(Justin Sullivan/Getty Images)

Gov. Jerry Brown’s revised budget plan is a mixed bag for health advocates and some county officials.

Brown said the state would take the lead on a key provision of the federal health law — expanding Medi-Cal to more than one million Californians. Brown scrapped earlier plans to consider a more complicated, county-based system.

But Brown anticipates recouping more than $300 million from the counties next fiscal year – money that pays for public health programs and care for the uninsured. Brown’s rationale? With the full implementation of federal health reform next year, more people will enroll in Medi-Cal and fewer people will show up to county emergency rooms.

Farrah McDaid Ting with the California State Association of Counties says Brown’s proposal makes no sense. She says plenty of people will still rely on county services in 2014.

They are “people who qualify for Medi-Cal but don’t sign up, people who have a hard time signing up or staying on programs, the undocumented in our communities and those who are in between private health plans,” McDaid Ting said. “We need to retain enough funds to serve those people.”

That could be 3 to 4 million Californians who remain uninsured even after federal health reform is fully implemented, according to projections from UC Berkeley and UCLA. Brown and state health officials say they are developing a “mechanism” that will determine county savings based on real data.

Advocates fanned out across California Tuesday holding five statewide rallies, including one in front of state offices in Oakland, where they called for a rollback of cuts to adult dental care, children’s nutrition programs and other social services.         

“I think the most important number to remember is that one in four children in California are in poverty now,” Jamila Edwards Harris with the Children’s Defense Fund said. “And that number has only risen since budget cuts over the last five years.”

Brown’s budget also continues pending cuts to Medi-Cal providers, a plan that has been tied up in federal court since it passed in 2011.

(seliaymiwell/flickr)

While President Obama’s health care overhaul turns three on Saturday, many states are scrambling to get everything ready for the full rollout on January 1. California was the first state to pass legislation to set up a marketplace, and the Legislature has done a lot of work since. But there’s still a lot left to do — and fast.

To bring you up to date, three major sets of bills are before the Legislature in its Affordable Care Act special session. (Six bills total; Assembly and Senate have their own versions of three proposals).

Of those, two issues are key:

• Reforming the individual market
• Medi-Cal expansion (the state’s health insurance program for the poor.

As David Gorn of the CaliforniaHealthline reports, the California Legislature went on spring recess yesterday. These ACA bills are outstanding, much to the frustration of advocates. These special session bills take effect in 90 days, once they are passed. ACA proponents had hoped passage would have happened already.

As far as the individual market reform goes, those bills were hung up over technical language which appears to have been resolved (tie-back to the federal law’s individual mandate, for you wonks out there). Gorn reports that Sen. Ed Hernandez (D-West Covina) is confident the bill will be on Gov. Brown’s desk soon after the Legislature is back in session.

That’s the good news. More from CaliforniaHealthline:

The Medi-Cal expansion legislation, though, is a different story.

“The one we’re going to have trouble with is the Medicaid expansion bill,” Hernandez said. “We’re miles apart on that one.”

Assembly member Pan, who chairs the Assembly Committee on Health, said the hang-up on passage of the special session bills has to do, in part, with the debate over distribution of federal money. Counties are likely getting a large financial reprieve from optional Medi-Cal expansion and the state would like to get a piece of that.

“The governor is looking for sources of funding for the Medi-Cal expansion,” Pan said. “The expansion itself, though, is more of a policy issue than a budget issue. Those are big issues, so let’s not hold up the policy over other concerns.”

Hernandez the Medi-Cal expansion portion of the special session could be bumped into regular session.

“My sense is the administration wants to run this in the regular session,” he said. “That one’s going to be bottled up for a long time, and I can’t tell you how long.”

The Legislature is back in session on Monday, April 1.

Dr. Hasmukh Amin, a Bakersfield pediatrician, accepts Medi-Cal patients but says he has to turn away 25-30 people every day who are seeking a pediatrician who accepts Medi-Cal. Here he examines Marcus and Major Thompson. (Henry A. Barrios/The Californian)

In less than one year — Jan. 1, 2014 — Obamacare’s promise to bring health care to perhaps 1 million more poor California residents will be tested. That’s when Medi-Cal, the publicly funded health program for the poor and disabled, launches a huge statewide expansion.

