WOMEN’S HEALTH: Health Equity

CAPITOL WEEKLY PODCAST: This Special Episode of the Capitol Weekly Podcast was recorded live at Capitol Weekly’s Conference on Women’s Health which was held on Thursday, September 28, 2023.

 This is Panel 2 – HEALTH EQUITY

 PANELISTS: Sonya Young Aadam, California Black Women’s Health Project; Stephanie Brown, M.D., MPH, Sutter Health; Andrea Rivera, California Pan-Ethnic Health Network (CPEHN); Martha Santana-Chin, Health Net

Moderated by Ana Ibarra of CalMatters

This transcript has been edited for clarity.

TIM FOSTER: I’d also like to thank our moderator for today’s panel. Ana Ibarra covers health policy for CalMatters. Her stories focus largely on healthcare access and affordability. She has reported extensively on COVID-19 and California’s safety net programs. She started CalMatters in 2020. Prior to that, she spent four years at Kaiser Health News in Sacramento. Her work has also appeared in the Washington Post, the Los Angeles Times, USA Today, and other national news outlets. She grew up in the San Gabriel Valley in Southern California, and she currently lives in Bakersfield with her husband and their dog. And so I’m going to go ahead and turn that over to Ana now. If you have any questions, please post them in the Q&A function and we will try to get to them in the last 10 minutes or so of the program. So thanks again for tuning in.

Ana, thank you for taking over, and I’ll hand it over to you.

ANA IBARRA: Thanks so much, Tim. So I’m going to go ahead and introduce our speakers for today’s panel on health equity. So first we have Sonya Young Aadam. Sonya Young-Aadam, a University of Pennsylvania Wharton School of Business graduate, endeavors to develop and support transformative intervention in under-resourced urban communities, including south Los Angeles, where she was born and raised. In October 2014, she joined the California Black Women’s Health Project as chief executive officer. The organization was established in 1994 to empower Black women to take personal responsibility for their own health and to advocate for changes in policy that adversely affect the health status of Black women.

We also have Dr. Stephanie Brown. Stephanie Brown is a board-certified emergency medicine physician practicing at Sutter’s Alta Bates Summit Medical Center in Oakland and Berkeley. At the Institute, Dr. Brown is the clinical lead for Sutter Health Institute for Advancing Health Equity. And at the Institute, Dr. Brown contributes her clinical and population health expertise to advocacy, research, education, and innovation efforts to improve health outcomes for vulnerable people across Northern California.

We also have on our panel Andrea Rivera. She joined California Pan-Ethnic Health Network in June 2021 as the senior legislative advocate. She is responsible for the development and management of CPEHN’s state legislative and budgetary agenda. She plays an integral role building relationships with the state policymakers, partners, and other allies. Rivera’s commitment to uplifting the voice of communities of color has led her on a path of social justice advocacy.

“We’re really not addressing systemic and structural racism broadly enough. And they go so closely together that if you’re not dealing with one, you’re not really dealing with the other.” – Sonya Young Aadam

And lastly, but not least, we have Martha Santana-Chin, who currently serves as the Medi-Cal president for HealthNet. She is a proven leader with over 25 years of experience in driving better outcomes for underserved communities at managed care organizations. In her current role, Santana-Chin has executive oversight of the Medi-Cal line of business, serving over more than 2 million members. She works to provide access to high quality affordable care and partnering with community stakeholders to support local needs. She is also responsible for positioning the business in the market and oversees the carrying out of HealthNet’s product and service area growth.

So thank you all for being here. And I think this is a really important panel.

We know that we’ve seen –  oh you can turn on your cameras, I believe, now. So again, thank you all for being here. I am really excited to talk about… To have this discussion with you all on Health Equity because I think you’ve all been doing work on this area for many, many years. But I think for the general population, Health Equity in terms like disparities, really have started… We’re starting to hear more about them I think even more so after the height of COVID-19. One of the things that I remember hearing the most in reporting on COVID was that we now couldn’t hide disparities, that they were very obvious, and that this is something that we have been dealing with in health care for many, many years, but this sort of put a new lens to it. So let’s go ahead and get started.

I want to set the context a bit before we dive into some of our questions, or some of our topics. I was wondering if we can go around and really talk a bit about when you think about disparities and inequities in California’s health care, what comes to mind for you first? In the work that you do, what type of disparities are you trying to address? Sonya, why don’t we get started with you?

SONYA YOUNG AADAM: Certainly, thank you, Ana. It’s good to be in a space with you all today. And I appreciate the opportunity to be here to talk about this very important issue around Women’s Health. And given my work and my role with California Black Women’s Health Project when we think and speak about disparities we’re talking about disparities really in everything that pertains to our health. We find ourselves, that’s Black women and girls particularly in California, we find ourselves at the bottom of the list. We find ourselves at the bottom of the list where things are supposed to be good, and the top of the list where things are considered terrible in terms of health. And we think about disparities, and I think about disparities that… really I can’t isolate it from the issues and the challenges that we have in the state and in the nation around historical racism and how it continues to weave its way through all areas of our society.

