In Calif., even leading-edge counties face crisis in expanding Medicaid access

By any measure, the first year of implementing the Affordable Care Act has successfully reduced California’s uninsured population.

Expanding eligibility has meant the addition of 2.3 million members to California’s federally funded version of Medicaid, known as Medi-Cal. That brings the state’s Medicaid total to nearly 11 million people, according to the California Department of Health Care Services.

That’s good news for the poorest Californians, who can now visit a doctor without fear that a slew of medical bills will bankrupt them. The problem, however, is that the health care system has not caught up with the fast-paced growth in enrollees. You may now be enrolled in the health care system either through Medi-Cal or Covered California, but you might not see a doctor for quite a while. 

The New York Times recently reported that Medicaid networks all over the country are failing to meet regulated standards for provider access. Many patients must wait for months or travel long distances to see a doctor. In California, standards require that anyone enrolled in Medi-Cal should have to travel no more than 30 minutes, wait no more than 10 days to see a primary care doctor, and no more than two days for an urgent care appointment.

No study has been done specifically in California on wait times for appointments, but anecdotally, counties and nonprofits report that provider access is a big issue for Medi-Cal enrollees. They say that patients are waiting far longer than the standard times for appointments with primary care providers.

“The crisis is real,” said Alex Briscoe, director of Alameda County’s Health Care Services Agency.

It’s real enough that Gov. Jerry Brown recently signed into legislation a bill that will increase oversight of Medi-Cal managed care and Covered California provider networks.

By offering a certain network to consumers, managed care companies agree to meet the standards laid out by the state. The Sacramento Business Journal reported that the new regulation will look into whether managed care networks are actually meeting their obligations to provide timely access, adequate networks, continuity of care and quality management. The first reports are expected to be issued before 2015 open enrollment begins on November 15.

Most Medi-Cal enrollees are part of managed care plans, which rely significantly on safety net institutions such as county clinics and hospitals, to provide care. But many of those institutions are not adequately staffed to meet the state’s standards, said Briscoe of Alameda County.

Before the ACA reforms kicked in, Alameda County tried to plan ahead of the deluge of enrollees they knew were coming, Briscoe said. They built 100 new exam rooms, hired doctors and started to establish creative ways for helping people access care, such as establishing clinics at community colleges and day labor centers.

“We have perhaps the most progressive safety net in the state, with culturally relevant, high performing community health centers,” Briscoe said. “And we still have trouble attracting and retaining providers and offering timely access to primary care.”

Medi-Cal providers such as county clinics are at a distinct disadvantage when it comes to hiring new doctors. California’s reimbursement rates are among the lowest in the country.

If patients can’t see primary providers in a timely way, they may then be forced to use higher cost health care services, such as emergency rooms and specialty care, either because their ailment was not treated or simply because they are seeking access to care. And this, Briscoe said, could have big implications for health care costs.

Briscoe suggests Medi-Cal providers need to keep thinking creatively about how to offer primary care so that it’s cheap and meets patients’ needs. Schools, fire departments, even subway stations, are all potentially good locations for clinics, he said, adding that allternative hours – say, from 4 to 10 p.m. – could help divert patients from expensive emergency room care. 

“Without primary care, we will not be able to end the upward cost curve,” he said.

Before ACA started, there was an unmet need for more providers, said Amy Chen, a staff attorney with Bay Area Legal Aid Health Consumer Center. Now that need has been only exacerbated by a surge in additional enrollees from both Medi-Cal and Covered California.

“It’s just so many people,” Chen said.

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