Sandra Hernandez, CEO of California Health Care Foundation: Improving Access to Care Through Smart Workforce Strategies

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development, and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

Health insurance coverage is in the headlines once again as many Americans are soon expected to lose their Medicaid eligibility due to the end of the subsidies enacted during the pandemic. In contrast, North Carolina became the most recent state to expand Medicaid eligibility under Obamacare, something that it resisted doing for many years. But of course, having insurance doesn’t help much if people can’t get access to health care due to workforce shortages and other barriers.

We could not have a better guest today to help us understand the complicated dynamics at work in this area than Dr. Sandra Hernandez, President and CEO of the California Health Care Foundation. In addition to being a physician, Dr. Hernandez has decades of experience in public health and public policy and has been tapped by two California governors to share her expertise on access and affordability issues. Thanks so much for joining us today, Sandra.

Dr. Sandra Hernandez: Thank you, Van, nice to be with you.

Van Ton-Quinlivan: I would love for you to start by helping us understand the role that California Health Care Foundation plays.

Sandra: Sure. California Health Care Foundation (CHCF) is a statewide, private, independent healthcare-focused foundation. We live in a state with a number of healthcare foundations. CHCF focuses itself principally on delivery system improvements with a very keen eye and focus on low-income folks and folks who historically have not had great access, or do not today have great access, to the healthcare that’s available to folks with commercial coverage or otherwise.

Van: Many of our audience members are from education or workforce backgrounds. I was wondering if you could just elaborate a little bit on what you mean by delivery systems improvement?

Sandra: So, the way that California approaches the delivery of health care, particularly for people with low incomes, is through the state’s Medi-Cal program, or Medicaid, as we know it in other states. The Medi-Cal program serves thirteen million people in California. When I describe the health care delivery system, I’m principally talking about public hospitals, Federally Qualified Health Centers and delivery systems that are organized all across various regions in the state who provide care both to Medi-Cal patients, but also to Medicare patients and to commercially insured folks.

We spend a great deal of time focused in three areas. One is just to provide actionable data-driven evidence that allows the state to look at where there are gaps either in coverage, in access once you do have coverage, or in patient-centered care…care that actually provides care and services and really looks at patients comprehensively but also looks at population-based outcomes as well. So, when we describe the delivery system, we’re really talking about that full continuum of services that individuals would get by virtue of being enrolled in Medi-Cal or in Covered California or other programs that by and large provide access to comprehensive sets of benefits.

Van: I would imagine that as you’re thinking about these comprehensive services, the issue of workforce comes up frequently. I would love for you to share what your foundation is focused on right now, specific to workforce.

Sandra: Yes, you’re quite right. I should say that we shouldn’t skip over how important California has been as a state in the first goal, which is to get everybody covered with insurance. As you alluded to in your opening remarks, Van, we’ve been under a public health emergency because of COVID-19 where we’ve allowed for so-called presumptive eligibility. California Health Care Foundation has worked for well over a decade at both improving that enrollment system for folks into Medi-Cal but also, importantly, to expand coverage of Medi-Cal such that we don’t leave any population outside of coverage.

And you’re quite right, Van. Once you get beyond coverage, then you get into what does an insurance card mean and what does it mean to be a member of a health plan? Then, you do get into the issue of what I would describe as the adequacy of the network in health plans to actually provide the array of services for their members. Increasingly, for a number of reasons, the workforce itself is often an enormous challenge. We saw this quite clearly exacerbated during the pandemic. Even before the pandemic, we had several dynamics at play in the workforce.

One is the workforce itself was aging. Another is that the distribution of our workforce across California is quite uneven with large gaps and discrepancies with regard to coverage of, say, primary care physicians or psychiatrists or behavioral health specialists. We have both a maldistribution and a declining workforce by virtue of its aging. Then we really have what I would consider very old models for how we go about delivering care. That really gets us into work that CHCF is doing today in workforce post-pandemic.

We saw quite clearly that the pandemic exacerbated a tremendous amount of burnout in the existing workforce. We also saw significant parts of communities step forward during the pandemic to really help us address some of the emergent opportunities that came out of the pandemic by virtue of having vaccines to distribute. We have tried to describe what the workforce challenges are. We, along with some of our sister foundations, did a big statewide commission that looked at what the needs going forward were for the workforce in California, with a particular focus on primary care, behavioral health, and the workforce that serves our aging population.

That analysis and set of recommendations really does describe a map by which public sectors, philanthropic sectors, and nonprofit organizations could lean into the goals that were set forth in particular in those areas. CHCF has continued to work against the priorities that came out of those recommendations from that commission.

