Will Obamacare solve doctor access for Kern County poor?

Carlos, 7, Diane, 4, and Daniel head to school on a chilly December morning with their mother, Rubenia Romero. Without a car, the family is also forced to make the 40-minute walk to the local health clinic. Romero’s three children are on Medi-Cal. (Felix

This story originally appeared in The Bakersfield Californian.

One year from now, tens of thousands of uninsured Kern County residents will celebrate the bounty of health reform — they will finally have a chance at health insurance.

That’s when Medi-Cal, a publicly funded health program for low-income and disabled residents, will expand statewide, bringing the promise of coverage to perhaps 1 million more Californians.

But many local doctors and health care leaders fear that promise may be hollow.

“We’re so excited everybody’s going to have insurance. But they’re not going to be able to be seen,” said Debbie Wood, Bakersfield City School District’s coordinator of school health.

A CHCF Center for Health Reporting investigation found that Obamacare faces major obstacles in Kern County, where it’s already difficult for poor residents to find a doctor when they need one. As it is, many doctors and clinics that see these patients now are overwhelmed — a situation that experts say could worsen with the addition of thousands of new patients.

“We’re not even talking about 2014,” said Carmen Burgos of the nonprofit Greater Bakersfield Legal Assistance program. Burgos helps low-income Kern residents access health care and dental services. “Good luck finding a doctor who takes Medi-Cal now.”

More than 7 million Californians are now covered under Medi-Cal. In Kern County, one in four residents, most of them children, is enrolled in the program.

For many of them, accessing care already may mean skipping work or school to wait for hours at community clinics or renting cars for out-of-town trips to specialists who accept Medi-Cal patients.

They’re “scratching and hunting and picking to find access points for care today,” said Steve Schilling, CEO of Clinica Sierra Vista, which has 35 health centers in Kern, Fresno and Inyo Counties that accept Medi-Cal patients. “And they’re fighting to get into long lines at safety-net providers that are currently overburdened.” State officials say they constantly monitor access to Medi-Cal services, and have not found major problems in Kern County. In some cases, they have received fewer access complaints from Kern than elsewhere in the state, said Linette Scott, the chief medical information officer for the state Department of Health Care Services, which administers Medi-Cal.

“We aren’t seeing an access issue in Kern,” she said.

But local doctors and health care experts offer a starkly different portrait of access on the ground:

  • Desperate parents overwhelm the phone lines at Riverwalk Pediatric Clinic, a private practice in Bakersfield, searching for doctors who accept Medi-Cal, said pediatrician Hasmukh Amin. About half of the practice’s 20,000 patients already have Medi-Cal. "We say no to 25 to 30 callers per day,” Amin said. “We cannot handle any more volume. We are maxed out.” 
  • In the Bakersfield City School District, where nearly 90 percent of students live at or below the poverty level, Wood spends two-thirds of her day searching for doctors, dentists and mental health specialists who will take students with Medi-Cal. “It’s a huge, huge issue,” she said.
  • Some Arvin and Lamont residents get so frustrated waiting for a referral to specialists who accept Medi-Cal or finding doctors who speak Spanish that they go to Tijuana for their medical care and pay out of pocket instead, Burgos said.

Kern is among the state’s counties with the most to gain under the Medi-Cal expansion, which is a major piece of President Obama’s signature health law: Nearly 30 percent of county residents were uninsured during all or part of 2009, according to UCLA estimates.

The Medi-Cal expansion will broaden eligibility for the program by allowing applicants with higher incomes and allowing those who were previously ineligible, such as childless adults, to get coverage.

Estimates of how many Kern County residents will qualify under the expansion vary dramatically. Jacey Cooper, executive director of managed care at Kern Medical Center, pegged the number at roughly 38,000. Schilling and others believe it will be substantially higher.

But even as patient eligibility expands, local experts question whether doctor participation will grow to meet the expanded Medi-Cal population.

Kern County, along with the rest of the San Joaquin Valley, has among the worst doctor-to-population ratios in the state. And Medi-Cal physician participation is even worse.

An accurate count of how many Kern County doctors actively see Medi-Cal patients is hard to come by. As a state, California ranks poorly.

Two studies, including one published in the journal Health Affairs in August, show that 57 percent of California doctors accept new Medi-Cal patients. That’s the second-lowest rate in the nation after New Jersey. California’s neighbors, Nevada and Oregon, accept 75 percent and 80 percent, respectively.

The primary reason doctors don’t participate is financial, local doctors say.

