Thousands of low-income uninsured people in the San Joaquin Valley will be able to apply for Medi-Cal beginning next month, but the insurance might not do much good if there aren't enough doctors to go around.
Under the Affordable Care Act, as many as 135,700 Valley residents — 45,000 in Fresno County — could qualify for coverage as part of the sweeping health-care overhaul that aims to get all Americans insured. Statewide, 900,000 could be eligible.
The health law establishes new Medi-Cal eligibility rules, which open the program to low-income "childless adults" and working parents whose incomes slightly exceed the federal poverty line. The poverty line now stands at $11,490 for a single person, but under expanded Medi-Cal a single person earning less than $15,856, or 138% of poverty, will be eligible.
Victor Guzman of Fresno is happy about the new eligibility rules.
Guzman, 54, who lives in subsidized housing, gets by on $115 a month and $200 in food stamps, far below the poverty level. But he hasn't been able to enroll in Medi-Cal because he is an adult with no minor children to support.
He has diabetes and struggles with debilitating depression, but often can't afford to go to the doctor, even if it only costs $20 at a community health center.
"When you only get $115 a month it's difficult to stretch that out," he said. "I just try to be healthy."
Valley's need is great
Valley health officials say changes in Medi-Cal eligibility have the potential to ease medical hardships here more than elsewhere in the state.
The Valley has some of the highest uninsured rates, and many of those without coverage have had nowhere to go for care except hospital emergency rooms. The expanded Medi-Cal program could increase enrollment regionwide by 20% — more than 775,000 from Tulare to Modesto would be covered.
"We're going to have healthier people and in the long-term reductions in health costs," said Richard Yanes, health-policy advocate for Central California Legal Services in Fresno.
But there also is unease.
With less than two weeks before pre-enrollment begins Oct. 1 for the expanded Medi-Cal program, some in the health community question if the Valley is ready to enroll thousands. And more concerning, they say, is what happens once people are enrolled and begin looking for doctors. Medi-Cal is unpopular with health professionals, and the Valley has an overall doctor shortage and struggles now to provide care to those already insured.
If there aren't enough medical providers, "are people going to have a wonderful insurance card that they take to the emergency department?" asks Norma Forbes, executive director of the nonprofit Fresno Community Healthy Access Partners.
But first things first, Yanes said: "Are we going to have the ability to get people enrolled in a timely fashion?"
It's unknown how many will race to enroll in October. Besides the low-income uninsured, people who currently have employer-sponsored insurance and who meet the new Medi-Cal eligibility can drop out of expensive health plans and enroll in the government insurance program — without penalty to their employers. By some accounts that could be hundreds of thousands statewide.
Enrollment for as many as 600,000 outside Fresno County could be swift because they already are enrolled in the Low Income Health Program, which was designed to be a bridge to health-care reform, said Lucien Wulsin, executive director of Insure the Uninsured Project, an organization for health reform. Fresno County, however, did not create a program, and that could slow enrollment.
Readying for surge
Valley welfare officials said they've made preparations for an enrollment surge — though they can only hope they're ready.
Up and down the Valley, county workers have been added to process Medi-Cal applications. California and the federal government are spending $240 million to beef up county work forces statewide.
Fresno, for example, has 93 new positions — 59 dedicated to eligibility and enrollment processing, said Sanja Kovacevic-Bugay, deputy director of the Department of Social Services.
She is ready for new enrollees, Kovacevic-Bugay said, but added, "honestly, I am hoping for not a huge rush on Oct. 1."
A crush of people could show up at office counters or flood Medi-Cal regional call centers, such as one set up in Merced to field inquiries from Merced, Alpine, Amador, Calaveras, Inyo, Mariposa, Madera, Mono and Tuolumne counties.
The Merced call center, one of 13 in the state, will handle calls from potential Medi-Cal enrollees who have been transferred by Covered California, the state's health benefit exchange. Covered California will provide affordable health plans for individuals looking to purchase insurance beginning next month.
"We have 25 people in the call center," said Sommer Moniz, program manager at the Merced County Human Services Agency.
Counties are facing a massive task, but readying for the expanded Medi-Cal program is not unlike the challenge they encountered with welfare reform in the mid-1990s, said Frank Mecca, executive director of the County Welfare Directors Association of California.
"What we can control — the hiring of our staff, the training of our staff and modifications to computers — we're feeling good about," he said.
Counties depend on the Department of Health Care Services, which manages the Medi-Cal program, and the Covered California benefit exchange to make sure their pieces are in place. Mecca said last week state officials indicated everything is on track.
As much as they can, community health centers and hospital systems in the Valley have made preparations to help with a potential avalanche of new Medi-Cal enrollees. Many have counselors on their staffs to help people navigate the enrollment process for expanded Medi-Cal and Covered California.
At United Health Centers of the San Joaquin based in Parlier, seven workers have been assigned to help with enrollment and another will be hired soon, said Norma Macedo, director of special projects.
United has about 50,000 patients in eight centers from Parlier to Corcoran and has identified about 7,000 patients who will be eligible for the Medi-Cal expansion, Macedo said. Another 5,000 to 7,000 will remain uninsured, most of whom are undocumented immigrants and ineligible for benefits.
Training new doctors
Clinica Sierra Vista, which has community health centers in Bakersfield and Fresno, also has geared up to help people get insurance, but chief executive officer Stephen Schilling has been concentrating on finding doctors for the newly insured.
"We are recruiting 24/7," Schilling said. "We have vacancies, multiple vacancies almost all the time."
