California has led the nation in expanding access to health care for all. Yet communities of color, lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals, and persons with disabilities, continue to experience disparities in care and health outcomes. Despite a stated commitment to addressing these disparities and years of effort, state policymakers, health plans, systems, and providers have still not made significant progress. The data on persistent health inequities, including recent data on the disparate impacts of COVID-19 on communities of color, as well as the lived experience of people of color, points to a health care system that, as currently designed, often makes health outcomes worse through discriminatory treatment, high rates of uninsurance, geographic provider shortages, medical errors, lack of patient safety, and uncoordinated and late care, particularly for communities of color. The challenge to address systemic racism presented by this historic moment, only further heightens the imperative for California policymakers and stakeholders to implement specific actions to advance racial equity now.
Embrace and invest in community-based care
Rather than lay blame for disparate health outcomes on individuals for reluctance to seek care or on individual behaviors, we must acknowledge the history of racism, experimentation, exploitation, and exclusion in health care and how that affects the quality of care that people of color, individuals with disabilities, and LGBTQ+ people both experience and perceive today. All parts of the health care system must act with urgency and a willingness to create a radically different health system.
prioritize tracking, reporting, and reducing disparities
California’s health care system often perpetuates or even deepens inequities, particularly for communities of color. The populations most negatively impacted by social determinants have the least access to health care and experience the worst outcomes. To improve health care quality and reduce disparities, California must require health plans, systems, and providers to track, report, and improve health outcomes over time for key chronic conditions such as diabetes, asthma, hypertension, and depression. Holding health plans accountable for the quality of care provided to communities of color will create the incentives needed to ensure plans invest with broader stakeholders in appropriate strategies to address barriers to community health and reduce disparities.
implement equity as a strategic organizational priority
Change starts with diversifying leadership and governance, which must be a top priority. Equity should be built into all of a health plan or systems’ operations. DHCS and other health purchasers, systems, and plans must commit to equity at the highest levels.
remove barriers to engagement of diverse patients in quality and equity efforts
Meaningful engagement of patients, families and caregivers is often difficult to achieve due to a myriad of patient-related barriers such as low health literacy, lack of education and cultural and linguistic differences. Staff and provider-related barriers such as negative attitudes towards engaging patients, ineffective communication and high provider workloads can also hinder engagement. Many of these barriers can be addressed through better training and support. Financial incentives are also an important lever.
Give patients, family members and caregivers real decision-making power
Health plans, health systems and providers are often compliance-based in their approach to
engaging their patient populations which results in incomplete and ineffective results. Patient,
family, and caregiver engagement is more effective when individuals and community members are not just given advisory roles but instead have the power to make decisions and are given some control over the resources being spent. This more equitable model of engagement is necessary to ensure providers are focused not only on quality improvement but also addressing the social determinants of health.
tie feedback to meaningful and measureable quality improvement and disparities reduction goals
Health care purchasers are increasingly emphasizing payment models that reward cost and quality. However, our current measurement systems do not often take into account patient-centered goals such as culturally and linguistically appropriate patient-provider communication which can result in more meaningful health outcomes.
End stimatizig, disrespectful, and discriminatory treatment across all provider types
Despite California laws and practices aimed at combatting these types of behaviors, racial and other
discriminatory disparities in medical treatments and health status were raised across all seven of the
focus groups and have also been well-documented in numerous studies.
Strengthen access and quality of interpreter and language services
California has strong state laws and standards for language access (oral interpreters, written translations, and auxiliary aids and services), but there is weak enforcement, lack of dedicated funding, and no incentives for improvement.
Increase the Racial, Ethnic, Linguistic, and other Diversity of Health Care
Providers, Strengthen Team-Based Care, and Integrate CHWs, Promotoras, Peer Specialists, Personal Care Attendants, and Traditional Health Workers (e.g., Doulas, etc.)
Seven million Californians, the majority of them Latinx, African American, and Native American, now live in Health Professional Shortage Areas, a federal designation for counties experiencing shortfalls of primary care, dental care, or mental health care providers. These shortages are most severe in some of California’s largest and fastest-growing regions, including the Inland Empire, Los Angeles, San Joaquin Valley, and most rural areas. The California Future Health Workforce Commission’s
2019 report includes several actions the state can take to build and support the robust and diverse
health workforce required to meet California’s changing demographics and growing demands for health care services. Given the expected continued growth in health jobs, strategic investments in health workforce development and diversity also make economic sense as part of California’s post-COVID-19 recovery.
Integrate Equity and Cultural Humility into Continuing Education and Training of Health Care Providers
California has implemented state and federal cultural competency requirements, including a requirement that all physician continuing education includes a cultural competency component and a requirement for counties to develop and annually update cultural competency plans for the provision of specialty mental health and substance use disorder services (SUDS). Additionally, Medi-Cal managed care plans and qualified health plans in Covered California are required to report how they will meet the needs of culturally and linguistically diverse members. While these steps are promising, California’s demographics continue to evolve, as do best practices in cultural competency training and education.
