Health officials are recommending diet and exercise as alternatives to heavily advertised weight loss drugs like Wegovy and Zepbound, advice experts say is unrealistic.

“Of course he tried eating well and everything, but now with the medications, it’s better — a 100% change,” said Wilmer Cardenas of Santa Clara, who said his husband lost about 100 pounds over about two years using GLP-1s covered by Medi-Cal, California’s version of Medicaid.

California joined several other states in restricting an option they say is no longer affordable as they confront soaring pharmaceutical costs and steep Medicaid cuts under the Trump administration, among . Despite negotiated price reductions announced in November that would make the drugs available at a “dramatically lower cost to taxpayers” and enable Medicaid to cover them, states are going ahead with the cuts, which providers say may undermine patients’ health.

“It will be quite negative for our patients” because data shows people typically regain weight after stopping the drugs, said , medical director of the University of California-San Francisco Weight Management Program.

While California, , , and stopped covering adult GLP-1 prescriptions for obesity on Jan. 1, they continue to cover the drugs for other health issues, such as Type 2 diabetes, cardiovascular disease, and chronic kidney disease.

, , and Wisconsin are planning or considering restrictions, according to KFF’s .

That reverses a trend that saw 16 states covering the medications for obesity as of Oct. 1. Interest in providing the coverage “appears to be waning,” the survey found, likely due to the drugs’ cost and other state budget pressures. North Carolina pulled back GLP-1 coverage in October, but reinstated it in December, bowing to court orders despite a lingering budget shortfall.

Catherine Ferguson, vice president of federal advocacy for the American Diabetes Association and its affiliated Obesity Association, said it’s not clear how states will adjust to the White House plan to lower the cost of several of the most popular GLP-1s through TrumpRx, an online portal for discounted prescription drugs. The price of Wegovy, for example, will be $350 per month for consumers, versus the current list price of nearly $1,350, and Medicare and Medicaid programs will pay $245, according to the plan.

“Many states are facing budgetary challenges, such as deficits, and are working to address the impacts of the changes to Medicaid and SNAP,” Ferguson wrote, referring to the Supplemental Nutrition Assistance Program. “As more details become available for the Administration’s agreements, we will see how state Medicaid responds.”

The Department of Health and Human Services referred questions to the White House, which did not respond to requests for comment on states’ termination of Medicaid coverage for the weight loss drugs.

California projected its costs to cover GLP-1s for weight loss would have more than quadrupled over four years to if it didn’t end Medi-Cal coverage for that use. Medi-Cal has covered weight loss drugs since 2006, but use of GLP-1s soared only in recent years. By 2024, more than 645,000 prescriptions were covered by Medi-Cal across all uses of the medications. The California Department of Health Care Services could not readily provide a breakdown of whether the drugs were for weight loss or other conditions.

When asked whether the state would reconsider its plans in light of the announced price cuts, Department of Finance spokesperson H.D. Palmer said it had no plans to do so. California’s cut is written into .

California officials would not say how much it could save under the TrumpRx plan, citing federal and state restrictions on disclosing rebate information.

Health providers don’t expect the Trump administration’s negotiated price cuts to make much difference to consumers, because pharmaceutical companies already offer some discounts.

“The out-of-pocket costs will still be very cost-prohibitive for most, especially individuals with Medicaid insurance,” Thiara said.

is among the other states that ended their coverage Jan. 1. Officials with the New Hampshire Department of Health and Human Services did not respond to requests for comment.

About 1 in 8 adults are now taking a GLP-1 drug for obesity, disease, or both, up 6 percentage points from May 2024, according to released in November. Over half of users said their GLP-1s were difficult to afford, and many who had stopped the treatment cited the cost.

Public and private payers have been trying to wean patients off to save costs. California health officials said Medi-Cal members and their health care providers “other treatment options that can support weight loss, such as diet changes, increased activity or exercise, and counseling.” That echoes advice from the New Hampshire Medicaid program.

California Department of Health Care Services spokesperson Tessa Outhyse said in an email that the official advice to try those other approaches now “is not meant to dismiss any past efforts, but to encourage Medi-Cal members to take a renewed, proactive, and medically supported approach with their healthcare provider that may appropriately include these additional options.”

But that may be unrealistic, said , founding director of the Center for Clinical Nutrition at Keck School of Medicine of the University of Southern California.

“We definitely want patients to do their part with the diet and exercise, but unfortunately, and from a practical standpoint, that itself frequently is not enough,” Hong said, adding that usually by the time patients see doctors they have already failed at achieving results through those means.

Hong understands why Medicaid programs, as well as private providers, want to cut back on covering the drugs, which can cost per patient per year. However, they can produce twice the weight loss as the medications typically used previously, he said.

A school of medical thought supports patients’ gradually ending their use, but Hong said obesity is generally considered a chronic condition that requires indefinite treatment.

“Once they reach their target weight, a lot of people will try to see whether or not they can wean off,” Hong said. “We do see a lot of patients — when they try to get off, unfortunately, then the weight comes back.”

Medi-Cal members under age 21 for purposes including weight loss, California officials said, citing a federal requirement.

Medi-Cal members are able to keep their GLP-1 coverage if they can demonstrate it is medically necessary for purposes other than weight loss, the department said. Members who are denied coverage can seek a hearing, the department said in to members.

Members will still be able to pay for the prescriptions and may be able to use various discounts to lower costs. Another option is new pills to treat obesity, which will be cheaper than their injectable counterparts. The a pill version of Wegovy on Dec. 22, which will likely run $149 per month for the lowest dosage, and similar weight loss pills are expected to be available in the first half of the year.

While Cardenas said his husband, Jeffer Jimenez, 37, uses GLP-1s primarily for weight loss, Jimenez’s prescription is for his diabetes, so the couple hoped to continue receiving coverage through Medi-Cal.

“He tried a thousand medications, pills, natural teas, exercise program, but it doesn’t work like the injections,” Cardenas said. “You need both.”

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For more than two decades, the community health worker has supported hundreds of families throughout southeast Los Angeles by helping them sign up for food assistance, sharing information about affordable health coverage, and managing medications for their chronic illnesses. She’s guided by the expression “an ounce of prevention is worth a pound of cure.”

But she makes only around $20 an hour from a community health organization and must hold down a second job to make ends meet. “They pay us very little and expect too much,” she said in Spanish. “We build trust. We offer support. We’re the shoulder people rely on, but we don’t get fair wages.”

California looked to professionalize thousands of community health workers such as Hernández to improve the health of immigrant populations, particularly Hispanic residents, who often experience of chronic diseases, are more , and face more cultural and linguistic barriers when trying to access services. Studies show their work hospitalizations as well as emergency room and urgent care visits.

The state hewed closely to a series of put out in 2019 to standardize training and certification, integrate these workers into the health care workforce, and provide fair wages, including reimbursements through Medi-Cal, the state’s Medicaid health insurance program, to compensate for work that traditionally has been done on a volunteer basis or for low pay. But six years in, California has backed out of many of those initiatives.

The state has eliminated a certification program and rolled back nearly all funding to train and expand this workforce even though it set a goal of by this year. Although Medi-Cal began covering their services, participating health plans set uneven billing requirements, making it difficult for workers to get reimbursed. And the state didn’t follow through on a planned pay raise.

With federal funding cuts just passed and President Donald Trump targeting immigrants for deportation — even with the Department of Homeland Security — advocates fear California is abandoning its health equity initiative for immigrants, people of color, and people with low incomes when they say that effort is needed most.

“We’re in a very dire situation right now,” said Cary Sanders, senior policy director for the California Pan-Ethnic Health Network, a statewide health equity advocacy group.

