In summary

Upcoming contract negotiations between the state and Medi-Cal managed care plans can address health care inequities.

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By Kiran Savage Sangwan, Special to CalMatters

Kiran Savage Sangwan is the executive director of the California Pan Ethnic Health Network, a statewide health advocacy organization focused on addressing racial and ethnic health disparities,

While California has made tremendous progress over the past decade in narrowing the coverage gap in health care, our systems continue to fail communities of color who fare worse on average than white people on key health indicators. 

These inequities can be addressed by making sure equity is prioritized in upcoming contract negotiations between the state and Medi-Cal managed care plans, based on the conclusions of our multi-year project, Centering Equity in Health Care Delivery and Payment Reform: A Guide for California Policymakers. 

The project was informed by focus groups which we held across the state with Black, Latinx, Asian and Pacific Islander, American Indian/Alaska Native, LGBTQ+ and persons with disabilities. Among the findings, participants reported facing stigma and discrimination, a lack of community centered care, and barriers to accessing quality interpreter services. 

As COVID-19 has ravaged our state, conversation and attention has turned to the stark health inequities that have existed for generations, and now exacerbated by the pandemic. We propose six bold, urgent, multi-sector strategies for achieving health equity and addressing the needs of those most impacted by the current pandemic:

  1. Center equity in quality and payment reform: If we want to achieve results, we must pay for health care differently. In other words, our dollars must be specifically tied to the attainment of health equity goals. There is broad agreement that health care should focus on value, not on volume. Yet, a 2019 report by the California Health Care Foundation showed that the quality of care delivered by Medi-Cal health plans has remained stagnant, often falling short of value indicators. 
  1. Engage patients, families and caregivers: Health care operates as a hierarchy, with consumers at the bottom of the food chain. If we are to eliminate racial inequities, we must flip this. Consumers need real decision-making power within health systems. Community health centers, for example, are run by boards of directors that are comprised of a majority of patients.
  1. Strengthen culturally and linguistically appropriate care: Not all health care can or should happen in a doctor’s office. Embracing a broader understanding of health care, including how communities might prefer to receive it, is essential. The evolution of health care prioritized what works for payers and providers over what works for consumers. People of color should have more opportunity to participate in the health care workforce and should be able to find providers from our communities. 
  1. Improve and integrate physical, behavioral and oral health care: Despite an understanding of the importance of mental health care, it remains nearly impossible for many low-income consumers to find accessible, relevant mental health care in California. This is true too of substance use disorder treatment and dental care. Not only are these delivery systems often separate from health care, they are riddled by problems such as narrow networks, improperly applied limitations and barriers, and a lack of consumer outreach and education. 
  1. Hold health plans and systems accountable: California is in the beginning stages of the first re-procurement for Medi-Cal health plans. At the start of ACA implementation, health plans walked away with eye-popping profits while they continued to score below average on quality care. Commercial plans, like Anthem and Health Net, will need to bid for new contracts with the state. This is a tremendous opportunity for California to shift the paradigm and truly embrace health equity by leveraging our power as a purchaser and regulator. 
  1. Improve the social determinants of health: It is indisputable that health care quality impacts our health. However, social conditions – housing affordability, environment and climate change, access to healthy food, etc. – can have an even greater impact on our health. We can and should address both. 

Equity requires a fundamental redistribution of power and resources. We cannot achieve equity without shifting power from those who have it today to those who are most impacted. California elected officials, policy makers, health system administrators and insurers all have a role to play if we are to build a more equitable present and future.


Kiran has also written about how COVID-19 has shown that California must fix inequities in health care for communities of color.

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