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Midwives are specialized maternity care clinicians who support birthing people’s reproductive health through pregnancy, childbirth, and postpartum care. Midwives, ob/gyns, and family physicians are trained to deliver babies in California. An element of successful midwifery care is appropriate consultation with ob/gyns and transfer to physician care if the need arises. Although midwives are the primary maternity care providers in many industrialized nations — which have significantly better maternal health outcomes than the US — they are an often-overlooked workforce in this country.

Access to Midwives Is Critical to High-Quality Maternity Care

In California and nationwide, a worsening ob/gyn shortage paired with hospital labor and delivery unit closures have generated interest among advocates and some policymakers, who are pushing to expand the number and scope of practice of midwives.

• California credentials two types of midwives: nurse-midwives and licensed midwives.
• In 2021, there were 420,000 births in California, with 86% of those delivered by physicians and 13% delivered by midwives. With California’s demand for ob/gyns projected to exceed supply by 1,160 full-time equivalents by 2030, midwives could help address the workforce shortage and other maternity care access issues that loom large.
• Midwifery care is recognized by many health policy experts as an important model for improving maternity care outcomes and addressing racism-based disparities in maternal health care, especially when provided by culturally and racially concordant providers.
• Robust research demonstrates that midwifery care results in positive health outcomes. These include lower rates of cesarean sections and fewer interventions during birth, as well as higher rates of spontaneous vaginal birth and higher patient experience scores.
• In a survey of California mothers, a majority said they would want or consider a midwife for a future pregnancy.

Aspiring Midwives in California Face Shrinking Training Options

• Certified nurse-midwives: The state has 1,200 certified nurse-midwives — nurses with graduate training from approved nurse-midwifery programs who provide care mostly in hospitals. California has only two education programs for nurse-midwifery, and one is not currently admitting students.
• Licensed midwives: California’s 500 licensed midwives are providers trained in approved three-year programs who mainly practice in birth centers and homes. The state currently has no accredited midwifery training programs for licensed midwives, though two are in the works with funding from the California Department of Health Care Access and Information.

Policy Considerations: What Can State Leaders Do to Increase Access to Midwives?

• Expand professional autonomy. The state statutes for licensed midwives and nurse-midwives impose a narrower scope of practice than their training allows and require physician oversight in certain situations, undermining their professional autonomy. Nearly 9 in 10 licensed midwives identify government scope of practice restrictions as a “major” (39%) or “minor” (49%) problem in their practices. Among nurse-midwives, 10% consider this a “major” and 27% a “minor” problem in their practices.
• Integrate midwives into the health care system. In addition to ensuring access to midwives who have professional autonomy, truly integrating midwives into maternity care in California requires the respectful inclusion of midwives as members of the health care team as well as broad insurance coverage of midwifery services in both hospital and community settings.
• Increase funding to grow the midwifery workforce. Expanding access to midwifery care in California requires financial support for midwifery students to reduce barriers to education, for clinical sites to take in midwifery students, and for midwives of color to diversify the workforce.
• Streamline licensing requirements for birth centers. Research shows freestanding birth centers provide high-quality, midwife-led care that can produce excellent outcomes for birthing people and babies. But due in large part to California’s onerous licensing requirements that many experts say do not improve safety, at least 19 birth centers have closed since 2020, leaving the state with only five licensed birth centers.

To learn more:

• Cochrane Library: Midwife Continuity of Care Models Versus Other Models of Care for Childbearing Women
• CHCF: Understanding California’s Midwife Workforce
• CHCF: Midwives Speak: Integration Challenges in California’s Health System
• CHCF: Advancing Midwifery and Birth Equity in California
• CHCF: Listening to Mothers in California survey (2018)

The post What Is a Midwife? — Policy at a Glance appeared first on California Health Care Foundation.

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The Enhanced Care Management (ECM) program, launched in January 2022 as part of California’s CalAIM (California Advancing and Innovating Medi-Cal) initiative, represents a significant transformation in how Medi-Cal serves members with complex needs. This report, Perspectives from the Field: Up Close with ECM Providers, examines the early implementation experiences of ECM across different populations of focus (PDF).

During summer 2023, a UCSF Health Systems Leadership Pathway team interviewed 18 organizations providing ECM services across California. Their investigation revealed four critical insights:

• ECM Implementation Is Complex
  • Organizations face challenges including variable provider capacity, inconsistent data quality from health plans, diverse needs across different populations, varying requirements between managed care plans, and limited established protocols in this new program.
• Variation Is the Norm
  • The absence of standardized approaches to ECM delivery across California has created significant administrative burdens for providers, who must adapt to different systems and requirements.
• Success Is Being Achieved
  • Despite obstacles, ECM providers are effectively helping patients navigate fragmented systems and access needed services, demonstrating the program’s potential value.
• Better Measurement Standards Are Needed
  • Beyond enrollment and engagement metrics, ECM providers lack key performance indicators to target and measure program impact, making it difficult to demonstrate outcomes.

Program Evolution

ECM implementation has been phased, beginning in 2022 with three populations in 25 counties and expanding statewide six months later. Additional populations were added throughout 2023, with the final two — birth equity and people transitioning from incarceration — launching in January 2024.

This report offers valuable guidance for providers, Medi-Cal managed care plans, and California Department of Health Care Management administrators as they continue to develop ECM as a critical benefit for Californians with complex medical, behavioral, and social needs. The findings highlight both challenges and opportunities in this ambitious effort to transform care delivery for vulnerable populations.

About the Authors

A research team of UCSF medical residents and fellows worked with a team from California’s Department of Health Care Services to interview 18 ECM organizations. Providers describe their implementation efforts, impact of the program so far, and rollout challenges.

