California legislature continues push to restore Medi-Cal reimbursement rates

Whenever his parents drive him from San Jose to a hospital 300 miles away in Los Angeles, Juan España Jr. dreams of the day he won't have to make the twice-a-month trip anymore.

In the pre-dawn hours on the road, the 16-year-old often thinks about becoming a doctor so he can find a cure for his hypercholesterolemia, a condition that results in an abnormally high level of LDL cholesterol, the "bad" kind.

But for the past five years, Cedars-Sinai Medical Center in L.A. has been the nearest hospital that accepts Medi-Cal and offers a lifesaving machine that filters his cholesterol, which has resulted in fatty deposits on both his elbows.

With 12.3 million Californians receiving Medi-Cal, the program now serves almost a third of the state's population.

Lawmakers such as Assemblyman Rob Bonta, D-Alameda, and Sen. Ed Hernandez, D-West Covina, say that the best way to attract more Medi-Cal providers is by restoring a 10 percent reimbursement rate cut the Legislature approved in 2011 when the state was still swimming in red ink.

On Tuesday morning, a coalition of doctors, nurses, hospitals, health clinics, dentists, insurers and health care workers demanded as much during a rally on the state Capitol steps.

For an average patient visit, Medi-Cal now reimburses doctors $41.48, while Medicare, the nation's health program for the elderly, pays $102.45.

While a court injunction prevented the Medi-Cal cut from going into effect until this fiscal year, it will now continue indefinitely, despite the avalanche of new recipients, which is making it harder and harder for Medi-Cal recipients to find doctors. Next year the state projects it will "save" $214.5 million by not restoring the cut.

"We're not asking for a raise," said Dr. Jay W. Lee, the newly installed president of the 9,000-member California Academy of Family Physicians. "We're asking to reinstate the 10 percent cut -- money that otherwise was there to begin with."

As more than a million Californians have come to discover since January 2014 after their private insurance kicked in through the Affordable Care Act, many health plans narrowed their networks of doctors and hospitals to hold down premiums, frustrating enrollees trying to access health care.

But for the almost 4 million Medi-Cal enrollees who have signed up over the same period, the prospect of timely care and easy access can be even more daunting, since many doctors won't accept Medi-Cal's reimbursement rates -- which are among the lowest in the country.

"Most of my colleagues won't do it -- and that was true before the expansion under the ACA," said Dr. Ted Mazer, a San Diego-based ear, nose and throat doctor who stopped taking on new Medi-Cal patients in 2006.

"They will not deal with the system that does not value their service," he said, "and they will not take the losses that are necessary in order to accommodate the state's promise to provide care."

The Department of Health Care Services, which oversees the program, emphasizes that more than 80 percent of Medi-Cal members are enrolled in managed-care health plans required to meet the same network adequacy and access requirements as other private health plans in California. Officials say their department is keenly monitoring access to care and is increasing some Medi-Cal reimbursement rates in certain medical specialties as necessary.

But that's hard for Oakland resident Jose Abel Berumen, who is in an Anthem Blue Cross managed-care Medi-Cal plan, to believe. More than a year after his employer dropped him from a private insurance plan, forcing him onto Medi-Cal, he's had no luck finding a surgeon who will fix a painful hernia.

"What's the point of being covered if you don't have access to a doctor?" he asked. "The system is broken."

For his part, Juan España Jr. said he'd like to tell Gov. Jerry Brown that "a lot of people in the Bay Area really need more help." For España, that means having resources closer to home "so I don't have to go so far away" for treatment.

Tuesday's rally in Sacramento came on the heels of two bills that sought to restore the cuts but derailed last week.

Now, with billions in better-than-expected revenue for the next fiscal year, budget committees in both chambers are trying to make second passes at the issue before June 15, the Legislature's deadline to approve a budget. Brown has until June 30 to sign off on that budget.

Officials in Brown's Finance Department have pointed out that the $91.3 billion Medi-Cal budget for 2015-16 is almost $10 billion more than the current fiscal year. More than half of the cost comes from the federal government, but the state increased its contribution from the general fund by $700 million for the next fiscal year, up to $18.2 billion.

Moreover, Finance Department spokesman H.D. Palmer said some of the additional funds will be used to restore cuts to providers who can show that the cuts create a barrier to access for Medi-Cal patients.

Before the state restores any more cuts, Palmer said, "we would like to see how that will translate into increased service and access to those Californians who need it."

But Lee, the family physician, challenges that statement, pointing to the skyrocketing numbers of Medi-Cal enrollees in 2014 who have sought medical treatment in hospital emergency rooms -- something Obamacare was supposed to address.

"It's already an underfunded mandate," Lee said of the current Medi-Cal system. "And the issue is self-evident to me and my 9,000 colleagues that -- compared to the number of people enrolled -- the number of doctors has not dramatically changed."