In Valley, Affordable Care Act called a blessing or a nightmare

This article originally appeared in the Fresno Bee

The Affordable Care Act gets mixed reviews after its first year in the central San Joaquin Valley.

Many consumers say it’s a blessing to have insurance for the first time.

Others say it’s been a nightmare to find doctors willing to accept the new insurance plans.

There’s little doubt, however, about the effect of the law on the Valley, where about one in five people had no health insurance prior to the federal act.

More than 200,000 people in counties from Fresno to Merced enrolled in insurance plans for 2014 under the Affordable Care Act, also called Obamacare.

“Obviously, it was something that was needed,” said Sanja K. Bugay, deputy director of the Department of Social Services for Fresno County.

The vast majority of the Valley’s newly insured are beneficiaries of an expanded Medi-Calsystem that included more families and allowed adults without children for the first time to be eligible for the state-federal insurance for the poor. In Fresno, Kings, Madera, Merced and Tulare counties, nearly 160,000 people became new Medi-Cal enrollees.

About 48,000 in the five counties got their insurance through Covered California, the state’s insurance exchange that was created to help people find affordable private insurance. Almost 90% who enrolled in plans were eligible for federal subsidies to help pay for monthly insurance premiums.

Sam Rashad, a Fresno health insurance broker and certified Covered California insurance agent, helped about 100 people apply for Medi-Cal benefits and about 75 to enroll in Covered California health plans for 2014.

One of the Covered California consumers he helped was his wife, Maria Rashad. They have benefitted from a key aspect to the Affordable Care Act — its mandate that says no one can be denied insurance for pre-existing conditions.

For years, Rashad tried to find an insurance plan for Maria, 50. She has suffered from migraines since age 12.

Ever since Maria lost a job about 20 years ago and lost her employer-sponsored health insurance, every insurance company that Rashad contacted about insurance for his wife denied her application because of her pre-existing migraine condition.

When he told Maria no one would insure her, she was shocked: “Are you kidding me, you’re an insurance agent and you can’t even get insurance for your wife?”

Over the years, the medical bills began to mount: a one-month supply of medicine cost $350, a visit to the hospital emergency department was about $3,000. For the past five years, the family had been on the brink of filing bankruptcy because of Maria’s medical bills, Rashad said.

Now, with a Covered California health plan, Maria pays a $179 monthly premium. She pays $5 to fill a prescription and $15 to see a doctor. “Covered California is the best thing that could have happened to us,” Rashad said.

A scramble for doctors

California’s insurance exchange gets rave reviews for enrolling people in insurance plans but less so for access to health care.

Consumers in the Valley and statewide have had surprises when they made appointments: Doctors that they thought were accepting their plans were not.

Large medical groups in Fresno, such as the Central California Faculty Medical Group, as well as doctors in individual practices have refused to accept reimbursements offered by Covered California health plans.

“The whole idea of the Affordable Care Act is a good idea,” said Dr. Patrick Golden, a Fresno internist in individual practice. “The more people who can be served the better; it’s just that the compensation should be fair to the providers.”

Making matters worse for patients, many thought doctors were participating in plans because their names appeared on lists that were provided by the insurance companies and by Covered California. But in many cases, the lists were filled with errors.

Covered California has been beneficial for consumers who couldn’t get insurance, said Toni Memory of Fresno. “But those of us who never had a problem, suddenly we got sucked into this mess,” she said.

In March, Memory bought a health plan that was marketed as a Covered California plan for her 18-year-old son. The insurance was cheaper than adding him to her health plan offered by her employer.

Before buying her son’s policy, Memory said, she checked to make sure his doctor was participating. But when she took her son to an appointment, she discovered otherwise.

Memory said the doctor would not see her son, who had passed out on a camping trip, hit his head on a rock and had a seizure. He seemed to be fine, but she wanted his doctor to examine him. So Memory got a list of doctors from her insurance company and called them, but none of them would see him, either. So, she had to take him to Children’s Hospital Central California to be seen in the emergency department.

Memory is shopping now for a new plan for her son for 2015. This time, she’s found an insurance broker to help her pick a policy, but she’s still leery.

“I get really angry when I see those commercials about how happy people are that have Covered California,” she said. “I just walk away.”

Medi-Cal caseloads explode

The crush of new Medi-Cal patients has also strained health-care resources in the Valley.

In Fresno County alone, 81,000 people were added to the Medi-Cal caseload between October 2013 and April 2014, the first open enrollment for Covered California. Medi-Cal applications are accepted year-round, but the Covered California enrollment deadline spurred Medi-Cal sign-ups as well.

“A lot of people who work part-time who have a reasonable hourly wage but just don’t have enough hours went to Covered California and found out they qualify for Medi-Cal,” said Gregory Hund, executive director of CalViva Health, the locally governed Medi-Cal managed care plan for Fresno, Kings and Madera counties.

So far, CalViva has been able to find primary care doctors for the new members, Hund said.

But patients may not get the doctor of first choice, he said.

Bugay said the Fresno County Department of Social Services initially expected it would add 45,000 to its Medi-Cal roster. It’s taken months to process almost double that number of applications.

A clunky interface between county computers and CalHEERS, a new online-application system created for the state, contributed to a slowdown, Bugay said. Communication between county computers and the state has improved, she said, and “we’re now almost within our normal kind of processing time (of 45 days).”

Alondra Cruz, 19, a Fresno City College student, signed up for Medi-Cal in March and was still waiting for an insurance card more than seven months later.

But Cruz was taking the wait in stride. She had never had insurance. A part-time job at a high school didn’t provide insurance and she couldn’t afford a private policy.

Medi-Cal gives her peace of mind, she said. “I don’t get sick very often, but if I break an arm, I’m going to need insurance to get the doctor and get it fixed.”

The Affordable Care Act has “really made a difference to real people, having access to medical care,” Bugay said.

And despite bumps in implementing the law, she said: “I think we had a very successful year in Fresno County.”

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