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Health In An Age Of Change: State Health Czar Diana Dooley Reflects On The ACA's Impact


Diana Dooley, secretary of the California Health and Human Services Agency, oversees 13 departments and supervises the state’s rollout of the federal Affordable Care Act, including Covered California, the state’s insurance marketplace, and the Medi-Cal program for the poor. Gov. Jerry Brown appointed her in late 2010. A native of Hanford, she earlier served as president and CEO of the California Children’s Hospital Assn. She worked for Brown during his first administration.

She sat down for an interview with Deborah Schoch, a senior writer for the CHCF Center for Health Reporting.  Here is an edited version of their conversation.

Q: Do you think that Kaiser Permanente, which started in California, is emerging as the model that we’re moving to with the Affordable Care Act?

Dooley: Moving to coordinated care is at the heart of the Affordable Care Act. So I wouldn’t say Kaiser, per se, but Kaiser did this out of its own needs during World War II in the shipyards, where it was providing care to its workers because it needed workers. And investing in them holistically. You’ve got people who are a part of your team. And the team provides care when you need it and health incentives when you don’t. And if we can all do that, it will cost less. So that was the fundamental principle.

I don’t want to be in a position of endorsing any one model or another by name, but the concept of creating a plan of care that treats the whole person and is invested in health instead of in treatment, is what is revolutionary, I think, about the Affordable Care Act.

Q: Medi-Cal’s reimbursement rates in California are among the lowest in the nation. Has that thrown the supply of Medi-Cal providers out of whack?

Dooley: We have 70 percent of our Medi-Cal population in managed care. No other state comes even close to that number. Which argues for our efficiency, that we’re managing the care. For example, it may be that fewer of our people need to go to the doctor. If we’re paying our providers on a capitated basis, and our plans are managing their care, we are getting value. We’re paying less for the health of our Medi-Cal beneficiaries.

Q: Since Jan. 1, Medi-Cal has seen twice the number of enrollees as Covered California. Given the enrollment problems, do you think you’re expanding it more than you should at this point?

Dooley: [Laughs] We didn’t have an option to expand. I mean, the federal law is: If you’re eligible, you get the coverage. We exceeded our most optimistic projections of enrollment—at Covered California, and with Medi-Cal. And so we are in the position of dancing as fast as we can to catch up and accommodate this. We had childless adults who had no care at all. All of those people flooding into the system—there is going to be a pretty significant period of adjustment. And I think, despite the frustration and anxiety of people who weren’t able to get their enrollment confirmed.... This was the first time, maybe in their lifetime, that they had even the hope of getting coverage. And we’re getting them. Any reasonable person would look at this and say, we’re not going to snap our fingers and, you know, turn the lights on. We’re going to have to work through this, and we are.

Q: The ACA operates on the principle that everyone must be covered for quality of care to go up and costs go down. The exclusion of undocumented immigrants means a large chunk of people will go uninsured. What do you think should happen?

Dooley: We clearly need comprehensive immigration reform. But it’s fundamentally a federal issue. And the Affordable Care Act left them out altogether. We’re very busy making what we’ve already done work. It breaks my heart to see people who have needs that we can’t meet.

Q: You’ve said we’re in this season of disruption, and you’ve described it as an in-between stage that morphs into something else. Where is it morphing to?

Dooley: Well, I hope and believe that by focusing on health and outcomes and not procedures and unit costs of care, we can become, as I set as a goal in 2012 with our “Let’s Get Healthy, California” work, the healthiest state in the nation by 2022. That’s sort of the North Star for me.

And I think focusing on health, and creating payment systems and delivery systems that are incentivized for people to be healthy—and that happens when you have team approaches and payments that are on a per-person basis, so that you are looking for ways for people to be healthy, and not ways to be reimbursed for their illness—you can get to that state of health. 

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