Racism in My Experience Part 7
California Health Policies
I’ll start with health care, which I know best. California once had a large and extensive system of public hospitals, which cared for the poor regardless of income or citizenship status, and many local district hospitals (public entities with taxing authority) that cared for residents of the local hospital district. After the passage of Medicaid in 1965 and the state’s implementation, which covered many of California’s poor, public hospitals began to close – often then acquired by private hospitals. After the expansion of Medicaid to the working poor in the early 70s, many more public hospitals closed until by the early ’80s only about ten large counties still had them. The closure of public hospitals located in poor communities meant that the state’s uninsured lost their assured local access point to health care, to be discussed in greater detail later.
In 1982-3, California, then under the leadership of Governor Jerry Brown, eliminated Medicaid’s health coverage for the working poor (the Medically Indigent Adults or MIAs), exactly as Massachusetts had done 7 years before. I still do not understand why Assembly Speaker Willie Brown and esteemed Department of Health Services Director Beverlee Myers allowed that to happen or what their vision was. Yes, the state was in a steep recession causing a big budget deficit, but it was short and succeeded by rapid economic growth. This cut endured for the next thirty years, and it inflicted a lot of fully preventable pain on the poorest and most vulnerable Californians.
The state’s uninsured rate steadily shot up from about 3 million in ‘83 until over 7 million Californians were uninsured (up to 20% of residents under age 65) at the peak. Hispanics were disproportionately represented among the uninsured due to their over-representation in low wage jobs and in those sectors of the economy like agriculture or restaurants where employers typically did not offer coverage. Non Hispanic White and black Californians were uninsured at roughly equal rates.
At the same time, California also embraced “price competition through selective contracting” to slow the rise in the costs of medical care. Many private hospitals then exited the Medicaid program (higher percentages of Hispanics and African American) and focused their care and services on the more highly paid private sector patients (higher percentage of non-Hispanic whites). This led to a sharply delineated, three tier system of medicine for Californians. Tier 1 (the most expensive) for the privately insured, tier 2 (the most comprehensive) for the publicly insured, and tier 3 (primarily emergency care) for the uninsured, supplemented by local community clinics in those communities where they existed. Prior to California’s implementation of the ACA, tiers 2 and 3 were of roughly equivalent size – about 7 million each.
If you have any doubts about how segregated by race and class the health system has become and remains to this day in LA, I’d invite you to walk through the wards of St. Francis Hospital of Lynnwood and Martin Luther King Hospital in Willowbrook, and then go for a comparable walk through the wards of Cedars Sinai and UCLA Reagan (Westwood) and Santa Monica Hospitals. Then I’d suggest visiting MD Anderson Cancer Center in Houston to see what a hospital system integrated by class and race looks like.
California’s 58 counties are responsible under state law for health care to their uninsured indigent residents. However each county sets its own eligibility standard, and some very large counties like Orange and San Diego take the position that they are not responsible for their undocumented uninsured workers because they are not lawful residents. My consistent impression is that the hostility and racism in California has been far more severe towards Latino immigrant communities than towards African Americans; it is a toxic witch’s brew of race, language and nationalist xenophobia towards a hard working, low wage, exploited minority, that seems to be pretty deeply engrained. State funding for county health is not equitably distributed among the counties based on reasonable and transparent criteria such as their numbers of uninsured in poverty, but rather are based on antiquated distribution formulas dating from 1979 and 1982-3 respectively, they bear little relevance to the numbers and distribution of California’s uninsured today. The net effects of the lack of coverage and of the state’s financing disparities is to disadvantage some of the poorest counties with lots of uninsured Hispanic farmworkers like Tulare or Imperial; it also disadvantages health care for undocumented immigrant workers in the large, heavily populated Southern California counties without public hospitals (i.e. San Diego and Orange).
After the passage of the Affordable Care Act (Obamacare) in 2010, California, which had been trying to expand coverage for two and a half decades after the MIA dump, was well positioned and strongly financially incentivized to implement the ACA; it quickly and successfully did so under the leadership of the Schwarzenegger and Brown administrations. Public sector coverage expanded quite dramatically -- 5 million new eligibles in MediCal and up to 1.5 million newly enrolled in private individual (but publicly subsidized) coverage through Covered California. California’s uninsured numbers then fell precipitously (to less than 3 million uninsured Californians, about 7% of those under 65), and it demographically changed. About 60% of the remaining uninsured Californians are now undocumented as opposed to less than 20% prior to the ACA. After a long, 15-year struggle in the state legislature and with successive Democratic and Republican Governors, California has begun to cover some of the younger (children and young adults) undocumented uninsured in MediCal.
