DECEMBER 2023 Issue Brief Paving the Way to Health Equity Learning from California State Government Introduction Inequitable access to health care has caused measur- This report, based on research by the California Pan- able harm to many Californians, in particular to Black, Ethnic Health Network (CPEHN), is the first-ever survey Latino/x, and other racial/ethnic communities, as well and documentation of health equity initiatives enacted as to the lesbian, gay, bisexual, transgender, queer, by the California state government since the onset of and questioning (LGBTQ+) and disability communi- the COVID-19 pandemic, and provides an overview of ties. Gaping health disparities reflect the state's long health equity programs and activities being conducted history of discrimination embodied in contracts, through California state agencies and departments, laws, and everyday practices of businesses and civic as well as through the legislature and the governor's agencies at all levels. office. The authors' goal is to inform Sacramento stakeholders about the status of health equity efforts Recent events, including the COVID-19 pandemic in the California state government. - which disproportionately impacted historically mar- ginalized groups - and racial/ethnic-focused violence The research included a review of published materi- and unrest fueled by the killing of George Floyd and als, including statutes, proposed legislation, public many others, sparked a renewed public reckoning statements, and department and agency reports. The and commitment by the state of California to address authors and other researchers at CPEHN interviewed California's long history of racial injustice and inequi- key informants from state agencies and departments ties, the impacts of which are felt immensely today, as well as legislators and staff (see Appendix). and to focus on advancing health equity.1 California State Activities Lasting Harms of Anti-Black Discrimination Advancing Health Equity In 2023, the California Reparations Task Force pub- lished its final report, which details the institutional The following sections summarize the activities and racism that has been pervasive throughout Califor- programs of California's governor's office, state agen- nia's history, including the role of state institutions in cies and departments, and the legislature. Although perpetuating it.2 The harms are felt today in health many of the equity-related initiatives are relatively new, disparities, including maternal and infant health out- some have been well established over many years. comes, unmet mental health needs, and other critical markers. Black physicians and medical students remain underrepresented today, indicating the long Governor's Office reach of racial bias in medicine. The state's efforts in health equity and racial equity include the following actions by the governor: $ 2019: Appointed the first California surgeon gen- alignment and implementation of CalHHS initia- eral, Nadine Burke Harris, MD, MPH, an expert in tives to reduce health inequities and disparities.9 As addressing the root causes and social drivers of part of this proposal, CalHHS did the following: health.3 $ Directed all departments to appoint a senior $ 2019: Created the Healthy California for All leader as a chief equity officer, with the aim of Commission, which was tasked with planning a uni- embedding equity in day-to-day operations. fied financing system for health coverage.4 $ Launched the Justice, Equity, Diversity, and $ 2019: Issued a historic apology to California Native Inclusion (JEDI) workgroup, tasked with improving Americans and establishment of a Truth and Healing data collection and measurement, developing an Council.5 agency and department equity dashboard, imple- menting trainings, and ensuring language access. $ 2020: Signed Assembly Bill 3121, Chapter 319, Statutes of 2020, establishing the nation's first state- $ Expanded California Leads as an employer, wide Reparations Task Force to benefit the African strengthening the state's efforts to recruit and American/Black community.6 support a state workforce reflective of California's diverse population. $ 2020: Developed a health equity metric (HEM) tying local government's ability to reopen businesses with $ Encouraged participation by all CalHHS agencies its ability to eliminate disparities in COVID-19 posi- and departments in the Capitol Collaborative on tivity rates in the most vulnerable communities.7 Race and Equity (CCORE), a program that would increase the capacity of state employees to $ 2022: Issued Executive Order N-16-22, requir- engage in racial equity work. ing California state agencies and departments to engage in equity activities, gather input from com- munities that have been historically disadvantaged, and increase access to federal funding.8 This execu- CalHHS Departments Addressing Health tive order created a Racial Equity