A spokesperson for Gov. Gavin Newsom, Elana Ross, said “the state has taken difficult but necessary steps to ensure fiscal stability” and that the administration continues to have a dialogue with community health workers. Ross added that the Democratic governor, a , remains committed to defending immigrants being targeted by the Trump administration.

‘Our Office Is on the Street’

There are more than 60,000 community health workers nationwide, including roughly 9,200 in California, and this workforce is projected to grow 13% over the next decade, three times as fast as for all occupations, according to from the U.S Bureau of Labor Statistics. But experts say these numbers are an undercount given the various titles community health workers hold and that many work outside of health care and governmental institutions.

Community health worker is an umbrella term that includes peer supporters and community health representatives. These workers, often known as promotores, who work in clinics, hospitals, public health departments, and local nonprofits, places where they are trusted and have a grasp of their community’s most pressing health needs.

Besides helping people manage chronic illnesses such as heart disease and diabetes, they promote reproductive health, children’s health, and oral hygiene, and they help prevent injuries and review medications. They can make people feel safe when reporting domestic violence and other abuses. They also connect people to housing and food assistance. “The community health worker is not sitting at a desk,” Hernández said. “Our office is on the street.”

Back in 2019, the California Future Health Workforce Commission recommended integrating community health workers into the health care system, and in 2022, the state authorized over three years for the California Department of Health Care Access and Information, which oversees health care workforce development, to recruit, train, and certify them.

The agency sought to standardize training and certification, but some community groups feared that would create barriers to entry by not giving enough credit for lived experiences and cultural competency. But just as the agency offered more flexibility and allowed community-based training, the state slashed $250 million in funding last year due to budget constraints. This year, the certification program was officially eliminated.

Spokesperson Andrew DiLuccia said the agency is now considering a program to accredit community organizations rather than individual workers and plans to spend its remaining $12 million on technical assistance, workforce development, and salaries for those working with immigrant communities.

According to the National Academy for State Health Policy, offer a voluntary or mandatory community health worker certification program.

Some community health advocates say California’s missing an opportunity to carve a career path for this workforce. Currently, some courses offered by nonprofits, counties, and colleges , a degree, English fluency, or prior experience. Most are concentrated in the San Francisco or Los Angeles area, leaving in much of the state.

Lourdes Bernis, a dentist from Ecuador, is a model for how community health workers could be integrated into the health care system. She began as a volunteer promotora more than a decade ago and in 2019 received free training from Los Angeles County, allowing her to move into a full-time job with benefits for the county’s Department of Mental Health to help Spanish-speaking women manage depression and anxiety as they recover from drug use.

Bernis now plans to become a peer-to-peer support specialist inside hospitals and clinics. Meanwhile, many of her colleagues with decades of experience remain stuck in low-paying roles and can’t afford training to advance. “There are promotoras who have 20 to 25 years of experience, but they are still volunteering,” Bernis said in Spanish.

Medi-Cal’s Role

To pay community health workers, Medi-Cal began covering their services in July 2022, but California for them after voters approved Proposition 35, which hiked the pay of physicians, hospitals, community clinics, and other providers instead. Since then, the state has yet to establish a uniform system for how health plans should contract with organizations that employ community health workers.

“We have to jump through hoops,” said Maria Lemus, executive director at Visión y Compromiso, a Los Angeles-based nonprofit representing community health workers. “It just causes havoc, because each plan could have different requirements.”

Lemus said it took the organization nearly six months to establish payment with one health plan.

And though Medi-Cal reimbursements are tied to individual tasks, ranging from $9.46 to $27.54 for 30 minutes of work, advocates say they aren’t fully compensated for the time they spend building trust and following up with patients. Advocates say these workers should earn at least $30 a visit, with benefits, but many earn about , often without benefits.

Advocates say they’re surprised by how infrequently these services are used in a program with 15 million Californians. More than 16,000 Medi-Cal enrollees used these services in the first year, rising to 68,000 last year, according to state data. “I don’t think it’s reached the potential that the governor talked about, and that we all imagined that it could possibly achieve,” Sanders said.

Griselda Melgoza, a spokesperson for the California Department of Health Care Services, said the agency, which administers Medi-Cal, has seen “a steady, upward trend” and believes the data underestimates utilization because the benefit is sometimes bundled with other services.

to assess whether Medi-Cal managed care plans are doing enough outreach and education to enrollees about community health services died this year.

More Crucial Than Ever

With health funding cuts from the Trump administration and passage of the GOP’s tax and spending legislation, advocates fear there will be even less funding and support for community health worker positions, shrinking a workforce tackling health disparities. Already, Fresno County’s Department of Public Health said it has cut its community health workers by more than half, from 49 positions to 20.

Yet, outreach is more crucial than ever. As the Trump administration continues immigration raids, which appear to have targeted in the state, advocates and policy researchers say community health workers could act as intermediaries for immigrant patients afraid to seek medical care in hospitals and clinics.

Without a state certification program, no raises, and dwindling training funds, the path to professionalizing community health workers is unclear, leaving workers feeling left behind.

“The community trusts me,” said Hernández, the veteran community health worker, “but at the government level, there’s still a long way to go before this work is valued and fairly compensated.”

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The 61-year-old Anaheim resident cares for her adult daughter, who is blind, and for her sister, a military veteran with severe post-traumatic stress disorder and other mental health conditions. Medi-Cal, the state’s version of Medicaid, pays Williams to care for them, and she relies on that income, just as her sister and daughter depend on her.

“Let’s be real. We shouldn’t have to be here tonight,” Williams told a raucous standing-room crowd of over 200 people at a recent town hall. “We should be home, spending time with our loved ones and our families, but we’re here. And we’re here to fight, because when politicians try to take away our health care, we don’t have the option to sit back and let it happen.”

The House last week approved a Republican budget plan that could shrink Medicaid spending by $880 billion over 10 years, only partially paying for an extension of expiring tax cuts from President Donald Trump’s first term, plus some new ones he has promised, totaling .

A spending cut of that magnitude would have a huge impact in California, with nearly 15 million people — more than a third of the population — on Medi-Cal. of Medi-Cal’s $161 billion budget comes from Washington.

Williams was among about a dozen providers, patient advocates, disabled people, and family members who stood up one after the other to tell their stories. Rep. Young Kim, a Republican whose district includes this relatively affluent Orange County city, declined an invitation for her or a staff member to attend. But her constituents delivered their message loud and clear to her and the other Republicans in Congress: Hands off Medicaid.

Josephine Rios, a certified nursing assistant at a Kaiser Permanente surgical center in Irvine, said her 7-year-old grandson, Elijah, has received indispensable treatments through Medi-Cal, including a $5,000-a-month medication that controls his seizures, which can be life-threatening. Elijah, who has cerebral palsy, is among the more than 50% of California children covered by Medi-Cal.

“To cut Medicaid, Medi-Cal, that’s like saying he can’t live. He can’t thrive. He’s going to lie in bed and do nothing,” Rios said. “Who are they to judge who lives and who doesn’t?”

Two thirds of Californians across party lines to Medi-Cal, according to a new survey by the California Health Care Foundation and .

The town hall here was one of three organized late last month by “Fight for Our Health,” a coalition of health advocacy groups and unions, to target Republican House members whose California districts are considered politically competitive. The other two were in Bakersfield, part of which is represented by Rep. David Valadao, and Corona, home to Rep. Ken Calvert. Multiple other town halls and protests have sprung up across the country in recent weeks.

