I have always thought it was important that women in leadership positions invest time and effort in helping other women to advance in their careers. More and more I have realized the importance of encouraging young women to pursue leadership positions as they plan their education and pursue their careers. I have made a personal commitment to do more to encourage young women down a leadership path.
Earlier this month I gave a keynote presentation at an event focused on healthcare career pathways. The audience was comprised of high school and college students. My goal was to encourage the group to pursue their higher education and consider a career in community health centers specifically, but certainly health care more broadly. I wanted to impress upon them the possibility of pursuing a leadership role in whatever health career they chose. I told them about my own personal and professional journey which led me to become a Managing Attorney of a law firm at the age of 28 and the CEO of a nonprofit at the age of 31. I hoped to strike a balance between encouragement and inspiration to help them realize their potential for a leadership role was within their grasp.
I was very moved when a young woman came up to me after my presentation – she was in tears as she spoke to me – and she told me it was the first time in her life that an accomplished Mexican-American woman had told her that she could do it. She told me that my presentation made her feel that even though she would have struggles along the way, and it would be hard, that she too could become a CEO one day. I could tell that she had greatly needed to hear the words of encouragement I spoke that day, and it reaffirmed for me that I, and others like me in leadership roles, need to do more to support young women – particularly Latinas – and help them realize their full potential. These young women are the future. We need to do more to reach young women and encourage them to shoot for the stars.
Looking back on my path toward becoming a CEO, I am often reminded of the tremendous support I had along the way. As a child, I was instilled with the confidence and wherewithal that I could do anything I set my mind to. My parents were instrumental in my success from the beginning. In particular, my mother served as a role model and mentor to me from a very young age. As an Executive Secretary at San Jose City College, seeing my mother in action professionally during in my youth helped me to understand the importance of professionalism, commitment and high standards.
She also supported me unconditionally in the high educational goals I set for myself – such as aspiring to attend UC Berkeley and Yale Law School – which are now both my alma maters. My mom was my first mentor, showing me through her own actions the importance of a strong work ethic and leadership ability. She empowered me through her example that I could do anything or be anything I wanted – but she also showed me I was going to have to work hard to achieve success – just as she did. It would not be handed to me.
Later in my professional life, I had the benefit of befriending some amazing women who have helped to guide me with their constant motivation, guidance and constructive feedback. I have been blessed with amazing mentors — women who provided more than just support – they were my constant cheerleaders and they provided critical professional and personal advice to me along my leadership journey — all of them helped to make me who I am today.
There is a glaring need for more women in leadership – both in the nonprofit sector and in corporate America. A 2015 Guidestar report found that women make up less than half – 43 percent – of nonprofit CEOs. A similar study by the University of Denver and The White House Project, found that women constitute only 21 percent of leadership roles among nonprofits, though they make up 75 percent of the workforce.
As President of the Castellano Family Foundation, I have become much more aware of how these issues are playing out in philanthropy. The latest data from the Council on Foundations Grantmakers’ Salary and Benefits research found that women hold only 31 percent of the CEO positions in the largest foundations and only 41 percent of all surveyed foundation board members are women. This is despite the fact that women represent 73 percent of full-time foundation staff. When I look around at my fellow association CEOs in Sacramento, I see hardly any women and nearly no women of color. The issue in corporate leadership is even more dire with Forbes reporting that only 23 Fortune 500 companies have women CEOS – that’s less than five percent! This is truly unacceptable! And this doesn’t even get to the issues of pay equity and the fact that women make 80 percent of what men make for the same work according to a 2017 report from the American Association of University Women. We will save that for another day.
The bottom line is we need to do more – and it starts with us. As women we should look to our daughters, our nieces, our cousins, our friends, our employees, and our peers. We can lead by example, show them and tell them that women can lead. That they are leaders now and they should work to be the leaders of the future. As women we often hold ourselves back – whether it be a promotion or a new job or a new opportunity of some kind. We owe it to ourselves and each other, and more importantly, to those coming up behind us. As women, we all need to take a more proactive role in empowering and challenging the young women in our lives to see themselves in leadership roles. If we don’t let them know of the possibilities and most importantly – that we believe in them – they may never reach their true potential.
Which is why I am giving back and encourage all of you to do the same. Because we had so much support along the way, we really need to make that investment in each other. As women it’s important that we support each other personally and professionally – as friends and family. Or in leading by example – something each and every one of us can do as well – showing the young women in our lives what is possible through our own actions.
