During the COVID-19 public health emergency, a federal continuous coverage requirement prohibited states from disenrolling anyone from Medicaid. The end of the requirement in March 2023 marked the beginning of the “unwinding,” during which California resumed regular Medi-Cal redetermination processes.

During the unwinding, California processed nearly 11 million Medi-Cal renewals resulting in approximately two million people being disenrolled. Two-thirds of these disenrollments were for procedural issues (e.g. missing paperwork), not because the person was determined ineligible.

Between November 2023 and April 2024, the California Department of Health Care Services partnered with SSRS to conduct six monthly surveys to learn about the experiences of enrollees procedurally disenrolled. A number of survey respondents participated in a qualitative follow-up study to elicit further information about their perspectives, the impact of their disruption in coverage, and their suggestions for how the renewal process could be improved.

The principal findings:

• Although some Medi-Cal enrollees who were procedurally disenrolled expressed satisfaction with the renewal process, it was also very common for enrollees to be unaware of the need to renew their Medi-Cal coverage or how to do it, or to end up feeling confused, intimidated, or unsupported once they attempted to renew.
• Enrollees with chronic conditions and disabilities, those with limited English proficiency, and those who have highly fluctuating incomes shared uniquely difficult challenges during the renewal process, putting them at extra risk to lose coverage.
• Although many participants indicated that procedural disenrollment had little impact on them, as they were readily able to reenroll or obtain other coverage, some participants reported that procedural disenrollment had negative effects on access to care, their physical and emotional health, and in some cases, their financial well-being.

Participants’ suggestions for improving the renewal process to minimize procedural disenrollments in the future included the following:

• Improving communication about the process
• Simplifying the renewal packet
• Enhancing availability and quality of customer service
• Providing greater transparency about what happens after the renewal form is submitted

These lessons take on new urgency as Congress (at the time of publication) considers a reconciliation bill that could add even more administrative hurdles to Medicaid enrollment and renewals. Hundreds of thousands of eligible Medi-Cal enrollees (possibly more) would lose coverage because they have difficulty navigating an even more burdensome renewal process. In the face of this federal threat, California should heed the lessons of the unwinding and take action now to streamline the process and improve communication and customer service for enrollees.

This is a companion paper to Lessons from the Medi-Cal Unwinding: How California Protected Coverage and Policy Options to Improve Renewals, which explores other important lessons from the unwinding and recommendations.

The post Lessons from the Medi-Cal Unwinding:Enrollee Experiences and How They Would Fix Renewals appeared first on California Health Care Foundation.

The COVID-19 pandemic triggered unprecedented growth in Medi-Cal enrollment, fueled by the federal continuous coverage requirement that prohibited disenrollments during the federal public health emergency. The end of the requirement in March 2023 marked the beginning of the “unwinding,” during which California resumed regular Medi-Cal redetermination processes.

During the unwinding, California processed 11 million redeterminations, the most of any state in the nation. Roughly two million people were disenrolled, and 66% of these disenrollments were due to procedural reasons (e.g., missing paperwork rather than a determination of ineligibility).

This report examines California’s approach to the unwinding, highlights key successes and challenges, and identifies opportunities to improve Medi-Cal renewals going forward. These lessons take on new urgency as Congress (at the time of publication) considers a reconciliation bill that could add even more administrative hurdles to Medicaid enrollment and renewals. Hundreds of thousands of eligible Medi-Cal enrollees (possibly more) would lose coverage because they have difficulty navigating an even more burdensome renewal process.

In the face of this federal threat, California must do what it can now to streamline and improve the process.

Successes:

• Adoption of federal flexibilities. California adopted over a dozen federal flexibilities to minimize inappropriate disenrollments, improve contact information accuracy, and streamline eligibility verifications.
• Increased ex parte renewals. California’s ex parte renewal rate more than doubled during the unwinding, rising from 31% to 63%, reducing administrative burdens and preventing unnecessary coverage losses.
• Robust outreach and communications. A statewide multimedia campaign, multilingual materials, and community-based partnerships helped inform members about renewal requirements.
• Data transparency. California provided detailed, disaggregated unwinding data through an interactive public dashboard, enabling stakeholders to track trends and target approaches.
• Stakeholder engagement. Regular collaboration between the state, counties, managed care plans, and community-based organizations improved coordination and messaging.

Notable challenges:

• Eligibility worker capacity and training. Counties faced workforce shortages and long call-center wait times, creating barriers for members attempting to renew coverage.
• Operational inefficiencies. Manual data entry and system issues, including the simultaneous implementation of a new statewide eligibility system, slowed processing and led to avoidable procedural disenrollments.
• Member confusion and outreach limitations. Some enrollees reported not receiving renewal notices, while others were overwhelmed by redundant or confusing outreach messages.
• Variability in county-level coordination. Collaboration between counties and community-based organizations was inconsistent, with some organizations struggling to obtain necessary case information to assist members with the renewal process.

Future opportunities:

• Extend or permanently adopt key federal flexibilities to maintain high ex parte renewal rates and reduce administrative burdens.
• Enhance training and capacity for eligibility workers through improved funding, technology adoption, and interactive learning opportunities.
• Streamline application and renewal processes with simpler forms, better data integration, and automation of eligibility verifications.
• Improve member outreach and accessibility by identifying enrollees’ preferred communication methods and collecting data on outreach effectiveness to better target messaging.

Explore a companion CHCF research paper, Lessons from the Medi-Cal Unwinding: Enrollee Experiences and How They Would Fix Renewals, for more recommendations on improving renewal processes, outreach and communication, and customer service.

The post Lessons from the Medi-Cal Unwinding: How California Protected Coverage and Policy Options to Improve Renewals appeared first on California Health Care Foundation.

When Sally Dolfini, 74, was diagnosed with retinal detachment a few years ago, she and her husband drove three hours south to see an eye specialist in Santa Rosa who could preserve her vision surgically. The couple lives in rural northern California, and they were eager to return home the day after the procedure. They soon discovered this was a false hope. As part of her recovery, she had to wait for the pressure in her eye to decrease. They spent thousands of dollars on food and motel lodging during a three-week stay until it was safe for her to drive back to Ferndale in Humboldt County.

“It’s stressful to have to go out of the area to see specialists,” said Dolfini. “I’m worried about the lack of access to medical services as I continue to age.” Last year she traveled 520 miles round-trip to the University of California, San Francisco for a complex colonoscopy procedure. An endocrinologist even farther away at Stanford Medical Center manages her Type 1 diabetes. In May, Dolfini’s 80-year-old husband Steve was diagnosed with prostate cancer, and they plan to travel 150 miles south for diagnostic imaging to determine if the cancer has spread. 

Access to specialists and primary care providers in rural Northern California has worsened as physicians retire and communities struggle to enlist and retain new doctors. “By the time we recruit a new doctor, another one is retiring,” said Mike Wiltermood, CEO of Enloe Medical Center, an independent hospital-based health system in Chico. “The physician shortages that used to be temporary are now chronic.”

Shasta County Declares Public Health Crisis

In response to the shortage, Shasta County Health Officer James Mu, MD, declared a “public health crisis” and warned the situation will deteriorate unless action is taken.

“The county’s medical workforce is aging, and the pace at which new physicians are entering practice locally is not sufficient to meet either current demand or future needs,” he said in a June 11 statement.

About 11.4 million Californians — one-quarter of the population — live in federally designated Primary Care Health Professional Shortage Areas. Hospital administrators and physicians cite many reasons for the increased difficulty of finding and keeping specialists, including the cost of maintaining a clinical practice and long work hours due to the lack of providers available to care for patients and share emergency call duties.

As the specialist physician workforce shrinks, doctors are becoming increasingly worried about the health impacts on patients. “They are skipping colonoscopies, skipping follow-up care with oncologists, skipping infusions with rheumatologists, and skipping sleep apnea testing because our few local specialists are at capacity and other appointments are too far away,” said Dannielle Harwood, MD, a family medicine physician in Chico. She also oversees residency programs for Healthy Rural California, a nonprofit group working to improve health and health equity in Northern California. “It’s frustrating and sad because I see my patients losing function and increasing their risk of other types of health complications.”

‘Burnout’ Sparks Retirement Plans

To increase specialist access, Partnership HealthPlan of California, the local Medi-Cal health plan for more than 900,000 members in 24 northern counties, recently surveyed physicians from 17 specialties in Butte, Humboldt, Lake, Mendocino, and Shasta Counties. About 55% of specialists said they plan to retire in the next five years. Their top reasons were burnout, advancing age, financial pressures, and lack of support and resources.  

Northern California’s specialist shortage reflects a national trend. Although the number of annual medical school graduates has increased over the past 20 years, Medicare-funded residency opportunities for graduates have not increased since 1996. Moreover, specialty care has become less economically viable because Medicare physician payments (adjusted for inflation) have been cut by 20% over the past two decades, according to the American Medical Association.

Partnership’s survey underscores the importance of innovating solutions. Providers and hospital leaders in these counties are sharing ideas and experimenting with creative approaches. “There are many people who are interested in serving in rural communities and have a heart for doing that, and many of them have grown up in rural areas of northern California,” said Harwood. “We need to create pathways for them to do this work.”

