Evicted from his San Diego County apartment last July, McEwen — who endured repeated concussions during his six seasons in the NFL — scoured housing listings for anything he could afford.

Working as a part-time groundskeeper at a golf course for $15 an hour, his frantic search turned up nothing. So, feeling overwhelmed by rents pushing $3,000 a month for a one-bedroom apartment, he made a plan: move into his truck or rent a storage container to live in — an alternative he turned to when he was previously homeless in 2004.

McEwen is hopeful that a massive health care initiative in California offering new, specialized social services will help him get back on his feet. He is one of nearly 145,000 low-income Californians enrolled in CalAIM, an endeavor Gavin Newsom, the state’s Democratic governor, is spearheading to transform its Medicaid program, called Medi-Cal, into a new kind of safety net that provides housing and other services for people who are homeless or at risk of becoming homeless and have complicating conditions like mental illness or chronic disease that can make it difficult to manage life.

California launched the initiative in early 2022, rolling it out quietly, with health insurers and community groups scrambling to provide social services and benefits that fall outside traditional health care. It’s a five-year, $12 billion social experiment that Newsom is betting will eventually cut soaring health care spending in Medi-Cal, the largest Medicaid program in the country with 15.5 million enrollees.

The state is contracting the work to its 23 Medi-Cal managed-care health insurance companies. They are responsible for delivering a slew of new benefits to the most vulnerable enrollees: not only those with housing insecurity, but also people with mental health or addictive disorders; formerly incarcerated people transitioning back to society; seniors and people with disabilities; children in foster care; and Californians who frequent hospital emergency rooms or are admitted often to short-term skilled nursing facilities.

While only a sliver of the state’s Medi-Cal patients are enrolled in CalAIM, tens of thousands of low-income Californians could qualify for the new benefits. They’re eligible for help in finding housing and for paying rental move-in costs like security deposits.

But the help goes beyond housing. The state is also providing the most at-risk patients with intensive case management, alongside pioneering social services — such as healthy home-delivered meals for diabetes patients and mold removal in homes of patients with severe asthma.

Top state health officials say that with such an ambitious program — using Medicaid to help solve homelessness and combat chronic disease — they expected the rollout to be bumpy. After 2026, when the initiative’s funding ends, the state plans to prove the experiment works and permanently adopt the benefits. Meanwhile, other states are closely watching California, hoping to learn from its successes and failures.

“California is a leader, and it’s always experimenting in new and interesting ways,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “What it can do is provide proof of concept, and then this can grow to other states.”

Insurers, in essence, are building a new health care workforce, contracting with nonprofit and for-profit organizations to enroll the most vulnerable — and expensive — Medi-Cal patients. They’re hiring social workers and case managers to find those who rack up extreme health care costs in hospital emergency rooms, nursing homes, prisons, jails, and mental health crisis centers.

As Newsom sees it, the immense investment will pay off for taxpayers. Targeting people cycling in and out of costly institutions will reduce health care spending, he argues, while also helping people get healthy. State health officials say 5% of high-need Medi-Cal patients account for roughly half of all health care spending in the low-income health care program.

The most important currency in pulling off this massive health care experiment is trust. And that is being built on the ground, with community outreach workers scouring hospitals and homeless encampments, for example, to find those eligible for CalAIM.

The most at-risk Medi-Cal patients are being linked to specialized teams deployed under a new entitlement benefit at the heart of the initiative called “enhanced care management.” While other services like covering security deposits are optional, this is not. Health insurers are required to accept people who are most in need and provide a wide range of health and social services.

It can be simple things like arranging an Uber to get to a medical appointment or buying a computer for an enrollee looking for a job. Or purchasing a bike for a low-income kid. But it also involves intensive, one-on-one work that can require case managers to take patients to get an identification card, make nighttime phone calls to ensure patients are taking medications, and hunt down available apartments.

“This is the missing piece, and it’s the hardest work — the most costly work,” Newsom said in an interview with KFF Health News. “People on the streets and sidewalks, they’ve lost trust. They’ve become socially isolated. They’ve lost connection, and so developing that is so foundational.”

‘My Own Prison’

McEwen, who was a tight end for the NFL team now known as the Washington Commanders and later for the San Diego Chargers, was hailed as a “legacy.” But playing professional football took an extreme toll.

“My position was to block for the quarterback, and back in the day, you were allowed to hit people in the head,” McEwen said, recalling regular concussions on the field that he’d snap himself out of by sniffing ammonia packets. He helped lead the Washington team to a Super Bowl victory in 1987, but in the decades since, his health has deteriorated.

McEwen has struggled for years to find regular work while dealing with thoughts of suicide, anger, forgetfulness, and depression that he says stem from traumatic brain injuries sustained during his football career. At 57, he endures continual pain from ruptured disks in his neck and spine, along with shortness of breath from severe heart disease.

He’d holed up in his apartment for years, with curtains nailed to his windows, drowning his pain with alcohol. “I basically created my own prison,” he said.

After he was evicted last July, a longtime friend swooped in to let him stay temporarily in a spare bedroom at his family’s house just outside San Diego. But McEwen’s financial and emotional struggle to find stable housing hasn’t ended.

“We don’t call it fear. Us ballplayers, we call it excitement,” McEwen said on a rainy morning in early March, his eyes swelling with tears. “I’m excited. I know what’s at stake. My life is at stake.”

Housing instability is just one part of it. He’d often forget to take his medications for high cholesterol and clogged arteries. He felt paralyzing anxiety and his brain was so scrambled he’d miss important doctor appointments — a side effect, he said, of the concussions.

McEwen knew he needed help.

He’d learned from a friend that California was helping Medi-Cal patients with not just medical needs but also social services, and he started making calls, insisting on getting in. “I said wait, you’re giving people a coach? Someone who can make appointments for me and go to my doctor visits with me?”

Weeks after receiving his eviction notice, his Medi-Cal insurer, Molina Healthcare, connected him with a personal care manager, whom McEwen calls “my advocate, someone who can teach me how to do for myself and give myself a life worth living.”

But who gets in the program is often a roll of the dice, depending largely on which Medi-Cal insurance company a person is enrolled in. Persistence plays a big role.

Despite early glimmers of hope, the rollout has been chaotic. Providers on the ground scramble to find any available housing for enrollees. Groups implementing the initiative say inadequate funding and dire health workforce shortages have severely constrained their ability to serve all those in need. And enrollment by health insurers is uneven, with some quickly approving new benefits for their members while others are denied. Some insurers provide on-the-spot Uber rides for doctor appointments while others offer only a bus pass.

“What is being offered is insufficient, and this program is not set up to support those who are actually the most vulnerable and need the most intensive support,” said Nancy Behm, associate director of CalAIM for a San Diego nonprofit called People Assisting the Homeless, or PATH.

Operating under contracts with Blue Shield of California, Molina Healthcare, and Health Net, PATH launched intensive case management and housing services in January 2022. But it has since stopped providing intensive case management benefits largely due to a lack of sufficient funding to do the grueling work of connecting with homeless people living in encampments. “We’re hitting barriers on every front,” Behm said.

Newsom, with his soaring political ambitions, is promising to help the most vulnerable Californians. Termed out in 2026, speculation is mounting that the two-term governor is eyeing a presidential run, and he’s using health care as a core issue to elevate his national profile. In reality, his Medi-Cal initiative is falling far short.

“This is an extremely ambitious program, but it doesn’t come close to helping the entirety of the population it’s targeting,” said Doug Herman, who worked for former President Barack Obama and former Los Angeles Mayor Eric Garcetti. “This isn’t a policy solution big enough to really make a dent in homelessness.”

No Walk in the Park

On a brisk morning in late February, Jeannine Nash pulled into the drive-thru of a Jack in the Box in Chula Vista, just south of San Diego. She dug in her wallet to find $8.17 for 10 breakfast sandwiches to hand out to homeless people on her regular rounds visiting encampments.

“It helps me to come out here before work, to get an idea of what the needs are,” Nash said as she approached a nearby homeless woman slumped over on a sidewalk who had nothing with her but a brand-new walker and hospital discharge paperwork tucked in a plastic bag.

Nash is director of referrals for Serene Health, a for-profit health care company that is one of nearly 500 provider organizations being paid to link homeless people or those at risk with intensive case management, housing, and other services.

A recovering addict herself, Nash said her life experience has helped her connect with people living outside and struggling with substance use disorders. She figures out how to get those who appear resistant to accept services. “So many people are distrustful of authority,” said Nash, who has a son who is homeless.

“This is very, very dear to my heart,” Nash said. In her decades since becoming sober, she has gained deep experience getting the people most at risk of spiraling deeper into crisis into treatment beds and even apartments. She’s cultivated relationships with housing and nursing home agencies so she can quickly identify openings.

But her job comes with extraordinary challenges. She often has to level with people living outside, telling them there is simply nowhere for them to go. “There’s just not enough beds or housing out there,” she said. “And if you don’t have an income, it’s not going to happen.”

Nash handed the homeless woman in the doorway two sandwiches, coaxing her to eat. The woman, Christina Gallegos, 38, was suffering from extreme liver damage due to chronic drinking and had crawled the few blocks from Scripps Mercy Hospital in Chula Vista, where she was discharged the night before.

She had been in the emergency room, her hospital discharge paperwork showed — one of several ER trips she’d made in the past month. She was given the walker but couldn’t walk and dragged it into a doorway for shelter.

“We see this all the time. It’s getting really bad,” Nash said, texting her contacts to find a bed for Gallegos. “She’s definitely eligible. It’s just finding somewhere for her to go that is going to be hard.”

Gallegos has Medi-Cal but hasn’t been enrolled in the new benefits California is offering. She was among an estimated 8,500 homeless people identified in San Diego County in 2022, a 10% increase since 2020.

San Diego County is massive and populous, and while homeless encampments permeate suburban enclaves like Chula Vista, homeless people are largely clustered in San Diego’s downtown neighborhood and its parks.

One popular place to pitch a tent is Balboa Park near the San Diego Zoo. Its canyons and sprawling green lawns are peppered with tent communities, whose inhabitants plead for help from community groups. Many hang on to business cards from homeless outreach workers in hopes of scoring a shelter bed or permanent housing. While some people do get housing, many feel as if outreach efforts amount to broken promises.

One man, David Lloyd, pulled from his pocket a phone number for an outreach worker from the homeless services provider PATH, who told him that he was on a waiting list for housing but that he could be waiting in the queue for years.

“It’s a big list,” said Lloyd, 66. “I just want to get off the streets. I’m tired of the cops harassing me all the time.”

Cally Wood, 35, said she is addicted to fentanyl and has been on the waiting list for housing for more than a year. “It just feels really impossible,” she said. “There’s nothing affordable.”

Health insurance executives, including Martha Santana-Chin, Medi-Cal president for Health Net in California, said Medi-Cal managed-care plans are making progress in helping get people off the streets and into services. Yet she acknowledged the initial rollout falls short.

“We just don’t have the housing supply that we need,” Santana-Chin said, “to be confident that all of these folks who need support and services are going to get permanently placed.”

