In 2013, California regulators fined the insurer $4 million for failing to reduce wait times, giving patients inaccurate information, and improperly tracking appointment data. And in 2023, KP agreed to pay $50 million, the largest penalty ever levied by the state’s Department of Managed Health Care, for failing to provide timely care, maintain a sufficient number of mental health providers, and oversee its providers effectively.

Now, Kaiser Permanente is back in the hot seat as mental health workers in Southern California wage a strike that’s in its fourth month. KP therapists and union representatives accuse the HMO giant of saddling workers with excessive caseloads and often forcing patients to wait twice as long as the state allows for follow-up appointments. They say that the staff is burned out and that this work environment makes it hard to recruit clinicians, exacerbating the staffing problem.

KP rebuffs these claims, saying the union is parading out old problems, seeking to create “an inaccurate and outdated perception” of KP’s care. They say the union’s pay demands are “in direct contrast to our commitment to providing quality, affordable care.”

Kaiser Permanente — the largest commercial health plan in California, with about 9 million members — is far from alone in struggling to provide adequate mental health care. A pandemic-induced shortage of health care workers has created obstacles for all health plans in recent years, on top of a preexisting scarcity. Moreover, many therapists decline to contract with insurers. And lingering bias in the health care system against mental health services — and patients — may also be at play.

Federal and state laws require health plans to provide mental health care on par with medical care. But many people who have sought therapy can vouch that those measures, known as mental health parity laws, do not seem to be followed consistently. You can spend hours or even days calling every therapist allegedly in your insurance company’s network and come away empty-handed.

Secret-shopper surveys of 4,300 randomly selected outpatient providers listed as accepting new patients showed that “an alarming proportion” of them were unresponsive or unreachable, according to a federal government report issued last month. And while that was true for medical providers, it was consistently worse for mental health and substance abuse care, according to the report.

In California, state regulators have been conducting behavioral health care investigations of the insurance companies they regulate to help identify the extent and causes of delays in care.

So far, the DMHC has investigated nine health plans (not including KP) and found dozens of violations related to appointment availability, timely access, quality of care, and patient appeals, department spokesperson Rachel Arrezola says. The agency also has identified numerous “barriers” that do not necessarily break the law but may make it more difficult for patients to get care, she says.

Mark Peterson, a professor at UCLA’s Luskin School of Public Affairs, notes that the open-ended nature of therapy can conflict with health plans’ focus on their bottom lines. “It may be once a week, it may be more than once a week and go on for years,” Peterson says.

For insurers, he says, the question is, “How do you put an appropriate limit on that?”

And the unwillingness of many therapists to accept insurance companies’ payment rates, or to abide by their restrictions, often leads them to decline participation in health plan networks and charge higher rates. That, Peterson says, makes therapy financially inaccessible for a lot of people seeking it.

Even if you have some coverage for therapy outside your health plan network, your insurer will pay only a percentage of the rate that it recognizes as legitimate. “If your therapist is charging $300 an hour, and your insurance company only recognizes $150 an hour, and they only pay 50% of what they recognize, now you’ve got a quarter coverage of your therapy,” Peterson says.

Since Kaiser Permanente is a closed system and patients don’t get reimbursed for care outside the network, access problems for its patients can be “highly pronounced,” Peterson adds.

In California, KP has accounted for over $54 million of the $55.7 million in mental-health-related fines the DMHC has levied on insurers in the past two decades. That includes the $50 million fine imposed in 2023, which was part of a settlement in which KP agreed to fix deficiencies the department found and to invest an additional $150 million in projects intended to enhance access to mental health care, not just for KP members, around California.

Officials at the National Union of Healthcare Workers, which represents some 2,400 KP mental health workers in the ongoing Southern California contract talks, say the HMO could easily invest enough to become a paragon of high-quality mental health care if it wanted to.

Greg Tegenkamp, the lead union negotiator, says KP could “lead the way to do the right thing.”

Kaiser Permanente says it already is doing the right thing, even as it acknowledges past shortcomings. In a recent statement, it said it has invested over $1 billion in new treatment spaces and more mental health providers since 2020.

“We’ve grown our workforce and increased our network of skilled therapists so that any Kaiser Permanente member who needs an appointment is able to get timely, high-quality, clinically appropriate care,” the company says.

In addition to higher wages and lower patient loads, workers want more time to complete follow-up tasks outside sessions and the reinstatement of a pension that was eliminated for those hired in Southern California after 2014.

Kaiser Permanente says that it already pays its mental health workers in Southern California about 18% above the market rate and that the current proposal would raise pay even more. KP recently raised its proposed wage increase by a modest amount, according to union officials.

KP refutes reports from workers about long wait times for patients seeking mental health appointments. It says the average wait time is 48 hours for urgent appointments and six business days for nonurgent ones, “which is better than the state’s requirement” of no more than 10 days.

But workers say KP patients still face long delays for follow-up appointments.

“It’s really hard for our patients to get regular, frequent appointments,” says Kassaundra Gutierrez-Thompson, a KP therapist in Southern California who is on strike. Gutierrez-Thompson says she’s seen it from both sides, since she is also a patient who sees a KP psychiatrist for depression and recently faced a big rescheduling delay after one of her appointments was canceled without notice.

As a provider, Gutierrez-Thompson says, she and her colleagues are expected to see patients “back-to-back-to-back.” She says some of her colleagues developed urinary tract infections when they couldn’t get to the bathroom. One even started wearing adult diapers, she says.

“The working conditions are like a factory,” Gutierrez-Thompson says. “We do such human work, but they would love for us to be robots with no needs and just see patients all day.”

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As California wildfires stretch into the colder months and hurricane survivors sort through the ruins left by floodwaters, let’s talk about an underreported victim of climate change: the emotional well-being of young people.

A nascent but growing body of research shows that a large proportion of adolescents and young adults, in the United States and abroad, feel anxious and worried about the impact of an unstable climate in their lives today and in the future.

Abby Rafeek, 14, is disquieted by the ravages of climate change, both near her home and far away. “It’s definitely affecting my life, because it’s causing stress thinking about the future and how, if we’re not addressing the problem now as a society, our planet is going to get worse,” says Abby, a high school student who lives in Gardena, California, a city of 58,000 about 15 miles south of downtown Los Angeles.

She says wildfires are a particular worry for her. “That’s closer to where I live, so it’s a bigger problem for me personally, and it also causes a lot of damage to the surrounding areas,” she says. “And also, the air gets messed up.”

In April, Abby took a survey on climate change for kids ages 12-17 during a visit to the emergency room at Children’s Hospital of Orange County.

Rammy Assaf, a pediatric emergency physician at the hospital, adapted the survey from one developed five years ago for adults. He administered his version last year to over 800 kids ages 12-17 and their caregivers. He says initial results show climate change is a serious cause of concern for the emotional security and well-being of young people.

Assaf has followed up with the kids to ask more open-ended questions, including whether they believe climate change will be solved in their lifetimes; how they feel when they read about extreme climate events; what they think about the future of the planet; and with whom they are able to discuss their concerns.

“When asked about their outlook for the future, the first words they will use are helpless, powerless, hopeless,” Assaf says. “These are very strong emotions.”

Assaf says he would like to see questions about climate change included in mental health screenings at pediatricians’ offices and in other settings where children get medical care. The American Academy of Pediatrics recommends that counseling on climate change be incorporated into the clinical practice of pediatricians and into medical school curriculums, but not with specific regard to mental health screening.