Some Delay Retirement for Longtime Patients

A number of rural specialists in counties north of Sacramento have been delaying retirement so patients they have known for years are not abandoned. Kusum Stokes, MD, a 74-year-old gastroenterologist, was drawn to the coastal hills and welcoming community in Eureka when she started practicing 40 years ago. “It was fun raising kids in a small community where I could work and also volunteer in the school and attend all their school activities,” said Stokes. “Wherever we went, I would see patients.”

There were three gastroenterologists in the area for two decades, but within the last five years two of them retired. As the last gastroenterologist there, Stokes is slowly reducing her hours. She provides acute care in the hospital one week a month and sees patients one day a week in the office. “I am delaying full retirement because somebody has to take care of these people,” Stokes said. “I feel obligated because the community has given me a lot, and I want to keep helping patients.”

The consequences of the specialist shortage are painfully clear in the emergency room, she said. “They are getting diagnosed later with more acute cases of colitis, Crohn’s disease, and colon cancer,” she said. “These patients are going to the emergency department because they wait until the symptoms are more severe.”

Patients with diseases requiring specialist care frequently receive care from visiting physicians hired by health care facilities to fill short-term gaps in services. R. Douglas Matthews, MD, a colorectal surgeon at Valor Oncology in Chico and Redding, as well as a medical director at Partnership HealthPlan, has cancer patients who have seen two or three different visiting doctors by the time they start treatment, and they continue seeing new temporary physicians following treatment. These doctors are more expensive for hospitals than hiring long-term staff physicians. “The care feels fragmented,” said Matthews, whose father was a colorectal surgeon in Chico. “Many patients feel that the continuity of care is worth the burden of travel to bigger cities.”

Primary Care Providers as Proxies

The specialist shortage is also forcing patients to turn to their primary care providers for help managing conditions that would typically be seen by cardiologists, urologists, rheumatologists, and others. “My patients have become more complex,” said Kelvin Vu, DO, chief clinical officer at Open Door Community Health Centers, which serves Humboldt and Del Norte Counties. “I am forced to manage medical conditions that are normally being monitored by specialists, so I have less time to do primary care.”

With no rheumatologists nearby, Vu researched how to work up and treat rheumatoid arthritis patients with prescription drugs. “These are potent medications, so I had to figure out the labs needed to monitor the patients, the potential interactions with other drugs, and how long to keep the patient on the medications,” Vu said. He also discovered that certain insurance companies would not cover the medications he prescribed because he was not a rheumatologist. He has become a proxy specialist for cardiology, endocrinology, gastroenterology, and a variety of other fields. As he absorbs patients with these conditions, wait times for appointments with him increased from a week or two to a few months.  

‘These Are My People’

Health care leaders are eager to find solutions. One strategy is to train family medicine doctors to provide certain types of specialty care. Ruby Bayan, MD, a 75-year-old adult, child, and addiction psychiatrist in Eureka, took this approach when she retired in March from her role as medical director of Waterfront Recovery Services. Founded by Bayan and a colleague in 2017, Waterfront is the only detox program north of Sacramento that provides medication-assisted treatment for drug and alcohol withdrawal as well as a residential treatment program. Patients enter the program to overcome substance use disorders but often have undiagnosed mental health conditions such as bipolar disorder, schizophrenia, or depression.

“If they are not diagnosed, they will often go back to the addiction,” Bayan said.

She was unable to recruit a replacement psychiatrist and trained a family medicine doctor and a family nurse practitioner to provide medical and mental health care for substance use disorder patients at Waterfront. For difficult cases, she is available to come to the clinic to evaluate a patient in person. “As long as I am in Humboldt County, these are my people,” Bayan said.

Adding Specialty Residencies

For Open Door the ob/gyn shortage prompted the organization to have family medicine doctors who have completed a one-year obstetrics fellowship deliver most of the babies. Since the pandemic, telehealth has increased access to care that can be done virtually, but for cases that require in-person appointments, specialists are needed. “I would like to find ways to make it more appealing for a specialist from outside the area to regularly rotate through a clinic one day a week or month,” said Tory Starr, CEO of Open Door. “Organizations could provide transportation, a place to stay, and clinical space and set up the contracts including billing for these doctors.” 

Attracting specialty residents to rural hospitals is a strategy, said Jerry Myers, chief medical officer of Mercy Medical Center in Redding. He previously worked at a community hospital in Colorado Springs that partnered with Baylor College of Medicine to bring in fourth-year residents for two-month rotations. “Once the residents experienced working and living in the community, it was easier to attract them to work here after they completed residency,” he said.

In Chico, Healthy Rural California addressed the physician shortage by launching family medicine and psychiatry residency programs. The community lost 45 medical providers when Feather River Hospital closed due to wildfire damage from the Camp Fire in 2018. Twelve doctors enrolled, and the next goal is to create a specialty residency pathway program. Harwood is optimistic that many participants will practice in the community after their training.

“The majority of them are from Northern California, and they really envision themselves practicing in rural communities,” Harwood said. “We were provider-poor after the wildfire, and I hope the program reduces the risk that patients will have to drive hundreds of miles to get the care they need.”

Garnering Government Support

Local governments in Northern California have joined efforts to increase the number of physicians. In May, the Shasta County Board of Supervisors reviewed the feasibility of establishing a medical school in the region. Then in June, Shasta Health Officer James Mu, MD, declared a “public health crisis.” Earlier this year, a Humboldt County supervisor hosted a panel that summarized findings from interviews of medical professionals about recruitment and retention needs in the county.

Robert Moore, MD, MPH, MBA, chief medical officer of Partnership HealthPlan, is eager to see hospitals and community health center organizations advocate for Medicare reimbursement reform. “Medicare is the driver for all reimbursement systems,” he said, noting that the current low payment levels are a key barrier to attracting physician specialists to rural areas. As the specialist population dwindles, more patients forgo care altogether, and when obstetricians are unavailable, young families become less likely to settle in rural areas, hampering economic growth.

“Among the medical societies in the northern regions, the number one topic is the loss of specialists,” Moore said. “This is very stressful to providers. We are responsible for the health care of patients, and linking the specialty health needs of these vulnerable communities to the falling Medicare clinician pay rate is more likely to lead to a permanent fix.”

Authors & Contributors

Heather Stringer

Freelance writer and editor

Heather Stringer is a freelance health and science journalist based in San Jose. She studied civil engineering at Stanford University and started her journalism career at a daily newspaper in Fremont. Heather began covering health care as a staff writer and editor at a nursing magazine and launched her freelancing career in 2003. Her work has been published in Scientific American, Monitor on Psychology, Cure, Proto, and Nurse.com.

Shaun Walker

Freelance Photojournalist

Shaun Walker is a former staff photojournalist and later also photo editor at the Times-Standard in Eureka, where he worked for nearly 25 years. He has done freelance work for the New York Times, Los Angeles Times, San Francisco Chronicle, and other major publications, as well as for local organizations. He also does wedding, nature, and portrait photography. He loves to travel the world, hike, and do whitewater and sea kayaking.

The post New Survey Highlights Worsening Shortage of Physicians in Rural Northern California appeared first on California Health Care Foundation.

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California’s CalAIM (California Advancing and Innovating Medi-Cal) initiative was designed to transform care for people facing multiple health and social challenges, including homelessness and serious behavioral health conditions. Organizations implementing CalAIM programs have reported that these services are making a dif­ference for them and the Californians they serve. But what about the people themselves? In Their Own Words: What Californians with Multiple Health and Social Needs Say About Their Care focuses on their essential perspective. Participants’ direct quotes are included throughout the report.

In partnership with CHCF, EVITARUS interviewed 99 Californians across the state living with at least one of these four challenges: serious mental illness, homelessness, substance use disorders, or functional impairments like cognitive decline or vision loss. EVITARUS also conducted eight focus groups with caregivers. The goal was to understand what people with multiple health and social needs actually experience when they try to get care. The findings reveal both the promise of CalAIM’s vision and opportunities to improve implementation.

Key Findings

The research reveals six insights that can strengthen care delivery:

• Most participants (65%) experience four or more complex needs simultaneously, requiring coordination across multiple systems.
• Trust with providers is crucial — participants value empathy, fair treatment, and culturally resonant care.
• Basic needs like housing, food, and employment often take priority over health concerns.
• Participants face significant barriers to care, including long wait times and limited access, particularly for mental health and dental services.
• There is a strong desire for “one-stop shopping” models that integrate multiple services.
• Navigation support is essential, particularly for those with limited digital literacy or language barriers.

Care managers who coordinate appointments, arrange transportation, and help navigate complex systems were described by many participants as “lifesaving.”

Advisory Group Insights for Implementation

CHCF’s CalAIM Implementation Advisory Group provided specific reflections to translate these findings into practice. They highlighted the importance of patient autonomy — putting patients’ goals first and assisting them with what they say their primary need is. The group also highlighted the critical importance of hiring people with lived experience or a cultural connection to the community. They stressed that building trust takes time and consistent staffing. Working to reduce staff turnover is crucially important. Finally, care managers benefit from, and are more likely to stay, when they receive training in trauma-informed care.