The Valley has been designated by the federal government as a medically underserved area. Except for the San Bernardino-Riverside region, the San Joaquin Valley has fewer primary-care and medical specialists than anywhere in the state.
The Valley has 45 primary-care doctors for 100,000 people and 74 specialists per 100,000. The national recommendation is no fewer than 60-80 primary care doctors and 85 to 105 specialists per 100,000 patients.
And finding health professionals who accept Medi-Cal patients is more difficult because of a 10% cut in state reimbursement, health officials said. Primary-care doctors, however, will get a federal boost in Medi-Cal pay for two years, which could help with doctor recruitment.
Schilling is convinced training doctors locally is the key to a bigger doctor supply and the Affordable Care Act has provided money for it. This year, Clinica joined forces with Fresno Healthy Community Access Partners to create a primary-care residency program based at Clinica's center on Divisadero Street in Fresno.
The three-year residency program, with four students, began last month.
But the clinic-based residency program's future depends on whether Congress will reapprove funding. It costs $150,000 a year to train a resident, Schilling said.
The program needs $1.8 million for the three-year training, but there is no guarantee that Congress will renew the Affordable Care Act allocation for the program before it expires on Sept. 30, 2015, he said.
With Republicans vowing to overturn the health law, Schilling said: "I have real concern this Congress can come to consensus to keep alive this one part of Obamacare."
Residency programs are adding doctors, but Forbes said they fall short of the impending need. "We have a lot of activity going on to try and increase the doctors, but I'm concerned that we're going to have enough in time."
To a large extent, the onus of providing doctors for new Medi-Cal patients will fall on managed care organizations, such as CalViva Health, the locally governed Medi-Cal managed care plan for Fresno, Kings and Madera counties.
Under California law, managed care organizations must maintain an adequate network of health providers to meet state standards, said CalViva executive director Gregory Hund.
CalViva, which now has about 213,000 members, expects to have enough providers for additional members, Hund said. There are 13 hospitals, 105 clinics, 395 primary-care doctors, 1,498 specialists and 102 other providers in its network.
But CalViva could have a problem rounding up enough dentists for adults on Medi-Cal. The state restored partial dental services this year after cutting dental coverage to adults in 2009. The Fresno area has 43 dentists per 100,000. The recommended number is 69 per 100,000.
One of the desired outcomes of getting the low-income uninsured enrolled in Medi-Cal is to relieve overcrowded emergency departments, but it's unclear if that will happen.
Medi-Cal patients use hospital emergency rooms more than the uninsured and privately insured patients, according to a UC San Francisco study released Tuesday.
Researchers looked at California ER data from 2005 to 2010 and found Medi-Cal patient use of emergency rooms increased 13.9% compared to increases of 3.79% and 2.89% for privately insured and uninsured patients. And the Medi-Cal patients were more likely to be in the ER with serious illnesses, the university said.
The researchers cited lack of access to primary-care doctors as a possible reason for the higher ER visit rates by Medi-Cal patients, the university said.
Valley hospital officials said time will tell whether expanding Medi-Cal reduces ER use.
"It should expand the number of people who have health insurance, and we hope that means they're going to establish a relationship with one of our providers or with another provider and won't need to use the emergency department," said Dave Larsen, chief financial officer at the Adventist Health Central Valley Health Network in Hanford.
Adventist is adding primary-care providers at clinics in Reedley, Parlier and Riverdale, and has brought in specialists at clinics in Selma and Hanford to increase outpatient access to doctors, which ideally would reduce patient trips to the emergency department.
Kaweah Delta Health Care System in Visalia has rural health clinics in Exeter, Lindsay and Woodlake and is looking to expand to more cities, for the same reason.
Last year, the hospital had 80,000 emergency room visits, including 20,000 for nonemergencies, said Gary Herbst, senior vice president and chief financial officer at Kaweah Delta Health Care District.
Forbes believes once people are enrolled, they can be educated about how to use insurance for primary and preventive care, which should reduce ER visits and reduce health costs for everyone over the long run, she said.
Spreading the word
But first, people have to know they can enroll.
Information about the expanded Medi-Cal program has been slow to reach people, maybe because the emphasis has been placed on Covered California health plans.
Guzman said he had not heard about the Medi-Cal expansion and that he could apply until a Clinica Sierra Vista worker explained the new eligibility rules to him.
"Information like this is not well spread," he said. "This is something not everyone knows."
Josefina Medina de Gutierrez of Mendota also recently found out about the insurance from a United Health Centers worker. In the past, she said, she had been turned down for Medi-Cal because the family's annual income was too high.
She works seasonally at an onion packinghouse. Her husband works full-time in farm labor but has no insurance through his employer. They have four children.
She plans to apply for the expanded Medi-Cal program. "I will apply and it will be a big help to us," she said.
"My husband has gone to the doctor for his diabetes that he was recently diagnosed with. He was taking his medicine but he ran out and now we can't afford to buy any more," she said. The medicine was $800.
Guzman has had a similar dilemma. "Two months ago, I couldn't come to my appointments at Clinica Sierra Vista," he said. "It was going to be $20 for the doctor and $20 for blood testing" — money that he didn't have.
Now, he said, he'll be making an appointment — to apply for a Medi-Cal card.
About this series
Bee health writer Barbara Anderson examines how the Affordable Care Act will change health plan availability. Sept. 8: Details about the choices that consumers will face
Sept. 15: How the federal law will affect small and large employers in the Valley
Today: How Obamacare will change Medi-Cal
Staff writer Robert Rodriguez contributed to this report. The reporter can be reached at (559) 441-6310, firstname.lastname@example.org or @beehealthwriter on Twitter.