Hampered by Sweeps

Across the region, sweeps of homeless encampments are common and becoming part of everyday life for people living outside. Deteriorating and unsanitary conditions on the streets fuel public frustration.

Newsom has ratcheted up the practice of clearing encampments, arguing that people dealing with homelessness should not be allowed to live outdoors, despite a dearth of alternatives. He’s allocating state funding to cities and counties to remove tents from streets and sidewalks and move people into any shelter or housing available. San Diego Mayor Todd Gloria, also a Democrat, is unapologetic about adopting the approach.

“We’re doing the cleanups that are necessary for public safety,” Gloria told KFF Health News. “These conditions are unsanitary, and it puts people’s health and safety at risk, and it leads to people dying. Some people disagree with me under the guise of caring for these individuals, but the sidewalk is not a home.”

Outreach workers on the ground, however, say the enforcement crackdown only makes their jobs harder. One of the most critical goals of the new Medi-Cal initiative is to regularly visit people on the streets, build relationships with them, and help them with health care needs, all while preparing them for housing — if it becomes available.

“This really takes a lot of time. Sometimes you start with just bringing someone socks or a bottle of water. It can take 70 encounters for someone to accept our help,” said Andrea Karrer, an outreach worker with PATH. “But that time is what allows you to build trust with someone, and when they have to constantly move, you have to find that person, and sometimes start all over.”

And the disruptions ultimately cause people without housing to get sicker and visit the ER more often, she and other outreach workers said.

“When you have to move every two or three days, getting to the doctor or staying on medication is not the biggest priority. You’re in survival mode,” Karrer said.

A Labor-Intensive Effort

Serene Health is one of hundreds of providers enrolling Medi-Cal patients into intensive case management. Together, they have signed up 108,000 patients statewide so far, according to California’s Department of Health Care Services, which administers Medi-Cal. An additional 28,000 are receiving the new housing services such as security deposit payments and help identifying affordable housing.

“A lot of the stuff we’re doing is just really new to health care,” said Jacey Cooper, the state’s Medicaid director. She said that health insurers are offering housing services in all 58 counties, yet she acknowledged that the need exceeds capacity.

“It takes time for that infrastructure to come to fruition,” Cooper said of the challenge of identifying housing for Medi-Cal patients who frequent hospital ERs. “We are in a massive education moment of even making sure people understand who’s eligible and how to refer, and educating the entire delivery system, from hospitals to providers.”

Meanwhile, Newsom is asking the Biden administration for permission to add another housing benefit that would cover up to six months of direct rent payments.

Veronica Ortiz, a lead care manager for Serene Health, has Craig McEwen on her roster of about 60 patients — a large caseload that is difficult to manage.

But Ortiz bubbles with compassion and energy and said working with patients like McEwen has given her even more drive to make a difference. The work is arduous, but McEwen is quickly becoming more independent, she said.

“When we come into their lives, we’re strangers, so we have to spend a lot of time meeting face-to-face with people and helping with anything they need, otherwise they’re not going to trust us.”

But help didn’t come fast enough for Donna Fontenot, a San Diego County resident who is being evicted from her apartment this month. Her landlord told her she had to leave following repeated ER trips, hospitalizations, and skilled nursing home stays stemming from an initial fall in 2022 that left her in a wheelchair.

“I’m petrified and absolutely panicking, I have nowhere to go,” Fontenot said. With one hospitalization alone costing an average of $18,000 in California, Fontenot, who is on Medi-Cal, has racked up high health care costs.

She has been hospitalized eight times since March 2022, she said. And on five occasions, her injuries to her feet and legs were so extreme that she needed placement in a nursing home.

Yet her Medi-Cal insurer, the San Diego-based Community Health Group, instituted a rule that to qualify for some housing services, she must have a child under 18. So she isn’t receiving housing assistance that could help her. She is, however, enrolled in intensive case management. But she was not aware of that until KFF Health News informed her.

“I feel like I won the lottery,” she said. “Is it going to help me?”

Her care manager hasn’t been as involved in her life as Ortiz has been with McEwen. Fontenot continues to search on her own for housing, and recently asked to be switched into Serene Health to get more hands-on assistance. “I’ve never needed help like this before. I feel so broken,” she said in tears. “Where am I going to go?”

Today, Ortiz is helping McEwen search for housing. She also has focused on helping him get his heart condition under control and find more stable work.

In March, he landed a job as a security guard patrolling sporting events, including at football stadiums. And he scored a hard-to-get surgery appointment for late this month to help unclog the arteries in his heart.

“Before Veronica, I was waiting to die. I was eating and drinking to die. But she showed up for me. Somebody cared about me. And that gave me the courage to share with her what my dream would be,” McEwen said. “I thought I needed football to be loved — then I’d be worth it.

“But I know now that my true purpose is to be of service and to be there for my daughter. I decided to get back on the field, instead of sitting on the sidelines.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

States are barred from using federal Medicaid dollars to pay directly for rent, but California’s governor is asking the administration of President Joe Biden, a fellow Democrat, to authorize a new program called “transitional rent,” which would provide up to six months of rent or temporary housing for low-income enrollees who rely on the state’s health care safety net — a new initiative in his arsenal of programs to fight and prevent homelessness.

“I’ve been talking to the president. We cannot do this alone,” Newsom told California Healthline.

The governor is pushing California’s version of Medicaid, called Medi-Cal, to fund experimental housing subsidies for homeless people, betting that it’s cheaper for taxpayers to cover rent than to allow people to fall into crisis or costly institutional care in hospitals, nursing homes, and jails. Early in his tenure, Newsom proclaimed that “doctors should be able to write prescriptions for housing the same way they do for insulin or antibiotics.”

But it’s a risky endeavor in a high-cost state where median rent is nearly $3,000 a month, and even higher in coastal regions, where most of California’s homeless people reside. Experts expect the Biden administration to scrutinize the plan to use health care money to pay rent; and also question its potential effectiveness in light of the state’s housing crisis.

“Part of the question is whether this is really Medicaid’s job,” said Vikki Wachino, who served as national Medicaid director in the Obama administration. “But there is a recognition that social factors like inadequate housing are driving health outcomes, and I think the federal government is open to developing approaches to try and address that.”

Bruce Alexander, a spokesperson for the Centers for Medicare & Medicaid Services, declined to say whether the federal government would approve California’s request. Yet, Biden’s Medicaid officials have approved similar experimental programs in Oregon and Arizona, and California is modeling its program after them.

California is home to an estimated 30% of the homeless people in the U.S., despite representing just 12% of the country’s overall population. And Newsom has acknowledged that the numbers are likely far greater than official homeless tallies show. Top health officials say that, to contain soaring safety-net spending and help homeless people get healthy, Medi-Cal has no choice but to combine social services with housing.

Statewide, 5% of Medi-Cal patients account for a staggering 44% of the program’s spending, according to state data. And many of the costliest patients lack stable housing: Nearly half of patients experiencing homelessness visited the emergency room four times or more in 2019 and were more likely than other low-income adults to be admitted to the hospital, and a large majority of visits were covered by Medi-Cal, according to the Public Policy Institute of California.

“What we have today doesn’t work,” said Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, explaining his argument that housing is a critical component of health care. “Why do we have to wait so long for people to be so sick?”

The federal government has already approved a massive social experiment in California, known as CalAIM, which is transforming Medi-Cal. Over five years, the initiative is expected to pour $12 billion into new Medi-Cal services delivered outside of traditional health care. In communities across the state, it is already funding services for some low-income patients, including paying rental security deposits for homeless people and those facing eviction; delivering prepared healthy meals for people with diabetes; and helping formerly incarcerated people find jobs.

The transitional rent program would add another service to those already available, though only a sliver of the 15.4 million Medi-Cal enrollees actually receive those new and expensive social services.

Rent payments could begin as soon as 2025 and cost roughly $117 million per year once fully implemented. And while state officials say anyone who is homeless or at risk of becoming homeless would be eligible, not everyone who qualifies will receive new services due to capacity limits. Among those who stand to benefit are nearly 11,000 people already enrolled in Medi-Cal housing services.

“The ongoing conversation is how do we convince the federal government that housing is a health care issue,” said Mari Cantwell, who served as Medi-Cal director from 2015 to 2020. “You have to convince them that you’re going to save money because you’re not going to have as many people showing up at the emergency room and in long-term hospitalizations.”

Health care experiments in California and around the country that funded housing supports have demonstrated early success in reducing costs and making people healthier. But while some programs paid for housing security deposits or participants’ first month of rent, none directly covered rent for an extended period.

“Without that foundational support, we are playing in the margins,” Newsom said.

State health officials argue that paying for six months of rent will be even more successful at reducing health care costs and improving enrollees’ health, but experts say that, to work, the initiative must have strict accountability and be bundled with an array of social services.

In a precursor to the state’s current initiative, California experimented with a mix of housing assistance programs and social services through its “Whole Person Care” pilot program. Nadereh Pourat, of the UCLA Center for Health Policy Research, evaluated the program for the state concluding that local trials reduced emergency visits and hospitalizations, saving an average of $383 per Medi-Cal beneficiary per year — a meager amount compared with the program’s cost.

Over five years, the state spent $3.6 billion serving about 250,000 patients enrolled in local experiments, Pourat said.

And a randomized control trial in Santa Clara County that provided supportive housing for homeless people showed reductions in psychiatric emergency room visits and improvements in care. “Lives stabilized and we saw a huge uptick in substance use care and mental health care, the things that everybody wants people to use to get healthier,” said Dr. Margot Kushel, director of the University of California-San Francisco’s Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, who worked on the study.

But insurers implementing the broader Medi-Cal initiative say they are skeptical that spending health care money on housing will save the system money. And health care experts say that, while six months of rent can be a bridge while people wait for permanent housing, there’s a bigger obstacle: California’s affordable housing shortage.

“We can design incredible Medicaid policies to alleviate homelessness and pay for all the necessary supportive services, but without the adequate housing, frankly, it’s not going to work,” Kushel said.

Newsom acknowledges that criticism. “The crisis of homelessness will never be solved without first solving the crisis of housing,” he said last week, arguing California should plow more money into housing for homeless people with severe mental health conditions or addiction disorders.

He will ask the legislature to put before voters a 2024 ballot initiative that would infuse California’s mental health system with at least 6,000 new treatment beds and supportive housing units for people struggling with mental health and addiction disorders, many of whom are homeless. The proposed bond measure would generate from $3 billion to $5 billion for psychiatric housing and treatment villages aimed at serving more than 10,000 additional people a year. The initiative also would ask voters to set aside at least $1 billion a year for supportive housing from an existing tax on California millionaires that funds local mental health programs. 

“People who are struggling with these issues, especially those who are on the streets or in other vulnerable conditions, will have more resources to get the help they need,” Newsom said.