California has one of the nation’s lowest payment rates, ranking 47th of 50.

“They don’t get enough reimbursement even to meet their office needs,” said Dr. Madhu Bhogal, medical director for the neonatal unit at Bakersfield Memorial Hospital. “They’re losing money on health care for Medi-Cal.”

Amin, the pediatrician, provided an example: Private insurance companies reimburse between $60 and $120 for a typical pediatric office visit for a sore throat or ear infection, he said. Medi-Cal, he said, pays $27 to $37.

“When you accept Medi-Cal patients, you pay the price for it,” he said. “The reimbursement is very low.”

As a result, many doctors don’t participate.

“There definitely is a shortage. This is a big problem here in Bakersfield,” said Anthony Thomas, a pediatrician at Bakersfield Memorial Hospital.

When Thomas closed his private pediatric practice several years ago, more than half of his patients had Medi-Cal.

“I was a primary care physician for 11 years in this community,” he said. “I took a lot of Medi-Cal. It just undermines you.”

Thomas calls the shortage “acute” and said the only way to fix the Medi-Cal access challenges is by paying doctors more. “Raising rates really is the key,” he said.

Rates are going up — temporarily at least — as a result of Obamacare.

Starting this month for two years, reimbursement rates for many primary care services in Medi-Cal will jump to Medicare levels, funded by the federal government.

In California, the change is dramatic. On average, fees will increase by 136 percent, according to the Kaiser Commission on Medicaid and the Uninsured.

“The payment increase is a significant incentive that we anticipate will help attract new primary care physicians to the Medi-Cal provider network,” said Norman Williams, spokesman for the Department of Health Care Services.


The clinics, which are among the few providers that don’t limit the number of Medi-Cal patients they see, are inundated.

More than half of Clinica Sierra Vista’s patients have Medi-Cal, Schilling said. He believes that figure may reach 65 percent after Obamacare’s main provisions kick in next year.


“I’m not suggesting I have complete, perfect access for even the current Medi-Cal,” Schilling said. “I’m swamped. I’ve got lines out the door every morning. I’ve got waiting rooms that are packed all day long. I don’t have enough rooms and I don’t have enough providers and I don’t have enough space and places.”

But many people on Medi-Cal have no other choice, Wood said.

“They go to the clinics and they sit there for six, seven, eight hours. They may have an appointment at 8 a.m. and not be seen until 4 in the afternoon,” she said.

While they ultimately receive care at the clinics, they pay for the crowded conditions in other ways, Wood said.
“Many of our families are in agricultural work,” she said. “If they miss a day they don’t get paid. So they go to the emergency room.”

In November, Rubenia Romero’s 9-month-old son, Daniel, had diarrhea and a 100-degree fever.

The single mother doesn’t own a car. So, she settled Daniel in the stroller and bundled her other two children up for the 40-minute walk to the Clinica Sierra Vista on Brundage Lane in Bakersfield.

They arrived shortly after 8 a.m., but Romero was told her son couldn’t be seen that day because he didn’t have an appointment. The clinic staff directed her to go to a hospital if she thought it was an emergency, she said.

“That’s the way it is always,” she said. “If you don’t have an appointment, they won’t see you.”

Thankfully, she said, Daniel recovered.

“I get angry because I feel that if you have Medi-Cal, it’s coverage, but nobody wants to see him,” Romero said.


Medi-Cal recipients also face obstacles finding specialists, and there’s little indication that situation will improve under Obamacare. Unlike primary care doctors, specialists won’t receive the two-year rate increase for seeing Medi-Cal patients, giving them little incentive to take more.


Wanda Pierce, Standard School District nurse, said some of her students with complex medical problems have trouble finding pediatric endocrinologists, neurologists and other specialists.

Those students often end up being referred to doctors out of town.

“To get specialty care, most of them go to Children’s Hospital Los Angeles or Children’s in Madera,” Pierce said. “They usually miss at least a day of school. … It’s hard to have a doctor so far away.”

Having an out-of-town doctor — even within the county — poses transportation challenges to many people on Medi-Cal.

Residents of rural Arvin and Lamont, for example, can’t easily get to Bakersfield, Burgos said. There’s a bus, but once they get to Bakersfield, they have to transfer several times and hope they make it to the medical office on time, she said.

“In California, we always think of everybody having a car, but everybody doesn’t have a car,” Pierce said. “And those that have a car, sometimes it can only be used in town because it’s not reliable. It might not make it to Fresno or L.A.

Click to enlarge.

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