The coalition has reprised a campaign — part of a broader national movement — that fought against the GOP’s unsuccessful 2017 effort to repeal the Affordable Care Act.

The Republicans’ loss of House control in the 2018 midterm elections has been widely attributed to their stance on health care. Valadao was among the GOP members who lost their seats in 2018, though he took his back two years later.

Still, he voted for the House budget proposal last week, despite the fact that of the population in his district is on Medicaid — the highest in the state — and even though he is one of eight GOP House members who to Speaker Mike Johnson warning about the “serious consequences” of deep cuts to Medicaid. Valadao’s office did not respond to requests for comment.

Calvert, who’s been in the House and eked out reelection last November, also voted for the budget, as did Kim. All nine GOP members of California’s congressional delegation supported it, as did all House Republicans except one.

Critics of the budget plan say it helps the rich at the expense of society’s most vulnerable — an argument that was vigorously repeated at the Tustin town hall. But supporters of the plan say that extending the tax cuts, key provisions of which are at the end of this year, would avoid a large tax hike for average Americans and benefit low-income families the most.

“American families are facing a massive tax increase unless Congress acts by the end of the year,” Calvert said in a statement to ºÚÁϳԹÏÍø News before the vote. He vowed the GOP would not touch Social Security or Medicare. He did not offer similar assurances on Medicaid, but said, “We are not interested in cutting the social and healthcare safety net for children, disabled, and low-income Americans. We are focused on eliminating waste, fraud, and abuse.”

The document greenlit last Tuesday does not specify spending cut details, though it instructs the Energy and Commerce Committee, which oversees Medicaid and Medicare spending, to cut $880 billion — a large chunk of the up to $2 trillion in total cuts. The GOP’s razor-thin majority means Johnson will have a narrow path to get a more detailed budget passed. Republican support, whether from fiscal hawks who want deeper spending cuts or House members worried about slashing Medicaid, could ebb and flow as the details are hashed out.

Moreover, the House must reach a compromise with the Senate, which has passed a much narrower budget resolution that leaves the big tax cuts out for now.

Like Kim, Valadao and Calvert declined invitations to attend or send staffers to the town hall meetings in their regions. At the Tustin meeting, multiple speakers chided Kim for her absence. At one point, the large screen behind the podium flashed a picture of an empty chair with the words, in large block letters, “Congresswoman Kim, we saved you a seat.”

Kim spokesperson Callie Strock said in an email that Kim and her local staff had preexisting commitments that night. She added that Kim is “committed to protecting and strengthening our health care system.”

But those in attendance were clearly worried.

“It’s a moral obligation for all of us to look at the most disadvantaged people in our country and take good care of them,” said Beth Martinko, whose 33-year-old son, Josh, has autism and relies on Medi-Cal for his care. “This has no place in politics.”

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And as California’s first-term governor positions himself as the national Democratic Party pit bull, no other issue is defining his political rise like health care.

“Where the hell is my party?” Newsom as it became clear that the U.S. Supreme Court was poised to . “Why aren’t we standing up more firmly?” He later took out a television ad accusing Florida’s Republican leaders of “.”

Over the past year, Newsom has lobbed against Florida Gov. Ron DeSantis, a , and Texas Gov. Greg Abbott — both Republicans — for their positions on guns and abortion. He has taken to national TV and social media to dub California an that welcomes women from around the country — and is that would enshrine the right to abortion in the state constitution. And he’s framing gun violence as a public health crisis, saying that Democrats need to more aggressively challenge Republicans to enact sweeping gun safety laws.

— Gavin Newsom (@GavinNewsom)

“It’s time to put them on the defense — we’re sick and tired of being on the defense,” Newsom said in late July as he that allows Californians to sue gun-makers for negligence, a law allowing private citizens to sue abortion providers or those who help women seeking an abortion.

Newsom, a former mayor of San Francisco, is also to tout his health care accomplishments. He is crowing about coverage to millions of previously uninsured Californians — a holy grail issue for Democrats agitating for universal health care — and California’s attempt to force down drug prices by entering the generic drug market. He also argues that, on his watch, California has led the nation in its response to the covid-19 pandemic, pointing to his decision to impose the first statewide stay-at-home order in the country, in March 2020.

Political strategists and national health care experts say health care is a winning issue for the Democratic Party as it readies for a midterm election battle in November — and as Democrats seek a strategy to retain the White House in 2024. And they say Newsom could be a strong contender.

“You can’t look at Gavin Newsom and say he wouldn’t be a very attractive option,” said Chris Jennings, a based in Washington, D.C., who worked under Presidents Barack Obama and Bill Clinton. “He seems to relish debates at a time when people are looking for a fighter, and he’s well positioned, having notched some progressive health care wins. But it hasn’t been at the expense of scaring away moderates.”

Newsom, who last year handily defeated a Republican-driven recall attempt and is expected to coast to reelection in deep-blue California in November, denies that he’s laying the groundwork for a presidential bid and says he supports President Joe Biden unequivocally.

But as he takes to the airwaves and social media to boast about his health care bona fides, he appears to be exploring a national campaign and is putting a spin on his California record. For instance, although he says California offers “universal access to health care coverage,” many Californians remain uninsured, can’t afford coverage, or can’t get treatment even if they have health insurance.

“His achievements are often embellished, and pronouncements of success are often made before the hard work is done,” said Rob Stutzman, a Republican strategist in California. “And there’s plenty of things for people like Ron DeSantis to point to about California that are utter failures, like the homelessness crisis.”

Polling shows for and Vice President , also a Californian, and a recent national CNN poll found that to run in 2024. One suggested that Newsom could prevail in a general election matchup against DeSantis or former President Donald Trump.

“I think we as Democrats are standing up to the right wing, but Gavin Newsom has a certain edge to his critique, and I like it. I think it’s feisty, I think it’s strong, I think it’s fearless,” said former U.S. senator Barbara Boxer, a California Democrat who retired from office in 2017 but is working to elect Democrats to national office.

“Health care is important to him, and he figures out a way to get things done,” she said. “When the time is right, I would be proud to support him.”

Newsom campaign spokesperson Nathan Click said Newsom believes Biden should run and will not challenge him but argues he can elevate key Democratic issues such as abortion rights.

Republican leaders are coming after doctors like it’s the Salem witch trials.My latest “truth.”

— Gavin Newsom (@GavinNewsom)

“He’s leading by example and taking the fight to Republicans, making them own how they are taking away people’s rights and freedoms,” Click told KHN. “He realizes that he has agency on this question and how the Democratic Party is going to rebuild.”

A spokesperson for Abbott slammed Newsom for ignoring problems on his home turf, such as the homelessness epidemic and the high cost of living. The DeSantis campaign did not respond to requests for comment but has .

“Governor Newsom should focus on all the and coming to Texas,” said Abbott press secretary Renae Eze.

DeSantis hits back against Newsom's attacks: 'People vote with their feet'

— Fox News (@FoxNews)

Newsom during his first run for governor, promising to “lead the effort” that puts the government in charge of delivering care.

But in office, , instead of universal health care that keeps the current system intact but expands coverage.

“California is the FIRST and ONLY state in the nation offering universal access to health care coverage,” Newsom said in back-to-back campaign emails in late July. “We have the . We are making our own insulin in California.”

But California is not making its own insulin yet. And though Newsom has said California offers universal access to health care, coverage remains too expensive for many low- and middle-income residents, and Medi-Cal — California’s Medicaid program — is riddled with problems that for many.

“We as Democrats have to be honest enough to acknowledge that coverage does not automatically mean adequate or timely care,” said Democratic strategist Garry South, a longtime Newsom ally. “The fact is that under Medi-Cal they’re often not getting good care that is timely and appropriate to meet their health care needs.”