We have very much been interested in three separate areas in workforce. The first has to do with Promotores de Salud and community health workers, and I would love to talk to you more about that, Van. I think that’s an area that is exciting, is growing, is scaling, is being reimbursed, and there are really important reasons for expanding that part of the workforce.

We’ve been interested in doulas, for example, as a way to address Black maternity outcomes, which have been disproportionately negative for over 200 years, if not more. Doulas are a very interesting workforce that we’ve also been trying to build. We’ve been very interested in telehealth and telemedicine, of course, as a way to leverage the existing workforce that we have. We’ve done some interesting work around expanding prescribers in the psychiatric space with a psychiatric nurse practitioner program that we did with the partnership of some of our CSU partners.

I would say that in general, we’re very focused on looking at the primary care model and the primary care team and its composition. We’ve done a lot of work with nurse and nurse practitioners’ scope of practice. We’ve done work in community paramedicine, again, trying to use every drop of workforce that we have in California to its fullest capabilities with, by and large, a focus on trying to expand the base of those different types of professions within the workforce arena.

Van: Sandra, I’m curious, as you talk about sort of rethinking the primary care team and its composition, where is the point of leverage or where is the point of change?

Sandra: You know, I’m a primary care internist, as you noted, and the old model really was a primary care physician carrying a battery of X hundreds of patients. I think what we envision as a new model is really looking at how we do primary prevention? How do we do education? How do we do early screening? And how do we build that capacity into teams such that we’re making best use of a limited and costly part of the pyramid of workforce, primary care docs?

We’re still trying to improve that pipeline, obviously. But that’s a long, long process to get us to expand that workforce. So, the idea here is to really have the primary care clinician deal with more complex issues and be able to use a workforce — including promotoras, community health workers, CNAs, and a variety of different types of nurses — as a team to be able to manage things that are more standard or that lend themselves more to protocols and where you can do certifications and training, which also gives us the opportunity, potentially, to expand those pipelines and do a little bit more around workforce development and economic development.

Because, of course, one of the reasons we have thirteen million people on Medi-Cal is we have so many very low-income folks in the state. So, when we think about the primary care team, it’s with that eye to be able to use limited resources in the most complex arenas and really try to expand the knowledge base and the reach and the lived experience and the cultural competency that you get from people who are coming from the community and are earlier in their health care careers.

Van: Sandra, when you are explaining this future of care model, it seems so obvious, but yet it isn’t here today. I’m wondering, what are the barriers that keep us in the old model?

Sandra: That’s a good question, Van. I would say it’s a couple of things. As you know, there’s a lot of inertia in health care.  We were working at this scope of practice with nurse practitioners, as a very good example, for many years. We as a state were clearly not at the cutting edge in that arena. Our colleagues at the California Medical Association and other organizations have been reluctant to allow others into what they view as their space. There’s old history in that. A lot of that is, in my view, unnecessary fear of somehow being pushed out.

As I said, Van, the state needs every drop of primary care capability we can get, and it’s also a question of how people use their time and how they see themselves using their time. There’s concern about, “I want some of the run of the mill stuff as well as some of the complex stuff as a way to balance my workload.” But it doesn’t really take into account the system needs. I think if you look at the system broadly, we would argue that nurses practicing at the top of their license does not impede the need or the necessity or the capabilities of well-trained primary care clinicians in whatever field they might be in — family practice, OB, psychiatry, et cetera.

Van: Dr. Bechara Choucair — who, with Kaiser Permanente actually provided Futuro Health with initial funding — has made the comment that the pandemic showed how the hospital system and the public health system were running parallel, rather than complementary, to each other. I was wondering what your thoughts are about that comment?

Sandra: I think he’s quite right. You know, my public health work and my clinical work were both in San Francisco. San Francisco is quite unique in that the academic medical center, the public hospital and the health department work very much in alignment. The health commission really oversees both the public health functions and the major delivery systems in the city with Laguna Honda Hospital and San Francisco General Hospital.

In that situation, you can absolutely see the benefits of a public health system being completely synchronized — data, infrastructure, resources — to be able to address a pandemic like we’ve just experienced with the COVID-19 pandemic. A lot of the challenges in this parallel structure, to be sure, come from workforce shortages. What I didn’t mention yet is we also have very siloed data systems and information systems. So, one of the things that I think really laid bare the weaknesses of the fragmentation between public health and healthcare delivery during the pandemic was just the fact that all of these systems work off different data collection mechanisms. Some of them are real time, some of them are not and some is collected by counties and then sent to the state.