But making a promise is one thing, and delivering is another.

In some places, it’s already tough for many poor California residents to find a doctor who is able –- or willing — to see them when they need one.

From the sprawling Los Angeles basin to the sparsely populated rural north, many medical providers who currently see these patients say they are overwhelmed, a situation that could worsen when those newly covered by Medi-Cal arrive for care.

The epicenter is California’s Central Valley, where high rates of uninsured residents, coupled with persistent doctor shortages, create a potentially combustible brew that could thwart the success of the health care law.

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

Progam Expansion

More than 7 million Californians are currently covered under Medi-Cal, and expanding the program is a major piece of President Obama’s health care overhaul, called the Affordable Care Act.

(Graphic: CHCF Center for Health Reporting)

Between 2014 and 2019, roughly 1 million to 1.4 million more Californians will enroll in Medi-Cal as a result, according to UCLA and UC Berkeley estimates.

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

State officials say that there’s sufficient access to Medi-Cal services and that they are constantly monitoring to ensure that recipients can get care.

“We do believe that the Medi-Cal provider network provides adequate access in California now,” said Norman Williams, spokesman for the state Department of Health Care Services, which administers Medi-Cal. The state also is “adequately preparing for 2014 and the expansion.”

But doctors and health care experts across California offer a starkly different portrait of access on the ground.

• “We’re experiencing provider shortages right now,” said Alex Briscoe, director of the Health Care Services Agency in Alameda County, home to the cities of Oakland and Berkeley. He sees pressure points across the entire county, from less-populated areas to denser communities. “Patients often wait months to get access to care,” he said.
• Desperate parents overwhelm 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 Los Angeles County, more than 1 million people –- about one-third of them on Medi-Cal –- were seen at 174 health clinics in 2011, said Louise McCarthy, president of the Community Clinic Association of Los Angeles County. When asked whether there will be enough doctors to serve the growing population of Medi-Cal patients, she replied simply, “No.”

Low Rates

Medi-Cal is California’s version of the federal Medicaid program, and the Golden State ranks poorly in doctor participation compared with other states.

Two studies, including one published in 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, doctors themselves say. California has one of the nation’s lowest payment rates, ranking 47th of 50.

Ted Mazer, an ear, nose and throat specialist in San Diego, chairs the California Medical Association’s committee that focuses on Medi-Cal policy. He said doctors lose money providing care under Medi-Cal. For example, he said, Medicare, the federal health insurance program for people 65 and older, pays doctors about $76 for a regular office visit. One private insurance company pays about $71.

Medi-Cal? It pays $24, he said.

About six years ago, Mazer began limiting his participation in the program.

These low Medi-Cal rates are being addressed — temporarily at least — by Obamacare.

Starting this past January and lasting 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 Williams of the Department of Health Care Services.

People wait in line at Clinica Sierra Vista at the East Bakersfield Community Health Center. Some were waiting before they opened at 7:30am. (Casey Christie / The Californian)

Once Obamacare is fully implemented in January, hundreds of thousands of Californians will move from the ranks of the uninsured to the insured. That’s the good news. The downside: many California counties already face a shortage of primary care doctors — a shortage that is especially acute in the Central Valley.

How those newly insured — especially those who will be enrolled under Medi-Cal — will access care is an especially pressing question in Kern County, as the CHCF Center for Health Reporting has been exploring under a series, Desperate for Doctors.

A chief problem is not only the shortage of primary care doctors, but also the question of whether physicians accept Medi-Cal patients. If individuals and families hold Medi-Cal insurance, but can’t find a doctor who will accept it, their new coverage isn’t much help.

A straightforward starting point would be to quantify how many doctors there are and how many accept Medi-Cal. But, in a great piece of reporting, Emily Bazar found that there’s little agreement on these two critical pieces of information — within statewide agencies.