Commission to Equity* develop resources, best practices, and tools. Department of Aging Department of Child Support Services California Health and Human Services Department of Community Services and Development Agency Department of Developmental Services Department of Health Care Access and Information The California Health and Human Services Agency (CalHHS) includes 12 departments tasked with Department of Health Care Services administration and oversight of state and federal pro- Department of Managed Health Care grams for health care, social services, public health, Department of Public Health and rehabilitation (see sidebar). CalHHS's efforts in Department of Rehabilitation health equity and racial equity include the following Department of Social Services key actions: Department of State Hospitals Emergency Medical Services Authority $ 2022: Requested $500,000 in state fiscal year *Boldface indicates departments whose leaders were interviewed by 2022–23 to coordinate the development of an CPEHN for this report (see Appendix). Equity Strategic Plan. The goal is to improve the Paving the Way to Health Equity: Learning from California State Government 2 The following sections summarize the equity work through staffing and budget commitments. All staff of specific CalHHS departments and agencies. This are required to have training in implicit bias and in summary is not inclusive of all of each department's mitigating bias.15 activities. $ 2019: HCAI's Office of Health Care Affordability will include equity as an important component of California Department of Aging its work.16 The California Department of Aging (CDA) oversees and administers funding for programs that serve older $ 2022: Convened the Hospital Equity Measures adults, adults with disabilities, family caregivers, and Advisory Committee to identify health care quality residents in long-term care facilities.10 It contracts with measures for hospitals to report progress on equity a network of 33 Area Agencies on Aging, which man- goals. The reports are mandated by Assembly Bill age a wide array of services. 1204 (2021), and the committee's recommended measures are currently under review and will The CDA has prioritized equity in aging in its Master be implemented by HCAI through regulations. Plan for Aging, to ensure all Californians have access to Assembly Bill 1204, Chapter 751, Statutes of 2021, opportunities and services to live how and where they also requires HCAI to update its community bene- choose, regardless of age, disability, race, ethnicity, fits requirements for hospitals to address the needs immigration status, and other demographic charac- of an expanded list of "vulnerable populations," teristics.11 The department also created a Direct Care which includes racial and ethnic groups experienc- Workforce Initiative, which focuses on the support of ing disparities in health outcomes, the unhoused, older workers doing direct care.12 These workers iden- people with disabilities, people identifying as tify primarily as Black, Latino/x, Asian American, and LGBTQ+, people with limited English proficiency, Pacific Islander. and other socially disadvantaged groups.17 Department of Health Care Services Department of Health Care Access and The Department of Health Care Services (DHCS) is the Information state's Medicaid agency.18 It finances and oversees The Department of Health Care Access and Information California's health care safety net, providing about (HCAI) oversees the collection and reporting of data 15 million people with health care coverage. DHCS from the state's health care sector, including health is in the process of implementing several new equity- plans and hospitals; analyzes the cost and affordabil- focused activities internally, including the following: ity of health care; and provides support for the health workforce.13 HCAI is advancing equity work in the fol- $ 2022: Hired a new health equity officer.19 lowing ways: $ 2023: Updating its strategic plan to ensure equity is $ 2019: Began collecting and reporting data from a central component.20 California hospitals on their supplier diversity, or $ 2023: Codesigning a Health Equity Roadmap with business with certified minorities; women; lesbian, Medi-Cal enrollees and other external stakeholders.21 gay, bisexual, and transgender (LGBT) people; and veterans with disabilities, as required by Assembly $ 2023: Establishing a state-level, patient-cen- Bill 962, Chapter 815, Statutes of 2019.14 tered Medi-Cal beneficiary advisory committee to enhance consumer engagement.22 $ 2019: Advancing health equity as a strategic pri- ority by having agency and department leadership formally sponsor the work, as well as champion it Paving the Way to Health Equity: Learning from California State Government 3 DHCS has also recently approved several equity- Department of Managed Health Care focused initiatives, including the following: The Department of