Assaf says anxiety about climate change intersects with the broader mental health crisis among youth, which has been marked by a rise in depression, loneliness, and suicide over the past decade, though there are recent signs it may be improving slightly.

A 2022 Harris Poll of 1,500 U.S. teenagers found that 89% of them regularly think about the environment, “with the majority feeling more worried than hopeful.” In addition, 69% said they feared they and their families would be affected by climate change in the near future. And 82% said they expected to have to make key life decisions — including where to live and whether to have children — based on the state of the environment.

And the impact is clearly not limited to the U.S. A 2021 survey of 10,000 16- to 25-year-olds across 10 countries found “59% were very or extremely worried and 84% were at least moderately worried” about climate change.

Susan Clayton, chair of the psychology department at the College of Wooster in Ohio, says climate change anxiety may be more pronounced among younger people than adults. “Older adults didn’t grow up being as aware of climate change or thinking about it very much, so there’s still a barrier to get over to accept it’s a real thing,” says Clayton, who co-created the adult climate change survey that Assaf adapted for younger people.

By contrast, “adolescents grew up with it as a real thing,” Clayton says. “Knowing you have the bulk of your life ahead of you gives you a very different view of what your life will be like.” She adds that younger people in particular feel betrayed by their government, which they don’t think is taking the problem seriously enough, and “this feeling of betrayal is associated with greater anxiety about the climate.”

Abby believes climate change is not being addressed with sufficient resolve. “I think if we figure out how to live on Mars and explore the deep sea, we could definitely figure out how to live here in a healthy environment,” she says.

If you are a parent whose children show signs of climate anxiety, you can help.

Louise Chawla, professor emerita in the environmental design program at the University of Colorado-Boulder, says the most important thing is to listen in an open-ended way. “Let there be space for kids to express their emotions. Just listen to them and let them know it’s safe to express these emotions,” says Chawla, who co-founded the nonprofit Growing Up Boulder, which works with the city’s schools to encourage kids to engage civically, including to help shape their local environment.

Chawla and others recommend family activities that reinforce a commitment to the environment. They can be as simple as walking or biking and participating in cleanup or recycling efforts. Also, encourage your children to join activities and advocacy efforts sponsored by environmental, civic, or religious organizations.

Working with others can help alleviate stress and feelings of powerlessness by reassuring kids they are not alone and that they can be proactive.

Worries about climate change should be seen as a learning opportunity that might even lead some kids to their life’s path, says Vickie Mays, professor of psychology and health policy at UCLA, who teaches a class on climate change and mental health — one of eight similar courses offered recently at UC campuses.

“We should get out of this habit of ‘everything’s a mental health problem,’” Mays says, “and understand that often a challenge, a stress, a worry can be turned into advocacy, activism, or a reach for new knowledge to change the situation.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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California, like other states, depends heavily on federal dollars to provide care for its poorest residents. Analyses at the time showed the GOP’s proposals would cut Medicaid funds flowing from Washington by tens of billions of dollars, perhaps even more, forcing state officials to rethink the scope of Medi-Cal.

But the GOP efforts ended in failure — iconically crystallized by Arizona Republican Sen. John McCain, sick with terminal brain cancer, issuing his decisive early-morning thumbs-down.

More than seven years later, here we go again.

With Donald Trump preparing to reenter the White House, bolstered once more by Republican majorities in both houses of Congress, expectations are high that the GOP will quickly resurrect its long-desired goal of cutting Medicaid.

Republicans want to finance large tax cuts, and the GOP platform under Trump pledges not to touch Social Security or Medicare. To be sure, that’s not set in stone. But for now, as my KFF colleagues have noted, Medicaid looks an awful lot like low-hanging fruit. (KFF is a health information nonprofit that includes KFF Health News.)

Health officials in California and across the nation are on edge about the possibility of large-scale Medicaid cuts being enacted as soon as next year. Such cuts would have an outsize impact in the Golden State, whose 14.7 million Medi-Cal enrollees exceed the entire populations of all but three other U.S. states. Medi-Cal provides health coverage for over 40% of the state’s children and pays for nearly 40% of births. It is a crucial source of funding for safety net hospitals and community clinics.

And over 60% of its $161 billion budget this year comes by way of Washington.

The potential for big federal cuts to Medicaid may have been a factor in Democratic Gov. Gavin Newsom’s decision to call a special session of the state legislature this week.

California could seek to offset a sharp drop in federal dollars with higher taxes or cuts to other state programs. But both those options could be politically untenable. That’s why many health experts think leaders in Sacramento would almost certainly have to consider shrinking Medi-Cal.

That could mean cutting any number of optional benefits, such as dental services, optometry, and physical therapy. It might also mean rolling back some of the ambitious expansion Medi-Cal has undertaken in recent years. That could include some aspects of California Advancing and Innovating Medi-Cal, a $12 billion program of services that address patients’ social and economic needs in addition to their medical ones.

Some observers fear federal cuts could affect the approximately 1.5 million immigrants living in the U.S. without authorization who are enrolled in Medi-Cal at an annual cost of over $6 billion, nearly all of it funded by the state. But others say a more likely route would be to reduce payments across the board to the managed care plans that cover 94% of Medi-Cal enrollees, rather than target any specific groups of people.

“Medicaid is on the chopping block, and I don’t think that’s speculation,” says Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research. “It is widely viewed by potential members of Trump’s administration as a program that is too broad and needs to be brought under control.”

Whether they can succeed this time remains to be seen. But more on that later.

People who have followed previous GOP efforts to downsize Medicaid say a variety of previously attempted methods might be back on the table this time. They could include outright caps on federal Medicaid dollars; elimination of the core Affordable Care Act policy under which the feds pay 90% of the cost of expanding coverage to a wider swath of low-income adults; a work requirement, which could depress enrollment; and rule changes intended to make it harder for states to draw federal Medicaid dollars through the use of taxes on health care insurers known as MCOs.

The first Trump administration proposed but later dropped changes to the rules governing such taxes. If similar changes were adopted this time around, they could cause financial headaches in California, which has frequently used MCO taxes to offset Medi-Cal spending from state coffers.

Proposition 35, recently passed by California voters, could also be at risk. The initiative calls for the MCO tax to become a permanent fixture in 2027, pending federal approval, with the goal of financing billions of dollars in new Medi-Cal spending, primarily to increase funding for doctors and other providers. A federal rule change could upend those intentions.

Termination of the federal government’s 90% coverage of the ACA Medicaid expansion would put a gaping hole in the Medi-Cal budget. Medi-Cal spent over $34 billion in fiscal year 2023 covering the roughly 5 million people who enrolled as a result of the expansion, and nearly $31 billion of that amount was paid by the federal government.

If the feds’ share dropped back to its regular Medi-Cal rate of 50%, California would have to pony up nearly $14 billion more to keep the expansion enrollees covered — and that’s just for a year.

A more ambitious GOP push, including both spending caps and a rollback of federal support for the Medicaid expansion, could really send California officials scrambling.

In 2017, the state’s Department of Health Care Services issued an analysis showing that a legislative proposal filed by a group of Republican U.S. senators to cap Medicaid spending and end enhanced funding for the ACA expansion, along with some other cuts, would result in nearly $139 billion of lost federal funding to California from 2020 to 2027.

“There are almost limitless changes state leaders could make to Medi-Cal if they are forced to do that,” says David Kane, a senior attorney at the Western Center on Law & Poverty. “And we fear that burden will almost certainly hurt poor people and immigrants the most.”