But in general, this lack of data integration, which the state now does have a plan for, creates this fragmentation and duplication and people fall through the cracks. We repeat tests and exams in one system to the other, but more importantly, we’re not able to deploy resources based on real time data when you’re faced with a pandemic or an epidemic.  I think one of the things that the delivery system has come to appreciate coming out of COVID-19 is it was not as ready to respond in large part because those relationships with public health and with counties in many cases were non-existent, were nascent, were fragile. In a crisis, it’s really not the time you want to try to be building data systems or trust across those systems, and I think trust is a big part of this.

Van: Do you worry about — I call it recidivism — but will we go back to our old patterns?

Sandra: It’s easy to fall back into old patterns, Van, but I’m an optimist. I think that what we have seen with the data exchange effort that the state has put forward is really a recognition that we — all of us, all the delivery systems — sit on tremendous amounts of data that is really not very useful if we’re not able to share it with the rest of our systems. People do not interface in just one place. And so we need to be much more facile with our data and be able to share it in centralized ways such that we’re delivering much more timely care, but also much more timely data, again, to try to allocate limited resources particularly when we’re in emergency situations.

So, I’m an optimist. I think there’s been a lot of bridges that have been built post-pandemic. I think people have come to deeply appreciate the role of the public health delivery system, if you will, for population health. A lot of the health systems relied on Federally Qualified Health Centers and on health departments to be able to reach into communities that they were not able to reach into when we were in the acute phases of COVID-19.  I think that has brought about a realization that we have different assets, and we need to be able to use them in a much more synchronized and efficient way.

Van: Well, Futuro Health is contributing towards the capacity in the public health system. We’re working on a federal grant with Berkeley, Cal State Long Beach, Cal State East Bay and a number of community colleges to build out public health informatics certificates that lead into degree pathways. So, I thought I’d mention that.

Sandra:  I’ll just say, Van, I worked in numerous roles in public health, and I would just put in a plug to say that these are very important roles that we need to bring fresh talent into. So, I’m super excited that Futuro Health is doing that. The other thing that came out of this is that our public health schools are now working together in an affiliated way to begin to look at what kinds of offerings we have in different schools of public health across the state, and really to find a way in which we can share information, curriculum, and what people learned during the pandemic. That’s really the first time that all the public schools have come under one rubric, and I think that’s one wonderful thing coming out of the pandemic in thinking about how we utilize our public health systems and thinking about training into them in a much more strategic way.

Van: Well, it’s good that there’s some silver linings from the pandemic.

Sandra: Yes.

Van: So, Sandra, I was wondering if you could tell our audience a bit more about how California is taking steps to expand eligibility to Medi-Cal for low-income Californians regardless of their immigration status. Can you connect the dots for us on how this feeds into your work in health equity?

Sandra: Absolutely. As I mentioned earlier, you can’t really do population health, you can’t really think about health equity as a county, as a city, as a region, if you don’t have everybody in the system. That is simply quite clear. It’s true whether you’re talking about tuberculosis management; it’s true if you’re talking about HIV; it’s true if you’re talking about COVID-19. You really do need to have everybody into a system, whatever that might be — Medi-Cal, Covered California, commercial, et cetera.

So, there has been a longstanding effort to expand to everybody in the state of California the ability to enroll in Medi-Cal, if even only with state Medi-Cal dollars and not utilizing federal dollars because of prohibitions that exist with regard to immigration status. We have many, many immigrants in California, and over the years, we have been slowly expanding their access to Medi-Cal. We started with a younger population, we’re up to an older population. In this last budget beginning in January 2024, everybody — regardless of age — who might be undocumented would be eligible to enroll in Medi-Cal. A caveat: eligibility does not necessarily translate into enrollment. So, there will always be an effort, I think, to make sure that everybody who is eligible gets enrolled in a program that they might be eligible for, and in the case of Covered California, they draw down the appropriate subsidies that they’re also eligible for.

So, California has been on this path to cover everybody, to get to universal coverage.  January 2024 is really the last piece of that long  journey. What we’re facing at the moment are some headwinds because, as I think you mentioned earlier, the public health emergency has ended. Presumptive eligibility, therefore, has ended. So, people will have to go through the somewhat onerous process of getting re-certified for eligibility and there’s an enormous effort going on in the state of California today that CHCF is very much involved with to do that. It’s a campaign meant to reach a population that historically has stayed out of health care except for when they have emergency needs because of concerns of immigration, of reporting, of eligibility, of co-pays, of bills that they might get after they show up for care.

So, there’s a tremendous amount of educating and outreach and, frankly, trust-building to make sure that this expansion actually reaches the population it’s intended to reach and that we make up whatever lag we might have in the re-eligibility process now that presumptive eligibility under the emergency has ended.

