Redesigning Access: Dr. Monica Soni on Healthcare that Works

Recorded in November, 2024, Meg welcomes Dr. Monica Soni, Chief Medical Officer of Covered California, a free service that connects Californians with brand name health insurance under the Affordable Care Act. 

Dr. Monica Soni is the Chief Medical Officer of Covered California and a practicing primary care physician. She is a board member at Mercy Housing California and previously served on the Los Angeles County Hospital and Healthcare Delivery Commission. Dr. Soni holds a medical degree from Harvard Medical School and is deeply committed to improving population health, reducing disparities, and ensuring healthcare is accessible and affordable for all.

In this episode of Game-Changing Women of Healthcare, Monica speaks about driving meaningful healthcare reform from within one of the country’s largest health insurance marketplaces. With nearly 1.8 million Californians enrolled, Covered California is tackling some of the system’s toughest challenges: provider shortages, cost barriers, health plan accountability, and fragmented care. Dr. Soni opens up about launching statewide initiatives that link financial incentives to quality improvement, reducing deductibles for enrollees, and holding health plans to a higher standard.

A practicing primary care physician and former commissioner for the Los Angeles County Hospital and Healthcare Delivery Commission, Dr. Soni brings a unique, on-the-ground perspective to policy leadership. This is a must-listen for anyone passionate about the future of equitable, high-quality, and sustainable care.

Further Reading:

-Dr. Monica Soni’s LinkedIn: https://www.linkedin.com/in/drmonicasoni/

-Covered California: www.coveredca.com

-Mercy Housing California: https://www.mercyhousing.org/california/

-The California Kids Investment and Development Savings Program (CalKIDS): https://calkids.org/about/

-California Child Savings Account Program: https://www.capta.org/child-savings-account

-UCLA: https://www.ucla.edu/

-Charles R. Drew University of Medicine and Science: https://www.cdrewu.edu/

Episode Credits: 

The Game-Changing Women of Healthcare is a production of The Krinsky Company. 

Hosted by Meg Escobosa. 

Produced by Meg Escobosa, Calvin Marty, Chelsea Ho, and Wendy Nielsen.

Edited, engineered, and mixed by Calvin Marty. 

All music composed and performed by Calvin Marty. 

©2025 The Krinsky Company

Creators and Guests

Host

Meg Escobosa

Meg Escobosa has 15 years of innovation consulting experience, focusing on the unique challenges of healthcare since 2012. For The Krinsky Company, Meg leads client engagements overseeing advisory board design, creation and management. She also leads industry research, expert recruitment and trend analysis to support corporate innovation initiatives centered on the future of healthcare. Her background in innovation and strategy consulting began at IdeaScope Associates where she was involved all aspects of strategic innovation initiatives including understanding the voice of the customer, industry research and aligning the executive team to invest in promising strategic growth opportunities. Meg received her BA in Latin American Studies from Trinity College in Hartford and her MBA in sustainable management from the pioneering Master’s degree program, Presidio Graduate School. She is also on the board of a non-profit foundation focused on researching and developing technology to support a sustainable society. She lives in San Francisco with her husband and two teenage daughters.

Producer

Calvin Marty

A man of many hats, Calvin Marty is a Podcast Producer, Editor, Engineer, Voice Actor, Actor, Composer, Singer/Songwriter, Musician, and Tennis Enthusiast. Calvin produces, engineers, edits, mixes, and scores The Game-Changing Women of Healthcare. Calvin is also the creator of the 2020 podcast, irRegular People, among others. Find his music under the names Calvin Marty, Billy Dubbs, Nature Show, and The Sunken Ship. Over his long career as an actor, Calvin's has voiced many Radio and TV commercials for a wide-range of companies and products and has appeared in small on-camera roles on shows such as Chicago Fire and Empire.

What is The Game-Changing Women of Healthcare?

The Game-Changing Women of Healthcare is a podcast featuring exceptional women making an impact in healthcare today. We celebrate our guests’ accomplishments, setbacks, and the lessons they've learned throughout their careers. We dig into the many healthcare issues we face today and how these innovative leaders are working to solve them. Join host Meg Escobosa in conversation with some of the many brilliant, courageous women on the front lines of the future of health.

Monica Soni: Workforce shortages - there's not a lot of after hours access. I can't even get my kids to get their vaccines on weekends or evenings. And I have a very reputable primary care provider whom I love, but that's not how it's set up. And I would have to take the day off of work and pull my kids outta school so we know that that's still a challenge, and so I think credit to our health plans for mailing colorectal cancer screening kits home, sending blood pressure machines home, thinking about more accessible forms of access. Put incentives in place, too. A little bit of money to get your cancer screening done, that works for folks too. The evidence suggests that.