Since he became governor in 2019, Newsom has expanded Medi-Cal to living in the state without legal authorization. This year, he approved to open the program, by 2024, to all Californians who are income-eligible, regardless of immigration status.

Newsom is also allocating billions to bring to the most vulnerable and expensive Medi-Cal patients, including homeless people and people with drug addictions. And after a Republican-controlled the Affordable Care Act penalty on uninsured people in 2017, Newsom approved an insurance requirement for Californians and state-based subsidies to help low- and middle-class residents purchase coverage.

Despite these major expansions, an estimated 2.3 million Californians under 65 will remain uninsured, by University of California researchers.

Richard Figueroa, a longtime health policy expert who now serves as deputy cabinet secretary for Newsom, argues the administration has made nation-leading strides to expand health insurance but acknowledged that California will never be able to expand coverage to everyone.

“We will always have some uninsured, given the kind of patchwork system that we have. There’s no requirement that people be enrolled, even if it’s affordable and even if it’s free,” Figueroa told KHN. “We’re filling a big gap in the access piece of the puzzle.”

Newsom’s expansion of health care coverage to all immigrants regardless of status may also open him up to criticism should he mount a bid for national office.

“Whether saying ‘I was able to achieve these things in liberal California’ translates to the rest of the country will be the question,” Jennings said. “When it comes to subsidizing immigrants, most national politicians have concluded that you can’t take that position and win nationally.”

Celinda Lake, a political strategist who helped lead polling for Biden’s 2020 campaign and conducts polling for the Democratic National Committee, said Newsom could deflect political attacks if he can make the case that he’s providing better care while saving taxpayer money.

“Democrats are fired up, and voters don’t understand why more can’t get done in Washington,” Lake said. “Whoever is in the Democratic primary, you’re going to have to be for universal health care. And if Gov. Newsom runs in 2024 or 2028, he can point to what he’s done in California to show it can work.”

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But there’s a lot more at stake for Californians’ health care than mask and vaccine mandates.

Newsom, a first-term Democrat, argues that their fundamental ability to get health insurance and medical treatments is on the line.

Republicans are seeking to “take away health care access for those who need it,” according to his statement in the voter guide sent to Californians ahead of Tuesday’s recall election.

Exactly where all the leading Republican recall candidates stand on health care is unclear. Other than vowing to undo state worker vaccine mandates and mask requirements in schools, none have released comprehensive health care agendas. Nor has Kevin Paffrath, the best-known Democrat in the race, who wants to keep existing vaccine and mask mandates.

Outside of his pandemic measures, Newsom has, in conjunction with the legislature, funded to help low- and middle-income Californians buy health insurance; imposed a state on uninsured people; and extended eligibility for Medi-Cal, the state’s Medicaid program for low-income people, to undocumented immigrants . This year, he signed legislation to further expand eligibility to unauthorized immigrants ages . Republicans opposed all those initiatives.

Voters, who have been mailed ballots, have two choices to make: First, should Newsom be removed? Second, who among the 46 replacement candidates should replace him? A Public Policy Institute of California released Sept. 1 showed that 58% of likely voters want to keep Newsom in office.

To see where the leading recall candidates stand on health care, KHN combed through their speeches and writings, and scoured media coverage. Republicans John Cox and Kevin Kiley and Democrat Paffrath also consented to interviews. Republicans Larry Elder and Kevin Faulconer did not respond to repeated requests for interviews.

Larry Elder

Elder, 69, a conservative talk radio host, is of other candidates in polls. Elder believes health care is a “commodity,” not a right, and wants government out of health insurance.

He opposes Obamacare — even some of the most popular provisions of the 2010 law embraced by other Republicans, such as allowing children to stay on their parents’ health insurance until age 26 and guaranteeing coverage for people with preexisting medical conditions.

“Forcing an insurance company to cover people with pre-existing conditions completely destroys the concept of insurance,” Elder wrote in a

In a on creators.com, he wrote that he would end Medicaid, the state-federal health insurance program for low-income people, and phase out Medicare, the federal insurance program for older Americans and some people with disabilities. (As governor, he would not have the authority to do either.)

Instead, he wants people to rely primarily on high-deductible health plans and pay their hefty out-of-pocket costs with money they have saved in tax-free accounts.

Elder told he doesn’t think taxpayers should spend money on “health care for illegal aliens” but also recently told he has no plans to limit their eligibility for Medi-Cal, saying it’s “not even close to anything on my agenda.”

Elder calls himself “pro-life” but has said he doesn’t foresee changing in California. Still, anti-abortion activist Lila Rose that Elder had promised her he would cut abortion funding and veto legislation that made abortion more accessible.

Kevin Faulconer

In campaign stops and debates, the mayor of San Diego from 2014 to 2020 has cast himself as a moderate, experienced leader who worked with Democrats to clear the city’s streets and provide shelters for homeless people.

Faulconer, 54, often refers to San Diego’s success at decreasing homelessness as one of his greatest achievements in office. But that success came only after a 2017 killed 20 people and sickened nearly 600 others, most of whom were homeless. Faulconer and the city council sooner to open more restrooms and hand-washing stations, despite warnings from health officials.

The city’s in the number of people sleeping on the streets from 2019 to 2020 resulted largely from efforts to curb the spread of covid by placing people in shelters.

A fiscal conservative, Faulconer is moderate on health care. He supports abortion rights and two years ago not to restrict them.

If elected governor, Faulconer said, he would push to expand California’s paid parental leave program to 12 weeks at full pay. Currently, new parents get of their income for up to eight weeks.

John Cox

Cox, 66, has centered his campaign — as he did his against Newsom — on his business credentials. The lawyer and accountant thinks the solution to California’s health care troubles lies in the free market, for example by letting patients know the cost of care ahead of time so they can shop for a better deal.

“I understand that health care is expensive, and families can’t afford it very well,” Cox said in an interview with KHN. But that’s because “there’s not enough price discrimination, not enough consumer orientation, not enough consumer choice.”

Health care is expensive partly because doctors and hospitals can charge whatever they want, and patients overutilize care because they don’t have to pay the full price, he said.

He favors health savings accounts with some government assistance for low-income people, which he said would make consumers more discriminating and keep health care prices in check. But he doesn’t want to take profit completely out of health care.

“I certainly want companies to make money from providing health care,” Cox said. “Because I think that’s what gives them an incentive to innovate.”

Kevin Kiley

Kiley, 36, a state Assembly member representing a suburban Sacramento district, often speaks out against government interference in people’s lives. The former teacher and attorney believes government rules about insurance coverage, doctor-patient relationships and independent contracting have contributed to higher health costs.

Like Elder and Cox, he wants more transparency and consumer choice in health care.

“I’m not sure it’s necessary to be continually specifying what every single plan needs to entail,” Kiley said in an interview with KHN. “I don’t know that legislators are always in the best position to be weighing in.”

Rather than provide health benefits to undocumented immigrants, Kiley said, lawmakers should scrutinize Medi-Cal, which covers about one-third of Californians but is failing to provide basic preventive care, including childhood vaccines, to some of its neediest patients.

Kiley downplayed the coverage gains made under Obamacare that have reduced the state’s uninsured rate from about 17% in 2013 to about 7%, saying a reduction was inevitable because of state and federal requirements to get health insurance or be penalized.

He has authored , which did not pass, to increase funding for K-12 student mental health, which he says has only become more urgent in the pandemic.

Kevin Paffrath

Paffrath, 29, made his fortune giving financial advice on YouTube and in Southern California.

