“Medicare for All,” the political dream of extending federal health program for the elderly and disabled to all Americans, still gets the headlines. But here in the nation’s most populous state, it is Medicaid—or Medi-Cal, as the federal health program for the poor is called in California—that comes closest to providing a universal safety net. Medi-Cal deserves more attention now because its no-or-low-cost health services provide a vital backstop in this time of pandemic and freefalling employment, and because it holds possibilities that have yet to be realized.

Medi-Cal spending, which comes mostly from federal funds, has grown rapidly over the past decade. And this past week, even as the governor and legislature agreed on a state budget with plenty of cuts, Medi-Cal kept on growing. Overall spending on Medi-Cal is budgeted for a 12 percent increase in 2020-21, to more than $110 billion. This increase covers surging enrollment—the governor’s office has estimated an additional 2 million people will join Medi-Cal this year after losing jobs or insurance.

Medi-Cal now is the most important anti-poverty program in a state with persistently high poverty rates. An estimated 14.5 million Californians—more than one-third of us—will be on Medi-Cal by summer’s end, double the number in 2010. Medi-Cal has been woven into the fabric of our lives, from infancy to near-death. Roughly half of California children are on Medi-Cal. So are some two-thirds of our nursing home residents. And if the current economic collapse becomes a long-term depression, millions more Californians will end up depending on Medi-Cal for our healthcare, too.

Medi-Cal’s rapid expansion into a safety net for all Californians represents triumph, trouble—and opportunity.

The triumph belongs to the Affordable Care Act, also known as Obamacare. Before that law passed in 2010, Medicaid, originally an after-thought in the 1965 federal law that established Medicare, covered only certain categories of poor adults—like parents with children, or people with certain conditions. But Obamacare funds states to open Medicaid eligibility to virtually all low-income adults under 138 percent of the poverty line—about $17,600 for an individual, or $36,000 for a family of four. No state embraced Obamacare’s Medicaid expansion more fiercely than California, which even covered income-eligible children and young adults (up to age 26) who had been excluded from the federal program due to their immigration status.

This expansion, combined with the establishment of exchanges for purchasing insurance, got results: the percentage of uninsured Californians dropped from 18 percent to 7 percent over the last decade. The impact of this shift is visible in poorer places like the San Joaquin Valley, where Medi-Cal expansion, and the money it brought into healthcare, produced a surge of new clinics and health facilities. (Staffing such places, however, remains a challenge.)

But that expansion caused trouble—the program struggled to keep up with the needs of all the new enrollees. While millions now may be protected from financial ruin if they get sick because Medi-Cal is paying the bills, Medi-Cal does not guarantee them high-quality healthcare.

The obstacles lie in the way care is disbursed. In California, more than 80 percent of people on Medi-Cal are enrolled in managed care organizations, which are paid by the state to provide enrollees with care. And managed care is not performing as well as it should. A 2019 report on Medi-Cal managed care plans found that the quality of their care declined or stayed flat on most measures between 2009 and 2018, according to the California Health Care Foundation. The same study showed declines in two-thirds of measures involving healthcare for children.

Improving quality is difficult because Medi-Cal mirrors the complexity of the state. Though Medi-Cal is a federal program overseen by the state, the managed care plans operate at the county level. Depending upon the county they live in, Californians on Medi-Cal are offered different plans from different entities. Some counties have just one publicly managed plan; other counties have the “two-plan” model, with a public and a commercial option; and other counties, notably San Diego, offer multiple commercial choices.

So if you’re on Medi-Cal, your experience varies depending on your plan and where you live. You’re more likely to get the care you need in Yolo County, which has just one plan, the well-regarded Partnership Health Plan, than next door in Sacramento County, which has a confusing array of commercial plans. Health plan management can differ widely within regions. In Southern California, Orange County’s CalOptima is still associated with scandals in the past decade. But Inland Empire Health Plan, serving Riverside and San Bernardino counties, is considered a model.

These Medi-Cal challenges represent an opportunity. Before the pandemic hit, 2020 looked like the year the state was going to improve the program. Health advocates were pushing to raise the state’s standards for the Medi-Cal managed care plans, so that they would have to show continuous improvement in the health outcomes of their customers. Children’s advocates were working to make Medi-Cal better for kids.

And earlier this year, the governor was pursuing a highly ambitious set of proposals called CalAIM (for California Advancing and Innovating Medi-Cal). The proposals involved using Medi-Cal more broadly to help the most vulnerable Californians—particularly people who are homeless and those caught up in the justice system—with their most difficult challenges, from mental health to housing. At the same time, CalAIM proposed to simplify the complex Medi-Cal program, with the goal of producing better health outcomes for more people.