The post In Their Own Words: What Californians with Multiple Health and Social Needs Say About Their Care appeared first on California Health Care Foundation.

Across the country, states are recognizing that this growing subset of Medicaid members with complex health conditions who experience homelessness requires a different approach.

This issue brief, A Home and Healing: How Medicaid Improves Health and Lowers Costs Among Members Experiencing Homelessness, explores the reasons and methods behind multiple state Medicaid programs’ efforts to address the challenge of helping people move from the streets to permanent housing and health stability. The states cross the political spectrum and include Arizona, California, Louisiana, Maryland, Massachusetts, Montana, and North Carolina. The brief is available for download below.

A New Approach to Medicaid

States implementing these initiatives are discovering that addressing housing needs through Medicaid creates a pathway to better health outcomes while saving money. By covering services that help members secure and maintain housing, Medicaid programs can break the cycle that keeps people experiencing homelessness caught between the streets and emergency rooms.

The post A Home and Healing: How Medicaid Improves Health and Lowers Costs Among Members Experiencing Homelessness appeared first on California Health Care Foundation.

About 1.6 million Californians face interconnected challenges that make it extraordinarily difficult to access health care and find the support they need within our complex web of health care and social services systems. They confront daunting hurdles whether they are experiencing homelessness or housing insecurity; struggling with serious mental illness; managing chronic conditions; or living with substance use disorder or cognitive decline.

To learn more about their perspectives, CHCF partnered with EVITARUS, a noted Los Angeles firm that conducts opinion research and public policy analysis. The firm’s extensive research included in-depth interviews with 99 individuals and eight focus groups of caregivers across California. The key takeaway? Trusted relationships improve care.

Recently, I interviewed Shakari Byerly, PhD, MPP, who led the research team and has a deep understanding of how social needs affect health outcomes. Her findings and observations reveal not only what assistance people need but the importance of delivering services with dignity, cultural understanding, and genuine care. Our conversation was edited for length and clarity.

Q: Your research uncovered several major themes about what Californians with multiple health and social needs value most when they receive care. The first one is trusted relationships with providers — a fundamental element that many people struggle to find.

A: We were really struck by how much the personal relationship matters, even when providers can’t meet every need. That relationship goes a long way toward making people feel listened to and treated with empathy. We thought of it as emphasizing the “care” in health care. In many situations, people said they didn’t feel that the caring nature of treatment was present. Some of this stems from system overload. Patients can see there isn’t enough housing or treatment program capacity available. The constant turnover in care managers was particularly frustrating. But when services were delivered with empathy, participants told us it made a tremendous difference by helping them feel seen and heard.

Q: Many participants talked about their goals and sense of agency during these discussions. How did that fit into the picture?

A: It starts with asking the person about what’s important to them. That can often get lost when we’re just trying to move people through services. People wanted to feel like they had some self-determination and to partner with their providers. Many said providers typically do not ask about the goals they might have for their own health or what being healthy and well would look like in their lives. Another common concern was that, given the complexity of the challenges they may be facing, providers often don’t recognize that they may not be able to follow through with aspects of the recommended treatment plan. Patients responded positively when they felt seen not as a case number but as a human being trying to be healthy and move toward stability.

Q: You mentioned cultural resonance as being particularly important. How does that differ from what we typically think of as cultural competency?

A: We’ve moved away from just checking boxes about cultural competency. Cultural resonance is about providers truly understanding nuances like language, family dynamics, or healing traditions. People need care that speaks to their lived experiences. Many participants talked about needing to experience fair treatment and the elimination of racism in care settings. That’s not only about individual provider behavior — it’s also about systemic change.

Q: You also found that people’s basic needs come before their health care. What surprised you most about how people with multiple health and social issues prioritize their needs?

A: Housing came up again and again — 61 out of 99 participants emphasized it as foundational. It has a direct impact on health. People without stable housing spend time every day meeting basic needs, such as keeping warm, obtaining food, taking a shower. That takes so much time that they neglect longer term concerns like health. But housing needs vary widely. People recovering from substance use disorder told us they’re often placed with others who are still using drugs or alcohol, and that jeopardizes their progress. Women with trauma histories sometimes find themselves in shelter situations that re-traumatize them.

Employment support came up too. Many people want to work and need that economic bridge before they can fully engage with health care.

Q:  How did health care services show up in these conversations?

A: People are frustrated that they often have to reach crisis levels before qualifying for help, particularly in the behavioral health system. That’s a system failure.

Participants want robust preventive services with flexible eligibility requirements. They may not be dealing with a serious mental illness but may need counseling and therapy. They want help maintaining their own stability, not just crisis intervention.

Dental needs connected to maintaining health were a recurring theme. Some participants, particularly seniors, talked about long wait times and how the default treatment under Medi-Cal was extracting teeth rather than repairing them. Living with missing teeth makes it harder for people to eat healthy food or to find a job.

What really came through was how interconnected everything is. Someone might have critical health care needs, but if they don’t have housing, healing becomes nearly impossible. They want to eat healthy foods, but they can’t do that until they can get their teeth fixed. The system often treats these as separate issues, but people experience them all at once.

Q: You identified integrated care and “one-stop shopping” as a key theme. What do you mean?

A: The people we interviewed were recruited by community-based organizations, which are trusted by their clients to provide an array of crucial social services. Participants told us if they could get a fuller range of services that include health care, counseling, and other supports at these familiar locations, it would transform their experience. The power of services coming to people rather than the other way around is especially crucial for seniors with mobility challenges and people in underserved rural areas. It also matters for people experiencing homelessness. Street medicine providers showed us the value of care navigators and street team members building relationships over time with people experiencing homelessness.  

Q: Navigating the system seems like it should be straightforward, but clearly it isn’t. What feedback did you get about the tremendous importance of care navigators?  

A: One quote really captures it: “If I don’t know what’s available, how do I know what to ask for?” People are told, “You just have to ask,” but they don’t even know what exists. Many people, especially seniors, struggle with resources that are only delivered online and want to walk into an office and talk to a person, even if there’s a wait. When you submit an online form, you don’t know where it goes or who sees it. There’s no way to follow up. And when information is translated into other languages, it can still be confusing or use terms people don’t understand.

Q: What do caregivers have to say about all this?

A: The emotional toll on caregivers — both family members and paid providers — is profound. Family caregivers need financial support because many are sacrificing their own income and health to provide care. They need training, mental health support, and respite care.

Q: What would meaningful change look like for the people you talked to?

A: It starts with hiring staff who have cultural and experiential backgrounds in common with the people they are helping. Those go a long way toward building trust and improving outcomes. We also need to address the high turnover rate in care management that forces people to start over with new providers by retelling their story and rebuilding trust.

We need trusted community organizations to provide more comprehensive services, either on their own, or by partnering with other organizations. More housing that is appropriate to people’s specific needs. And we need care managers who won’t assume people can figure it out themselves and will provide help navigating available services.

The system needs multiple entry points — not just digital platforms — with clear, accessible information about available services. And throughout all of this, we must center the human relationship. People want partners in their journey toward health, not just service providers checking tasks off a list.

Q: What does your research tell us about the future of health care in California?

A: These findings validate CalAIM’s efforts to achieve whole person care that recognizes how health, housing, and social needs interact. These new programs must honor what people told us they need: care delivered with empathy, cultural understanding, and respect for their agency. In addition to coordinated services, they need trusted relationships. Most importantly, we need to remember that behind every complex need is a human being trying their best to stay healthy and stable. If we can keep that humanity at the center of our reforms, we’ll build a system that truly serves all Californians.

Authors & Contributors

Melora Simon

Associate Director, People-Centered Care

Learn more about Melora Simon

Connect on LinkedIn

Harrison Hill

Photographer and Filmmaker

Harrison Hill is a documentary photographer and filmmaker based in Los Angeles, California. His work focuses on social justice issues centered around communities of color in the US.

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The post Trusted Relationships Are Essential for Californians with Multiple Health and Social Needs appeared first on California Health Care Foundation.

When Tiffany Damikolas gets home from work at the clinic in Santa Ana, she likes to throw the ball around with her 10-year-old son. And she can watch her 8-year-old daughter do gymnastics after school on Wednesdays, “stress free!” for the first time in years.

Life changed for Damikolas early this spring. Until then, she labored into the evenings reviewing patient charts and drafting medical notes that she couldn’t complete during the day. Her children had to sit quietly with their screens until mom came up for air. Then on April 7 the AltaMed health clinics turned on a new ambient listening technology in her exam room.

Now she doesn’t have to take notes on the computer while talking to patients. The artificial intelligence (AI) device listens to the conversation, transcribes it, analyzes and refines the content, and then cranks out a written summary for the patient in 15 seconds. The AI scribe also drafts a medical note for the doctor to review, edit, and approve later.

This AI tool has given Damikolas her life back — her life in medicine and her life as a mom.