But big Medicaid cuts are not a foregone conclusion. After all, when Trump was in the White House in 2017, Republicans also had House and Senate majorities and still did not achieve their goal. The political stars could be aligning differently this time, but the GOP has only a razor-thin majority in the House.

A decade into the ACA’s Medicaid expansion, some 21 million people across the country have coverage through it, embedding the program more deeply in the nation’s health care landscape. According to a 2023 study from Georgetown University, Medicaid and the related Children’s Health Insurance Program cover a higher proportion of the population in rural counties than in urban ones. And as we know, rural America leans strongly Republican.

Will GOP members of Congress, faced with a vote on cutting Medicaid, buck their own constituents?

Edwin Park, one of the authors of that Georgetown study, thinks there’s a chance big cuts can be averted. “Large numbers of Americans are either on Medicaid, have family members on Medicaid, or know somebody on Medicaid,” says Park, a research professor at Georgetown’s McCourt School of Public Policy. “Hopefully its popularity and its importance will win the day.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is 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. Learn more about KFF.

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The Yes on Prop 35 campaign has raised over $48 million as of Sept. 9, according to campaign filings with the secretary of state. The measure would use money from a tax on managed-care health plans mainly to hike the pay of physicians, hospitals, community clinics, and other providers in Medi-Cal, the state’s version of Medicaid.

For many months, there was no organized opposition. But shortly after Labor Day, a small group of community advocates, including the League of Women Voters of California, California Pan-Ethnic Health Network, and The Children’s Partnership, announced they were united against it.

“We do not have the deep pockets that the proponents of the initiative do,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. No fundraising has been recorded from opposition groups thus far.

Gov. Gavin Newsom hasn’t taken a public stance, but he has warned that the proposal to lock in how proceeds from the managed-care tax are used would hamstring his administration’s ability to address the state’s yawning budget gap.

The people represented by some of the opposition groups include Medi-Cal patients who are among the state’s most vulnerable — children, seniors, people with disabilities, and the chronically ill — as well as some workers who provide ancillary care to them.

The opponents say that if Proposition 35 passes, the patients, workers, and programs they care about could lose millions of dollars included for them in this year’s state budget. That’s because the ballot measure would supersede the budget, and it leaves them out of the health tax proceeds.

The budget currently provides tens of millions of dollars a year to raise the pay of community health workers, nonemergency medical transport drivers, and private-duty nurses, among other personnel. It also funds the cost of a new program, scheduled to start Jan. 1, that allows children through age 4 to stay on Medi-Cal without requiring their families to prove eligibility every year. Child health advocates say that will help avoid potentially harmful gaps in coverage.

Mayra Alvarez, president of The Children’s Partnership, estimates the program would bring coverage stability to about 1.2 million California kids. But funding for it will be at risk if Proposition 35 passes, she warns.

It’s not that the money for that program, or the pay increases for ancillary health care workers, would necessarily go away forever. But advocates would have to fight for it in subsequent budget rounds.

Dustin Corcoran, CEO of the California Medical Association, told me that in addition to the Medi-Cal pay hikes, and some funding for medical education and extra residency slots, the initiative would provide $2 billion a year in 2025 and 2026 to the state’s general fund, “which the legislature can appropriate as they see fit, which vastly exceeds the cost of the programs you mentioned.” CMA and Planned Parenthood Affiliates of California are leading the charge on Proposition 35.

Corcoran’s comments suggest that the groups worried about losing funding if Proposition 35 passes should be able to get it restored in future budgets. Given the current fiscal crisis, however, not everyone is buying it.

“We’re short tens of billions of dollars,” says Ramon Castellblanch, vice president of the California Alliance for Retired Americans, which opposes the measure. “For these people to say, ‘Wait, the general fund is going to cover it’ — is that called gaslighting?”

Proposition 35 proponents say that children, seniors, and disabled or chronically ill people also use doctors, hospitals, and community clinics, for which the measure does provide extra money.

They argue the initiative will go a long way toward addressing Medi-Cal’s historically low pay rates, enticing more providers to participate in the program and enabling those who already do to take more Medi-Cal patients.

“This will be the most significant investment in the Medi-Cal system since the Affordable Care Act,” Corcoran says. “I think it holds great promise for improved access to care, improved quality of care, shorter wait times for all Californians in our ERs, and elimination of health care deserts that are popping up in too many parts of our state.”

Another concern raised by Proposition 35 skeptics is that a long-threatened change in federal rules governing how states collect managed-care taxes to fund Medicaid could torpedo the plans of California — and some of the other 18 states with such a tax.

Proposition 35 sets specific dollar amounts through 2026, which are based on the managed-care tax approved by the federal government last year. But the tax, which California has had in some form since 2009, must be renewed and federally approved every three years. That means that the tax requires another federal approval starting in 2027, the year the ballot measure would make funding permanent.

California’s managed-care tax comes from a levy imposed on health plans, based on monthly numbers of both Medi-Cal and commercial insurance enrollees. The money raised is matched by the federal government, doubling the spending power.

Federal rules require that the health plans be reimbursed for the tax they pay on their Medi-Cal membership. Since the Medi-Cal rate is around 100 times as much as the rate on commercial membership, 99% of the revenue from the tax is on the Medi-Cal side, thus holding many of the health plans almost entirely harmless and minimizing any impact on premiums.

But the federal government has been warning California for years, most recently in a letter it sent in late 2023 accompanying its approval of the managed-care tax, that it will require more balance between the commercial and Medi-Cal levies. Were it to change the rules in that direction, it could cause a major headache in California for a couple of reasons.

First, as proponents of Proposition 35 readily acknowledge, there is no political appetite for an increase in the amount of tax raised on commercial health plan memberships. That’s because it would likely lead to a rebellion by health plans or a jump in premiums that would anger employers, privately insured individuals, and plenty of other people. In that case, the only way to comply would be to lower the tax rate on Medi-Cal enrollment, which would significantly reduce revenue.

Second, though the ballot measure contains flexibility for small changes, it requires a three-fourths majority vote in the legislature for any major changes. That would be a tall order.

“Say the federal administration comes back and says, ‘You can’t do this anymore,’ which seems likely,” says Savage-Sangwan, who is also a spokesperson for the opposing coalition. “We’re going to be stuck with a whole lot less money.”

So far, however, the feds have not followed through on repeated warnings, and Proposition 35 proponents seem to be betting the threat of changes will prove nothing more than bluster.

We’ll see.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is 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. Learn more about KFF.

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The goal of the agency, established in 2022, is to make care more affordable and accessible while improving health outcomes, especially for the most disadvantaged state residents. That will require a sustained wrestling match with a sprawling, often dysfunctional health system and powerful industry players who have lots of experience fighting one another and the state.

Can the new agency get insurers, hospitals, and medical groups to collaborate on containing costs even as they jockey for position in the state’s $405 billion health care economy? Can the system be transformed so that financial rewards are tied more to providing quality care than to charging, often exorbitantly, for a seemingly limitless number of services and procedures?

The jury is out, and it could be for many years.

California is the ninth state — after Connecticut, Delaware, Massachusetts, Nevada, New Jersey, Oregon, Rhode Island, and Washington — to set annual health spending targets.

Massachusetts, which started annual spending targets in 2013, was the first state to do so. It’s the only one old enough to have a substantial pre-pandemic track record, and its results are mixed: The annual health spending increases were below the target in three of the first five years and dropped beneath the national average. But more recently, health spending has greatly increased.

