CaliforniaS $12 billion Medicaid makeover banks on nonprofits buy-in

Published

2 years ago

May 16, 2024

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May 16 2024 KFF Health News

For much of his young life, Jorge Sanchez regularly gasped for air, at times coughing so violently that he'd almost throw up. His mother whisked him to the emergency room late at night and slept with him to make sure he didn't stop breathing.

"He's had these problems since he was born, and I couldn't figure out what was triggering his asthma," Fabiola Sandoval said of her son, Jorge, now 4. "It's so hard when your child is hurting. I was willing to try anything."

In January, community health workers visited Sandoval's home in Turlock, a city in California's Central Valley where dust from fruit and nut orchards billows through the air. They scoured Sandoval's home for hazards and explained that harsh cleaning products, air fresheners, and airborne dust and pesticides can trigger an asthma attack.

The team also provided Sandoval with air purifiers, a special vacuum cleaner that can suck dust out of the air, hypoallergenic mattress covers, and a humidity sensor — goods that retail for hundreds of dollars. Within a few months, Jorge was breathing easier and was able to run and play outside.

The in-home consultation and supplies were paid for by Medi-Cal, California's Medicaid health insurance program for low-income residents. Gov. Gavin Newsom is spearheading an ambitious $12 billion experiment to transform Medi-Cal into both a health insurer and a social services provider, one that relies not only on doctors and nurses, but also community health workers and nonprofit groups that offer dozens of services, including delivering healthy meals and helping homeless people pay for housing.

These groups are redefining health care in California as they compete with businesses for a share of the money, and become a new arm of the sprawling Medi-Cal bureaucracy that serves nearly 15 million low-income residents on an annual budget of $158 billion.

But worker shortages, negotiations with health insurance companies, and learning to navigate complex billing and technology systems have hamstrung the community groups' ability to deliver the new services: Now into the third year of the ambitious five-year experiment, only a small fraction of eligible patients have received benefits.

"This is still so new, and everyone is just overwhelmed at this point, so it's slow-going," said Kevin Hamilton, a senior director at the Central California Asthma Collaborative.

The collaborative has served about 3,650 patients, including Sandoval, in eight counties since early 2022, he said. It has years of experience with Medi-Cal patients in the Central Valley and has received about $1.5 million of the new initiative's money.

By contrast, CalOptima Health, Orange County's primary Medi-Cal insurer, is new to offering asthma benefits and has signed up 58 patients so far.

"Asthma services are so difficult to get going" because the nonprofit infrastructure for these services is virtually nonexistent, said Kelly Bruno-Nelson, CalOptima's executive director for Medi-Cal. "We need more community-based organizations on board because they're the ones who can serve a population that nobody wants to deal with."

Newsom, a Democrat in his second term, says his signature health care initiative, known as CalAIM, seeks to reduce the cost of caring for the state's sickest and most vulnerable patients, including homeless Californians, foster children, former inmates, and people battling addiction disorders.

In addition to in-home asthma remediation, CalAIM offers 13 broad categories of social services, plus a benefit connecting eligible patients with one-on-one care managers to help them obtain anything they need to get healthier, from grocery shopping to finding a job.

The 25 managed-care insurance companies participating in Medi-Cal can choose which services they offer, and contract with community groups to provide them. Insurers have hammered out about 4,300 large and small contracts with nonprofits and businesses.

So far, about 103,000 Medi-Cal patients have received CalAIM services and roughly 160,000 have been assigned personal care managers, according to state data, a sliver of the hundreds of thousands of patients who likely qualify.

"We're all new to health care, and a lot of this is such a foreign concept," said Helena Lopez, executive director of A Greater Hope, a nonprofit organization providing social services in Riverside and San Bernardino counties, such as handing out baseball cleats to children to help them be active.

Tiffany Sickler runs Koinonia Family Services, which offers California foster children mental health and other types of care, and even helped a patient pay off parking tickets. But the program is struggling on a shoestring budget.

"If you want to do this, you have to learn all these new systems. It's been a huge learning curve, and very time-consuming and frustrating, especially without adequate funding," she said.

Brandon Richards, a Newsom spokesperson, defended CalAIM, saying that it was "on the cutting edge of health care" and that the state was working to increase "awareness of these new services and support."