Reduced Physician Documentation Burden

AltaMed Health Services is one of the largest Federally Qualified Health Centers (FQHCs) in the United States, with 38 clinics in Los Angeles County and eight in Orange County, where Damikolas is a pediatrician and regional medical director. The ambient listening product that AltaMed introduced is called Abridge.

There are many AI products on the market that can listen to the patient encounter and draft a medical note, including from  industry giants like Microsoft. The reason AltaMed went with Abridge is that its technology has been trained to listen to and understand many different languages. Abridge offers health care customers 28 languages, including the 16 most-often spoken in the US.

For an immigrant-rich population like Southern California, that’s the essential skillset. Medi-Cal providers are expected to be able to communicate with patients in 18 languages, including Ukrainian, Vietnamese, and Laotian.

“We think about making sure this technology can spread to every single doctor and every single spoken language,” said Shiv Rao, MD, the cardiologist who is CEO and founder of Pittsburgh, Pennsylvania-based Abridge. “That’s what it takes to meet patients where they are. That sacrosanct moment between the professional and the patient — that trickles down to all the other aspects of care delivery.”

Supporting AI Adoption with Funding

The California Health Care Foundation (CHCF) is keen to support these language capabilities and to make sure ambient scribing and other AI tools are available to providers participating in the Medicaid marketplace. For that reason, the foundation’s Innovation Fund invested $750,000 in Abridge’s Series D funding in an effort to ensure that the safety net has equitable access to AI. There’s growing evidence that ambient scribing technologies improve the experiences of providers and their patients, and ambient scribing is estimated to be one of the fastest growing technology adoptions in health care, said Stella Tran, senior program investment officer with the Innovation Fund.

“It’s critical that safety net providers have the same access to these technologies as their counterparts,” Tran said. Because of the impact and ease of implementation, ambient scribing could open the door to other AI adoption for safety net providers. “Many of our providers are interested in using AI, but there’s a range of considerations for them. How much does this cost? How do we do it safely? How do we inform our patients?  Starting with a tool like ambient scribing enables providers to see the benefits of AI in their program and establish the foundation for other implementations.” 

Many AI products have not been developed or tailored to support safety net providers. A patient visit at a FQHC may require a provider to understand different languages being spoken in a single conversation that is rich with data on social determinants of health. “It’s a critical feature for our providers — the ability for the ambient scribe to automatically switch between two languages without user input, like, say, Spanglish, and surface important parts of the conversation to manage care for the patient.”

Abridge agrees with this approach, Rao said.

“CHCF wants that technology to be further optimized for parts of the health care system that often don’t see cutting edge technology early enough,” said Rao. “Safety-net providers are often last to benefit from paradigm-changing technology. We are proud to be leaders here, to be pioneering new technologies and features that can benefit these sorts of delivery systems and providers and patients.

“It’s a privilege to do something that nobody has really done in health care before — to distribute technology to everybody at the same time, to scale impact very quickly,” Rao said. “We are becoming part of the core infrastructure of care delivery.”

Medicine’s Longtime Documentation Challenges

Documentation has been a source of frustration in medicine and nursing forever. Practitioners are required to get everything down in writing as they constantly update the patient chart. But the obligation to write the chart conflicts with the need to listen closely to the patient, to maintain eye contact, to be fully present to comprehend what the patient is saying — and not saying. Sometimes body language holds the clues to grasping what’s really going on.

The burden of documentation varies across medical specialties, but it is heaviest in primary care, said Eric Lee, MD, medical director of clinical informatics at AltaMed. Conversations between patient and primary-care physician “can switch gears in the middle of a visit. ‘Oh, I forgot, can I ask you about this as well?’ How do you capture all that, as opposed to a specialist or surgeon, who has one primary concern or procedure, and all the conversation is focused on that?”

The electronic medical record (EMR) was supposed to ease the burden. It didn’t. On the contrary, physicians have experienced working with the EMRs, particularly during the early generations, as cumbersome, user-unfriendly, and exasperating. Doctors are required to click through checklists of boxes and pop-up alerts that may have nothing to do with why the patient came to see them that day. Also, Lee added, “If you’re typing, some of the cognitive burden is, ‘Am I typing correctly? Are my fingers on the right keys? Am I paying attention to nonverbal cues?’”

EMRs are cited as one of the primary factors leading to clinician burnout. “Two out of five doctors don’t want to be doctors within the next two to three years,” Rao said. “And 27% of nurses don’t want to be nurses much longer. We have a public health emergency, acknowledged or not.”

The health care industry is starting to regard AI as a force multiplier, something that can unburden physicians from the clerical overload that is making them so unhappy, and that can reclaim the humanity that’s been buried in the practice of medicine. 

Two Dozen Patient Encounters a Day

A typical doctor’s day at AltaMed involves 20 to 24 patient visits, with very little time between appointments to clean up notes or prepare for the next one. The doctor must document and compose a medical note for each of those visits by the end of the workday, which can stretch well into family time at home.

The AI transcribing service offers them the chance to “offload that administrative burden and get back to the joy of practicing,” Lee said. He sees AI as “the start of a journey, of freeing providers to be able to do what they went to school for in the first place.”

At the end of the day, he said, “we want to diagnose what ails you, get you better, establish those kinds of relationships between the patient and the doctor. What we didn’t go to school for is: Am I billing the wrong code? How do I deal with the insurance company denying my request for the patient to see a specialist?”   

About half of AltaMed’s nearly one-half million enrollees report a preferred language that is not English. Some 40% speak Spanish, and Russian recently displaced Mandarin as the No. 3 language. Farsi, Arabic, and Korean are near the top of the list. Back in 2021, Lee became enamored of an early-generation AI scribe product. “But it didn’t offer language other than English,” he said. “I couldn’t pitch it to my board.”

For AltaMed to invest in a product, it must be useable with all its patients. It must be good at translating, at summarizing, at learning through repetition. And it must be trustworthy. After the first week in operation, about 200 out of 300 eligible providers had signed up to use Abridge, Lee reported. “It’s been very popular.” 

‘Done With Charts When I Leave the Office’

Documentation “gets in the way of the physician-patient relationship,” Damikolas said. In her role as a regional medical director, she leads many specialty physicians, including family practice, ob/gyn, and internal medicine. Each of these specialties “has a lot of requirements that can really bog down the visit.” Some docs choose to have a conversation, and document later — on break, at lunch, at home with family.

Damikolas, 40, speaks Spanish, but she’s not a native speaker. “I have to work at it,” she said. About 80% of her patient population is Spanish speaking. Very often a parent speaks only Spanish while the child speaks English. The conversation flips back and forth naturally, and that’s not so easy to capture in a patient note.

“I can’t speak Spanish and type in English at the same time,” she said. “I often was not able to do documentation while talking to the patient. I had to do it once I got outside the room, so that made me late for my next patient.”

What sold her on Abridge was one patient visit at which a child and parent went back and forth seamlessly between English and Spanish. The Abridge scribe “had everything we had talked about, it knew who was speaking and what they said. It was very validating. It was ready as soon as we left the exam room. Fifteen seconds. No waiting, no down time.”

Since Abridge was introduced in April, “I am done with my charts when I leave the office,” she said. “Half the time, my morning session charts are done with a bow on them before I go to lunch. Never before did I have my morning session done before lunch.”

The speed with which the AI scribe updates the chart can have real patient-care ramifications. “If I see a baby at 8 in the morning, and that baby gets sicker in the afternoon and has to come back, that note will be done,” she said. “Often, same-day medical documentation was sparse. Now we have a same-day second visit, and it’s there. We are going to see more accuracy in medical documentation.”

Providers at AltaMed choose whether to use the AI scribe or not. To use it, they must attest that they are going to use it responsibly. That means they have to review the notes carefully and make any corrections, and they must inform the patient and obtain their consent.

“In the six weeks I have been using it, I have never had a patient decline,” Damikolas said. She has used it with patients speaking Russian, Mandarin, and Farsi, “and I have had zero problems.”

“I think my stress level is lower, and I am more excited about going to work,” Damikolas said. “Personally, I am more happy and more fulfilled, having that administrative documentation pressure lessened. It works better than I thought it was going to work.”

Authors & Contributors

J. Duncan Moore, Jr.

External Author

J. Duncan Moore Jr. is a freelance writer based in Kansas City, Missouri, who has been writing about health care for more than 25 years. He is a founder of the Association of Health Care Journalists.

Kyusung Gong

Visual Artist

Kyusung Gong is an independent photojournalist based in Los Angeles and the Orange County area. He is a former staff photographer at the Orange County Register. He is working on an MFA degree in photography at the Academy of Art University and is a journalism lecturer at Cal State Long Beach.

The post AI Technology Gives Doctors More Time for Patients and Family appeared first on California Health Care Foundation.

Cynde Soto, a quadriplegic who requires around-the-clock care, has been on Medi-Cal for most of her life. Recently, she came into a modest inheritance, about $8,000, that has helped cover her daily expenses. But it also means that she would lose her state health insurance under a proposal from Gov. Gavin Newsom.