For transitional rent, six months of payments would be available for select high-need residents enrolled in Medi-Cal, particularly those who are homeless or at risk of becoming homeless — and those transitioning from more costly institutions such as mental health crisis centers, jails and prisons, and foster care. Medi-Cal patients at risk of inpatient hospitalization or who frequent the emergency room would also be eligible.

“It’s a pretty big challenge; I’m not going to lie,” said Jacey Cooper, the Medi-Cal director. “But we know that people experiencing homelessness cycle in and out of emergency rooms, so we have a real role to play in both preventing and ending homelessness.”

Public health experts say the problem will continue to explode without creative thinking about how to fund housing in health care, but they warn the state must be wary of potential abuses of the program.

“It has to be designed carefully because, unfortunately, there are always people looking to game the system,” said Dr. Tony Iton, a public health expert who is now a senior vice president at the California Endowment. “Decisions must be made by clinicians — not housing organizations just looking for another source of revenue.”

For Stephen Morton, who lives in the Orange County community of Laguna Woods, the journey from homelessness into permanent housing illustrates the amount of public spending it can take for the effort to pay off.

Morton, 60, bounced between shelters and his car for nearly two years and racked up extraordinary Medi-Cal costs due to prolonged hospitalizations and repeated emergency room trips to treat chronic heart disease, asthma, and diabetes.

Medi-Cal covered Morton’s open-heart surgery and hospital stays, which lasted weeks. He landed temporary housing through a state-sponsored program called Project Roomkey before getting permanent housing through a federal low-income housing voucher — an ongoing benefit that covers all but $50 of his rent.

Since getting his apartment, Morton said, he’s been able to stop taking one diabetes medication and lose weight. He attributes improvements in his blood sugar levels to his housing and the healthy, home-delivered meals he receives via Medi-Cal.

“It’s usually scrambled eggs for breakfast and the fish menu for dinner. I’m shocked it’s so good,” Morton said. “Now I have a microwave and I’m indoors. I’m so grateful and so much healthier.”

Your neighbor. Your co-worker.

You.

California’s Medicaid program, called Medi-Cal, serves a whopping 15.4 million people, offering care from cradle to grave: Half of all births are covered by Medi-Cal, as are more than half of all stays in nursing homes.

Everything about Medi-Cal is massive, from its upcoming fiscal year budget of $139 billion to the expansive list of benefits and services it offers. The way the program works — or doesn’t — could spell life or death for many enrollees.

“It’s critical, from the single pregnant mom, to the extremely frail elderly population that needs a nursing home,” said Jennifer Kent, former director of the state Department of Health Care Services, which administers Medi-Cal. “If it weren’t for Medi-Cal, so many people would either be dead or would be severely compromised.”

In a new series, California Healthline will shed light on Medi-Cal’s successes and failures through the experiences of its enrollees. They include Stephanie Lammers, who can’t get her troubling abdominal symptoms checked at a clinic 50 miles from her small Calaveras County town because the transportation Medi-Cal is supposed to provide isn’t trustworthy; Carolina Morga Tapia, a Fresno woman who credits Medi-Cal with helping her have five healthy children; and Lucas Moreno Ramirez, a Los Angeles County man with stage 4 lung cancer who had to fight to keep his treatment going.

Medi-Cal is at a critical juncture as it attempts to serve the needs of a diverse patient population with a dizzying array of medical needs — from childhood vaccinations and cancer screenings to state-of-the-art care for rare genetic disorders. Roughly half of enrollees are Hispanic, and, next year, California will become the first state to expand eligibility to all immigrants who qualify, regardless of their legal status.

Medi-Cal is also undertaking several new initiatives that aim to save taxpayer money and improve quality. State officials are demanding that the 23 health insurers that serve most Medi-Cal patients provide better care — or face significant penalties, including potential expulsion from the program.

The state is also adding innovative social services that fall outside the traditional realm of medicine, including helping some enrollees pay for rent and buy groceries.

“People are watching California,” said Cindy Mann, who served as federal Medicaid director under former President Barack Obama. “What the state is doing is ambitious and very aggressive. It makes a significant mark on health care and health policy, not just because of the size and breadth of its program, but by being very comprehensive.”

But only a sliver of enrollees will get the new social services, even as many patients struggle to obtain basic care or get in to see their doctors. In reality, the type of care you get in Medi-Cal depends on where you live and which insurer provides your benefits.

That means the program is working for some, but failing for many others.

If you are in Medi-Cal, we would like to hear from you, whether you live in a big city or a rural region, regardless of your age, race, or ethnicity, and whatever your medical, dental, or mental health condition. Have you had difficulty seeing the right doctor for what ails you, even to the point of putting your life at risk? Or did Medi-Cal provide good care, perhaps sparing you serious harm or disability? Either way, please consider sharing your experience with us.

Here are snapshots of patients who have used the program at a critical time in their life.

‘I Just Don’t Go to the Doctor Anymore’

When Stephanie Lammers leans over to put on her shoes, it feels as if she’s squishing something inside her abdomen, she said.

Lammers, 53, has been suffering from frequent bouts of nausea, pain, and bloating for six months.

Her gastroenterologist wants to perform diagnostic procedures, including a colonoscopy and, if anything shows up, a biopsy. But Lammers, who lives in a motel with her boyfriend and teenage daughter in the Gold Rush town of San Andreas, doesn’t have a working car and can’t readily get to the clinic — which is 50 miles away.

For Lammers, like many Medi-Cal enrollees who live in rural areas, lack of transportation is a major impediment to obtaining care. The problem is particularly acute for patients who need to see specialists.

Lammers’ dermatologist and eye doctor are over an hour away from San Andreas, the county seat of Calaveras County, about 125 miles northeast of San Francisco. She isn’t seeing a neurologist, despite a series of mini-strokes and stress-related seizures. And she hasn’t been to a podiatrist in two years, even though her toes are twisted over one another and hang down, causing her to trip. She’s often in excruciating pain when she walks.

Medi-Cal is supposed to provide free transportation to enrollees who can’t otherwise get to their appointments.

But Lammers, whose health plan is California Health & Wellness, owned by Centene, the nation’s largest commercial Medicaid insurer, stopped using its ride service nearly a year ago, after she missed dozens of appointments because drivers just didn’t show up, she said. She was getting threatening letters from doctors’ offices over the no-shows.

Once she had to hitchhike more than 30 miles home from a counseling appointment. On other occasions, Lammers said, she did not receive the reimbursement she was owed for arranging her own rides.

“I just don’t go to the doctor anymore,” Lammers said. “If I go to the doctor, my boyfriend has to take the day off work, and if he takes the day off work, we have no money.”

During the last three months of 2022, Lammers canceled five appointments she had scheduled for the diagnostic abdominal procedures because her boyfriend had to work each time and couldn’t take her. She finally stopped rescheduling.

California Health & Wellness contracts with Modivcare, a Denver-based medical transportation company that is no stranger to patient complaints and lawsuits.

Before she gave up on the ride service, Lammers said, she would call California Health & Wellness to try to resolve the issue, only to be told that Modivcare was a separate company. “I’m like, ‘If you guys hired them and put them in charge of transportation, who oversees their screw-ups?’”

Courtney Schwyzer, a member of a legal aid team representing Lammers on various Medi-Cal matters, said the failure of medical ride services is a systemic problem. In late February, Schwyzer and her fellow attorneys filed a petition in court that she hopes will force the state Department of Health Care Services to address the problem.

California Health & Wellness spokesperson Darrel Ng said the company monitors the quality of its contractors, but a shortage of transportation providers in rural areas “has created unique challenges.”

Modivcare provides more than 4 million rides for Medi-Cal recipients annually, and more than 99% are without complaint, said Melody Lai, a company spokesperson.

Lammers, who is unemployed and trying to start a custom craft business called Stuff by Steph, said doctors have warned her that if she doesn’t reduce her stress level, it could shorten her life. But arranging medical care is the most stressful thing in her life right now, so she doesn’t try anymore.

“In order to keep from dying, I have to not go to the doctor,” she said.

‘It’s a Blessing’

Medi-Cal helped save the life of Carolina Morga Tapia, a 30-year-old, full-time mother of five who lives with her family amid almond groves in an agricultural enclave of Fresno.

Nine years ago, a bacterial infection triggered premature labor during the 25th week of her second pregnancy, and Morga Tapia almost died. She spiked a fever, bled profusely, and needed immediate transfusions and emergency surgery. After several days in critical care, she fully recovered.

But the doctors could not stop the premature birth, and her baby came out weighing just 1 pound. She and her husband, David Nuñez, named her Milagros Guadalupe, and she died four days later, on Sept. 13, 2013 — a Friday.

In each of her subsequent pregnancies, Medi-Cal paid for Morga Tapia to get shots of synthetic progesterone, intended to prevent another preterm birth. Those shots — one a week for about 20 weeks — can cost an average of more than $10,000 per pregnancy.

Morga Tapia and Nuñez, a construction worker, signed up for Medi-Cal when she was pregnant with her first child more than a decade ago. They’ve been on the same Anthem Blue Cross Medi-Cal plan ever since.

“It saves a lot of money, and it’s a blessing to have that extra help.”

Morga Tapia

The plan paid for prenatal care through all six of Morga Tapia’s pregnancies, and it has provided all the medical and dental care the family needs, she said.

“Without Medi-Cal, we would have to be paying for all of our children,” said Morga Tapia. “It saves a lot of money, and it’s a blessing to have that extra help.”

Her children, four girls and a boy, range in age from 1 to 10. They all go to the same children’s clinic and see the same pediatrician.

The kids, all in good health, get routine checkups, vaccinations, and other preventive care, Morga Tapia said. She gets appointment reminders via text and cards in the mail notifying her when it’s time for the kids’ vaccinations and wellness checks, as well as her Pap smears, she said.

Her family’s experience contrasts sharply with the state’s assessment of their health plan, according to a report on quality of care in Medi-Cal issued late last year. The report, which evaluated Medi-Cal health plans on pediatric care, women’s health, and chronic disease management, put Anthem Blue Cross in the lowest tier, and below par on multiple measures in numerous counties, including Fresno.

Another state report, released in late January, detailed how quickly insurers provide appointments for their patients, and put Anthem Blue Cross’ Medi-Cal plan near the bottom of the heap.

Anthem Blue Cross spokesperson Michael Bowman said in a statement that the period covered in the reports coincided with the covid-19 pandemic, “when our safety net providers dealt with significant challenges with workforce and appointment availability.”

Morga Tapia doesn’t give the insurer low marks. “It’s different for everybody. I have a good healthy family, and what Medi-Cal covers is really fortunate for us,” she said.

‘I Don’t Want to Die Yet’

In late 2021, doctors gave Lucas Moreno Ramirez a few months to live.

Struggling with diabetes and late-stage lung cancer, Moreno Ramirez suffered debilitating pain as he hacked and labored for breath. His doctors recommended that he stop treatment and start hospice care.

He felt as if they were giving up on him.

“They said they’re going to give me opioids for my pain and help me have a comfortable death,” said Moreno Ramirez, 68, who lives in Norwalk, in Los Angeles County. “I told them I don’t believe in that. I don’t want to die yet.”

