Medicaid as a Catalyst for Community 

In California, it’s a tale almost worthy of Hollywood.

In 2008, Alex Briscoe, the Director of Alameda County’s Health Care Services Agency, stood watching a demonstration against the police after the shooting of a young black man, Oscar Grant III, by a white police officer.  He was there with the Medical Director of the Emergency Medical Services (EMS) Division that he oversees, and together they watched the angry, largely black, crowd of demonstrators stop yelling at the police when a fire truck went by. Instead of yelling, they waved.

To most, this would have been an idle observation but for Briscoe it sparked an idea. He had spent almost 15 years trying to get primary and preventative health care to low-income, largely black, communities. Given that 85% of fire fighters are trained as Emergency Medical Technicians (EMTs) and that every fire department in the county was contracted to provide EMS, the fire fighters’ unique alliance and standing in the community made them the perfect health care delivery mechanism.

Briscoe’s journey started with adolescent health, specifically as a mental health provider in communities living in multi generational poverty in Oakland, California. He realised that what kids in poor communities really need is a bridge to overcome the stigma associated with behavioural health so focussed on providing them with a nurse practitioner to give them sports physicals and talk to them about who they’re sleeping with. He wanted to maximise their chances of getting that care so he looked to provide it where they were – in the schools in their communities.

Getting the health care paid for was relatively easy – Medicaid had that covered, mostly via entitlements that if properly accessed are a relatively generous source of funding., he says. However, finding the money to build the clinics was harder. That’s when Briscoe discovered that school bonds are the most popular tax in the US – 85% of them are passed, an unusually high proportion, seemingly because voters tend to support putting money towards schools. By partnering with Oakland Unified School District, and then combining Medicaid money with the school bonds, he was able to establish tailored adolescent health clinics in schools in low-income communities, something they were previously struggling to do. This school-based health care model continues today and is now in 28 schools.

Although Briscoe’s aim was to improve access to care for low-income communities, he also discovered an operational efficiency. There’s usually a 30% no-show rate amongst Medicaid users but by being in schools the clinics were able to fill absent students’ appointments because their patients were right there on their doorstep. Briscoe describes this as the “operating efficiencies that a ‘poor’ location can provide us”.

But beyond the discovery around operational efficiency, Briscoe’s experience with school bonds also taught him an invaluable lesson – that when you start from what a community really needs you can find innovative ways to fund it, if you look hard enough. Briscoe describes this as the heart of his approach: see the challenges as opportunities, bring unabashed financial sophistication to them, and see the people you serve not in terms of their problems but as part of the solution. He believes this entrepreneurial approach can tackle what are often seen as intractable social problems.

For many health care innovators bringing care closer to people is a big idea. For Briscoe, though, it’s only the beginning of a more ambitious vision. He sees the role of the Agency to hire “community-based organisations”. We’re “an $800million funder and thought leader”, he says, “but not a direct service provider…We don’t want to do anything”.

This is not just about using public dollars to create local jobs, though. Briscoe believes that one of the reasons why people from under-served communities do not access more health care is because they struggle to connect with today’s health care professionals. He sees improving access to care as a battle to overcome the divide that has developed between low-income, often black, communities and professional, often white, ones.

This takes us back to the Oscar Grant III demonstration and the fire truck. When Briscoe saw the demonstrators wave he realised that what he was seeing was the “trust and alliance”, as he calls it, that the local community has with fire fighters, many of whom are from the same community.

At the time when Briscoe saw the demonstrators waving he was dealing with an H1N1 outbreak and trying to figure out how to immunise 200,000 people who had little access to primary care. When he saw the “trust and alliance” between the demonstrators and the fire fighters, he realised that the fire service was “underutilised medical capacity” – the trust they’d earned from the community, combined with their EMT skills, positioned them perfectly to deliver high quality care to their neighbours.

To make that happen, though, Briscoe needed to use the powers of his Health Officer to declare a local state of emergency. Doing so changed the scope of practice of paramedics and allowed fire fighters to give immunisations at the fire stations, something they cannot do in normal conditions. “People flocked to their fire stations”, he says. But it wasn’t the number of people that impressed Briscoe, it was who they were – people from low-income communities, places where there was little primary care and little connection with health care professionals.

This makes Briscoe believe that the “delivery system has to change”. He believes it’s more effective when people the community know and trust deliver it. He believes that part of the role of health care dollars has to be to enable neighbours to better care for each other. “It has to be health care for people by people,” he says.