Claudia Boyd-Barrett is a longtime journalist based in Southern California. She writes regularly about health and social inequities.

From UCSF Health Services Leadership Pathway:

• Justin Zhang, MD, a third-year internal medicine resident
• Helen Pu, MD, a pediatric hospital medicine fellow
• Diana Funk, MD, a chief resident in internal medicine
• Reem Al-Atassi, MD, now completing a fellowship at the University of Pittsburgh Medical Center
• Edgar Pierluissi, MD, professor of clinical medicine at UCSF, and faculty adviser for the Health Systems Leadership group

Authors & Contributors

Claudia Boyd-Barrett

External Author

Claudia Boyd-Barrett is a longtime journalist based in Southern California. She writes regularly about health and social inequities. Her stories have appeared in the Los Angeles Times, San Francisco Chronicle, San Diego Union-Tribune, and California Health Report, among others.

Boyd-Barrett is a two-time USC Annenberg Center for Health Journalism fellow and a former Inter American Press Association fellow.

UCSF Health Systems Leadership Pathway

The post Perspectives from the Field: Up Close with ECM Providers appeared first on California Health Care Foundation.

When Kimberly Seals Allers became pregnant in 2000, she instinctively applied her journalism skills to researching pregnancy and childbirth statistics among Black women and birthing people. She was shocked to learn that education and income are not protective factors for Black families — and this remains true today. After her childbirth experience at a top-rated New York City hospital gave her a firsthand view of disrespect and discrimination inflicted on so many Black women and birthing people, Seals Allers pivoted from journalism to birth equity work. She has since become a leading voice pushing to shift the mainstream media narrative surrounding Black maternal health away from the theme of “doom and gloom.”

She is the founder and executive director of Narrative Nation, a nonprofit organization that creates media content and technology to address health disparities and share positive Black birthing stories. One of Narrative Nation’s projects is Irth, a Yelp-like app in which women and birthing people of color can rate and review ob/gyns, maternity hospitals, and pediatricians. On the back end, the reviews are anonymized and turned into robust patient experience insights and data. With CHCF support, Irth is piloting a statewide project on hospital quality improvement and patient safety data analysis to reduce racism and bias in Black maternity care and birth experiences.

Seals Allers also has been a pioneer in shifting the narrative about lactation support, especially in Black communities. I interviewed her about the unique perspective she brings to birth equity work, her advocacy for Black breastfeeding, and the importance of building a sustainable doula workforce for the long term. Our conversation has been edited for length and clarity.

Q: You are not a medical professional, but you are a major contributor to the birth equity movement. How does your background create opportunities and challenges for advancing this work?

A: I believe my contribution to this field that I love so much is bringing a different lens to the issue. I didn’t arrive at this work through a public health program or through medical school, both of which are their own forms of conditioning. I came to this work as a journalist by trade who was motivated by my own birth experience.

I had a wonderful career as a business journalist. I covered Wall Street, I worked at Fortune magazine, I worked at the New York Post. I did not think about birth equity at all until I became pregnant. Then I started researching my own situation and learned that Black women back then were twice as likely as White women to die and three times more likely to have a preterm low-birthweight baby. I was terrified by the statistics about Black women, and the explanation for why this was happening was unsatisfactory.

At that time, we were not having the conversations about equity and the impact of racism that we’re having now. When I started delving into those subjects, they inspired me to pivot from writing and producing news to supporting birthwork. My instinct was to write. My first book, The Mocha Manual to a Fabulous Pregnancy, explored Black pregnancy and childbirth through a sociocultural lens.

We need all types of people in birth equity work — not just the researchers, not just the data people. The beauty of having people in birth equity who are not from traditional maternal and child health backgrounds is that they can bring unique perspectives.

Q: Your experiences giving birth to two children inspired you to found Narrative Nation. How did you come up with that name, and what is your organization’s approach to shifting narratives?

A: I named it Narrative Nation because I believe that narratives drive everything. Back in 2018, I was talking about the danger of the doom and gloom narrative in Black maternal health. I wrote about it in Women’s eNews. And quite frankly, I took a lot of heat for that because people were saying, “No, Kimberly, we have to put out the grim statistics. How do we make them care? They’re not going to know.” And I said, “Well, at what cost, and to whom?”

There was a lot of focus on how do we get White people to care, which includes funders and policymakers. But nobody was thinking about the impact on the Black subjects of those narratives. It was important to me to shift the focus to our people and to say that the doom and gloom narrative is harmful.

We get a lot of questions from pregnant people asking things like, “Hey, should I write a will before I go into labor?” These things should not be on our minds at this time. When you’re afraid, your cervix might not dilate, so negative narratives can have a medical impact in addition to an emotional one.

It is important to recognize that there’s value in changing the storyline — that we can tell another story, and that Black women and birthing people must tell it themselves. That’s why I launched the Black Birth Joy Line (844-5-GETJOY), a toll-free phone line to hear stories of positive Black birth experiences. We are analyzing the story transcripts and creating an instructional tool for doctors and nurses to learn from these stories.

Q: Your 2017 book, The Big Letdown, took a deep look at the forces in health care and big business that converge to undermine breastfeeding. In California, Black birthing people have the lowest in-hospital breastfeeding initiation rates of all races/ethnicities. What are the greatest opportunities to promote Black breastfeeding today?

A: I’m one of the creators of Black Breastfeeding Week, so breastfeeding is incredibly important to me. I have really pushed for diversification of our lactation workforce. Increasing breastfeeding rates in our community won’t happen until we have more lactation consultants who reflect our communities. There’s a trust issue. “This is my breast. It’s a highly personal part of my body.”