So the disparities that we see, they don’t happen in isolation they happen in a system and in a space where they are allowed to happen, where they are sometimes even institutionally ingrained in a system. And sometimes where we see what is often considered unconscious bias, or we see that people are operating in ways that maybe they don’t realize that they are part of a big problem. But the changes that we recently saw around disparities, where we really started talking about equity, Health Equity, inequities, and sort of the language change, we had a narrative shift. I continue to use “disparities,” because I know that that is something that when people see numbers, when they see data they tend to at least respond to that.

“We can’t –  health care – we can’t do everything, but we can screen for it, we can acknowledge it, we can talk about the fact that structural racism is affecting our patients” – Stephanie Brown

When you’re talking about inequities, people just say, “Oh what’s not fair, what’s not just.” But when you talk about disparities and you see them in such extreme numbers, to me, I challenge health care all the time. “What about triaging? Isn’t that what you do? Don’t you care for the most difficult cases? Don’t you separate those and distinguish them so that you’re paying attention to them.” So, in my view, we’re not really addressing disparities broadly enough, because we’re really not addressing systemic and structural racism broadly enough. And they go so closely together that if you’re not dealing with one, you’re not really dealing with the other.

AI: Dr. Brown, you want to go next?

STEPHANIE BROWN: Sure, thank you. Thank you for that, getting us off to such a great, important start, Sonya. At the Sutter Health Institute for Advancing Health Equity, we, as Sonya also mentioned, we look at everything. And we’re really looking at quality metrics, really thinking about, when we think about disparities, we’re talking about disparities in health outcomes, and really measurable differences that we can then do something about, create innovative ways to deliver healthcare that’s different and can really close those gaps.

So we have three main focus areas, chronic disease equity, so it’s looking at things like cardiovascular disease, diabetes, cancer screenings. We also look at mental health equity, which is very, very important, and then we also have a big focus area on maternal and birth equity, which we know the Black maternal Health Crisis is just… It is, also as Sonya mentioned, it is a product of structural and systemic racism. And we, again, as she said, we have to start there in order to address the problem.

We also have a very big initiative at Sutter Health around the social determinants or social drivers of health. We know that the conditions in which we are born, we live, we work, we go to school, our access to health care and other important things in our lives are really driving 80 to 90 percent of our health, our total health. And so we’re really focused on how we build meaningful community-based partnerships that can really address the social drivers of health, because if we don’t do that part as well, we can’t help people achieve their optimal health. You have a 15-minute doctor visit, and then the rest of your life is outside of there, and that’s the part, we as a healthcare organization really want to understand, we’ve got to measure this and understand it so that we can figure out how we can best partner and build these partnerships so that we can achieve that.

“You start to think, ‘Okay, we have made some progress,’ but in the grand scheme of things, it’s relatively minimal, and race still just continues to be this determining factor in whether you’re able to live or thrive and have a full and healthy life.” – Andrea Rivera

We can’t –  health care – we can’t do everything, but we can screen for it, we can acknowledge it, we can talk about the fact that structural racism is affecting our patients, and then we can build those partnerships and really make a difference and start to see those gaps and disparities close.

AI: Andrea, why don’t we have you go next?

ANDREA RIVERA: Thank you all so much. It’s a pleasure to be here today. And I think I’d like to really focus on the role that racial disparities have played into all of this. I think a lot of that has already been said. But I would say that for racial disparities, that’s where we really see things largely unchanged, stubbornly embedded.

Even despite all this I would say more of an interest from state leaders over the recent years, when we look at the data and the access rates, the utilization rates, communities of color still underutilize their health care. Part of it is access, and I would say that there’s been a sharpened focus on expanding access to care. But it also is more related to use of care and utilizing those services. Because that’s where you really see the most jarring racial inequities, that communities of color are just not accessing mental health, services related to physical health.

And then we talk about COVID-19 and how that really pulled back the curtain for a lot of the things that we already knew existed, and I think it just really exposed all these inequities. And then you think about how it’s incredibly unfortunate that it required a pandemic for leaders to acknowledge, and really make that acknowledgement that these things like social determinants are the root causes and disproportionately impact communities of color.

For CPEHN and the partners that we work with, we’ve been drumming the beat on racial inequities for quite some time, really as a core principle to ensuring that we can adequately combat health inequities. And we’ve been doing this since 1992, when LA experienced the hardship of Rodney King. And then you fast forward to 2020, when we saw the murder of George Floyd, and then you start to think, “Okay, we have made some progress,” but in the grand scheme of things, it’s relatively minimal, and race still just continues to be this determining factor in whether you’re able to live or thrive and have a full and healthy life.

“We’ve got to make sure we have coverage for everybody. And the recent additions of even the undocumented populations, I know we’re not all the way there yet, but we’re more or closer to it than most other states.” – Martha Santana-Chin

Ana Ibarra: Thank you. Martha.

