What should California’s health care priorities be in 2020? Here are some ideas
Note to readers: Each week through November 2019, a selection of our 101 California Influencers answers a question that is critical to California’s future. Topics include education, healthcare, environment, housing and economic growth.
Get weekly updates on the issues that matter to you: Sign up for the California Influencers newsletter here.
▪ ▪ ▪
California Influencers this week answered the following question: What should the most important priority in the area of health care policy be for Governor Newsom and the State Legislature in 2020? Below are the Influencers’ answers in their entirety.
“Incentivize quality and efficiency in chronic disease care”
Richard Pan, California State Senator (D-Sacramento)
As we strive to achieve universal access, affordability and quality in health care, California must address disincentives to improve care for chronic conditions, including behavioral health. The sickest 10% represent two-thirds of health care costs, while the healthiest 50% cost only 3-4%. About 40% of California adults report having at least one of chronic condition. Chronic conditions are responsible for 75% of health care spending, representing the greatest opportunities for efficiency.
However, to remain viable, health plans must enroll enough healthy people to fund care for people with chronic conditions. Becoming the best plan for chronic conditions may force rising premiums, when people with chronic conditions disproportionately seek enrollment. Adverse selection discourages sustained investment in care or benefit improvements for chronic conditions.
Risk-adjusted payments may incentivize quality and efficiency in chronic disease care. When plans and health systems see success in gaining resources for providing care for people with chronic conditions, this incentive will stimulate innovation and efficiency to improve quality and reduce costs. As a major health care purchaser, California can align incentives across Medi-Cal, Covered California and CalPERS to drive sustainable improvement and efficiency in health care delivery for chronic disease care.
Mental Health and Substance Use Disorder Must Be A Priority in 2020
Marie Waldron, California State Assemblywoman (R-Escondido)
More than anything else, the state needs to dramatically improve the way it provides mental health and substance use treatment to Californians. For too long, our health care system has treated mental health as an afterthought, rather than a major contributor to individuals’ health and wellbeing. That needs to change as our homeless, incarcerated and loved ones are suffering.
Making major investments in both our mental health workforce and facilities will ensure that patients have access to care when and where they need it. We also need to improve Medi-Cal coverage for evidence-based mental health and addiction treatment – doing so will ensure those problems can be addressed early and don’t spiral into chronic conditions that are difficult and expensive to treat. California should also update the way it delivers care by creating a more improved and comprehensive “hub-and-spoke” system in which a patient initially works with a central office (the hub) to get connected with specialists (spokes) like community mental health services, mobile crisis team interventions and peer support. Keeping patients in supportive care for longer periods with the goal of reducing hospitalizations and emergency room visits ensures improved outcomes and cost savings.
Create a health equity agenda to improve health of all Californians
Chet Hewitt, President and CEO of the Sierra Health Foundation
I would not encourage Governor Newsom to focus on a specific health policy or issue. Instead, I would urge him to take the bold step of initiating a health equity policy agenda to substantially improve the health and well being of all Californians, particularly the poor.
A growing body of evidence has affirmed that much of an individual’s physical health is dependent not on experiences they have in a hospital or doctor’s office, but rather on the experiences they have every day at work, at home or in their community. These experiences are known as the “social determinants of health”, and we see their effects in health measures ranging from cardiovascular disease to diabetes and more. For example, the CDC reports that approximately 80% of cardiovascular disease is preventable, and estimates the disease’s treatment cost at $1 billion a day nationally; a figure that pales only in comparison to the poor health and mortality it represents. In this case prevention is the best approach, and includes eating a healthy diet, maintaining a healthy body weight and not smoking.
Similarly, the most effective responses to the diabetes epidemic mirror those of heart disease and will require the elimination of food deserts, improving access to healthy foods, and ensuring every neighborhood has safe places for kids and adults to engage in physical activity. Working at the intersections of these realities is the agenda I believe the Governor should pursue. Such an approach would be groundbreaking in California and the nation, and invaluable to turning the health care cost and disparity curves in more sustainable and equitable directions.