And then they put more money on the line, upside opportunities for providers too, in areas that were really hard. And the closer that the relationship has been between the plan and the providers, the more effective they are. The understanding of on-the-ground issues is better. I don't know that it's as intimate of a relationship as it could be, but the more that it is, I think the better that it will be.

Meg Escobosa: Welcome to the Game-Changing Women of Healthcare, featuring exceptional women making an impact in healthcare today. Together, we dig into the many healthcare issues we face today and how these innovative leaders are working to solve them. We celebrate our guests’ accomplishments, setbacks, and the lessons they've learned throughout their careers.

I'm Meg Escobosa. Join me in conversation with some of the many brilliant and courageous women on the front lines of the future of health.

Meg Escobosa: Hi everyone, and welcome to the next installment of the Game Changing Women of Healthcare. I'm your host, Meg Escobosa. Today on the show we have Dr. Monica Soni, Chief Medical Officer of Covered California, which is a free service that connects Californians with brand name health insurance under the Affordable Care Act. Dr. Soni received her medical degree from Harvard Medical School and continues to see patients as a primary care physician.

She's also a board member for Mercy Housing California, one of the country's largest affordable housing organizations, and previously she served as a commissioner for the Los Angeles County Hospital and Healthcare Delivery Commission. We recorded this episode in November, 2024.

Monica, welcome to the show. Thanks so much for being here.

Monica Soni: Thank you so much for having me. Thrilled to be here.

Meg Escobosa: Let's start with the basics. What is the core mission of Covered California and who do you serve?

Monica Soni: Yes. Well, you did a great job in the introduction, but Covered California really is California's Obamacare. We now serve actually nearly 1.8 million folks. It's record high for us. From the top of the state all the way down to the border, and our mission really is to make sure that we are providing affordable, high quality, equitable care to all Californians.

Meg Escobosa: Access to care is such a key issue. Can you kind of give us a state of the union, what is the state of access today and how do we compare to some other states?

Monica Soni: Yes. That's a great question. So amazing strides have actually been made in California. We were almost up to 17% uninsured rate back before the Affordable Care Act got passed. We are now down to 6%. And those, yeah, and those improvements have been actually sort of disproportionately benefited communities of color, Hispanic, Latino folks, and also black African American folks in California, and certainly low income folks , as well. So we're very proud of that. Are we the best? No, there's a couple other states that actually beat us. So Massachusetts, I think Hawaii, also have a little bit lower of an uninsured rate, but I mean in that 10-year period to make the strides that we've made - really a lot to be proud of.

Meg Escobosa: Yeah, that's, I mean, it would be great to hear what are some of the things that you've been able to do to enable that and what barriers have you been able to overcome for people?

Monica Soni: Absolutely. I mean, we are lucky that we're in such close partnership with other California public purchasers, so over the same time that Obamacare got created, we also had the ability to expand Medi-Cal so those two things happening in tandem have really been critical and paramount and Medi-Cal, this year actually, 2024, expanded to low income folks regardless of documentation status. So that was really sort of the last area where it had not been possible to actually insure folks. So that was really meaningful.

And then on the covered California side, when we first opened our doors, people were literally lining up around the block to be able to get coverage. I hear stories all of the time of, I heard a woman who was telling me that she cried the first time she bought her own policy because she had a history of breast cancer, had, you know, preexisting condition, had been unable to get the care that she needed before the Affordable Care Act. That changed and she sort of lives in this state of gratitude for what the ACA did.

Today's a very different issue, right? The 6% that remain, they know Covered California exists, some of them are really making a choice between other needs, other priorities and the cost of care, despite, frankly, how affordable our services are at this point in time. It's less a knowledge gap and much more you know, will, or we haven't done a good job at Covered California in making the business case to them as to why insurance is so important.

Meg Escobosa: Yeah, I remember, when Obamacare was starting there was such pushback against the penalty if you didn't get insurance. What is the status with that? Listeners may well know this, but curious where we are on penalties versus carrots.

Monica Soni: Yes. Yes. Well, you know, the last time we had a Trump administration, there was a lot of repeal and replace, and one of the things that got really moved out from the federal landscape was the individual mandate, but California stepped back in and said, well, we are gonna have our own individual mandate. So that does mean that in the state of California, there is a tax penalty if you don't have continuous coverage. I will say, I'm proud to say that, that those pool of funds that have been collected from true penalties actually have been redeployed back into Covered California to reduce out-of-pocket costs.