Managed Health Care (DMHC) licenses and oversees managed care plans.29 Its Help $ 2021-23: A requirement that Medi-Cal managed Center receives and resolves consumer complaints care plans (MCPs) and other partners improve quality about managed care plans. DMHC plans to include outcomes and reduce health disparities, incorpo- "equity" in upcoming revisions of its mission and stra- rate social drivers of health in their work, and make tegic plans. the program more consistent and seamless for peo- ple to access and use as part of the state's Medi-Cal In 2022, DMHC convened a Health Equity and waiver, California Advancing and Innovating Medi- Quality Committee to identify quality measures for Cal (CalAIM).23 CalAIM also removes barriers for health plans to report progress on advancing health those seeking behavioral health care and includes equity, as required by Assembly Bill 133, Chapter 143, a Population Health Management (PHM) program Statutes of 2021.30 The committee recommended that requires MCPs to assess enrollee risk levels, that 13 quality measures be applied to all DMHC- determine a person's unmet social needs, and pro- regulated health plans, with performance data vide care coordination across all health settings.24 stratified by member demographics.31 Notably, the committee recommended holding all health plans to $ 2022: Beginning in 2024, Medi-Cal will be available the same quality performance benchmark, regard- to all income-eligible people regardless of immigra- less of payer. The committee's recommendations are tion status.25 currently under review and will be implemented by $ 2022: DHCS has made changes to health plan DMHC through regulations. contracts, effective January 1, 2024, including the following:26 California Department of Public Health The California Department of Public Health (CDPH) $ Requiring MCPs to routinely and publicly report is responsible for public health policy setting, health on access, quality improvement, and health equity education and promotion, disease monitoring, health activities. facility licensing, health professional certification, vital $ Linking plan payment to quality and equity for records maintenance, emergency preparedness, and the first time. MCPs must identify physical and environmental health.32 behavioral health disparities and inequities in access, utilization, and outcomes by race, ethnic- The department has a long history of involvement in ity, language, and sexual orientation; and must equity initiatives through the following activities: have focused efforts to improve health outcomes within the most impacted groups. $ 2009: Launched the California Reducing Disparities Project (CRDP) to achieve mental health equity $ Requiring MCPs to have a chief health equity for five California populations: African American, officer. Latino/x, Native American, Asian and Pacific Islander, $ 2022–23: Enabling health systems to bill for ser- and LGBTQ+ people.33 vices provided by community health workers and $ 2012: Was instrumental in the CalHHS-led Let's Get doulas, who will be instrumental in connecting Healthy California initiative, with its goal of making members to care.27 California the healthiest state in the nation; CDPH $ 2023: Creating a $700 million primary care provider houses the program's website and monitors indica- practice transformation program to advance health tors and goals.34 equity.28 Paving the Way to Health Equity: Learning from California State Government 4 $ 2012: Established the Office of Health Equity California Department of Social Services (OHE), which has been at the core of the state's The California Department of Social Services (CDSS) equity efforts in recent years.35 oversees cash assistance, food and nutrition, support services, and programs for immigrants and refugees, $ 2015: Published a strategic plan and work plan people who are hearing or visually impaired, victims focused on equity and is currently planning to make of human trafficking and disasters, and people without its Racial Equity Action Plan (REAP) public. secure housing.40 $ 2022: Developed a Baseline Organizational Assessment for Equity Infrastructure to assist its local CDSS defines health equity broadly: "When a person's health department partners in meeting COVID-19 race, gender, sexual orientation, gender identity, abil- challenges.36 ity or disability, national origin, language, or any other aspect of their identity can no longer predict their life outcomes."41 Its Office of Equity was created in 2020, CERI Takes on Gaps Highlighted During and a Racial Equity Action Plan (REAP) was adopted in Pandemic 2021, with the following priorities:42 The CDPH is implementing a $2.6 million California Equitable Recovery Initiative (CERI), with grantmak- $ Foster a culture of diversity and inclusion within the ing through The Center at Sierra Health Foundation.37 department. The undertaking is a response to the structural