The state’s Department of Health Care Services (DHCS) report there are 2,023 Kern County doctors who see Medi-Cal patients, Bazar writes. Starting point, yes? But this number was a surprise to people on the ground in Kern County. From Bazar’s report:

Here’s what Sandi Palumbo, executive director of the Kern County Medical Society, says:

“Whaaaattt!? I didn’t even know there were that many licensed physicians in Kern County.”…

There aren’t.

The state Medical and Osteopathic Medical Boards, in charge of licensing doctors who practice in California, show about 1,200 physicians in Kern County, more than 800 fewer than the state’s statistic.

A DHCS spokeswoman told Bazar that the discrepancy could be accounted for by doctors who are licensed in other counties, but practice in Kern. Palumbo didn’t buy it.

Bazar reports that DHCS says there are 104,239 doctors statewide who are enrolled as Medi-Cal providers. But the California Medical Association doesn’t buy that number, either. From Bazar’s report:

Lisa Folberg, vice president of medical and regulatory policy for the California Medical Association … says the state’s number is “ridiculously overinflated.” …

She points to the number of doctors licensed by the state with addresses in the state: About 107,000.

Folberg said there’s no way that almost every doctor in the state accepts Medi-Cal. “Every study across the nation shows that not all physicians participate in Medicaid,” she said.

State officials again had an explanation for these conflicting numbers: there is currently no expiration date on a doctor’s enrollment in Medi-Cal. But starting this month, the Affordable Care Act requires that state’s confirm a doctor’s participation in the program every five years.

Perhaps that 104,000 number of doctors who accept Medi-Cal will decline.

“It would be really helpful for policymakers to have an agreed upon set of facts,” Andrew Bindman, director of the University of California-based California Medicaid Research Institute, told Bazar.

Staff writer Rachel Cook of The Bakersfield Californian contributed to Emily Bazar’s report.

Gov. Brown is proposing California's counties relinquish some of their state health funding once the Affordable Care Act is in place. (Justin Sullivan/Getty Images)

We’re now 354 days from the rollout of the Affordable Care Act next Jan. 1. While the governor declared the state’s participation in the Medicaid expansion at his budget unveiling yesterday, he also proposed two ways to handle that expansion.

Under one scenario, the state will continue to administer the program. Under the other, each of California’s 58 counties will oversee running Medi-Cal, California’s version of Medicaid, for its own residents.

The Affordable Care Act dictates that the federal government will pay 100 percent of the cost for those people newly eligible for Medicaid, and in both proposals, the state’s position is that California counties will get some fiscal relief once those federal dollars start flowing.

But don’t get too excited, counties.

California Secretary of Health and Human Services Diana Dooley yesterday referred to a “conversation” around “appropriate sharing” that needs to happen between the state and its counties around financial responsibilities.

“Conversation” might prove to be a euphemism for what could become a vocal debate between the state and the counties. And maybe between counties themselves.

Alex Briscoe, Director of Alameda County’s Health Care Services Agency, told me this morning that “sharing” presumes that current state funding is sufficient to meet the needs of the indigent poor, an idea he called “simply preposterous.”

“There’s an assumption we’ve been fully funded,” he said. “That is simply not accurate.”

Counties bear the responsibility for caring for poor uninsured adults, and Alameda is one of 55 California counties that has moved forward with implementing a Low Income Health Plan (LIHP), a bridge to the 2014 Medi-Cal expansion. About a half-million Californians are currently enrolled.

Bill Walker, Contra Costa County’s Health Director, says he would support having county-level responsibility for overseeing the Medi-Cal expansion. “The devil is alwyas in the details win terms of agreements between the state and the county,” he told KQED’s Mina Kim yesterday. “And obviously at the end of the day, the question is what are the rates, what is the cost sharing, and how do the dollars flow?”

But whether the state or counties handle the Medi-Cal expansion, there will still be at least two million people who lack insurance, as Sarah Varney explained at Kaiser Health News:

Those residents, many of whom are undocumented and barred from buying their own insurance coverage through “Covered California,” the state’s online marketplace, and are ineligible for any public insurance programs, will continue to rely on county-run facilities and safety-net clinics.

