Dr. Mark Ghaly is stepping down as head of the California Health and Human Services Agency after an eventful tenure that included the eruption of the COVID-19 pandemic, Gov. Gavin Newsom announced Friday.
Newsom called Ghaly “a driving force for transformative changes to make healthcare more affordable and accessible,” whose leadership during the pandemic “saved countless lives and set the stage for our state’s strong recovery.” The governor’s office also credited Ghaly with reimagining Medi-Cal, the California Medicaid program; overhauling the state behavioral health system; and launching efforts to make crucial medications more affordable, among other initiatives.
Ghaly was appointed in 2019 to lead the state agency, which oversees a slew of California departments and offices that handle public health, mental health, assistance to people with developmental disabilities and a range of other health and social services.
Ghaly will stay at the agency through the end of the month. Newsom is appointing California Department of Social Services Director Kim Johnson to replace Ghaly in October. The Times talked to Ghaly this week about his tenure.
This conversation has been edited for length and clarity.
What were the three biggest challenges you faced at Health and Human Services, and what are the three biggest challenges facing your successor?
One of the big ones was navigating, under the governor’s leadership, this state through our COVID response — that obviously is a huge one. The second one, I think, is really addressing a comprehensive overhaul of our safety net …. And then the third piece has been, how do we make sure that for all Californians, we’re making progress to keep these basic necessities affordable, like healthcare … ?
The successor will certainly need to continue implementing the really thoughtful policy agenda that has stitched together … this real tapestry of programs and services that, when implemented successfully, I think really changed the arc of the lives of a lot of Californians, in particular the most vulnerable.
The focus on the principles of equity … I have no doubt that will continue to be a focal point. And then just on the last point, there’s a lot of pundits and detractors on the affordability agenda: Can we make thoughtful policy decisions and implement them to make things more affordable for Californians?
Having started a year before the pandemic, if you knew then what you know now, is there anything that you would do differently, in terms of the COVID response in California?
If you had told me that we had to successfully navigate California — the largest state in the nation — with one of the lowest end death rates from the disease, with a very thoughtful path to economic recovery, and while achieving that, build up and grow the California Health and Human Services Agency’s investment by nearly 50% over these six years, I would have said, ‘Sign me up for that job any day of the week. What a privilege.’
But of course, there are things that happened during the pandemic, that as it goes on and you think through it, you hope you may do something different in the future. And I would say No. 1 on the list for me … is how we supported young people with learning and school.
You’ll remember early on, the question about how to handle … schools as places where people become infected and go home and infect other vulnerable people — we were learning more about this sneaky airborne virus that mutated as it went along. And we made decisions in this state to have kids stay home, [to] really lean into virtual distance learning, and it stuck much longer than I think people had hoped …. And the governor put together a number of programs that supported their education in all sorts of forms.
But I think knowing what we know now about both the virus, the length of the pandemic — some of that information would have been helpful in those early days, weeks, months, around how we supported kids in schools.
During your time at the agency, we’ve seen some major changes in how California handles severe mental illness: the opening of CARE Court and Senate Bill 43, which broadened the definition of grave disability for involuntary treatment …. Do you think it is bringing about the change that was hoped for?
When I say the full transformation of the safety net, I can think of no better issue, single issue to focus on than behavioral health. Under Gov. Newsom’s leadership, we have changed from a focus on mental health to behavioral health, to include the very real need to focus on addiction and substance use disorders, its connection to things like housing instability and homelessness, its connection to incarceration.
When I came into this job, in my actual interview with the governor before I was appointed, we talked about how much we wanted to change the trajectory of people with serious mental health and behavioral health conditions, because in so many ways, the often ending place for individuals was jail, incarceration, prison ….
[With CARE Court] our goal was not just to get people in the line, but to get people in the front of the service line that so often are left outside to decompensate … until they do something that gets them arrested, and then suddenly we start to wrap around some of the care that they need, but often in the worst environment possible.