So hospitals have to think about diversifying the lactation support they offer. Does their workforce reflect the community they serve? Everybody’s being asked this question across industries, and hospitals need to ask the question too.

That said, just because someone has the same skin tone as you does not mean they haven’t been affected by the cultural training that often happens in medicine. Hiring Black doctors and nurses is not a panacea. We have Black and brown birthing people leaving reviews in Irth that are not positive, and they have been against Black providers or nurses. The medical field has a deep culture that has impacted people in their practice. I just want to point that out because diversifying the workforce is an important place to start for a lot of people, but that should not be the end of our due diligence.

Q: Many doulas and other birthworkers are motivated to serve their communities even though the time demands are significant and wages are often insufficient. What practices do you support to sustain this workforce?

A: Everyone is excited about training doulas, but nobody gives much thought to sustaining them. There’s no support for doulas – they’re going into these oppressive health care environments, and mentoring opportunities are not very structured.

We most closely touch this issue through our Irth ambassador program, a perinatal workforce sustainability program. It’s an opportunity for doulas and other birthworkers to receive professional development support and access to a peer learning community in exchange for completing Irth reviews.

If we are saying that something is important for birth equity, we must think about sustaining that workforce beyond what has often been unacceptable reimbursement rates. That’s just step one. We should be talking about what the floor for paying doulas is – not what the ceiling is.

Birthworkers who participate in the Irth ambassador program are paid, and every ambassador has access to a licensed therapist in their city who does bi-monthly group sessions. Ambassadors can also book individual hours with the therapists. The mental health of birthworkers is deeply concerning to me. When I listened to some of the stories of doulas, I’m like, “I don’t know how y’all go back to work.”

Q: What policy or practice changes would improve maternal and infant health outcomes for Black families?

A: My short-term goal is to drive more accountability and transparency to help health care systems do better by Black and Brown women and birthing people. That is why we are trying to increase the number of reviews posted in Irth. Our pilot programs with systems such as Cedars-Sinai [in Los Angeles] and Temple University Hospital [in Philadelphia] involve getting patient reviews, which we then analyze to identify opportunities for improvement.

Within the next five years, I want Irth to be the public accountability mechanism driven by Black and Brown birthing people that health care systems pay attention to. In the long term, we are pushing for system transformation.

Authors & Contributors

Amber Bolden

Amber Bolden, MPP, is a freelance communications consultant and member of the Los Angeles Chapter of the National Association of Black Journalists. She works as a consultant facilitator for the Village Fund, the community grantmaking program for the African American Infant and Maternal Mortality (AAIMM) prevention initiative. She has worked on several community development initiatives and served as a founding member of the Sankofa Birthworkers Collective in the Inland Empire.

Amber is a board member of Tru Evolution, a direct service health equity nonprofit organization that prioritizes the LGBTQ+ community by providing HIV, health, housing and community services.

The post Shifting the Narrative About Black Birthing Experiences appeared first on California Health Care Foundation.

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California has taken bold steps to expand access to community-based care through Medi-Cal by adding coverage for three critical workforces: community health workers/promotores/representatives (CHW/P/Rs), doulas, and peer support specialists. These trusted providers are transforming how care is delivered to California’s most vulnerable populations. CHCF brought representatives from these workforces together to learn more about how they intersect with each other in policy and in practice. These publications illuminate what we learned and help to clarify the similarities and differences between them in Medi-Cal.

Download these complementary resources to understand how these workforces are reshaping California’s health care landscape:

• Comparing Three Medi-Cal Benefits: Community Health Workers, Doulas, and Peer Support Specialists (Fact Sheet)
  A detailed side-by-side comparison of how these three benefits work under Medi-Cal, including provider requirements, billing codes, and service definitions. Essential reading for providers, plans, and administrators implementing these programs.
• Understanding Community Health Workers, Doulas, and Peer Support Specialists in Medi-Cal (Fact Sheet)
  A concise overview of how these three workforces are defined under Medi-Cal and how their roles intersect and differ. Perfect for those seeking a quick understanding of these new benefits.
• Understanding and Alignment Among CHW/P/Rs, Doulas, and Peer Support Specialists (Issue Brief)
  An in-depth exploration of how these workforces view themselves, their shared challenges and opportunities, and their vision for the future. Based on convenings with workforce representatives, this brief offers rich insights into how these providers are working to advance health equity.

Together, these resources provide a comprehensive look at California’s emerging community-connected workforce and its potential to transform care delivery for Medi-Cal members.

The post Understanding California’s Community-Connected Workforce appeared first on California Health Care Foundation.

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Doulas are non-medically trained professionals who provide health education, advocacy, and physical and emotional support for pregnant and postpartum people before, during, and after childbirth. A critical part of the maternity care workforce, doulas are not licensed as clinical providers and do not deliver babies. Nevertheless, the inclusion of doulas on labor and delivery teams is strongly correlated with positive health outcomes, especially for Black birthing people.

Empowering Birthing People and Improving Perinatal Outcomes

Research suggests doula care is associated with lower rates of c-sections, birth complications, and preterm births, as well as higher patient satisfaction and rates of breastfeeding. Because doulas center the needs and voices of their clients, doulas can be especially beneficial for birthing people of color, who face the greatest inequities in birthing outcomes.

• Medi-Cal coverage for doulas. In 2023, California’s Medi-Cal program began paying for doula services for the first time, opening the door for doula-attended births and related services for Medi-Cal enrollees. Because Medi-Cal covers 40% of California births, this represents a significant opportunity to advance birth equity.
• An expanding doula workforce. Today, nearly 250 doulas provide support for Medi-Cal enrollees giving birth across the state.
• Tracking doula-attended births. Doulas attended 11% of Medi-Cal births in 2018 and 8% of births covered by private insurance. These numbers climb to 15% of total births for Black mothers.