A former landscaper and factory worker, Moreno Ramirez learned he had to be his own advocate, fighting for the care he believed he deserved from Medi-Cal.

He said his Christian faith gave him strength, and over the next few months, Moreno Ramirez pushed the program and his doctors to keep battling his cancer, using a different treatment with fewer side effects than chemotherapy.

“I believe in prayer,” he said. “But I believe in science and medication, too.”

Moreno Ramirez is one of the roughly 1.6 million Californians enrolled in both Medicare, which covers people who are 65 and older or have disabilities, and Medi-Cal, which kicks in to cover the costs and benefits that Medicare doesn’t.

He also relies on his Medi-Cal insurer to help him navigate the byzantine system. L.A. Care, the largest Medi-Cal plan with nearly 2.6 million members, connected him with a care manager who worked with him to identify a different treatment called Tagrisso and advocated for him to get it. 

Even with the new medication, Moreno Ramirez’s coughing fits returned last year, and his symptoms grew so painful he suspected the cancer was growing. He asked to see his pulmonologist but was told the first appointment would be in June 2023. So he switched doctors and scored an appointment nearly six months sooner.

“My old doctor didn’t help me. I didn’t trust him,” Moreno Ramirez said. “He was always too busy for me. I told my doctors, ‘Give me a chance.’”

Having taken his care into his own hands, he says he’s not in pain, his cough has subsided, and he feels hopeful for the future. “Now I feel good,” he said.

He has also sought more attention for his diabetes and received a continuous glucose monitor to measure his blood sugar. It’s better controlled now than it has been in decades, he said.

“You have to stand up for yourself and advocate,” said Joann Pacelo, the care manager who helped Moreno Ramirez change doctors, get quicker referrals to specialists, and get approved for in-home nursing visits.

“A lot of times it’s difficult with Medi-Cal because the doctors are busy and the reimbursements are so low, but no one should be denied the care they deserve.”

]]> 442191 https://californiahealthline.org/news/article/californias-resolve-questioned-after-it-grants-medi-cal-contract-concessions/ Thu, 26 Jan 2023 10:00:00 +0000 https://californiahealthline.org/?post_type=article&p=439188 California’s decision last month to cancel the results of a long-planned bidding competition among commercial health plans in its Medicaid program has some industry insiders and consumer advocates wondering whether the state can stand up to insurers and force improvements in care for millions of low-income beneficiaries.

In a backroom agreement announced in the final days of 2022, Gov. Gavin Newsom’s administration, facing lawsuits, granted concessions that allowed major insurers to claw back business they would have lost had health officials stuck with the state’s initial contract awards for managed-care plans. Oakland-based Blue Shield of California and St. Louis-based Centene Corp. — which owns Health Net, the largest commercial health plan in Medi-Cal, the state’s version of Medicaid — were among those that had aggressively challenged the initial results.

“They had this long process, and then they just sort of struck deals,” said Maya Altman, who retired a year ago after nearly 17 years as CEO of the Health Plan of San Mateo, which did not participate in the bidding. “It’s kind of weird. Not transparent — very much behind closed doors.”

It was a remarkable change of course that came four months after the state had announced its initial contract awards. The Department of Health Care Services, which oversees Medi-Cal, had spent years preparing for the bidding competition and touted it as an important means of addressing substandard care. Eight commercial Medi-Cal plans, covering around 30% of the program’s 13 million managed-care enrollees, were required to submit bids for contracts worth about $70 billion over five years.

Noncommercial, locally governed Medi-Cal plans that cover the other 70% of managed-care enrollees did not have to submit bids, but they will be required to sign the same new contract as the commercial plans, scheduled to take effect next year.

State officials said their new decision avoids uncertainty after the losing health plans — Health Net, Blue Shield of California, Community Health Group, and Aetna — threatened drawn-out legal action. It also dramatically reduces the number of Medi-Cal enrollees who will have to switch plans — from an estimated 2.3 million to about 1.2 million. And state officials said it strengthens their ability to enhance Medi-Cal through the new contracts, which will contain requirements for higher-quality care, greater transparency, and more equitable access.

Other states have faced legal disruption after they put their Medicaid contracts up for bid. In Louisiana, for example, Centene and Aetna in 2019 protested the results of a rebidding process, which led that state to nullify its awards and start over. The new results were announced nearly two years later, with Centene and Aetna among the winners.

“When you create disputes, and lawsuits, they always put some uncertainty into things,” Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, told KHN. “We feel that we ended up in a place where we achieved certainty. We have a set of [health] plans who are committed to this.”

Consumer advocates had worried that lingering uncertainty would hinder the rollout of a far-reaching nearly $12 billion, five-year Medi-Cal initiative to provide nonmedical social services that address socioeconomic factors such as homelessness and food insecurity, widely viewed as key health indicators.

Still, the state’s decision to throw out the bidding results has many patient advocates and some health plan executives questioning the value of future contract competitions and even whether health officials will effectively enforce the higher standards in the new contract.

“It would be extremely disappointing if poor-performing plans were able to litigate their way into participating in Medi-Cal,” said Abbi Coursolle, a senior attorney in the Los Angeles office of the National Health Law Program.

Tony Cava, a spokesperson for the Department of Health Care Services, said the bids submitted were still “incredibly valuable,” because they showed how the health plans intend to improve care. He said commitments made in the bids will be incorporated into the new contracts. Cava also said the department, which had not previously held a statewide bidding competition, now intends to hold one every five years.

Patient advocates and industry insiders gave the state credit for fining health plans that fell short of quality and access standards in a report issued late last year. But they also noted that several of the health plans that will continue to operate in Medi-Cal — including Molina Healthcare and Health Net — were among the lowest performers.

When the state announced its initial awards in August, Blue Shield was shut out, despite its large health care footprint statewide and its long-standing efforts to curry favor with the state’s political class. The state also said initially that it would take Los Angeles County, a huge Medi-Cal contract, away from Health Net.

Between 2018 and 2022, Blue Shield spent at least $31 million on lobbying, political donations, and other contributions, including $20 million to a state homelessness fund Newsom set up, according to a KHN analysis of filings with the secretary of state and the California Fair Political Practices Commission. Health Net parent Centene spent at least $5 million over that period, mostly on lobbying and political donations.

Under the new arrangement, Blue Shield will keep its San Diego County Medi-Cal business after initially losing it in the contract competition, though it will not get a contract in any of the other 12 counties where it bid. Its roughly 129,000 San Diego enrollees will not have to switch plans, but over 100,000 other Medi-Cal members in San Diego will still have to switch, as Health Net and Aetna exit.

In Los Angeles County, Health Net will retain its primary Medi-Cal contract, but will have to split its 1.1 million members 50-50 with Molina under a subcontract. Molina already subcontracts with Health Net in the county, but currently has only 80,000 enrollees under that arrangement.

Some observers questioned how the split can be maintained. Cava said half of new Medi-Cal enrollees in L.A. County don’t choose a plan and are assigned to one instead, according to the most recent data. These assignments will be used to help balance enrollment between Health Net and Molina, he said.

The state and the five participating health plans issued an unusual joint statement, and the plans put a positive spin on it. Centene said the state’s revised decision “is in the best interest of millions of members.” A Blue Shield executive said it was “honored to continue serving Medi-Cal beneficiaries in San Diego County.”

In an investor call this month, Molina’s CEO, Joseph Zubretsky, noted that his company’s Medi-Cal membership will double with the new agreement, though it would have tripled under the state’s initial decision. He summarized the situation for Molina as “taking three steps forward, taking one step back, and ending up being two steps ahead.”

Consumer advocates, patients, and medical professionals expressed relief that the new agreement allows Community Health Group, the largest Medi-Cal health plan in San Diego County, to keep operating there. Had the initial results held, it would have lost its contract, and its 335,000 members would have had to choose new plans.

Christine Xayalinh, a member of Community Health Group in Escondido, said the plan afforded her treatment for Type 2 diabetes and referred her to University of California-San Diego for a successful gastric bypass.

“I know some people do have concerns about their health insurance,” Xayalinh, 29, said, “but for me, it’s been a lifesaver.”

With the contract awards decided, the state’s hope of improving Medi-Cal will hinge on its ability to enforce the new contracts.

“The focus now needs to be on making sure that works,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. “This is a very vulnerable population of Californians who are not getting what they need.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Around the same time, James Woodard, a homeless man, appeared for his third visit that week. He wasn’t in medical distress. Nurses said he was likely high on meth and just looking for a place to rest.

In an overflow tent outside, Edward Green, a restaurant cook, described hearing voices and needing medication for his bipolar disorder.

The three patients were among dozens who packed the emergency room at MLK Community Hospital, a bustling health care complex in South Los Angeles reincarnated from the old hospital known as “Killer King” for its horrific patient care. The new campus serves the 1.3 million residents of Willowbrook, Compton, Watts, and other neighborhoods — a heavily Black and Latino population that suffers disproportionately high rates of devastating chronic conditions like diabetes, liver disease, and high blood pressure.

Arguably, none of the three men should have gone, on this warm April afternoon, to the emergency room, a place intended to address severe and life-threatening cases — and where care is extremely expensive.

But patients and doctors say it is nearly impossible to find a timely medical appointment or receive adequate care in the impoverished community, where fast food is easy to come by and fresh fruits and vegetables are not. Liquor stores outnumber grocery stores, and homeless encampments are overflowing. A staggering 72% of patients who receive care at the hospital rely on Medi-Cal, the state’s Medicaid program for low-income people.

“For some people, the emergency room is a last resort. But for so many people who live here, it’s literally all there is,” said Dr. Oscar Casillas, who runs the department. “Most of what I see is preventable — preventable with normal access to health care. But we don’t have that here.”

The community is short 1,400 doctors, according to Dr. Elaine Batchlor, the hospital’s CEO, who said her facility is drowning under a surge of patients who are sicker than those in surrounding communities. For instance, the death rate from diabetes is 76% higher in the community than in Los Angeles County as a whole, 77% higher for high blood pressure — an early indicator of heart disease — and 50% higher for liver disease.

But dramatic changes are afoot that could herald improvements in care — or cement the stark health disparities that persist between rich and poor communities.

Gov. Gavin Newsom is spearheading a massive experiment in Medi-Cal, pouring nearly $9 billion into a five-year initiative that targets the sickest and costliest patients and provides them with nonmedical benefits such as home-delivered meals, money for housing move-in costs, and home repairs to make living environments safer for people with asthma.

The concept — which is being tested in California on a larger scale than anywhere else in the country — is to improve patient health by funneling money into social programs and keeping patients out of costly institutions such as emergency departments, jails, nursing homes, and mental health crisis centers.

The initiative, known as CalAIM, sounds like an antidote to some of the ills that plague MLK. Yet only a sliver of its patients will receive the new and expensive benefits.

Just 108 patients — the hospital treats about 113,000 people annually — have enrolled since January. Statewide, health insurers have signed up more than 97,200 patients out of roughly 14.7 million Californians with Medi-Cal, according to state officials. And while a growing number of Medi-Cal enrollees are expected to receive the new benefits in the coming years, most will not.