Newsom has proposed restoring a $2,000 limit on an individual’s assets — including savings accounts and property other than a home and a car — and $3,000 for couples to qualify for Medi-Cal. Anyone 65 and older or disabled who exceeds that limit would be ineligible. Newsom also is proposing a cap on how much home care Medi-Cal enrollees like Soto could receive.

In unveiling the proposal, Newsom said that California has a “spending problem” and needs to make “difficult choices” to address the state’s $12 billion deficit, which he attributed in part to growing Medi-Cal costs. His proposal would save the state $94 million this budget year and more than $500 million the next year, according to the governor’s budget document.

But health advocates say that it’s almost impossible for someone to live with just $2,000 in assets in California. Rent often exceeds that amount, and medical expenses not covered by insurance quickly add up.

Advocates say Newsom’s proposal unfairly targets people with disabilities and the elderly — those who are most likely to need full-time care and have fixed incomes.

“It’s draconian — $2,000 is no safety net for people,” said Kim Selfon, an attorney with Bet Tzedek, a legal services organization in Los Angeles.

For Soto, a Medi-Cal limit on assets would mean she would either lose the caretakers who help her bathe and eat or have to spend all of the money except for $2,000. With the inheritance, Soto said she can afford repairs to her Long Beach condo and buy medical supplies that Medi-Cal doesn’t cover, such as bandages or nutritional drinks to supplement her diet.

“It’s not cheap being disabled,” Soto said. “I’m really scared. I cannot live without my help.”

When Asset Limits Were Lifted, Medi-Cal Enrollment Surged

Some lawmakers and disability advocates have argued against the asset limit for years. They say it forces people into poverty and hasn’t kept up with rising inflation and cost of living. 

Newsom agreed to raise the limit to $130,000 per person in 2022. Then in 2024, the limit was erased completely. Now Newsom wants to bring back the original limit of $2,000, an amount that was set in 1989. 

This would reinstate complex rules about wealth and property that kept thousands of seniors and disabled people from qualifying for Medi-Cal. Under those rules, an individual’s first home and car are exempt, but other properties count toward the $2,000 limit. The balance of a 401k or retirement account are exempt, although payouts are considered income. Life insurance, cash on hand and savings accounts also count towards the limit. Even certain types of funeral plots count. 

The test would apply only to people 65 and older as well as those with disabilities, which creates a financial cliff for those about to turn 65. Medicare, which many seniors use for health insurance, does not cover long-term care and requires some co-pays, so many people use Medi-Cal to supplement their Medicare benefits.

In a recent Assembly hearing, Newsom administration officials said when the limit was eliminated, far more people enrolled in Medi-Cal than anticipated, contributing to the state’s growing costs. Between 112,000 to 115,000 people enrolled compared to early estimates of just 40,000, said health care services director Michelle Baass.

Seniors make up a small portion of all Medi-Cal enrollees, but they’re about twice as expensive as the average enrollee because they use more medical care. The elimination of the asset test last year contributed to most of the senior enrollment growth and cost the state about $500 million more than expected, according to a report by the nonpartisan Legislative Analyst’s Office. 

Still, lawmakers during the hearing questioned the prudence of kicking seniors and people with disabilities off of the program and whether it would actually save money in the long run. 

Assemblymember Pilar Schiavo, a Democrat from Santa Clarita, said these groups would need more expensive care like nursing home stays or homeless services if the asset test were reinstated.

“This is going to lead to more homelessness of seniors and the disabled. That’s what’s going to happen, and that will cost our state money too,” Schiavo said.

Making It ‘More Expensive to Age in California’

Al Sanderson, one of Selfon’s clients, says that’s exactly what would happen to him. The Redondo Beach resident broke his neck three years ago in a surfing accident that left him paralyzed.  

Sanderson said his monthly rent costs more than the asset limit. He has significant savings as a former high school physical education teacher and baseball coach that he uses to pay for utilities, transportation and things that his kids need now that he no longer works. 

If he got kicked off of Medi-Cal and lost his caretakers, Sanderson said he would lose his independence.

“How am I going to pay people to come help me? How am I supposed to survive and live? I’d have to go to a nursing home,” Sanderson said.

Without full-time home care, both Sanderson and Soto would most likely end up in nursing homes, a more expensive option that is covered by Medi-Cal. The state pays on average more than $114,000 per person each year for nursing home care, according to Justice in Aging, which pushed for the elimination of the asset test. In contrast, the average annual cost of in-home care is less than a quarter of that, $25,400 a year.

Kevin Prindiville, executive director of Justice in Aging, said Newsom’s proposal would “make it more expensive to age in California.”

California’s elimination of the asset test came under fire this month from congressional Republicans, who claimed that it allows the “wealthiest Californians” to get free health care. But lawyers with legal aid organizations that help people enroll in Medi-Cal say that’s not happening. 

Regardless of their assets, Medi-Cal enrollees still need to meet income limits, which are currently 138% of the federal poverty level, or about $1,800 per month, said Linda Nguy, a lobbyist with the Western Center on Law and Poverty. 

“Our clients are not millionaires,” Nguy said. “We’re talking about people with very low incomes who aren’t able to access the health care services that they need.”

Ronald Dallatorre, 58, enrolled in Medi-Cal just two months ago. He had been looking forward to getting caretakers to help him at his Compton home so that his wife could take a break. 

Dallatorre got sick with COVID-19 in April 2020. He spent four weeks on a ventilator and almost a year in a hospital. Now the former heavy duty mechanic has Guillan-Barré syndrome, an autoimmune disease that attacks the nervous system, causing muscle weakness and numbness.

Dallatorre uses a wheelchair and can’t move his hands. His wife quit her job with L.A. Unified School District to take care of him full-time. The Dallatorres also own a second home that a close family friend lives in, rent-free. Under the proposed budget, Dallatorre would be ineligible for Medi-Cal because of this property.

If he is kicked off Medi-Cal because of the asset test, Dallatorre said his medical costs would still be covered through his wife’s insurance, but they can’t afford caretakers. His wife would have to continue as his full-time support.

“I worked 40 years of my life never receiving help, always paying taxes. I was glad to do it because I thought maybe when I need it, somebody will be able to help me,” Dallatorre said. “I didn’t know how stupid the system is.”

This article was first published by CalMatters on May 29, 2025.

Authors & Contributors

Kristen Hwang, MJ, MPH

Reporter, CalMatters

Kristen Hwang reports on health care and policy for CalMatters. She is passionate about humanizing data-driven stories and examining the intersection of public health and social justice.

Prior to joining CalMatters, Kristen earned a master’s degree in journalism and a master’s degree in public health from UC Berkeley, where she researched water quality in the Central Valley. She previously worked as a beat reporter for The Desert Sun and a stringer for The New York Times California COVID-19 team.

https://calmatters.org/

The post ‘I’m Really Scared’: Elderly and Disabled Californians With More Than $2,000 Could Lose Medi-Cal appeared first on California Health Care Foundation.

To bridge this workforce gap, a growing number of community health workers, case managers, first responders, and other health and social care workers are training to become lay counselors who can provide mental health support. They learn how to create a therapeutic alliance with clients, a key predictor of positive mental health treatment outcomes.

“If people receive any care for mental health conditions, they often get a 10-minute consult and a prescription,” said Harvard psychiatrist Vikram Patel, a pioneer of lay counseling and chair of the Department of Global Health and Social Medicine at Harvard. “Brief evidence-based psychosocial interventions are preferred by patients over medication, and they have the greatest impact among populations with the lowest access to care.”

The Lay Counselor Academy, based in California, teaches nonlicensed providers how to cultivate empa­thy, trust, mutual respect, and partnership with clients to help them meet their goals. Lay counselors also receive regular clinical support from licensed clini­cians. The academy was founded in 2022 by Elizabeth Morrison, PhD, LCSW, a psychologist and licensed clinical social worker, and lay counselor Alli Moreno. Studies show that the clients of lay counselors have similar outcomes to the clients of licensed clinicians.

Lay Counselor Academy

• Ideal candidates: People with strong interpersonal skills, high levels of self-awareness, the ability to establish trust quickly, empathic communication skills, and humility.
• What they learn: Cognitive behavioral therapies, motivational interviewing, behavioral activation, preventing vicarious trauma, mandated reporting, and more.
• How they learn: One in-person session and 13 live, virtual sessions to acquire skills to help people struggling with anxiety, depression, suicidality, sub­stance use, and other issues.

Impact of Lay Counseling

A third-party evaluation of the Lay Counselor Academy found the program has the potential to:

• Increase workforce diversity. Graduates were 41% Latino/x; 17% Asian, Native Hawaiian, and Pacific Islander; 17% White; 9% multiracial; and 8% Black.
• Improve services. Almost three-quarters (74%) said the lay counselor training improved their ability and effectiveness in helping people with mental health struggles “a lot” or “a great deal.”
• Boost job satisfaction. Nearly 75% reported their job satisfaction increased “somewhat” or “a lot” after participating in the training.
• Fully leverage licensed providers. Organizations that sent staff members to the Lay Counselor Academy reported that integrating these lay counselors into their behavioral health treatment teams allowed licensed staff to focus on higher-need cases.

