We can build a health system for all Californians

COVID-19 has revealed serious flaws in our health system, but none is more distressing than the deep racial and ethnic inequality exposed by the pandemic.

With Latinx and Black people dying at higher rates than the rest of the population, communities of color are much more likely than other groups to say they’re having trouble accessing telehealth services and paying medical bills.

In a January poll from the California Health Care Foundation, fully half of Californians say they believe it is harder for Black and Latinx people to get the health care they need when they are sick. And while there is only limited data on who’s getting the vaccine, the early numbers are raising concerns that Black and Latinx communities will once again fall to the back of the line.

There is no easy solution to these problems. But the evidence shows the need for at least one urgent response: Doing everything we can to create a health care system — and a physician workforce in particular — that looks a lot more like the people it serves.

One good place to start is at the very beginning, with California’s medical schools.

There is ample research showing Latinx and Black physicians are more likely to care for underserved patients, more likely to elicit trust from minority patients, and that Spanish-speaking patients are more likely to have better clinical outcomes when Spanish-speaking physicians help them manage complex diseases. The evidence additionally shows diverse medical school environments help all students learn — and improve graduates’ ability to treat diverse patient populations.

When it comes to diversity, though, California’s current physician workforce has a long way to go: Latinx make up almost 40% of the state’s population, but are only 7% of the state’s physicians. More than 6% of Californians are Black, compared to only 3% of the state’s physicians.

These are huge shortfalls that will take time to close. Further complicating matters: Californians have voted against relying on affirmative action to address these issues — first with the passage of Proposition 209 in 1996 and again last fall with the rejection of Proposition 16.

The good news is we’ve learned a lot over the last two decades about other ways to build the health system California needs. Now is the time to reinforce those strategies.

We published a new report this winter exploring longterm trends in state medical school enrollment and found the racial and ethnic diversity of California medical school students has largely recovered from sharp declines after Proposition 209 — thanks to a variety of successful initiatives that focus on preparing, admitting and training students committed to caring for California’s underserved patient populations.

Several factors played an influential role — from the adoption of “holistic” review to the creation of a UC Riverside campus in 2013. One of the most successful initiatives we tracked is the UC Programs in Medical Education (UC PRIME), which combines targeted recruitment with additional training to help graduates meet the needs of underserved populations.

UC PRIME has now expanded across six UC campuses, but the state’s efforts to create a more representative health system can’t stop there. To build a truly diverse physician workforce, our research shows the need for investment in programs that prepare students for medical school, as well — building a broader pool of competitive medical school applicants who reflect the diversity of the state.

The blue-ribbon 2019 California Future Health Workforce Commission put a 10year price tag on some of the most promising investments — from expanding advising and mentorship programs for low-income college students ($159 million) to funding post-baccalaureate training programs for people from disadvantaged backgrounds ($26 million).

These numbers shouldn’t shock us. Instead, they should give us hope, that even in the midst of a pandemic that has exposed serious flaws in so many of our institutions, we can build a health system that works for all Californians — and looks like them too.

Janet Coffman is a professor of health policy at the Healthforce Center at the University of California, San Francisco, Janet.Coffman@ ucsf.edu. Dr. Alicia Fernández is a professor of medicine and director of the University of California, San Francisco, Latinx Center of Excellence, Alicia.Fernandez@ucsf.edu.