For nonprofits and businesses, CalAIM is a money-making opportunity — one that top state health officials hope to make permanent. Health insurers, which receive hefty payments from the state to serve more people and offer new services, share a portion with service providers. Related StoriesStudy links higher-potency cannabis use in youth to increased risk of psychotic experiencesUncovering the psychological toll of entrenched school practices on childrenClinical trial in Seattle aims to transform treatment approaches for pediatric IBD

In some places, community groups are competing with national corporations for the new funding, such as Mom's Meals, an Iowa-based company that delivers prepared meals across the United States.

Mom's Meals has an advantage over neighborhood nonprofit groups because it has long served seniors on Medicare and was able to immediately start offering the CalAIM benefit of home-delivered meals for patients with chronic diseases. But even Mom's Meals isn't reaching everyone who qualifies, because doctors and patients don't always know it's an option, said Catherine Macpherson, the company's chief nutrition officer.

"Utilization is not as high as it should be yet," she said. "But we were well positioned, because we already had departments to do billing and contracting with health care."

Middleman companies also have their eye on the billions of CalAIM dollars and are popping up to assist small organizations to go up against established ones like Mom's Meals. For instance, the New York-based Nonprofit Finance Fund is advising homeless service providers how to get more contracts and expand benefits.

Full Circle Health Network, with 70 member organizations, is helping smaller nonprofit groups develop and deliver services primarily for families and foster children. Full Circle has signed a deal with Kaiser Permanente, allowing the health care giant to access its network of community groups.

"We're allowing organizations to launch these benefits much faster than they've been able to do and to reach more vulnerable people," said Camille Schraeder, chief executive of Full Circle. "Many of these are grassroots organizations that have the trust and expertise on the ground, but they're new to health care."

One of the biggest challenges community groups face is hiring workers, who are key to finding eligible patients and persuading them to participate.

Kathryn Phillips, a workforce expert at the California Health Care Foundation, said there isn't enough seed money for community groups to hire workers and pay for new technology platforms. "They bring the trust that is needed, the cultural competency, the diversity of languages," she said. "But there needs to be more funding and reimbursement to build this workforce."

Health insurers say they are trying to increase the workforce. For instance, L.A. Care Health Plan, the largest Medi-Cal insurer in California, has given $66 million to community organizations for hiring and other CalAIM needs, said Sameer Amin, the group's chief medical officer.

"They don't have the staffing to do all this stuff, so we're helping with that all while teaching them how to build up their health care infrastructure," he said. "Everyone wants a win, but this isn't going to be successful overnight."

In the Central Valley, Jorge Sanchez is one of the lucky early beneficiaries of CalAIM.

His mother credits the trust she established with community health workers, who spent many hours over multiple visits to teach her how to control her son's asthma.

"I used to love cleaning with bleach" but learned it can trigger breathing problems, Sandoval said.

Since she implemented the health workers' recommendations, Sandoval has been able to let Jorge sleep alone at night for the first time in four years.

"Having this program and all the things available is amazing," said Sandoval, as she pointed to the dirty dust cup in her new vacuum cleaner. "Now my son doesn't have as many asthma attacks and he can run around and be a normal kid."

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism. Source:

KFF Health News

Politics

Child poverty strategy unveiled – but not everyone’s happy

Published

2 hours ago

December 5, 2025

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Starmer wants to lift half a million children out of poverty - but does his plan go far enough?

A new long-awaited child poverty strategy is promising to lift half a million children out of poverty by the end of this parliament – but critics have branded it unambitious.

The headline announcement in the government’s plan is the pledge to lift the two-child benefit cap, announced in Rachel Reeves’s budget last week.

It also includes:

• Providing upfront childcare support for parents on universal credit returning to work
• An £8m fund to end the placement of families in bed and breakfasts beyond a six-week limit
• Reforms to cut the cost of baby formula
• A new legal duty on councils to notify schools, health visitors, and GPs when a child is placed in temporary accommodation

Many of the measures have previously been announced.

The government also pointed to its plan in the budget to cut energy bills by £150 a year, and its previously promised £950m boost to a local authority housing fund, which it says will deliver 5,000 high-quality homes for better temporary accommodation.

Downing Street said the strategy would lift 550,000 children out of poverty by 2030, saying that would be the biggest reduction in a single parliament since records began.

But charities had been hoping for a 10-year strategy and argue the plan lacks ambition.