In 2022, growth in health care expenditures exceeded Massachusetts’ target by a wide margin. The Health Policy Commission, the state agency established to oversee the spending control efforts, warned that “there are many alarming trends which, if unaddressed, will result in a health care system that is unaffordable.”

Neighboring Rhode Island, despite a preexisting policy of limiting hospital price increases, exceeded its overall health care spending growth target in 2019, the year it took effect. In 2020 and 2021, spending was largely skewed by the pandemic. In 2022, the spending increase came in at half the state’s target rate. Connecticut and Delaware, by contrast, both overshot their 2022 targets.

It’s all a work in progress, and California’s agency will, to some extent, be playing it by ear in the face of state policies and demographic realities that require more spending on health care.

And it will inevitably face pushback from the industry as it confronts unreasonably high prices, unnecessary medical treatments, overuse of high-cost care, administrative waste, and the inflationary concentration of a growing number of hospitals in a small number of hands.

“If you’re telling an industry we need to slow down spending growth, you’re telling them we need to slow down your revenue growth,” says Michael Bailit, president of Bailit Health, a Massachusetts-based consulting group, who has consulted for various states, including California. “And maybe that’s going to be heard as ‘we have to restrain your margins.’ These are very difficult conversations.”

Some of California’s most significant health care sectors have voiced disagreement with the fledgling affordability agency, even as they avoid overtly opposing its goals.

In April, when the affordability office was considering an annual per capita spending growth target of 3%, the California Hospital Association sent it a letter saying hospitals “stand ready to work with” the agency. But the proposed number was far too low, the association argued, because it failed to account for California’s aging population, new investments in Medi-Cal, and other cost pressures.

The hospital group suggested a spending increase target averaging 5.3% over five years, 2025-29. That’s slightly higher than the 5.2% average annual increase in per capita health spending over the five years from 2015 to 2020.

Five days after the hospital association sent its letter, the affordability board approved a slightly less aggressive target that starts at 3.5% in 2025 and drops to 3% by 2029. Carmela Coyle, the association’s chief executive, said in a statement that the board’s decision still failed to account for an aging population, the growing need for mental health and addiction treatment, and a labor shortage.

The California Medical Association, which represents the state’s doctors, expressed similar concerns. The new phased-in target, it said, was “less unreasonable” than the original plan, but the group would “continue to advocate against an artificially low spending target that will have real-life negative impacts on patient access and quality of care.”

But let’s give the state some credit here. The mission on which it is embarking is very ambitious, and it’s hard to argue with the motivation behind it: to interject some financial reason and provide relief for millions of Californians who forgo needed medical care or nix other important household expenses to afford it.

Sushmita Morris, a 38-year-old Pasadena resident, was shocked by a bill she received for an outpatient procedure last July at the University of Southern California’s Keck Hospital, following a miscarriage. The procedure lasted all of 30 minutes, Morris says, and when she received a bill from the doctor for slightly over $700, she paid it. But then a bill from the hospital arrived, totaling nearly $9,000, and her share was over $4,600.

Morris called the Keck billing office multiple times asking for an itemization of the charges but got nowhere. “I got a robotic answer, ‘You have a high-deductible plan,’” she says. “But I should still receive a bill within reason for what was done.” She has refused to pay that bill and expects to hear soon from a collection agency.

The road to more affordable health care will be long and chock-full of big challenges and unforeseen events that could alter the landscape and require considerable flexibility.

Some flexibility is built in. For one thing, the state cap on spending increases may not apply to health care institutions, industry segments, or geographic regions that can show their circumstances justify higher spending — for example, older, sicker patients or sharp increases in the cost of labor.

For those that exceed the limit without such justification, the first step will be a performance improvement plan. If that doesn’t work, at some point — yet to be determined — the affordability office can levy financial penalties up to the full amount by which an organization exceeds the target. But that is unlikely to happen until at least 2030, given the time lag of data collection, followed by conversations with those who exceed the target, and potential improvement plans.

In California, officials, consumer advocates, and health care experts say engagement among all the players, informed by robust and institution-specific data on cost trends, will yield greater transparency and, ultimately, accountability.

Richard Kronick, a public health professor at the University of California-San Diego and a member of the affordability board, notes there is scant public data about cost trends at specific health care institutions. However, “we will know that in the future,” he says, “and I think that knowing it and having that information in the public will put some pressure on those organizations.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is 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. Learn more about KFF.

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“The guy was up there screaming and squirming. Then the cab caught on fire,” Trammell says. “I couldn’t move him. He burned to death right there in my arms.”

Memories of that gruesome death and other traumatic incidents he had witnessed as a firefighter in Mountain View, California, didn’t seem to bother Trammell for the first seven years after he retired in 2015. But then he started crying a lot, drinking heavily, and losing sleep. At first, he didn’t understand why, but he would later come to suspect he was suffering from post-traumatic stress disorder.

After therapy failed to improve his mental well-being, he heard about the potential benefits of psychedelic drugs to help first responders with PTSD.

Last July, Trammell went on a retreat in Puerto Vallarta, Mexico, organized by The S.I.R.E.N. Project, a nonprofit that advocates the use of psychedelics and other alternative medicines to help first responders. He took psilocybin mushrooms and, the next day, another psychedelic derived from the toxic secretions of the Sonoran Desert toad. The experience, he says, produced an existential shift in the way he thinks of the terrible things he saw as a firefighter.

“All that trauma and all that crap I saw and dealt with, it’s all very temporary and everything goes back into the universe as energy,” Trammell says.

Abundant research has shown that psychedelics have the potential to produce lasting relief from depression, anxiety, PTSD, addiction, and other mental health conditions. Many universities around the United States have programs researching psychedelics. But experts warn that these powerful drugs are not for everybody, especially those with a history of psychosis or cardiovascular problems.

Most psychedelic drugs are prohibited under federal law, but California may soon join a growing number of local and state governments allowing their use.

A bill working its way through the California Legislature, would allow the therapeutic use of psilocybin; mescaline; MDMA, the active ingredient in ecstasy; and dimethyltryptamine, the active ingredient in ayahuasca, a plant-based psychoactive tea. The drugs could be purchased and ingested in approved locations under the supervision of facilitators, who would undergo training and be licensed by a new state board. The facilitators would need a professional health credential to qualify.

The bill, co-sponsored by Sen. Scott Wiener (D-San Francisco), Assembly member Marie Waldron (R-San Diego), and several other lawmakers, follows last year’s unsuccessful effort to decriminalize certain psychedelics for personal use. Gov. Gavin Newsom, a Democrat, vetoed that bill, though he extolled psychedelics as “an exciting frontier” and asked for new legislation with “regulated treatment guidelines.”

Wiener says the new bill was drafted with Newsom’s request in mind. It is supported by some veterans and first responder groups and opposed by numerous law enforcement agencies.

One potential roadblock is the state’s budget deficit, pegged at between $38 billion and $73 billion. Newsom and legislative leaders may choose not to launch a new initiative when they are cutting existing programs. “That is something we’ll certainly grapple with,” Wiener says.

The legislation, which is making its way through committees, would require the new board to begin accepting facilitator license applications in April 2026. The system would look somewhat like the one in Oregon, which allows the use of psilocybin mushrooms under the guidance of state-licensed facilitators at psilocybin service centers. And like Oregon, California would not allow for the personal use or possession of psychedelics; the drugs would have to be purchased and consumed at the authorized locations.

Colorado, following the passage of a ballot initiative in 2022, is creating a system of regulated “healing centers,” where people will be able to legally consume psilocybin mushrooms and some other psychedelics under the supervision of licensed facilitators. Colorado’s law allows for the personal use and possession of a handful of psychedelics.

