California is a national leader when it comes to providing health care coverage to low-income residents. The state was one of the first, in 2014, to expand Medicaid — known in California as Medi-Cal — under the Affordable Care Act, which allowed millions of previously ineligible low-income adults to qualify for the program.
Since then, California has expanded the program to people without legal immigration status — first to children in 2016, then to young adults in 2019, and most recently to adults 50 and older. Gov. Gavin Newsom has committed to covering all remaining eligible adults by 2024.
These expansions are a major step towards health equity in California, steps I’ve advocated for. But expanding health coverage is only the beginning. Now it’s time for California to lead the way again by shoring up quality and access within the system.
A third of Californians rely on Medi-Cal for health care. But actually getting that care is difficult for many, according to Jose Torres, policy and legislative advocate with Health Access California, a statewide health care consumer advocacy organization. Patients often can’t find Medi-Cal providers in their neighborhoods and have to travel unacceptable distances to get care, he told me. Many also face difficulties finding providers that speak their language or who understand their culture, a factor that worsens racial disparities in health care.
The result is that even though they have health coverage, access to care is often second-rate and serves to perpetuate health disparities. Due to societal inequalities, people of color are disproportionately low-income and enrolled in Medi-Cal.
Medi-Cal’s flaws often mean that vulnerable Californian’s are forced into an impossible situation where they must opt to travel long distances or begin a challenging search process to find providers that accept their coverage. This ultimately and unnecessarily leaves low-income people of color with poorer health outcomes and worse experiences in the health care system.
Policymakers need to do more to protect the health of Medi-Cal recipients. California needs to ensure “that people have access to a provider that is within their neighborhood, within their community … that it follows the various time and distance standards set out within Medi-Cal,” Torres said.
Issues with Medi-Cal access are especially dire in California’s rural areas, such as Kern County in the San Joaquin Valley. These areas are much more likely to have health provider shortages. I spoke with Angel Galvez, CEO of Bakersfield American Indian Health Project, an Urban Indian health program that serves predominately indigenous communities in Kern County. About 75 percent are Medi-Cal patients. Getting to a doctor or specialist is very hard, he said.
“When it comes to access to care, it’s always ‘we live very far and our transportation service is very limited,’’’ he said. Those who do manage to get to a clinic that accepts Medi-Cal – usually a nonprofit health center funded by federal and state dollars, often find that it’s understaffed. Low reimbursement rates and lack of budgetary flexibility make it hard for these clinics to retain physicians and nurses.
Mental health services are particularly difficult for California’s Medi-Cal patients to access. Carolina Valle, senior policy director at the California Pan-Ethnic Health Network, said a recent study by their members found that the state’s provider directories are often flawed.
“Our partners found a number of really significant issues,” she said. These included “not actually accepting Medi-Cal patients despite being listed as a provider who was accepting patients.”
Provider directory inaccuracies have long plagued California’s health care system. A 2014 investigation by the California Health Report found that 50 percent of doctors in online provider directories across three counties studied could not be reached or did not have openings. In 2015, lawmakers passed a bill requiring insurers to update their provider directories at least quarterly. But as recently as last year, our reporting found ongoing network directory problems.
These struggles are amplified even further for patients with limited English proficiency who often struggle to find mental health providers that speak their native tongue. According to Valle, the majority of these patients are experiencing mild to moderate mental health problems due to stressors relating to COVID, finances and other everyday issues. In theory, they should be able to access non-specialized care relatively easily, she said. Yet many face difficulty finding a provider who will see them in a timely manner.
Rural neglect, provider shortages and mental health access barriers exacerbate existing health inequities. So, what can be done?
One solution is to improve reimbursement for nonprofit providers, especially those in rural areas. As my conversation with Galvez revealed, it’s hard for rural health centers to retain and attract providers because of federal and state limitations on how they spend funds, and because private hospitals can lure clinicians by offering higher pay. State officials should work to help nonprofit health care centers attract talent. This could be through a combination of incentives, loan forgiveness programs and higher reimbursement rates.
California policymakers should also work to promote language and cultural competencies in the state’s health workforce. To meet the needs of our state’s diverse Medi-Cal population, we need a corps of trained providers who are culturally and linguistically competent. I’ve written about how California can strengthen its health workforce to improve patient care. This issue remains pressing.
California is leading the nation with its efforts to extend health care coverage to all. But the job isn’t finished. If we truly want a health system that works for everyone, policymakers must now turn their attention to fixing major problems with quality and access that continue to undermine health equity in the Golden State.
Denzel Tongue writes a column for the California Health Report about the intersection of racial justice, public policy and health equity. A native of Oakland, he works in public health and holds a master’s degree from the Goldman School of Public Policy at UC Berkeley.