But now, with the state’s health bureaucracy consumed by COVID, CalAIM is on hold. So is a proposed expansion of Medi-Cal to cover senior citizens who are undocumented.

In this pullback you can see the shadow of political reality: Medi-Cal, as part of a federal program, remains vulnerable to the national partisan struggle over healthcare. Congressional Republicans still seek cuts in Medicaid, and the Trump administration remains committed to overturning Obamacare through legal challenges and regulatory changes. What’s more, if Congress doesn’t produce more aid for California, it could force future cuts in payments to Medi-Cal providers.

Nevertheless, the program seems poised to keep growing because the need is so great. Payments to managed care plans should be tied to measures of access, quality of care, and patient outcomes. And California must train more and better healthcare workers if quality is going to improve. Medi-Cal is such a big part of California healthcare that improvements to the program could benefit the whole system.

Starting today, Californians—especially those of you who get health insurance from your employers—should demand that the state do better by Medi-Cal. Because the way the world is going, you’ll need Medi-Cal before you know it.

The post How a Health Care Safety Net for the Poor Became California’s Top Priority appeared first on Zócalo Public Square.

I wish California children were doing as well as California children’s hospitals.

Even as the Golden State has maintained the nation’s highest child poverty rate, underfunded its schools, and made housing prohibitively expensive for families, California has developed a system of children’s hospitals that seems to occupy a parallel universe in which kids’ needs actually come first.

California has 13 children’s hospitals—eight private not-for-profits (in San Diego, Orange, Los Angeles, Long Beach, Loma Linda, Oakland, Palo Alto, and Madera) and five within University of California medical centers. Collectively, they receive more than two million visits from injured, disabled, and sick children annually.

In these children’s hospitals, you can see California’s ability to be kind, egalitarian, and generous to a fault—and also how our budget politics and piecemeal policymaking frustrate our aspirations for children.

Children’s hospitals offer a rare place where California’s rich and poor mix; the surgeon who operated on TV comedian Jimmy Kimmel’s son also performs surgery on kids on Medi-Cal, California’s version of Medicaid. These hospitals treat everyone; nearly two-thirds of their patients are eligible for Medi-Cal, compared to about one-third of patients in community hospitals. And virtually everyone is covered, since all California children, even undocumented kids, are insured because of Obamacare and state law.

Children’s hospitals thrive on this mandate: While they lose money on Medi-Cal patients, they make up for it by being aggressive with commercial insurers who cover a minority of their patients, through other government programs, and through powerful fundraising operations for private donations.

And, like other interest groups, children’s hospitals have won taxpayer dollars through the ballot. This November, California voters are all but certain to approve Prop 4, the third general obligation bond to support children’s hospitals in the past 14 years. Through this and other support, these hospitals have become juggernauts, with sprawling medical centers, top pediatric research and training operations, suburban satellites, and well-paid executives.

California’s children’s hospitals have come a long way from their mostly humble origins. Children’s Hospital Los Angeles started in 1902 as a small Chinatown building with 14 patients and one doctor who made house calls on horseback. UCSF Benioff Children’s Hospital Oakland was founded as a hospital for babies in 1912. Rady Children’s Hospital in San Diego and the predecessor hospital of Lucile Packard Children’s Hospital at Stanford both began their lives as convalescent facilities for children crippled by chronic illnesses like polio.

The greater scale of such facilities today reflects changes in the state’s health care and demographics. Even though the number of children in California has stagnated, demand has grown for specialized care for pediatrics, and visits to the hospitals have soared. Technological advances have created new avenues for care, especially for children with rare or difficult-to-treat diseases.

A McKinsey study of children’s hospitals found greater scale—which involves building regional pediatric networks with outlying clinics and partnerships with other institutions—is essential if such institutions are to survive and grow in an era of market consolidation and attempts to cut costs. Packard Children’s Hospital at Stanford has been particularly aggressive in expanding its network, and children’s hospitals have supported federal legislation that would allow them to expand their networks across state lines.

Because the populations of California and America are rapidly aging, most traditional hospitals are handling older, Medicare patients. Since Medicare reimburses at higher rates than Medicaid (especially in California, which has some of the country’s lowest reimbursement rates), it’s inefficient for hospitals to accommodate the special needs of children patients, who are overwhelmingly on Medicaid.

The result: California kids are increasingly referred to these specialized children’s hospitals. As a Southern California father of three, I’ve been redirected to Children’s Hospital Los Angeles by my pediatrician, by local after-hours clinics, and by the Huntington Hospital emergency room for my kids’ minor maladies—a broken finger, a small piece of a plastic toy stuck up a nose, a painless bit of swelling in the groin. A generation ago, my two siblings and I never saw the inside of a children’s hospital.