Leverage Opportunities to Expand Access to High Quality, Culturally and
Linguistically Appropriate Services through Telehealth and Other Innovations Resulting from COVID-19
While telehealth technology and its uses are not new, recent policy changes during the COVID-19 pandemic have reduced barriers to telehealth access and resulted in more widespread adoption of virtual care as an important modality for the delivery of primary, oral, behavioral and specialty care.
invest in and support patient and family-centered care
Patient-centered care can improve quality and advance health equity by providing care that is
respectful of, and responsive to, individual patient preferences, needs, and values, and ensures Patient- and family-centered care should include engagement of parents, adult children, and other
family members and caregivers as appropriate and designated by patients.
Increase Access and Utilization of Behavioral Health Services in both Medi-Cal Managed Care Health Plans and Commercial Health Plans
Despite federal and state laws that require parity for access to behavioral health care, behavioral
health care continues to be extremely challenging for consumers to access in both commercial health plans and Medi-Cal. Consumers face obstacles such as lack of education about how to access behavioral health care, health plan denials, long wait times, shortages of culturally and linguistically appropriate providers, and poor quality of care. Recent data shows disparities in access to behavioral health services for adults in Medi-Cal managed care plans, with consumers of color and limited-English proficient beneficiaries having much lower access to behavioral health services than their White and English-speaking counterparts. Particularly since COVID-19 appears to be disproportionately exacerbating the behavioral health needs of low-income communities of color, it is critical that consumers can access behavioral health services through their Medi-Cal managed care plan, and that these services are culturally and linguistically responsive.
Invest in a Broad Array of Behavioral Health Integration Models
Under the Cal-AIM proposal, California has suggested one form of integration where one entity – Medi-Cal managed care plans – would be responsible for the physical, behavioral, and oral health needs of their members. We question an approach that would place health plans at the center of this model, driven primarily by payment efficiencies rather than system and provider integration, and instead recommend exploring alternatives. Currently, health plans are responsible for the
physical health care for consumers living with serious mental health conditions but have consistently failed to deliver appropriate care. As a result, people living with serious mental illness continue to die, on average, 10 to 20 years younger than their counterparts, primarily due to poorly-managed chronic physical health conditions.
Integrate a Culturally and Linguistically Appropriate, and Comprehensive Drug-Medi-Cal Organized Delivery System for Communities of Color
While communities of color have similar mental health and substance use treatment needs to White people, their ability to access services is much lower. Their involvement in the criminal justice system is also much higher due to racism and implicit bias. One way to address racial and ethnic disparities in the criminal justice system is to provide substance use prevention and treatment to communities of color in community settings. Stigma and discrimination associated with accessing services are other barriers to treatment for many communities of color. Access to integrated care
should also be expanded, as services for prevention and treatment of substance use disorders have traditionally been delivered separately from other mental health and general health services, yet communities of color are likely to seek help in a primary care setting.
Expand Access to Preventive Dental Care through Payment Reform
California’s Medi-Cal dental system produces significant disparities in access to oral health. In California, people of color make fewer visits to the dentist or dental clinic, and more older adults of color have lost teeth to decay and gum disease than White adults. Children, in particular, suffer lifelong consequences of limited access to early and preventive dental care. California could adjust current payment structures in Medi-Cal dental to incentivize preventative care over surgical or specialty care. For example, New Jersey’s Medicaid program offers primary care physicians an incentive payment for pediatric dentistry referrals. To achieve this, California could create an evidence-based advisory group for the Medi-Cal dental program to guide decisions and make sure they are based on the best evidence and science and not merely on cost.
Strengthen Health Plan Oversight and Accountability
California has strong state laws and standards to regulate health care services plans including managed care organizations. These standards help to ensure patients, families and caregivers can see their doctors and specialists in a timely manner, access free translation and interpretation services, and receive treatment for certain mental health conditions, amongst other requirements. However, enforcement of state laws is often weak with little to no long-term consequences.
Leverage Financial and Payment Arrangements to Drive Innovation
and Reductions in Disparities
Health plan rates and how plans contract with providers could be more closely tied to improved performance on quality and disparities reduction requirements.
Invest in Prevention
The U.S. spends more on health care than any other country. Yet we rank lower than several other
nations in life expectancy, infant mortality, and other health life indicators. When people receive
preventive care, such as immunizations and cancer screenings, housing and other social supports, they have better health and lower health-care costs.
Support Stronger Linkages between Health and Social Safety-Net Providers
Promoting and achieving health and well-being will require much needed investment in cross-sector
partnerships and collaboration in order to ensure effective communication across systems.
Require Local/Regional Collaboration and Investments in Community Health
Ultimately, promoting and achieving health and well-being requires identifying and addressing regional population health needs, eliminating health disparities, achieving health equity, and investing in community health. The success of regional interventions requires a collaborative approach with shared responsibility distributed across public, private and non-profit sectors.