This is the age of Medi-Cal.

“Medicare for All,” the dream of extending federal health coverage for the elderly to all Americans, dominates headlines. But in California, it is Medicaid—or Medi-Cal, as the federal health program for the poor is called here—that rules. Medi-Cal, and its no-or-low-cost health services, already constitute California’s most important anti-poverty program—and hold even greater possibilities for the future.

Medi-Cal spending, mostly from federal funds, has grown rapidly over the past decade. This past week, even as the governor agreed to a state budget with many cuts, Medi-Cal kept growing, to $112 billion in 2020-21. This increase covers the two million people, who are projected to join Medi-Cal after losing jobs or insurance during the pandemic. 

All told, 14.5 million Californians—more than one-third of us—are on Medi-Cal, double the number in 2010. Roughly half of California children are on Medi-Cal. So are some two-thirds of our nursing home residents. And if our economic downturn becomes a depression, millions more Californians will end up depending on Medi-Cal for our healthcare, too.

Medi-Cal’s rapid expansion into a safety net for all Californians represents triumph, trouble—and opportunity. 

The triumph belongs to the Affordable Care Act, aka Obamacare. Before that law passed in 2010, Medicaid covered only certain poor or disabled adults. But Obamacare funded states to open Medicaid eligibility to virtually all low-income adults. No state embraced Obamacare’s Medicaid expansion more fiercely than California, which covered undocumented children and young adults who had been excluded from the federal program because of their immigration status. Medi-Cal expansion, and the state’s insurance exchanges, got results: the percentage of uninsured Californians dropped from 18 percent to 7 percent over the last decade. 

The trouble is that the program has struggled to meet the needs of its new enrollees. While millions now may be protected from financial ruin if they get sick because Medi-Cal is paying the bills, Medi-Cal does not guarantee them high-quality healthcare. 

The obstacles lie in the way care is disbursed. In California, more than 80 percent of people on Medi-Cal are enrolled in managed care organizations, which are paid by the state to provide enrollees with care. And managed care is not performing as well as it should. A 2019 report on Medi-Cal managed care plans found that the quality of their care declined or stayed flat on most measures between 2009 and 2018, according to the California Health Care Foundation

Improving quality is difficult because Medi-Cal mirrors the complexity of the state. Though Medi-Cal is a federal program overseen by the state, the managed care plans operate at the county level. Your choice of plans, and your Medi-Cal experience, is different in each county. You’re probably better off in Yolo County, with one well-regarded Partnership Health Plan, than in Sacramento County, which has a confusing array of commercial plans. While Orange County’s CalOptima has a reputation for scandal, Inland Empire Health Plan, serving Riverside and San Bernardino counties, is considered a model.

These Medi-Cal challenges represent opportunity. Before the pandemic, 2020 looked like the year of Medi-Cal reform. Health advocates were pushing new standards for the quality of care offered through the Medi-Cal managed care plans. And the governor was pursuing an ambitious set of proposals called CalAIM that would use Medi-Cal more broadly to help the most vulnerable Californians—particularly the homeless—with difficult challenges like mental health and housing. 

But now, with the state’s health bureaucracy consumed by COVID, CalAIM is on hold. This pullback offers political protection. Medi-Cal remains vulnerable to the national partisan struggle over healthcare. But it seems poised to keep growing because the need is so great. Improvements can’t come soon enough. Payments to managed care plans should be tied to measures of access, quality of care, and patient outcomes. California needs more health professionals to treat more Medi-Cal enrollees.  

Medi-Cal is such a big part of California that improving it could benefit our whole health system. That’s why Californians—even those with health insurance from employers—should demand that the state do better by Medi-Cal. With the way the world is going, you’ll need Medi-Cal before you know it.


Joe Mathews writes the Connecting California column for Zócalo Public Square.