New Frontiers of Health: A Partners in Care Interview Series with Secretary Diana S. Dooley
PART ONE OF THREE: “California is as large as many nations, and healthcare has always been a high priority. Because of California’s early actions on healthcare, we were ready to start new reforms with the right people and infrastructure.”
Partners in Care Foundation will present the Vision & Excellence in Healthcare Leadership Award to Diana S. Dooley, Secretary of Health and Human Services for the State of California, at its 19th Annual Tribute Dinner. Secretary Dooley sat down with Partners in Care Foundation for a three-part interview leading up to the event, which will take place at the Beverly Hilton Hotel in Beverly Hills on Monday, June 4, 2018.
In part one of this interview series, Secretary Diana Dooley talks about California’s successful roll-out implementing the Affordable Care Act, and what it took to pass and implement this robust legislation over the better part of a decade with bipartisan cooperation.
Our healthcare system is complex because it has been built up over time. Prior to World War II, most Americans paid for their own medical care. During World War II the federal government exempted employer-paid health benefits from wage controls and income tax, which made employer-provided health insurance more popular than the previously more common individual health insurance.
The healthcare industry changed significantly about 20 years later in the 1960s when the U.S. government implemented Medicaid—Medi-Cal in California—and Medicare, further fragmenting the system.
“Everything since 1965 has been added on in a haphazard way,” says Secretary Dooley. “Sometimes the state provides a benefit for one thing, but completely ignores another. For example, we may care for vulnerable children, breast cancer, or HIV, but we then overlay broad-based screening factors, like income, so not everybody qualifies.”
“Many talk of ObamaCare. However, before it was ObamaCare, the same program was RomneyCare in Massachusetts and SchwarzeneggerCare in California,” adds Secretary Dooley. “Governor Schwarzenegger supported healthcare reform in California years before the Affordable Care Act. In 2010, Schwarzenegger and legislators launched a bipartisan effort for the Medicaid expansion through a special contract with the federal government. California committed to Medicaid expansion well before 2014, in a county-state-federal government program.”
Secretary Dooley goes on to say, “California is as large as many nations, and healthcare has always been a high priority. Because of California’s early actions on healthcare, we were ready to start new reforms with the right people and infrastructure. Our running start with the Affordable Care Act and Covered California was the result of bipartisan efforts, proactive planning, good infrastructure, and having the right teams in place.”
Soon after Secretary Dooley was appointed by Governor Brown, California was still in the depths of a budget crisis in early 2011. “There was a lot of anxiety over budget cuts in health and human services programs,” according to Secretary Dooley. “As a result, I thought it would be best to bring people to the table and look beyond the actual delivery of health services and the cuts that we were having to make to find solutions.”
“While we hoped the voters would approve a temporary tax increase in 2012 and the Affordable Care Act would be able to proceed, this was the context for Let’s Get Healthy, California,” states Dooley. “We set a very ambitious goal to make California the healthiest state in the nation by 2022. Healthy children learn better, healthy adults are more productive, and healthy seniors can enjoy more active years.”
If you ask Secretary Dooley what she thinks about the Affordable Care Act, she will tell you most types of requisite insurance, such as auto insurance have been around for a long time, and she’s right. The concept of insurance is believed to be about as old as humanity itself. Insurance policies can be traced back to ancient Babylonia when merchants, who had loans, paid lenders an additional sum to provide a guarantee against losses if commodities were lost or harmed during shipping.
In comparing health coverage to no-fault auto insurance, Secretary Dooley acknowledges that California has required drivers to carry liability insurance for about 40 years, and some states have required coverage going back even farther.
“Everyone must have auto insurance—it works because everyone has it,” adds Secretary Dooley. “Health coverage is premised on a similar commitment, and universal coverage, both from the rightness and the moral position, holds that everyone should have some form of basic healthcare—a trip to the emergency room shouldn’t bankrupt your family. It is also the right thing from a market standpoint, and a business standpoint. Like any insurance, you must share the risk to make it work.”
PART TWO OF THREE: “Some people think change is driven by government. However, I have a little different view. I believe government is more like the rider on a thoroughbred holding the reins, and the market and the body politic are the main actors.”
In this, second of our three-part interview series, Secretary Diana Dooley talks about the early years of her career working for Governor Jerry Brown, predictions of a rapidly growing population of older adults, and why you can’t put nearly five million people into health coverage without changing the way care is delivered.
When asked how she got her start in healthcare, Secretary Diana Dooley humorously says, “Let me try to put a little context around this career and employment history so people don’t say this woman can’t keep a job.”
