SACRAMENTO, Calif. 鈥 California Attorney General Rob Bonta sailed to victory in the Nov. 8 election, riding his progressive record on reproductive rights, gun control, and social justice reform. As he charts a course for his next four years, the 50-year-old Democrat wants to target racial discrimination in health care, including through of software programs and decision-making tools used by hospitals to treat patients.
Bonta, the first Filipino American to serve as the state鈥檚 top prosecutor, asked 30 hospital CEOs in August for a list of the commercial software programs their facilities use to support clinical decisions, schedule operating rooms, and guide billing practices. In exchange, he . His goal, Bonta told KHN, is to identify algorithms that may direct more attention and resources to white patients than to minorities, widening racial disparities in health care access, quality, and outcomes.
鈥淯nequal access to our health care system needs to be combated and reversed, not carried forward and propagated, and algorithms have the power to do either,鈥 Bonta said.
It鈥檚 too early to know what Bonta will find, and his office will not name the hospitals involved. The California Hospital Association said in a statement that such bias 鈥渉as absolutely no place in medical treatment provided to any patient in any care setting鈥 and declined to comment further.
Advocates have high hopes for what Bonta will find 鈥 and for the next four years. 鈥淲e expect to see a lot more from him in this full term,鈥 said Ron Coleman Baeza, managing director of policy for the California Pan-Ethnic Health Network. 鈥淭here is much more work to do.鈥
Last year, Gov. Gavin Newsom appointed Bonta as attorney general after Xavier Becerra left the position to join the Biden administration as secretary of the U.S. Department of Health and Human Services. In the Nov. 8 election, which won him his first full term, Bonta faced Republican challenger Nathan Hochman, a former federal prosecutor on prosecuting violent criminals and pulling the deadly synthetic opioid fentanyl off the streets. In contrast, Bonta advocated for gun control and decriminalizing lower-level drug offenses, and in January advised law enforcement officials for murder when a fetus dies, even if their drug use contributed to the death.
In , Bonta had about 59% of the statewide vote, compared with 41% for Hochman.
Bonta, formerly a state legislator representing the East Bay, will be eligible to run for a second full term, which could allow him to serve for nearly 10 years.
His wife, Democratic state Assembly member Mia Bonta, was among the public officials who after a leaked draft of a U.S. Supreme Court opinion that was published in May revealed the justices would likely repeal Roe v. Wade. After they did, the attorney general threatened against local jurisdictions that tried to adopt abortion bans.
Bonta called health care a right for all Californians and said he wanted to help people of color and low-income communities get more access to doctors and treatments, as well as better care. 鈥淚t鈥檚 something I鈥檝e been actively working on as an elected official my entire career, and even before that,鈥 said Bonta, whose father helped organize health clinics for Central Valley farmworkers.
But remains an elusive goal, even as it has become a catchphrase among advocates, researchers, politicians, and health care executives. And as with most aspects of the state鈥檚 mammoth health care system, progress comes slowly.
The Newsom administration, for example, will require managed-care plans that sign new Medicaid contracts to hire a chief equity officer and pledge to , including in pediatric and maternal care. The state鈥檚 Medicaid program, known as Medi-Cal, serves people 鈥 most of whom are people of color. But those changes won鈥檛 come until 2024, at the earliest.
State lawmakers are also trying to minimize racial discrimination through legislation. In 2019, for example, they passed a law that mandates for health care providers serving pregnant women. Black women are as likely to die from having a baby as white women.
In recent years, researchers that racial discrimination was baked into the diagnostic algorithms that doctors use to guide their treatment decisions. One model predicted a for vaginal births among Black and Hispanic women who previously had a cesarean delivery than among white women, but failed to take into account patients鈥 marital status and insurance type, both of which can affect the success rate of a vaginal birth. Another, used by urologists, assigned Black patients coming into emergency rooms with 鈥渇lank pain鈥 a of having kidney stones than non-Black patients 鈥 even though the software鈥檚 developers failed to explain why.
Some researchers likened such medical algorithms to risk assessment tools used in the criminal justice system, which can lead to higher bail amounts and longer prison sentences for Black defendants. 鈥淚f the underlying data reflect racist social structures, then their use in predictive tools cements racism into practice and policy,鈥 in the New England Journal of Medicine in 2020.
Bonta is seeking the hospital industry鈥檚 cooperation in his algorithm investigation by framing racial and ethnic disparities as injustices that require intervention. He said he believes that his inquiry is the first of its kind and that it falls under the California Department of Justice鈥檚 responsibility to protect civil rights and consumers. 鈥淲e have a lot of depth,鈥 he said of his 4,500-employee agency.
Coleman Baeza and other advocates for health care consumers said the attorney general should also monitor nonprofit hospital mergers to ensure that health care facilities don鈥檛 reduce beds in underserved communities and crack down on predatory medical lending, particularly in dental care.
鈥淭hey violate existing consumer protections, and that falls squarely within the AG鈥檚 jurisdiction,鈥 said Linda Nguy, a senior policy advocate for the Western Center on Law and Poverty.
Nguy urged Bonta to go after underperforming health plans when they fail to contract with enough providers so patients can get timely appointments, even though the California Department of Managed Health Care is the state鈥檚 main health insurance regulator.
鈥淒uring covid, the health plans were essentially given a pause on reporting of their timely access. But that pause is over, and the plans have to meet these requirements,鈥 Nguy said. 鈥淗e can ask for that utilization data.鈥
Bonta remains circumspect on a particular issue related to race.
His office has been facilitating California鈥檚 reparations task force, which issued a nearly this year that noted that Black Californians had shorter life expectancies and poorer health outcomes than other groups. In surveys of hospitals across the country, Black patients with heart disease 鈥渞eceive older, cheaper, and more conservative treatments鈥 than white patients, the report said.
The task force could recommend cash compensation for Black Californians who can establish ties to enslaved ancestors, but Bonta hasn鈥檛 endorsed that plan. The final report is due in July.
鈥淚f we can move the needle, then we should,鈥 Bonta said. 鈥淭here are a whole set of different possible solutions, pathways to get there.鈥
This story was produced by , which publishes , an editorially independent service of the .
