San Francisco Chronicle, March 2, 2013
In less than one year, the Affordable Care Act's promise to bring health care to perhaps 1 million more California residents will be tested. On Jan. 1, 2014, Medi-Cal, the publicly funded health program for low-income and disabled residents, launches a huge statewide expansion.
But making a promise is one thing, and delivering is another.
In some places, it's already difficult for many poor California residents to find a doctor who is able - or willing - to see them. Many medical providers who see these patients say they are overwhelmed, a situation that could worsen when those newly covered by Medi-Cal arrive for care.
"We're not even talking about 2014. Good luck finding a doctor who takes Medi-Cal now," said Carmen Burgos of the nonprofit Greater Bakersfield Legal Assistance program. Burgos helps low-income Kern County residents find health care and dental services.
More than 7 million Californians are covered under Medi-Cal, and expanding the program is a major piece of President Obama's signature health law.
Between 2014 and 2019, another 1 million to 1.4 million Californians will enroll in Medi-Cal, according to UCLA and UC Berkeley estimates.
The Medi-Cal expansion will allow applicants with higher incomes and those who were previously ineligible, such as childless adults, to get coverage. State officials say there's sufficient access to Medi-Cal services and they are constantly monitoring to ensure recipients can get care.
"We do believe that the Medi-Cal provider network provides adequate access in California now," said Norman Williams, spokesman for the state Department of Health Care Services, which administers Medi-Cal. The state also is "adequately preparing for 2014 and the expansion."
But doctors and health care experts disagree.
"We're experiencing provider shortages right now," said Alex Briscoe, director of the Health Care Services Agency in Alameda County. "Patients often wait months to get access to care," he said.
Medi-Cal is California's version of the federal Medicaid program, and the Golden State ranks poorly in doctor participation compared with other states.
Two studies, including one published in the journal Health Affairs in August, show that 57 percent of California doctors accept new Medi-Cal patients. That's the second-lowest rate in the nation after New Jersey.
California's neighbors, Nevada and Oregon, accept 75 percent and 80 percent, respectively. The primary reason doctors don't participate is financial, doctors themselves say.
Here, too, California scores badly, with one of the nation's lowest reimbursement rates, ranking 47th of 50.
Eye surgeon and ophthalmologist Andrew Calman is an associate clinical professor at UCSF. He also has a practice in San Francisco's Mission District, and about 10 percent of his patients are on Medi-Cal, he said.
Calman said he wants to help as many patients as possible, but because he loses money on Medi-Cal patients, he must limit the number he accepts. Calman said Medi-Cal pays him $22 for a regular visit; Medicare and private insurance reimburses between $60 and $100.
"We're performing an important service, but there is a limit to how much of that we can do and still have a viable practice. We have to pay our rent, we have to pay our salaries to our staff. We have to pay insurance. If it costs me on average $60 to see a patient, there are only so many I can see at $20 before I close my doors."
In theory, Calman said, the Affordable Care Act is supposed to improve access by covering those who have been previously uninsured. In practice, however, he said it will be hard for many of the newly insured to find doctors willing to see them.
Low Medi-Cal payments are being addressed - temporarily at least - by the Affordable Care Act.
Starting this past January and lasting through 2014, reimbursement rates for many primary care services in Medi-Cal are rising to Medicare levels, funded by the federal government.
In California, the change is dramatic. On average, payments will increase by 136 percent, according to the Kaiser Commission on Medicaid and the Uninsured.
"The payment increase is a significant incentive that we anticipate will help attract new primary care physicians to the Medi-Cal provider network," said Williams of the Department of Health Care Services.
But improving access to care will involve more than convincing more doctors to participate, said Linette Scott, the department's chief medical information officer.
It will be about changing the way care is delivered, she said. As the state moves more Medi-Cal recipients into managed care, she said, models of treatment will rely more on teams of health professionals to care for patients, not just individual doctors.
Plus, health plans must ensure there are enough doctors and other medical providers in their networks to provide that care, Williams said.
Clinic capacity stretched
In some communities, many Medi-Cal patients have no other choice than clinics, said Debbie Wood, coordinator of school health for the Bakersfield City School District, where nearly 90 percent of students live at or below the poverty level.
"They go to the clinics and they sit there for six, seven, eight hours. They may have an appointment at 8 a.m. and not be seen until 4 in the afternoon," she said. While patients ultimately receive care at the clinics, they pay for the crowded conditions in other ways, Wood said. "Many of our families are in agricultural work," she said. "If they miss a day they don't get paid. So they go to the emergency room."
Louise McCarthy, president of the Community Clinic Association of Los Angeles County, said clinics are working double-time to hire more doctors and increase capacity, but no one is sure whether their efforts will be enough.
"At a certain point, the clinics are going to need to say, 'I need to cap enrollment or cap my patient load,' " she said. "It's critical we take on new patients in a sustainable manner."
The CHCF Center for Health Reporting is an independent news organization based at the University of Southern California's Annenberg School for Communication and Journalism and funded by the nonprofit California HealthCare Foundation at www.centerforhealthreporting.org. E-mail: email@example.com