MARTHA SANTANA-CHIN: Good morning. Thank you. And I very much appreciate the comments that everybody has already expressed, agree wholeheartedly with most of what’s already been said. When you think about inequities, it really is everything. And the way that we think about it as a health plan is, how can we take the silver lining that was presented to us through the aftermath, and the awareness that the pandemic did bring on inequities. And we are optimistic that many of the policy changes that have been implemented more recently will have a longer-term impact. The charge for us now is to execute on many of those things. And so, as you think about community health workers, doulas, and the promise that they might bring to really making systemic change, it’s very powerful, if we do it right. If we make sure that the workforce looks like the people that we serve, comes from the communities that we serve, has lived experiences, and is able to build the trust that we so desperately need to build, we can break down some of those system barriers that we all know exist.

The other thing, though, is that there is a lot to do still. And one of the things that has happened in the state that we should all be very proud of is that coverage has been an absolute imperative. Like, we understand healthcare coverage is the starting place. We’ve got to make sure we have coverage for everybody. And the recent additions of even the undocumented populations, I know we’re not all the way there yet, but we’re more or closer to it than most other states.

That being said, we’ve got to serve all these people. And we know, especially in our Medi-Cal program, that there is a shortage of clinicians, physicians. We know that in most of the states that have heavy concentrations of Medi-Cal members or patients, they’re health professional shortage areas. And we also know that the physicians that are serving these communities don’t look like the people that they’re serving, and that the pipelines on the medical school front aren’t any better. We’ve got to improve that. There’s a lot of room for improvement.

So, from an inequities perspective, one of the things that we really believe is critically important is not only executing on the policy and the opportunities we have ahead of us, but to also start to focus on what’s next, which is that pipeline for getting more culturally congruent providers in the system. So we’re hoping that that also begins to get a lot more attention by way of policy and by way of systems, because we’ve got to be able to have a better representation of underrepresented communities in the medical field.

AI: Thank you for that and I’m glad everything you’ve mentioned is on my list to talk about. So, we’re off to a great start. And I feel like we can’t talk about Health Equity and Women’s Health without really talking about maternal health. And I already see some audience questions about this topic. And so I know that one of the grimmest stats in medical care is the rate of pregnancy-related deaths. Maternal mortality rates among Black women are three times higher than those of white women, according to CDPH, although I know that depending on the source, sometimes that is a little bit higher. There’s also a disparity based on the type of health insurance for birthing mothers. Women on Medi-Cal tend to fare worse than women on private insurance. These aren’t new findings, but it seems like every so often we see the news story, the report about this. And so I want to talk to Sonya and Dr. Brown about this.

Sonya, maybe I can start with you on, because this isn’t new, because we know, we’ve known this for years, we have the data. Why haven’t we seen significant improvements in this area? What’s lacking? What are we missing? What can we do next?

SYA: Well, you say we have the data, but California’s report on this subject was just released. It’s been 30 years since there’s really been that level of intensive reporting on this subject. And so the report is out. I’m very proud to say that California Black Women’s Health Project, and myself we’re part of an advisory group that was led by Black Women for Wellness to get this report completed and produced. And it’s… The data certainly it’s a thing that we all know, we know what is happening, particularly if you’re working in this area, if this is a sort of a cause for you. And so many people have entered into this work because of their own lived experiences with this challenge.

And then they begin to advocate and begin to ask the question, why is this happening? And then you learn that it’s something that’s very pervasive around our community, our families, our sisters. And we hear about it. But we had trouble for so many decades getting, not even just the state, because we’re really talking about this nationally it’s not just a California issue, although people expect for us to be doing better and we’re not. But finally getting legislators, getting hospital systems, getting the public health department to begin to talk about this issue and allow us to express it and acknowledge what the root cause is.

“I feel inspired, encouraged, particularly as California is… Sort of the door is open and it’s hard to close it at this point” – Sonya Young Aadam

I live in Los Angeles County. Our offices… Our organization is state-wide, but we’re headquartered in Los Angeles County. And I will tell you, it was Dr. Barbara Ferrer, who’s the head of county public health department, was the first person that I ever heard to acknowledge that racism is a root cause in this issue. Really, I’ve been up and down the State, and I would hear different advisory groups and different medical professionals in different public health departments that would not even want to say that race was a factor in this, so what do you say? You admitted it or you’re acknowledging it at a system level, and then the states delivered an intention to invest in the perinatal equity initiative.

That is really right now a game changer and it has given room and space for everything from financial investment to other resources, to statewide campaigns, to the opportunity for counties to develop intentional interventions around this, and some of it has to do with letting the public know that we are developing and working all of us to develop alternatives because we cannot always trust that the medical system will be there to provide us with a safe and sacred birth. We can see the data.

So what do we do in the interim? Part of it is the development of community-defined practices, the building of our own systems and supports, the expansion of doula care, midwifery, those things that we know in our community from our history and our heritage and our culture, that have an opportunity to hold us and to support us through what is supposed to be one of the most amazing and beautiful experiences of our lives. And at the same time, we know that the medical and the healthcare system, the traditional system is at least acknowledging that something needs to be done, that changes need to be made. Where do they do it? How do they do it?