Future Considerations

In the United States, the turnover rate among behav­ioral health workers is high due to low wages, growing work demands, and insufficient workplace support. Additional pathways for employment in the behav­ioral health field are needed for providers with a bachelor’s degree or less. “Many of us in health care already rely heavily on chaplains and crisis counselors to provide crucial mental health support without tra­ditional clinical licenses,” said CHCF Senior Program Officer Mariana Torres, MSW, LCSW. “With the proper training, we can upskill more workers to deliver evi­dence-based therapy that aligns with the cultural and linguistic backgrounds of the communities they serve.”

To learn more:

• Evaluation of the Lay Counselor Academy, 2025 (PDF) (Prism Partners Group and Mary Rainwater LLC): Findings show the effectiveness of lay counseling.
• New Workforce of Lay Counselors Strives to Bridge Mental Health Care Gaps (CHCF Blog)
• The Emerging Field of Behavioral Health Paraprofessionals (National Governors Association): Describes how states are regulat­ing and credentialing an untapped pool of behavioral health workers.

The post What Is Lay Counseling? appeared first on California Health Care Foundation.

With a Starbucks coffee cup in her hand and a half gallon of milk under her arm, Florence Owens let herself into Carol Crooks’ Oakland apartment on a Monday morning, announced herself with a cheery “hello,” walked through the book-filled living room, and got to work in the kitchen.

“I see you went popcorn-crazy this weekend,” Owens teased as she brushed kernels off the counter into a garbage can. Crooks, who relies on a walker or wheelchair, can steady herself against the counter while waiting for corn to pop. But back, knee, and foot problems have left the 77-year-old silver-haired retired teacher incapable of most food preparation and cleanup.

Like nearly 800,000 other Californians, Crooks depends on aides from In-Home Supportive Services, a program funded through Medi-Cal, California’s version of Medicaid. Owens has worked as Crooks’ aide for almost three years. In addition to cooking and cleaning, she helps her shower, shops for groceries, drives her to medical appointments, and runs other errands.

Medicaid In-Home Services Could Shutter

For more than 50 years, low-income seniors and disabled people have been able to stay in their California homes — and out of more costly nursing facilities — with help from government-paid aides. But in their latest bid to renew President Donald Trump’s tax cuts, House Republicans released a plan on May 11 that would axe about $625 billion over 10 years from Medicaid, and could threaten funding for Owens and other In-Home Supportive Services workers. (Editor’s note: The bill adopted by the US House of Representatives on May 22 would cut Medicaid by at least $716 billion, the largest reduction in the program’s history, according to Congressional Budget Office estimates analyzed by the Center on Budget and Policy Priorities.)

While a major structural overhaul of Medicaid appears increasingly unlikely, Republicans continue to wrestle with how to cut the budget. Several proposals would disproportionately target California, according to Larry Levitt, KFF’s executive vice president for health policy. Federal cuts, coupled with the state’s existing budget woes, could inflict a “double whammy for California and trigger reductions in Medi-Cal and other state programs,” he said. KFF is a health information nonprofit that includes KFF Health News, the publisher of California Healthline. California Healthline is supported by the California Health Care Foundation.

Although federal law compels states to offer certain services, such as nursing home care, they’re under no obligation to cover home-based care for low-income seniors and disabled people like Crooks, leaving the in-home services program particularly vulnerable to cuts, said Amber Christ, managing director of health advocacy for the nonprofit legal group Justice in Aging. In the wake of the Great Recession, California made a series of funding cuts to in-home support aides. Lawsuits temporarily stopped the bulk of the cuts, but a court settlement led to an 8% reduction in 2013 and an additional 7% cut in 2014.

Forcing Seniors Into Nursing Homes

Further reducing these services would inevitably force more people to move into nursing homes, Christ said. “It would be an enormous setback from the progress we have made to provide care in the home and the community to support older adults and their families,” she said. “I think it will cost people’s lives.”

Owens supports herself and her teenage son with what she earns working 136 hours a month for Crooks. She’s confident she can figure out another way to make a living, so she’s less worried about losing her $20-an-hour income than she is about Crooks’ losing her independence.

“I absolutely adore Carol,” said Owens, 36, as she chopped onions for Crooks’ breakfast. “I look at her as a grandma.”

From a makeshift desk where she’d been scrolling through emails, Crooks affectionately eyed Owens and announced, “You’re adopted.”

In his May 14 budget proposal (PDF), California Governor Gavin Newsom trimmed funding for In-Home Supportive Services, most notably by putting weekly caps of 50 hours on provider overtime and travel, reinstating an asset limit, and eliminating the service for immigrant adults without legal status who aren’t already enrolled.

The proposed changes are unlikely to affect Crooks, but if congressional Republicans slash Medicaid spending, the Democratic governor warned May 14, California could not afford to backfill all the proposed federal cuts. Almost two-thirds of the $28.3 billion California has budgeted for the in-home support program is supposed to come from endangered federal Medicaid funding. The state legislature must pass a balanced budget by June 15, regardless of the status of federal funding negotiations.

Owens delivered an omelet and a mug of coffee to Crooks. “I know these are politicians,” she said, “but they still have to understand the elders are our roots. And I’m sure they have to have some kind of heart.”

Crooks is less certain, more anxious. “If they start messing with my programs,” she said, “I’m in trouble.”

Burt Conell, 64, is also worried. A paraplegic, he’s been confined to a wheelchair for 30 years since, despondent after his girlfriend left him, he jumped in front of a train. He relies on in-home aides to help him bathe and clean his San Francisco apartment.

When he heard the government might cut his funding, he imagined being unable to shower, getting rashes and bedsores, and having to move into a nursing home. Again, he contemplated suicide.

“It made me feel like I was using so much resources that I shouldn’t exist,” he said.

Dire Situation for People with Disabilities

At an April meeting of San Francisco’s Disability and Aging Services Commission, Commissioner Sascha Bittner asked about the fate of In-Home Supportive Services, on which she relies. “We don’t know what’s going to happen,” Executive Director Kelly Dearman replied, adding that Medicaid cuts could result in a decrease in the number of hours San Francisco beneficiaries, like Conell and Bittner, who is quadriplegic with a speech disability, receive. “It’ll be dire,” Dearman concluded.

Every day, around 30 people contact California Advocates for Nursing Home Reform seeking advice on how to get in-home help, said Maura Gibney, the nonprofit’s executive director. These days, the group frequently hears from recipients who have achieved a semblance of normalcy in the aftermath of a major setback, such as a stroke, but fear they’ll lose their benefits, she said.

“It’s hard to really give people reassurance at this time because I don’t think any of us know what will happen,” Gibney said.

Lately, when she hears from people looking for in-home help for the first time, Gibney wonders if their efforts will end up being pointless. “It feels a little bit like trying to show somebody how to get into the building as the top floor is on fire,” she said.

Paul Dunaway, who directs Sonoma County’s Adult and Aging Division, described the dearth of information he and his staff have to offer older and disabled people about future services as “anxiety-provoking.”

“There’s a lot of chaos happening and not much to really grab onto yet about the funding on the federal level,” Dunaway said.

Uncertainty and fear about service cuts, coupled with weaning off pain medicine from a back surgery, left Crooks — who retired from teaching after being diagnosed with bipolar disorder — unable to sleep, she said, and she spiraled into her first manic episode in more than a decade.

Owens was sweeping the living room but stopped to listen as Crooks talked about being tired, worried, and feeling out of control. “I told her, ‘Regardless, I’m gonna always be here for you, no matter what,’” Owens said.

Crooks, wearing a T-shirt picturing the Statue of Liberty with her hands covering her face, nodded. “It helped a lot,” she said.

Nonetheless, without an in-home aide, Crooks said, she would have no choice but to move into a nursing home — a fate she cannot bear to consider.

“It wouldn’t be a home,” she said. “It’s where people go to die.”

This article was first published on May 15, 2025, by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source of health policy research, polling, and journalism.

Authors & Contributors

Ronnie Cohen

Freelance journalist

Ronnie Cohen is a freelance journalist in Mill Valley, California. She writes mainly about health and inequality and contributes regularly to KFF Health News and NPR. Her work has appeared in The New York Times, the Washington Post, and Reuters, among other major media outlets.

In the middle of her journalism career, Cohen briefly attended law school only to realize just how much she loves being a journalist.

The post Californians Receiving In-Home Care Fear Medicaid Cuts Will End Their Independent Living appeared first on California Health Care Foundation.

Ian Morrison, a futurist and health policy expert who served on the California Health Care Foundation board of directors in the early 2000s, died on February 5, 2025, in Menlo Park. He was 73.

The cause of death was idiopathic pulmonary fibrosis, the family said.

Morrison grew up in Glasgow, Scotland. He earned advanced degrees in geography and urban planning before emigrating to Vancouver, Canada. There he met his wife Nora and earned a PhD in urban studies at the University of British Columbia.

