I spent two days last week at the California Primary Care Association (CPCA) office in Sacramento attending our Workforce Convening: A Pathway to Building a Long-Term Primary Care Strategy aimed at developing strategies to address California’s primary care workforce shortage. I am proud to have sat across the table with leaders and stakeholders from all sectors – academia, nonprofit, government, and business – to develop public policy and programmatic priorities and identify advocacy strategies.
We can no longer afford to wring our hands about this problem. The time for action is now. For many years, community health centers have become increasingly vocal about the primary care workforce shortage in their communities. Each year, despite incremental efforts to address their concerns, the crisis has only worsened. The tremendous success of health care reform, resulting in the expansion of health insurance to five million Californians, only exacerbated this brewing crisis. Two years ago, CPCA decided it was necessary to tackle the issue head-on. We had to make it THE issue for CPCA and our newly formed advocacy affiliate, CaliforniaHealth+ Advocates.
To help quantify the challenge, CPCA commissioned a report last year that found California would need 8,243 additional primary care physicians, or 32 percent of our current workforce, by 2030. The report, titled “Horizon 2030: Meeting California’s Primary Care Workforce Needs,” provided a sobering analysis of the situation and underscored the challenges health centers face in the recruitment of primary care clinicians.
Responding to CPCA’s report, CaliforniaHealth+ Advocates developed a multi-pronged advocacy strategy to bring about much needed solutions. The centerpiece of this strategy was a successful joint advocacy campaign with the California Medical Association and the California Academy of Family Physicians, among others, to secure an investment of $100 million for primary care workforce programs in California. This monumental appropriation was designed to support and expand primary care residency programs, teaching health centers, and help recruit providers to practice in medically underserved areas. We were particularly pleased with the investment in Teaching Health Centers, which will result in utilizing community health centers as residency training programs for physicians – greatly increasing the likelihood that they will practice in primary care in an underserved community.
Coming into 2017, California’s health centers were excited and energized, ready to build on our funding victory to begin addressing the myriad of issues that plague our ability to educate, train, recruit and retain the professionals that keep our state healthy. But, our excitement and energy was dealt a devastating blow when, in his 2017-18 budget proposal, Governor Brown eliminated the $100 million workforce investment – all of it.
Backtracking on this investment hinders existing primary care residency programs and eliminates the potential for expansion or the development of desperately needed new residency programs in underserved communities. It was a shortsighted move motivated by placing immediate fiscal considerations over a recognition that California’s primary care work force, and thereby health care access for all Californians, is in jeopardy.
CPCA recently partnered with the Healthforce Center at the University of California, San Francisco to publish a report titled “California’s Primary Care Workforce: Current Supply, Characteristics, and Pipeline of Trainees.” This report finds that previously identified deficits in California’s primary care workforce persist and will be exacerbated in the coming decade as the supply of primary care physicians in California retire. Our pipeline is insufficient to meet the population’s needs. The report also found that there are large disparities between the diversity of the California population and the diversity of all medical clinicians.
While we have an overall shortage of physicians, our need is, and will continue to be, particularly great for physicians of color. By 2050, racial and ethnic minorities are projected to account for half of the U.S. population. Currently, Latinos represent 40 percent of California’s population, but only represent five percent of physicians. Less than 20 percent of physicians speak Spanish, and physicians who speak Middle Eastern or Asian languages are even less prevalent.
Among advance practice graduates, the statistics are starker. Latinos only represent seven percent of allopathic medical school graduates, three percent of osteopathic medical school graduates, nine percent of nurse practitioner graduates, and 14 percent of physician assistant graduates.
College degrees in science, technology, engineering and mathematics (STEM), which feed advanced healthcare practice degrees, may contribute to these insufficient results. According to a recent Addeco report, approximately 271,000 graduates a year earn a degree within a STEM, but in 2013, Latinos represented only nine percent of total STEM degree and certificate recipients.
This diversity shortage is particularly acute for community health centers. Of the 6.2 million patients we serve, 54% are Latino and 36% percent speak a language other than English. The current situation is simply unacceptable and is only projected to worsen. As organizations which have committed themselves to addressing this crisis, CPCA and CaliforniaHealth+ Advocates are already working to find solutions.