These hospitals are not merely comfortable; they are among the nicest buildings you’ll ever encounter, period. I’ve found the children’s hospitals in both L.A. and Orange counties to be carefully designed for juvenile happiness. My only problem with one visit to a Children’s Hospital Los Angeles outpatient center in Arcadia was tearing my sons away from the most robust entertainment system they had ever encountered.

“The hospital is somewhere you feel safe and have support,” says Max Page, a 13-year-old actor (known best for a Super Bowl car commercial in which he played Darth Vader), who has spent his life in and out of children’s hospitals in Southern California for heart procedures. His mother, Jennifer, told me that Children’s Hospital Los Angeles is reliably “colorful, loud, and fun,” with good food and a farmers market in the hospital. Such additional comfort services are funded by private donations, hospitals officials note.

These comforts also reflect a growing marketplace: As children’s hospitals grow, parents now have choices and can shop among them; competition also comes from lower-cost retail clinics and telehealth services. That’s healthy. So is new pressure for children’s hospitals to produce more data that allows for better evaluation of their quality.

While the hospitals are nice, they aren’t heavens. They face challenges —in the slow growth of the child population, the pressure on Medicaid funding by congressional Republicans (avoid mentioning the name of House Speaker Paul Ryan, who wants to turn Medicaid into block grants, inside any California children’s hospital), and health insurers’ efforts to control costs via narrower provider networks and the tiering of health insurance plans. And as children’s hospitals grow in importance, they will likely face more scrutiny of their operations, their charitable care, and their results in the future.

You probably won’t hear much of this context in the run-up to November voting on Prop 4, the $1.5 billion bond for children’s hospitals. But the measure should spur debate. Should we help fund the children’s hospitals’ capital needs through general obligation bonds? Those bonds must be paid back from the general fund—the repayment for $1.5 billion in bonds is estimated at $2.9 billion over 35 years—which cuts into funds that would go to other programs serving children.

I, for one, would prefer a dedicated stream of tax revenues to avoid the debt service costs, or perhaps even a payment from rainy day fund revenues. But securing either might be politically impossible. And relying on our volatile state budget is dicey. In fact, the children’s hospitals turned to bond measures after a general fund program for hospital infrastructure was eliminated during the 1990s.

And to the children’s hospitals’ credit, spending on previous bonds has been responsible. The new Prop 4 bonds is small, especially compared to November’s $8.9 billion Prop 3 bond for water, which comes on top of another $4 billion water bond passed by voters in June.

So yes, one could ask whether children’s hospitals offer children too much. But the better question is why other programs for California children offer so little compared to our children’s hospitals.

The post Why Are California’s Children’s Hospitals So Much Nicer Than Other Services for Kids? appeared first on Zócalo Public Square.

All of this came up recently, when for the first time in many years I enrolled in
Medi-Cal Insurance, courtesy of the Affordable Care Act, at 46. I am not alone in being newly insured in California. In the past few years, 3.4 million Californians have gotten coverage through Medi-Cal and Obamacare. There are millions like me, but when I was uninsured I didn’t feel like I was part of a group, I felt very alone. Strangely, being insured has not felt entirely normal or comfortable either: Experiencing something so many people are used to felt foreign to me. For one thing, I had to come face to face with my own heart.

Getting seen was easy. I was set up with a nurse practitioner, a friendly woman who zipped in with a laptop, then cringed and recoiled when I ran off just a portion of my family medical history. She turned me loose on a series of appointments that felt like one of those old cartoons where a gear-laden machine is whirring and clanking while Raymond Scott’s “Powerhouse” theme plays. A mammogram so fast and efficient I barely realized it was happening (though I saved the little stickers they put on my nipples as a souvenir), blood work (Anemic! Do not pass go! Have more blood drawn and take iron!) and a full physical. Whew!

Given my history, I was then quickly dispatched to a cardiologist. I was both frightened that he might find something terrible and slightly optimistic that it might be fixable if only because I’m still alive.

Physical health wasn’t something I gave much thought to until my mother died; while she was diabetic, a smoker, and a fan of kielbasa and cheese omelets, she was also trim and fairly active. When she died I was morbidly obese, a description I loathe and say loudly in a bad John Houseman voice. I spent eight years worrying about it, then began strength training and lost about a third of my total body weight. I was healthier, but it didn’t allay the fear that I was genetically predestined for a similar fate.