So this year plan, plan year 2025 is the highest level of affordability we’ve ever had to be able to offer folks, we're actually wiping away deductibles for the vast majority of our enrollees and have reduced out-of-pocket costs for primary care, for generic drugs. And I didn't mention this, but you know, one in four of our enrollees pays $10 or less a month in premiums. It's incredibly affordable at this point in time.

Meg Escobosa: So fantastic to hear. When we first learned about Covered California and engaging with you and your responsibilities, you talked about three arms that you are focused on. Can you describe the three arms and then we want to talk first about the accountability program?

Monica Soni: Yes, for sure. So I've been at Covered California - it's approaching two years. I feel so lucky to be here. As you mentioned, I'm a practicing primary care doc. I was in the clinic this morning and to be able to sit where I sit and think about both how to serve the 1.8 million that I'm responsible for, but also think about the broader landscape in the state, and also kind of nationally, has been incredible.

So our primary relationship is with health plans, the Kaisers, the Anthems, the Blue Shields of the world. And we have a few mechanisms to make sure that you don't just have an insurance card that you can't use anywhere, but that you can use the providers that you wanna see and that you actually get high quality and like I said, equitable care. That's one big kind of chunk of what I focus on is what we call health plan accountability, we have contract mechanisms in place around that.

And then we have our own actual data set. So we actually get full claims directly from all of the plans. And so it's not just a matter of, you tell me you're doing a good job, it's a matter of I can run my own analytics and see what's going on, and I can disaggregate all of our, my own data to see where there are disparities or inequities. And so that's another huge chunk of what I spend my time on, is really letting the data guide us and, and lead us as well

And then I hope this is the last arm that I shared. I'm the last arm now I was like, what did I say? It's thinking about affordability, right? Like we still here and, and this is the predominant reason we still have a 6% uninsured rate is, it’s still too unaffordable for folks and that - no matter how many subsidies we have coming in from the federal government or from the state, it's the underlying cost of care. It's the unit cost, which continues to increase for all of us, regardless of our source of coverage.

Meg Escobosa: So even patients who are getting insurance through Covered California are getting those additional bills that come after the appointment. They're getting that supplemental, “Hey, there's this $23 from your last doctor's visit.”

Monica Soni: It is true, and we have standardized benefits so that regardless of what plan you have chosen, primary care visits can only cost this much in terms of copay and your, you know, specialty visits can only cost so much. But you know, there are folks that are again, making decisions about rationing their budget. Frankly, this is what we've been told, “Do I go to the grocery store? Do I pay for the transportation to make it to work? Or do I pay my premium or this out of pocket cost for that primary care visit?” So when you have someone making choices like that, $10 actually is quite a lot in terms of a copay for a visit.

Meg Escobosa: And for the health plans, the commercial plans that are participating, their brand name plans. What's their rationale for being a part of this? I mean, it seems like they've gotta do more work, actually, to participate and to make themselves available to this population. Do you see any potential risks to losing some health plans because they have higher, you know, accountability expectations that you guys are putting on them?

Monica Soni: Yeah, it's a fantastic question and I, and I love it because the truth is we are not an all comers market, right? There are other states where there - it's a little bit more flexible to come on. And in those states you have just a proliferation of plans and also offerings. We don't, we have a very high bar to come in.

We are a over 10 year staple marketplace. We can be picky and we can be choosy. And if you can't prove to us that you're bringing higher quality, more providers, some other benefit to our consumers. We don't want you here. And if you've been here and you cannot show us that you actually continue to deliver on that mission and vision, we are fine for you to leave, and we have had a couple plans that have exited over the last couple years, mostly for financial viability reasons. But to your point, because our expectations are high and, and some of them just couldn't quite cut it.

Meg Escobosa: So you do have some data that you've looked at. Do you have those results and can you share a little bit about what you've seen so far and how are you feeling about them?

Monica Soni: Yes, I'm feeling great. So maybe I'll start with a quick background, which is, as I mentioned, there's, you know, three public purchasers in California. There's our Medicaid agency, there's us, the exchange, and then it's what the employees are covered through, which is called CalPERS and the three of us. We really have a lot of market power. We represent over 45% of all Californians, and so we've made a choice to do things together. Same contract language, similar programs, same measures.

And so the program that I was sharing with you before is called our Quality Transformation Initiative done in alignment with those other purchasers, and we kept it simple. We had seen really stagnation in the quality of care that had been delivered in a quantitative way. We could see we weren't actually getting a lot for our dollar in terms of preventive care, cancer screenings, immunizations for kids, etc.