In 1985, Morrison moved to California and joined the Institute for the Future, becoming president in 1991 and president emeritus in 1998.

For four decades, he advised government, industry, and nonprofits, primarily in health care, working independently and with the Harris Poll, Harvard School of Public Health, Accenture, and Leavitt Partners. He specialized in forecasting and planning with an emphasis on health care.

Author and Expert on Change

Morrison worked with more than 100 Fortune 500 companies in health care, manufacturing, information technology, and financial services. He was a New York Times bestselling author of The Second Curve — Managing the Velocity of Change, published in 1997, and Healthcare in the New Millennium: Vision, Values and Leadership, which came out in 2000.

“Ian was a powerhouse thinker who possessed formidable technical knowledge of the health care system and an ability to hear where people experienced pain points in it,” said CHCF President and CEO Sandra R. Hernández, MD.

“His futurist views were informed by what was happening in the world and by what was possible and important to do,” Hernández said. “Ian was so good at taking complex strategic questions and using both serious analysis and humor to push health care leaders to think differently about the future. His unique approach earned respect from leaders of hospitals, health plans, safety net organizations, and start-ups, as well as academics.”

In addition to his time on the CHCF Board of Directors, which he also chaired, Morrison served on the boards of Martin Luther King Community Healthcare in Los Angeles, the Center for Health Design, and the research and education arm of the American Hospital Association (AHA).

“Using data-based assessments and firsthand experience with both governmental and market-oriented systems, Ian deployed a humble futurist orientation and his incredible sense of humor to make his counsel compelling and digestible,” AHA President Emeritus Rich Umbdenstock said in the organization’s tribute to Morrison. “He and his many gifts will be missed.”

While Morrison was funny and irreverent at work, family and friends knew him as warm-hearted, insightful, and joyous. He was married to Nora for 44 years, and together they traveled the world, playing many great golf courses on their trips. They cherished family traditions like their annual visit to Priest Lake in Northern Idaho.

He is survived by his wife; their son David, his wife Lydia, and their son Elias; and their daughter Caitlin, her husband Joe, and their son Jacob. Morrison is also survived by his sister Fiona and her husband Dennis in Canada, as well as extended family in Scotland and Canada.

Authors & Contributors

Avram Goldstein

Senior Engagement Officer

Learn more about Avram Goldstein

The post Remembering Ian Morrison, Thought Leader and Former CHCF Board Chair appeared first on California Health Care Foundation.

For older adults and people with disabilities, long-term services and supports (LTSS) provide crucial assistance with daily activities like eating, bathing, and medication management. Although some receive care in nursing facilities, many prefer staying in their homes with support from home and community-based services (HCBS).

California is joining other states in shifting Medicaid LTSS from fee-for-service to managed care. This transition offers promising opportunities to:

• Enhance coordination for HCBS users
• Improve state cost predictability
• Strengthen service delivery systems

However, without careful planning, these changes could disrupt vital care for vulnerable Californians.

Learning from Experience

California can benefit from the experiences of 24 states that have implemented Medicaid managed LTSS (MLTSS) over three decades. Their journeys reveal key strategies for success:

• Implementing robust continuity-of-care protections
• Building and maintaining strong provider networks
• Establishing proactive oversight mechanisms

This explainer, Moving HCBS to Medicaid Managed Long-Term Services and Supports: Considerations  for California and Other States, highlights practical approaches to guide California’s transition to MLTSS. By applying these lessons, California can create a system that honors individual preferences, supports community living, and ensures high-quality care for those who depend on these essential services. CHCF is proud to support the production of this paper.

The post Moving HCBS to Medicaid Managed Long-term Services and Supports appeared first on California Health Care Foundation.

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Quality of Care: Chronic Conditions Almanac — 2024 Edition

October 31, 2024

Facts and Data

Report

Long-Term Care in California — 2024 Edition

This Almanac describes the state’s supply, use, and quality of long-term care, including Medi-Cal’s long-term services and supports, nursing facilities, assisted living, and home health care.

December 13, 2024

Facts and Data

US Health Care Spending: Who Pays? — 2024 Edition

June 3, 2024

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

When most people think of Medicaid, they think of health insurance — a public program for low-income families, older adults, children, and people with disabilities. But that’s only part of the story. Medicaid isn’t just about health coverage. Medicaid is one of the largest and most effective economic engines in the United States.

Each year, the federal government alongside states invest billions of dollars into Medicaid. That money doesn’t sit in government accounts — it moves through communities. It keeps hospitals open, supports hundreds of thousands of jobs, sustains rural health systems, and fuels a growing workforce of home care aides, behavioral health providers, and community-based service workers. For every dollar spent, Medicaid generates ripple effects far beyond health care. It helps the restaurant worker stay employed, enables older adults to remain in their communities, and gives entrepreneurs the security to open their small businesses.

Medicaid, the Economic Driver

Yet despite this, Medicaid is rarely discussed as an economic driver.

Too often, it’s treated as little more than a budget line — a cost to be managed or trimmed. But this view is dangerously short-sighted, especially now.

The country is at a crossroads. Pandemic-era coverage protections have ended, and more than 10 million people have already lost Medicaid as part of the so-called “unwinding” process. Meanwhile, states are grappling with strained safety-net systems, workforce shortages, and budget uncertainty. These challenges are real — but so are the opportunities.

Because Medicaid is about more than health insurance. It’s about jobs, stability, and economic growth.

Every time Medicaid pays for a doctor’s visit or funds a home health aide, that payment supports a job. That job supports a family. That family strengthens a local economy. And as Medicaid evolves — covering services like housing supports, nutrition, behavioral health, and social services — its economic impact only grows.

It also boosts workforce participation. When people have health coverage, they stay healthier, miss fewer days of work, and avoid financial ruin from medical bills. Medicaid gives working parents, caregivers, and people managing chronic conditions the stability they need to stay employed and contribute fully to their communities.

Reframing Our Understanding of Medicaid

The evidence is clear, especially in states that expanded Medicaid under the Affordable Care Act. Expansion has fueled job growth, strengthened hospitals, improved family financial stability, and helped prevent rural health systems from closing their doors.

I saw this firsthand in California, where I served as Undersecretary of the state Health and Human Services Agency. Medi-Cal, the state’s Medicaid program, covers more than 15 million people — roughly one in three Californians. Through initiatives like CalAIM, California has used Medicaid funding not just to treat illness but to tackle the root causes of poor health: housing instability, food insecurity, mental illness, and more. Along the way, the state has created new opportunities for employment and forged cross-sector partnerships that strengthen both community health and local economies.

This kind of innovation should be the norm — not the exception. But it requires reframing how we see Medicaid.

Proposed federal Medicaid cuts could lead to 217,000 lost jobs in California, $37 billion in reduced economic output in the state, and $1.7 billion in lost state and local tax revenue, according to the UC Berkeley Labor Center.

At the same time, two recent polls — one national by the Kaiser Family Foundation (KFF) and another focused on California by the California Health Care Foundation (CHCF) — show overwhelming bipartisan support for Medicaid. The KFF poll found that 82% of Americans want Medicaid funding to be either maintained or increased, while only 17% support cuts. In California, the numbers are even more striking: the CHCF poll found that 87% of Californians want Medi-Cal funding preserved or expanded, with just 13% favoring cuts. And for many, Medicaid is personal — more than half of Americans say they or a family member have benefited directly from the program. These numbers cut across political, geographic, and demographic lines, underscoring that Medicaid isn’t just popular — it’s essential.

Medicaid, the Strategic Asset

Policymakers in Washington, D.C., face hard fiscal choices. But weakening Medicaid would be counterproductive. It would hurt families, destabilize local economies, and undercut workforce participation at a time when employers are already struggling to hire and retain talent.

The question we should be asking isn’t whether we can afford Medicaid — it’s how we can make Medicaid work harder for our communities. How can we align it with other public and private investments to drive better health outcomes and greater economic resilience?

The answer starts by seeing Medicaid not as a budget burden, but as a strategic asset — a catalyst for growth, stability, and economic prosperity.

In a time of economic and social uncertainty, we have a choice: pull back or invest in smarter systems that deliver for people and strengthen the economy. Medicaid should be at the center of that strategy.

It’s time we start treating it that way.

This article first appeared in LinkedIn on April 13, 2025 and is reprinted here with permission. The author updated it with additional data before publication here.

Authors & Contributors

Marko Mijic

Former undersecretary, California Health & Human Services Agency

Marko Mijic is the former undersecretary of the California Health and Human Services Agency (CalHHS). He is currently a managing director at Sellers Dorsey and an Impact Fellow at the UC Berkeley School of Public Health.

At CalHHS, he managed 12 departments and five offices, overseeing more than 34,000 employees and an annual budget exceeding $260 billion. In this role, he focused on refining government operations, enhancing access to health and human services, and advancing an equitable recovery from the pandemic. He served under two governors and three CalHHS secretaries during his tenure.

Mijic’s leadership emphasized improved services for marginalized communities, including older adults and individuals with disabilities, grounded in a commitment to justice, equity, diversity, and inclusion. 

