Obamacare: Medi-Cal a waiting game for many low-income Californians

Julie Moreno felt lucky to be among more than 2.7 million previously uninsured Californians to be added to Medi-Cal, the state's health care program for the poor.

Until she needed cataract surgery.

For three months after her November 2013 diagnosis, the 49-year-old Mountain View resident said, she tried to get an appointment, but each time she called, no slots were available. Desperate and worried, she finally borrowed $14,000 from her boyfriend's mother to have the procedure done elsewhere last February.

One year into the explosive, health law-induced growth of Medi-Cal, it appears one of the most alarming predictions of critics is coming true: The supply of doctors hasn't kept up with demand. One recent study suggests the number of primary care doctors in California per Medi-Cal patient is woefully below federal guidelines.

"If you're pregnant, you get help," Moreno said. "But if you're 49 and not pregnant, you have to wait for everything."

In fact, seven months after Moreno's surgery, her original surgeon's office called just to say they still couldn't fit her in.

At least 1.2 million Californians have signed up for a private insurance plan since enrollment began in October 2013 under the Affordable Care Act, better known as Obamacare. But it's Medi-Cal that has witnessed the largest growth -- 2.7 million since the controversial law opened the program up to many more recipients in January 2014.

By mid-2016, more than 12.2 million people -- nearly a third of all Californians -- will be on Medi-Cal, state health officials say.

Those officials continue to insist that the current delays to see a doctor and crowded emergency rooms are all part of to-be-expected growing pains. But many experts say the problems are so widespread they shouldn't be ignored.

"California did a good job of getting people signed up, but they basically stuck their heads in the sand and assumed that California physicians would just jump right on board and want to take more Medi-Cal patients," said Dr. Del Morris, president of the California Academy of Family Physicians, which represents many of the first-line doctors who treat Medi-Cal patients. "It's unacceptable to say, 'We are not ready for you yet, you'll just have to suffer with your disease.'"

Morris and other experts say the situation is about to get worse, in part because of Medi-Cal's health care reimbursement rates.

For years, the rates paid by Medi-Cal — called Medicaid in the rest of the country — have been among the nation's lowest. A provision of Obamacare hiked the rates for primary care doctors to the substantially higher Medicare rates for two years, but those increases ended on Dec. 31. A second blow came last month when the state cut the Medi-Cal reimbursement rate by another 10 percent, a reduction approved by California lawmakers in 2011 but delayed in a court battle that doctors ultimately lost.

Even before the latest cuts, Medi-Cal doctors -- particularly specialists -- in California's rural areas often seemed nearly impossible to find. And the shortage of Medi-Cal physicians appears to be causing spikes in the number of Medi-Cal patients being treated in hospital emergency rooms around the state. Data from the Office of Statewide Health Planning and Development show that in the first three quarters of 2014, "treat and release" visits to emergency rooms by Medi-Cal patients jumped 30 percent from the same period the year before.

At least once a week at the MayView Community Health Center in Mountain View, the clinic is so swamped that it is forced to send Medi-Cal patients to hospital emergency rooms "because they cannot go anywhere else," clinic operations director Harsha Mehta said.

Since January 2014, Axis Community Health in Pleasanton has added about 1,700 new Medi-Cal patients to its five facilities that serve the Tri-Valley area, bringing the total to about 14,000. While 700 of those patients were already being treated at Axis before they enrolled in Medi-Cal, the overall jump in new patients is forcing Dr. Divya Raj, Axis' medical director, to hire more hard-to-find doctors.

A recent report by the California HealthCare Foundation that tried to determine if the state has enough doctors to handle the influx of Medi-Cal patients reinforces Raj's trepidation.

The report found the ratio of patients to full-time primary care doctors participating in Medi-Cal -- including family medicine physicians, general internists, pediatricians and ob/gyns -- was 35 to 49 physicians per 100,000 enrollees, well below the federal guidelines of 60 to 80.

"We had a shortage of primary care doctors before this flood (of Medi-Cal enrollees) came about," said Dr. Steven Harrison, a veteran primary care doctor who directs a residency program for such physicians at Natividad Medical Center in Salinas. "Now we have a dire shortage."

The report, however, did say the access to specialists participating in Medi-Cal met federal guidelines.

Some health care industry players argue that Medi-Cal is simply undergoing a shakeout period and will get better over time.

"There's a lot of talk about physician shortages in California, and I don't buy it," said Bill Barcellona, vice president of the California Association of Physician Groups. "We have plenty of doctors -- in fact, we have an oversupply of specialists in many areas, like the coastal areas."

While acknowledging that California has "very low" Medi-Cal reimbursement rates, Gov. Jerry Brown last year told this newspaper that the state's Medi-Cal costs had increased by $2.5 billion in an 18-month period -- to more than $30 billion in the current fiscal year.

"Will the doctors be there?" Brown asked. "We are watching that very carefully. But it's hard to come up with more providers, I have to tell you that."

The California Department of Health Care Services, which oversees the Medi-Cal program, says there are 84,628 fee-for-service physicians enrolled in Medi-Cal, 44,538 of whom have a specialty. The total number represents about 80 percent of the state's 106,284 licensed and practicing doctors.

Morris, however, calls those numbers "laughable" because the state's list includes any doctor who has seen at least one Medi-Cal patient in the last year.

Mari Cantwell, chief deputy director of the department, said officials are not aware of significant access problems and that "we are continually monitoring access to ensure members are able to receive care." Should problems arise, she said, the department can increase reimbursement rates in certain geographical areas.

Cantwell also said she believes that moving more Medi-Cal enrollees into managed care -- as opposed to traditional fee-for-service plans --will reduce access problems. Eighty percent of Medi-Cal enrollees are now in managed care.

Not every patient is unhappy. Ron Correll, 48, a Pleasanton tutor who has been on Medi-Cal for a few years, said he isn't too bothered by the long waits at the Axis clinic. It still takes him awhile to get regular appointments, he said, but he's got a good primary care doctor he likes, so he's flexible about the wait times. And even with the delays, Correll said, echoing a widespread sentiment: "It's still better than having no insurance."

Maria Johnson, a new Medi-Cal enrollee, is far less sanguine. After blood started showing up in her urine in June, it took a series of appointments until she was diagnosed with bladder cancer in early October. Johnson was frantic the cancer was spreading as she waited six weeks more to have her tumor removed.

"It seemed like they were playing Russian roulette with my life," said the unemployed Santa Clara resident, who is in her late 50s. "I'd like to ask my doctor: 'If it were your mother, or your wife, or your daughter, would you have made them wait that long for surgery?'"