All joking aside, Secretary Dooley reveals, “Right out of college, I was hired as an analyst in state service. In 1975, I had the extraordinary good fortune to be assigned to the personal staff of Governor Jerry Brown to work on legislation.”
“Communications is an essential component of working on legislative proposals,” says Dooley. “From my work as an analyst, I transitioned to serve as an advocate for Governor Brown’s legislative priorities, which I did until the end of his term in 1983.”
Her experience in communications paid off, and after Secretary Dooley left the Brown Administration, she established a communications and public relations firm focused on client needs through paid media, earned media, print materials, and events.
“My attorney husband frequently encouraged me to go to law school, but I had jobs I liked, so I held off on law school until I was 40. I found my legal education and law practice provided a new forum to use my communication and analytical skills.”
As Secretary Dooley adds, “When Valley Children’s Hospital recruited me as corporate legal counsel and vice president of communications, I found my background in both government and communications helped tremendously in navigating the complexity of healthcare delivery.”
Today, Secretary Dooley credits her extensive experience as a government analyst, public relations consultant, attorney, and healthcare executive with providing her those necessary and deep-seated principles that help her understand the specific challenges healthcare faces today on a state and national level.
“The pace of change has accelerated dramatically over my professional career,” admits Secretary Dooley. “I remember taking a social sciences class in 1970 at Fresno State. The professor presented demographics and described our generation, now known as baby boomers, as the locusts moving through society. He predicted that we would overwhelm the education system, the employment market, and transportation. Certainly, our generation has had an impact on virtually every aspect of society. The most compelling—and startling—data at the time predicted the baby boomers moving into retirement—that’s where we are now. Even then, we knew we would end up with costly retirement and healthcare systems. We “boomers” have been like a big animal in the belly of a python—greatly impacting our society and the way we do business.”
As interesting as these predictions were, no one predicted the way our healthcare system has evolved. “We are forcing health and human services to deliver care in diverse ways simply due to the sheer volume of cases,” emphasizes Secretary Dooley. “The Affordable Care Act (“ACA”) brought more than five million people into coverage in California alone. It is impossible to provide care to this many new people without changing the ways we deliver that care.”
Secretary Diana Dooley credits these health and human services improvements to the Affordable Care Act coverage expansions, to the variety of delivery tools, and to how that care is delivered. One specific development is the way we manage chronic illness with dually eligible Medicare and Medicaid people—typically low-income seniors or disabled adults who are eligible for Medi-Cal (because of their disability and income status) and Medicare. We provide a lot of in-home services for people so they’re not in nursing homes, and nursing home delivery is changing, too.”
The Secretary goes on to say, “Some people think change is driven by government. I have a different view. I believe government is more like the rider on a thoroughbred holding the reins, and the market and the body politic are the main actors. And that was true of the ACA. Certainly, the Obama administration saw the need for healthcare reform, but healthcare reform had been building for 15 years prior to 2010. And, one cannot anticipate all the future changes that will happen. We do need to be attentive to the demands that are going to be placed on the infrastructure and systems of today and tomorrow because as it stands healthcare is very complex. If I had a magic wand, I would make the system far less complex. I would try to make it more rational so that people could make clearer choices, but as a lawyer I understand laws, governments, and administrations change—and change takes time. There is also a move against congregate care or living in large institutions, and we’re seeing new kinds of community living environments for fragile seniors that would otherwise be in a nursing home.”
Partners in Care Foundation should see many innovations resulting from new, emerging, and available services and technology, and Secretary Diana Dooley agrees.
“There is a lot of buzz about digital firms getting involved in healthcare. For example, Amazon getting involved in pharmacy or other areas,” suggests Secretary Dooley. “Walmart is setting up clinics within their stores. I think the market is going to drive change. The fundamental responsibility of government is to protect the health and welfare of its citizens and to encourage innovation, but not allow the market to do whatever it pleases without oversight.”
“President Trump recently appointed a replacement for Tom Price as Secretary of the United States Department of Health and Human Services (HHS). The HHS Secretary has a lot of discretion, and so if they are really committed to dismantling healthcare, it may be a rough road ahead,” concludes Secretary Diana Dooley. “I’m an eternal optimist, so my glass is always half full. I am committed to remaining vigilant and keeping a watchful eye on what they do.”
Secretary Diana Dooley concludes, “I think any major backsliding on improvement to the healthcare system will be tough because the genie is out of the bottle, and fitting him back into the lamp is next to impossible.”
PART THREE OF THREE: “We need a robust public policy conversation about the future of non-physician caregivers bridging the gap between healthcare and social care.”
