Don't Get Sick: The crisis in Stanislaus County

Dr. Negin Taher examines Donna Dudley, 47. (Darryl Bush/The Modesto Bee)

A health care crisis is sweeping the Central Valley, devastating middle-class and poor families and threatening to overwhelm the region’s fragile safety net.

The deep recession has pushed the ranks of the uninsured here to unprecedented levels. At the same time, a dire state budget deficit has forced lawmakers to drastically scale back or eliminate key health care programs for the state’s poorest residents.

At the nexus of these two trends lies a troubling new reality: Across class lines, people are struggling to access care — or simply are going without.

Doctors and nurses at county and nonprofit clinics say they're seeing mounting numbers of out-of-work professionals and laid-off blue-collar workers joining the chronically poor and undocumented in waiting rooms throughout the region.

In the past few years, growing numbers of unemployed workers have added 700,000 to the ranks of the state's uninsured, bringing the total to 7.1 million.

In Stanislaus County, more than 90,000 people are uninsured, including a quarter of all adults ages 18 to 64, according to the most recent census data. An additional 105,000 low-income residents are enrolled in the state's Medi-Cal program.

"When people become uninsured, not only do they live sicker, they die younger, they're one emergency away from financial ruin and there are very few options available," said Anthony Wright, executive director of Health Access California, which advocates for affordable health care for all Californians. "It's a tattered safety net that has gotten worse because of the budget crisis."

Federal health care reform has begun gradually rolling out — expanding coverage through small businesses and community health centers, and providing new insurance options for young adults and people with pre-existing conditions. But many of the bill's major provisions — which, as passed, would ensure some form of coverage for virtually all legal residents — will not take effect until 2014.

Until then, with cuts to health care on the horizon in Sacramento, and with California burdened with one of the nation's worst unemployment rates, some patients are finding there's no safety net left to catch them.

While the whole state is suffering, counties in the Central Valley — including Stanislaus — have been hit particularly hard.

• In the past five years, applications to the county's Indigent Adult Health Services program for the uninsured rose more than 40 percent.

• Some 55,000 Stanislaus County adults on Medi-Cal saw their dental, podiatry, psychology and other "optional" benefits eliminated in July 2009.

• The county Health Services Agency, a system of six primary care clinics that was ailing before the recession, has lost 126 positions since 2005, a quarter of its staff. As a result, the clinics see 14,000 fewer patients than they did five years ago.

• County Behavioral Health and Recovery Services, which oversees mental health and drug and alcohol services, closed three mental health clinics five years ago and in the past three years lost almost 200 employees — nearly 40 percent of its staff.

Asked where the uninsured mentally ill can go to access care, Denise Hunt, the department's director, said simply: "I don't know."

"It's been very difficult," she said. "Let's just put it that way."

Unprecedented need

While numbers help outline the contours of the crisis, they don't capture the frustration and embarrassment that Dr. Del Morris, the county medical director, sees in many new patients seeking care from the county clinics.

"They've never experienced in their life having to do this kind of thing," he said. "Some of them have given up a lot of pride."

He rattles off a list:

• A 56-year-old truck driver, uninsured since he was laid off in September 2009, who spent months unable to refill his diabetes and hypertension medications because he couldn't afford to see a doctor

• A 28-year-old businessman, uninsured since his business closed in the fall of 2009, who came to the county for follow-up care after being shot in an attempted carjacking

• A 26-year-old medical receptionist, uninsured since she lost her job 18 months ago, who relapsed into a severe depression because she could no longer afford her medications

"Many people I take care of who need health care and can't get it are people who are just like me," Morris said. "They didn't do anything wrong. They just got sick."

The county has seen a surge in uninsured adults applying for indigent health services, pushing the patient count in that program from 5,953 in 2006 to 7,829 in 2010 — a 32 percent increase. During the same time period, funding for the program, which comes from sales tax and vehicle license fees, dropped from $14.4 million to $12.6 million.

Ineligible for help

The vast majority of the county's uninsured adults are not enrolled in any program. Many had assumed their jobs were secure and that, if something happened, the safety net would be there to catch them. Now, because of tight restrictions on income levels and assets, they are finding they're not eligible for government help.