In the coming weeks and months, here are a few of the projects we will be advancing:
- Stop the Budget Cut: Governor Brown’s 2017-18 budget proposal eliminates the $100 million primary care workforce investment that the legislature and Governor committed to just last year, it must be stopped. This money was intended to support and expand physician training programs in California. If the funding is not reinstated, there isn’t room for expansion and existing programs may falter. We are advocating for funding restoration in the state’s 2017-18 budget and beyond. Thankfully the Assembly Budget Subcommittee, led by Assemblymember and Emergency Room physician Joaquin Arambula, took the first step towards defeating the proposal when they voted unanimously to reject the Governor’s proposal on Feb. 28.
- Save the Teaching Health Center program: Teaching Health Centers focus on training primary care physicians in community health centers. They are in jeopardy if Congress fails to enact legislation that extends funding for the Teaching Health Center Graduate Medical Education (THCGME) program past September 30, 2017. The two-year partial-funding extension Congress approved on a bipartisan basis early in 2015 will sunset unless Senators and Representatives agree on similar legislation in the next few months. We are advocating for a long-term extension of funding at pre-2015 funding levels.
- Advance policy solutions: The public policy priorities and advocacy strategies developed in the recent two-day Workforce Convening will form the basis of a multi-year public policy agenda. It was my honor and privilege to bring such a distinguished group together to find real solutions. Now we must put energy and effort into getting these solutions adopted and implemented.
As community leaders who are committed to the health of California, we need to lead the charge on addressing the workforce crisis. We need to protect funding for training and education. We need to protect our programs and create new ones. We need to find long-term solutions that will withstand the test of time. CPCA is committed to leading the charge to address the diversity of the primary care workforce of the future. The health of everyone in our state depends on it.
Every day since last November’s election, we have waited with anticipation, wondering what President Trump and the Republican Congress would do with the Affordable Care Act. Through all the tweets, leaks, concept papers and trial balloons, our concern and trepidation grew. The President told us it would be great. Congress told us they had “a better way.” These are promises we were leery of.
After 117 days, they finally released their plan – the American Health Care Act (AHCA) – and they were both wrong. Plain and simple it’s bad. It’s really bad. You can read our analysis here, but it’s everything we had feared, and more.
The Republicans are rolling back healthcare coverage for our most vulnerable communities. They are adopting a healthcare rationing formula called a “per capita cap” for Medicaid, which will force states to reduce Medicaid eligibility and coverage. Previously uninsured adults, who gained coverage for the first time under the Medicaid Expansion, will once again be at risk of losing coverage when the federal government reduces their share of program funding. The AHCA will defund healthcare exchanges by eliminating consumer subsidies. The AHCA will defund Planned Parenthood. Through the AHCA, Republicans are abandoning hard working, low-income people who need our help the most.
It’s truly devastating, because, in California, the Affordable Care Act is working. Five million people who previously were uninsured gained coverage under the ACA in California – 3.7 million under the Medicaid program and 1.4 million in Covered California – the most successful health care exchange in the country. People are healthier. Communities are healthier. Parents can go to work, children can go to school, and tens of thousands of healthcare workers have good jobs that provide for their families. It has changed millions of Californians’ lives for the better.
The AHCA, commonly referred to as TrumpCare, is the exact opposite. It will increase sickness, suffering, and pain for patients and healthcare providers. According to the report that was just released from the Congressional Budget Office and the Congressional Joint Committee on Taxation, 24 million people will lose their insurance coverage by 2026. 14 million people will lose their coverage in 2018 alone.
At the state level, the impact will be just as devastating. According to a report by Capital Link, 1.5 million Californians served by community health centers could lose access to Medi-Cal services if the ACA is rolled back, exchanges are eliminated, and Congress doesn’t renew operational funding for community health centers. The financial stakes are just as high; the state could see a $3.8 billion economic reduction and a loss of over 27,000 jobs from the community health center system alone.