In this third and final part of our interview series, Diana S. Dooley, Secretary of Health and Human Services for the State of California, talks about her wish list for healthcare, its future, and non-physician caregivers playing an expanded role in preventative care, patient care, and social services—specifically community-based organizations.
As Secretary Dooley previously mentioned, if she had a magic wand or the ability to make one thing come true, she would try to make it easier for people to make clearer choices. However, she was never given that wand. She does describe moments leading up to major change during the budget crisis and how she took matters into her own hands to standardize an unstandardized system.
“It’s what we tried to do in Covered California. We wanted people to understand what it is they’re buying, so we standardized benefits and required everyone to use the same names for the same things. In 2012, we gathered a lot of information about what people wanted, as we were still in the depths of the budget crisis. In the Spring of 2012, we began Let’s Get Healthy, California—before the November voting. There was a lot of anxiety about the cuts we were making in health and human services programs, and to alleviate that anxiety and forward the moment to implement the Affordable Care Act, I wanted to bring people to the table so together we could look beyond delivery of services and the cuts that we were having to make,” said Secretary Dooley. “I convened a group of about 30 professionals on a task force and another 40 or so on a technical advisory group, and we met very intensely for six months between June and November 2012, and together we developed a set of six basic goals that we put markers around. We had 39 indicators and we set a very audacious goal that California would be the healthiest state in the nation by 2022. And every year since then, we’ve annually updated those measures.”
Secretary Dooley’s task force and technical advisory group built a public website, which still works today to try and make government more accessible. The data it collects can be used not only by academics, but by anybody working in a community. Let’s Get Healthy California focuses on highlighting innovations already in place around the state. And, every year since inception, Secretary Dooley has used a variety of techniques to bring attention to positive local action that supports the targets.
“For example, we had a school superintendent in a small mountain county east of the Central Valley, who started a fitness program in cooperation with the local Adventist Hospital and Anthem Blue Shield,” said Secretary Diana Dooley. “They provided some funding and put in a nutrition educator and a physical education teacher in every grammar school and middle school. In just a few years, they moved the fitness level of their fourth and eighth grade from something like 35% to 65% improvement in health standards—it was remarkable.”
Secretary Dooley took these success stories and made them available at the California School Boards Association. By using the tools the state had put into place, she was able to illustrate how a community can fix problems—through community engagement. “Most of my career has been spent in a small rural California community where we roll our sleeves up and solve problems. And that’s what I’ve tried to bring to my role here in government as well.”
If you ask Secretary Dooley about non-physician caregivers playing an expanded role in preventative care and social services at community-based organizations, such as Partners in Care Foundation, she responds with, “I think this is really the new frontier.”
“In the ’70s, when Governor Brown was governor the first time, we did some significant work with some of the allied professionals. But we didn’t see much forward motion until recently when more forms of care are being provided by non-traditional providers. “Part of what the ACA does is put pressure on the system to utilize more diverse types of care – especially preventative and integrated care,” said Secretary Dooley. “For example, we are now teaching patients that they don’t always have to see a physician or go to the emergency room for certain types of care—others can help with their health.
The resources available go far beyond the technology of video and telehealth. “You’ve also got community health workers and “promotores” in the Latino community. You’ve got a lot of social workers that are working in healthcare settings through clinics and the network of provider physician groups. You’ve got hospitals moving into outpatient care, conducting a footprint so they are not just hospitalizing someone who arrives in the emergency room for care. Organizations, like Partners in Care Foundation, working on outreach to educate patients and prevent emergency room-to-hospitalization repetition and backsliding.”
Secretary Dooley went on to say, “We need a robust public policy conversation about the future of non-physician caregivers bridging the gap between healthcare and social care.”
“I serve on the California Future Health Workforce Commission chaired by Janet Napolitano, University of California, and Lloyd Dean, Dignity Health. For example, what do professionals learn to think of as priorities? Are they learning to be patient-focused—have better engagement with the patients, or top-down focused in the way that they have prescribed answers? What things should we be thinking about as leaders in our variety of places: not just government, but in the private sector and in the educational community. How should we be training and teaching and educating people to be the workforce of the future?”
Dooley suggests nobody has all the answers to many of the questions people are asking, but it is important to ask these questions.
For information on sponsorship opportunities and tickets to the 19th Annual Vision & Excellence in Health Care Leadership Tribute Dinner, please go to picf.org/tributedinnersponsorship, or contact Stephanie Wilson, VP, Development at Partners in Care Foundation, at email@example.com 818.837.3775 x121