In California, the cities of Oakland, San Francisco, Berkeley, Santa Cruz, and Arcata have effectively decriminalized many psychedelics, as have other cities around the United States, including Ann Arbor, Michigan; Cambridge, Massachusetts; Detroit; Minneapolis; Seattle; and Washington, D.C.

Psychedelics such as psilocybin, ayahuasca, and peyote have been used for thousands of years by Indigenous populations in Latin America and the current-day United States. And some non-Indigenous groups use these substances in a spiritual way.

The Church of Ambrosia, with locations in San Francisco and Oakland, considers psilocybin mushrooms, also known as magic mushrooms, a sacrament. “Mushrooms affect the border between this world and the next, and allow people to connect to their soul,” says Dave Hodges, founder and pastor of the church.

Hodges was behind an unsuccessful attempt to get an initiative on the California ballot this year that would have decriminalized the possession and use of mushrooms. He hopes it will qualify for the 2026 ballot.

The pending California legislation is rooted in studies showing psychedelics can be powerful agents in mental health treatment.

Charles Grob, a psychiatry professor at the University of California-Los Angeles School of Medicine who has researched psychedelics for nearly 40 years, led a study that found synthetic psilocybin could help reduce end-of-life anxiety in patients with advanced-stage cancer.

Grob says MDMA is good for couples counseling because it facilitates communication and puts people in touch with their feelings. And he conducted research in Brazil that showed ayahuasca used in a religious context helped people overcome alcoholism.

But Grob warns that the unsupervised use of psychedelics can be dangerous and says people should undergo mental and medical health screenings before ingesting them. “There are cases of people going off the rails. It’s a small minority, but it can happen, and when it does happen it can be very frightening,” Grob says.

Ken Finn, past president of the American Board of Pain Medicine, says that psychedelics have a number of side effects, including elevated blood pressure, high heart rate, and vomiting, and that they can trigger “persistent psychosis” in a small minority of users. Legal drugs also pose risks, he says, “but we have much better guardrails on things like prescriptions and over-the-counter medications.” He also worries about product contamination and says manufacturers would need to be tightly regulated.

Another potential problem is health equity. Since insurance would not cover these sessions, at least initially, they would likely attract people with disposable income. A supervised psilocybin journey in Oregon, for example, can cost more than $2,500.

Many people who have experienced psychedelics corroborate the research results. Ben Kramer, a former Marine who served in Afghanistan and now works as a psilocybin facilitator in Beaverton, Oregon, says a high-dose mushroom session altered his worldview.

“I relived the first time I was ever shot at in Afghanistan,” he says. “I was there. I had this overwhelming love and compassion for the guy who was shooting at me, who was fighting for what he believed in, just like I was.”

Another characteristic of psychedelic therapy is that just a few sessions can potentially produce lasting results.

Trammell, the retired firefighter, hasn’t taken psychedelics since that retreat in Mexico 10 months ago. “I just felt like I kind of got what I needed,” he says. “I’ve been fine ever since.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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Until Jan. 1, 3 million Medi-Cal beneficiaries, mainly those who are aged, blind, disabled, in long-term care, or in the federal Supplemental Security Income program, faced limits on the value of financial accounts and personal property they could hold to qualify for coverage. Now, nearly 2 million of them will no longer face these restrictions, putting them on par with the roughly 12 million other Medi-Cal beneficiaries who don’t have asset limits.

They still must be below Medi-Cal’s income threshold, which for most enrollees is currently $1,677 a month for a single adult and $3,450 for a family of four. However, the change will eliminate a lot of paperwork for applicants and the county workers who verify their eligibility.

For a long time, this group of Medi-Cal beneficiaries could have no more than $2,000 in the bank — $3,000 for a married couple — though the home they lived in, as well as one car and certain types of other personal property, were exempt.

“If you had $5,000 in assets, you would have to spend $3,000 on something to prove that you were beneath the limit to qualify,” says Tiffany Huyenh-Cho, a senior attorney at the advocacy group Justice in Aging. “We had people who prepaid rent, spent money on car repairs, bought a new couch or appliances — things to reduce their assets in order to get to the $2,000 limit.”

Now, Huyenh-Cho adds, “you don’t have to remain in deep poverty. You can save for an emergency; you can save for retirement or for a security deposit if you want to move.”

And those who have hoped to leave a little something for their children when they die can now do so, even if they need expensive long-term care.

The first phase of the rule change was implemented in July 2022, when the threshold was raised dramatically to $130,000 for an individual and $195,000 for a two-person household, making it a nonfactor for the vast majority of those concerned. After all, most people with incomes low enough to qualify for Medi-Cal would not have that much saved. For this reason, the total elimination of the so-called asset test ushered in this year is expected to help fewer people financially than the first change did.

Still, there are some people with more than $130,000 in the bank whose savings would have been wiped out in shockingly short order had they needed long-term care in a nursing facility or at home. Now, they can qualify to have Medi-Cal pick up that cost.

Joanne Shinozaki, a resident of Granada Hills, a Los Angeles neighborhood, hired private full-time caregiving last year for her mother, Fujiko, who has dementia. But it cost nearly $11,000 a month, which Shinozaki quickly realized would burn fast through the roughly $200,000 in savings her father had left when he died early last year. Reluctantly, she put her mom in a memory care home, which was less expensive. But after a 10% increase in January, it is now costing $9,000 a month, although that includes food and utilities.

Because of the money Shinozaki’s dad left, her mom did not qualify for Medi-Cal under the old rules. But now, that money no longer counts against her. Shinozaki, a veterinarian who quit her job to coordinate her mother’s care, needs to return to work soon. She has applied for Medi-Cal for her mom and is waiting for it to be approved.

“It would mean being able to bring her back to the house where she’s lived since 1988, if she’s well enough to come home,” Shinozaki says. To do that, she will need to get her mom access to caregivers via Medi-Cal’s In-Home Supportive Services program.

Indeed, another benefit of the change in eligibility rules is that it supports the caregiver economy, says Kim Selfon, a Medi-Cal and IHSS policy specialist at Bet Tzedek Legal Services, which provides free legal assistance to people in LA County.

Advocates who work with Medi-Cal enrollees and applicants say they often have to explain the difference between assets and income. “I think a lot of people are confused,” says Stephanie Fajuri, program director at the Center for Health Care Rights, an LA-based nonprofit that helps people navigate Medi-Cal and Medicare. “They say, ‘What do you mean? I could be making $1 million a year?’ And we say, ‘No, that’s income.’”

So, let’s be clear: Under the new rules, yes, you can have a second house. But if you are renting it out, that’s income — and given today’s rental prices, it will likely disqualify you from full Medi-Cal benefits. You can also keep an investment account regardless of the balance, but distributions from it as well as any interest, dividends, and capital gains it generates are also income.

Again, most beneficiaries are unlikely to have a large pool of assets and still have income low enough to qualify for Medi-Cal. But if you suddenly inherit a modest sum, or even a large one, now you can keep it, though it may briefly affect your coverage.

Unfortunately, the 1.1 million Medi-Cal beneficiaries receiving Supplemental Security Income are still subject to an asset test, because different rules apply to them.

Advocates and legal aid attorneys say there hasn’t been enough public education about the elimination of the asset limits and that many people still believe their bank accounts or personal property rule them out.