biases $ Use data to make inequities visible. in public systems that became particularly apparent in the disproportionate impact of COVID-19 on certain $ Advance equity through training, tools, and techni- populations. cal assistance. Grants of up to $300,000 are focused on closing ra- $ Improve language access and access for communi- cial, ethnic, and other disparities related to COVID-19 ties with disabilities. and associated chronic conditions. Community-based organizations can use the funding for projects to $ Support ongoing partnerships with those communi- reduce underlying inequities that have contributed to ties most affected by inequities. disproportionate harm. Four subcommittees are tasked with equity respon- sibilities in the following areas: communications and training, language access, workforce equity, and data. CDPH's Health Equity Definition California's governmental entities use varying defini- tions of "health equity" as they proceed with their Other California Agencies and work. The state's Health and Safety Code Section Departments 131019.5 defines it as "efforts to ensure that all Various state agencies and departments outside of people have full and equal access to opportunities CalHHS have also been working to support health that enable them to lead healthy lives."38 The CDPH equity and racial equity, including those described in Office of Health Equity assessment defines "orga- the following sections. nizational commitment to equity" as intersectional (including race/ethnicity, disability status, age, gender, and socioeconomic status) and something that "is California Department of Insurance seen and felt internally and externally; reinforced in The California Department of Insurance (CDI), as reg- culture and communication."39 ulator of insurance plans, protects Californians from excessive or discriminatory insurance rates and any Paving the Way to Health Equity: Learning from California State Government 5 unfair practices.43 The agency views health equity in a Covered California broad sense that includes historically disadvantaged Created as part of the Affordable Care Act, Covered groups, such as undocumented and LGBTQ+ popu- California provides health insurance to more than 1.7 lations, as well as certain racial groups. Existing staff, million Californians.49 Health equity has been part of led by Insurance Commissioner Ricardo Lara, have the mission, vision, and values of Covered California assumed responsibility for work on health equity. since its founding in 2011.50 Covered California hired its first equity officer in 2017, and the position was moved The CDI is implementing an Insurance Diversity in 2018 to be part of plan management, responsible Initiative (established in 2011), which encourages for overseeing health plan contracts.51 There is now procurement from diverse suppliers and enhanced an entire division focused on health equity, quality, diversity among insurer governing boards.44 The disparities reduction, and the social determinants of department participates in the National Association of health. Covered California's DEI program has a road Insurance Commissioners (NAIC) Special Committee map, and DEI questions about hiring, training, and on Race and Insurance, where it is working to lower organizational culture are part of the annual employee the cost of health care and to promote access to care survey.52 Specific health equity requirements, including and coverage.45 The work has a specific focus on peo- collection and use of demographic data from health ple of color, low-income and rural populations, and plan members and stratification of quality measures historically marginalized groups, such as the LGBTQ+ by those demographic data, are included in Covered community, people with disabilities, and American California's contracts with its qualified health plans.53 Indian and Alaska Native people. The committee is also researching health care disparities and insurance Strategic Growth Council responses to the COVID-19 pandemic and its impact The Strategic Growth Council (SGC) is a state Cabinet- across demographic populations. level committee that coordinates various activities of state agencies.54 Its Health in all Policies Initiative is a California Public Employees' Retirement collaborative approach to improving health by incor- System porating health considerations into decisionmaking The California Public Employees' Retirement System across sectors.55 The SGC defines equity as ensuring (CalPERS) provides health insurance for over 1.5 mil- that all people "have the same fair opportunities to lion state and local government employees, retirees, health and well-being regardless of place and race," and their families.46 Equity is integrated throughout with a specific definition of "racial equity" in its Racial CalPERS's 2022–2027 strategic plan.47 The agency Equity Action Plan (REAP).56 The plan was revised in expects