The post Medicaid Is One of America’s Strongest Economic Engines. Why Don’t We Treat It That Way? appeared first on California Health Care Foundation.

As a physician, I have witnessed patients struggle with health issues caused or complicated by housing instability. It is terribly distressing to see a patient who could potentially live a healthy life encounter persistent structural obstacles to regaining a safe and reliable place to live.  

On March 12, I had the privilege of moderating a CHCF briefing that brought together leaders from California state government and providers of health care and social services to discuss how Medi-Cal’s three housing Community Supports are addressing homelessness. The “housing trio” — housing transition navigation services, housing deposits, and housing tenancy and sustaining services — were developed through Medi-Cal’s CalAIM initiative; they are designed to bring a more integrated and people-centered approach to caring for people with the most complex health and social needs, including those experiencing homelessness.  

More than 100 people attended in person at the Department of Health Care Services (DHCS) auditorium in Sacramento, and 650 more watched the live webcast. This strong attendance underscored the urgency and importance of the homelessness problem to our state. You can watch the complete video replay on our website.  

The Intersection of Health and Housing

Margot Kushel, MD, director of the Benioff Homelessness and Housing Initiative at UCSF, opened the briefing with insights from the California Statewide Study of People Experiencing Homelessness. She highlighted the ways that homelessness combines with physical and behavioral health problems to create a vicious cycle: Health issues increase the risk of homelessness, and living unhoused worsens health through exposure to trauma, sleep deprivation, environmental hazards, and impeded access to care. 

Kushel emphasized that the right interventions at the right time can prevent, mitigate, or end homelessness. While many will eventually resolve their housing situation independently, strategic support can dramatically reduce the duration of homelessness from years to months or even weeks. 

Cross-Sector Collaboration Breaks Down Barriers

The heart of the briefing was a panel discussion that started with the elephant in the room: how DHCS is thinking about the future of CalAIM in the face of federal uncertainties. 

Susan Philip, MPP, the DHCS deputy director of health care delivery systems, was crystal clear in her response. “As a state, as a department, we are fully committed to Community Supports and the scaling of them. We’re not going to speculate what the federal government might do, but … just to reiterate … we are fully committed. As [DHCS] Director Michelle Baass likes to say, ‘We are pedal to the metal on this.’”  

The panel discussion revealed both the challenges and the promising solutions that have emerged through the CalAIM initiative and the housing Community Supports. 

Cheryl Winter, MPH, associate director of California state policy at the Corporation for Supportive Housing, highlighted a fundamental challenge: Housing and health care organizations operate in different worlds with different languages, systems, and, crucially, funding mechanisms.  

“Homeless and housing service providers are having to enter into a new and very complex system of care, moving from a grant-funded system where you’re receiving funding up front, and you serve as many people as you possibly can, to one where you submit the data and reports and receive payment 30 to 90 days after services are provided,” Winter said. This misalignment creates significant cash flow challenges for community-based organizations (CBOs) trying to provide housing supports. 

Philip pointed to the emergence of “flex pools” as a promising strategy.  

“These local administrative entities braid together different funding streams to address cash flow problems,” Philip said. “They’re helping housing providers cover immediate costs like deposits and transitional rent that would otherwise be impossible under traditional Medi-Cal reimbursement timelines.” 

She added that administrative “hubs” are becoming critical intermediaries between CBOs and Medi-Cal managed care plans. These hubs handle the complex claims and invoicing processes so that each community-based organization doesn’t have to become a Medi-Cal billing expert overnight, she said. “That way, the CBO can focus on the bread and butter of actually serving the Medi-Cal members, and the administrative hub can work with the managed care plans on billing,” Philip said. 

The Housing Supply Challenge

Even with these innovations, there simply aren’t enough affordable units available for people with low incomes. 

“There are tens of thousands of people now receiving housing transition navigation services through Medi-Cal, which is incredible,” Winter said. “But providers have nowhere to navigate them to. This impacts everyone — the member, the providers, and the plans.” 

This reality resonated deeply with me. During my years practicing alongside Kushel at San Francisco General Hospital, we often wished we could write a “prescription for housing.” Today, through CalAIM, we’re closer to that reality. But unless the underlying housing shortage is addressed, our efforts will fall short. 

Expanding the Housing Support Toolkit

Philip detailed how DHCS has strengthened its commitment to whole-person care through CalAIM. “We know that housing stability is crucial for health and well-being, directly impacting physical, mental, and behavioral health,” she said. 

Beyond the initial trio of housing Community Supports, DHCS now offers these housing supports: recuperative care and short-term post-hospitalization housing. In December, the department began covering six months’ rent for unhoused people with complex health needs or transitioning out of a treatment, detention, or shelter facility. 

Setting Ambitious Goals Through Interagency Collaboration

Dhakshike Wickrema, MCP, the deputy secretary of homelessness at the California Business, Consumer Services and Housing Agency (BCSH), shared how the California Interagency Council on Homelessness is coordinating efforts across state departments and agencies. 

Its Action Plan for Preventing and Ending Homelessness in California has a goal of increasing the percentage of people experiencing homelessness who move into permanent housing from 18% a year to at least 60% annually over three years. 

“That’s an ambitious goal, but it’s the way we want to make sure every state agency and every state department is thinking about how to help people exit unhoused situations to permanent housing situations,” said Wickrema. “Those are places where there’s a sense of stability, a sense of dignity, where people can really take care of their health and be reunited with family and friends if that’s something they want to do, but really use CalAIM and other resources to turn that chapter in their lives.” 

This cross-sector approach is showing promising results. According to the statewide Homeless Data Integration System, about 63,000 people moved from homelessness into permanent housing in 2024. Philip noted that a forthcoming RAND/UCLA study will provide more comprehensive data on outcomes for individuals receiving housing Community Supports, including emergency department use and total cost of care. 

Audience Questions

From there, we invited audience questions, but unsurprisingly we could not get to all of them in the time remaining. Here are my responses to some additional questions from the Zoom audience that weren’t addressed at the briefing.  

Q: In Santa Barbara County, we have many providers of services. What is challenging is that to coordinate care holistically, it’s hard to link efforts. Any suggestions about how to make this work more seamlessly? 

A: This is a great question. Effective cross-sector partnerships are the cornerstone of work to improve outcomes for people experiencing homelessness. Coordination and collaboration take planning and care. A two-year, CHCF-funded project focused explicitly on bringing together partners from the health care and homelessness sectors, and it recently concluded. This brief captures lessons from that initiative. Here are a few takeaways:  

• Don’t just talk, do something! Come up with a project that would benefit from cross-sector engagement, and don’t let development of a perfect plan keep you from getting started. Our teams found that it’s better to get going, learn from doing, and adapt as needed rather than risk “analysis paralysis.” 
• “Boundary crossers,” the people who work in one sector and then move to work in another, play a crucial role in facilitating relationship development and progress between collaborating sectors.  
• Engaging people experiencing homelessness and/or those with lived experience of homelessness offers valuable insights that can inform the development of programs that will impact them and their community. 

Beyond these insights, communities in California can use resources that are available to support cross-sector collaboration. For example, the Providing Access and Transforming Health (PATH) Technical Assistance Marketplace offers free resources and technical support to help organizations implement Enhanced Care Management and Community Supports.  

Q: Each county in California has a different managed care plan assigned, and the individual counties often manage their own version of Medi-Cal. There is no data sharing within the county and plans. Often unhoused folks move from county to county, which poses a problem. How would you advise the plans to support these efforts? 

A: Although Medi-Cal is a statewide program, each of California’s 58 counties separately administers the program for most residents who live within that county. When someone moves to a new county and wants their Medi-Cal to continue, they need to ask for an “inter-county transfer.” The transfer process can be especially complicated for people experiencing homelessness. 

In that vein, we supported Homebase and the Western Center on Law and Poverty to create a practical guide, Moving with Medi-Cal: Inter-County Transfers.  

The Pathway Forward: Integration and Collaboration

A clear consensus emerged from our discussion at this briefing: No single sector can solve homelessness. The health care system brings valuable skills in assessment and individualized care planning. Housing experts understand the complex landscape of affordable housing resources. Government agencies provide crucial funding and policy frameworks.  

Only by working together can we create lasting solutions. 

The integration of Medi-Cal housing supports was a significant step forward in California’s approach to homelessness, which recognizes that health and housing are inextricably linked. While challenges remain, particularly around housing supply and cross-sector coordination, the innovations give us reason to be hopeful. 

As I reflect on the rich discussion at our briefing, I’m reminded that behind every statistic is a person deserving of dignity, health, and a place to call home. By breaking down walls between health care, housing, and social services, we’re building a more compassionate and effective system for Californians experiencing homelessness. The journey ahead is long, but partnerships forming today are laying the groundwork for effective and meaningful change. 

Authors & Contributors

Michelle Schneidermann

Director, People-Centered Care

Learn more about Michelle Schneidermann

José Luis Villegas

Independent photojournalist

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 How Medi-Cal Is Tackling Homelessness Through Innovative Housing Solutions appeared first on California Health Care Foundation.