Top state health officials argue that the broader Medi-Cal population will benefit from other components of CalAIM, which is a multipronged, multiyear effort to boost patients’ overall physical and mental health. But doctors, hospital leaders, and health insurance executives are skeptical that the program will fundamentally improve the quality of care for those not enrolled — including access to doctors, one of the biggest challenges for Medi-Cal patients in South Los Angeles.

“The state is now saying it will allow Medicaid dollars to be spent on things like housing and nutritious food — and those things are really important — but they’re still not willing to pay for medical care,” Batchlor said.

Batchlor has been lobbying the Newsom administration and state lawmakers to fix basic health care for the state’s poorest residents. She believes that increasing payments for doctors and hospitals that treat Medi-Cal patients could lead to improvements in both quality and access. The state and the 25 managed-care insurance plans it pays to provide health benefits to most Medi-Cal enrollees reimburse providers so little for care that it perpetuates “racism and discrimination,” she said.

Batchlor said the hospital gets about $150, on average, to treat a Medi-Cal patient in its emergency room. But it would receive about $650 if that patient had Medicare, she said, while a patient with commercial health insurance would trigger a payment of about $2,000.

The hospital brought in $344 million in revenue in 2020 and spent roughly $330 million on operations and patient care. It loses more than $30 million a year on the emergency room alone, Batchlor said.

Medicaid is generally the lowest payer in health care, and California is among the lowest-paying states in the country, experts say.

“The rates are not high enough for providers to practice. Go to Beverly Hills and those people are overdosing on health care, but here in Compton, patients are dying 10 years earlier because they can’t get health care,” Batchlor said. “That’s why I call it separate and unequal.”

Newsom in September vetoed a bill that would have boosted Medi-Cal payment rates for the hospital, saying the state can’t afford it. But Batchlor isn’t giving up. Nor are other hospitals, patient advocates, Medi-Cal health insurers, and the state’s influential doctors’ lobby, which are working to persuade Newsom and state lawmakers to pony up more money for Medi-Cal.

It’ll be a tough sell. Newsom’s top health officials defend California’s rates, saying the state has boosted pay for participating providers by offering bonus and incentive payments for improvements in health care quality and equity — even as the state adds Medi-Cal recipients to the system.

“We’ve been the most aggressive state in expanding Medi-Cal, especially with the addition of undocumented immigrants,” said Dustin Corcoran, CEO of the California Medical Association, which represents doctors and is spearheading a campaign to lobby officials. “But we have done nothing to address the patient access side to health care.”

***

The hospital previously known as Martin Luther King Jr./Drew Medical Center was forced to shut down in 2007 after a Los Angeles Times investigation revealed the county-run hospital’s “long history of harming, or even killing, those it was meant to serve.” In one well-publicized case, a homeless woman was writhing in pain and vomiting blood while janitors mopped around her. She later died.

MLK Community Hospital rose from its ashes in 2015 as a private, nonprofit safety-net hospital that runs largely on public insurance and philanthropy. Its state-of-the-art facilities include a center to treat people with diabetes and prevent their limbs from being amputated — and the hospital is trying to reach homeless patients with a new street medicine team.

Still, decades after the deadly 1965 Watts riots spurred construction of the original hospital — which was supposed to bring high-quality health care to poor neighborhoods in South Los Angeles — many disparities persist.

Less than a mile from the hospital, 60-year-old Sonny Hawthorne rattled through some trash cans on the sidewalk. He was raised in Watts and has been homeless for most of his adult life, other than stints in jail for burglary.

He hustles on his bike doing odd jobs for cash, such as cleaning yards and recycling, but said he has trouble filling out job applications because he can’t read. Most of his day is spent just surviving, searching for food and shelter.

Hawthorne is one of California’s estimated 173,800 homeless residents, most of whom are enrolled in Medi-Cal or qualify for the program. He has diabetes and high blood pressure. He had been on psychotropic medicine for depression and paranoia but hasn’t taken it in months or years. He can’t remember.

“They wanted me to come back in two weeks, but I didn’t go,” he said of an emergency room visit this year for chronic foot pain associated with diabetes. “It’s too much responsibility sometimes.”

Hawthorne’s chronic health conditions and homelessness should qualify him for the CalAIM initiative, which would give him access to a case manager to help him find a primary care doctor, address untreated medical conditions, and navigate the new social services that may be available to him under the program.

But it’s not up to him whether he receives the new benefits.

The state has yielded tremendous power to Medi-Cal’s managed-care insurance companies to decide which social services they will offer. They also decide which of their sickest and most vulnerable enrollees get them.

One benefit all plans must offer is intensive care management, in which certain patients are assigned to case managers who help them navigate their health and social service needs, get to appointments, take their medications regularly, and eat healthy foods.

Plans can also provide benefits from among 14 broad categories of social services, such as six months of free housing for some homeless patients discharged from the hospital, beds in sobering centers that allow patients to recover and get clean outside the emergency room, and assistance with daily tasks such as grocery shopping.

L.A. Care Health Plan, the largest Medi-Cal managed-care insurer in Los Angeles County, with more than 2.5 million enrollees, is contracting with the hospital, which will provide housing and case management services under the initiative. For now, the hospital is targeting patients who are homeless and repeat emergency room visitors, said Fernando Lopez Rico, who helps homeless patients get services.

So far, the hospital has referred 78 patients to case managers and enrolled 30 other patients in housing programs. Only one has been placed in permanent housing, and about 17 have received help getting temporary shelter.

“It is very difficult to place people,” Lopez Rico said. “There’s almost nothing available, and we get a lot of hesitancy and pushback from private property owners not wanting to let these individuals or families live there.”

Patrick Alvarez, 57, has diabetes and was living in a shed without running water until July, when an infection in his feet grew so bad that he had several toes amputated.

The hospital sent him to a rehabilitation and recovery center, where he is learning to walk again, receiving counseling, and looking for permanent housing.

If he finds a place he can afford, CalAIM will pay his first month’s and last month’s rent, the security deposit, and perhaps even utility hookup fees.

But the hunt for housing, even with the help of new benefits, is arduous. A one-bedroom apartment he saw in September was going for $1,600 a month and required a deposit of $1,600. “It’s horrible, I can’t afford that,” he said.

Hawthorne needs help just as badly. But he’s unlikely to get it since he doesn’t have a phone or permanent address — and wouldn’t be easy for the hospital to find. The homeless encampments where he lives are routinely cleared by law enforcement officials.

“We have so many more people who need help than are able to get it,” Lopez Rico said. “There aren’t enough resources to help everyone, so only some people get in.”

***

L.A. Care has referred about 28,400 members to CalAIM case managers, roughly 1% of its total enrollees, according to its CEO, John Baackes. It is offering housing, food, and other social services to even fewer: about 12,600 people.

CalAIM has the potential to dramatically improve the health of patients who are lucky enough to receive new benefits, Baackes said. But he isn’t convinced it will save the health care system money and believes it will leave behind millions of other patients — without greater investment in the broader Medi-Cal program.

“Access is not as good for Medi-Cal patients as it is for people with means, and that is a fundamental problem that has not changed with CalAIM,” Baackes said.

Evidence shows that basic Medi-Cal patient care is often subpar.

Year-over-year analyses published by the state Department of Health Care Services, which administers Medi-Cal, have found that, by some measures, Medi-Cal health plans are getting worse at caring for patients, not better. Among the most recent findings: The rates of breast and cervical cancer screenings for women were worse in 2020 than 2019, even when the demands that covid-19 placed on the health care system were factored into the analysis. Hospital readmissions increased, and diabetes care declined.

“The impact of covid is real — providers shut down — but we also know we need a lot of improvement in access and quality,” said State Medicaid Director Jacey Cooper. “We don’t feel we are where we should be in California.”

Cooper said her agency is cracking down on Medi-Cal insurance plans that are failing to provide adequate care and is strengthening oversight and enforcement of insurers, which are required by state law to provide timely access to care and enough network doctors to serve all their members.

The state is also requiring participating health plans to sign new contracts with stricter quality-of-care measures.

Cooper argues CalAIM will improve the quality of care for all Medi-Cal patients, describing aspects of the initiative that require health plans to hook patients up with primary care doctors, connect them with specialty care, and develop detailed plans to keep them out of expensive treatment zones like the emergency room.

She denied that CalAIM will leave millions of Medi-Cal patients behind and said the state has increased incentive and bonus payments so health care providers will focus on improving care while implementing the initiative.

“CalAIM targets people who are homeless and extremely high-need, but we’re also focusing on wellness and prevention,” she told KHN. “It really is a wholesale reform of the entire Medicaid system in California.”

A chorus of doctors, hospital leaders, health insurance executives, and health care advocates point to Medi-Cal reimbursement rates as the core of the problem. “The chronic condition in Medi-Cal is underfunding,” said Linnea Koopmans, CEO of the Local Health Plans of California.

Although the state has restored some previous Medi-Cal rate cuts, there’s no move to increase base payments for doctors and hospitals. Cooper said the state is using tobacco tax dollars and other state money to attract more providers to the system and to entice doctors who already participate to accept more Medi-Cal patients.

When Newsom vetoed the bill to provide higher reimbursements primarily for emergency room care at MLK, he said the state cannot afford the “tens of millions” of dollars it would cost.

MLK leaders vow to continue pushing, while other hospitals and the powerful California Medical Association plot a larger campaign to draw attention to the low payment rates.

“Californians who rely on Medi-Cal — two-thirds of whom are people of color — have a harder time finding providers who are willing to care for them,” said Jan Emerson-Shea, a spokesperson for the California Hospital Association.

For Dr. Oscar Casillas at MLK, the issue is critical. Although he’s a highly trained emergency physician, most days he practices routine primary care, addressing fevers, chronic foot and back pain, and missed medications.

“If you put yourself in the shoes of our patients, what would you do?” asked Casillas, who previously worked as an ER doctor in the affluent coastal city of Santa Monica. “There’s no reasonable access if you’re on Medi-Cal. Most of the providers are by the beach, so emergency departments like ours are left holding the bag.”

Almost 2 million of California’s poorest and most medically fragile residents may have to switch health insurers as a result of a new strategy by the state to improve care in its Medicaid program.

A first-ever statewide contracting competition to participate in the program, known as Medi-Cal, required commercial managed-care plans to rebid for their contracts and compete against others hoping to take those contracts away. The contracts will be revamped to require insurers to offer new benefits and meet stiffer benchmarks for care.

The long-planned reshuffle of insurers is likely to come with short-term pain. Four of the managed-care insurers, including Health Net and Blue Shield of California, stand to lose Medi-Cal contracts in a little over a year, according to the preliminary results of the bidding, announced in late August. If the results stand, some enrollees in rural Alpine and El Dorado counties, as well as in populous Los Angeles, San Diego, Sacramento, and Kern counties, will have to change health plans — and possibly doctors.