Since the early 80’s, California has been changing its delivery system from fee for service, reasonable cost reimbursement rates, open panel systems towards capitation, negotiated payment rates, and closed panel systems. That means less than nothing to most of you, but essentially it means moving from a traditional Medicare model with lots of choice of providers towards a Kaiser model with a much smaller and more tightly controlled panel of providers. The Kaiser delivery system is nimbler and more flexible, more coordinated and often more accountable for the care it delivers than the Medicare model is. However Kaiser’s large size often impedes its rapid change, and in California it has been supplemented with mixed success by public HMOs and by private HMOs from both the non-profit and for profit sectors. Some deliver excellent care, others not so much.
In the process of California’s implementation of delivery system reforms, California hospital systems ended up closing their unprofitable, less competitive hospitals or selling them to large for profit and non-profit hospital chains, which then closed the money losing wards and services (like ERs and trauma centers for a time). These closures happened most commonly for those smaller community and district hospitals based in low-income communities with a payer mix that includes high percentages of publicly insured or uninsured patients. Closures and sales to large non-profit and for profit hospital chains also have occurred in the state’s rural communities which don’t have enough providers to begin with and lack the high percentages of patients with well-reimbursed private employment based coverage that undergird the large profitable hospital systems in the cities and the suburbs. In essence our state’s delivery system reforms have been hollowing out our vital delivery systems to minorities living in inner city and rural California. If one looks at the data, we are developing health care system that is becoming ever more segregated by race and class without any explicit intent to do so.
California’s public hospitals have been facing immense evolutionary challenges as coverage expands and shifts towards better-coordinated delivery systems. Their historical model had been episodic and emergency room and inpatient centric care, and the new delivery system places a primacy on strong and effective primary care, strong outpatient delivery networks and on continuity of patient-physician care. When the state of California expanded coverage for prenatal care and deliveries in the late 80’s, public facilities lost their traditional roles in delivering babies for poor mothers to those private hospitals and doctors that offered more attractive and responsive maternity services in less crowded settings. Would public hospitals now close as so many of their previously uninsured and MediCal fee for service patients had moved into MediCal managed care coverage, or could they evolve sufficiently and quickly enough? To date, their important evolution has succeeded in keeping their doors open, their revenues flush, and their patients loyal.
Covid 19 poses a new threat to their viability, and to date the Trump Administration has shown little capacity or interest in assuring the public hospitals and other safety net providers are kept open, with the Congressional largesse of $150 billion going primarily to large for profit hospital chains and those delivery systems with healthy bottom lines, not to the hospitals and doctors struggling with enormous caseloads of Covid 19 patients and disproportionate deaths of black and Latino patients.
Health coverage in and of itself does not equal, although it does contribute towards, good health outcomes; those good and bad health outcomes vary widely by race and gender. For example Asian women in LA live on average to just short of 90 years of age; while African-American men in LA have a life expectancy of just over 72 years of age. https://usc.data.socrata.com/stories/s/Life-Expectancy-in-South-Los-Angeles/p3wg-4cc9/ Latinos live longer than do whites even though white incomes, wealth and education levels are far higher, probably due to the healthier lifestyles of new immigrants.
Farm workers in California’s Central Valley have had a life expectancy of only 49 years of age; many are undocumented Hispanics. https://farmworkerfamily.org/information and California Institute for Rural Studies, In Their Own Words, Farm Worker Access to Health Care in Four California Regions (2002). Agricultural workers and food processors are particularly at risk from Covid 19 due to crowded living conditions, hazardous working conditions, low incomes, and little access to medical care. https://insideclimatenews.org/news/03042020/covid-farmworkers-california-climate-change-agriculture. And it’s getting worse. https://abc7news.com/gavin-newsom-press-conference-today-coronavirus-in-california-covid-update-cases/6336809/
I first heard that statistic presented by UC Davis researchers; I remembered back to an oral argument I made before an appellate judge nearly 20 years earlier. We were challenging a Dukakis Administration policy limiting General Relief to individuals who were “unemployable” as evidenced by a medical finding, I was arguing for a broader definition of employability that included factors such as age, education, occupational status and training. The judge asked how old my client the plaintiff was and when I replied 50, he responded that wasn’t old after all he was 70 and rode horses early every morning. He was absolutely right for a distinguished jurist in excellent physical condition with a lifetime tenure on the state bench; he was wrong for a Spanish speaking woman of less than a sixth grade education who was worn down from working in the fields beginning at age 12. I wished that I had had that UC Davis study 20 years earlier to back me up; the judge might have better understood and been more receptive to my oral argument. That small recollection really goes to the heart of the difficulty that law makers and policy makers and jurists encounter in setting and deciding social policy for people of radically different ethnic, economic, educational, income, cultural and class backgrounds and the importance of diversity in all branches of government. There has been an effort to homogenize and Christianize the American experience, yet we have been diverse from our very beginnings.