We are fortunate at California Black Women’s Health Project to be a part of a number of collaboratives where we are working closely with the system to integrate community-defined care, to integrate our own support and services along with a medical model to provide this warm hand-hold navigation through these systems for black women and birthing people. It’s necessary, it feels like we’re in a time where there is the possibility of the hope for this thing, where for a long time… We couldn’t even get anybody to talk about it. So we are in a place where you can feel better about the potential.

But at the same time, and Dr. Brown mentioned it, and I think maybe Andrea mentioned it, the health professional shortage and the lack of diversity in healthcare, it’s like this combination of things that makes it particularly challenging. So at least where we have non-clinical birth support, and then the midwifery and potentially we will grow the numbers of black midwives. That’s a whole another level of disparity, challenge, inequities, racism in a practice that used to be one of the richest ones that we had to support birth in our communities. That changed and because of systems and money and all of the things that we’ve already talked about.

So I feel inspired, encouraged, particularly as California is… Sort of the door is open and it’s hard to close it at this point, so we hope that we will continue to see progress, investment resources, acknowledgement, legislative changes, more opening. I believe very much in expanding the scope and practice of certain people along the continuum of healthcare, because we need to come into a healthcare space differently, we’re not… The “15 minutes” that Dr. Brown talked about, that is not enough to build a level of comfort for some of us, and the transfer of knowledge that you hear from a doctor, I tease my mother all the time that we have to Google out to determine what the doctor actually wrote and we’re like, “Okay, now let’s translate that so that we can say what it is the doctor told you to do next.”

There are so many things that need to be addressed by a community-integrated approach, as far as I’m concerned, is the most important thing that we can do in this area of maternal disparities at this point.

AI: Thank you Sonya. Dr. Brown you just wrote about this for Capitol Weekly, and one of the lines that stood out the most to me was, you’re a physician, both of your parents are physicians, but you’re still very scared to be part of the statistics. Can you talk… you work at a health system, can you talk, I guess, at the clinical level, what is being done by hospitals, by health systems, to improve these gaps and these disparities?

SB: Absolutely, and that point is just so critically important with regard to Black maternal health and the mortality rate, because your zip code can’t save you, your income level, your education, all of the things that we think of like, “That will increase my access, I can understand, my health literacy is better, I can advocate for myself.” But regardless, all of those things tend to be the same, the mortality rate is three to four times as much for Black women compared to white, nothing can save you, and that is very frightening, that’s frightening for all of us. And knowing that racism, discrimination and bias are the root causes of this problem. As the health system… We’ve got to both, as it’s been mentioned before, improve and seriously invest in our pipeline. Because racially concordant care has been proven over and over again to improve health outcomes for different communities.

“This crisis also demands innovation. We have to innovate. We cannot do the same thing that we’ve been doing. It’s just not working.” – Stephanie Brown

So we’ve got to train more Black clinicians, and the institutions that serve Black women have to do a better job of recruiting and not just recruiting, but recruiting and retaining a diverse workforce. This calls for a strong commitment to diversity, equity and inclusion, that creates a place of belonging where racism and discrimination are not tolerated, and the commitment to diversity must go all the way to the top of the organization.

So that’s the first thing, is really that commitment to the workforce to creating a space for where racially concordant care can happen, and really investing in the pipeline.

This crisis also demands innovation. We have to innovate. We cannot do the same thing that we’ve been doing. It’s just not working. And so at the Sutter Health Institute for Advancing Health Equity, what we really aim to do is start with the data, so we define the problem with real numbers, the real patients that we take care of, and then we can create interventions.

When we understand what’s happening, we can disrupt that cycle and really create new interventions and approaches to how we deliver care. So we are currently piloting several programs in our maternal health innovation labs that are studying some new approaches. We are looking at the use of Postpartum depression screening apps, for example, which now, if you can really start to screen, increase the number of touches, for example, that a patient can have with the health care system where we don’t have to drag them in for an inconvenient appointment time for 15 minutes and think we’re gonna do everything, but really creating a new space and opportunity using technology to do screenings and connect people whenever they’re having a mental health need in the peripartum period.

That is gonna make a big difference. And we’re also looking at doula care, and we’ve heard Sonya mention that, but again, we need to understand, we need to evaluate and understand how we can incorporate such a valuable resource into the health care setting. We don’t know everything inside of the walls of health care, we’ve got to build these bridges and these community partners, and really start to evaluate it with real numbers and really look at outcomes and think, “How can we expand the way that we take care of people to include innovative models that will really start to move the needle here?”

So it’s really starting with the data, recognizing that racism is the root cause, and then building the workforce that we need and committing to it. And then also really trying to mitigate and weed out the unconscious bias that really is pervasive. We’ve got a lot of innovation and programming as well around unconscious bias, which I think we may get to in a later segment, so I’ll stop there.

SYA: Can I just add, as Dr. Brown mentioned innovation. I think that when we think about culture, we don’t have a healthcare system that’s really designed to look at cultural differences in care. Maybe it is for some cultures maybe. But for the black community in particular, we are a collective work or collectivism is what’s important. Not like our individualism, we probably like to respond better to group care, to group opportunities, to coming together.