“I’m still shocked and I’m still reeling from it,” said John Sturm, one of about 325,000 members of Community Health Group, the largest Medi-Cal plan in San Diego County, which could lose its contract. “Which doctors can I keep? How long is it going to take me to switch plans? Are there contingency plans when, inevitably, folks slip through the cracks?” Sturm wondered.

Sturm, 54, who has three mental health conditions, largely because of childhood sexual abuse, said finding a psychologist and psychiatrist he could trust took a lot of time and effort. He pointed to the disruption caused by the rollout of Medi-Cal’s new prescription drug program this year, despite assurances it would go smoothly.

“I have concerns, and I know other people in the community have concerns about what we’re being told versus what the reality is going to be,” Sturm said.

Arguably, the biggest loser in the bidding is Health Net, the largest commercial insurer in Medi-Cal, which stands to lose half its enrollees — including more than 1 million in Los Angeles County alone. St. Louis-based Centene Corp., which California is investigating over allegations it overcharged the state for prescription drugs, bought Health Net in 2016, in part for its Medicaid business, of which L.A. is the crown jewel.

But the state’s health plan selections are not set in stone. The losing insurers are fiercely contesting the results in formal appeals that read like declarations of war on their competitors and on the state. Some of the losers essentially call their winning rivals liars.

The stakes are high, with contracts in play worth billions of dollars annually. Insurers that lose their appeals with the state Department of Health Care Services, which runs Medi-Cal, are likely to take their complaints to court. That could delay final decisions by months or years, causing a headache for the department, which wants coverage under the new contracts to start Jan. 1, 2024.

State officials hope to spend the rest of this year and all of 2023 ensuring the chosen health plans are up to the task, which includes having enough participating providers to minimize disruptions in care.

“Member access and continuity are really our top priorities as part of this transition, and we have dedicated teams that will be working with the health plans on the transition planning and the continuity planning,” Michelle Baass, director of the department, told KHN.

Baass also noted that enrollees have continuity of care rights. “For example, if a member is currently under the care of a doctor during the prior 12 months, the member has the right to continue seeing that doctor for up to 12 months, if certain conditions are met,” she said.

The competitive bidding process is an effort by the department to address persistent complaints that it has not effectively monitored subpar health plans.

Eight commercial insurers bid for Medi-Cal business in 21 counties. They were required to submit voluminous documents detailing every aspect of their operations, including past performance, the scope of their provider networks, and their capacity to meet the terms of the new, stricter contracts.

The new contracts contain numerous provisions intended to bolster quality, health care equity, and transparency — and to boost accountability of the subcontractors to whom health plans often outsource patient care. For example, the plans and their subcontractors will be required to reach or exceed the 50th percentile among Medicaid plans nationally on a host of pediatric and maternal care measures — or face financial penalties.

They will also be on the hook for providing non-medical social services that address socioeconomic factors, such as homelessness and food insecurity, in an ambitious $8.7 billion, five-year Medi-Cal initiative known as CalAIM, that is already underway.

Local, publicly governed Medi-Cal plans, which cover about 70% of the 12.4 million Medi-Cal members who are in managed care, did not participate in the bidding, though their performance has not always been top-notch. Kaiser Permanente, which this year negotiated a controversial deal with the state for an exclusive Medi-Cal contract in 32 counties, was also exempt from the bidding. (KHN is not affiliated with Kaiser Permanente.)

But all Medi-Cal health insurers, including KP and the local plans, will have to commit to the same goals and requirements.

In addition to Health Net, Blue Shield of California and Community Health Group — which have contracts with Medi-Cal only in San Diego County — are also big losers, as is Aetna, which lost bids in 10 counties.

Blue Shield, which lost in all 13 counties where it submitted bids, filed a fiercely worded appeal that accuses its rivals Anthem Blue Cross, Molina, and Health Net of failing to disclose hundreds of millions of dollars in penalties against them. It accused those three plans of poor performance “and even mendacity” and said they filled their bids with “puffery,” which the state “bought, hook, line and sinker,” without “an iota of independent analysis.”

Health Net’s appeal slammed Molina, which beat it out in L.A., Sacramento, Riverside, and San Bernardino counties. Molina’s bid, Health Net said, “contains false, inaccurate and misleading information.” The whole bidding process, it said, was “highly flawed,” resulting in “erroneous contract awards that jeopardize the stability of Medi-Cal.”

In particular, Health Net said, the Department of Health Care Services “improperly reopened the procurement” after the deadline, which allowed Molina to make “comprehensive changes” that raised its score.

The protesting health plans are requesting that they be awarded contracts or that the bidding process start over from scratch.

Joseph Garcia, chief operating officer for Community Health Group, said, “It would be easiest for all concerned if they just added us. They don’t have to remove anybody.”

Community Health Group has garnered an outpouring of support from hospital executives, physician groups, community clinics, and the heads of multiple publicly governed Medi-Cal plans who sent a letter to Baass saying they were “shocked, concerned, and very disappointed” by the state’s decision. They called Community Health Group “our strongest partner of 40 years,” for whom “equity is not a buzzword or a new priority,” noting that more than 85% of its staff is bilingual and multicultural.

Community Health Group noted in its appeal that it had lost by less than a point to Health Net, which won a San Diego contract — “a miniscule difference that in itself resulted from deeply flawed scoring.”

Garcia said that if Community Health Group loses its appeal, it will “absolutely” sue in state court. A hearing officer appointed by Baass to consider the appeals has set deadlines to receive written responses and rebuttals by Oct. 7.

There is ample precedent for protracted legal battles in bidding for Medicaid contracts. In Louisiana, Centene and Aetna protested the results of a 2019 rebidding process, which led the state to nullify its awards and restart the bidding. The new results were announced this year, with Centene and Aetna among the winners. In Kentucky, the state court of appeals issued a ruling this month in a contested Medicaid procurement that had been held two years earlier.

Another factor could delay the new contract: California is juggling several massive Medi-Cal changes at the same time. Among them are the implementation of CalAIM and the anticipated enrollment of nearly 700,000 unauthorized immigrants ages 26-49 by January 2024, on top of nearly a quarter-million unauthorized immigrants 50 and older who became eligible this year. And then there’s the recalculation of enrollees’ eligibility, which will take place whenever the federal covid-19-related public health emergency ends. That could push 2 million to 3 million Californians out of Medi-Cal.

“Just hearing you list all those things gave me a minor panic attack,” said Abigail Coursolle, a senior attorney at the National Health Law Program. “They are making a lot of work for themselves in a short amount of time.”

But, Coursolle added, the state has “a very positive vision for improving access and improving the quality of services that people in Medi-Cal receive, and that’s very important.”

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Still, Rubio worried about what they can’t keep out, pointing to a corner in her bedroom where black clusters of mold were forming.

“That right there, it’s all just getting bigger,” she said in Spanish.

Rubio and her five kids have had asthma for years. Rubio and her oldest son were diagnosed first, almost 20 years ago. She said the doctors told her a number of things could trigger asthma, including dust mites, mold, cockroaches, pesticides, and air pollution.

The Rubio family is among roughly 2 million low-income Californians who have health insurance coverage through Medi-Cal, the state’s Medicaid program, and have been diagnosed with asthma. About 220,000 of them have poorly controlled asthma, according to state data.

At the beginning of this year, the California Department of Health Care Services rolled out a program to help Medi-Cal recipients improve their health by eliminating asthma triggers in their homes. The program will offer select enrollees remediation services like removing mold, installing air purifiers, and even replacing carpeting, blinds, and mattresses.

The asthma efforts are part of CalAIM, an ambitious initiative to transform Medi-Cal and target the state’s sickest and most expensive patients. It is expected to cost at least $8.7 billion over five years.

But five months after the asthma program launched, families in the San Joaquin Valley are still struggling to get these services.

“The thing that bothers me the most is it’s more cumbersome for the patient,” said Kevin Hamilton, director of the Central California Asthma Collaborative, the organization coordinating with five Medi-Cal health plans to deliver these services in the San Joaquin Valley.

For example, the Rubio family would first need a referral from a source such as a medical provider. From there, their Medi-Cal health plan would have to approve the referral. Then the partnering community-based organization — in this case, the collaborative — would visit the home to determine what services are needed. The organization then would return the assessment to the health plan for one final approval before it could move forward with the services.

So how many Valley residents have Medi-Cal plans referred to the Central California Asthma Collaborative for services since the program launched Jan. 1?

Just one, according to Hamilton.

That’s out of the thousands of eligible Medi-Cal patients in Madera, Fresno, Tulare, Kings, and Kern counties, said Jacey Cooper, California Medicaid director. She acknowledged the program’s slow start but said that was expected.

“I think identifying individuals, training providers to make referrals for new services, education, and outreach to providers and beneficiaries, all of those things take a little bit of time to get nuanced and implemented,” she said.

Back in Madera, Maria Rubio examined the wood under the sink in her kitchen. It’s expanding due to humidity, which is another asthma trigger.

“I asked the landlord to change it, but they just put in another wood panel and painted over it,” she said.

She said she has tried to ask her landlord to fix these issues, but she’s usually met with no response or cheap fix-it solutions. And she said she’s scared to keep asking.

“I didn’t want to ask for anything more because we’ve been kicked out of our rental before, with nowhere to go,” she said.

A community health worker told her about the state’s new asthma services, she said, and she thinks they could be really helpful.

“I heard that there’s going to be assistance to help us live a little better in our home, so we don’t continue to suffer from these illnesses,” she said.

Her family could qualify for the program but would generally need to get a referral. Rubio is hesitant to go to the doctor because of bad experiences. It’s one more obstacle the state faces in helping families that need these services the most.

California Healthline senior correspondent Angela Hart contributed to this report.

This story is part of the Central Valley News Collaborative, which is supported by the Central Valley Community Foundation with technology and training support from Microsoft Corp.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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In the three months since she began eating the customized meals, De Los Santos has learned to manage her diabetes by maintaining a healthy blood sugar level.

Two hours to the south, in Indio, Vidal Fonseca gets ready for his third dialysis appointment of the week. He, too, battles kidney disease and diabetes. The 54-year-old former farmworker was released from the hospital in November with an order to follow a strict diet, but he makes a mess in the kitchen and struggles to get his glucose under control. He doesn’t receive the prepared meals.

Here in California’s vast Inland Empire, where more than half of adults have diabetes or are at risk of developing diabetes, one health plan is delivering medically tailored meals to select patients. In bringing food straight to their door for a few months, state officials hope patients will develop healthier eating habits long after the shipments stop. It’s all part of a grand state experiment to improve the health of some of its sickest and costliest patients.

California’s five-year initiative, known as CalAIM, will test whether Democratic Gov. Gavin Newsom can slow public spending on Medi-Cal, the state’s Medicaid program for people with low incomes, which skyrocketed to $124 billion this fiscal year, up nearly threefold from a decade ago. Medi-Cal managed-care insurers will try to keep people out of expensive health care institutions by delivering social services, such as helping patients find housing, removing toxic mold from their homes, and delivering medically tailored food.