For the people being kicked out of Medicaid and Covered California, Republicans have touted Health Savings Accounts and Tax Credits as the answer. But, as I shared on my blog in February, found here, HSAs and tax credits are designed for the rich. For low-income people, they are a plan for bankruptcy, not healthcare.
The per capita cap proposal transforms a compassionate entitlement program, which ensures every covered person gets medically necessary care, to a highly vulnerable budgetary line item that could be decimated by the state budget debate.
Patient protections enshrined in the ACA will be hit as well. Barriers to care, which the ACA systematically dismantled, will be restored under TrumpCare. Essential health benefits – eliminated; funding for prevention and public health – eliminated; income stability protections – eliminated; enhanced match rate for Children’s Health Insurance Program – eliminated. TrumpCare is a plan to make things worse.
Simply enrolling in Medicaid will become more difficult under the new plan. For example, TrumpCare eliminates an ACA-allowed grace period that allowed people to get care while they waited to get a copy of the required citizenship and immigration documentation. Now, all documentation must be presented at the time of enrollment. Retroactive eligibility, that allowed Medicaid to cover medical bills incurred right before enrollment, has been cut short, too. Another significant barrier is coverage redetermination, which will be required every six months, rather than the already arduous annual process.
Overall, TrumpCare creates more bureaucracy, less coverage, and fewer providers. That is the opposite of great.
I could go on and on about the negative implications of TrumpCare, but I will save you the grief because I think you get the point. TrumpCare abandons the low-income communities we have spent a lifetime protecting and I cannot support it. I hope you would agree.
By Carmela Castellano-Garcia, Esq.
If the Affordable Care Act is repealed, Californians will suffer. Members of the United States Congress need to know that before they vote. Millions of lives will be impacted. The actions of the congressional majority will have real consequences affecting the health of their constituents.
If Congress repeals the Affordable Care Act without a viable, simultaneous replacement, five million Californians will lose their insurance coverage. California’s uninsured rate will likely double, returning to rates not seen since 2013.
Nearly four million low-income, uninsured and uninsurable Californians, who are covered under the Medicaid expansion, will be left out in the cold. Covered California’s 1.2 million consumers, who are empowered by the ACA to shop for affordable healthcare plans that offer comprehensive coverage in the state run exchange, will be left alone to navigate a commercial marketplace in turmoil.
The impact on jobs and the economy is just as bad. According to a University of California Berkeley Labor Center Report, it is estimated that 209,000 California jobs would be lost if the ACA were repealed. Financially, California’s gross domestic product would take a $20 billion hit along with a $1.5 billion reduction in tax revenue.
Many of those jobs, which pay well and offer employee benefits, would be located in the low-income communities served by community health centers. Fresno, Kern, San Bernardino, San Joaquin, Stanislaus, and Tulare Counties would be especially harmed due to their community’s high level of reliance on Medicaid expansion and above-average unemployment rates.
Additionally, 800,000 mostly low-income women will lose their ability to pick the healthcare provider of their choice if Planned Parenthood, which provides myriad of primary care services to women and men, is defunded.
If Congress doesn’t address the expiration of key health center funding by this September, community health centers in California will lose up to 70 percent of the federal grant which helps keep our doors open and preserves our ability to serve everyone who is need.
People covered by private insurance or employer-sponsored insurance are not immune. The chaos in the insurance marketplace caused by all of these disruptions will drive premiums up.
If the path to ACA repeal cannot be reversed, the replacement plan must address three key issues.
First is ensuring access to care through the preservation of California’s healthcare safety-net. Community health centers serve 1 in 7 Californians, 57 percent of whom are on Medicaid. Our patients are among the states most vulnerable and include more than 400,000 agricultural workers, nearly 300,000 people experiencing homelessness, and more than 28,000 veterans. Thirty six percent of our patients don’t speak English and 32 percent of our patients are children. We cannot abandon them.
Protecting the safety-net requires broad healthcare coverage programs like the Medicaid expansion and protecting federal health center funding. Ensuring access to care also includes the preservation of Planned Parenthood, which makes up a significant portion of the state’s primary care network for low-income communities.