So the way our system and our society is set up where individual healing, individual this, individual approaches. The 15 minutes, we can share 15 minutes and 15 of us can show up and get probably a better level of care, and then we can talk about it and come together to work together to care. So the even innovation system, sort of stepping out of what the medical books and the training and the practices tell you have to be done.

“We saw with Medi-Cal re-determinations that almost half of all people that lost their coverage are of Latinx” – Andrea Rivera

That is something that… The opportunity is there. And I hoped after COVID that we would see so much more of that, but we moved to telemedicine, which was, “Oh now you can’t go back from that,” which is great, but I wish that we would’ve be able to move to a more culturally supported, representative of how people would seek and access care, and how that could be much better done, particularly for our community, ’cause I know that that would be a better opportunity for health care.

AI: And I wanna bring Medi-Cal into this because California has put a lot of work into expanding the Medi-Cal program, and I believe starting in January 1st, we’ll see the remaining group of undocumented folks qualify for full scope Medi-Cal coverage. And I want to ask Andrea, the work you’re doing at CPEHN. And I don’t know there’s a way, or if anyone’s measuring this, but people who are gaining this new access to Medi-Cal, are you seeing any improvements in terms of them seeking routine care, or do we see them… Do we see more women seeking mammograms, getting prenatal care earlier-on, doing cancer screenings more routinely, what are you hearing? What do we know about how this new access to Medi-Cal is rolling out for these populations?

AR: Yeah, and thanks so much for that question. I think, obviously, all these expansions to Medi-Cal to make it a more holistic healthcare system have been super important, but I go back to what we see when we start to compare what access looks like and then actual utilization. And that’s where you see so much drop off. I think that there’s… And rightfully so, because relatively this expansion of Medi-Cal and Health For All is pretty young. It’s been around for 10 years, the campaign. But in the grand scheme of things, there’s been, I think, more of an effort to do education and outreach, get people enrolled in coverage, and that is the important first step… but as far as that second step to educate folks on, “Well, what are the benefits that you can get?”

A lot of people don’t know that you can get dental benefits under Medi-Cal, vision, all these mental health services that really go into ensuring that you have the most accessible care, and that sort of, I think the issue here.

And then I also wanna take us a little bit of a step back, and I think we saw with Medi-Cal re-determinations that almost half of all people that lost their coverage are of Latinx, and then in addition to that, we already knew that Latinos were more likely to be uninsured than any other community of color in the state.

And so there’s definitely a lot more that we can do, I would say, to ensure that people are actually getting the mental health care that they need, the preventative care to address these issues like maternal mortality rates and making sure that people have comprehensive perinatal services and postpartum care. These expansions to Medi-Cal, to provide doula services, community health worker services, these are all part of, I think that the part of the issue that we still have to resolve, which is, what are we doing to ensure that communities of color are actually utilizing these services and these benefits?

I think the other part of the issue, and this was talked about earlier that the health care workforce, it does not reflect the diversity of our state. There’s so much more that we can do to ensure that our workforce is culturally accessible, linguistically accessible, and this is where I sort of go back to the important role that community health workers and doulas play, because these are culturally accessible workforces, they come from the communities that they serve. And I think that there’s been, over the last couple of years, a lot more of a focus on what we can do to integrate these community-based frontline workers, but these conversations are relatively new, and I think that there’s a lot more for us to continue to address as far as how we can make sure that we actually see the successes that we want with all these expansions to Medi-Cal and that people are not just getting enrolled in care, but also accessing their care.

AI: Martha, I think that leads right to you, How are we… Health plans, the state… are working to make sure that people are using services, how are plans and the state working to pretty much improve outcomes overall? I know there’s a lot of work in that area. So maybe you can talk a bit about what you and HealthNet are doing.

MS-C: Yeah, absolutely. In the big scheme of things, these programs are very young, they’re in their infancy. What we are really focused on is making sure that we start with having strong networks, networks of community health workers, doulas and other members of the care team that can help expand access if we do it right.

So a physician who’s caring for administrative care coordination type of work could probably care for more people if we partner them with a community health worker or they understand the value that the doula can bring to their practice. So first, we’re focusing on the partnerships that it’s gonna take to really build the workforce that we need to deliver the value that is intended. So we’re partnering with organizations that are very local, very grassroots, very community-based, that have been doing some of this work for decades, quite frankly, through grant-funded programs, and we’re helping them figure out how to create programs that are sustainable, draw revenue streams from the benefits that we now have available, and getting them connected with technical assistance providers so that they could fulfill their aspirations to become a solid network providers.

There’s a lot that we have to do still in the state to build the kind of workforce that it’s really gonna take for us to deliver the value. As an example, we have over two million members, and we believe that roughly 70% of them actually qualified to get community health worker support. That’s thousands of people that it’s gonna take to get that job done. We don’t have thousands and thousands of people in the workforce today. So step one, partnerships with local community-based organizations to build the workforce that we’re gonna need to deliver the care.

The second piece is building that ecosystem, making sure we’re partnering with practices, federally-qualified health care centers and others, so that they could connect with and expand their teams with these networks of supportive services providers that can help their practices.