People may also fear the state will take their house and other assets after they die to recoup what it spent on their care. That worry could intensify now that people can keep all their assets and still be on Medi-Cal. But a 2017 change in the law restricted the state’s ability to put a claim on your house or other assets after you die and made it relatively easy to insulate them entirely.

The state can claim only up to the amount Medi-Cal spent on certain medical services, including long-term and intermediate care and related costs. Even in those cases, it cannot touch your home or any other asset if you have protected it by putting it in a living trust or through some other legal move that keeps it out of probate court. And the state can’t put a claim on it if there is a co-owner who outlives the Medi-Cal beneficiary.

“Now that people can hold unlimited assets, they need to be more cognizant of protecting them should they need long-term care,” says Dina Dimirjian, a staff attorney at Neighborhood Legal Services of Los Angeles County.

The Department of Health Care Services, which oversees Medi-Cal, has published on its website (dhcs.ca.gov) an FAQ on the elimination of the asset test. Another good source of information, and legal assistance, is the Health Consumer Alliance (healthconsumer.org or 888-804-3536).

The end of the asset test will also cure a big bureaucratic headache for beneficiaries and applicants and free up countless hours for Medi-Cal eligibility workers in county offices.

“People had to navigate this and figure out what counts and what doesn’t count, and they had to prove it, and the county had to verify it,” says David Kane, a senior attorney at the Western Center on Law & Poverty. “It’s a good thing we can say goodbye to it.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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A partir del 1 de enero, Medi-Cal implementará nuevos contratos estandarizados con sus 22 planes de salud gestionados, que cubren en total al 99% de los inscritos.

Los nuevos contratos refuerzan la aplicación de medidas de calidad, especialmente para mujeres y niños; y exigen que los planes de salud informen públicamente sobre el rendimiento de los proveedores médicos, ―y en algunos casos otras aseguradoras, en las que delegan atención―. También ordenan que los planes revelen la cantidad de inscritos que no tienen acceso a la atención primaria, y que inviertan más para cubrir esa brecha.

Además, comprometen a los planes a una mejor integración de la atención física y mental, y a una mayor capacidad de respuesta a las necesidades culturales y lingüísticas, la orientación sexual e identidad de género de los miembros.

Para cumplir con estas promesas, los reguladores estatales deberán ser más estrictos de lo que han sido hasta ahora. Pero eso podría ser difícil, ya que los cambios están ocurriendo al mismo tiempo que varias otras iniciativas que podrían competir por la atención del personal y confundir a algunos beneficiarios.

A partir del próximo año, más de 700,000 inmigrantes sin papeles serán elegibles para una cobertura completa de Medi-Cal. Además, se espera que aproximadamente 1.2 millones de beneficiarios en 21 condados deban cambiar de planes de salud después que el estado reorganizara el conjunto de aseguradoras el año pasado, y varios condados cambiaran la forma en que ofrecen Medi-Cal.

Algunos condados solo tendrán un plan. Donde haya más de uno, los inscritos que estén perdiendo su plan deberán elegir uno nuevo.

Kaiser Permanente, el gigante de la atención gestionada con sede en Oakland, comenzará un nuevo contrato directo con el estado en 32 condados, un gran cambio administrativo que no debería interrumpir la atención para la mayoría de los inscritos.

Y, por primera vez, se cambiará a miles de inscritos de Medi-Cal en cuidados residenciales a planes de atención gestionada, ya que el estado acelera su distanciamiento del Medi-Cal tradicional, de pago directo.

Todo esto ocurre en medio del llamado desmantelamiento de Medicaid (que comenzó cuando terminaron las protecciones de la pandemia), por el cual más de 900,000 personas han sido eliminadas de Medi-Cal hasta ahora, un proceso que, se espera,  continúe hasta el próximo verano.

“Mi cabeza está dando vueltas pensando en todo eso sucediendo al mismo tiempo”, dice John Baackes, CEO de L.A. Care Health Plan, el plan de Medi-Cal más grande del estado, con casi 2.6 millones de miembros. “Nuestro centro de llamadas está abarrotado”.

Tony Cava, vocero del Departamento de Servicios de Atención Médica (DHCS), que supervisa Medi-Cal, dijo que los nuevos contratos, firmados por todos los planes de atención gestionada de Medi-Cal, proporcionarán una “cobertura de calidad, equitativa y completa”, enfatizando en la prevención y “ofreciendo servicios que aborden las necesidades de atención a largo plazo a lo largo de la vida del miembro”.

Y en un acción innovadora, los nuevos contratos también requieren que los planes de salud reinviertan por primera vez una parte de sus ganancias, entre el 5% y el 7.5%, en las comunidades donde operan.

También ofrecen una serie de incentivos y penalizaciones, que incluyen retener un pequeño porcentaje de los pagos a los planes de salud con la posibilidad de que lo recuperen alcanzando objetivos de calidad y equidad en salud.

Y los planes de salud rentables que no cumplan con las expectativas deberán reinvertir un 7.5% adicional de sus ganancias en la comunidad. Todo esto se suma a las multas aumentadas que los reguladores pueden imponer a los planes de salud con bajo rendimiento.

Los nuevos contratos de Medi-Cal también consagran elementos clave de CalAIM, un experimento de $12 mil millones y cinco años, ya en marcha, en el que los planes de salud buscan proporcionar una variedad de servicios sociales para los miembros de Medi-Cal más necesitados, incluida asistencia para vivienda y comidas adaptadas médicamente, con el argumento de que la pobreza y las inequidades sociales relacionadas a menudo están en la raíz de los problemas de salud.

Hasta ahora, sin embargo, la implementación ha sido lenta.

Abbi Coursolle, abogada senior en la oficina de Los Ángeles del National Health Law Program, dijo que el requisito de que los planes informen públicamente sobre la atención proporcionada por sus proveedores médicos subcontratados debería aumentar la responsabilidad, ayudando a los inscritos a navegar mejor por Medi-Cal. “Esto es un avance en el que los defensores han estado prestando atención durante más de una década”, dice Coursolle. “Hay tanto ir y venir de la gente entre el plan de salud y el grupo de proveedores. Eso diluye tanto la responsabilidad”.

Otro gran cambio para Medi-Cal es la eliminación de la llamada prueba de límite de activos para un cierto grupo de inscritos, incluidas personas de edad avanzada, ciegas, con discapacidades, en atención a largo plazo o en Medicare.

Además de cumplir con los requisitos de ingresos, las personas han tenido que mantener el valor total de sus activos personales por debajo de ciertos umbrales para calificar para Medi-Cal. Los activos contados incluyen ahorros, ciertas inversiones, segundas viviendas e incluso segundos automóviles.

Hasta el año pasado, esos límites eran tan bajos, $2,000 para un individuo, que las personas prácticamente no tenían la capacidad de acumular ahorros si querían estar en Medi-Cal. A mediados de 2022, sin embargo, el límite se elevó a $130,000, lo que significó que para la mayoría de las personas sujetas a la prueba, los activos ya no eran una barrera para la elegibilidad.

En 2024, la prueba de activos se eliminará por completo.

Pero dado el cambio del año pasado, la eliminación total probablemente genere solo unos pocos miles de nuevos inscritos en Medi-Cal. Aún así, debería prevenir que las personas tengan la molestia burocrática de tener que demostrar que están por debajo de cierto umbral de activos.

Si quieres tener más información sobre la prueba de límite de activos, el DHCS tiene respuestas sobre el tema en su sitio web (dhcs.ca.gov).