that its health equity staff will grow in the near 2021 to include more regular reporting and public future as its work on health equity with its contracted discussion opportunities on the council's progress. In health plans increases, in alignment with health plan 2018, the SGC piloted the Capitol Collaborative on contract requirements from Covered California and Race and Equity (CCORE) to increase the capacity of Medi-Cal. The agency hired a chief diversity, equity, state employees to engage in racial equity work.57 and inclusion (DEI) officer in 2021 and conducts staff Participants receive training and tools to apply to policy and board trainings on implicit bias.48 Staff noted that decisionmaking, programs, and budgeting. Support is because the CalPERS budget is not dependent on provided through the SGC, the Public Health Institute the legislature, it can be nimbler in changing its orga- (PHI), and an external organization, Race Forward, and nizational culture. its Government Alliance on Race and Equity (GARE) program.58 In 2021, CCORE completed a 15-month learning cohort with 25 California state entities.59 Paving the Way to Health Equity: Learning from California State Government 6 California Legislature Conclusion The California State Legislature itself has become The executive and legislative branches of the state of more diverse in recent years, and currently has 10% California are engaged in efforts to promote health LGBTQ+ legislators and at least 41% women leg- and racial equity, as the authors' research has detailed. islators (no data are collected on legislators with disabilities).60 Several processes are in place for furthering work on equity, including the CalHHS JEDI workgroup, the The California State Assembly has a number of select SGC CCORE program, and the governor's Racial committees focused on addressing racial inequities, Equity Commission. including those on Latina Inequities; Racism, Hate, and Xenophobia; Reparatory Justice; Status of Boys Although equity activities have increased at the and Men of Color; and Workforce Development and state level, significant opportunities exist for greater Diversity in the Innovation Economy.61 alignment, improvement, and engagement. Various California agencies and departments have devel- Legislation remains a central driver of change in oped best practices and lessons learned that offer the state's departments and agencies, for example, valuable insights for equity initiatives across the Assembly Bill 133, Chapter 143, Statutes of 2021, state. At this critical juncture for change, the state which requires managed health plans to report per- of California has a great opportunity - and respon- formance on quality and equity measures to DMHC,62 sibility - to right historical inequities and give all and Assembly Bill 1204, Chapter 751, Statutes of 2021, Californians the opportunity to achieve their fullest which requires hospital equity reports and an expan- potential for health. sion of the definition of underserved populations for hospital community benefits from HCAI.63 House Resolution 39, which was passed in 2021 and is now being implemented, requires the assembly to explore methods to integrate equity more for- mally into its daily activities.64 The assembly hired an equity advisor, reporting to the chief administrative officer, to serve as the assembly's lead on policies related to DEI.65 Paving the Way to Health Equity: Learning from California State Government 7 Appendix. Key Informant Interviewees Office of the Governor California Department of Insurance Richard Figueroa, MBA, Deputy Cabinet Secretary Michael Martinez, Senior Deputy Commissioner and Legislative Director California Health and Human Services Agency Stesha Hodges, JD, Assistant Chief Counsel and Chief Marko Mijic, MPP, Undersecretary of Health Equity and Access Office Department of Health Care Services California Public Employees' Retirement System Pamela Riley, MD, MPH, Chief Health Equity Officer Lisa Albers, MD, Assistant Chief, Clinical Policy and and Assistant Deputy Director, Quality and Population Programs Division Health Management Adrian Naidu, MS, Health Equity Officer Department of Public Health Strategic Growth Council Rohan Radhakrishna, MD, MPH, Deputy Director and Kirin Kumar, Deputy Director of Equity and Government Director, Office of Health Equity Transformation Department of Managed Health Care Jazmine Garcia Delgadillo, DrPH, MPH, Health and Mary Watanabe, Director Equity Program Manager Nathan Nau, MBA, Deputy Director, Office of Plan Monitoring Offices of California Legislators and Legislative Staff Department of Health Care Access and Senator Richard Pan, MD, MPH Information Senator María Elena Durazo, JD Elizabeth Landsberg, JD, Director Assembly Speaker Anthony Rendon, PhD Elia Gallardo, JD, Deputy Director of Legislative and Assemblymember Cecilia Aguiar-Curry Government Affairs, and Health Equity Officer