Like the nurse practitioner, my cardiologist was also quick on his feet, but able to focus and mono-task with me, which I appreciated enormously. I told him the truth—I’d had chest discomfort lately, likely due to the severity of my anemia. I’d spent the past two years adrift, not quite homeless, while seeking a permanent home. Getting fresh food was sometimes challenging—many pizza bagels were involved. A big reason that I returned to Ukiah after trying in vain to find a new community to call home is that I can walk to everything I need, including every one of those appointments, which means getting at least some exercise every day. The cardiologist was kind and liked my odds of survival, but suggested a few tests to be on the safe side. I was convinced that the surest way to find trouble is to look for it, but also had a real fear that something portentous might turn up. We agreed a treadmill test was a good starting point.

I’d never been on a treadmill before and the day of the test I was a wreck, making nervous jokes while being prepped and laughing with a seal bark at them when nobody responded. It went well—except the monitors picked up irregular beats before and after the test, during the sonograms. (Very strange to be lying there on a table looking at my heart as it beat in real time, calmly before the test and a bit frantic after. It looked like it was trying to say something, or maybe sing.)

Seggel (the smallest one) with her mother and a relative.

For most of my life I have stayed healthy via a blend of common sense and voodoo. Lots of vegetables, but also regular dips into the work of Andrew Weil, Diane Stein, and Louise Hay, the New Age healer whose book Heal Your Body taught me that my recurring ingrown toenails are caused by “worry and guilt about (my) right to move forward.” I can’t argue with that assessment—I was a nervous kid with frequent insomnia and those old habits are hard to shake—but the fact remains that my toes still hurt. Whether because of magic or luck I’ve never had a medical emergency.

After the treadmill test, to provide a closer look at my irregular heartbeats, I wore an adhesive patch monitor for two weeks. It was unobtrusive but the glue was itchy, and a string of days in the triple digits melted it off entirely and forced me to lash it down with medical tape. Even if I’d wanted to ignore it I couldn’t, which meant I thought about it—and what it might be sensing—a lot. My bucket list has always been a one-item affair—survive until you kick said bucket—and that was definitely influenced by the presumption that I was sick or would be soon. The only change to my daily routine was trying to walk a little faster on errands in hopes I’d impress the monitor; beyond that, I was resigned to working with whatever it revealed.

Two weeks after dropping the monitor in the mail I found out that all is well—my irregular beats were safe, normal “reboots” to sinus rhythm, and my heart could potentially see me through to antiquity. First there was a twinge of guilt, as though I had taken time away from actual sick people. Then it gradually sunk in that things were better than expected. I still have trouble accepting this good news without skepticism.

It’s not that I enjoyed the assumption that there’s something wrong with me, but lacking much in the way of connection to my family it felt like one area where my membership would be assured. And given how grating optimism can appear, and what an actual grind it is to practice, taking shelter in a brusque fatalism was comfortably familiar, like the rituals of folding laundry or filing.

When you’re poor asking for help is also a ritual, but one that used to be much harder. Changes in the way healthcare is organized made signing up, and showing up, more pleasant than in my youth. Medi-Cal no longer tallies your visits with stickers, for one thing; it’s all on a card just like any other form of insurance, and thus much more discreet. Being on the low end of the financial spectrum has its stealth privileges, too; nobody’s trying to hustle me into a fancy full-body scan.

Things are far from ideal, though. When the hospital called to pre-register me for the treadmill test, I showed up in the system as having no coverage at all. To get to the bottom of this I had to call a county office where nobody picks up the phone and an outgoing message forbids leaving voice mail, a dead end in the maze. What now? I got around this by calling a satellite office in Fort Bragg and having them transfer my call back to the inland Ukiah office. Exactly why it worked is a mystery, but it’s likely they have fewer clients to deal with on the coast, and certain that a call identified as coming from within the system gets higher priority than one from outside.

It took a week for them to find and restore my records, and apparently I was one of many people to whom this happened. All that cancelling and rescheduling was exhausting and added to my anxiety about the test.

Over the past two years my sense of what baseline health can be has shifted. I originally moved out of Ukiah ready for a change—after nine years I had no social ties strong enough to compel me to stay, and that isolation was a terrible feeling. But when I could not find another place to go it was a former boss who put in a good word for me with my current landlord. The first time back at my favorite thrift store after a two-year absence, I was greeted like a hero home from battle. It felt funny to be remembered by people, a kindness I took to heart.

Being part of the health care system is important, no doubt; preventive care is a blessing, even when it’s not perfectly executed. But being part of a neighborhood has an immunizing effect that I feel everyday. Living here I can walk to the farmers market for fresh, local food, and to the library to scare myself on WebMD or even look things up in books. If I don’t have any strong ties, I do have several threads, a web of connections that also holds healing potential. And as I’ve come to terms with my potential vitality, I’m wondering what I may have missed while I was sitting by the phone waiting for the grim reaper to call.

The post Medi-Cal and My Wary Heart appeared first on Zócalo Public Square.