A record 4.5 million children (about 31%) are living in poverty in the UK – 900,000 more since 2010/11, according to government figures.

Phillip Anderson, the Strategic Director for External Affairs at the National Children’s Bureau (NCB), told Sky News: “Abolishing the two-child limit is a hell of a centre piece, but beyond that it’s mainly a summary of previously announced policies and commitments.

“The really big thing for me is it misses the opportunity to talk about the longer term. It was supposed to be a 10-year strategy, we wanted to see real ambition and ideally legally binding targets for reducing poverty.

“The government itself says there will still be around four million children living in poverty after these measures and the strategy has very little to say to them.”

‘Budget for benefits street’ row

The biggest measure in the strategy is the plan to lift the two-child benefit cap from April. This is estimated to lift 450,000 children out of poverty by 2030, at a cost of £3bn.

The government has long been under pressure from backbench Labour MPs to scrap the cap, with most experts arguing that it is the quickest, most cost-effective way to drive-down poverty this parliament.

The cap, introduced by Conservative chancellor George Osborne in 2017, means parents can only claim universal credit or tax credits for their first two children. It meant the average affected household losing £4,300 per year, the Institute for Fiscal Studies calculated in 2024.

The government argues that a failure to tackle child poverty holds back the economy, and young people at school, cutting their employment and earning prospects in later life.

However, the Conservatives argue parents on benefits should have to make the same financial choices about children as everyone else.

Shadow chancellor Mel Stride said: “Work is the best way out poverty but since this government took office, unemployment has risen every single month and this budget for Benefits Street will only make the situation worse. “

‘Bring back Sure Start’

Lord Bird, a crossbench peer who founded the Big Issue and grew up in poverty, said while he supported the lifting of the cap there needed to be “more joined up thinking” across government for a longer-term strategy.

He has been pushing for the creation of a government ministry of “poverty prevention and cure”, and for legally binding targets on child poverty.

“You have to be able to measure yourself, you can’t have the government marking its own homework,” he told Sky News.

Lord Bird also said he was a “great believer” in resurrecting Sure Start centres and expanding them beyond early years.

The New Labour programme offered support services for pre-school children and their parents and is widely seen to have improved health and educational outcomes. By its peak in 2009-2010 there were 3,600 centres – the majority of which closed following cuts by the subsequent Conservative government.

PM to meet families

Sir Keir Starmer’s government have since announced 1,000 Best Start Family Hubs – but many Labour MPs feel this announcement went under the radar and ministers missed a trick in not calling them “Sure Starts” as it is a name people are familiar with.

The prime minister is expected to meet families and children in Wales on Friday, alongside the Welsh First Minister, to make the case for his strategy and meet those he hopes will benefit from it.

Several other charities have urged ministers to go further. Both Crisis and Shelter called for the government to unfreeze housing benefit and build more social rent homes, while the Children’s Commissioner for England, Dame Rachel de Souza, said that “if we are to end child poverty – not just reduce it” measures like free bus travel for school-age children would be needed.

The strategy comes after the government set up a child poverty taskforce in July 2024, which was initially due to report back in May. The taskforce’s findings have not yet been published – only the government’s response.

Sir Keir said: “Too many children are growing up in poverty, held back from getting on in life, and too many families are struggling without the basics: a secure home, warm meals and the support they need to make ends meet.

“I will not stand by and watch that happen, because the cost of doing nothing is too high for children, for families and for Britain.”

Sports

Isles top juggernaut Avalanche with ‘surprise’ win

Published

2 hours ago

December 5, 2025

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Isles top juggernaut Avalanche with 'surprise' win

Greg WyshynskiDec 4, 2025, 11:39 PM ET
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ELMONT, N.Y. — The Colorado Avalanche entered Thursday night’s game at the New York Islanders as a juggernaut, having lost just once in regulation in 26 games. Islanders coach Patrick Roy’s message to his team before that game: “If there’s a team that could surprise them, it’s us and the way we’ve been playing.”

St. Patrick was prophetic: Roy’s team defeated the mighty Avalanche 6-3 to snap Colorado’s 17-game point streak in a statement win for the Islanders (15-10-3).

The Islanders built a 4-0 lead against Colorado and responded every time the Avalanche crept back into the game. That included a late third-period penalty kill, as the Avalanche pulled goalie Mackenzie Blackwood for a 6-on-4 advantage. Forward Casey Cizikas iced the win with an empty-netter.