One of the things that we often hear from our provider community is how hard it is to reach the unengaged. And in some cases it’s not because physicians and practices aren’t trying, it’s because we have bad phone numbers, bad addresses. It’s hard to get ahold of ’em, but they’re on the rolls. And so, now with these new services and benefits, we can start to do some more grassroots work to knock on doors, to really inform policy to make sure that when people are applying for benefits, they’re giving cell phone numbers and an ability for plans to text with them, because there’s restrictions around some of that today.

So the next is creating that ecosystem, to really make sure that we’re using these benefits at optimal rates, and then measurement. So, there are a number of areas that we’re really focusing on, your traditional quality metrics, preventative screenings, prenatal, postpartum care, are only a few examples, but we’re also very intentionally focused on measuring engaging the unengaged.

Are they connecting with the healthcare system? Are they accessing community health worker benefits? Are they connecting with their primary care providers and the like? So that’s the other part of this. And then more recently, because of changes that have happened with, reimbursement levels. In the Medi-Cal program, we struggle with getting providers that care for commercial populations to care for Medi-Cal populations. The money’s just not there for them to sustain their practices. And so, the recent change or the recent investment through the budget to elevate the level of reimbursement for maternal health providers, primary care providers, and behavioral health providers, is something that we as health plans have been advocating for, for a very long time. And we’re finally making some movement in that direction.

I’ve been working with the Medi-Cal program for over 30 years, and the only thing I had ever heard about rates before is this threat that when budget threats met crisis levels, that we were gonna have to cut 10%, that infamous 10% reduction finally going away. And now we’re talking about getting a little closer to parity. So maternal health providers, primary care providers, and behavioral health providers, the idea is that we wanna be able to reimburse them at the equivalent of at a minimum 87.5% of Medicare.

That’s not gonna get us to parity, in the commercial space some of these providers are getting 120% of Medicare, 140, it just depends on the part of the state in which you operate, but it’s a step in the right direction.

And the reason I raise that is because as we’re standing up these services, as we’re standing up these benefits that are intended to address some of those disparities and get people navigating through the health care system much more efficiently, we have to care for expanding that physician pipeline because without that access we’re never gonna be able to make the inroads that we’re gonna need to make.

So at a very high level we’re really focusing on the systems, scaling these services, scaling these benefits, but doing it in partnership with community and really focusing on engaging people with lived experiences that speak the language. Because we understand that in order to make progress we’ve gotta build trust. That’s step number one. And as you’ve heard other panelists describe so eloquently it’s just, we’ve gotta start there. And so, there’s still, like I said, there’s still a lot of work to do, but we’re moving the pieces forward as best as we can and in partnership with our communities.

AI: Yeah. And so we do wanna get to questions, I think, in five minutes, because we do have a lot of questions from the audience. So for anyone who wants to answer this one, at the state level are there any recent bills or actions that you’ve seen, and some of you have mentioned some already, that you think can really make a difference or that you’re really hopeful will make a difference in advancing the work around equity that you all are doing, any bills or new laws, any budget allocations that you think are very promising to help us in this area? Feel free to jump in. Anyone.

SB: I can start. Thanks for the question. So, AB85 would ensure that health teams have resources to conduct the social determinants of health screenings, make referrals in community, and then also provide community navigation services. So, as I mentioned, and we keep talking about the social drivers of health are responsible for so much, the vast majority, 80 to 90 percent of our overall health.

So this bill sponsored by Assemblywoman Dr. Akilah Weber, would really provide funding for that to happen. So it’s critical that health care organizations will be able to play our part in screening for these vital needs. And what happens, again, I keep talking about that 15-minute visit, but we’ve gotta find ways, how are we supposed to expand what people need to do to screen to make those referrals and to build those ties back to the places that our patients live and work and go to school without the ability to do it, we’ve gotta have the ability to expand that time period.

And you do that by providing the funding to do it. We cannot continue to have unfunded mandates, onto our already stressed health care workforce. So at Sutter Health Institute, in partnership with our population health division, we have been, as I mentioned, studying how to best screen for and address the social drivers of health in a variety of health care settings. So in the acute care side, as well as in the ambulatory side. So that means inside of the hospital and in the community, in our clinics. And that happens in real-time at the point of care. So understanding how can we address these critical components of who our patients are and what they need in such a challenging, existing climate of these short visits and other realities of our healthcare landscape. So again, the funding, AB85 would demonstrate a clear understanding and commitment to the vital nature of addressing the social drivers of health.

AR: And I’d like to jump in here too, and just quickly say that for CPEHN I think that we’re particularly excited about recent investments in Medi-Cal to now provide community health workers as a fully covered benefit. There was also just this year, the recent expansion to provide mobile crisis services to people who are enrolled in Medi-Cal.