If the state drains the counties of health care funding, says Anthony Wright, executive director of Health Access, an advocacy group, “You run the risk of losing public hospitals and clinics at exactly the moment we need all the capacity we can get.”

Later this month, the governor is expected to call for a special legislative session on health care issues.

HHS Secretary Kathleen Sebelius, shown here speaking at a conference in Washington last week. (Chip Somodevilla/Getty Images)

The Obama Administration handed down a key rule Monday on its health care overhaul having to do with Medicaid, or Medi-Cal in California. States must expand to the federally mandated 138 percent of poverty in order to receive matching funds for those newly eligible for the program.

Because the Supreme Court ruling in June had struck down the requirement that states participate or lose existing match funds, some states thought there might be flexibility in the expansion. But the answer to that question is a clear “no” as Secretary of Health and Human Services Kathleen Sebelius explained in a letter to governors.

In a briefing last week, California’s Health and Human Services Secretary Diana Dooley indicated she was waiting for guidance from the feds about the Medicaid expansion and might not expand to the full 138 percent limit.

In an email, a spokesperson for the state’s department of health and human services said staff is currently evaluating the new information and declined to comment further at this time.

Consumer advocates said it was good to have the matter settled. “We thought that it was the case,” Anthony Wright, Executive Director of Health Access told me in a phone call, “but it’s good for the federal government to provide clarity and hopefully this allows the states to move forward with all deliberate speed.”

It’s expected that more than four million Californians will be newly eligible for Medi-Cal. Under the Affordable Care Act, the federal government will pay 100 percent of the cost of those new eligibles from 2014 to 2017. After that, the match will phase down to 90 percent by 2020.

By Emily Bazar, CHCF Center for Health Reporting

(Paul Goyette/Flickr)

I’ve spent many months reporting on dental care for poor California children, looking into what kind of access they have to treatment.

(About half of kids in the Medi-Cal dental program see a dentist annually, although figures vary wildly by county.)

But I haven’t focused as much on the dentists who participate in the program, called Denti-Cal.

A new report by health care consultant Barbara Aved does just that. Based on her research, Aved concludes that 25 percent of California’s general dentists participate in the program.

Why not more? Here are some of Aved’s primary conclusions, based in part on a survey of dentists in five counties that she says reflect California as a whole. Out of about 2,000 general and pediatric dentists invited to participate, 322 responded.

• Of dentists who do not participate, 97 percent cited the state’s low reimbursement rates as the No. 1 reason. California’s rates, Aved said, are among the lowest in the nation.

“Unlike physician practices, dental practices are in large part solo or two-person practices,” she said. “It’s really like a small business. Economically, it just doesn’t make sense to do business where you’re not going to be fully reimbursed.”

• Many dentists also blamed their non-participation on the bureaucratic requirements associated with enrolling and billing.

“Make the claim process simple and straightforward; quit denying claims for stupid, little reasons and obscure criteria,” wrote one dentist who responded to the survey.

“I would rather treat some people for nothing than jump through all the hoops Denti-Cal makes you go through,” wrote another.

• Some dentists complained about patients breaking appointments and other compliance issues.

Aved’s study, which also analyzed 2011 Denti-Cal claims data, was commissioned by dental plans LIBERTY Dental and HealthNet.

The Department of Health Care Services (DHCS), which administers Denti-Cal, has a very different take on the percentage of California dentists who participate: Two thirds of dentists, or 66 percent.

“What we’ve done with our numbers is take a look at verifiable data, data that was collected and that represents the actual figures that are kept by the state of California,” said spokesman Norman Williams. “It wasn’t a survey. … It’s actual data and that’s what we base our numbers on.”

But Aved pointed to a California HealthCare Foundation report on Denti-Cal from 2010 that also concluded that 25 percent of California dentists accept Medi-Cal patients.

Williams said current dentist participation in Denti-Cal already “ensures sufficient access,” but the department is taking several steps to boost participation. They include:

• Developing a survey for Denti-Cal beneficiaries to determine their satisfaction with the program;
• Offering a new customer service line to help children and their families locate participating dentists; and
• Reaching out to dentists to urge them to join the program or take more Denti-Cal patients.