So we decided to put some money on the line. So all of our health plans have a percent of premium at risk. This first year, it's 1% and it will go up 2%, potentially 3% to a cap of 4% if they don't deliver on high quality care. We kept it simple. Diabetes control, blood pressure control, colorectal cancer screening, and childhood immunization. This is just standard stuff that folks should be getting if they have insurance, but we had a wide spectrum. We had some plans that were hitting it and some plans below the 25th percentile nationally. Pretty bad. And I will say that between 2022 and 2023, which is the results that I, that we just, you know, got in and, and shared publicly, we saw the most improvement we had really ever seen over the course of our existence.

We saw that 12 out of our 13, health plan products, because we've got HMO and PPO, had an increase in performance both for diabetes and for high blood pressure. And 10 out of 13 actually saw an increase in their colorectal cancer screening rates. And you might say, “Oh, well that's artifact, it's background noise,” or something like that.

And, and so we said, “Well did our improvement, you know, and even if you do a three year trend, did it outstrip other lines of business that have outstripped national performance.?” And it did. And when you hear - the plans actually shared this week at our board meeting, we asked three to come. Like, what have they done? One of them actually said, “It was, frankly, they said it was only because of this program that they started to invest in quality.” Like, I mean, that's what was said in the meeting, publicly. And that's, that's the truth. There really was no financial imperative or business reason to invest in quality until we started to have this downside risk.

Meg Escobosa: Penalty. Yeah.

Monica Soni: Penalties. I'm sorry to say that's just the reality of motivators when healthcare is a financial game, right?

Meg Escobosa: Yes, and I'm curious if their providers, who they contract with are they sharing best practices? Are they sharing what they're doing as well to get their patients in for these preventative treatments or, you know, screenings?

Monica Soni: Yes. I think in the best case scenarios. And of course the plans they threw a lot at the wall to try, to see what still what stuck. But in the best case scenario, there was sort of multiple things happened. You know, one was just, it's not that easy to get in to see a provider. Right? We still know that there's workforce shortages and there's not a lot of after hours access. I can't even get my kids to get their vaccines on weekends or evenings, and I have a very reputable primary care provider whom I love, but that's not how it's set up. And I would have to take the day off of work and pull my kids outta school to get them vaccinated so we know that that's still a challenge. And so I think credit to our health plans for mailing, you know, colorectal cancer, screening kids home, sending blood pressure machines home, thinking about more accessible forms of access. They definitely put incentives in place too. Right? A little bit of money to get your, you know, cancer screening done. That works for folks too. The evidence suggests that, and then to your point, they change some of the provider contracts, they put more money on the line, opportunities for providers too, in areas that were really hard. And the closer that the relationship has been between the plan and the providers, the more effective they are. The data is better, the understanding of on the ground issues is better. I still think there's a lot more work to happen in that space. I don't know that it's as intimate of a relationship as it could be, but the more that it is, I think the better that it will be.

Meg Escobosa: Right. This issue of friction between payers and providers is a longstanding challenge and obviously where you can find shared incentives, shared goals, that's where you're gonna make a big difference. You know, this kind of brings me to, perhaps to listeners who might be entrepreneurial or in the private sector. Can you think of things that the market can do to serve, make this better, help you with your goals as well. Is there anything that you have a wishlist for that perhaps our audience could start tinkering at and you know, figuring out?

Monica Soni: What a good question. I have a very long wishlist. Well, I think one of the saddest, you know, sort of states of affairs is still how disconnected and firewalled just information is in sort of some shocking ways.

I'll share a story from, just like today for me in clinic, I saw a gentleman who had just had open heart surgery a month ago. And came in on blood thinners, but the visit was just like, “Oh, needs like blood thinner,” you know, titration, I had no records. I had no idea what was going on. He didn't have, he was super with it, but like had a kind of sketchy you know, a few pieces of paper and some handwritten notes. And so it was, it was through detective work and guessing. I was like, “Well, are you on any antibiotics?” “Oh yeah, I have this pill.” “What is that?” “Pill starts with an L.” “Is it Linezolid?”

Yeah. I mean, that was how I spent this morning, and it's like that's unacceptable. Right? We're all, I'm sitting in front of an electronic health record. I have a telephone right here. I have two personal devices in front of me. He has his own device. How is it that I cannot understand what happened in this critical hospitalization for someone sitting in front of me. So that still to me, remains a huge barrier, and I believe that we have not fully democratized or freed the data. Like why doesn't he have it on his device? Why isn't that something he could have pulled up right in front of me?