Improve Medi-Cal through CalAIM
Zach Friend, Second District Supervisor for Santa Cruz County
With broad based attempts to reduce coverage and access to care at the federal level, especially for the most vulnerable populations, our state should focus on improved Medi-Cal protections through implementation of the California Advancing and Innovating Medi-Cal (CalAIM) program. This ambitious but actionable program envisions a broader delivery system and payment reforms, which could improve coordination and access for patients to everything from County programs, dental services, behavioral health and managed care.
Specifically, CalAIM would manage member risk and need through Whole Person Care approaches and addressing social determinants of health, move Medi-Cal to a more seamless system for the patient by reducing complexity and increasing coordination and improve quality outcomes through system modernization payment reform.
The Governor has advocated for leveraging Medi-Cal as a tool to address particularly vulnerable populations and CalAIM would be an important step toward this goal.
Pass Universal Healthcare Legislation, strong health care bills
Bonnie Castillo, Executive Director of the California Nurses Association
With health care reform dominating the 2020 election news—and Medicare for All front and center—we are in a unique moment. Governor Newsom promised he would be the “health care governor” and has voiced support for single payer. The time is now for Governor Newsom to build on the unprecedented momentum and work to pass California legislation guaranteeing health care as a human right. As longtime fighters for Medicare for All, at both the state and federal level, nurses know how important it is for him to lead the nation on this issue.
We also urge Governor Newsom to pass good health care policy, signaling to the legislature that they should continue sending him strong health care bills, dedicated to keeping patients safe and hospitals open to serve the community. For a healthier, safer California, Governor Newsom could prioritize using his position to “fight like a nurse” to protect our patients.
Ensure that Coverage Translates into Meaningful Access
Dr. Joseph Alvarnas, Vice President of Government Affairs and Senior Medical Director for Employer Strategy at City of Hope
If I could impart a single concern to Governor Newsom and the legislature as they navigate the complexities of improving California health care, it is that health care coverage frequently does not translate into meaningful access to care for those who need it. As a hematologist, I have cared for far too many cancer patients who, prior to their referral, received poor, ineffective, piecemeal care that was delivered with unnecessary delays. Cancer does not wait patiently for our health care system to finally get it right.
Cancer care is different. Cancer patients need rapid access to appropriate diagnostic testing that leads to a correct diagnosis; care that is delivered by physicians who are experts in that type of cancer; access to appropriate clinical trials when the standard of care is inadequate to meet their needs; and immediate access to a National Cancer Institute-designated Comprehensive Cancer Center when their care needs exceed what can be appropriately delivered in the community practice setting. Providing health care coverage to Californians is not a meaningful end unto itself; our leaders should not rest until they ensure that coverage translates into meaningful access to the right care, at the right place, at the right time.
The “Health 4 All” Roadmap
Dr. Robert Ross, President and CEO of The California Endowment
The top policy issue of 2020 for Governor Newsom and our legislature is plotting the affordable path to universal health coverage and relevant reforms for Californians – and I do mean ALL Californians.
As I see it, there are four doors to choose from to achieve Health-4-All in our state. Two are boldly radical, one is more modestly radical, and the fourth is incrementally bold.
The two boldly radical approaches are either Single Payer and/or Medicare for All – with Medicare for All serving as the less scary, more accessible varietal to the American public. In a recent Kaiser Family Foundation poll, Single Payer polls at 48% favorability while Medicare for All does much better at 62% favorability. Opinions vary as to whether a state can climb the Single Payer or Medicare for All mountain without the federal government as a willing partner.
The more modestly radical approach is to bring back the “public option” idea into civic and policy discourse – a popular theme as the Obama White House debated strategy before landing on the Affordable Care Act. The idea here is that consumers have a (competitive) choice between a government-run health insurance agency and private health insurance plans.
And “Door Number Four” is a more incremental approach: to build on a platform of elements we have now. This means building on Obamacare/The Affordable Care Act, using the successful Covered California Health Exchange as a stepping stone, and reforming the state Medi-Cal program to improve care quality, care coordination, and rein in costs. A new state-led initiative called Cal-AIM utilizes the state Medi-Cal program as a lever for such reforms.
Finally, it’s certainly reasonable to pursue the “boldly incremental” path immediately, and lay the groundwork for single payer along the way.