Van: Speaking about trust-building, let’s move to the topic of community health workers. You’ve been advocating for the use of community health workers as a great way to increase access and provide culturally competent care. Please tell us why these roles are so important, and how the roles are changing in this environment.

Sandra: Sure. Well, I think we have come to appreciate — as we are all trying to understand social determinants of health and historical disparities in health outcomes — just how important cultural competency and lived experience really is for people to be able to come into healthcare systems and really understand how they work. I would add, we’re now also faced with the problem of misinformation that is prevalent in communities and where people get information. We saw this a little bit in the vaccines around COVID-19. One of the important qualities of promotoras and community health workers is that they are from the community. They are known to the community, and really are the closest people to really being able to build a trusted relationship and to share information that is scientifically based. At the same time, they are able to encourage people to get enrolled in the programs that they’re eligible for, and also to be able to get them into earlier care.

I think as we try to shift the cost challenges that we have in healthcare, one of the things we need to do is better primary care, better early education, better prevention and screening. This is a workforce that is very well trained to be able to do that, and in the past was really funded on a grant from this person or a grant from that organization. Today, with the legislation that’s been passed in California, it is now actually a billable service and really is taking what I view as a very important asset of community strength and bringing it into a formal work economy.

Whether you’re a health plan, or a Federally Qualified Health Center, or you’re a community-based organization that wants to provide community supports under Medi-Cal, we now have a very well-primed workforce that has the trust of community and I think can help tip us towards more prevention, more screening, more healthy education in a way that in the past was more haphazard, and wasn’t sustainable from a financing point of view.

So, we’re very excited about the goal that the state has to triple that workforce and to do that in a way that maintains trust, maintains the cultural competency that’s so important to our very diverse communities in the state. It’s a workforce that is as relevant in rural areas as it is in urban areas, so it is super important to the state. We think it solves a number of issues and we’ve spent a lot of time trying to understand what the best practices are so that as we standardize it as a reimbursable service, we don’t lose the cultural competency and the trust and the kind of “boots-on-the-ground” spproach that has made it such an efficient and important part of our more informal workforce, historically.

Van: And with this workforce, if California is successful in… was it 25,000 new community health workers?

Sandra: That’s right.

Van:  …we’re essentially bringing in a lot of folks who would not have considered a career in care previously. I wonder if you could lay out some of the possible career paths they could take once they’ve entered healthcare?

Sandra: It’s a really important question because, as I alluded to, during the pandemic we funded a lot of nonprofit organizations to mobilize into community, many of them using community health workers. These are workers that are generally very low-paid folks. So, one of the things that I think we see as an opportunity is that their experiences as we go through certifications and as we go through more trainings allow them to build skills and, hopefully, interest in other roles in healthcare. That might be in public health as we mentioned previously. It might be in plan administration. It might be in a nursing pathway of some sort. I think there is at least the potential to start to build on credentials and pack credentials. I know Futuro Health is doing a lot in this space.

There are a lot of technical jobs in healthcare that likewise are in need of additional workforce that we haven’t talked about today. And so I think as these folks get more credentials and are able to stack some more skills, the possibilities for jobs that pay more and that also fill increasing needs that we have in healthcare, we think, is a very promising prospect.

Van: That’s very exciting… to draw on this much broader workforce and bring them into the future of care. I was wondering if you could give us some thoughts around your work in behavioral health and how systems can do a better job of caring for the whole person. I know this is front and center on a lot of policy makers’ minds.

Sandra: It really is. CHCF did some polling pre-pandemic. We sort of try to take the pulse of what low-income folks are feeling and needing as a way to help us think about our own priorities as a foundation. We had been interested in behavioral health for some time largely because behavioral health, mental health and substance use disorder have been such siloed programs. We’ve got a behavioral health “carve-out” in the state that makes it very complicated for how we decide who has a mild condition versus who has a chronic mental health condition, who’s responsible for those patients or not. We also have just an incredible mismatch of demand and need.

When we polled this pre-pandemic, behavioral health was very much at the top of people’s minds. Post-pandemic — where we’ve come out of three years of social isolation and young people online being schooled and social media sort of consuming people’s time because there really wasn’t a lot of opportunity for any other kind of socializing — that demand and that mismatch is probably more severe than it has ever been. I think we have to approach that in a very multifaceted way.

We need telehealth and telemedicine capabilities. That definitely works in some places. We’ve done some evaluation on that. We have funded a couple of startup companies who have this as a goal. One of them was focused on high school students and offers a bilingual capability and they’ve now got a contract with LA Unified School District, so we’re very excited about that. But I think we also just need to recognize that we’re going to need to go upstream.