Californians Are Increasingly Interested in Doula Care

Studies show growing appreciation among mothers for care provided by doulas:

• 57% of women overall express interest in having doula support in a future birth, including 18% who “definitely” want a doula and 39% who would consider it.
• 66% of Black women prefer doula care — the highest rate of any racial/ethnic group — including 27% who say they would “definitely” want doula support for their next birth.

Policy Considerations: What Can State Leaders Do to Continue Expanding Access to Doulas?

• Promote expanded insurance coverage for doula care. Most insurance plans do not cover doulas, which is a major obstacle to birth equity.
• Raise awareness about the doula workforce. As evidence of the positive impact doulas can have on maternity care grows, more information is needed on how to attract people to this workforce and offer adequate compensation.
• Expand training opportunities through doula hubs. Support is also needed to expand doula hubs, which are centralized repositories of resources and training tools that are critical for helping doulas enroll to become Medi-Cal providers.

To learn more:

• DHCS: Doula Services as a Medi-Cal Benefit
• National Health Law Program: California Doula Workforce Analysis 2024 (PDF)
• The CHCF Blog: More Doulas Are Needed in California’s Health Workforce
• CHCF: Listening to Mothers in California survey (2018)

The post What Is a Doula? — Policy at a Glance appeared first on California Health Care Foundation.

A growing body of research suggests that a maternity care workforce that reflects the diversity of the people it serves and encompasses a range of provider types can deliver better care and positive outcomes for babies, mothers, and birthing people.

This series of conversations takes a look at the critical roles of doulas, lactation professionals, mental health professionals, and midwives.

Featured Resources

Expert Perspective

Shifting the Narrative About Black Birthing Experiences

A conversation with birth equity advocate Kimberly Seals Allers about improving maternity care for Black women and birthing people.

February 6, 2025

Maternal Health

How We Can Reduce Racial and Ethnic Disparities in Maternal Mental Health

July 12, 2024

Maternal Health

More Doulas Are Needed in California’s Health Workforce

April 15, 2024

Maternal Health

Diverse Maternity Care Workforce Essential to Advance Birth Equity

March 14, 2024

Health Workforce

The post Maternity Workforce Insights appeared first on California Health Care Foundation.

Through structured conversations, interviews, interactions, and observations of in-person activities with providers, health plan members, and CBOs, Molina Healthcare identified three essential learnings that might be helpful to other organizations collaborating with communities on reducing racial disparities in maternal health care.

Lesson 1: Building trust through community engagement must come before information gathering

Building relationships to establish trust is critical before formal qualitative data collection from an underserved community can begin. Mimi Velazquez, health equity program manager for Molina Healthcare, developed relationships in the Inland Empire over six months by attending local health meetings with public health agencies, meeting with leaders of local CBOs, and joining Black maternal health community collaboratives.

The trust-building process not only involved connecting with long-standing partners and building new connections but also repairing relationships within Molina Healthcare’s network to help address and resolve existing issues. For example, CBOs shared with Velazquez that they had provided services to Molina Healthcare’s members but had yet to be paid. This prompted Molina Healthcare to create more direct connections between CBOs and their billing department to resolve any standing issues, and as a result, those CBOs became more willing to share insights with Velazquez.

In its efforts to build credibility in the community, Molina Healthcare also realized the importance of acknowledging the historical oppression often encountered when engaging with underserved communities and the mistrust these communities can experience due to past exploitation and lack of follow-up from research initiatives. “Research projects are known for coming into a community, taking data, publishing information, and then the community never hears from them again and they feel used,” says Velazquez.

In an effort to repair and honor the value of community members’ time and wisdom, Molina Healthcare provided monetary compensation ($100 per interviewee) to people sharing their lived experiences, whether they were providers, health plan members, or CBO representatives.

Through consistency and demonstrated actions over time, Molina Healthcare earned trust — community partners noted that they now feel more connected, seen, and heard by the health plan.

Lesson 2: Health plans must prioritize sharing information — for members and for providers

Through the interview process with members and providers, Molina Healthcare learned of information gaps that exist for their prenatal and postpartum members, as well as for doulas serving the community. Members shared that they didn’t have sufficient information about their doula care options and doulas shared they didn’t have information about how to contract with Molina Healthcare. This information gap is particularly harmful for patients who identify as Black, Indigenous, and People of Color who are most in need of culturally appropriate care options which doulas can often provide, to ensure positive health outcomes. It also aligns with lower rates of doula usage by Medi-Cal members in the Inland Empire, despite this region having the second highest number of Medi-Cal enrolled doulas in the state.

Members shared that they didn’t have timely information about the types of services doulas offer or how to choose a doula best suited for their maternal care needs. One of their members shared, “When I found out that I could get a doula and signed up, Riverside County was busy as far as the availability. I was told I could have maybe three or four visits with the doula before I had the baby and three or four visits after. But by the time I finally got matched with a doula, I was pretty close to my due date,… And I didn’t even know that the insurance would cover doula services!” Not only did this member miss their opportunity to receive timely care, but they were unaware that their health plan covered doula services due to lack of information sharing.

Additional members suggested a possible solution in the form of a handbook of doulas in their region, sorted by relevant demographics, as well as a welcome packet from the health plan with information about doulas and the services they provide. Of note, the Department of Healthcare Services offers an FAQ page for Medi-Cal members around doula services.

Similarly, doulas also voiced a need for more communication from the health plan. They asked for workshops about contracting with Molina Healthcare and to be recruited to provide doula care in rural areas where they live, which are known as health care deserts. Listening to doulas was therefore just as important as listening to members when understanding how information gaps were impacting maternal health care delivery.