If elected, Paffrath said, he would create 80 emergency facilities across the state to connect homeless people with doctors and substance use and mental health treatment. And he would require schools to offer better mental health education.

He also wants to create vocational programs for interested students ages 16 and up. With better job training and higher salaries, Medi-Cal rolls would naturally shrink, he argues.

“It’s not Californians’ fault that one-third of Californians are on Medi-Cal,” Paffrath said in an interview with KHN. “It’s our schools’.”

Paffrath supports the Affordable Care Act and said he is willing to consider questions such as whether California should adopt a single-payer health system or manufacture generic prescription drugs.

Paffrath said he’s most interested in cutting health insurance red tape, which creates bureaucratic hurdles for patients, makes doctors spend more time on paperwork than patient care, and discourages new providers from entering the field.

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Then Janelle Bercun, a licensed clinical social worker, who is also in the room, will look at Mom or Dad and pipe up: What is this like for you? Your frustrations? Joys? Challenges? And she stays to work with the parent long after the pediatrician has left.

The facility’s team-based treatment is a pilot project, funded by philanthropies. Yet the approach, which California may soon incorporate on a large scale, could hold the key to fostering a healthy home environment where children thrive, child development experts say. Incorporating therapy for the parents, they say, can lower a child’s risk of future mental disorders stemming from family trauma and adversity.

Pediatricians’ offices generally don’t offer formal counseling or guidance to a child’s guardian because they can’t bill insurance for these services. That could soon change for the roughly 5.4 million children on Medi-Cal, California’s Medicaid program for low-income residents, and their parents.

The 2021-22 state budget, which Gov. Gavin Newsom is expected to sign by Monday, dedicates $800 million, half of it in federal funds, to this new behavioral health benefit over four years. Experts say it would make California the first state to pay for “dyadic care,” treating parents and children simultaneously.

“A baby is not showing up by themselves to the pediatrician’s office. The caregiver is coming in with their own strengths and stressors,” said , a pediatric psychologist who launched the initiative at the Children’s Health Center at Zuckerberg San Francisco General Hospital.

“Without a healthy caregiver, we can’t have a healthy baby,” Margolis added. “It is the most obvious thing in the world. It is unbelievable it has taken this long to pay for this service.”

The new program is among a suite of behavioral health initiatives included in the nearly $263 billion state budget negotiated between Democratic lawmakers and Newsom, who has made mental health services a signature issue.

The state will spend the next year drafting guidelines for the services that could be covered and working with insurance providers on new billing codes for the new benefit. Beginning July 1, 2022, caregivers who enter a clinic or pediatrician’s office with a child up to age 21 for routine well visits will be matched with a social worker or behavioral health specialist. They may be screened for depression, treated for tobacco and alcohol use, or offered family therapy, said Jim Kooler, assistant deputy director of behavioral health at the California Department of Health Care Services. New mothers will get postpartum care; parents could also get help obtaining food vouchers, housing or other help.

“It’s a pretty amazing array of services that will be available,” Kooler said. “It’s things we wouldn’t necessarily think about right away, but the health of the young person is impacted.”

States including New York and Colorado fund programs that offer holistic care to parents and children together. But California will be the first to offer the service as part of Medicaid pediatric care, said Jennifer Tracey, senior director of growth and sustainability for The nonprofit organization runs HealthySteps, a program that supports babies and toddlers with integrated care in 24 states, Washington, D.C., and Puerto Rico. Getting the benefit funded in the nation’s most populous state was a “groundbreaking” win for children’s advocacy groups, Tracey said.

“We haven’t seen any other state make this kind of investment,” she said. “I hope we’ll see other states following California.”

Newsom and lawmakers this year had a $76 billion budget surplus and $27 billion in federal aid to fund an array of programs, but they won’t come cheap. New outlays include up to $1.3 billion a year to expand health care to undocumented immigrants age 50 and older; $12 billion for homeless programs over the next two years; $4.4 billion in behavioral mental health for people up to age 25 over five years; and $300 million to bolster the state’s public health system beginning next July.

Critics say the spending commits Californians to programs that could be hard to fund in the future. And while offering a new Medi-Cal benefit might be worthwhile, California lawmakers would be better off fixing flaws in the government insurance program, said Susan Shelley, vice president of communications for the Howard Jarvis Taxpayers Association.

For example, the state pays physicians who participate in Medi-Cal among the lowest rates in the nation, she said. And a by the California State Auditor found that just under 48% of children enrolled in Medi-Cal went to the doctor for a preventive visit in 2016-17.

“It’s unwise to commit taxpayers to this,” Shelley said. “All these little kids are going to grow up and have one huge tax bill.”

Offering caregivers preventive behavioral treatment has proven to save money by avoiding bigger health problems down the road, according to legislative budget documents. An by HealthySteps of its sites in New York, Colorado, Arizona and Kentucky showed average annual savings to Medicaid of 204% for patients enrolled in their program. The group reports that children were eight times more likely to receive developmental screenings and twice as likely to go to well visits when their parents participated in the .

“It’s a realization that it’s not just about providing services today, but it’s about thinking about the services that will help defer costs down the road by doing the right things today,” Kooler said.

Making a visit to the pediatrician’s office more welcoming to parents, and getting mothers screened for depression and other behavioral issues, could improve California’s dismal rate of child developmental screenings, said Sarah Crow, managing director of

“California, if it really wants to prioritize children’s health, then we really need to pull out all the stops and start thinking of new, culturally relevant ways to serve our families,” Crow said.

At the clinic in San Francisco, Bercun, the social worker, visits with caregivers for as long as they need, usually about half an hour but sometimes up to an hour. She counsels a mom about a job loss, shows a dad how to soothe his crying infant and guides another mom to lovingly say no to a toddler on the verge of a tantrum. She has helped caregivers develop safety plans if there is violence in the home and has connected them to community resources.

And then there’s the pandemic: She talks families through the isolation so many have felt.

“It’s working through these moments and feeling less alone and building confidence,” Bercun said. “It’s about holding space to explore feelings. My hope is that one day all families could benefit.”

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The modest increase follows an average statewideÌýÌýon coverage that started in January of this year, which was the previous record low.

The rate changes will vary across regions, ranging from an average increase of 5.6% in Santa Clara County to reductions of 2.1% in southwestern Los Angeles County and 2.6% in Mono, Inyo and Imperial counties.

Before the announcement, some industry observers had called for rate cuts, given the windfall health plans have reaped so far this year from lower spending on care. The COVID-19 pandemic shut down elective surgeries in the spring and has continued to sharply reduce patient visits to doctors, emergency rooms and outpatient clinics.

But Peter Lee, Covered California’s executive director, told California Healthline that lower spending by insurers due to the pandemic had “very, very little” impact on 2021 premiums.

Covered California’s insurance carriers “are seeing their health care costs rebound and are projecting that for the balance of the year they will catch up on the health expenses they thought they were going to spend for 2020,” Lee said. Health plans in the exchange projected increases in non-COVID medical costs of 4% to 8% next year and did not think they needed to budget extra for the pandemic, he said.

The rate increase was modest mainly because of a surge of new, “healthier” enrollees both during theÌýÌýcoverage and the current “special” enrollment period — recently extended to Aug. 31 — for people whose coverage has been affected by the pandemic, Lee said. Covered California said an analysis of the medical risk and demographics of these newcomers showed “they are healthier on average than the equivalent cohorts from 2019.”

But Kaiser Permanente said in a regulatory filing that it saw no change in the overall health of enrollees, and Anthem Blue Cross expected a less healthy patient mix, pushing costs up about 2.2%.