We have contract requirements trying to encourage that and support it, but we're a few steps removed and so it's been really hard for us at Covered California to inflect change in that connect data exchange space.

Meg Escobosa: Yeah, and just to, on that point alone, is the provider protecting themselves by keeping this data to themselves? Is there something that's just inherent in the dynamic that's. Promoting this that we just don't think about that we can get to the root cause and get rid of that problem.

Monica Soni: I think there are very select areas where that's true and, and where I respect why those kind of firewalls exist. So some has been in reproductive health. Especially as there's been shifts in that. So I'll leave that kind of over there. I don't think we should necessarily free all data. In the past, sort of HIV/AIDS was another one that folks just didn't feel like they wanted that information freely shared. The stigma has changed. I feel there's a lot less resistance about that.

And then substance use disorder, mental health would be kind of the other one where folks don't necessarily want their information out there. But frankly, in this situation it was none of those things. It was really just like outta sight, outta mind. Right. Like, this person's discharged. I took those stitches out. Go forth and figure it out. I was like, that a little bit crazy. Like, here I am trying to figure it out with not nothing to go from really at all. so I think, yeah. I don't think it's provider community driving. That is my feeling.

Meg Escobosa: Yeah. Yep. Just the nature of the structure of our system, our care and fragmented technology

Monica Soni: And fragmented payment systems as well. Absolutely.

Monica Soni: Next thing on my wishlist, I think we are trying to do everything we can from our seat to address the persistent disparities in care A along a number of demographic factors. It's not just race and ethnicities, certainly income level, the type of insurance that you have. Where you live, regions, rural, urban, super rural. But I do think there's, when we try to engage with our health plans around this, there's a feeling of overwhelm. And I think the feeling of overwhelm comes from, well, how can you solve every different community’s and every different, you know, person's problems. And to me it's so sad that that's kind of the feeling. Instead, what an opportunity to learn from community, learn from folks with lived experience. Think about what a culturally tailored or specific intervention might be, and then scale it once it's sort of been shown that it works in that circumstance, appreciating that not everything lifts and shifts. So I think that's one I would just love more. Community voice and power sharing everywhere. That would be on my wishlist for sure.

Meg Escobosa: I totally can see how that would be impactful. Those are meaty and worthwhile and seem like they would actually have an impact. So, you are - part of the work that you're doing is the population health investment?

Monica Soni: Yes.

Meg Escobosa:I think this is so exciting. I know you're planning for it in 2025. Yep.

Can you talk about the vision that you have and what you hope to achieve and, and maybe even speak to if you have data and evidence or anything that that kind of illustrates why you believe this is a good strategy and what impact you're hoping to accomplish?

Monica Soni: Yes. Thank you for that question. So. The Quality Transformation Initiative, we were thrilled that it worked in the first year, but we didn't hit it out of the park.

Right. We had, we're still gonna be collecting $15 million from our health plans for under performance on those high impact measures. And, you know, our hope is, and what's that,

Meg Escobosa: uh, what's the ratio like that's 15 million out of, I mean, what percentage does that represent?

Monica Soni: Yeah, that's actually a good question.

I don't have my denominator right at my fingertips, but what I'll say is that what we had estimated was that it would be more like 29 million had they not improved. So we saw some significant improvement between one year and and another, which is nearly cutting it in half. Nearly. Cutting it in half, exactly.

So I think it can be done that we collect. Mm-hmm. No dollars if the plans continue to improve, which is what we want them to do. But in the meantime, we had sort of this ancillary benefit of dollars to play with a little bit. And I think traditionally most programs like this, the money kind of flows back to the health plans.

And I had just started my job here, and so I asked like, does it have to? And the answer was no. And so then I asked, well, what else could we do? And appreciating that we're not the smartest people in the room, and this is. Not our core competency. We pulled together an advisory council, which included a current covered California consumer, folks from a bunch of different industries.

Health plans too. Clinicians too. And we did a bunch of literature review and we pitched stuff. We were like, well, what about this? And how about that? Oh, nice, nice. But the most important. Yeah, it was super fun. Yeah. But the most important part was that we started by listening to current covered California enrollees.

So to some of the questions you asked about data, we first just called a bunch of folks who were part of that initial quality transformation initiative and said, Hey, what's helping you be healthy and well, or what's getting in the way of you being healthy and well, and just listened amazing.

And then we sent out a survey. We didn't have any money to do it, so I just sent out a survey and hope people would respond. We got an amazing response. We got over 900 enrollees answering questions for us, again about their health, their wellness, and what would make a difference from an investment perspective and, and some of what we heard.