Lesson 3: Health plans must follow through on community-informed programmatic interventions

Acting on the information shared with them was Molina Healthcare’s critical next step to maintaining trust and making progress on maternal health equity. In addition to fixing CBO payment issues, Molina Healthcare is now actively responding to members’ and providers’ requests related to doula care. Molina Healthcare offers a guide to members seeking doula services and has provided workshops on how doulas can contract with the health plan. Molina Healthcare is also looking to secure a doula consultant from among the interviewees to help the health plan in its efforts to equitably build out its doula services.

Another important example of action is Molina Healthcare’s efforts to continue to foster relationships and maintain or build trust across the Inland Empire. For example, CBOs have invited Velazquez to participate in the qualitative data collection process for their community health needs assessments and organizations that support Black maternal health in the region are now partnering with Molina Healthcare.

By building meaningful partnerships based on trust, prioritizing the elimination of information gaps that serve as barriers to care, and by committing to acting on learnings from members and providers, Molina Healthcare is optimistic that those efforts will soon translate into more equitable maternal health care. How might your organization partner with community stakeholders to create maternal care interventions that eliminate health disparities?

The California Improvement Network (CIN) is a learning and action community that advances equitable health care experiences and outcomes for Californians through cross-sector connections, spreading good ideas, and implementing improvements. Learn more about the California Improvement Network, a project of the California Health Care Foundation that is managed by Healthforce Center at UCSF, and sign up for the CIN newsletter.

The post Listening to Community Voices: A Health Plan’s Approach to Reduce Racial Disparities in Maternity Care appeared first on California Health Care Foundation.

Goal 1. Improving Access to Coverage and Care

We work to broadly strengthen California’s health care safety net so all Californians — especially those who qualify for Medi-Cal — have access to the care they need when they need it.

Key Focus Areas:

• Affordable Coverage: Ensuring that all with low incomes have affordable health insurance coverage and that all who are eligible for Medi-Cal are enrolled.
• Medi-Cal Improvement: Driving improvement and ensuring accountability around access, quality, and equity in Medi-Cal.
• Health Workforce: Developing a health workforce that reflects the diversity of California. Streamlining education and training options to reduce the cost and time it takes to become a health care worker. And cultivating the next wave of clinical leaders through the CHCF Health Care Leadership Program.
• Primary Care: Ensuring that all Medi-Cal members have access to high- quality, linguistically and culturally responsive primary care. Focusing on specific improvement related to primary care payment and financing, equity in primary care, and transforming the way primary care is delivered.
• Black Health Equity: Improving care and outcomes for Black Californians by working with health care partners to interrupt racism, build transparency and accountability around equitable care, and diversify the health care workforce. Includes work to advance Black birth equity in California.

Goal 2. Advancing People-Centered Care

We work to ensure that Californians — particularly those enrolled in Medi-Cal — receive responsive, comprehensive, and coordinated care that supports their health and well-being, and reduces inequities.

Key Focus Areas:

• Behavioral Health: Transforming mental health and substance use treatment so wherever and however care is delivered, it is effective, appropriate, and accessible, thereby improving outcomes and reducing inequities. Includes work to improve detection and treatment of maternal mental health conditions.
• People with Complex Needs: Helping Medi-Cal enrollees with challenging health or social circumstances get high-quality medical care and supportive services that improve their lives. Particular focus on people experiencing homelessness and older adults with low incomes, and supporting implementation of CalAIM.

Goal 3. Laying the Foundation

We invest in people, knowledge, and networks that are necessary for making meaningful change possible in California’s health care system.

Key Focus Areas:

• Market Analysis and Insight: Providing facts and data so decisionmakers have a market-wide view of California’s complex health care ecosystem.
• High-Quality Health Journalism: Supporting health journalism so Californians have
  access to timely, relevant information about the most pressing health care issues.
• State Policy Leadership: Developing the leadership and skills of California’s health state policy sector.
• Technology and Innovation: Enabling safety-net organizations and entrepreneurs to
  work together to bring needed innovation to the delivery system. Includes CHCF’s program-related investments aimed at innovation in Medi-Cal, promoting data exchange to support whole person care, and harnessing the power of AI to improve care and outcomes in the safety net.

The post Goals & Strategy appeared first on California Health Care Foundation.

As a member of CHCF’s program staff herself, Stephanie has led the foundation’s portfolio in maternity care for over a decade, including work to improve maternal mental health care, promote Black birth equity, and reduce unnecessary cesarean sections statewide. Earlier at CHCF, Stephanie led its transparency-focused effort to develop metrics for quality improvement and accountability in the fields of maternity care, cancer, and orthopedics.

Before joining CHCF, Stephanie was a policy analyst in the health unit of RAND Corporation, where she conducted health policy research and evaluations for such clients as the US Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, and health plans. She has also held research and management positions at Kaiser Permanente, MD Anderson Cancer Center, and the UCLA Center for Health Policy Research.

Stephanie received a bachelor’s degree in English and history from Amherst College, a master’s of public health in health services research and policy from the University of Texas at Houston, and a doctorate of philosophy in health services research and policy from the University of California, Los Angeles.

The post Stephanie Teleki appeared first on California Health Care Foundation.

Behavioral Health

The burden of untreated behavioral health conditions — encompassing mental health and substance use disorders — is both a major public health problem and a delivery system challenge. CHCF works to improve systems of behavioral health care and to focus on integrating mental health, substance use, and physical health services to achieve the best outcomes for Californians with low incomes.