Second is affordability and clarity. Covered California, which is our state-run healthcare exchange, built a competitive marketplace that for the first time put consumers in the driver’s seat by giving them a clear picture of the coverage plans from which to choose. They also kept the plans affordable. In December 2016, Covered California reported that 60 percent of consumers receiving tax credits could get a Bronze plan for less than $10 per month that provides free preventive care and protection for high-cost medical events.
Third and last is a commitment to healthcare workforce. This might not seem as obvious in the healthcare debate as coverage and affordability, but it is just as important. California is experiencing a primary care workforce crisis that is limiting access to care for everyone, not just people who are low-income. The ACA addressed workforce issues by creating Teaching Health Center Graduate Medical Education Program, among others. In California, the legislature and Governor need to recommit to the $100 million healthcare workforce investment that was promised in last year’s budget, but eliminated in this year’s budget proposal.
If Congress repeals the ACA without a viable, simultaneous replacement that addresses these key issues, Californians will suffer. Californians will be sicker. We cannot allow that to happen. We cannot go backwards. The consequences in our local communities are dire and Congress needs to know that when they vote.
In House Republican Leader Kevin McCarthy’s words, the care and coverage provided under the Affordable Care Act is akin to the federal government giving some people cars, but those cars are missing two tires, leak gas, and have a busted transmission. Other people are being forced to buy cars they don’t want.
McCarthy and the Republicans in Congress believe they can fix the proverbial “car crisis” and save our patients (I can’t in good conscious refer to our patients in automobile terms) through the judicious use of health savings accounts (HSA) and tax credits. In their view, HSAs and tax credits provide a broad-based, responsible foundation of healthcare reform.
If that was the case and these were viable solutions, I would be very supportive. But they’re not, so I’m not. HSAs and tax credits don’t work for low-income communities. Allow me to explain.
HSAs are tax-advantaged savings accounts that are normally tied to high-deductible health plans, which can be used to pay for certain medical expenses. People who use HSAs in high deductible plans can place a portion of their income, tax-free, into an HSA and then use that money, tax-free, to pay their medical bills. Because their high deductible plan would not start covering any medical expenses until they’ve spent at least a thousand or more dollars out of their own pocket (or their HSA), they would have a lot of medical bills to cover.
Current law requires an HSA-qualifying high deductible plan to have at least a $1,300 deductible for single coverage and $2,600 for families, along with a $6,550 out-of-pocket maximum for singles and $13,100 for families. This means that a family using a high deductible plan will spend $2,600 out of their HSA before their coverage kicks in and require that same family to potentially spend up to $13,100 in a single year, too.
For the low-income communities we serve, these out-of-pocket expenses are inconceivable and it is misleading to say they’re not. Our patients are struggling to provide their family with food and shelter, but now they have to come up with thousands of dollars to cover their share of medical expenses before their insurance even kicks in? That’s a plan for bankruptcy, not healthcare.
Republicans have discussed a refundable tax credit to offset these bankruptcy-inducing costs, but that is misleading as well. Under the Republican proposals that have been floated so far, flat-rate tax credits (that ignore family income) would be issued monthly to purchase healthcare coverage and anything left-over can go into an HSA.
While it sounds simple, it’s not. For low-income families, it can be disastrous. For example, if President Trump succeeds and allows people to buy insurance across state lines, out-of-state insurance plans may start manipulating the price point of insurance premiums to match or exceed the monthly tax credit amount, forcing families to spend one-hundred percent of the tax credit on premiums in a high deductible health plan, without any funding for the HSA that helps pay the plan’s high deductible.
In this situation, families will be forced to purchase bare-bones high deductible plans that don’t cover vital primary care needs and won’t have an HSA to help cover the high deductibles – they will have to pay out-of-pocket. Again, a plan for bankruptcy, not health care.
HSAs and tax credits may work for more affluent people, but they cannot be the foundation of the healthcare replacement plan for the low-income communities we serve. Quite simply, it diminishes the quality of coverage and dramatically increases financial risk for communities who are already struggling to make ends meet.
For these reasons, I cannot support them.
I just finished a webinar with more than 500 health center advocates and wanted to share with you, what I shared with them.
