California has been a leader in implementing public policy that fosters equitable access to quality palliative care. Five key policy changes have been instrumental in laying the groundwork for scaling palliative care services and for supporting goal-aligned treatment (see “Statewide Policy Changes Driving Progress in California”).
Statewide Policy Changes Driving Progress in California
| Date | policy change | contributions to progress |
|---|---|---|
| 2006 | Assembly Bill 1745 (Nick Snow Children’s Hospice and Palliative Care Act) | Required California to pursue a Medi-Cal waiver to enable children with serious illness, regardless of prognosis, to receive palliative care concurrently with curative treatment. The requirement served as a precursor to Senate Bill 1004. |
| 2008 | Assembly Bill 3000 | Establishes Physician Orders for Life-Sustaining Treatment (POLST) in law and requires clinicians to honor the form. |
| 2014 | Senate Bill 1004 | Requires the Department of Health Care Services (DHCS) to set standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services to eligible members. Law was effective in 2018 and updated in 2019 to include children. |
| 2021 | Assembly Bill 133 (California POLST eRegistry Act) | Authorizes the California Emergency Medical Services Authority to establish a statewide POLST electronic registry system. |
| 2023 | DHCS D-SNP Requirement (PDF) | Requires Dual Eligible Special Needs Plans to provide access to palliative care services for eligible members (effective 2024). |
“I never thought I’d see the day that I would combine ‘palliative care’ and ‘benefit’ together. It just lets me know that this is a movement that is growing and moving forward.”
— Kim Beverly, MSW, MSG, Palliative Care Clinical Program Manager, Blue Shield of California
Statewide Policy Changes to Support Specialty Palliative Care
California’s legislation supporting specialty palliative care began with the passage of Assembly Bill (AB) 1745, known as the Nick Snow Children’s Hospice and Palliative Care Act of 2006. AB 1745 established a Medi-Cal waiver program to provide home-based palliative care for publicly insured children with serious illness, regardless of prognosis. The program was implemented in 11 counties and offered services such as nursing visits, respite care, psychosocial support, massage, and expressive therapies like art and music.
Lessons from the Field
Teri Boughton, policy consultant to the California State Senate Committee on Health, who worked on development of SB 1004, highlighted three reasons the legislation passed successfully without opposition:
- Pediatric palliative care had demonstrated high satisfaction rates among caregivers and providers, decreases in hospitalization rates, and either cost savings or cost neutrality.
- The proposed legislation would not cost the state any money and was assumed to be budget neutral to Medi-Cal plans.
- Many policymakers had experienced serious illness within their families and, as a result, could understand and support the benefits of quality palliative care.
AB 1745 laid the foundation for Senate Bill (SB) 1004, passed in 2014 and implemented in 2018, which mandated the California Department of Health Care Services (DHCS) to set standards and provide technical assistance for Medi-Cal managed care plans (MCPs) to ensure the provision of palliative care services to eligible members. Soon afterward, AB 1745 was sunset and the provision of children’s palliative care was included as part of SB 1004. In 2023, five years after the implementation of SB 1004, the Medi-Cal requirements of MCPs served as the basis for the requirement that all Dual Eligible Special Needs Plans (D-SNPs) offer palliative care beginning in 2024. D-SNPs are Medicare Advantage plans that provide care to people enrolled in both Medicare and Medicaid (“dually eligible” enrollees).
Policy Changes to Support POLST
In 2008, AB 3000 was signed into law, establishing Physician Orders for Life-Sustaining Treatment (POLST) in California. The law enabled use of POLST forms in the state, which direct health care providers in the use of specific medical interventions aimed at resuscitation or sustaining life if patients cannot speak for themselves. This policy expanded access to information and processes that give people approaching the end of life more control over their medical treatment.
In 2021, AB 133 required the California Emergency Medical Services Authority to establish a statewide electronic registry system for POLST. The purpose of the registry is to help ensure that patients’ completed POLST forms are available wherever the patient receives care. That same year, the Coalition for Compassionate Care of California contracted with the State of California to provide subject matter expertise and stakeholder management to assist and guide the state through the research, planning, and implementation of a secure electronic POLST registry.
Palliative Care in Statewide and National Initiatives
Palliative care has also been incorporated into several of California’s statewide health initiatives, significantly increasing its visibility (see “Statewide Initiatives That Incorporate Palliative Care”).
Statewide Initiatives That Incorporate Palliative Care
| date | initiative | contributions to progress |
|---|---|---|
| 2012 | Let’s Get Healthy California Framework (PDF) | Establishes a framework for assessing and monitoring the health of Californians; includes access to palliative care as one of the indicators for monitoring health across the lifespan. |
| 2021 | Master Plan for Aging (PDF) | California’s blueprint for navigating changing demographics over the next 10 years, it includes access to palliative care and POLST as priority initiatives. |
| 2022 | CalAIM (PDF) (California Advancing and Innovating Medi-Cal) Initiative — Enhanced Care Management (ECM) | ECM requires comprehensive health assessments including a screening process for assessing the need for palliative care. |
In addition to statewide policy changes, national policy changes have contributed to the increase in palliative care capacity across California (see “National Policy Changes Driving Progress in California”). Although statewide policies have been the primary driver of increased palliative care capacity in Medi-Cal, national policies impacting Medicare Advantage and accountable care organizations have helped drive expansion across other payer types.
National Policy Changes Driving Progress in California
| date | policy change | contributions to progress |
|---|---|---|
| 2010 | Affordable Care Act | Created new mechanisms to pay for or provide incentives for incorporating palliative care, including accountable care organizations, bundled payments, concurrent care demonstration program, and penalties for preventable readmissions. |
| 2018 | CHRONIC (Creating High-Quality Results and Outcomes Necessary to Improve Chronic) Care Act | Paved the way for Medicare Advantage plans (PDF) to cover home-based palliative care and other nonmedical services that benefit people with serious illness. |
| 2024 | Value-Based Insurance Design Hospice Carve In | Requires advance care planning support for all enrollees with serious illness, provision of access to timely and appropriate palliative care services, and provision of transitional concurrent care (disease-modifying treatment delivered after hospice enrollment). |
For full source information, see California’s Palliative Care Evolution — Drivers of Progress in Advancing Palliative Care (PDF).