Facts and Data

Our research provides essential information on California’s health care landscape to drive improvement. We collect, analyze, and share timely data to inform policymaking, identify disparities, and support evidence-based solutions for a more equitable health system.

Health Care Costs/Affordability

Rising health care costs remain a major challenge in California and across the nation. CHCF’s work sheds light on trends in state and national health care spending, as well as on the affordability of health care for consumers, to spur dialogue and action toward policy solutions.

Health Equity

All Californians should have the opportunity to achieve their fullest potential for health. CHCF is working with a wide range of partners to remove structural barriers to care and build a just and equitable health care system that is designed to redress, not perpetuate, the inequities that too many of our fellow Californians face.

Health Insurance Coverage

During the COVID-19 pandemic the percentage of Californians with insurance has hit an all-time high. However, much work remains to ensure that all Californians can get and stay covered. CHCF produces data and analyses to inform efforts to protect coverage gains and further expand coverage so that all Californians can get the health care they need.

Health Workforce

Over the next decade, California faces a number of health workforce challenges, including a population that is growing, aging, and becoming more diverse. To meet these and other challenges, California must develop a modern health workforce that delivers smarter, more affordable care. That will require a new generation of health professionals with roles, skills, and workflows that match our latest understanding of how best to deliver high-quality, high-value care.

Homelessness

On any given day, more than 150,000 people experience homelessness in California. Being homeless is dangerous to your health: People who live on the streets die an average 20 years earlier than people who are housed. CHCF has launched work to improve the delivery of health and social services to people experiencing homelessness, with the goal of promoting care that is responsive, person-centered, and focuses on the patient’s emotional, physical, and psychological needs.

Maternal Health

Giving birth is the primary reason for hospitalizations in the US and California.  Annually, 500,000 babies are born in the state, with half paid for by Medi-Cal. There are significant, unwarranted variations in maternity care quality, alarming disparities, and wasted resources. CHCF aims to improve quality and lower the costs of maternity care in California, especially for birthing people with low incomes, by ensuring appropriate care and reducing disparities in outcomes. 

Medi-Cal

Medi-Cal is the state’s health insurance program for Californians with low incomes, including over 40% of all children, half of those with disabilities, over a million seniors, and one in five workers. CHCF reports provide data and analysis on how well Medi-Cal is serving Californians.

Older Adults

Too many older adults with complex health issues face multiple obstacles to getting the care and support they need. There are nearly three million Californians over age 50 who struggle to make ends meet while also facing significant health challenges. These adults, who get their care through Medi-Cal and, in some instances, Medicare, describe themselves as being in fair or poor health, and two-thirds report a disability due to a physical, mental, or emotional condition.

Primary Care

Our work in primary care strengthens the foundation of California’s health system. We support initiatives to expand access, enhance quality, address workforce shortages, and promote team-based care models that deliver comprehensive, culturally responsive services.

Technology and Innovation

From ending the opioid crisis to making care affordable for all, solving health care’s most intractable challenges will require innovative solutions. Through direct investments, grants, and partnerships, CHCF helps innovations succeed and scale in the safety net.

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In 2023, officials with the state’s health insurance marketplace, Covered California, faced a welcome but challenging dilemma: How might they invest a new revenue stream to improve the overall health of the 1.8 million Californians enrolled in the exchange’s health plans?

The available money — which totaled about $15 million in 2024 — is the byproduct of Covered California’s new Quality Transformation Initiative (QTI). It requires insurers selling health plans on the exchange to meet minimum quality and equity benchmarks for high blood pressure and diabetes treatment, colorectal cancer screenings, and children’s vaccinations. Plans that fall short of the benchmarks must pay financial penalties to Covered California. These increase over time if the plans continue to underperform.

Health plans, which participated in the QTI’s creation, had assumed the penalty money would return to them in some other form, said Monica Soni, MD, Covered California’s chief medical officer. But as she and other department officials discussed what to do with the funds in early 2023, alternate ideas emerged.

“It was pretty out of the box to say, I don’t know, can we just give it back to the people?” said Soni. “Or could we give it to primary care providers? Or should we build parks? We really started from spaghetti-on-the-wall style.”

Reinvesting Population Health Funds

The project that emerged over the next 16 months was an innovation in the world of health insurance. Covered California will take money from fines levied against health insurance companies and give it directly to their members in the form of debit cards to purchase food and financial incentives for completing childhood vaccinations. Some money will be given to medical providers serving Covered California plan enrollees to help them modernize and better serve their patients.

These distributions, called Population Health Investments or PopHI (pronounced “poppy”), aim to tackle underlying social and structural problems that contribute to poor health. Funds will be deployed starting in February 2025.

“We know that we are severely underinvesting in population health and the provision of social services across California,” said Kristof Stremikis, MPP, MPH, director of market analysis and insight for the California Health Care Foundation. Stremikis served on the independent panel that advised Covered California on where to direct the QTI money. “This generates, in a way that is unique, some additional resources that can help address important, underfunded public health priorities in the state,” he said.

Covered California Offers What PopHI Members Want

To home in on best uses for the funds, Soni and her team enlisted help from Covered California plan enrollees. They called hundreds of individuals directly and sent out thousands of electronic surveys in English and Spanish to ask what challenges enrollees faced in staying healthy and accessing care and what they thought the money should be used for. They also interviewed providers serving Covered California patients, health plans, and consumer advocates.

Almost 1,000 enrollees responded to the surveys, and another 137 participated in in-depth qualitative interviews. What emerged was a list of common concerns, including the high costs of food, housing, utilities, and transportation. Food insecurity was at the top of that list, especially for people with chronic health conditions. Soni said this is likely because many Covered California enrollees are financially stretched but earn too much to be eligible for safety-net programs, like Medi-Cal, food aid, and utility assistance. Costs are high for people with chronic health conditions because copayments for multiple doctor visits and medications can add up significantly.