Both of these things really go hand in hand with this concept of the community-defined evidence-based practices and quite honestly, really honor what community members have been asking for, for a long time: To really start to be innovative and utilize forms of trauma-informed care, culturally competent care like CHWs, mobile crisis services that move us away from how we’ve traditionally treated mental health and other illnesses and diseases, to it being more of like a public health kind of issue. And really looking more holistically instead of like, “Well, what can we do to just… ” prevention and intervention is also important, but what are some of those tactics that we can use to ensure that people have the navigation services that we’ve talked about through CHW. So that they do utilize their benefits and understand, “Well, maybe I’m enrolled in Medi-Cal, and that also means that I can enroll for other social safety net programs,” and sort of have that ability to work with someone that can really understand their needs.

AI: I’m being told we gotta move to audience questions now. So I’ll just go in order here. So the first one says, “My question is related to the individual level. I’m hearing a lot of stories of nurses ignoring birthing people of color, downplaying their pain and leading to tragedy. What is being done on the ground level to ameliorate communication and racial understanding to lead to better healthcare provision to birthing people of color?” Whoever thinks they can answer this, please jump in.

SB: I can start really quickly. So, the Senate Bill 464 is the California Dignity and Pregnancy Act. And one component of that requires that any hospital or facility that provides perinatal care, that all of those clinicians and staff are required to undergo unconscious bias training. And so that really can help to bring the things… We have all grown up in this environment and whatever ways that we’ve been conditioned by our society, and knowing that structural racism, systemic racism, it affects all of us. And so the way that we move unconsciously can determine, it can be life or death for people, just like we said, not believing someone is in pain or discounting their symptoms, things like that.

And so really that training is designed to bring people to focus and really understand how to think about when you’re interacting with someone that is different from you to overcoming that bias. We’ve taken this further at Sutter Health. So we trained, about 2500 perinatal clinicians and staff. For this requirement, we’re up to about 85% of our workforce, that’s required to take that training. But what’s really exciting also, we’ve done a few other things.

We had a symposium in the last fall on unconscious bias that was done in partnership with the California Medical Association, Physicians for Healthy California, California Primary Care Association, andGenentech was our gracious sponsor for that. We were able to bring thought leaders and experts in this field including assemblywoman Dr. Akilah Weber, together in a forum with over 400 attendees, to discuss what are the innovations around unconscious bias, because we know that clicking through a 30-minute training isn’t going to be enough. So how do we take this further and really bring this work, in measurable ways, to the forefront.

We’ve also, several of our medical groups at Sutter Health went beyond this sort of mandated training and said, “Hey, we are not perinatal clinicians or staff, but we feel strongly we want all of our physicians and staff to be trained as well.” And so they took this initiative, and so at the institute, we were able to then pilot and evaluate what it looks like for all clinicians to undergo unconscious bias training.

And then even further, which I’m really proud about, is that all of the clinician leaders across the system voted to require unconscious bias and health equity-related education and training for credentialing. So if you are going to be a clinician working at Sutter Health as of January 1st, 2024, everyone is required to undergo this type of education, and that is self-governance. We did that on our own, and we are so proud of that… To be a Sutter clinician. We care for over 3 million people in Northern California. And the fact that we stepped up to the plate to do that and require that of ourselves is really sort of moving us in the right direction as well on the ground.

SYA: Do I have time to comment on that?

AI: Yes, please. Sonya, go ahead.

SYA: Okay. Okay. Thank you. Dr. Brown, I’m so happy to hear you talk about it, because earlier in this panel you talked about the need for things to come from the top. And now you’re talking about it also even coming, I wouldn’t say from the bottom, but I think you understand what I’m saying. But it is a matter of these things meeting at a place where you see these changes and the desire to be a better provider, a better caring space for people, that you’re seeing it sort of penetrate its way from the top to the bottom, bottom to the top. And I’m so happy to hear about that, and I look forward to learning more.

I wanted to add though, that there is also, from the patient side, we’ve always advocated even before there was this great awakening around equity and disparities and the talk around even maternal and reproductive health challenges, disparities that for Black patients visiting clinicians I’ve always encouraged them, “Don’t go alone.”

And it’s because there’s just an opportunity maybe for you to inspire better communication. It’s like you show up and maybe the person on the other side in the white coat or jacket may feel just an opportunity to have a better relationship with you if there’s someone else asking questions as well. And so having doulas, we’re just even if we’re not only talking about maternal health, but having a birth worker, having a community health worker, having someone there to support creating a safer environment for any person seeing a health professional when you’re talking about your pain, because those things that you say, it gave me… and it always just makes me cringe because it’s really so deeply rooted in the dehumanization of Black people in this country. Like, our pain isn’t real, and our… We can handle more pain than other races.

It just goes back and so deep that it’s not something that’s gonna change, sort of like with just the unconscious bias training or just this innovation or that law or that legislation. It is so deeply rooted. If there’s that feeling, even in the history of medical training and education that gets a person in front of you to say that “you either only want opioids or you want this,” or “you’re not really feeling it,” that comes from some deeper place. And I think it’s just there’s safety to me in numbers.

There are changes, but it could take generations for us to really see the absence of that kind of thinking in an environment and knowing that the patient’s life is at stake. If they are complaining that they have problems in their leg or pain, and then you don’t realize they’re blood clots, and then ultimately you have that loss of life or potentially some… The loss of the child.

