Researchers Find Racial Health Equity Not a Priority in CalAIM
One of the stated goals of the CalAIM Medicaid transformation effort in California is to reduce racial health inequities. But researchers interviewing managed care plans and service providers in three counties working to address homelessness through CalAIM funding found little focused effort to address racial health equity.
Among other things, CalAIM is designed to dismantle forms of structural racism by investing nearly $2 billion in helping Medicaid health plans and medical providers forge stronger alliances with local social service organizations and public health agencies in addressing the complex health and social needs of Medicaid beneficiaries, including paying for non-medical services.
Researchers are engaged in a study, funded as part of the Robert Wood Johnson Foundation’s Systems for Action research program, to evaluate the effectiveness of CalAIM in integrating social service and public health organizations into Medicaid coordinated systems of care for individuals with complex health and social needs.
One of the researchers presenting during a recent Systems for Action webinar is Caroline Fichtenberg, Ph.D., research scientist in the Department of Family and Community Medicine and University of California, San Francisco, and co-director of SIREN (Social Interventions Research & Evaluation Network).
“This is our initial analysis, but overall, from talking to service providers in the homeless services space, Medicaid managed care plans and technical assistance providers in three counties, there was a disappointing lack of focus on racial equity across all three groups,” Fichtenberg said.
For this study, researchers focused on three counties: Humboldt, Santa Cruz County and Los Angeles. They interviewed 25 service provider organizations as well as seven managed care plans, and six technical assistance providers. These are organizations that are hired by the state to run collaboratives to help groups participate in CalAIM. The research team did the interviews from March through October of last year, and that was midway through the third year of CalAIM implementation.
“We were specifically interested in how racial health equity is being advanced through CalAIM implementation,” Fichtenberg explained. “We decided to focus on services being provided to individuals experiencing homelessness, which is one of the major populations receiving services through CalAIM.”
They also decided to focus on housing-related community supports. These include housing transition navigation services, which means helping people who are homeless get into more stable housing situations; housing deposits, which pays first month's rent and move-in fees and furniture for people who are moving into a new space; housing, tenancy and sustaining services, which supports individuals staying housed once they have become housed; and then recuperative care, providing a place for individuals who are coming out of the hospital or who don't have a stable home to get better after a hospitalization.
One of the goals of CalAIM on paper is to to reduce racial health inequities. So the researchers asked service providers: Do you think that CalAIM is effectively doing that, and why or why not? They also asked: How is your organization thinking about racial health equity as part of CalAIM implementation?
“Overall, from the community-based organization service providers, we heard that they really did not have that much to say about racial health equity and this was pretty disappointing,” Fichtenberg said. “Generally, when we asked this question, they were a little off guard. They didn't have that much to say about it, and they hadn’t thought about it that much. It was a little bit disappointing and indicated to us that that this was clearly not a huge priority.”
Summarizing the responses, she said that service providers said they felt that because the underserved are disproportionately people who are marginalized by racism and other factors, they would be automatically helping address racial equity. “So, they are saying that given that homelessness is so racialized, by accident almost, even without making that a priority, connecting all our clients to enhance care management, for example, will help ensure that our clients who are disproportionately part of marginalized races have an easier time to accessing healthcare services,” she said.
People said that the way that they are ensuring that they are addressing health equity is by treating everyone the same. Many spoke of the cultural and language concordance and diversity of staff being a key element. Others said that the managed care plans they work with really haven't been focusing on this, so there hasn't been too much guidance in terms of how they want service providers to capture that information and to track it. “So this organization felt like they were not really getting any signals from the plans that this is something they should focus on,” Fichtenberg said.
Another researcher on the project is Rohan Rastogi, M.D., M.P.H., clinical fellow, National Clinician Scholars Program, Division of General Internal Medicine at ZSFG, University of California, San Francisco. He shared results from the conversations with seven managed care plans. Five of them were participating only at the local level — in a single county or in a single, isolated region — and two are in multiple counties.
The researchers asked them: How are you thinking about racial health equity as a part of CalAIM implementation? “Unfortunately, again, what we heard from a lot of managed care plans was that this is not really a priority for them,” Rastogi said. “This is particularly disappointing because we heard from some of the service providers that they felt like they needed instruction from the managed care plans, and yet, we heard from almost a majority of the managed care plans that they hadn't put a ton of thought into it either.”
Rastogi reported that one Medicare plan representative said, “I think that some counties naturally are forced to do it just based on the distribution of members. But we do have a report that looks at who's enrolled by ethnicity, by zip code, so that's helpful. We actually built that out to really try to honor a level of equity. But I can't say that we're doing any type of training or credit engagement to really highlight what that looks like for our provider network.”
A couple of managed care plan representatives also said they felt that by serving the underserved and serving those who are more marginalized by systemic racism, and therefore had some of these health-related social needs that CalAIM intended to target, they were doing the equity work by default.
Others said that if they can engage some very local organizations, they're the ones that are going to know the population and have people on their teams that are probably reflective of the population that they're serving. For example, if they are engaging an organization that's in a county that does a lot of outreach on tribal lands, their staff members look like the people they're serving.
“So summarizing what the managed care plans said, really the main takeaway was that they felt that partnering with local community organizations was their primary intervention to advance equity, while some said that equity was not yet a priority,” Rastogi said.
Fichtenberg noted that although technical assistance providers seem to be thinking about equity the most and doing the most about it, “many felt that just by serving the homeless, they were disproportionately helping groups harmed by racism, which is true, but also not enough for really reducing health inequities,” she said.
“Some felt that treating everyone the same was the main way that they were doing it, which felt insufficient to us,” she added. “Some recognized the importance of removing obstacles preventing small, culturally competent providers from participating.”
“From reviewing this, it feels like racial equity needs to be built in from the beginning,” Fichtenberg said. “It can't be an afterthought, and the California Department of Health Care Services (DHCS) should be holding plans accountable for reducing racial inequities and doing more to support participation of small, culturally competent service providers, who clearly are facing obstacles.”
She said that the plans should also be focusing more on racial equity. “Finally, there should be more technical assistance to plans and service providers about how to provide services in ways that reduce racial inequities, and how to provide those services in culturally competent ways that address all the barriers that racism creates.”
