I recently celebrated with one of my patients as she met a major health goal: she maintained well-controlled blood sugar and blood pressure levels for a full year. In the eight years since our first visit, she struggled with consistent management of her diabetes, in large part due to challenges affording medications and nutritious food. In addition to caring for her two young children, she spent years as the primary supporter for her mother who suffered from complications from a severe stroke. Witnessing her mother’s decline in health only furthered this resilient young woman’s resolve to improve her own health, and I was excited to see her making progress towards this precious goal. 

Sadly, our shared joy was tempered by the harrowing realization that she might soon lose access to essential safety net services that buoyed the improvements in her health. We both knew that a significant part of her success was based on consistent Medi-Cal coverage and access to associated anti-hunger and anti-poverty support programs. The end of the federal COVID-19 Public Health Emergency (PHE) declaration on May 11, 2023, marked a reversal or regression of hundreds of federal and state legislative flexibilities that allowed for expansion of Medi-Cal services for the most vulnerable communities in California. 

Major Risks of the Great Unwinding of Medi-Cal Enrollments
For my patient and millions of other Californians who live at the margins of the social safety net, a critical piece of federal legislation prevented eligible patients from automatic disenrollment from Medi-Cal throughout the height of the COVID-19 pandemic. This resulted in a 16% increase in California’s enrolled Medi-Cal population since March 2020(1); this policy was especially impactful for increasing health access for low-income families, older adults, working adults, children, and people with disabilities(2). 

As a result of congressional legislation that de-coupled the Medi-Cal coverage requirements from the federal PHE declaration in December 2022, the automatic enrollment provisions expired on March 31, 2023, with an estimated three million Californians set to lose Medi-Cal coverage as the pre-pandemic enrollment cycles resume1. This is especially discouraging after the overall rate of insurance coverage in California reached 92% during the pandemic, the highest since 2016(3). 

The California Department of Health Care Services also used the PHE declaration to expand access to vital programs such as the Supplemental Nutrition Assistance Program (CalFresh) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)(1). The levels of food insecurity in poor neighborhoods dropped significantly through increased access to these assistance programs. 

Unfortunately, the federally-funded “Emergency Allotments” afforded to CalFresh recipients to support their nutritional needs ended in March 2023. School children will also lose their added Pandemic-Electronic Benefits Transfer (EBT) benefits after the 2022-2023 school year4. This could not come at a worse time, as the cost of groceries continues to skyrocket with deeper income inequality across the state. According to data from the California Association of Food Banks, each CalFresh recipient will lose $82 dollars a month as the benefits are removed; for elderly adults who qualify for the minimum, their benefits will drop from $281 to $23 per month(4). 

For my primary care colleagues working in under-resourced settings, the news of these dire policy reversals feels as though a life raft is being deflated from beneath us just as we were escaping the torrent of the pandemic. 

Advocacy in Action: UCSF Champion Provider Fellowship

My experience with the Champion Provider Fellowship helped transform the frustrations from my patients’ stories into catalysts for systems and policy changes. I witnessed firsthand the tremendous impact of collaboration between public health agencies, community health centers, and community-based organizations. 

Several of the amazing physicians and dentists from my Champion Provider Fellowship cohort are making impacts to address gaps in healthy food access through efforts including creating an outdoor garden and classroom and advocating for the inclusion of medically-tailored food and nutrition interventions as a covered health benefit.

From these powerful examples, I learned to use my position and privilege as a family physician to collaborate with community-based organizations in Riverside County. Together we conduct outreach events and share resources about Medi-Cal and CalFresh services for populations that suffer from generations of structural violence and health disparities. Our network of community health centers enlists patient navigators and community health workers to guide our patients through enrollment for these valuable programs. Our “Food is Medicine” program provides emergency supplies of nutritious shelf-stable food boxes to patients in need.

I also encourage my colleagues to learn about pending policy in the California State Legislature, as this is an incredible opportunity for collective advocacy in action. In March, I joined a delegation from the California Academy of Family Physicians to meet with our state senators and assemblymembers to discuss important pieces of legislation that impacted the health and well-being of our patients. We used the stories of our patients to highlight Assembly Bill 85 (AB85 - Weber) that would cover the costs of screening for social determinants of health and boost access to community health workers. This is critical to our efforts in maintaining the benefits of Medi-Cal enrollment for our most vulnerable patient populations. There are several active legislative policies that seek to close the gaps that threaten these communities through establishing medically supportive food and nutrition interventions as covered benefits under Medi-Cal or raising the CalFresh minimum benefit to account for inflation. 

These important advocacy efforts will help sustain the health success of my patient and millions like her in the coming months. When it seems that complex barriers are insurmountable, I reflect on the remarkable progress we’ve made through collective health action since the start of the COVID-19 pandemic. We relied on our trusted community relationships to navigate through the initial uncertainty and confront structural inequalities. And through our combined efforts, we identified practical solutions to continue the essential health coverage and benefits for our patients and their families.

References:

1. Department of Health Care Services (DHCS): Medi-Cal COVID-19 Public Health Emergency and Continuous Coverage: Operational Unwinding Plan - March 7, 2023. https://www.dhcs.ca.gov/Documents/PHE-UOP/Medi-Cal-COVID-19-PHE-Unwinding-Plan.pdf
2. Thompson, F. Medicaid and the “great unwinding”: a high-stakes implementation challenge. Brookings Institute – May 8, 2023. https://www.brookings.edu/blog/fixgov/2023/05/08/medicaid-and-the-great-unwinding-a-high-stakes-implementation-challenge/
3. Tolbert, J. 10 Things to Know About the Medicaid Continuous Enrollment Provision. Kaiser Family Foundation – April 5, 202 https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/
4. California Association of Food Banks. Cal-Fresh Emergency Allotments and Pandemic-EBT Are Ending. February 2023. https://www.cafoodbanks.org/wp-content/uploads/2023/03/2023_Emergency-Allotments-PEBT_Factsheet.pdf
5. California Association of Food Banks. 2023 State Policy Priorities. https://www.cafoodbanks.org/wp-content/uploads/2023/01/2023_CAFB_State-Policy-Agenda.pdf

Moazzum Bajwa, MD MPH MSc, is a Family Physician and an Assistant Clinical Professor of Family Medicine at UC Riverside School of Medicine.