So we have to do more, but I’m not sure that the do more… It’s like, how do you legislate the heart? How do you legislate that? You don’t.

We have to just become a better society, but if we’re not looking at racism and we’re not looking at culture, we’re not looking at the history and I’m speaking particularly with Black people in this country, if we’re not looking at that or willing to really acknowledge that, yeah, we’re not gonna address that. So we have to protect ourselves, too, when we come into these environments. We have to have ways and we have to have support to help us advocate for a safer environment when we’re in the health care system.

AI: Yeah. Thank you for that. And Andrea, thank you for helping me answer some of these questions on the chat. I see you’re doing that. I wanna jump to this question because a couple of you talked about this, getting people of color to use health care resources. The question says, “What would be the most effective way to encourage people of color to utilize health care resources while there is so much cultural distrust of the medical system, because of the attention being drawn to the disparities and mistreatment in communities of color that are so prevalent?” Andrea…

SYA: The public-private community connection, the integration of community-defined practices with the medical model. You’re not gonna get the trust unless you have those trusted… What did we do during COVID? It took the community to inspire and support, and I’m sorry, Andrea, I might’ve stepped on you, so forgive me for that. But it took the community to bring those folks together to be able to say, “Okay, I can maybe trust this and I’ll pursue this and I’ll get this.

Because you had to go to the trusted messengers in order to do that. And it’s gonna be… To me, it’s the same thing that’s necessary for how we move forward, in getting utilization rates up and may end looking at the potential of different models of care. And I really strongly believe in a group model. We, in Black communities, it’s the sister circles and we even do a brother circle, and we can provide services there that range from community practices all the way up the scale to talking about diabetes and training people around the issues and the challenges that impact our health in our communities.

AI: Yeah. Yeah. And there was a similar question asked to Andrea, and I don’t know if you’ve answered this one, Andrea, but it was, “hat do you think are the root causes for underutilization?” And you talked a little bit about this. I don’t know if you want to, and Sonya mentioned a couple of this too, if you wanna explain a bit more on that, Andrea.

AR: Yeah. And I did share a copy of a publication that CPEHN put out, I think in 2021 now. It is more specific to what some of the reasons are for why people don’t access mental health, under Medi-Cal. But I think there are a lot of common themes that we see throughout the healthcare system. So one of the things that we found was just the amount of time that it takes to find a provider being a really big barrier, having to go through all these complex systems of, “Oh, okay, searches now finding someone that’s close to me, somebody that speaks the same language as I do.” There’s so many different layers to that, and it really reduces the amount of options that people have.

And people, after a while just get frustrated and stop looking, or stop that whole process entirely. There’s also confusion around language access and so this is something that we already know. A lot of websites will use Google Translate or maybe are not translated in culturally competent ways and that is a really big issue, especially for the AAPI community where a lot of translations might be directly translated, but they’re not accounting for some of those needs.

And I’ll put a specific example: We were working with a partner on refugee and immigrant mental health, and they were talking about how the word for health in “mental health” on a website was directly translated and in their language it meant “crazy.” And so things like that where things are not being measured in culturally competent ways that deter people from getting care in the first place.

AI: And we have one minute left, but I did wanna get to this last question specifically for Martha. “I just would love to hear more about the community collab efforts. Are there any links with the details of the outcomes?” I don’t know if there’s a link you can share, if you can briefly explain in a minute, your answer.

MS-C: Yeah, so I’ll give you an example. One of the things that we recognize, we as health plans need to lean very heavily on community and some of these organizations that have been doing this work for many, many years. But we need systems change, in order to really make an impact, we need real systems change. And so, as an example, we supported the California Coalition for Black Birth Justice. And what they’re really very focused on is driving a coordinated agenda to mobilize key stakeholders across the industry, to drive policy change.

And as a result of some of that, just as an example, one of the ideas that’s being implemented by CMS is this idea that hospitals should be designated as Birth Equity, have a birth equity designation so that people understand that the practices within their hospitals are friendly to people of color.

And so those are the kinds of things that we really need to do a lot more of. But it’s that kind of thing. And on our website we’d also have some information about community health worker partnerships and a whole host of other things that we’ve done over the years, where we’ve piloted incubated ideas and then they actually turned out to be now full benefits. The doulas is an example of one of the things that we did in LA County that made a significant improvement in outcomes. And now it’s a benefit, but we did that many, many years ago.

AI: Thank you for that. And I think that’s time. So thank you all for joining me in this conversation. I know we could have talked a whole other hour about this. So I’ll kick it back to Tim.

Tim Foster: Yeah, thank you all for participating….

Thanks to our Women’s Health sponsors: THE CALIFORNIA HEALTH CARE FOUNDATION, THE TRIBAL ALLIANCE OF SOVEREIGN INDIAN NATIONS, WESTERN STATES PETROLEUM ASSOCIATION, KP PUBLIC AFFAIRS, PERRY COMMUNICATIONS, CAPITOL ADVOCACY, LUCAS PUBLIC AFFAIRS, THE WEIDEMAN GROUP and CALIFORNIA PROFESSIONAL FIREFIGHTERS