I heard higher rates of food insecurity in our population than I have ever heard. Wow. In any population, including Medicaid, the rates were up to 40%, four 0% for Spanish speaking folks with a chronic condition, agnostic to income level. So that was where I was like, yeah, what is happening? And our population are just living on the margin.

It really is folks who don't qualify for a lot of other benefits 'cause their income's a little bit too high. Mm-hmm. And have a lot of costs in California. It's just, it is expensive to be here.

Meg Escobosa: Yes.

Monica Soni: And so we asked, okay. We, once we heard that, we said, oh my gosh, once you hear something you have to figure out, you're compelled to do something about it.

And so we asked, well, you know, what could we do that would make a difference? And folks were like, well, any help you could give us for food, for transportation, for utilities, and because food insecurity had been so high and really cross cutting. That's one of the population health investments that we're funding.

We're giving folks a cash card that reloads every month. It scales up based on the size of your household. Just buy the things that you need. There's not a bunch of restrictions. It's not only apples or whatever, like Right. You just like, you're, we you're saying trust the consumer. We trust them.

Autonomy. Right. You're telling us you're hungry and you don't have enough money for food and we are trying to just meet that need for you. So that's one of the population health investments and we are actually doing pretty rigorous evaluation of it. There'll be kind of an embedded randomized control trial.

We have academic partners who will help us. Evaluate it. Yeah. So cool. Which is super exciting. So we'll learn and we'll learn how best to help folks. Mm-hmm. Which to me is the most important thing. And we'll publish on that so others can learn too. Been more outta box. I mean, even just

Meg Escobosa: the act of having cash to rely on regularly probably has other health benefits too.

Yes. Just that stress reduction. I mean, we know that's systemic, that can have big impacts.

Monica Soni: that's exactly right. And I think when I was in conversation with maybe folks that were not as supportive of this idea, I said, we already know, folks are telling us that they're making financial trade-offs by relieving, you know, something over here, you actually are going to increase health seeking behaviors and the ability to go to the doctor and get the care that they need.

'cause they're telling us they can't do those things because of these other financial barriers. So I think that's. Exact people know how to balance their own budgets and what's front of mind, and let's give it a try and then see what happens in re in results. Okay.

Meg Escobosa: This is so exciting. When can we look forward to hearing how it went and what you've learned?

That would be really fun to circle back and hear more about it.

Monica Soni: Yeah, so we are going live in February. Somehow it's coming. Yeah. Okay. Exactly. I know, I know.

Meg Escobosa: Just a couple months away. Right?

Monica Soni: February is the go live and the first prong of the population health investments will run for 12 months, but we'll be doing surveys along the way.

So I mean, probably like three or four months after launch we'll have really good data on how many folks. When we called them did screen in for food insecurity. What are some of the early results that we're seeing and, you know, what are they, what are they kind of, are they spending the funds every month?

Are they not spending the funds? So we'll have some of that pretty early on.

Meg Escobosa: Okay. Super cool. I wonder, do you, did you also do any kind of investigation on like data from the pandemic times when there was money sent to folks Yes. To help. Was there any evidence there that supported this strategy?

Monica Soni: I. Yes, absolutely. I mean there all of these sort of like the child tax credit, the pandemic funds, we know what works actually. Those are the largest scale interventions we've ever seen across the United States. Mm-hmm. And immediately you saw people's stress go down, their ability to kind of, um, stay employed.

Right, because sometimes there's a stop, like, oh, you're given money and people will stop working. There's no data that suggests that actually really happens, not any strong data. Mm-hmm. And then absolutely you do see some, depending on the study, different, improvements in health seeking behaviors and health outcomes.

Meg Escobosa: Fantastic. Well, good luck with that, getting that going. Thank you. There was something else. I remember when we first talked this may or may not be something you're, you're pursuing, but there was some discussion about investing funds for children. Um, that's

Monica Soni: it. Yes. Good memory. Um, we are also, so that's the, that's the second of the three population health investments that we'll launch in February.

So this one was a little bit more out of the box where we were thinking. we don't wanna be redundant to what the providers and the delivery system are doing. We don't wanna be redundant to what the health plans are doing. We wanna take this opportunity to invest in something that maybe hasn't traditionally been invested in.

And so that's this idea of how far upstream can you really move to. Mm-hmm. To. Keep people healthy, not even have them have chronic conditions. And so the state of California has started a program where every kid, regardless of income level, can claim a child's savings account from the state.