“Their level of food insecurity was higher than anything I’ve ever seen published, higher than Medicaid rates,” said Soni. “Once we saw the information, we couldn’t look away. We thought, gosh, what can we do to try to make a dent in this?”

Three Population Health Investments for 2025

Covered California officials settled on three population health investments that will launch in early 2025: grocery support, a childhood vaccine incentive program, and funding for primary care practices. They did this after gathering input from a 14-member advisory council that included state health officials, health insurers, health plan public purchasers, consumer advocates, and a current Covered California plan member.

Bianca Mahmood, the Covered California consumer serving on the PopHI Advisory Council, said she’s excited for the investments to start and likes that they go beyond regular medical interventions.

“If you can’t afford food for your family, you’re not particularly focused on your lab results or making it to an appointment or preventive care,” she said. “What I like about these PopHIs is that they take into account that there are these fundamental needs that are going unmet and look at how to supplement there.”

Grocery Support

The QTI will provide at least $960 a year to Covered California members with a chronic health condition whose household income is below 250% of the federal poverty level ($37,650 per year for one person and $78,000 for a family of four in 2024) and who report food insecurity. Eligible members will be contacted directly and will receive the money in $80 monthly installments or as a lump sum at the end of the year in order to rigorously study the impact of the program. The money will be loaded onto a debit card that can be used at grocery stores, at restaurants, and for food delivery services. Larger households will receive additional money based on guidelines established by California’s food aid program, CalFresh.

Vaccine Incentives

Families with children under two years old enrolled in Covered California plans will earn up to $1,000 by completing recommended well-child visits and vaccinations. Each milestone families meet earns $50 to $150, and money will be deposited directly into their child’s CalKIDS college savings account, which parents can claim using their child’s birth certificate number. The accounts were created by the state in 2022 to help families with children save for college. There are no income requirements for the program, and families will be contacted directly to enroll in the Covered California program, although all Californians born on or after July 1, 2022, are automatically eligible for a CalKIDS account.

The college savings program aims to support kids’ health through preventive care and vaccines and to foster future financial well-being by increasing the likelihood that they will attend college, said Soni. Research shows that students from families with low and moderate incomes who have college savings accounts are much more likely to attend and graduate from a college, even when those accounts contain $500 or less.

Primary Care Practice Support

About 50 small, independent primary care practices that serve Covered California enrollees will receive technical assistance to help them improve care quality and reduce health disparities. This PopHI investment is tied to another program created by the state Department of Health Care Services that provides incentive payments to Medi-Cal providers — many of which also serve Covered California patients.

Broader Impact

With around 1.8 million enrollees, Covered California serves just a fraction of the state’s population. Still, Stremikis and Soni said they expect the PopHI initiative to have a wide-reaching impact. To improve scientific understanding of the effectiveness of different public health interventions, researchers at UCLA and UCSF will evaluate the programs, they said. At the same time, the investments and evaluation results could encourage other public health entities and states to try similar approaches.

Erika Hanson, a clinical instructor at the Center for Health Law and Policy Innovation of Harvard Law School, likened the PopHI initiative to investments of money from tobacco and opioid settlements in government public health programs. It’s also similar to investments of some taxes on sugar-sweetened beverages or various states’ requirements that Medicaid managed care plans reinvest a portion of their profits in the community. And while Medi-Cal recently began implementing one of these  community reinvestment initiatives, Hanson said she had not seen anything like this implemented by a health insurance exchange. “I’ll be watching this,” she said of Covered California’s PopHI program. “If it’s successful, I think it’s really replicable and would be exciting.”

In future years, Covered California may expand PopHI interventions to issues such as improving transportation and addressing health workforce shortages. That will depend on how well plans meet performance requirements and how much is collected in penalties. Either way, said Soni, Covered California consumers win.

“If we collect zero dollars, that’s still fantastic, right? That means that we’ve really lifted the bar on quality for all 1.8 million folks that we support,” she said. “And if the plans don’t meet the benchmarks, we’re going to use those funds and redeploy them in different ways that will help with health and wellness.”

Authors & Contributors

Claudia Boyd-Barrett

Claudia Boyd-Barrett is a longtime journalist based in Southern California. She writes regularly about health and social inequities. Her stories have appeared in the Los Angeles Times, San Francisco Chronicle, San Diego Union-Tribune, and California Health Report, among others.

Boyd-Barrett is a two-time USC Annenberg Center for Health Journalism fellow and a former Inter American Press Association fellow.

José Luis Villegas

José Luis Villegas is a freelance photojournalist based in Sacramento, California, where he does editorial and commercial work. He has coauthored three books on Latino/x baseball. His work appears in the Ken Burns documentary The 10th Inning and in the ¡Pleibol! exhibition that debuted at the Smithsonian Institution’s National Museum of American History and has been appearing at museums around the country.

Villegas’s work has been exhibited at the Museum of Fine Arts-Houston; the Baseball Hall of Fame in Cooperstown, New York; and at the Oakland Museum of California. Villegas also works as a medical photographer at Shriners Hospital in Sacramento.

The post Covered California Starts Innovative Program to Improve Population Health appeared first on California Health Care Foundation.

Health is a key value for Black Californians, who devote substantial effort to pursuing physical and mental well-being. But our active engagement in health care alone cannot move the dial on Black health equity. California must invest in targeted efforts to improve medical care for Black patients.

In late 2023, CHCF put out a call for projects that would improve clinical quality of care for Black Californians. The response was voluminous, with community clinics, hospitals, and technology start-ups from across the state proposing interventions that addressed the care continuum.