A friend of Briscoe’s was running a careers day at the local juvenile detention centre. He asked Briscoe to send some fire fighters, which he did, together with some trucks and even a helicopter. At the end of the day 16 out of the 90 boys said they wanted to be EMTs. Staff in the EMS division began volunteering at the detention centre, offering the young men training as EMTs and orienting them to the field of EMS. Soon thereafter, Briscoe worked with a local African American fire fighter to launch a training program sponsored by his agency that offered free EMT training at night in the Health Care Service Agency’s headquarters. Although there was initial interest, many young men did not complete the programme, partly because some of the local boys were getting shot or going back to jail.

Although Briscoe believed fire fighters were important local role models he realised that having them provide free training wasn’t enough. He applied for a grant from the Robert Wood Johnson Foundation for a project called EMS Corps. Every six months, 30 young men of colour from the community arrive at the Agency’s executive office, get a uniform and a living stipend, and are told that if they pass the national registry exam at the end of six months they’re guaranteed a job from an ambulance company or the health care system.

Job training and guaranteed employment for people from low-income communities is great, but that’s not what’s revolutionary about this programme, says Briscoe. What’s revolutionary is that “the same young people that we vilified as non-contributing members of our society will [become the ones that] save your life.”

“Give us a decade,” he says, “and half of all 911 first responders will be young men and boys of colour from this community. The tensions that we have around race and class are so significant that for the 105,000 people who call 911 this year, if half of them have an experience of a young black man saving their life, that will be transformative in ways that the health care system doesn’t even understand.”

Briscoe believes that when care comes from within communities, it starts to change them in profound ways that go beyond health care. Multi-generational poverty has created a deeply disempowering experience in poor communities, he says, but when someone realises that he can save a life his power starts to come back. And the wider community starts to see him differently.

It’s tempting to suggest that EMS Corps is not about health and hence not part of the Agency’s remit. While it’s true it has little to do with health care it has everything to do with the social determinants of health. “Health care is the best payer for social justice,” Briscoe says, “sometimes the only payer”.

Despite Briscoe’s claim that they don’t want to do anything, he describes his work as “reinventing the public sector as a place of creativity and innovation”. Although his starting point is the “pretty dramatic tensions on structural access to care, largely at the primary, preventative level”, it’s clear that he realises that providing care is not enough. He needs to find ways to use public dollars to create health, not just provide health care, as a longer-term solution.

After the local state of emergency had ended Briscoe suggested making clinics in fire stations, operated by EMTs, a standard part of the local care landscape, but met with significant resistance from the nurses’ union. They believe the EMTs’ scope of practice should remain restricted to responding to 911 calls and working at the scene of a medical emergency, and not be extended to providing ongoing care.

Briscoe sees this as a profession being self-interested rather than understanding the needs of the community they serve. In an attempt to prove that EMTs can provide ongoing care he has convinced the California Healthcare Foundation to fund a study on community para-medicine. Part of what he wants to look at is whether EMTs can be used to follow-up with patients post-discharge. Briscoe believes that, coated in the trust the community has in them, the EMTs will be more effective in encouraging patients to make their house safer, schedule follow-up appointments and take their medication.

Although he’s confident they’ll find EMT-led care effective he’s not convinced it’ll be powerful enough to overcome the union. But he wants to try, to start the conversation, and to ask if the health care professions have got lost in “shameless profiteering” rather than serving the needs of their patients and communities.

For the time being, and as a compromise, Briscoe has been able to establish a clinic next door to a fire station, staffed by regular health care professions not EMTs. While he doesn’t think it’ll prove the model of having locally-trusted EMTs lead more care, he thinks it’s at least a step in the right direction.

The debate about the future of care is almost entirely anchored in how the health care profession and industry can improve quality, access and cost. But Briscoe sees a bigger vision. He sees a bigger role for communities to take care of each other and approaches his stewardship of public money with the “creativity and innovation” needed to make that happen.

Briscoe’s journey – from wanting to bring care closer to people, finding new ways to fund it, understanding the importance of local trust, and then trying to catalyse community cohesion by giving disadvantaged people a chance – is a powerful illustration of how just providing health care is not enough. At Wellthcare, we’re proud to call him a ‘Wellth Creator’ and hope others will follow his lead.

This article was co-authored by Leigh Carroll, a Wellthcare Explorer, and Pritpal S Tamber. It was also published in MedCrunch and MedCity News.