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Medi-Cal Is Failing

About 160,000 people in the Sacramento area are uninsured even though they could be signed up for the state’s low-income healthcare plan, Medi-Cal. Instead, they are paying bills from their own pockets, or incurring costs on overburdened county clinics and hospitals.

The same problem exists statewide: Nearly three million low-income Californians eligible for Medi-Cal have not signed up — a monumental failure rate of a program that guarantees low-cost coverage for about elevent million Golden State residents, plus some level of reimbursement for their medical providers.

One reason for Medi-Cal’s low enrollment rate is ignorance: Eligible individuals simply don’t know. But the registration process is also complicated — and, even if you do sign up, there's no guarantee HMOs are giving patients the care they need.

“Right now, people need to know they’re eligible and go sign up,” said Robert Philips, director of health programs with the Sierra Health Foundation, a private Sacramento-based group working to improve health care. He says many people receiving Medi-Cal coverage only learn by chance that they are eligible after becoming injured or ill and visiting a hospital, “when the eligibility worker tells them.”

Trouble is, some hospitals and clinics, Phillips says, don’t have such workers onsite, and eligible Medi-Cal patients may be seen and treated without ever learning that they could have received state and federal assistance.

But there is another problem with Medi-Cal: The enrollment process can be so laborious and time-consuming that tens of thousands of people in the Sacramento area don’t even bother signing up, or can’t complete the process once they start.

“Right now, it’s so complicated,” said Kelly Bennett-Wofford, executive director of Sacramento Covered, a local organization that provides direct assistance to people interested in getting screened and, if eligible, signed up for Medi-Cal. “There are so many determining factors that you need to process to figure out if you’re covered.”

Copies of bank statements, trust-fund records, properties owned, vehicle registration, birth certificate, and other forms may need to be handed over to the county worker to help determine if an individual qualifies.

“Generally, the more paperwork that you ask of people, the less likely they are to sign up for something,” said Vanessa Cajina, a legislative advocate with the Western Center on Law and Poverty in Sacramento.

Improvements to the existing system, and relief for uninsured low-income Californians, is on the way. The Affordable Care Act — what has been called “Obamacare” for several years now — takes effect on January 1, 2014, and will greatly simplify the Medi-Cal application process.

The criteria for determining if one is eligible will be reduced — culled down to just age, family size and income, which must be less than 138% of the federal poverty level.

This means that a person between 19 and 65 years of age living alone and making less than roughly $15,900 per year will qualify for Medi-Cal. For each additional person in the household, the income limit increases by about $5,500. Moreover, an electronic system coordinated by state and federal offices will help process each applicant’s information.

In all, the Affordable Care Act will increase the number of Californians eligible for Medi-Cal by more than a million people statewide — and perhaps as many as three million, by some projections. Currently, 8.5 million are signed up with Medi-Cal, according to state officials.

When the Affordable Care Act kicks in, Sacramento County is going to see significant Medi-Cal uptake.

“There are probably 200,000 people uninsured right now in the county,” said Ethan Dye, with county’s Health and Human Services Department. “We’re forecasting that 30%-50% of them will apply for Medi-Cal within the first year, with more coming later.”

Assemblyman Richard Pan, a strong health-care advocate, is currently pushing outreach efforts to notify those eligible for Medi-Cal that they can sign up, with the hope that California will hit the ground running when the Affordable Care Act takes effect in four months.

Although county governments have strong financial incentive to sign up their residents for Medi-Cal, since the program brings them both state and federal reimbursement, many counties’ efforts to inform the public that the state could be paying their medical bills have been lacking to nil, according to Pan. He plans to ramp up outreach efforts in partnership town halls, churches, clinics and hospitals.

Other problems in the Medi-Cal system may be too deeply ingrained to be eliminated. Most troubling, in many critics’ opinions, is the possibility that enrolled Medi-Cal members might not be receiving medical attention when they want it.

That’s because of the way that the state pays health-maintenance organizations, or HMOs such as Healthnet and Molina. They receive money based on the estimated population of eligible Medi-Cal patients in their service area — whether or not those people ever visit a hospital.

“There is concern that this arrangement could cause an HMO to discourage someone from receiving care, since they get paid no matter what,” Assemblyman Pan said.

But exactly how HMOs, hospitals and other providers treat — or don’t treat — Medi-Cal patients based on payment quibbles is an entirely gray area, lacking in authority oversight.

“No one knows whether or not the level of access we’re paying for is on par with what we’re receiving,” said Phillips at the Sierra Health Foundation.

Assemblyman Pan recently authored legislation that if passed into law could improve some of Medi-Cal’s shortcomings and increase public transparency in the system. Assembly Bill 209 would require the state’s Department of Health Care Services to hold public meetings every few months to report on the quality of both health and dental care through Medi-Cal HMOs and providers. The state would also be required to appoint an advisory committee tasked with making recommendations to officials on how to improve healthcare quality.

Beginning in 2014, Medi-Cal will serve single adults without children, who have previously not been eligible. This group of people, some have said, likely includes a disproportionate number of single men with drug and alcohol problems — expensive additions to the Medi-Cal population. Federal reimbursements will be ramped up to help soften the expected blow for providers — but they will still take a hit.

Already, Medi-Cal has been a costly program to enact.

“We hear all the time how hospitals can’t even break even because they have a high number of Medi-Cal participants,” said Bennett-Wofford, at Sacramento Covered.

Providers, after all, only receive fractional compensation for each Medi-Cal patient they see. This system may have two opposite effects, according to analysts, either creating incentive for providers to not serve Medi-Cal patients at all, or actually driving stronger preventative efforts so that providers can avoid having to cover the cost of expensive treatment later.

Thus, Medi-Cal under the Affordable Care Act will put to the test whether social healthcare in America can work, and it remains to be seen whether enhanced Medi-Cal will drain hospitals of their resources — or if it helps to keep millions of Californians out of them in the first place.

This article first was published in the Sacramento News and Review.

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