Visionary Organizations

I’m proud to announce the recipients of grants through CHCF’s Pulse of Change: A Black Health Initiative. These were awarded to eight visionary organizations working to create a safer and stronger health system for Black Californians. These groups have deep knowledge about the interaction among health systems, cultural strengths, and health outcomes. We hope their insights will help us learn how to improve quality in California’s health care system by advancing Black health equity.

Over two years, the Pulse of Change leaders will conduct their quality improvement interventions, assess progress toward their goals, and, if appropriate, implement sustainability plans enabling providers to integrate the changes into regular clinical practice. Along the way, we will share the successes, challenges, and lessons learned to help health equity leaders adopt or improve upon the approaches demonstrated in this initiative.

I hope you will join us on this journey.

Meet the Pulse of Change Leaders

Baywell Health (formerly West Oakland Health Council) will provide culturally concordant patient navigation services and social interventions to 100 Black East Bay residents with uncontrolled hypertension and diabetes. Baywell intends to use home and community visits, clinic appointments, and post-clinic follow-ups to control diabetes and hypertension rates, and to increase cancer screening rates and vaccination uptake.

Culture Care, a Berkeley-based telemedicine start-up, will support two cohorts of pregnant Black women and birthing people with prenatal and postpartum care up to one year after their deliveries. The company uses a virtual group care model with interdisciplinary teams consisting of an ob/gyn, a mental health therapist, a lactation expert, and a pediatrician. Culture Care does not compete with patients’ primary prenatal care providers but instead infuses equity into their health care experiences through access to an all-Black clinician team.

Marin City Health and Wellness Center will pilot a program to improve hypertension control for Black patients in Marin City through enhanced care and social interventions. The program will screen patients for high blood pressure and social needs, provide care management support, and engage patients’ families and friends in lifestyle change activities.

Riverside Community Health Foundation aims to lower hypertension rates among Black adults in Riverside County through early screening and intervention that includes community and faith-based partnerships. The foundation will provide free mobile blood pressure screenings, reduce transportation needs, and establish a health care environment where Black patients feel heard, respected, and empowered. Patients with high blood pressure will be referred to providers for quality management through the use of community health workers trained to measure blood pressure and promote patient adherence to follow-up visits, provision of timely care, and patient education services. Data on clinical outcomes and patient engagement and satisfaction will be collected to ensure equity.

San Diego Community Birth Center is the only Black-owned birth center in San Diego County. Its project aims to improve Black maternal and infant health outcomes by lowering rates of perinatal anxiety, postpartum depression, and preeclampsia through culturally congruent midwifery care. Prenatal patients will receive care that includes social interventions and resources, as well as strong coordination with hospitals.

San Ysidro Health is one of the largest and most comprehensive Federally Qualified Health Centers in San Diego County. It will pilot a program to increase colorectal cancer screenings among Black patients ages 45 to 75. The effort will use a care coordination team to identify screening barriers faced by Black patients, gather input from patients on those barriers, and design and test process changes. Patients with a positive screen will be quickly linked to a specialist for follow-up care and treatment.

The Solid Start Initiative recognizes that pregnancy is a critical window for disrupting intergenerational trauma. It will leverage this opportunity to improve mental health for Black patients at Zuckerberg San Francisco General Hospital and Trauma Center’s obstetrics, midwifery, and gynecology clinic. The goal is to strengthen coordination between Black patients and lead care managers who can streamline perinatal depression screenings and mental health care, as well as connect patients to doulas.

Sutter Health aims to improve heart failure treatment outcomes and build trust with Black patients in the East Bay market. The Sacramento-based health system will enroll patients with heart failure in a virtual pharmacy ambulatory care clinic to ensure they receive optimal treatment, and provide patients with food insecurity access to a digital nutrition program and free food vouchers through Instacart Health. Sutter Health will collaborate with Black patients to develop health equity quality indicators and collect data on patients’ encounters with anti-Black racism in the health care system.

Authors & Contributors

Katherine Haynes

Senior Program Officer, Improving Access

Learn more about Katherine Haynes

Connect on LinkedIn

Paula Ginsborg

Digital Design Strategist

Learn more about Paula Ginsborg

Connect on LinkedIn

The post CHCF Launches Initiative to Enhance Black Health Equity in California appeared first on California Health Care Foundation.

San Diego Community Birth Center is the only Black-owned birth center in San Diego County. Its project aims to improve Black maternal and infant health outcomes by lowering rates of perinatal anxiety, postpartum depression, and preeclampsia through culturally congruent midwifery care. Prenatal patients will receive care that includes social interventions and resources, as well as strong coordination with hospitals.

The post San Diego Community Birth Center appeared first on California Health Care Foundation.

Culture Care, a telemedicine start-up, will support two cohorts of pregnant Black women and birthing people with prenatal and postpartum care up to one year after their deliveries. Culture Care uses a virtual group care model with interdisciplinary teams consisting of an ob/gyn, a mental health therapist, a lactation expert, and a pediatrician. Culture Care does not compete with patients’ primary prenatal care providers but instead infuses equity into their health care experiences through access to an all-Black clinician team.

The post Culture Care appeared first on California Health Care Foundation.

The Solid Start Initiative recognizes that pregnancy is a critical window for disrupting intergenerational trauma. It will leverage this opportunity to improve mental health for Black patients at Zuckerberg San Francisco General Hospital and Trauma Center’s obstetrics, midwifery, and gynecology clinic. The goal is to strengthen coordination between Black patients and lead care managers who can streamline perinatal depression screenings and mental health care, as well as connect patients to doulas.

The post Solid Start Initiative appeared first on California Health Care Foundation.