considered individually. We recently published a review by researchers at the Center for Excellence in Primary Care at the University of California, San Francisco, that explores how the state’s huge corps of registered nurses might fill a bigger role in delivering primary care to counteract the decline in the supply of primary care clinicians. The authors of that report observe: “Untethered from the confines of fee-for-service payment systems, in the future, more and more primary care will be delivered by alternative methods, such as telephone visits and electronic communication, thus improving the convenience and care experience for patients and their families. Nurses are in a unique position to build on trusting patient relationships to fill these needs as the health coaches, health educators, and chronic care managers of the future.”
This report, in its directness and simplicity, lays out a compelling case for deploying the dynamic cadre of registered nurses at their maximum clinical capacities to free up nurse practitioners, physician assistants, and physicians; to expand the capacity of primary care practices; and to solidify the health system’s social bond with patients. Of course there is no single path that every provider can or should follow to more efficiently and effectively use available nursing resources. The report recognizes the vast diversity among providers and offers a menu of a dozen strategies for expanding RN responsibilities for a large share of primary care visits. The ideas in the UCSF report are examples of the system, regulatory, and payment transformations that will be required if we are to meet the health care needs of our population.
CHCF aims to lead the way to better health care for all Californians. We know we can’t achieve this alone — it will take everyone in health policy, academic training centers, work force partners, and philanthropic communities working together to make progress. In his 1966 speech to the Medical Committee for Human Rights, Dr. Martin Luther King Jr. captured the essence of why we do this work: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Improving access to primary care is a big, multifaceted challenge requiring technical expertise, community, and commitment. It won’t be easy, but for Californians the reward for success will be profound.
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.