South L.A. Clinic Offers Look at Reform’s Promise, Limits

A visit to the T.H.E. Health and Wellness Center in South Los Angeles offers a very different perspective on what health reform means at the ground level, at least compared to the typical media diet of enrollment updates and website glitches.

Many of the clinic’s predominantly poor, African-American patients are dealing with multiple chronic diseases such as diabetes, hypertension, and H.I.V. That’s on top of unusually high levels of mental health disorders, drug abuse, alcoholism, crushing poverty and unhealthy diets. Dr. Derrick Butler, responsible for managing many of the clinic’s toughest cases, affectionately referred to some of his patients as “train wrecks” when speaking to a group of journalists at the 2014 California Health Journalism Fellowship visiting the clinic last week.

Hearing Dr. Butler talk of the daily challenges of managing such patients suggested both the great leaps forward made possible by health reform, but also the limits that even a much-changed system must confront in treating some of the sickest patients in the most beleaguered communities.

First, the good news: As Butler sees it, one of the biggest changes wrought by reform is the expansion of managed care to populations who before relied on episodic visits to the emergency rooms – or went without. Under reform, more of the clinic’s patients now qualify for Medicaid, and some previously eligible patients are being made newly aware they’ve qualified all along, thanks to an ongoing outreach campaign. Yet the shift to managed-care plans also means doctors and health plans now must educate patients in a new way of receiving care.

“In a managed-care setting, now you’re actually part of a system where you have to follow the rules of that system, and this system is encouraging you to keep wellness care, to seek primary care,” he said. “Many people never had relations with one doctor.”

That newfound continuity with a single doctor can be absolutely crucial for patients managing multiple, complex diseases such as diabetes and H.I.V.

“For most of those chronic issues it takes a chronic relationship,” he said, adding that the area’s low education level means patients often don’t understand the importance of simple health and diet concepts that others take for granted. Patient education can be key: “A small seed you can plant in their head in that visit that they can take outside can actually make a huge difference in the long run.” That can be as simple as “Drink water, not soda,” or “Eat less salt to manage your blood pressure.”

Another of the Affordable Care Act’s biggest boons, Butler said, has been the expansion of access to specialty care to patients who formerly went without – or waited far too long for a specialty referral.

“One of the reasons I’m so busy now is getting referrals for patients who have waited to be referred for years sometimes – diabetics with retinopathy, people with arthritis who need orthopedic care,” he said. “Simple things like going to an eye doctor and getting glasses.”

MelbaDenise Donnell, the clinic’s outreach manager, is overseeing ongoing efforts to get local residents screened, signed up for insurance, and back into the clinic for follow-up appointments. “Unfortunately, doing outreach – it’s pulling teeth,” Donnell said. “A lot of times they won’t come in.”

Butler, an H.I.V. specialist, says a huge backlog of patients are now trying to seek specialty care, prompting concerns about a shortage of providers and long wait times. But for clinics in poor areas, like T.H.E., more fundamental challenges remain.

“A lot of people have transportation issues,” Butler said, citing a patient who’d have to take three bus transfers to get to a specialist 10 miles away. Clinic driver Calvin Woodard, featured in an extensive L.A. Times series on the T.H.E. clinic by Anna Gorman, routinely picks up patients who otherwise can’t get to appointments. “Poor people have problems that if you’re not poor you don’t necessarily understand.”

Neil Martin, a psychotherapist at T.H.E., understands that fact far more than most. He describes one of his patients as typical of the stories he hears every day: A 58-year-old female whose life gradually deteriorated after she lost her clerical job at Sony in 2006. She ended up spending two years in a homeless shelter.

“Over the last 8 years, things just went into free fall,” Martin said. “Her health got bad, and then her mental health got bad. She never sought treatment for her mental health until now.”

He estimates that about 80 percent of the patients he sees have some form of depression. PTSD is common.

“A story I’ve been hearing a lot since I’ve been here is that I lost my job some years ago and I’ve just never been able to recover,” he said. “It really becomes a vicious cycle.”

This year, Martin said he’s seen a spike in Medi-Cal patients because mental-health is now covered under the program thanks to the Affordable Care Act.

But both Martin and Butler said there’s only so much they can do when patients are actively abusing drugs, aside from offering referrals to rehab or 12-step programs.

“If a patient is actively using, they don’t usually stick around with me for very long,” Martin said.

Butler told the story of a patient who has relapsed with crack cocaine at least three times in the five years he’s been seeing the man.

“When he’s sober, he’s on his meds and he’s not detectable for the (H.I.V.) virus – he’s doing great,” Butler said. “When he falls off the wagon, he goes straight down hill: His T-cells drop, his viral load shoots straight up.”

After watching the man go through countless rehab sessions and jail stints, Butler is at a loss.

“I don’t know what to do with him,” he said. “It’s one nut I don’t know how to crack. I’ll be very honest. I do my best.”

The Affordable Care Act’s expanded mental health and substance abuse services will only go so far for some patients, Butler suggested. Deeper social and cultural drivers of drug abuse and mental health disorders will remain, he said, and expanded services will help some but not at all.

“You can’t fix everybody – but what’s the tool to help them fix themselves?” Butler asked. “I don’t know that answer yet. I’ve tried every way with people – what’s it going to take to motivate you?”