I. Not my program. Right. Just from the state. Mm-hmm. So that started in 20, I think 2022 is like any kid born after 2022. But the uptake of newborns has been actually a little bit low. And I think it's just been hard to like, catch those new babies. And so we thought, well, we've got babies, um, and, and we want them to be healthy.

Yeah. And so we are actually every kid under the age of two that is on covered California. If we're gonna be outreaching to those families, first of all, letting them know about this opportunity to already claim their account. And then we'll be adding up to a thousand dollars more into each kid's account for them enc, you know, tied to them going to well-child visits and getting some of their vaccines.

Trying not to be, you know, or really burdensome, but encourage them, you know, to do these good health seeking behaviors. So yes, that's also February.

Meg Escobosa: That's so cool. Yes, I mean, honestly, it just feels like a good investment.

Monica Soni: Exactly. And the data's so clear. When I saw the data, I was like, what the, you know, increase in matriculation to two and four year colleges is like significantly higher and you don't have to put that much money in the account.

Once you get to $800 in the account, kids are more likely to get educated, which we know is a path to upward mobility, which we know is a path to health.

Meg Escobosa: right. Super cool. You were on a panel at Health Yes. On redistributing healthcare dollars. Yes. So interesting. And one of the discussion points was around prevention and sort of investing in prevention.

commercial health plans are disincentivized from investing in that because patients aren't with them for very long. It's on average three years I think. Mm-hmm. People move jobs. It's, if you get it through your employer. Given what you know and what you're seeing do you believe this is a straightforward argument for a single payer who's covering lives for the long haul?

Like what do you say to that? And I know we're in a, I know we're talking about a new White House and different priorities. Yeah. But you know, is it a very straightforward argument for a single payer

Monica Soni: So it was an interesting panel. I agree with you. And you know, our churn is even higher than what the, what you just quoted.

Ours is about 15 months. Oh wow. Okay. Yeah. Folks come in. We're really meant to be a bridge to employer, other types of coverage. So this is a, a particularly fascinating question for us as an active purchaser, and part of why I think that collaborative between Medi-Cal and, you know, CalPERS is so important is it doesn't matter who is your purchaser, what plan you have.

Like, we've decided that those things are important, which is sort of what you're saying, right? Is like, could the purchaser all be aligned on this? Right. What I said on the panel, and what I will say today is, regardless of how you feel about single payer. I think we as Americans have decided that when there is a true market failure, that's where we want government intervention, right?

Yeah. Like if the market can do it, let the market do it. And in prevention, unfortunately, it isn't clear that there's always an ROI, right? Most of us are not gonna be super expensive to the healthcare system, and so doing. Just excellent things for us doesn't save frankly, anybody, any money. It just costs money.

Well, what kind of free market intervention can you have in a circumstance like that? You either have to incentivize folks doing that, Allah, electric cars, or you know mm-hmm. Things like that. Or you have to have government intervention. And so I think. This is just the facts and what we in America have done historically.

And I think it's up to us to decide if we have the will to either incentivize it in some different structures or have a government intervention that does support that. So, you know, I think there's a few different paths to get there. This, what I told you about today is our attempt. Mm-hmm. To try to do that in whatever microwave we can.

And I think the rest is, sort of, is up to us frankly, is how vocal will we all be about our desire to not just have sick care.

Meg Escobosa: Right. Absolutely. Because it's expensive. We can't, it's unsustainable. We don't have the workforce to do it. There's all the pressure points, so it has to be done just how.

Monica Soni: Yes.

Meg Escobosa: So. Going back to your roots and, and maybe your educational roots, I was looking at the, that you have a degree in anthropology. An undergrad degree in anthropology, and then you went on to get a medical degree. Yes. You know, is there a connection between anthropology and medicine that you saw at the time?

Was it what? Tell me about that. Decision process and I have a college student, daughter. Yes, yes. And, , so she's been deliberating between things and it's so exciting to be on this side of that process to parent somebody going through it.

But it's cool to see where you are. You've made such an incredible impact to the work you're doing. Thank you. And looking back. I'd love to hear how you made that decision to pursue medicine after doing an anthropology.

Monica Soni: Well, I, I love your parent lens because I will say my dad wasn't that pleased with my choice at the time.

He was like, what, what, what are you going to do with that degree? But I'll figure it out. Yeah. I was like, I'm gonna see, um, I love studying anthropology and it's true that there's sort of a, um, a niche piece of it that's medical anthropology and I just remember starting to learn about. A little bit it's medical history, but also intersecting with like what was happening culturally at the time.