I should say, Van, because I’m a bit of an optimist, I do think that one of the good things the pandemic accelerated in behavioral health is a challenge that we’ve looked at for many, many years, and that’s the stigma associated with mental illness.  I think coming off the pandemic, that stigma has sort of washed away. I think everybody talks about mental illness in a different way. It doesn’t have the same taboo.  And sure, in cultural communities there may be long cultural taboos around this, but I think as a general societal topic, mental health in particular has come out as being something that is important for our schools. It’s important for a workplace. It’s important for our delivery system. Really, businesses need to think about it. It is a sort of a societal responsibility for us to address our behavioral health and mental health needs in a much more comprehensive way. So, I think that’s the upside.

Looking at how to accelerate workforce in this space is going to continue to be a challenge. But one of the other things we think is super important is to be able to cross-train workforce. For instance, primary care physicians getting support through e-consults. Do you actually need to see a psychiatrist to manage these medications? Or can I, as a primary care physician, manage them with an e-consult support behind me? So, again, really thinking about how do we use a scarce resource as effectively as possible and doing cross-training?

Then, it’s super important that people not have to make a separate appointment to get my behavioral health needs met or my diabetes or my hypertension or my CHCF managed in a different environment. That requires really thinking about making care much more integrated for people so that we look at them in their entirety.  I think that’s a very important part of what we need to do in care redesign as well.

Van: Well, you’ve given us much to think about and many provocations in this healthcare field. I wonder if we could just close out by giving you an opportunity to describe what’s next for your foundation and for you?

Sandra: I mentioned at the top of the podcast that we’re very interested in the Medi-Cal program. California does have a very bold initiative — so-called CalAIM — which is under a waiver from CMS. We have four or five years or so to implement these initiatives. And these initiatives are, I think, very bold, very complex, and very hard to get off the ground.

There’s a lot of effort in California, of course, on care for people who are unsheltered. We have a very large population that does not have stable housing. How do we provide care to them where they are, even while others work on housing stock and housing as medicine, but also street medicine? We’re doing a tremendous amount of work right now looking at how do we provide care to people who are unsheltered in some stable, consistent, appropriate way. By the way, promotoras and community health workers are often part of those teams.

Medi-Cal has an “in lieu of,” so there’s some opportunities to pay for things in Medi-Cal that we didn’t use to pay for such as transportation, food, and so-called community supports. We can also pay for enhanced care management for the people in Medi-Cal who utilize a tremendous amount of health care but don’t get the kind of health outcomes that those exposures to the health care system, one would think, should improve their care and their quality of life.

All of that is being managed through the lens of our Medi-Cal plans. So, we do a lot of work with our plans on testing some of these new provisions under CalAIM about trying to scale them, learn from them in real time. At the same time, we recognize that while there isn’t an immediate goal of getting everybody off the streets, we should begin to look at respite care, street-based care, ways to reach folks and connect them even if it’s to where they are, taking services to our most needy and underserved folks. This CalAIM program is a significant focus of CHCF and I suspect will be for the foreseeable future.

I mentioned data exchange earlier, Van. We’re going to stay in that space. We think it’s really important to achieve a much better use of very expensive resources and we think there’s a lot to be benefited from data exchange. You also probably know that there’s an Office of Health Care Affordability, so there is always going to be a focus on health care affordability even if we do nothing less than reduce the rate of rise in how much health care consumes of our GDP. I think everybody who works in health care recognizes that while expending money on health care is an important human right, the fact of the matter is we need to achieve health equity while we reduce the amount of burden that we spend on healthcare so that we can invest in other social programs, educational programs and housing programs.

So, I think CalAIM is sort of this interesting intersection of recognizing our historical underinvestment in social programs that then create these social determinants of health that have disproportionately impacted Black and Brown communities over many, many decades.  I think the goal would be how do we focus on health equity, how do we take our learnings from the pandemic, apply them, really accelerate the work that the state is trying to do around workforce and work with all of our other partners across the state, because it will take a public-private partnership.

Everything we envision doing largely requires a new pipeline of people to do it. We have a lot of young people in the state who’ve now come out of a pandemic and suddenly know what public health is. I think it’s an opportunity for us to engage them in this long-term effort that we’re in.

Van: Well, I know my audience would no doubt agree when I say, thank goodness we have your leadership and expertise at the helm. So, thank you for doing the work that you’re doing every day. It’s so important. Thank you so much, Sandra.

Sandra:  Thank you, Van. Nice talking with you. I appreciate all the work that Futuro Health does and I look forward to talking with you again soon.

Van: I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.