Without insurance, they suffer through their illnesses — postponing the expense of doctors' visits by taking to bed for days, buying over-the-counter medications or trying alternative, less expensive, therapies.

When her husband was laid off last year after working 13 years as an equipment operator for Hilmar Cheese, 56-year-old Maria Contreras was no longer insured through his work. Suddenly, she had no access to medications she takes for cholesterol and thyroid problems. On a friend's advice, she started eating oatmeal and drinking special fruit juices. While she and her husband search for work, she doesn't know what else to do.

"This is the first time I've been without insurance," she said in Spanish. "It's very difficult now that I'm not so young anymore."

Dr. Eric Ramos, chief medical officer at Doctors Medical Center in Modesto, said decisions to postpone care are common among uninsured patients — and, as co-pays and deductibles spiral upward, they are increasingly common even among the insured.

"Absolutely, they do not want to come in for a simple sore throat or a cough. … They're going to wait a lot longer and may come in when it's been detrimental," he said.

In some cases, delaying care eventually leaves people so ill they end up in the hospital. During the past five years, local emergency rooms have seen a 64 percent increase in visits by the uninsured.

Many newly uninsured patients swallow their pride and seek care from a network of private safety net providers, including Golden Valley Health Centers, Aspen Family Medical Group, Planned Parenthood and St. Luke's Family Practice.

Statewide, many of these safety net clinics have received a bump in recent years from federal grants, but also lost a big chunk of state funding in 2009.

At Golden Valley Health Centers, about 40 percent of the patients are now uninsured, compared with about 33 percent two years ago.

Mike Sullivan, Golden Valley's CEO, says he suspects some of that growth is because the county clinics have reached capacity.

"They therefore don't become a safety net anymore," he said.

Seniors, those with disabilities hurt

Years of cutbacks to state programs have not only affected the uninsured — they've also hurt people with disabilities, frail seniors and others who depend on the state's Medi-Cal insurance plan for disabled and low-income residents.

From 2006 to 2010, an additional 10,000 people were added to county Medi-Cal rolls. The county clinics have been unable to meet that growing need, said Mary Ann Lee, director of the Health Services Agency.

"Our ability to serve additional patients is very limited," she said.

In 2009, after the Medi-Cal "optional" benefits — including dental, podiatry and psychology — were eliminated, George Sharp, an advocate with the Disability Resource Agency for Independent Living in downtown Modesto, said worried disabled clients would call asking how they could go to the dentist or access mental health care.

"We honestly didn't have an answer for them," he said.

A host of other programs have been scaled back or eliminated in recent years, among them AIDS and HIV case management, testing and outreach; guidance for pregnant and parenting teens; support for families with mental health and substance abuse problems; and case management for seniors.

Jill Erickson, a manager with the county department of Aging and Veterans Services, particularly laments the loss of the Linkages program — which provided visits and phone calls to more than 100 frail elderly and disabled people until state cuts eliminated it last year.

"It just feels like we're not providing the level of care that we once were able to do," she said. "We felt so distraught. How can we just stop seeing them, stop caring for them?"

Mental health care cut severely

Perhaps most damaged of all, many county leaders agree, are the county's mental health services. As a result of years of cutbacks, the mental health system now has the capacity to see just over 9,000 patients a year — down from more than 12,000 in 2004.

Since that time, three outlying clinics have closed, reducing access to mental health care for people living in the county's rural areas. Programs to rehabilitate mentally ill offenders and serve the homeless mentally ill have also been cut.

"Every year," says Hunt, director of County Behavioral Health, "we have reduced and reduced and reduced and reduced."

As the state economy continues to gasp for breath — and with more drastic cuts being proposed in Sacramento — Stanislaus county residents are adjusting to a new bottom line: In 2011, health care has become a luxury many can't afford.

Christine Van Etten, a 39-year-old mother of three, lost her job in medical billing after slipping and cracking her hip. No longer insured, she can't pay for the surgery she needs in order to fix it — and generally puts off going to the doctor when she gets sick.

"You wander through Walgreens to see what you can take to make it better," she said. "You are scared not knowing when this will end."

Bee staff writer Ken Carlson can be reached at kcarlson@modbee.com.

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