Si te preguntas si estás entre los 1.2 millones de miembros de Medi-Cal que necesitan cambiar de plan de salud, y aún no has recibido una comunicación al respecto, el departamento tiene una herramienta en línea para informarte sobre los planes disponibles en tu condado a partir del 1 de enero.

Casi la mitad de las personas que necesitan cambiar de plan son miembros de Health Net en el condado de Los Ángeles que serán transferidos a Molina Healthcare como parte de un acuerdo de compromiso que el estado alcanzó el año pasado, para evitar enredarse en demandas de planes de salud enojados que perdieron en una competencia de licitación.

Si necesitas cambiar de plan y tienes suerte, tus médicos pueden estar en el nuevo plan. Asegúrate de verificar. Si no están, es posible que puedas mantenerlos por un año o el tiempo suficiente para completar un tratamiento que ya está en marcha.

El DHCS tiene una hoja informativa que describe tus derechos a tener esa continuidad. También puedes contactar a tu plan de salud actual para obtener información adicional o preguntar en la oficina de Medi-Cal de tu condado.

La Health Consumer Alliance (1-888 804 3536, o healthconsumer.org) es otra fuente de información y asistencia, al igual que el defensor del cuidado gestionado de Medi-Cal (1-888-452-8609, o MMCDOmbudsmanOffice@dhcs.ca.gov).

A pesar de las mejores intenciones del estado, la grave escasez de profesionales médicos podría ser un gran obstáculo.

“Mientras estas expansiones de la cobertura y estas innovaciones están ocurriendo, se está construyendo sobre una fuerza laboral de salud que ya está tensionada”, dijo Berenice Nuñez Constant, vicepresidenta senior de relaciones gubernamentales en AltaMed Health Services, uno de los grupos de clínicas comunitarias más grandes del estado.

Con escasez de personal o no, los planes de salud deben cumplir con sus obligaciones contractuales. Anthony Wright, director ejecutivo del grupo de defensa Health Access California, dijo: “A cierto nivel, se trata de hacer que los planes sean responsables de lo que prometen y de obtener decenas de miles de millones de dólares por ello”.

Este artículo fue producido por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation. 

KFF Health News is 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. Learn more about KFF.

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Starting Jan. 1, Medi-Cal, California’s Medicaid program, will implement new standardized contracts with its 22 managed care health plans, which collectively cover 99% of enrollees. The new contracts tighten enforcement of quality measures, especially for women and children; require the health plans to report publicly on the performance of medical providers ― and in some cases other insurers ― to whom they delegate care; and mandate that plans reveal the number of enrollees who don’t have access to primary care and invest more to plug the gap. They also commit plans to better integration of physical and mental health care and greater responsiveness to the cultural and linguistic needs, sexual orientation, and gender identity of members.

To realize these promises, state regulators will have to be tougher than they have been in the past.

But that might be difficult, because the changes are happening at the same time as a number of other initiatives that could compete for staff attention and confuse some enrollees.

Beginning next year, over 700,000 immigrants without permanent legal residency will become eligible for full Medi-Cal coverage. In addition, an estimated 1.2 million beneficiaries in 21 counties will need to change health plans after the state last year rejiggered the constellation of insurers and multiple counties switched the way they deliver Medi-Cal. Some counties will have only one plan left. Where there is more than one, enrollees who are losing their plan will have to choose a new one.

Kaiser Permanente, the Oakland-based managed care giant, will start a new direct contract with the state in 32 counties, largely an administrative shift that should not disrupt care for most enrollees. And thousands of Medi-Cal enrollees in residential care will be switched into managed care plans for the first time, as the state accelerates its move away from traditional, direct-pay Medi-Cal.

All of this is happening amid the so-called unwinding, in which over 900,000 people have been shed from Medi-Cal thus far, and disenrollments are expected to continue until next summer. The unwinding follows the termination of pandemic-era protections.

“My head is spinning thinking about all of that going on at the same time,” says John Baackes, CEO of L.A. Care Health Plan, the state’s largest Medi-Cal plan, with nearly 2.6 million members. “Our call center is stacked to the gills.”

Tony Cava, spokesperson for the Department of Health Care Services, which oversees Medi-Cal, says the new contracts, signed by all the Medi-Cal managed care plans, will provide for “quality, equitable, and comprehensive coverage,” emphasizing prevention and “offering services that address long-term care needs throughout a member’s life.”

And in a groundbreaking move, the new contracts also require health plans for the first time to reinvest a portion of their profits ― between 5% and 7.5% ― in the communities where they operate.

They also provide a number of carrots and sticks, which include withholding a small percentage of payments to health plans with a chance for them to earn it back by reaching quality and health equity benchmarks. And profitable health plans that don’t meet expectations will have to reinvest an additional 7.5% of their profits in the community. This is all on top of increased fines that regulators can levy on poorly performing health plans.

The new Medi-Cal contracts also enshrine key elements of CalAIM, a $12 billion, five-year experiment, already underway, in which health plans aim to provide a range of social services for the neediest Medi-Cal members, including housing assistance and medically tailored meals, on the grounds that poverty and related social inequities are often the root of health problems. So far, however, the rollout has been slow.

Abbi Coursolle, senior attorney in the Los Angeles office of the National Health Law Program, says the requirement for health plans to report publicly on the care provided by their subcontracted medical providers should increase accountability, helping enrollees better navigate Medi-Cal.

“This is a step forward that advocates have been paying attention to for over a decade,” Coursolle says. “There’s so much ping-ponging people back and forth between the health plan and the provider group. That dilutes accountability so much.”

Another big change for Medi-Cal is the elimination of the so-called asset limit test for a certain subset of enrollees, including people who are aged, blind, disabled, in long-term care, or on Medicare. In addition to meeting income requirements, people have had to keep the total value of their personal assets below certain thresholds to qualify for Medi-Cal. The assets that are counted include savings, certain investments, second homes, and even second cars.

Until last year, those limits were so low ― $2,000 for an individual ― that people had virtually no ability to accumulate savings if they wanted to be on Medi-Cal. In mid-2022, however, the limit was raised to $130,000, which meant that for the majority of people subject to the test, assets were no longer a barrier to eligibility. In 2024, the asset test will be eliminated altogether.

But given last year’s change, the total elimination will likely generate only a few thousand new Medi-Cal enrollees. Still, it should save people the bureaucratic headache of having to prove they’re below a certain asset threshold.

If you want to learn more about the asset limit test, the DHCS has an FAQ on the subject on its website (dhcs.ca.gov).

If you wonder whether you are among the 1.2 million Medi-Cal members who need to change health plans, and you haven’t already received communication on the subject, the department has an online tool to tell you the plans that will be available in your county as of Jan. 1.

Nearly half the people who need to switch plans are Health Net members in Los Angeles County who are being transferred to Molina Healthcare as part of a compromise agreement the state struck last year to avoid becoming mired in lawsuits by angry health plans that lost out in a bidding competition.

If you need to change plans and you’re lucky, your doctors may be in the new plan. Make sure to check. If they are not, you may be able keep them for up to a year or long enough to finish a course of treatment that is already underway. The DHCS provides a fact sheet outlining your rights to continuity. You can also contact your current health plan for additional information or ask your county Medi-Cal office. The Health Consumer Alliance (1-888‑804‑3536, or healthconsumer.org) is another source of information and assistance, as is Medi-Cal’s managed care ombudsman (1-888-452-8609, or MMCDOmbudsmanOffice@dhcs.ca.gov)

Despite the state’s best intentions, an acute shortage of medical professionals could be a big obstacle. “As these coverage expansions are happening, and as this innovation is happening, it is being built on a health workforce that is already strained,” says Berenice Nuñez Constant, senior vice president for government relations at AltaMed Health Services, one of the state’s largest community clinic groups.