Covered California said that other factors keeping the average rate hike low include the repeal of a federal tax on health plans, which reduced 2021 premiums by an average of 1.7%, and a cut next year in the “participation” fee health plans pay Covered California, from 3.5% of premiums to 3.25%.

The exchange provides coverage for about 1.5 million Californians who buy their own insurance. About 90% of them receive financial assistance from the federal or state government, or both, to help them pay for their premiums. Another 800,000 Californians buy coverage in the open market, where financial assistance is not available. About 600,000 of that group are in plans that mirror the ones available on the exchange and will see the same rate increase.

Glenn Melnick, a professor of public finance at the University of Southern California’s Sol Price School of Public Policy, differed with Lee’s view of the medical spending trend, saying health plans will likely continue to benefit from depressed patient volume next year, which will more than offset their assumed 4% to 8% increase in non-Covid costs.

Emergency room visits are lagging pre-pandemic levels by about 20% and outpatient volume is about 5% to 10% down, Melnick said. “I don’t see those people coming back unless there’s a vaccine – and when there’s a spike, more people will stay home.”

Michael Johnson, a health insurance industry observer and critic who worked as an executive at Blue Shield of California from 2003 to 2015, said next year’s premiums should be lower. “Preliminary indications are that rates for 2020 are way too high, so for 2021 they should be going down, not up,” he said.

The average statewide increase among Covered California carriers is smaller than what’s been proposed in many other states.

A KFF analysis last month of proposed 2021 rates in the exchanges of 10 states and the District of Columbia showed a median increase of 2.4%, with changes ranging from a hike of 31.8% by a health plan in New Mexico to a cut of 12% by one in Maryland. (Kaiser Health News, which produces California Healthline, is an editorially independent program of KFF.)

This year’s rate announcements come as the Affordable Care Act remains under threat from a federal lawsuit by Republican officials in 18 states,Ìý, who want to repeal it. If they prevail, more than 20 million people could lose their health coverage and popular consumer protections afforded by the ACA, including the ban on health plan discrimination against people with preexisting medical conditions, could be eliminated.

The Supreme CourtÌýÌýin the fall.

All 11 insurance companies operating in Covered California this year will remain in 2021, and no new ones will enter the marketplace. But Anthem Blue Cross and Oscar Health Insurance will expand their offerings geographically, the exchange said. Anthem will enter Inyo, Kern, Mono and Orange counties. Oscar will join the competition in San Mateo County. Many of the Covered California health plans are available only in certain regions of the state.

Kaiser Permanente is the largest carrier in the exchange, with about 526,000 enrollees this year, more than one-third of the total. Kaiser is followed by Blue Shield of California, with 392,000, and Health Net, with 232,000.

Kaiser is seeking an average increase of 0.9% in its individual market plans, including those sold in the exchange and outside of it, according to a filing with the state’s Department of Managed Health Care. Last year, Kaiser raised its rates by an average of 0.7%.

Blue Shield of California plans to cut rates by an average of 2.4% statewide, following a hike of 3.6% this year, according to its regulatory filings. One of the main factors in next year’s rate cut, it said, is that it set current premiums with a projection of medical costs that was too high.

Rates differ not only from carrier to carrier and region to region, but also by the covered person’s age. Premiums also differ by benefit level, from the cheaper “bronze” coverage tier up to the highest, known as “platinum.” The lower the premium, the higher the deductibles and coinsurance payments for care.

The individual deductible for the bronze tier inÌýÌýis set at $6,300, unchanged fromÌý. For the silver tier, the second-cheapest level of coverage, the full individual deductible in 2021 will be $4,000, also unchanged from this year. But many silver enrollees are in plans that offer financial aid to reduce their share of medical costs, and that can push the 2021 silver deductible as low as $75.

Moreover, numerous medical services are not subject to the deductible in silver plans, including primary care and specialist visits, lab tests, X-rays and other imaging. In bronze plans, the first three primary care visits are not subject to the deductible.

Covered California said that, on average, exchange enrollees who plan to renew for 2021 can save 7.3% on premiums by switching to the least expensive plan in the same tier of coverage.

The 2021 rates are subject to final review by the Department of Managed Health Care and the Department of Insurance, but significant changes are unlikely. The enrollment period for 2021 coverage starts Nov. 1 and runs through Jan. 31.

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El aumento modesto le sigue a un incremento promedio en la cobertura que comenzó en enero de este año, que también marcó un récord por lo bajo.

Los cambios en las tasas variarán según las regiones, desde un aumento promedio de 5.6% en el condado de Santa Clara hasta reducciones de 2.1% en el suroeste del condado de Los Ángeles, y 2.6% en los condados de Imperial, Inyo y Mono.

Antes del anuncio, algunos observadores de la industria habían instado a recortes de tasas, ya que este año se ha gastado mucho menos en atención médica no relacionada con el COVID, y la cantidad del dinero ahorrado ha sido enormemente superior al costo de tratar a pacientes infectados por el virus.

En la primavera, se cancelaron las cirugías electivas por causa de la pandemia de COVID-19 y se han estado reduciendo dramáticamente las visitas a oficinas médicas, salas de emergencias y clínicas ambulatorias.

Sin embargo, Peter Lee, director ejecutivo de Covered California, dijo que las compañías de seguros del mercado “están recuperando sus costos de atención médica y están proyectando que en lo que queda del año se pondrán al día con los gastos de salud que pensaban que iban a tener en 2020.”

Los planes de salud que participan en el Covered California proyectaron aumentos en los costos médicos no relacionados con COVID de 4% a 8% el próximo año, y no pensaban que necesitarían un presupuesto adicional para la pandemia, explicó.

El incremento de las tasas ha sido modesto principalmente debido a un aumento de nuevos afiliados “más saludables” tanto durante el período de inscripción regular para la como el período especial de inscripción actual, recientemente extendido hasta el 31 de agosto, para las personas cuya cobertura se ha visto afectada por la pandemia, dijo Lee.

Covered California dijo que un análisis del riesgo médico y de la demografía de estos recién llegados mostró que “son más saludables en promedio que las cohortes equivalentes de 2019”.

Pero Kaiser Permanente dijo en una presentación reglamentaria que no vio ningún cambio en la salud general de los beneficiarios, y Anthem Blue Cross esperaba una combinación de pacientes menos saludables, lo que elevó los costos en un 2.2%.

Covered California dijo que otros factores permitiendo limitar la magnitud del aumento de tasas incluyen la derogación de un impuesto federal sobre los planes de salud, que reducirán las primas de 2021 en un promedio de 1.7%, y un recorte el próximo año en la tarifa de “participación” que los planes de salud pagan a Covered California, del 3.5% a 3.25% de las primas.

El mercado brinda cobertura a aproximadamente 1.5 millones de californianos que compran su propio seguro. Alrededor del 90% de ellos reciben asistencia financiera del gobierno federal o estatal, o de ambos, para ayudar a pagar sus primas.

Otros 800,000 californianos compran cobertura en el mercado abierto, donde la asistencia financiera no está disponible. De ellos, alrededor de 600,000 están en planes que son idénticos a los de Covered California y verán el mismo aumento de tarifas.

Glenn Melnick, profesor de finanzas públicas en la Escuela de Políticas Públicas Sol Price de la Universidad del Sur de California, no estuvo de acuerdo con la opinión de Lee sobre la tendencia del gasto médico, diciendo que los planes de salud probablemente continuarán beneficiándose del volumen bajo de pacientes el próximo año, lo que compensará con creces su supuesto aumento del 4% al 8% en los costos no relacionados con COVID.