Frankly, all the things we'd gotten wrong in medicine, right? Like we'd done a lot of stuff that ended up being really harmful to people and dangerous and at the time seemed like it was a plus care and and medicine. And so I think for me, because I'm a primary care doctor who's mostly practice in Medicaid, you know, systems, this idea that.

I, I'll never have all the answers. Mm-hmm. And that I truly am meant to be. Yes. Mm-hmm. Yes. Mm-hmm. And, and know that like I come with my own particular lens situation. Some of that is like the western medicine lens. Some of it, of course is my own background. Some of it's the times that we happen to live in right now, and then there's a person in front of me that has their entire own lens and it's their body and it's their choices.

And I'm here as a consultant to try to. Provide information that, that hopefully is useful to them. So to me, I, it feels very connected and I hope that ultimately my dad believes that I made the right choice.

Meg Escobosa: He should be very proud of you. Absolutely. Well, no, I mean, even it's so wonderful because you have that cultural sensitivity, that early training is definitely applicable to the work you're doing.

Certainly as you see patients on a daily basis, but also as you design programs to serve a diverse population. and that's why I wanted to know because I wondered if it was sort of intentional, like, I see myself in medicine, but I'm gonna do this first 'cause I get to do this in my undergrad and I'll spend all those years in medical school.

Monica Soni: It was, it was definitely that, especially 'cause I, you know, I was good at science I guess, but it was a little bit boring. So to be able to do some of the other pieces of it were, I think made for a phenomenal experience. Undergraduate.

Meg Escobosa: Awesome. So cool. Speaking about like your journey to where you are.

I'm curious if you overcame any barriers yourself and were there any, was your resilience tested anywhere along the way?

Monica Soni: Yes. Well, many, many, many times along the way. You know, one of the things that was sort of funny is I was already well into my career, , as a physician leader when we were rolling out within LA County, some questions around screening for social determinants of health.

So we were testing like, well, what questions should we ask? Which ones are validated? And so we were looking at one around housing security and housing insecurity. And I was like, oh my gosh. Like I screamed positive to this for most of my life. And it had never. Entered my mind that I had been housing insecure and actually a number of other things as well, actually all the way through college.

Meg Escobosa: Wow.

Monica Soni: Um, and so yeah, I was a Harvard undergrad and my mom was, was really living in, in in very unstable circumstances. So I'd come, I came home for spring break and sometimes I wouldn't even know. Where she was Right. And where I, where I would be staying for that particular spring break or wherever. I, I wasn't, but I was very late in life before I was like, oh, is this me?

Like, am I, am I like underserved community? That's interesting. I think that's very interesting. And I, I mostly, , again, because of where I sit now and the things that I have in my life and the way I'm able to move to the world, I have so many privileges and so grateful for that and. Because I do still work in the county.

I really do see folks that continue to be very marginalized in ways that, that I am not. But yes, now in retrospect along the way, there's a lot of, um, hurdles I think to overcome. Although I also had a lot of support from people who loved and cared about me.

Meg Escobosa: I'm curious about, you know, it does sound like you prioritize help, obviously helping others, but as a mentor to others, do you mentor other folks?

Do you focus on people in medicine? Tell me about that. Yes for you.

Monica Soni: I, I, I hope that people would say that I mentor other folks. I, I think I myself have had amazing mentors and sponsors and I remember one really saying that being accessible and available has been one of like their greatest gifts from their mentors.

And so I thought about that a lot. And now because I'm in a slightly more visible role, I get a lot of inbounds. Right. Yeah. In kind of funny, funny ways. And I try to be accessible and responsive 'cause you just never. No, what that, what you have to offer that might be useful to that person on the other side.

So I do in a more formal way, I'm still on faculty both at UCLA and at Charles Al r Drew, which is a historically black medical school. And, so spend a lot of time thinking about certainly in medicine, those folks in the pipeline. And that's the future for all of us. So I really try to invest there and then whoever happens to make their way to me, I try to hold close and, and let them know like.

Whatever I can do for you in whatever way you wanna come to Thanksgiving. Come to Thanksgiving. You want me to read a personal statement, I'll read a personal statement. And we of course host interns that covered California too. 'cause I do believe that's part of our mission and responsibility. So yeah, I consider that a really important part of my responsibility.

Meg Escobosa: Well, I admire that so much. We are just. Thrilled to get this opportunity to talk to you because I know you're doing really important work and, it's very exciting and I wish you well. I know that there's a lot just getting off the ground, so good luck with that. Please come back and give us an update.

We'll maybe check in next year and let's all, , hope for the best and thank you.

Monica Soni: Thank you. Thank you. I would love to come back.

Meg Escobosa: Thanks so much, Monica.