The value of community health centers is more apparent now than ever. Over the past five decades we have successfully built one of the finest patient-centered healthcare systems in the nation. Millions of Californians, in fact, one in seven, choose to come to us for care. They trust us, they believe in us.
Now, post-election, our future and the future of health care in the state of California seems uncertain. Speculation runs rampant but facts do not. What we do know is that change is certain. Health care coverage for our patient population and the health care financing that keeps our doors open are at stake. It is a very dynamic situation that does not instill a lot of confidence in the future.
But, as I thought about the history of our movement and what we have already accomplished, I am encouraged because I know that we will endure and ultimately prevail. It may be a different path than we expected, but we will continue forward. Our patients will still have somewhere to go for care, they will not be left out in the cold. Not only because we are good people committed to low-income communities, but because we have built a nation-wide system of care that forms the foundation of health in our local communities. We are efficient and effective. That cannot be ignored or abandoned.
In rural communities, we are some of the only healthcare providers available. In Lassen, Mariposa, and Yuba counties, which are all rural, we provide care to more than 70% of those counties’ Medicaid beneficiaries. In agricultural counties like Merced, Kern, and Tulare, where our nation’s food is grown, half the county is on Medicaid and come to our health centers for care. In urban communities, we are the healthcare backbone of low-wage industries that keep our cities moving. Highly vulnerable communities, like children living in poverty, people who are homeless, and people who are living with HIV, rely heavily on us as well.
The patients we serve in these communities are among the sickest and most medically complex as well. Working in these communities has forced us to overcome significant challenges while continuing to deliver excellent healthcare at the local level. We have been doing it for decades.
For example, we have been longtime champions of integrated care models and health homes. They are our day-to-day reality, not just buzz words. Team-based care, which utilizes a broad spectrum of providers to meet the individual needs of the patient, have been in place at community health centers since our founding. We do it because it makes sense and it works. The same goes for health information technology, community health workers, and developing new value based reimbursement models.
Our reputation for delivering excellent healthcare in an efficient and effective manner is the primary reason we have enjoyed support from both Republicans and Democrats for more than 50 years. They have seen the proven results of our work and know how we benefit patients and communities alike.
We can make the financial case for taxpayers too. Health centers save, on average, $2,371 (or 24 percent) in total spending per Medicaid patient when compared to other providers, according to a recent multistate study published in the American Journal of Public Health. According to a report by Capital Link, Federally Qualified Health Centers (FQHCs) in California produce savings of $4.4 billion annually.
The benefit to our local economy is even greater. Statewide, community health centers have an $8 billion annual economic impact including 58,234 direct and indirect jobs in low-income communities. Those are good jobs that allow hard-working families to put food on their table and be productive members of our communities.
Because of our reputation with our patients and communities, we have grown as more people became insured and sought the care they long delayed. Last year, 6.2 million patients walked through our doors, a 28% increase from 2010. More than a million of those patients were part of the Medicaid Expansion and Covered California, who for the first time had access to comprehensive primary care and preventive care in their local community. Medical, dental, mental health and more, we offer a one-stop shop for people in need. We also offer important wrap-around services like enrollment in nutrition programs, social services and disaster relief. Combined, we offer the most important thing of all – peace of mind.
They say that you can’t buy peace of mind and I would agree. Reducing our programs to dollars and cents on a balance sheet exponentially undervalues what we do in local communities. Our value is incalculable.
Our value lies in decades of experience that have enabled us to make things work just right. Our value lies in the communities who trust us with their care. Our value lies in our ability to adapt to changing circumstances and business models. Our value lies in the fact that we are already here, operating, and ready to go.
Our path forward will be difficult, but our value cannot be ignored and it certainly cannot be abandoned. Using our sincerest tone and our loudest voice, we will continue to make that point clear. We will be heard. We will endure. Ultimately, we will prevail. It is what we have always done.