“Provide real relief to consumers by holding the health industry accountable”
Anthony Wright, Executive Director of Health Access California
California should continue toward universal coverage, while increasing industry oversight on cost, quality, and equity.
In 2020, California should keep up its momentum to universal coverage, building on the significant steps taken this year. Increasing affordability assistance in Covered California for middle-income Californians has helped bring premiums down, but more help is needed in our high-cost state. Expanding Medi-Cal to all income-eligible Californians regardless of age or immigration status would cut the uninsured rate even further. Our health system works better when everyone is included, getting primary and preventive care. Through the Healthy California for All Commission and elsewhere, we should plan for even bolder reforms possible when we have a more productive partner federally.
We must provide real relief to consumers by holding the health industry accountable – health plans and hospitals, drug companies and doctors – for protecting patients, improving quality and equity, and lowering health costs. For example, California can stop surprise medical bills, especially when an emergency room visit turns into an outrageously outsized out-of-network hospital bill. We need policy reforms to address inflated health prices, and the industry consolidation that drives them up. The recent Attorney General settlement with Sutter Health spotlights the market failures seen throughout the health system, which must be addressed one-by-one as well as through comprehensive reform.
Health Care Policy Needs to be Focused on Quality, not just Quantity of People Enrolled
Robin Swanson, Swanson Communications
With the Governor’s sweeping campaign promises made about creating a single-payer system, public discourse continues to be focused on how many people are enrolled in our health care system. While the goal of universal health care coverage is one we should strive to achieve, we need to take a step back and examine what we are actually providing for consumers once they finally get the elusive health care they were promised.
Basic questions need to be answered, like:
Do I get to see a qualified doctor or specialist with my health insurance plan?
Will I be denied diagnostic exams or procedures because my plan deems them too costly?
Will I see surprise charges for mismanagement when something is administered to me that I didn’t realize wasn’t covered under my plan?
Will my insurance plan deny coverage of the prescription drugs my doctor has deemed necessary?
If I’m injured in the course of treatment or misdiagnosed, will I have any real recourse?
The truth is, at the end of the day, far too many Californians already pay a premium for health care coverage don’t actually get. So, when we talk about expanding health care coverage to more people, it feels like we are asking them to jump onto an already sinking ship.
If we’re going to promise health care for all, let’s make sure it actually means something. That means strict coverage requirements and real, non-bureaucratic, timely consequences when those services aren’t rendered.
Address increasing costs of prescription drugs
Dustin Corcoran, CEO of the California Medical Association
Rising healthcare costs remain a major challenge in California and across the nation. One of the major drivers of increasing costs is the price of prescription drugs, which continues to be a problem despite the progress we have made in other areas of health care reform. Addressing drug costs has been a top priority for Gov. Newsom and in Congress, with Speaker Pelosi introducing legislation that would save patients from rising drug costs. In addition to pushing for federal action, California can and should do more to help patients, including expanding access to generic drugs and targeting drug companies and pharmacy managers that engage in anticompetitive business practices. By targeting bad behavior from companies that put profits over the needs of patients, California can ensure that those who need medicine are able to afford it.
We Need to Treat the Whole Person: Mental Illness and Substance Use Disorders
Le Ondra Clark Harvey, Director of Policy and Legislative Affairs at the California Council of Community Behavioral Health Agencies
We are privileged to have a Governor who understands the social policies and economic conditions that create the social determinants of health. Specifically, Governor Newsom has been an advocate of programs to prevent and treat mental illness. However, it is time to focus on the confluence of mental illness and substance use disorders which is defined as “behavioral health.” For too long, our state has compartmentalized mental illness and substance use disorders as though they are separate conditions, when they are co-occuring. This is most evident when we examine how funding is separately allocated for mental health and substance use disorder services. As the state becomes more aware of behavioral health, this should be reflected in how the state funds treatment and defines, expands and supports the workforce who provide behavioral health services.
Improvements to State’s Behavioral Health System Demand Urgency in 2020
Carmela Coyle, President and CEO of the California Hospital Association
Behavioral health is one of the greatest unaddressed issues of our time. It affects nearly half of us— whether we are young or old, rich or poor, white, Latino, African-American or Asian. And, for too long, the care and treatment of our bodies has been separated from the care and treatment of our brains. This fragmented approach has led to a lack of coordinated care for our family and friends across the state.