Las visitas a las salas de emergencias están a la zaga de los niveles pre pandemia en aproximadamente un 20% y el volumen de pacientes ambulatorios es entre un 5% y un 10% más bajo, dijo Melnick. “No veo que esas personas regresen a menos que haya una vacuna, y cuando haya un pico, más personas se quedarán en casa”.

Michael Johnson, observador y crítico de la industria de seguros de salud que trabajó como ejecutivo en Blue Shield of California de 2003 a 2015, dijo que las primas del próximo año deberían ser más bajas. “Las indicaciones preliminares muestran que las tasas para 2020 son demasiado altas, por lo que para 2021 deberían estar bajando, no subiendo”, dijo.

El aumento promedio en todo el estado entre los operadores de Covered California es menor que lo que se ha propuesto en muchos otros estados.

Un análisis de KFF de julio de las tasas propuestas para 2021 en los mercados de 10 estados y el Distrito de Columbia mostró un aumento promedio del 2.4%, con cambios que van desde un aumento del 31.8% por un plan de salud en Nuevo México hasta un recorte del 12% por uno en Maryland.

Los anuncios de tarifas de este año se producen en un momento en el que CA sigue amenazada por una demanda federal presentada por funcionarios republicanos de 18 estados, junto con la administración Trump, con la meta de revocar la ley.

De ganar la demanda, más de 20 millones de personas podrían perder su cobertura de salud y se podrían eliminar las protecciones populares para el consumidor que brinda ACA, incluida la prohibición de negar cobertura o cobrar más a las personas con condiciones preexistentes como hipertensión o diabetes.

La Corte Suprema planea escuchar el caso en el otoño.

Las 11 compañías de seguros que operan en Covered California este año permanecerán en 2021, y no entrarán nuevas en el mercado. Pero Anthem Blue Cross y Oscar Health Insurance expandirán sus ofertas geográficamente, según informó el mercado.

Anthem ingresará a los condados de Inyo, Kern, Mono y Orange. Oscar se unirá a la competencia en el condado de San Mateo. Muchos de los planes de salud de Covered California están disponibles solo en ciertas regiones.

Kaiser Permanente es el mayor operador en Covered California, con cerca de 526,000 afiliados este año, más de un tercio del total. A Kaiser le sigue Blue Shield of California, con 392,000, y Health Net, con 232,000.

Kaiser está buscando un aumento promedio de 0.9% en sus planes individuales, incluidos los que se venden en el mercado y fuera de él, de acuerdo con una presentación ante el Departamento de Atención Médica Administrada del estado. El año pasado, Kaiser aumentó sus tasas en un promedio de 0.7%.

Blue Shield of California planea reducir las tasas en un promedio de 2.4% en todo el estado, luego de un aumento de 3.6% este año, según sus documentos regulatorios. Según dijo, uno de los principales factores en la reducción de tasas del próximo año es que fijó las primas actuales con una proyección de costos médicos que era demasiado alta.

Las tarifas difieren no solo de un operador a otro y de una región a otra, sino también según la edad de la persona cubierta. Las primas también difieren según el nivel de beneficios, desde el nivel de cobertura “bronce” más barato hasta el más alto, conocido como “platino”.

Cuanto menor sea la prima, mayores serán los deducibles y los pagos de coseguro por la atención.

El deducible individual para el nivel de bronce en 2021 se establece en $6,300, igual que este año. Para el nivel de plata, el segundo nivel de cobertura más barato, el deducible individual completo en 2021 será de $4,000, también, el mismo que este año. Pero muchos afiliados en el nivel de plata están en planes que ofrecen ayuda financiera para reducir su parte de los costos médicos, y eso puede hacer que el deducible para 2021 baje hasta $75.

Además, numerosos servicios médicos no están sujetos al deducible en los planes de plata, incluidas la atención primaria y visitas a especialistas, análisis de laboratorio, radiografías y otros. En los planes de bronce, las primeras tres visitas de atención primaria no están sujetas al deducible.

Covered California dijo que, en promedio, los beneficiarios del mercado que planean renovar para 2021 pueden ahorrar un 7.3% en las primas al cambiar al plan menos costoso en el mismo nivel de cobertura.

Las tarifas de 2021 están sujetas a una revisión final por parte del Departamento de Atención Médica Administrada y el Departamento de Seguros del estado, pero es poco probable que ocurran cambios significativos.

El período de inscripción para la cobertura 2021 comienza el 1 de noviembre y se extiende hasta el 31 de enero.

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Chisholm calls that cut “the Big One,” and for some of his low-income patients, the consequences were catastrophic. Many of them had diabetes and could no longer afford the foot care so vital for people with the disease, which can constrict blood flow and cause serious nerve damage in the feet. Those patients stopped coming to see him.

He would see them again only when he was called to the emergency room to perform amputations on those whose disease raged unchecked.

“For so many of the working poor, losing this coverage was absolutely devastating,” Chisholm said. “It resulted in people having to choose between the basic necessities of life and going to the doctor. I saw a lot of hurt.”

This month, Medi-Cal restored podiatry and several other adult health benefits eliminated more than a decade ago, including eyeglasses and speech therapy, as well as hearing exams, hearing devices and other related services. The state’s 2019-20 budget provides to pay for the coverage.

About 13 million Californians — including 7 million adults — are covered by Medi-Cal, the state’s version of Medicaid.

“Millions now have access to these types of health care they didn’t have before,” said Anthony Wright, executive director of Sacramento-based Health Access California, a consumer advocacy group. “And we’ve seen that services such as podiatry, audiology and speech therapy are clearly medically necessary.”

Some health activists wonder why it took the state so long to restore the benefits. “A lot of these recession-related cuts came on the backs of the poor. Yet when the economic recovery came, we didn’t see their restoration,” said Linda Nguy, a policy advocate at the Western Center on Law and Poverty. “The low-income people who needed the medical services the most were the first to see them cut and the last to have them returned.”

Anthony Cava, a spokesperson for California’s Department of ÌýHealth Care Services, said the recently reinstated benefits are just the latest in an incremental restoration of care for the state’s low-income adult population. Acupuncture was brought back in 2016, and full dental benefits were restored in 2018, he said.

Raquel Serrano, a 67-year-old Fresno farm laborer, will become one of the many to take advantage of Medi-Cal’s resurrected benefits. Serrano learned she had diabetes a decade ago but signed up for Medi-Cal only recently. For years, she drank sugary soda with every meal and hot chocolate with bread at bedtime.

“My parents didn’t have the education about diabetes,” said Serrano’s son, Jose, the eldest of six children. “Soda was something we had on the table for breakfast, lunch and dinner. We drank soda, not water.” ÌýNow, he said, his mother will be able to see a podiatrist, get eyeglasses and fix her damaged teeth. “We think this will add years to her life,” he said.

Proponents of the restored benefits say the state will save money by providing foot care for people with diabetes, such as Serrano. A 2017 Ìýby UCLA researchers estimated that the use of preventive podiatric services saved Medi-Cal in 2014, attributable to avoided hospital admissions and amputations.

Lower-limb amputations increased across California by a staggering from 2010 to 2016, according to state hospital data reported by , a San Diego-based nonprofit investigative journalism organization.

Chisholm attributes the rise, in part, to the elimination of podiatric benefits for Medi-Cal patients. “We can’t say for sure,” he said, “but California suffered an avalanche of amputations after these cuts. Those are compelling numbers.”

Chisholm, who runs two podiatry offices in the working-class San Diego suburbs of National City and Chula Vista, said one elderly Latina woman who had been coming to him for years was unable to pay out-of-pocket after Medi-Cal stopped covering her treatments in 2009, so he offered to treat her for free.