I do think the governor’s many programs that focus on behavioral health … when you take a step back and look at it all together, it’s essentially giving Californians and local government tools that they never had to be able to dream differently and put together a program that, I think, really gives us a credible shot to catch people much earlier in their trajectories with the challenges of behavioral health conditions, rather than what we so frequently do ….
I think we’re going to see these programs really pay off as they become more deeply seated [and] we work through some of the obvious operational challenges.
California has been expanding Medi-Cal, its Medicaid program, to cover many more people, but there’s been concern from healthcare providers that it doesn’t pay them adequately, which results in a shortage of providers willing to accept Medi-Cal patients. How should California fix that problem?
A: I often tell the governor, ‘Look, there’s four basic things when you talk about health services. You think about benefits, you think about access, you think about quality, you think about eligibility.’ And I think the governor has addressed all of those areas ….
We made pretty big investments in some of what I’ll call the bread-and-butter rates in Medicaid, bringing them either to 100% or close to 100% of what Medicare pays in this part of the country. Because of some budget challenges, we had to back off some other planned investments for this coming year, but as that budget starts to hopefully turn around … I know those will be an ongoing place of focus.
Mind you, Medicaid has a lot of different ways for providers and plans to receive payment …. I think as you look at that in totality, the opportunities to recruit providers to take care of the Medicaid population is stronger than it was when Gov. Newsom took office six years ago.
That all said, this has to be an ongoing sort of balance and conversation about how we continue to support this program, because one in three Californians now depend on Medicaid. So many kids — more than 33%, closer to 50% of kids — are dependent on Medicaid. When you have that vital a safety net program, we must continue to keep our eye on all four of those elements: quality, access, eligibility and benefits.
Earlier this year, the Office of Health Care Affordability announced a target of 3% annual growth in healthcare spending, to be phased in over time. How do you anticipate that healthcare providers will reach that target, given the kinds of pressures that have ramped up costs in the past — things like labor costs and inflation?
I think it’s going to require some real movement away from our traditional views on how you operate healthcare. We’re going to really have to make some decisions about moving more things upstream — promoting prioritizing things like preventative care and primary care, helping support other access points for people where access is challenging, and frankly speaking, really looking at some of the benefits of each of the different entities in the whole healthcare delivery system ….
We don’t expect everyone in California to always be there. There will be some conditions that legitimately push the markets in a different direction.
But as a whole, if we don’t chase a target that is both aggressive and achievable, that affordability problem that so many Californians face won’t just not get better — it is likely to get worse.
Reporters who cover the Capitol have raised concerns about interviews like this becoming rare. I know for me, personally, it’s been unusual to get anyone from the Department of Public Health on the phone. Why aren’t these departments routinely speaking directly to the media, instead of sending written statements?
Frankly, it is less about a lack of interest in speaking directly to the media — often, the interviews allow directors and leaders to very clearly convey nuance and important points.
My experience has been, so often the questions that reporters want answers to have some ability to be answered very clearly in a written form. And so we’ve used that frequently — not to sort of hide behind something or avoid the live interview — but because it seems and has been adequate in many of those conversations or requests.
One of the things I know you’ve been working on lately is this state plan on services for Californians with developmental disabilities. In California, these services have long been coordinated through a system of nonprofits called regional centers, which contract with the state. Do you believe that system is working for Californians and their families, and if not, what do you think needs to change?
One of the most important themes that got amplified during COVID was this notion of building trust through transparency …. And in my time and experience, I have heard loud and clear [from consumers and their families] that this system is not as transparent as it can be or that it should be, and I agree with that.
So part of the work of this new strategic plan … is recognizing that Gov. Newsom did something unprecedented. He took a rate study from before he came into office and implemented it …. We’re on a trajectory to fully implement that soon [Ghaly is referring to increases in rates paid to regional center vendors that provide services to people with disabilities] …. To say it plainly, we — given the level of investment — should become a lot more of a system that’s able to say “yes” to consumers, rather than “no” or delay.