I’m hoping to take what I have learned from the trailblazing mentors in my life to help to empower our future leaders of tomorrow. We must ensure that women have a seat at the table, as they will have a say in shaping the future. It is up to us to empower future generations, to push them, and to show them that anything is possible. As I looked into the eyes of the young woman who approached me at the career pathways presentation, I saw the impact of her realization that more was possible for her. The impact of knowing that there was someone in the world who had achieved a leadership position, and that someone believed in her and knew she could do it, too. Every young girl can be a CEO – it is possible – and working together we can help make it happen.
On Wednesday, May 3, 2017, I kicked off our biggest Day at the Capitol event ever with a celebration of the Affordable Care Act (ACA) on the West Steps of our State Capitol. I stood shoulder-to-shoulder with more than 300 community health center advocates and elected leaders, reflecting on the success we’ve had under the ACA. In California alone, the uninsured rate fell from 17.2 percent in 2013 to 8.6 percent in 2015 – giving more than 5 million Californians access to both care and coverage. The celebration of this monumental success was unfortunately overshadowed the following day when the House voted to repeal and replace the ACA with the American Health Care Act (AHCA), also known as TrumpCare.
The ACA is working in California and that is why it is so distressing that Congress is working hard to repeal and replace it. In California, the uninsured rate dropped across all racial and ethnic groups, with the greatest gains seen among Latinos. Community health centers saw a 63 percent increase in the number of Medi-Cal insured patients and, according to a study by the California HealthCare Foundation (CHCF), safety-net clinics are providing care to 54 percent, or 1.3 million, new patients enrolled in California’s Medicaid managed care plans after expansion. Yet even after all of these successes, Congress has introduced the American Health Care Act (AHCA) that threatens to rollback insurance coverage to 24 million Americans and decimate the Medicaid program.
We all worked very hard to stop this bill from passing. We made phone calls. We held rallies. We talked with our congressman about why we didn’t support the AHCA and why they shouldn’t either. Our efforts paid off, initially, when on March 24 House Republicans pulled the bill because they didn’t have the votes.
But their efforts persisted and the two (2) amendments that somehow got the AHCA across the line do not make the AHCA any better. In fact, they make it worse. The MacArthur Amendment – added to appease the more conservative Republicans – weakens protections for people with pre-existing conditions and allows states to opt-out of the Essential Health Benefits. So now sicker individuals, who will have more expensive health care costs and catastrophic plans, will once again be allowed. The Upton Amendment aimed to soften the blow for Republicans that did not want to renege on their promises to cover pre-existing conditions by allocating an additional $8 billion over 5 years to states that aim to create high-risk pools. Yet, experts agree that amount is not nearly enough to cover such an expensive endeavor as there are currently 2.2 million people with pre-existing conditions and $8 billion is barely enough to cover health care for 600,000 people.
What’s more shocking is that Members of Congress voted on this bill less than 24 hours after the final language was released and before it was scored by the Congressional Budget office (CBO). California’s entire GOP delegation were among the YES votes. How Members of Congress could pass a bill before analyzing the text and understanding its full impact is extremely disturbing.
Particularly distressing for Californians is that fact that our entire Republican delegation, all 14 members, voted for this bill. With this vote, California’s Republican Representatives are threatening to undermine the health insurance coverage of more than 13 million Californians – many of whom are their very own constituents – by voting in favor of legislation that dismantles the Medicaid Program and rolls back the Medicaid expansion, among other draconian provisions.
Roughly one-third of California’s population is enrolled in Medi-Cal, with the highest number of enrollees living in counties represented by Republicans. In particular, forty-percent of the population in counties represented by Representative Nunes, Representative McCarthy, Representative Denham and Representative Valadao – all of whom voted in favor of the AHCA – are Medi-Cal beneficiaries. Any step to remove the existing Medicaid funding guarantee, whether it be through caps, block granting, reduction in federal share of cost or the elimination of expanded eligibility, is a step in the wrong direction for California. It is a wrong step for the very constituents they pledged to represent.
Fortunately, both Republicans and Democrats in the Senate have publicly shared that this bill is not a viable replacement for the ACA. They have vowed to make significant changes to the AHCA. Many have said they are starting over from scratch. We don’t know what will be in the Senate version – it could very well still be devastating for California. Eventually, the revised bill will make its way back to the House and when it does, it is our job to keep up the pressure, be vocal and make sure that California’s Republican delegation does not make the same mistake twice. There’s simply too much at stake for them to put politics before their constituents’ well-being.
The ACA works in California thanks in large part to the legislative leadership we have in our state. Millions of Californians have benefited from the ACA. In a world of uncertainty, we are fortunate to have leadership in both the State Senate and Assembly looking out for the needs of California’s most vulnerable communities. We look forward to working with them in the future to ensure that the needs of these communities continue to be met.
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.