What then happens for a population with entirely different and distinct mental abilities and capacities? The severely mentally ill (SMI) have far lower life expectancy than the general population – ranging from age 49 to age 6o depending on the state and its policies towards the mentally ill. https://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm They die of the very same diseases as the general population but at much more elevated rates and far sooner. https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2011/no-health-without-mental-health.shtml
For its publicly insured population, California unfortunately separates mental health from physical health and from addiction treatment, putting them into three different programs with different leadership. And it creates barriers to practitioners from the three tri-furcated programs from readily communicating with each other about their common patient’s care. This siloed approach is exactly the wrong way to help those with serious mental illness. Too many mentally ill end up in county jails, state prisons or shot by the police when an approach by a mental health crisis counselor and consistent care and treatment from mental health counselors would be the right solution. The state has embarked on pilot programs to coordinate and integrate these services into “whole person care” for some individuals with SMI; some pilots include law enforcement. https://www.aurrerahealth.com/publications/whole-person-care-mid-point-check-in/ The shift towards whole person care was moving too slowly to help people with multiple co-morbidities even before the arrival of Covid 19, which has now put anxiety levels for many into the stratosphere. Our public health systems have long languished, neglected by the more pressing needs; now we are paying a terrible price of that neglect in lives lost and economic suffering.
Latinos, African Americans and Asians are far less likely than white Americans to seek and receive help for severe mental illness or addictions, partly due to cultural reasons, but also due to serious access issues for minorities and the lack of culturally appropriate care. https://www.calhealthreport.org/2018/07/26/minorities-much-less-likely-access-mental-health-care-state-data-suggests As a result, they end up with far higher rates of untreated mental illness. https://www.samhsa.gov/sites/default/files/covid19-behavioral-health-disparities-black-latino-communities.pdf
When Covid 19 hit in Los Angeles and the Bay Area, it appeared first in the highest income neighborhoods (exposure through international tourism on cruise ships and international plane flights), then it ravaged the state’s nursing homes (devastating patients and staff in the lowest quality settings most severely) and then the essential workers in the food industry (it has hit field workers and those in food processing the hardest). Imperial County, one of the state’s poorest and most agricultural counties was among the worst hit. Central Valley farmworkers and food processors are now being hard hit with heavy case and death rates from Bakersfield in Kern County to San Joaquin County. Deaths have been concentrated among the low-income minorities with the worst health status, most crowded living conditions, and the least reliable access to vital medical services. Congress appropriated $150 billion to help providers dealing with the Covid crisis, specifically including reimbursements for care to the uninsured. To date, the Trump Administration has been far more focused on helping the largest for profit hospital chains than the safety net facilities that have been hardest hit by the virus. Its efforts to implement Congressional intent to assure the uninsured receive testing and follow up care at no cost to the patient have been largely invisible.
The Governor and California’s local public health authorities acted quickly and resolutely to halt the spread of the pandemic in its initial phases. California began reopening quite extensively (far too fast and too soon) at the end of May coinciding with the Memorial Day holiday, and the spread then began increasing rapidly, particularly for those aged 18-40. Recently, new Covid 19 cases at being detected at close to the truly alarming levels being seen in Arizona, Texas and Florida. State officials were quick to shut the economy down and allocate federal CARES Act funding to allay economic distress; they were slower and highly inefficient and ineffective, however, to process the deluge of UI applications and get checks out to laid off workers and their families, particularly those working in the gig economy, like the self employed, the nail salon workers, the barbers, the stylists, the musicians and artists.
State and local officials were rapid and proactive in sheltering and temporarily housing some of the most vulnerable homeless, a population that has been fast growing in California and is disproportionately comprised of African-Americans. However homeowner NIMBY-ism reared its ugly head when counties tried to site the new shelters. Homelessness is rising fast due to the Covid 19 recession, and the local roads here in LA are filled at night with the newly homeless sleeping in their cars, but the pandemic has not yet mercilessly spread among the homeless. State and local officials were far slower in protecting inmates and staff in some state prisons and county jails where outbreaks took hold, and the disease has spread widely, leading to deaths and releases of prisoners to mitigate the spreading infection. They were seemingly asleep at the switch in rapidly testing and protecting the most vulnerable in long term care settings, and assuring PPE for the low paid essential health staff who provide their daily care; recently they have markedly improved their performance and the state’s death rates in long term care have now dropped.
Prepared by: Lucien Wulsin
Dated: 9/8/20