California has been leading the nation in efforts to close health care access gaps by transforming Medi-Cal. Despite achieving its lowest uninsured rate in 2022, many Californians still face significant barriers to accessing health care, leading to higher rates of illness and death, especially among low-income individuals and communities of color. 

In a media briefing on June 18, hosted by Ethnic Media Services, a panel of experts discussed the ongoing transformation of Medi-Cal and the challenges that lie in its tracks. The DHCS embarked on a statewide journey to listen to Medi-Cal members who have experienced health inequity. The feedback collected will go towards redesigning Medi-Cal.

Speakers

  • Pamela Riley, Chief Health Equity Officer and Assistant Deputy Director, Quality and Population Health Management, Department of Health Care Services (DHCS)
  • Debbie Toth, President and CEO, Choice in Aging
  • Michael Whalen, Program Director, The Bedford Center, Choice in Aging

Equity in Medi-Cal

Pamela believes that it shouldn’t matter where you live and who you are, healthcare is a human right and should be equitable. 

Riley highlights that with about 15 million Californians enrolled, Medi-Cal has already made significant strides toward advancing equity. She mentioned that as of January 1, 2024, Medi-Cal coverage is available to all income-eligible individuals, regardless of age or immigration status.

Other notable measures include eliminating asset limits so that your income is the only aspect considered when determining eligibility for Medi-Cal, establishing a Member Advisory Committee for feedback on Medi-Cal programs, expanding language access to include 18 languages, and creating new Community Supports that offer services beyond traditional health care, such as housing assistance, home accessibility modifications, healthy meals, and transportation to and from medical appointments.

“To listen to our members more directly to understand where our greatest health disparities lie and how we can improve them, DHCS also launched its three-phase Health Equity Roadmap Initiative,” said Riley.

The first phase, already completed, involved DHCS staff conducting 11 listening sessions hosted by community-based organizations across the state. Hundreds of Medi-Cal members shared the challenges they faced in accessing health care, with a particular focus on communities of color, individuals with disabilities, those in rural areas, and those with behavioral health issues such as substance use disorders.

“We often heard from members that they wanted Medi-Cal to cover certain services which were already covered — like dental, vision or mental health care — which told us that our communication could be improved,” Riley explained.

She also noted that members wanted to feel respected and heard in their native languages, leading to a requirement for all health care facilities to provide interpretation services in 18 threshold languages, including Arabic, Chinese, Hindi, Hmong, Russian, Spanish, and Vietnamese.

Alongside a report on the feedback from the listening tour, which will be released next year, the second phase will involve using this feedback to identify common themes. The third phase will outline specific steps to enhance the accessibility of Medi-Cal services.

Closing Health Access Gaps on the Ground

“In my 22 years here, there has never been anything like this. This is historic,” said Debbie Toth. Toth from Choice of Aging, one of the listening session hosts.

“DHCS reached out to us about talking with patients at our Bedford Center in Antioch,” Toth explained. The center primarily provides Alzheimer’s day health care and transition care from or to nursing facilities. “Because you could see the social determinants of health at play. We have elderly adults, but also younger low-income participants who may be in their 50s, yet their physical health is like somebody in their 80s. They may be unhoused, or have substance use or mental health support needs.”

“Our biggest challenge was that we’re working with a population with a lot of cognitive impairments, like mid-to-late-stage dementia, who can’t always express what they need directly,” Toth continued. “So Michael, our program director, broke the participants into small tables while also engaging their caregivers to better understand everyone’s needs for easier health care and language access.”

“Another challenge is that we’d always like to enroll more people, but we’re the only adult day health care center in the area,” added Michael Whalen, program director of The Bedford Center. “Many of our at-home caregivers are quite elderly themselves, so we had a unique opportunity to coordinate solutions for both them and their patients.”

Toth also highlighted financial challenges. “We have the DHCS Health Equity Roadmap, we have the California Master Plan for Aging, these policy frameworks set up to support people in their communities,” she said. “But if we have a recession, a change in administration, if we can’t pay livable wages, we lose the infrastructure, like we already are with the massive closures of adult day health care centers.”

As of June 2024, California has fewer than 300 adult day health facilities, compared to 365 before the Great Recession, when statewide closures began.

“Our greatest marker of success is keeping people out of skilled nursing facilities who don’t want to be there,” Toth said. “Our current de facto long-term care system is warehousing folks as they age or become disabled, and what’s so incredible is the community focus that DHCS has, rather than an institutional focus. They’re not just giving out questionnaires to clinics, but actually learning from the community whether their needs are being met.”

Toth shared an example of the importance of humility in addressing community needs. “When I started at Choice in Aging, there were Russian, Farsi, and English programs, but no Spanish program for our Spanish-speaking community members, so I created one. However, I quickly learned that they did not want it,” she said. “There were people from El Salvador, Mexico, Argentina, Spain, and their message was: ‘Just because we share a language, we don’t necessarily share a combined interest.’”

“It was a lesson to be learned,” Toth added. “Our needs aren’t necessarily based on one characteristic we share. It’s important to ask with humility what everyone’s needs really are, and then adapt, which is how DHCS is leading Medi-Cal right now.”