Brown colleague at reins of Health & Human Services

California’s Health and Human Services Secretary Diana Dooley has had a copy of Picasso’s famous portrait of Don Quixote on her wall since college. “I’m a bit of a windmill tilter,” she says.

The original windmill tilter hangs near a colored pencil drawing by U.S. Senator Dianne Feinstein of flowers in a vase and the fisheye view of the Earth that graced the cover of the original Whole Earth Catalogue.

Unlike other members of Gov. Jerry Brown’s cabinet, Dooley has a long history with the Democratic governor, serving in his legislation unit during the latter part of his first term as governor and running the office during his second term that ended in 1982. She sits on the Health Benefit Exchange Board that will determine lower cost health coverage options for Californians starting in 2014. Most recently, she was president of the California Children’s Hospital Association. She began her professional career as an analyst with the State Personnel Board.

CW: How have your first nine months been?
DD: You’ve hard the old adage “drinking from a fire hose?” There’s been so much to deal with. The heavy reductions. Of the $12 billion (in spending reductions) nearly half came from this agency. And very little of that is actually in state government work. It’s the services that we provide through the counties to the people who need those services.

How do you get the people the services they need with such a high degree of programmatic reductions?
We’re not doing more with less. We’re doing less with less. And there are people that aren’t getting all that they have received in the past. So a major priority for me has been to get leadership in the departments that will help make these reductions in ways that protect the base and give us something we can build forward on.

Do we have a health care system in this state or is it a disease treatment system?
There’s no question. It’s an illness treatment system. A real health care system making people healthier would have a much bigger investment on the front end but we don’t have the resources to do that because we’re spending so much money on the back end.

How is health care going to change in 2014?
There are three legs to the stool of health care reform. And because of all the attention around mandates and coverage, people think health care reform is just the exchange or coverage expansion. That’s a part of health care reform but it’s not all of it. Reforming the delivery system, assuring that we’re getting value is another part. Utilization and cost. The right level of care. Going to a clinic instead of something else might be better utilization. I’m not prejudging, I’m just saying we have to look at those things. And the third leg is prevention and personal responsibility for health. How do we incentivize people to avoid the health care delivery system or the illness treatment delivery system?

When you work on preparing for 2014, what’s the working estimate of how many more people will be on Medi-Cal?
Now there’s about 7 million people on Medi-Cal. Estimates vary widely about how many more will be added.  Most of the estimates are in the 3 (million) to 4 million range. That 3 (million) to 4 million eligible for Medi-Cal is the difference between 133 percent of poverty and 200 percent of the poverty level. There are anywhere from 1 million to 1.5 million Californians that might buy products on the exchange. Based on their income, some people will be eligible for subsidies on the exchange but anyone can buy from the exchange if they wish to. So it may be people buying on the open market now might like the vehicle the exchange represents. There are a lot of issues that need to be addressed about how the exchange will change both the insurance market and the delivery of care market.

Are there hospitals and doctors to take care of all these newly covered persons?
There are real capacity issues ahead.  There are capacity issues in our system, without any question, but part of that stems from creating expectations that exceed our ability to deliver. I think we have to have a very robust conversation about appropriate levels of care. Who does what in the health delivery system.

For example?
For example, how many services are provided by specialists and MDs and nurse practitioners and nurse assistants? The whole “scope of practice” question is one that the capacity limitations are going to force resolution of in terms of who does what in the medical delivery system. How many tests are necessary? One of the provisions in the (federal) Affordable Care Act is incentives to use evidence-based medicine. People use the word evidence-based medicine but what it means is limiting the provision of services to procedures and testing for which there is evidence of efficacy. So are we getting the right bang for our buck out of the medical system now? That’s an open question. Some of these resource pressures will demand the answers.

So I wouldn’t get an experimental treatment to help with whatever is wrong with me?
Not even an experimental treatment. For example, a couple of years ago, the Center for Disease Control commissioned a report done by experts that said every woman over 50 doesn’t need an annual mammogram. But our expectation is that women over 50 need annual mammograms. The Cancer Society and women’s groups criticized this report. But the evidence was clear – unless you had certain risk factors you didn’t need annual tests. We have so much advertising and promotion of drugs and procedures and testing that reconciling the evidence of what’s needed with the perception of what’s needed is a serious issue.

Kinda like politics. Its not what it is, it’s what it looks like.
I wanted to say one other thing about the 3 (million) to 4 million more people on Medi-Cal. A disproportionate number of those are healthy people because Medi-Cal is not an insurance product. Medi-Cal is a product where if you meet the income eligibility and, if you’re sick, you get enrolled. So the people who are eligible for Medi-Cal but aren’t enrolled now are for the most part healthy. The next level up of the newly eligible, it’s unclear how many of those will be healthy as well because there is a new income test.

What’s the governor want you to do here?
I am always learning from him. He fascinates me, as he does a lot of people. I’m very committed to what I think his priorities are of efficiency and personal reliance. So our goal is to help people be independent and be as healthy as they can be. Not just the people reliant on government but people more broadly. We’re making our systems more efficient and responsive. And as we build out the exchange and make health care affordable we need to do it in a way that is straightforward and understandable and efficient.
Also, I don’t think there’s any question, everybody has seen it all year long with this budget, the guy is pretty tight. He expects us to get as much out of every dollar that we spend on behalf of the people of California. I understand that message and I share that priority.

One of the things other cabinet secretaries say the governor says is , ‘Don’t wait around for me. Do your thing. Work with your fellow cabinet secretaries. Be self-reliant.’
We have done that. We have a good team. I brought everyone togeth er for a dinner party at my home. We aren’t waiting to have formal meetings with the governor. We are all figuring out what needs to be done and trying to do it. That’s what he wants us t
o be doing. My own priority is to exceed expectations. Promise low and deliver high. We have a lot of challenges and there are limits to the extent we can move the needle. You have a limited term, four years. One of them is down. So what can we do in the next three years that will make lives a little better. I don’t want to get grandiose about what change I think we can effect but we have to believe we can make change or we shouldn’t have taken these jobs.

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