CalAIM, which is expected to cost $8.7 billion, is unconventional because it is being carried out primarily by health plans, not county social service departments. It will serve only a sliver of the 14.5 million Californians enrolled in Medi-Cal. And the state is still developing a way to track health outcomes, meaning nobody knows yet whether it will save money.

“This is a new program, and often with new programs, you’re building the plane as you’re flying it,” said Shelly LaMaster, director of integrated care at Inland Empire Health Plan.

The health plan is one of two Medi-Cal managed-care insurers serving San Bernardino and Riverside counties and has about 1.5 million enrollees. Inland Empire Health Plan says about 11,000 of its enrollees will be eligible for deliveries of meals and food boxes. The average meal benefit has a value of $1,596 and lasts three months, though health insurers can choose to extend food deliveries.

Because plans decide which enrollees receive services, many worthy patients — even those enrolled in the same plan or who live in the same county — are being left out. In the Inland Empire, some patients have started receiving food while others are still getting enrolled. So far, 40% of the recipients are Hispanic, 35% are white, and 18% are Black, which tracks with the region’s demographics. (Hispanics can be of any race or combination of races.)

Initial deliveries for most participants will be frozen meals, varying from taco bowls to chicken curry. Later, they may receive boxes filled with fresh fruits, vegetables, whole-grain bread, pasta, and rice so they can prepare their own meals.

De Los Santos is among the lucky 720 enrollees who have been approved for the benefit since January. Participants must be referred to the program, but referrals can come from doctors, community groups, and family members — Medi-Cal enrollees can even refer themselves.

De Los Santos’ case manager identified her need after conducting an assessment. Then a dietitian screened her for her food preferences and health concerns to develop a nutrition plan.

Her first box of nutritionally tailored meals arrived in February from Mom’s Meals, one of two prepared-meal companies contracted by the Inland Empire Health Plan. Each week she receives convenient, microwave-ready meals and an information sheet with the macronutrient breakdown of each dish.

“I’m on an eating schedule now,” she said. “I’m eating lots of meats and salads and vegetables, like broccoli and cauliflower, that are good for me.”

Meanwhile, Fonseca, also an Inland Empire Health Plan enrollee, relies on his wife and daughter to figure out how to get his diabetes under control. After he was diagnosed in November, they scrambled to learn how to cook for him by looking up recipes online.

“Before he was diagnosed with renal disease, he was eating a diet high in iron-rich foods that are typical for us to eat, like lentils and beans, but not good for kidney disease,” said his 29-year-old daughter, Maria Cruz. “We were giving him poison.”

Fonseca said he had heard about food banks but not home-delivered meals. “The menu for someone in my condition with both renal failure and diabetes is very limited and specific,” he said in Spanish. “Talking to a nutritionist and receiving meals specifically made for me for free would be a huge help.”

But even though his conditions would qualify him for meal delivery, it’s up to the insurer to enroll him.

Participating in the program would alleviate the guesswork for his wife and daughter. Fonseca’s wife, Eufracia Constantino, still works in the fields. She wakes up at 4:30 a.m. to cook his breakfast every morning before she leaves for work. His daughter prepares lunch for him, which typically consists of chicken or fish, stir-fried vegetables, and hard-boiled eggs.

“I would usually be driving trucks with a burrito in one hand and the steering wheel in the other,” said Fonseca, who was an agricultural truck driver.

De Los Santos, who up until recently was the family breadwinner, has had to adjust to becoming a patient. Two months ago, her husband, Fermin Silva, became her state-funded paid caregiver and the couple struggles to pay rent and utilities. To save money, they will move into a two-bedroom mobile home next month.

“Now I don’t have to worry about buying my meals,” she said. “I would say I’ve saved about $150 a month.”

While she saves money, Fonseca spends an extra $100 a week to buy the healthy food his wife and daughter prepare for him.

“We’ve had to stretch my wife’s paycheck,” Fonseca said. “We don’t fill the grocery cart up like before.”

The California Department of Health Care Services, which runs Medi-Cal, hopes the patients who receive medically tailored meals will tap the health system less often. The goal is to make people healthier by empowering them to adopt better eating habits and learn to sustain a good diet. Although some recipients may have irreversible conditions, such as congestive heart failure or severe diabetes, officials still see opportunities to reduce hospital admissions and emergency room visits.

Studies have shown that providing meal delivery services helps reduce health care costs. State officials note that food benefits will be expanded over time and that there’s no price cap on the initiative.

But the health agency could not provide data on how many Medi-Cal patients are eligible for food delivery and won’t report the number of people receiving the service until later this year. The state plans to gauge the cost-effectiveness of these social services as the program expands, according to agency spokesperson Anthony Cava.

Inland Empire Health Plan officials say it could be challenging to identify the impact of an individual benefit since many members receive multiple services. And it takes time to realize health consequences.

De Los Santos’ meals will end soon. She declined an extension, saying she has learned enough about portioning and self-control. She feels confident about continuing her healthy diet with the help of her husband, who will cook for her.

“My husband tells me to slow down,” she said, “but I have so much more energy.”

Fonseca fears a lifetime of poor eating combined with a physically demanding job has taken a toll on his body. He used to work two fields in one day and traveled depending on the crop season. He never took time off. “Now all I have is time,” he said, “but the dialysis makes me feel exhausted.”

He asked his nurse about getting medically tailored meals.

“He has to be healthy to qualify to get on a kidney transplant waiting list,” said his daughter. “That’s our hope.”

En los tres meses desde que comenzó a comer estas comidas personalizadas, De Los Santos ha aprendido a controlar su diabetes manteniendo un nivel saludable de azúcar en la sangre.

Dos horas al sur, en Indio, Vidal Fonseca se prepara para su tercera cita de diálisis de la semana. También lucha contra la enfermedad renal y la diabetes. El ex trabajador agrícola de 54 años fue dado de alta del hospital en noviembre con la orden de seguir una dieta estricta, pero es un desastre en la cocina y tiene dificultad para controlar su glucosa. No recibe las comidas preparadas.

Aquí, en el extenso Inland Empire de California, donde más de la mitad de los adultos tienen diabetes o corren el riesgo de desarrollarla, un plan de salud ofrece comidas médicamente diseñadas a determinados pacientes seleccionados.

Al llevar alimentos directamente a las puertas durante algunos meses, los funcionarios estatales esperan que los pacientes desarrollen hábitos alimenticios más saludables que perduren hasta mucho después de que dejen de recibir los envíos. Todo es parte de un gran experimento estatal para mejorar la salud de algunos de sus pacientes más enfermos, y costosos.

La iniciativa de California, puesta en marcha hace cinco años, conocida como CalAIM, probará si el gobernador demócrata Gavin Newsom puede reducir el gasto público en Medi-Cal, el programa estatal de Medicaid para personas de bajos ingresos, que se disparó a $124,000 millones este año fiscal, casi el triple de una década atrás.

Las aseguradoras de atención de salud administrada de Medi-Cal tratarán de mantener a las personas fuera de las costosas instituciones de atención médica mediante la prestación de servicios sociales, como ayudar a los pacientes a encontrar vivienda, eliminar el moho tóxico de sus hogares y entregar alimentos médicamente adaptados.

CalAIM, que se espera que cueste $8,700 millones, es diferente porque lo llevan a cabo principalmente planes de salud, no los departamentos de servicios sociales de los condados. Servirá a solo una pequeña parte de los 14,5 millones de californianos inscritos en Medi-Cal. Y el estado aún está desarrollando una forma de rastrear los resultados de salud, lo que significa que nadie sabe aún si se ahorrará dinero.

“Este es un programa nuevo y, a menudo, con programas nuevos, estás construyendo el avión mientras lo estás volando”, dijo Shelly LaMaster, directora de atención integrada del plan de salud Inland Empire Health Plan.

El plan de salud es una de las dos aseguradoras que gestionan Medi-Cal en los condados de San Bernardino y Riverside, y tiene alrededor de 1.5 millones de afiliados. Inland Empire Health Plan dice que alrededor de 11,000 de sus afiliados serán elegibles para recibir comidas y cajas de alimentos. El beneficio promedio tiene un valor de $1,596 y dura tres meses, aunque las aseguradoras pueden optar por extender las entregas de alimentos.

Debido a que los planes deciden qué afiliados reciben servicios, muchos que los necesitarían  —incluso aquellos inscritos en el mismo plan o que viven en el mismo condado— quedan fuera. En Inland Empire, algunos pacientes han comenzado a recibir alimentos mientras que otros aún se están inscribiendo. Hasta ahora, el 40% de los destinatarios son hispanos, el 35% son blancos no hispanos y el 18% son negros no hispanos, lo que refleja la demografía de la región. (Los hispanos pueden ser de cualquier raza o combinación de razas).

Las entregas iniciales para la mayoría de los participantes serán comidas congeladas, que van desde tacos hasta pollo al curry. Luego, pueden recibir cajas llenas de frutas frescas, verduras, pan integral, pasta y arroz para que puedan preparar sus propias comidas.

De Los Santos se encuentra entre los 720 afortunados que desde enero obtuvieron la aprobación para  recibir el beneficio. Los participantes deben ser referidos al programa, y las referencias pueden provenir de médicos, grupos comunitarios y miembros de sus familias; los afiliados a Medi-Cal pueden incluso recomendarse a sí mismos.

El administrador de casos que trabaja con De Los Santos la identificó como una candidata para el beneficio después de hacer una evaluación. Luego, un dietista la evaluó para conocer sus preferencias alimentarias y preocupaciones de salud y crear un plan de nutrición.

Su primera caja de comidas nutricionalmente adaptadas llegó en febrero de Mom’s Meals, una de las dos compañías de comidas preparadas contratadas por Inland Empire Health Plan. Cada semana recibe comidas para calentar en el microondas y una hoja de información con el desglose de macronutrientes de cada plato.

“Ahora tengo un horario para comer”, dijo. “Estoy comiendo muchas carnes, ensaladas y vegetales, como brócoli y coliflor, que son buenos para mí”.

Mientras tanto, Fonseca, también inscrito en Inland Empire Health Plan, depende de su esposa e hija para controlar su diabetes. Tras recibir el diagnóstico en noviembre, navegaron Internet para buscar recetas para poder cocinarle.

“Antes de que le diagnosticaran la enfermedad renal, comía una dieta alta en alimentos ricos en hierro que son típicos de nosotros, como lentejas y frijoles, pero no son buenos para la enfermedad renal”, dijo su hija María Cruz, de 29 años. “Le estábamos dando veneno”.

Fonseca dijo que había oído hablar de bancos de alimentos pero no de comidas a domicilio. “El menú para alguien con insuficiencia renal y diabetes es muy limitado y específico”, dijo en español. “Hablar con un nutricionista y recibir comidas hechas específicamente para mí de forma gratuita sería de gran ayuda”.

Pero a pesar de que sus dolencias lo calificarían para la entrega de comidas, depende de que la aseguradora lo inscriba.