Labor shortage or not, the health plans must deliver on their contractual obligations. Anthony Wright, executive director of the advocacy group Health Access California, says, “On some level, this is about holding the plans accountable for what they are promising and getting tens of billions of dollars for.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is 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. Learn more about KFF.

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La mujer de 48 años, que trabaja como gerente administrativa en una organización sin fines de lucro, puede recibir atención de emergencia por un paquete limitado de beneficios que el estado pone a disposición de los inmigrantes sin papeles.

También ha podido tener sus mamografías, radiografías y análisis de sangre en clínicas que cobran en base a los ingresos del paciente. Sin embargo, conseguir citas lleva mucho tiempo y a menudo están lejos de su casa. “Es muy frustrante, porque tienes que tener tiempo para ir, y no puedes simplemente perder un día de trabajo”, dijo Milagro, quien pidió que no se publicara su apellido por temor a las autoridades de inmigración.

Milagro y su esposo se encuentran entre los más de 700,000 inmigrantes de entre 26 y 49 años que se espera que califiquen para el seguro de salud completo a partir del 1 de enero.

Ese día, California dará el paso final para abrir Medi-Cal, el programa de atención médica del estado para residentes con bajos ingresos, a todos los que cumplan con los requisitos de elegibilidad, independientemente de su estatus migratorio.

Como he informado con frecuencia, obtener atención de calidad a través de Medi-Cal puede ser un desafío. Pero esta población —a menudo sostén económico del hogar que no puede permitirse enfermar— podría obtener un acceso mucho mejor a servicios como atención primaria y especializada, chequeos dentales de rutina, medicamentos recetados, atención hospitalaria, análisis, pruebas de imagen, y servicios de salud mental.

Los nuevos inscritos se sumarán a más de 655,000 niños, adultos jóvenes de hasta 25 años y adultos de 50 años y más que ya se han registrado en Medi-Cal a través de expansiones anteriores para residentes sin papeles, según los datos más recientes del Departamento de Servicios de Atención Médica del estado.  

Defensores de inmigrantes indican que las personas sin seguro médico generalmente están más enfermas y mueren más jóvenes. “Esto cambiará la vida de las personas que ahora podrán hacerse chequeos regulares, análisis, saber si pueden tener diabetes o hipertensión”, dijo Sarah Dar, directora de políticas en la oficina de Los Ángeles del California Immigrant Policy Center.

Milagro dice que está emocionada. “Nunca tuve chequeos regulares cuando era más joven”, dice. “Ahora, soy más consciente de que necesito cuidar de mi salud”.

Extender la cobertura completa de Medi-Cal a individuos elegibles de entre 26 y 49 años, independientemente de su estatus migratorio, se estima que costará al estado $1.4 mil millones en los primeros seis meses y $3.4 mil millones al año con la implementación completa.

La estimación del estado de poco más de 700,000 nuevos inscritos se basa en el número de personas en el grupo de edad que ya están registradas para un conjunto más pequeño de beneficios, conocidos como Medi-Cal de “alcance limitado”, una de ellas, Milagro. Este grupo se transferirá automáticamente al Medi-Cal completo el 1 de enero.

El estado ha comenzado a enviar avisos informándoles de los beneficios ampliados y dirigiéndolos a elegir un plan de salud de Medi-Cal, a menos que vivan en un condado que solo tenga un plan.

Será más difícil llegar a los inmigrantes restantes en el grupo de 26 a 49 años cubiertos por esta expansión, ya que el estado no sabe quiénes son, dónde están ni cuántos son. Defensores de pacientes, grupos comunitarios y oficinas de bienestar de los condados enfrentan varios obstáculos: barreras de idioma, desconfianza en las agencias gubernamentales y el temor de que inscribirse en beneficios públicos pueda poner en peligro las posibilidades de obtener la tarjeta de residencia (green card).

Un desafío es convencer a los inmigrantes de que estar en Medi-Cal es poco probable que afecte su futuro estatus migratorio bajo la llamada regla de carga pública.

Defensores señalan que California de todos modos no comparte la información de los inscritos con las autoridades federales de inmigración. Pero el fuerte sentimiento anti inmigrante que fue tan fuerte durante la administración Trump, y persiste mientras la nación se prepara para las elecciones de 2024, “envió un mensaje a estas comunidades de que deberían vivir en las sombras y de que no merecen beneficios”, explicó Dar.

Incluso será difícil encontrar a aquellos que ya están en la versión limitada de Medi-Cal si su información de contacto no está actualizada. Y podrían no ser incluso conscientes de que formaban parte de Medi-Cal. Si, por ejemplo, tuvieron una crisis de salud, los llevaron a la sala de emergencias y simplemente se les pidió que firmaran algunos documentos para cubrir su tratamiento, podrían no entender lo que significa recibir un correo de Medi-Cal.

Y algunos pueden temer cualquier contacto con el gobierno.

Lena Silver, directora de políticas y defensa administrativa en Neighborhood Legal Services of Los Angeles County, dijo que condujo una sesión de capacitación donde una mujer que trabaja con jornaleros dijo que muchos tenían miedo de abrir los sobres que habían recibido.

El Departamento de Servicios de Atención Médica está liderando una campaña de divulgación en 19 idiomas que incluye anuncios en radio, televisión y redes sociales.

Lo que potencialmente complica las cosas es el hecho de que la expansión de los beneficios de salud a este último (y más grande) grupo de inmigrantes coincide con la llamada cancelación de Medi-Cal, en la que más de 900,000 beneficiarios, hasta ahora, han sido eliminados del programa, principalmente debido a trámites incompletos, al expirar las exenciones por la pandemia.

Los inmigrantes con Medi-Cal limitado también deben demostrar que continúan siendo elegibles en base a sus ingresos, para evitar ser eliminados en el proceso de cancelación, lo que también puede resultar confuso cuando dicha solicitud se suma al aviso que les informa sobre sus nuevos beneficios recién ampliados.

Si tú mismo eres indocumentado, o un amigo o un ser querido, hay recursos disponibles para ayudar a navegar el proceso de inscripción en Medi-Cal. Una página en el sitio web del Departamento de Servicios de Atención Médica (dhcs.ca.gov) explica la expansión y tiene preguntas y respuestas frecuentes en varios idiomas detallando los nuevos beneficios.

Si necesitas ayuda para inscribirte en un plan de Medi-Cal o llenar formularios para demostrar tu elegibilidad, prueba con Health Consumer Alliance (healthconsumer.org o 1-888-804-3536).

Las clínicas comunitarias también son buenas fuentes, al igual que las oficinas de los condados que administran Medi-Cal.

Brenda, residente del condado de Los Ángeles de 33 años que también pidió que no se publicara su apellido porque no tiene papeles, dijo que será “una gran bendición” obtener beneficios completos de Medi-Cal.

Brenda llegó desde México cuando era niña y ha tenido que pagar la mayoría de sus necesidades de atención médica de su propio bolsillo. Rara vez va al médico, no ha visto a un dentista en tres años a pesar de los dolores de muelas, y ha usado los mismos anteojos por cinco años.

En enero, planea hacerse una prueba de detección de cáncer de mama y diabetes, que es frecuente en su familia. Y dijo: “definitivamente quiero arreglar mis dientes. Siempre he querido una sonrisa Colgate”.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KFF Health News is 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. Learn more about KFF.

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