We are lucky that Governor Newsom has a deep understanding and passionate commitment to reversing the course of behavioral health care treatment. Since he took office, the governor has been a true champion — appointing Dr. Tom Insel as the state’s first-ever mental health advisor, and increasing statewide mental health funding by more than $300 million this year alone.
As we look to 2020, we are hopeful that the governor and the Legislature will continue to invest in improving California’s behavioral health system. Our state lacks the appropriate human and physical resources needed to address the rising need in behavioral health services.
To borrow from Governor Newsom himself – “This is an issue that demands to be treated on par with physical health…and with a sense of urgency.”
Healthcare accessibility for all means standing up to turf wars
Jeannine English, Former National President of AARP
Although there are numerous healthcare policy issues to be addressed by the Governor and Legislature our immediate focus must be accessibility.
California needs to continue efforts to bring the 3 million or so uninsured into health care coverage, primarily through Medi-Cal. Everyone in California needs to have access to affordable healthcare. But for many people, the costs of premiums and out-of-pocket costs are too high, even with the subsidy that the ACA provides and the added assistance the state provides for those that are not eligible for the federal subsidies.
But coverage isn’t enough if you can’t find a doctor. Only 16 of our 58 counties have sufficient numbers of primary care physicians. Yet California is 1 of 22 states that restricts nurse practitioners by requiring that they practice under physician oversight. Research has linked these restrictions to poorer access to care, lower use of primary care services and higher rates of hospitalization and emergency room visits. This means that increasingly more and more Californians will either go without care or visit emergency rooms for conditions like asthma or ear infections because of this lack of primary care. This is not about what’s best for patients. This is a turf battle between the California Medical Association (CMA) and the Nurse Practitioners. And the sad result is that while this turf battle is underway in Sacramento many people will not receive adequate health care.
The Legislature and the Governor need to recognize that by 2030 physicians will meet less than half of the demand for primary care. We need to stand up to the CMA and follow the recommendations of the National Academy of Medicine and the National Governors Association to increase the scope of practice for Nurse Practitioners to allow California to fill this need, provide accessible primary care and reduce costs.
Implement the Master Plan for Aging
Bruce Chernof, President and CEO of the SCAN Foundation
For the first time in the state’s history we have a governor, a treasurer, and strong leadership in the Legislature committed to a Master Plan for Aging for California. While the state has seen past efforts to organize for an aging state gather dust, we now have clear momentum and there is a critical need to act now in building the state we want to live in as we age. We at The SCAN Foundation uphold the following four elements as critical to the Master Plan’s success.
First, this means a plan that focuses on older adults thriving in their lives: health (physical, psychological, and social well-being); financial well-being; self-worth (purpose and empowerment); environment (supportive services, housing, food, and transportation); and community (family and friends).
Second, it will take time and patience combined with a clear commitment to set and measure goals that put people first rather than funding sources or the needs of programs or administering agencies. The Master Plan must ensure all of us can readily access the information and services we need, when we need it—regardless of eligibility distinction, income level, or place of residence. It will require both policy and financing commitments to advance a more person-first, efficient, and effective approach.
Third, and to be clear, this cannot and should not be a process that funds more of a system the way it is delivered today. It’s a commitment to incorporate aging into all policy areas, including housing, transportation, higher education, veterans affairs, and many others. All need to be equally engaged with strong leadership from the governor to ensure a holistic solution to California’s infrastructure and care system challenges. A successful Master Plan will also establish a framework for engaging new partners and spurring collaborative innovation across the public, private, and independent sectors. It will create equal accountability for all entities to creatively and comprehensively address our aging population’s needs now and in the future through a sound financing structure.
Finally, the Master Plan has the potential to reimagine aging with dignity and independence for all of us—impacting how society thinks about, plans for, and responds to life’s changes with age. The planning process should initiate a refreshed conversation on aging—as these issues are not limited to individuals over a certain age, but impact young people, families, and communities alike.
This story was originally published November 24, 2019 at 3:01 AM with the headline "What should California’s health care priorities be in 2020? Here are some ideas."