“That’s a really good hockey team over there,” Cizikas said. “They’ve proved it all season. They’re never out of a game, so you’ve got to complete it.”

Even after the loss, Colorado remained the NHL’s top team in points percentage (.815), goal differential (plus-47), offense (4.04 goals per game) and defense (2.19 goals against per game). The Avalanche have the NHL’s leading scorer in center Nathan MacKinnon (46 points) and the leading scorer among defenseman in Cale Makar (33 points).

But Islanders forward Mathew Barzal said New York’s 4-1 loss in Denver on Nov. 16 gave his teammates confidence they could hang with the NHL’s best.

“We feel like when we played them in Colorado, we probably should have won,” said Barzal, who had a goal and two assists in the win. “As a group, too, we know who we’re playing and that always makes a difference. Against Colorado, if we don’t show up, it could be ugly.”

The Islanders showed up on the scoresheet at 5:56 in the first period, on a controversial goal by forward Kyle MacLean. His shot sailed into the top corner of the net with Blackwood (36 saves) flat on the ice. Replays showed that after a scramble in the crease, the stick of Islanders center Marc Gatcomb had become wedged in Blackwood’s pads as Blackwood attempted to defend the net.

Colorado coach Jared Bednar challenged the goal. The NHL Situation Room cited Rule 69.7 in upholding the goal, which states that “in a rebound situation, or where a goalkeeper and attacking player(s) are simultaneously attempting to play a loose puck, whether inside or outside the crease, incidental contact with the goalkeeper will be permitted, and any goal that is scored as a result thereof will be allowed.”

Bednar disagreed with that assessment.

“Listen, I think goalie interference is a joke. If that’s not goalie interference, I don’t know what is. You can’t just shove the goalie’s pads out of the way to create a loose puck,” said Bednar. “I’m not going to challenge unless it’s obvious. And I thought that was obvious.”

On the other end of the ice, Islanders goalie Ilya Sorokin was great when he needed to be in making 35 saves against the high-octane Avalanche. Roy cited one save in the second period where Sorokin stopped Artturi Lehkonen on a 2-on-1 before Barzal increased their lead to 5-2 with a power-play goal.

“I think that gave us the confidence. Ilya made the key save at the right time,” said the coach.

The Islanders’ win over the Avalanche came on a poignant night at UBS Arena for the players. Their fathers and mentors were in attendance, ahead of their road trip to Florida. The game also marked the return of former Islanders star Brock Nelson, who was sent to Colorado at last season’s trade deadline. He received a standing ovation from Islanders fans after a video tribute.

It was just the second loss for the Avalanche (19-2-6) in the past 14 games.

“It’s closer than you think, but it still wasn’t good enough,” Bednar said. “We’ll refocus on the things that we need to do to make us successful.”

Sports

McDavid’s hat trick ties Messier, Oilers rout Kraken

Published

2 hours ago

December 5, 2025

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McDavid's hat trick ties Messier, Oilers rout Kraken

Associated Press

Dec 5, 2025, 12:29 AM ET

EDMONTON, Alberta — Connor McDavid had his 13th career hat trick to tie Mark Messier for fourth in Oilers history and added an assist in Edmonton’s 9-4 romp over the Seattle Kraken on Thursday night.

McDavid opened the scoring at 7:17 of the first period, made it 5-2 on a power play at 6:14 of the second and struck again on a power play at 6:59 of the third. He has 14 goals this season.

McDavid set up Leon Draisaitl‘s first-period, power-play goal for his 28th assist. Along with his 16th goal, Draisaitl had three assists for a four-point night of his own.

Matthew Savoie scored twice and Vasily Podkolzin, Zach Hyman and Mattias Janmark added goals. Evan Bouchard and Ryan Nugent-Hopkins each had three assists, and Calvin Pickard made 28 saves. The Oilers have won two of their last three to improve to 12-11-5.

Eeli Tolvanen, Frederick Gaudreau, Jared McCann and Jani Nyman scored for Seattle. The Kraken have lost four in a row to drop to 11-8-6.

Joey Daccord allowed five goals on 14 shots for the Kraken before being replaced six minutes into the second period by Philipp Grubauer, who also made 14 saves.