California’s Safety Net at a Crossroads

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Editor’s note: Since 2019, California has undertaken a series of major health care reforms that have reshaped the state’s health system. From Medi-Cal expansion and CalAIM to new workforce initiatives and data exchange, these changes represent some of the most transformational health policies in state history. 

Understanding how these initiatives work together — and their collective impact on Californians’ access to care — can be challenging. To provide perspective on these reforms, The CHCF Blog invited Marko Mijic, who held senior positions at the California Health and Human Services Agency (CalHHS) for nine years, include serving as undersecretary from 2021 to 2024, to share his insights. As someone who helped develop and implement many of these policies, Mijic offers a unique perspective on how they fit into California’s broader strategy. 

California has a transformative vision for how to build a Healthy California for All that goes beyond expanding access to health insurance coverage and health care. Under the leadership of Governor Gavin Newsom, the state aims to achieve better health outcomes for communities that have been left behind by building a more resilient safety net system and a more robust state economy. A healthier population leads to increased productivity and economic participation, especially for Medi-Cal enrollees, who typically hold lower-wage jobs.  

This vision aims to close the gaps that the COVID-19 pandemic exposed so starkly. A strong and well-designed safety net drives economic stability, strengthens communities, and supports population health. This promotes shared prosperity and enhances overall economic well-being. 

Over the past six years, California has made tremendous strides by increasing enrollment in Medi-Cal and Covered California health plans and integrating health and social services geared to the needs of the whole person and family. This work recognizes that access to health insurance and health care is necessary, but not sufficient, to guarantee better health outcomes. We cannot afford to stop there.  

Aligning Health Care Delivery with the Needs of People

At the core of this vision is CalAIM (California Advancing and Innovating Medi-Cal), the groundbreaking Medi-Cal initiative focused on whole-person care, preventive services, and coordinated care. It addresses non-medical drivers of health that do not originate within a clinic or a hospital. CalAIM moves us from a system that compartmentalizes services and reacts to health crises to one that emphasizes prevention and coordination. Through it, California is aligning health care delivery with the needs of people, ensuring that individuals do not only receive essential care in moments of crisis.  

CalAIM does not stand alone. It serves as the foundation that supports and connects multiple efforts aimed at reforming California’s safety net. Taken together, these reforms are so broad and complex that it will take many years for Californians to fully reap their benefits. These California programs were enabled in the same way they are in any state — through strong, cooperative partnerships with the federal government.  

Collectively, we need to make continuous improvements across multiple federal and state administrations, incorporating lessons learned at every step of the way. This requires patience, unwavering commitment, and the resolve to stay the course even during times of challenge or uncertainty. The work must remain grounded in the needs and experiences of everyday Californians and shielded from changing political winds.  

Following Blueprints for the Future 

California’s formal Master Plans for Aging, Developmental Services, and Early Learning and Care are guiding this transformation. They provide a roadmap to a safety net that can adapt to evolving demands. These blueprints emphasize long-term sustainability to withstand future challenges. As they evolve, these master plans will ensure that California’s health and social services systems remain responsive and grounded in equity.  

Additionally, the latest Medi-Cal managed care contracts are critical to this process, as they redefine expectations for health plans to prioritize integrating physical and mental health services while also addressing non-medical drivers of health, such as access to food, housing, and transportation. This approach creates a more robust, efficient, and equitable system providing quality services.  

Behavioral Health Care Provides Essential Support 

Increasing access to and integration of behavioral health services is central to Medi-Cal members and all the communities served by safety-net providers. California’s behavioral health initiatives, such as Proposition 1 and BH-CONNECT (California Behavioral Health Community-Based Organized Networks of Equitable Care and Treatment), focus on integrating care and ensuring the availability of comprehensive mental health and substance use services.  

Behavioral health challenges are often intertwined with other non-medical drivers of health, such as poverty and housing instability. California’s historic $4 billion investment in the Children and Youth Behavioral Health Initiative prioritizes prevention and early intervention by addressing mental health needs before they escalate as well as building resources to support kids who need help now. Responding to these needs holistically is essential to improving health outcomes and fostering long-term community resilience.  

Expanding Community Capacity to Shield Californians from Escalating Crises 

Investments in the Behavioral Health Continuum Infrastructure Program, the Community Care Expansion Program, and other efforts ensure Californians have access to community-based care that shields them from crises, thereby prioritizing resilience and well-being. By supporting community-based organizations and expanding capacity, California is helping to ensure that its health care safety net is strong enough to catch individuals and families before they experience homelessness or incarceration. By expanding access to residential care, crisis stabilization units, and wraparound services, California is anticipating needs and offering protection and stability in the community not in institutions. 

Adopting Affordability Efforts to Keep Costs Manageable 

California’s affordability initiatives, such as CalRx and the Office of Health Care Affordability, curb the growth of prescription drug and health care services costs by publishing health care prices and developing policies aimed at reducing out-of-pocket expenses for consumers. California is intentional in making health care costs sustainable for people with low incomes while lowering the financial barriers that keep many from seeking needed care. Success would lead to improved population health, increased productivity, and enhanced economic growth.  

Ensuring Connectivity Through Data Exchange  

The Data Exchange Framework acts as the wiring of the integrated system, enabling seamless real-time communication and coordination that allows health and social services providers to deliver cohesive whole-person care. The framework enables broader coordination and shared learning by creating information bridges between California’s health care system and external partners, such as housing providers and community-based organizations. This is vital for addressing complex, interrelated social challenges that require cross-sector collaboration. Effective and real-time data exchange will enable different systems to “talk” to each other and create a human services ecosystem that is more responsive to community needs.  

Building a Skilled Workforce 

California is creating a resilient health care infrastructure by building a pipeline of skilled workers and fostering a workforce culture that values diversity and equity. The Workforce for a Healthy California initiative invests in a culturally diverse labor force that reflects the state’s demography. This ensures that high-quality care is provided with cultural competence and delivered equitably. To address workforce retention, this initiative offers training and career development opportunities to help staff stay in the system. Demand is growing for health care professionals in California, especially those who are willing to work in underserved communities. Investing in this workforce can help meet the needs of the most diverse state population in the US.  

Government, Providers, and Communities as Co-Builders 

Government, health care providers, community-based organizations, and managed care plans all play critical roles in this grand collaboration. Each stakeholder brings unique and essential expertise, resources, and perspectives to the work. Government offers the policy and funding framework, while providers deliver the care. Community-based organizations ensure that the system is equitable and that it meets the needs of diverse populations. Managed care plans help to streamline services and connect the dots. By working together, these stakeholders create a system that is more responsive, adaptable, and focused on the well-being of all Californians. 

An Equitable, Resilient System that Benefits Everyone

The volume and complexity of these state initiatives may be overwhelming. It’s up to all of us involved in health and social policy to turn the puzzle pieces of the last six years into a cohesive reality that sparks cultural change and prioritizes equity at every level of implementation. Now more than ever, we need to be unapologetic about our progress and roll up our sleeves to build a system of hope, opportunity, and justice.  

Building this transformed safety net is a labor-intensive, long-term endeavor. It requires time, discipline, and openness to change. Health care providers, community-based organizations, and managed care plans must embrace a cultural shift to a system where collaboration, trust, and equity are first principles. We must find ways to work together to realize the promise of California as the place where we see our diversity as a strength and embrace our responsibility to take care of one another.  

This work demands resilience, collaboration, and unshakeable commitment. As part of any major transformation, challenges are inevitable. Each of us must be an active, fully engaged participant. When obstacles arise, we cannot retreat. We must dig deeper, solve problems creatively, and adapt together. 

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Authors & Contributors