Participar en el programa sería un alivio para su esposa e hija. Eufracia Constantino, esposa de Fonseca, todavía trabaja en el campo. Se despierta a las 4:30 de la mañana para prepararle el desayuno antes de irse al trabajo. Su hija le prepara el almuerzo, que generalmente consiste en pollo o pescado, verduras salteadas y huevos duros.

“Yo solía conducir camiones con un burrito en una mano y el volante en la otra”, dijo Fonseca, quien era camionero agrícola.

De Los Santos, quien hasta hace poco era el sostén de la familia, ha tenido que acostumbrarse a ser una paciente. Hace dos meses su esposo, Fermín Silva, se convirtió en su cuidador pagado por el estado, y la pareja tiene dificultades para pagar el alquiler, el agua y la luz. Para ahorrar dinero, se mudarán a una casa móvil de dos dormitorios el próximo mes.

“Ahora no tengo que preocuparme por comprar mis comidas”, dijo. “Yo diría que he ahorrado alrededor de $150 al mes”.

Mientras ella ahorra dinero, Fonseca gasta $100 adicionales a la semana para comprar los ingredientes de las comidas saludables que le preparan su esposa y su hija.

“Tuvimos que estirar el sueldo de mi esposa”, dijo Fonseca. “Ya no llenamos el carrito de las compras como antes”.

El Departamento de Servicios de Atención Médica de California, que administra Medi-Cal, espera que los pacientes que reciben comidas médicamente adaptadas lleguen a utilizar el sistema de salud con menos frecuencia.

El objetivo es hacer que las personas sean más saludables capacitándolas para que adopten mejores hábitos alimenticios y aprendan a mantener una buena dieta. Aunque algunos beneficiarios pueden tener condiciones irreversibles, como insuficiencia cardíaca congestiva o diabetes grave, los funcionarios aún ven oportunidades para reducir las admisiones al hospital y las visitas a la sala de emergencias.

Los estudios han demostrado que brindar servicios de entrega de comidas ayuda a reducir los costos de atención médica. Los funcionarios estatales señalan que los beneficios de alimentos se ampliarán con el tiempo, y que no hay un límite de precio en la iniciativa.

Pero la agencia de salud no pudo proporcionar datos sobre cuántos pacientes de Medi-Cal son elegibles para la entrega de alimentos y no informará la cantidad de personas que reciben el servicio hasta finales de este año. El estado planea medir la rentabilidad de estos servicios sociales a medida que se expanda el programa, según Anthony Cava, vocero de la agencia.

Los funcionarios de Inland Empire Health Plan dicen que podría ser un desafío identificar el impacto de un beneficio individual, ya que muchos miembros reciben múltiples servicios. Y se necesita tiempo para darse cuenta de las consecuencias para la salud.

Las comidas de De Los Santos terminarán pronto. Rechazó una extensión, diciendo que ha aprendido lo suficiente sobre porciones y autocontrol. Se siente segura de continuar con su dieta saludable con la ayuda de su esposo, quien cocinará para ella.

“Mi esposo me dice que desacelere”, dijo, “pero tengo mucha más energía”.

Fonseca teme que una vida poco saludable combinada con un trabajo físicamente exigente haya afectado su cuerpo. Solía ​​trabajar en dos campos en un día y viajaba dependiendo de la temporada de cultivo. Nunca se tomó tiempo libre. “Ahora todo lo que tengo es tiempo”, dijo, “pero la diálisis me hace sentir agotado”.

Le preguntó a su enfermera acerca de cómo obtener comidas médicamente diseñadas.

“Tiene que estar saludable para calificar para entrar en una lista de espera de trasplante de riñón”, dijo su hija. “Esa es nuestra esperanza”.

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She takes multiple painkillers every day. And the cause of her agony remains undiagnosed because, despite her tenacious efforts, she hasn’t been able to get a referral to a suitable doctor. Grant, 63, is in Medi-Cal, California’s version of Medicaid, the program for people with low incomes. She is enrolled in L.A. Care, one of two managed-care Medi-Cal health plans in Los Angeles County and the largest one in the state, with 2.4 million members.

L.A. Care and many of the other 24 Medi-Cal managed-care plans across the state outsource responsibility for their patients to independent physician associations and in many cases to other health plans. The subcontracted plans also delegate to IPAs, physician networks that in turn often hire outside management firms to handle medical authorizations and claims.

This multilayered, delegated care works in many instances and is common in managed-care Medi-Cal, which covers over 80% of the program’s 14 million enrollees. But advocates, state regulators and even some health plan executives agree it is confusing and creates obstacles for many Medi-Cal patients, who tend to be poor and from minority communities, often face language barriers and have high rates of chronic illness.

“You’re on Medi-Cal, your last 10 bucks is for the bus, and when you need something, you don’t know who to ask,” said Alex Briscoe, head of the California Children’s Trust and former director of the Alameda County Health Care Services Agency. “The complexity is like salt in the wounds of people trying to navigate the health care system.”

Moreover, health plans often exercise weak oversight of subcontractors, allowing some to get away with inferior care or unwarranted denials. The state has promised to tighten the rules for Medi-Cal plans and providers in new managed-care contracts scheduled to take effect in 2024.

Although spending on Medi-Cal is projected to reach a record $124 billion this fiscal year, medical providers frequently complain that its payments are insufficient — and critics say each layer of administration diminishes the pool of dollars available for health care.

The worst part is the physical toll such a confounding system can take on enrollees. Grant, who describes herself as a person of color, spends most of her time sequestered at home and has to gird herself with extra pain medication just to shop or do her laundry. “I was muscular. I always used my body. Now, I can’t even recognize myself,” she said.

Although L.A. Care is ultimately responsible for Grant, it delegates her care to a physician network called Prospect Medical Group. Prospect, in turn, contracts with a medical management company called MedPoint Management.

Grant said she’s gone from Prospect to MedPoint to L.A. Care and ultimately to the Department of Managed Health Care, one of the state’s two health insurance regulators, seeking authorization to see a thoracic surgeon about her rib cage. But the doctors to whom she’s been referred were either the wrong type, had already unsuccessfully treated her or had been sued repeatedly for malpractice. Some, she said, were no longer in practice or had moved out of state.

L.A. Care said in a statement that it “takes seriously all member concerns that are brought to the health plan’s attention” and is “troubled to learn when any resident in Los Angeles County is not getting needed medical care.”

L.A. Care, which relies on delegation more than any other Medi-Cal plan in the state, has about 58 subcontractors under its umbrella. That group includes three health plans — Kaiser Permanente, Anthem Blue Cross and Blue Shield of California — as well as about 55 physician networks. Community health clinics and the county’s public health system are also in L.A. Care’s network.

CalOptima, which runs Medi-Cal for Orange County’s 860,000 beneficiaries, subcontracts with Kaiser Permanente and 11 physician associations, said its chief operating officer, Yunkyung Kim.

The Alameda Alliance for Health, one of two Medi-Cal health plans in Alameda County, delegates full responsibility for about 43,000 of its 300,000 enrollees to Kaiser Permanente, said Scott Coffin, its CEO. It also subcontracts varying degrees of responsibility to a chain of community health clinics, a pediatric medical group and the county’s public health system, he said.

Typically, the health plans pay their subcontractors a fixed monthly fee per enrollee. The plans take a percentage of the money they receive from the state to cover the oversight of their subcontractors and are generally off the hook financially for care of those patients.

“It’s a reliable portion of our bottom line and gives some stability to our finances,” said John Baackes, L.A. Care’s CEO.

Health plan executives say subcontracting gives patients more choices.

In Los Angeles County, for example, the state contracts with two health plans: L.A. Care and Health Net. Because L.A. Care subcontracts with three other health plans and Health Net with one — Molina Healthcare — Medi-Cal enrollees can actually choose from six plans.

Skeptics say the idea of broader choice is illusory because whichever plan patients choose, they end up with specific physician networks and are usually restricted to their providers.

“They operate as these mini-plans within a plan, and their networks are very narrow,” said Abigail Coursolle, a senior attorney at the National Health Law Program in Los Angeles.

Medi-Cal enrollees can change providers every month if they wish, Baackes said. But some might not know they have that right, and others, like Grant, may not want to change. “I am reluctant to join another IPA because I’d lose my primary care doctor, and I’d have to start from scratch,” she said.

Switching providers every month is not conducive to good health, said William Barcellona, executive vice president of government affairs at America’s Physician Groups, which represents IPAs and medical groups.

When people first enter managed care, they need to be assessed for chronic illnesses and mental health and then given the care they need, he said. “You can’t do that when somebody can just move around the system every 30 days.”

When delegation is done right, it can be a more efficient way of delivering care, especially in large, populous counties with diverse communities.

“It’s like a contractor on a house. Would it make sense for the contractor to be doing the wiring and the plumbing and the drywall himself?” asked Jennifer Kent, who ran the Department of Health Care Services, which administers Medi-Cal, from 2015 to 2019. “He could, and if he’s good at it, great. But he’s probably not as efficient as if he’s overseeing the drywall guy and the plumber and he’s monitoring the quality.”

But it becomes a problem when the health plans’ oversight of the medical groups is lacking, Kent said. And that’s a big problem in Medi-Cal, agree advocates, patients and state health officials.

The new Medi-Cal contracts will “significantly strengthen and clarify requirements and expectations” on the managed-care plans with regard to oversight and compliance of their subcontractors, said Anthony Cava, a spokesperson for the Department of Health Care Services.

The contracts will specify which requirements to include in subcontractor agreements and designate certain functions that the managed-care plans may not delegate, Cava said. The contracts also will require the plans to report on timely access and quality of care for each of their subcontractors.

Currently, plans report data only in the aggregate, which hides wide variations in performance and enables subpar performers to evade detection. This means the health plan quality scores published by the state do not always reflect the real-life experiences of patients. Health plans have a hard time getting reports on patient visits from their physician groups, which in turn often have difficulty getting it from the doctors in their networks.

To be sure, some plans have already made efforts to measure the performance of their subcontractors.

The Alameda Alliance created a committee to monitor its subcontractors, Coffin said. It oversees annual audits and posts “dashboards” to track subcontractors’ performance.

Baackes said that when he first took the helm at L.A. Care in 2015, its physician groups offered care of inconsistent quality. He implemented a report card for all subcontractors, and since then, the laggards have upped their game, he said.

But Baackes is not a big fan of the sprawling delegated system he inherited. The administrative layers make it expensive, and each one “adds an opportunity for someone to drop the ball,” he said.

Grant and other enrollees who feel ill-served by Medi-Cal would certainly agree.

Last week, Grant finally saw a UCLA surgeon she thought could help her. The surgeon, who specialized in cardiovascular issues, didn’t have an answer for her ribcage problem but found a spot on her lung. Once again, Grant was left to her own devices and had to make several phone calls to arrange for a CT scan of the growth.

She praised her primary care doctor and his assistant as “caring and good people” who have tried to help her. But she feels betrayed by the system.

“It’s like they purposefully confuse you so they have the upper hand,” she said. “That’s how I see it. How could I not?”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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