The department is addressing complaints about bureaucratic obstacles by developing a webinar series, video tutorials and other materials for dentists to help them with enrollment and billing, Williams said.

But raising rates isn’t on the table.

“Because of our current economic situation, the state is not in a financial position to increase Medi-Cal payments to dentists,” Williams said.

Gayle Mathe, director of policy development for the California Dental Association, applauded the department for its recent moves to boost dentist ranks in the program. In many cases, she said, her association is partnering on these initiatives.

“We’re starting to see movement and changes in a positive direction,” she said. “And the department is really engaged in doing that.”

But the association questions the department’s conclusion that two-thirds of dentists participate Denti-Cal, saying that Aved’s figure is closer.

“We don’t have access to data, but the 25 percent is consistent with what we’ve heard anecdotally over the years,” Mathe said.

Aved said she’s concerned that not enough dentists participate as it is and worries that Denti-Cal isn’t prepared for the hundreds of thousands of new children coming into the program in the next few years. This will be primarily as a result of the transition of children from the publicly-funded Healthy Families program into Medi-Cal and the expansion of Medi-Cal under the Affordable Care Act.

“If it’s this way now, we should be worried about the future for sure,” she said.

(seliaymiwell/flickr)

More than 200 people filled a Sacramento hotel meeting room yesterday to celebrate the 25th anniversary of Health Access, the consumer health advocacy group. But it wasn’t all party — the event featured a four-hour symposium with speakers including Diana Dooley, secretary of the state Health and Human Services agency; key legislators who chair health committees; and long time health advocates.

And everyone was focused on one thing: implementation of the Affordable Care Act.

After joking that “I quake in my boots” over the amount of work that needs to be done between now and January 1, 2014, Secretary Dooley sounded a distinctly cautionary note of what to expect as the rollout of Obamacare progresses in California. “It’s going to take years to make this work,” she told the crowd. “There are going to be fits and starts, speed bumps that we’ll have to get over.”

She talked about her concerns around affordability and capacity. Then she reminded the crowd of the wait for more information from the feds. For example, the Affordable Care Act promises to fund 100 percent of those newly eligible for Medicaid. But in an acknowledgement to the “fiscal cliff” discussions in Washington, she said it’s unclear if some of that money may be pulled back.

“We’re not going to extend benchmark coverage beyond what is sustainable,” Dooley said, “because we cannot take it back. … I don’t want to be on the hook for promising things we can’t deliver.” She added that she wants to build on a stable foundation and maintain California’s position as the “lead car” among states implementing the ACA, but added, “I want to be honest with our partners about where the challenges are.”

With that, she had to leave, and three legislators took the podium with a decidedly different view of how the ACA should progress. Assemblymember Holly Mitchell argued that she felt it was a time to be “bold … You heard from the representative of the administration who has a much narrower view than I see,” she said. “We have another branch of government … clearly we have work to do to create policy and create legislation that can get a signature out of the governor.”

Ed Hernandez, chair of the Senate Health Committee, pointed specifically to bills he plans to introduce during the special legislative session expected to begin in early January. The Medicaid expansion bill is among them, he explained, saying the state should “draw down every federal dollar we can.” Assemblymember Richard Pan, who chairs the Assembly Health Committee, echoed a desire to get “as close as we can to universal coverage.”

Just before taking the podium for the last panel of the day, Ellen Wu, Executive Director of the California Pan-Ethnic Health Network, expressed a level of frustration with Dooley’s remarks, especially Dooley’s concerns about the cost of Medicaid expansion — and an apparent suggestion that California might not implement the expansion as fully as advocates would like. “We helped with Prop 30,” she said, referring to health advocates’ work on behalf of the passage of the governor’s education proposition. Communities of color “are 60 percent of California … and now we’re going to turn down federal dollars? It doesn’t make sense.” She said people of color feel they’re “getting the short end of the stick, always getting left behind.”

In that last panel of the day, Health Access Executive Director Anthony Wright pointed to the “10 short months we have until October, 2013″ when the new exchange will begin selling insurance. “The final obstacle is the clock. That should not curtail our ambition.”