Part of what keeps me going, outside of the work that I do each day, is pushing the envelope and striving to be bigger, bolder, and better in that work. A large part of how I do that is being one step ahead, always seeing the bigger picture – the end game – rather than getting caught up in the weeds and letting them hold me back. Which is why I have so enjoyed the work we are doing at the California Primary Care Association (CPCA) around our next strategic plan. It’s affording us the ability to look forward, get out of our own way, and mold the future we want for our organization and its members.
Over my nearly 20 years of leading this amazing organization, I have seen tremendous strength and innovation from its members. They have never been afraid to take bold steps forward and blaze a trail for others to follow. Community health centers have grown to become a network of more than 1,150 sites across the state serving nearly six million patients each year. That’s one in every seven Californians. And community health center revenue has grown from $795 million in 1997 to over $3.7 billion in 2015.
This is amazing growth in a relatively short amount of time, and we were able to accomplish much of this by coming together and working toward the greater good for everyone. Since the passage of the Affordable Care Act (ACA), we have made great strides in defining our own destiny through the three bold steps in our last Strategic Plan. As called for in that plan, we are currently in the process of implementing our payment reform pilot, the largest in the nation, with the State and our health plan partners. This innovation will allow health centers to transform the way they deliver care in a post-ACA environment where outcomes are paramount. We have created a robust training and technical assistance program to get our members ready for our payment reform pilot, ensuring their readiness and overall success.
We have also created a statewide brand, CaliforniaHealth+ to educate patients about the benefits of California’s community health centers. The “plus” represents all the services and support community health centers offer that go beyond primary care to encompass a whole health approach. The brand’s message is simple – “Whoever you are, we speak your language, honor your traditions and value your experiences. We treat everyone with respect and courtesy. We are a trusted friend and partner in your care.” We’ve had so much positive feedback on that messaging that we have also utilized the CaliforniaHealth+ name for our newly formed 501(c)(4) organization – CaliforniaHealth+ Advocates – which will advance the mission of community health centers through both state and federal advocacy and will provide more flexibility and capacity to advocate above and beyond what CPCA, a 501(c)(3) organization, is allowed to do.
While we have achieved some important milestones over the past few years, we have seen our share of challenges. We are currently operating in a space in which we are measured on value but paid on volume. We are facing a growing primary care workforce shortage, coupled with an increase in patient demand. We have celebrated the great success of the implementation of the Affordable Care Act here in California and are now realizing, as we plan for our future, that we may be victims of that very success. The lack of workforce capacity is making it more difficult to provide needed services. The healthcare landscape is changing, both here in our state and nationally. Additional health care delivery innovation is needed to address a growing complex patient population; and increased competition over resources and patients has required us to shift the way we think about what we do. On top of all of this, the current political climate has made our future uncertain in many respects.
But, one thing I have learned by criss-crossing the state, meeting with our members in their communities during seven regional strategic planning meetings this summer and fall, is that our members are up to the task. Every region is different and has unique challenges, but they are all ready to confront those challenges. Quite frankly, sitting in those meeting rooms and listening to our state’s brightest leaders define their own destiny, I was in awe. They are ready. We are ready.
For example, workforce issues were identified as the top challenge throughout the state. Health centers are ready to innovate in order to deal with this difficult challenge. They are embracing new payment models which will better incentivize team-based care in order to expand the types of providers available to serve their patients. The need to address social determinants of health is another issue we heard repeatedly. Health centers have a long track-record of being community-minded healthcare providers who are committed to the whole patient. Their commitment to food and housing security and addressing the non-health needs of their patients are second to none. But, listening to our members, they realize we must take these efforts to another level – we must address impacts of gentrification, violence, education inequities, and more. It was truly inspiring.
Pushing the envelope and striving to be better in our work is not an easy task. But the fact of the matter is, our members are up for the challenge. As we wrap up our regional strategic planning meetings, where nearly half of our member organizations turned out to inform our process, I am excited for what the future will bring. I am so proud to see how far we have come and where the health center movement is going. We are charting our own path and creating our own destiny. Soon we will have a new strategic roadmap to guide our journey through new and unknown areas. I look forward to embracing the next set of bold steps the California Primary Care Association and our member health centers will embark upon as we continue to be a driving force behind health care delivery for diverse communities throughout California.