But for some reason, whether shame or some bureaucratic confusion, she stopped coming anyway, he said. Chisholm lost track of her, until one day he was summoned to the emergency room to perform a below-the-knee amputation. She was the patient.

Though the benefits are now restored, many activists wonder if patients who need to see podiatrists, audiologists or speech therapists will be able to get appointments.

“Many of these providers have not worked with Medi-Cal for years, so it could be a challenge to accommodate all these patients,” said , associate director of the UCLA Center for Health Policy Research.

Chisholm said California has recently reduced the amount of paperwork required by health care providers to be reimbursed for services they offer to Medi-Cal patients. “It used to be a bureaucratic nightmare, including paperwork and documentation, to get the government to reimburse you for even the simplest procedures,” he said. “But that has improved, along with the rates for reimbursements.”

Many California doctors have long declined to treat patients enrolled in Medi-Cal because of the program’s low payment rates, but the state has — in some cases quite substantially — in each of the past two years.

But the latest restoration of Medi-Cal benefits is so new that many doctors and patients still don’t fully understand it.

Native Spanish speakers face an additional complication, said J. Luis Bautista, who runs two Central Valley clinics that serve primarily Latino patients, many of whom are on Medi-Cal. “What patients hear on the news and read on the internet is different. They’re not sure which services are covered and which aren’t,” Bautista said.

Chisholm said that despite efforts by his office and podiatrist trade groups to spread the word about the reinstated benefits, it has been slow to reach the public — and even some health care workers. Just recently, he overheard a receptionist in one of his offices turn away a Medi-Cal patient who had walked in seeking an appointment.

“I heard her tell the man, ‘No, we don’t take Medi-Cal,’ and I walked out of my office and said, ‘Yes, we do,’” Chisholm recalled. “This woman had been to all the meetings, she’d gotten the memos, it just didn’t click. But we got the patient in.”

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California now will pay doctors to screen patients for traumatic events known as adverse childhood experiences, or ACEs, if the patient is covered by Medi-Cal — the state’s version of Medicaid for low-income families.

The screening program is rooted in that suggests children who endure sustained stress in their day-to-day lives undergo biochemical changes to their brains and bodies that can dramatically increase their risk of developing serious health problems, including heart disease, asthma, depression and cancer.

Health and welfare advocates hope that widespread screening of children for ACEs, accompanied by early intervention, will help reduce the ongoing stresses and skirt the onset of physical illness, or at least ensure an illness is treated.

The higher the number of such adverse events — and so, the higher a child’s ACEs “score” — the higher the risk of chronic illness and premature death. About 63% of Californians have experienced at least one adverse childhood event, and nearly 18% have faced four or more, according to state health officials.

California is the first state to create a formal reimbursement strategy for ACEs screening, and the program will be open to both children and adults enrolled in Medi-Cal. The initiative is part of a larger championed by the state’s first surgeon general, , who is a national leader in the ACEs movement.

The public health impact could be significant as Medi-Cal covers 5.3 million kids — roughly 40% of all California children — and 6.3 million adults.

“It is a profound shift that’s going to change the type of prevention and management we do with families,” said Dr. Dayna Long, a pediatrician who is director of the Center for Child and Community Health at UCSF Benioff Children’s Hospital Oakland and helped develop the state-approved screening tool for children and teens. “We’re not going to make all the hard things go away, but we can help families build resilience and reduce stress.”

Here are five key things to know about ACEs and California’s new screening program:

1. How it works.

At a typical well-child visit, parents or caregivers will be asked to fill out a state-approved about potentially stressful experiences in their children’s lives. For children under age 12, caregivers fill out the survey. Young people ages 12-19 will complete their own questionnaire in addition to their caregivers’ questionnaire.

The questions will touch on 10 categories of adversity spanning the first 18 years of life: physical, emotional or sexual abuse; physical or emotional neglect; and experiences that could indicate household dysfunction, such as a parent who has a serious mental illness or addiction, having parents who are incarcerated or living in a home with domestic violence.

The screening will measure for experiences that could regularly trigger fear and anxiety, including homelessness, not having enough food or the right kinds of food, and growing up in a neighborhood marred by drugs and violence.

Long acknowledged some caregivers and children might be reluctant or unwilling to disclose sensitive information, particularly if they fear shame or repercussions. “We acknowledge it takes time to build trust,” she said. “But we want to encourage families to have hard conversations with their doctors and to understand how stressful events over the life of the child are impacting that child’s health.”

Physicians will review the responses and discuss them with caregivers during the visit. Doctors will have access to free online training on how to communicate with families and connect them to community resources. Physicians will be eligible for a $29 reimbursement for each Medi-Cal patient screened.

The responses are considered confidential patient information and won’t be shared with state officials. But researchers hope that aggregated information will be studied to improve care for patients with high ACEs scores.

2. The screenings are voluntary.Ìý

Doctors do not need to offer them, and patients and their caregivers do not have to participate. Doctors will need to complete online training before they can be paid for screening patients. The state will cover the costs of screening once a year for children and once in a lifetime for adults. But children are the main focus of the screening campaign.

3. What happens after the screening is less clear.Ìý

Community clinics often have social workers or “navigators” available to connect families to aid like food stamps or counseling. Doctors in private practice, however, are less likely to have those resources, said Dr. Eric Ball, an Orange County pediatrician who served on a committee advising the surgeon general on the ACEs campaign. Ball said local chapters of the American Academy of Pediatrics will work to educate doctors on how to help children who register high ACEs scores, because social services vary so much by county.

Doctors “are not going to get rich doing ACEs screenings, that’s not the point,” Ball said. “If we can pick up kids at higher risk for these issues down the road and mitigate it, that’s really exciting to me.”

4. Researchers aren’t yet sure which interventions will best help kids with high ACEs scores.Ìý

Long and her UCSF Benioff colleagues are how well the ACEs screening works and what interventions might be most effective. It’s one thing to help hungry families sign up for food stamps and free school lunches. It’s less clear how to help a child whose parent is in prison. Researchers have identified protective factors that can help children better resist the effects of toxic stress, including nurturing relationships with trusted adults, such as grandparents or teachers.

“The fact of screening is also an intervention,” Long said. “Being able to sit in a room with a pediatrician is not going to make those hard experiences go away, but it creates a freedom to talk about some things that are solvable. That’s therapeutic in and of itself.”

5. Not everyone agrees that widespread ACEs screening is a good idea.Ìý

Sociologist David Finkelhor, director of the Crimes against Children Research Center at the University of New Hampshire, is among those who caution that universal screening for ACEs is premature, given there is little consensus about the potential negative effects of screening or the best interventions.

“The good news is that we are focusing on these adversities that are clearly the source of so many downstream health and mental health problems,” Finkelhor said. “But the bad news is we’re moving way too fast, before we know how to best conduct this kind of screening and intervention, and we could get it wrong with pretty disastrous consequences.”

“Mostly, we don’t know what to do with somebody who has a high ACE score,” he said. “There are already long waits to get into family counseling or child mental health programs.”

For example, a doctor might be legally required to report previous abuse to authorities, upending a family even if the child no longer is exposed to the abuser, Finkelhor said.

“These are tough questions,” Long of UCSF acknowledged. Still, she said, screening is important, because it encourages physicians to engage in difficult conversations they might not otherwise have and pushes clinics to create links to supportive services and resources.

“That is the next phase, and that is important,” Long said. “We’re doing this because we care about your child and want them to grow into healthy adults.”

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