Assemblymember Alex Lee Department of Social Services Assemblymember Joaquin Arambula, MD Kim Johnson, Director Assemblymember Robert Rivas, MPA Marcela Ruiz, JD, Director, Office of Equity Department of Aging Susan DeMarois, Director Covered California Alice Hm Chen, MD, MPH, Chief Medical Officer Taylor Priestley, MPH, MSW, Deputy Director, Health Equity and Quality Transformation, and Health Equity Officer Rebecca Alcantar, MPA, Senior Health Equity Specialist Paving the Way to Health Equity: Learning from California State Government 8 About the Authors About the Foundation Cary Sanders, MPP, is senior policy director at the The California Health Care Foundation (CHCF) is California Pan-Ethnic Health Network (CPEHN). an independent, nonprofit philanthropy that works to Kiran Savage-Sangwan, MPA, is executive director at improve the health care system so that all Californians CPEHN. Ignatius Bau, JD, is a health equity and policy have the care they need. We focus especially on mak- consultant. ing sure the system works for Californians with low incomes and for communities who have traditionally CPEHN is a multicultural health policy organization faced the greatest barriers to care. We partner with dedicated to improving the health of communities leaders across the health care safety net to ensure they of color in California. CPEHN's mission is to advance have the data and resources to make care more just health equity by advocating for public policies and and to drive improvement in a complex system. sufficient resources to address the health needs of the state's new majority. We gather the strength of com- CHCF informs policymakers and industry leaders, munities of color to build a united and powerful voice invests in ideas and innovations, and connects with in health advocacy. changemakers to create a more responsive, patient- centered health care system. Paving the Way to Health Equity: Learning from California State Government 9 Endnotes 1. Robin L. Goldfaden et al., California Task Force to Study and 18. "Department of Health Care Services," California Department Develop Reparation Proposals for African Americans: Final of Health Care Services, accessed September 2, 2023. Report (PDF), State of California Department of Justice Office 19. Medi-Cal Children's Health Advisory Panel (MCHAP) Hybrid of the Attorney General, June 29, 2023. Meeting (PDF), California Department of Health Care Services, 2. Goldfaden et al., The California Reparations Report. December 8, 2022. 3. Office of Governor Gavin Newsom, "Governor Newsom 20. 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"California Equitable Recovery Initiative," The Center at Market QHP Issuer Contract: Advancing Equity, Quality, Sierra Health Foundation, accessed September 4, 2023. and Value (PDF), Covered California, August 1, 2022. 38. California Health and Safety Code Section 131019.5 (PDF), 54. "Welcome to the California Strategic Growth Council," California Department of Public Health, accessed September California Strategic Growth Council, accessed September 5, 5, 2023. 2023. 39. "Competencies," Equity Technical Assistance and Grant 55. "Health in All Policies Initiative," California Strategic Growth Management Portal, California Department of Public Health, Council, accessed September 2, 2023. accessed September 5, 2023. 56. Kirin Kumar (deputy director of equity and government 40. "About CDSS," California Department of Social Services, transformation, California Strategic Growth Council) and accessed September 4, 2023. 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September 2, 2023. 44. "Insurance Diversity Initiative (IDI)," California Department of 59. Lianne Dillon, "California State Government Teams Insurance, accessed September 4, 2023. Complete Racial Equity Learning Program," Local and 45. "Special (EX) Committee on Race and Insurance," National Regional Government Alliance on Race and Equity, November Association of Insurance Commissioners, accessed September 17, 2021. 4, 2023. 60. "LGBTQ Caucus Members," California Legislative LGBTQ 46. About CalPERS: Facts at a Glance for Fiscal Year 2021- Caucus, accessed September 5, 2023; and "Current 22 (PDF), California Public Employees' Retirement System, Members," California Legislative Women's Caucus, accessed January 2022. September 5, 2023. 47. 2022-27 Strategic Plan (PDF), California Public Employees' 61. "Committees: Select Committees," California State Retirement System, updated August 4, 2023. Assembly, accessed August 3, 2023. 48. 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California Health Benefit Exchange Board Minutes (PDF), Covered California, May 17, 2018. 52. Alice Chen (chief medical officer, Covered California), Taylor Priestley (deputy director, Health Equity and Quality Transformation, and health equity officer, Covered California), Paving the Way to Health Equity: Learning from California State Government 11