Health care choice is not just a preference, it is a lifeline for LGBTQ+ San Diegans and people living with serious chronic conditions. Continuity of care and access to trusted providers are essential for staying healthy; when those choices are narrowed, the consequences are immediate. Patients lose access to providers who understand their histories, identities and complex needs, forcing them back into an already difficult system to navigate.
As a gay San Diegan rooted in my community and committed to health care advocacy, I spend my days working with patients who rely on coordinated, specialized care to survive. Many are older adults living with HIV, hepatitis, cancer, liver disease or multiple chronic conditions. Many have spent decades learning — sometimes painfully — which providers and health plans they can trust. That trust is fragile. And right now, California is risking it.
CalAIM, the state’s major Medi‑Cal reform effort, was designed with good intentions: to streamline care, improve coordination and better serve people with the most complex needs. But one aspect of its implementation threatens to undermine those goals. Through a policy known as exclusively aligned enrollment, CalAIM is drastically limiting the number of health plans available to people who qualify for both Medicare and Medi‑Cal — the seniors and adults with disabilities known as “dual eligibles.”
In San Diego County, Medi-Medi enrollees still have multiple plans to choose from. But in neighboring counties like Imperial, residents have only one commercial option. Fewer plans may look like simplification, but in practice, it limits access and disrupts long‑standing care relationships.
This shift is happening at a time when California’s health system is already strained. Patient Advocates United in San Diego County’s environmental scan, conducted to illuminate the evolving landscape of care for seniors on Medi‑Cal and Medicare, found persistent barriers: fragmented service delivery, complex eligibility rules, workforce shortages and delays in accessing services. Older adults experiencing homelessness struggle with basic communication and medication access. Those living with Alzheimer’s or dementia face disconnected programs. Formerly incarcerated older adults fall through gaps between Medi‑Cal and Medicare enrollment. These are not theoretical challenges — they are daily realities for the people most affected by plan consolidation.
Layered on top of these challenges is national uncertainty. The Trump administration continues to shift direction on Medicare and Medicaid, revisiting eligibility and coverage rules in ways that make long‑term planning nearly impossible. In times like these, preserving access to high‑quality, experienced health plans is not a luxury. It is a safeguard.
For LGBTQ+ San Diegans, the stakes are even higher. Neighborhoods like Hillcrest have long served as hubs for culturally competent care. Research shows that LGBTQ+ individuals face discrimination in medical settings, and fear of mistreatment keeps many from seeking preventive care. Once affirming care is found, it’s critical to keep it — especially for patients facing additional social barriers.
When Medi‑Medi enrollees are forced to change plans, they often lose access to providers who understand their identities, histories and health needs. That disruption can lead to missed appointments, delayed diagnoses and disengagement from care. Even short gaps in care have serious consequences.
This is where specialized Medicare‑Medi‑Cal plans — Dual Eligible Special Needs Plans, or D‑SNPs — make a difference. These plans are designed for people with complex medical and social needs. They coordinate care across hospitals, specialists, mental health services and community supports. When multiple high‑quality D‑SNPs are available, plans compete to provide stronger networks and better benefits. Restricting options leaves the most vulnerable patients caught in the middle.
This is not about opposing CalAIM. It is about addressing implementation challenges so that vulnerable patients continue to receive coordinated care. California can uphold CalAIM’s goals while still allowing proven, culturally competent D‑SNPs to operate, ensuring smoother transitions, clearer communication and protections for patients who depend on existing provider relationships.
Health care reform should make care easier to access, not harder, and strengthen relationships between patients and providers rather than severing them. For all San Diegans, health care is not an abstract policy debate. It is personal. It is daily. And it all depends on trust.
California can still get this right, but only if patient choice remains part of the equation.
Suckow is chair of Patient Advocates United in San Diego County and lives in Hillcrest.