Will Lightbourne, a longtime director of state and local social services, emerged from retirement last month to become the director of the California Department of Health Care Services – just as record-breaking coronavirus cases tripled in the state. His predecessor lasted just four months before resigning his post.
A stitcher of safety net services since 1975, Lightbourne, 70, will oversee the Medi-Cal health system, which is expected to grow by 2 million people this month to cover the medical, dental and mental health care needs of 14.5 million Californians in this most desperate of times. His department purchases health care services for the newly unemployed, low-income families, pregnant women, seniors, people with disabilities, Native Americans and farmworkers.
A sign of the rapidly mounting difficulty in the state is evident in the Medi-Cal budget that has just been approved. In the 2019-20 fiscal year, the total funding was $99.5 billion. For the coming year, it will be $115.4 billion, a 16% increase attributed to the COVID-19 pandemic and resulting unemployment, according to state officials.
Before being appointed last month by Gov. Gavin Newsom to head health care services, Lightbourne served from 2011 through 2018 as director of the California Department of Social Services, where he launched a landmark effort to move more foster children out of institutions and into family-based settings. He is also credited with increased oversight of psychiatric drugs prescribed to youth in foster care.
Prior to his state service, Lightbourne was director of social services in Santa Clara, San Francisco and Santa Cruz counties. As head of the Santa Clara County Social Services Agency from 2000 to 2011, he worked to reduce the overrepresentation of kids of color in the child welfare system, and directed the closure of the local children’s shelter.
This conversation has been condensed and edited for clarity and length.
About a year ago when we spoke in your office, you seemed happily headed to retirement after 45 years in public service. How on earth were you convinced to come back during a global pandemic to head California’s $100 billion Medicaid program serving upwards of 13 million people?
We’re in a time that the young people have shown us the way – that it’s time to really start to address issues of social justice and equity. And when somebody calls you and says would you come run this thing that has such immense capacity to contribute to improving social conditions and health conditions, I don’t know how you can possibly say no.
California is reporting record daily counts of coronavirus cases and a surge in hospitalizations. What is the primary role of the Department of Health Care Services in fighting the pandemic?
DHCS primarily is the entity that contracts with health care providers who serve Medi-Cal beneficiaries, and so what the department has been doing since the beginning of the pandemic is obtaining waivers and extending flexibility out to the providers to basically say: Get services to people in virtually every way you possibly can. Don’t let the old rules constrain meeting people where they are – both people who are dealing with COVID exposure but also other people whose other health care needs are potentially made more difficult to engage in the traditional health setting.
So it’s a huge turn to telehealth activities. The department has issued guidance to make it clear that all COVID-related testing and treatment is considered emergency services, therefore, it is available to the fullest possible population, not just regular Medi-Cal beneficiaries.
The nonprofit news outlet CalMatters reported last year that “while California prides itself on diversity, in many ways state government looks more like the California of 30 years ago than the California of today.” They also found “there are (still) more white men named James in the California Legislature than African-American and Asian-American women combined.”
As a state leader of African descent, how has the latest chapter of the civil rights movement unfolding all around us affected you personally – and will it affect your work leading the agency responsible for the physical and emotional health needs of millions of people?
If the pandemic has illustrated nothing else, it has demonstrated inequities that are baked in and are systematic in our economy, in our education system, and in our health system. If you think about it, 53-54% of the people who have tested positive for COVID are Latino, whereas they only represent 39% of the population. African Americans are testing at about their rate in the population, but their fatality is double their rate in the population.
Those sorts of inequities, just on the pure health side, are extraordinary, and then with the non-pandemic events of the last weeks – driven by the realization of the powerlessness of communities of color relative to the authority structure – illustrates that we have a system that is fundamentally in need of re-engineering.
The Medicaid program in California is larger as a percentage of all health care than nationally is the case, and so we have to be really aggressive in terms of saying we will use our capacity through our contracting relationships, our managed care plans, our contracting with county behavioral health to really say equity has to be an absolute lens that we’re looking through. Social determinants of health have to be a forethought and not an afterthought of delivery systems.
How about you personally, how have you been affected by the Black Lives Matter movement?
Watching someone die for 8 minutes and 46 seconds is not something you can ever forget.
In 2019, California was faced with what Gov. Newsom described as “the state’s homelessness epidemic,” and you served on an advisory committee tackling the grave problem. Given that there is now a pandemic on top of that epidemic, how have homeless people fared in recent months?
The more marginal people have been, the more badly they have been hurt. And the homeless are among the very most marginalized. So with the sole exception of the nursing home population, which clearly has been in an extreme situation, that population aside, I’d say the homeless have fared the worst. If you move upstream a bit, it’s the low-income working population who haven’t been able to work from home or distance as easily, the farmworker population, the service sector population – it’s totally consistent with what you would expect in terms of who are the disadvantaged.
Given that, I’m actually trying to fathom having responsibility for all these folks and guiding them to health and wellness – and survival. How do they both inspire and challenge you right now? Are you feeling confident about figuring out solutions that are both socially equitable and financially viable?
The knowledge of the pain that some people are in is compelling. I don’t think you can ever be unaware of it. The power of DHCS is in the fact that it pays for, we pay for, the care for this population. And if we are adept in our purchasing processes and working with our partners in setting the incentives in the right places, we can really move the system of care to a place that is much more holistic in addressing the totality, a place where it’s much more of a wraparound to people’s needs.
You have worked for the state, San Francisco, Santa Clara and Santa Cruz counties running social services. What does the Newsom administration, and what do you personally, want to do at DHCS to better serve families involved in the child welfare system?
Working very closely with the new Office of the Surgeon General and others, and our counties, what we’re really going to be working toward is to really try to embed meaningful trauma-based services, both improved screening and services, at all levels of the delivery systems. The goal is to be sure that we’re supporting children where they are – and supporting their birth families and supporting their caregivers if it’s not the birth family – to be healthy. And that means a very strong relationship between the behavioral health system and the child welfare system.
Karen de Sá is the Safety Net Reporting Fellow for The Imprint, and a former investigative reporter for The Mercury News. She can be reached at firstname.lastname@example.org.