California is failing its low-income residents by declining to attract doctors who can treat people enrolled in its Medicaid program, according to a civil rights complaint filed with the federal government this week.
Medi-Cal, California’s Medicaid health program for low-income residents, provides free medical care for about 30 percent of the state’s population, including nearly 7.3 million Latinos. The Medi-Cal program covers U.S. citizens, residents, and even some undocumented immigrants who can meet eligibility requirements like income limits. An estimated 2.7 million immigrants live in California without status, which includes low-income children who could potentially qualify for the expanded, state-subsidized Medi-Cal coverage.
Under the Medicaid Act, Medi-Cal enrollees are entitled to the same health care available to other groups covered by other forms of health coverage. But the complaint alleges that Medi-Cal recipients don’t receive prompt medical assistance, forcing them to wait long periods of time to receive the medical care they need through the program.
Part of the issue stems from the fact that Medi-Cal offers low reimbursements to physicians and care providers, who in turn decline to treat enrollees because it doesn’t pay enough. California has the 48th lowest reimbursement rates of any Medicaid program in the nation, even though it has one of the highest concentration of enrollees.
If the Medi-Cal program itself “were considered one of the 50 states, it would be the fifth largest state,” Thomas A. Saenz, the president and general counsel of the Mexican American Legal Defense Fund, one of four groups that filed the complaint, said on a teleconference call on Tuesday. “It’s a massive issue.”
Reimbursement rates for medical specialties under Medi-Cal are lower than rates for the same care provided to Medicare beneficiaries and those with private insurance, which could pose a problem for people who have a regular source of primary care but need to be referred to other doctors for more complex procedures or diagnoses.
There are fewer specialty providers willing to take Medi-Cal’s low payments because they are often well below the costs of providing that care. “Physicians therefore have to cross-subsidize their Medi-Cal patients using payments from higher-income patients who pay out of their own pockets, or have employer-based insurance or unsubsidized private plans, resulting in most physicians having Medi-Cal enrollees as fewer than thirty percent of their patients,” according to the complaint.
That can result in people suffering prolonged bouts of pain, developing serious complications, or even ending up in emergency rooms. An August 2014 California HealthCare Foundation study found that there was an inadequate supply of physicians participating in Medi-Cal, or 35 to 49 primary care physicians per 100,000 enrollees, which is far fewer than the recommended 60 to 80 physicians per 100,000 people.
Saenz is concerned that the state is essentially “creating a two-tired health care system in California” — with one that includes people with private insurance, and another that includes patients who rely on Medi-Cal because they can’t afford private plans.
Analilia Jimenez Perea and her son Saul, who are two of the named complainants in this week’s action, fit into that second tier. Saul is a Medi-Cal patient who has cerebral palsy and is semi-paraplegic, but his mother is unable to get him the specialist care that he needs — namely a neurologist, an orthopedist, and an ophthalmologist. Jimenez Perea said that she gets rejected often when she tries to get an appointment for him at a special clinic because he’s on Medi-Cal.
“When he … has grand mal seizures, he falls down and it’s horrible,” Analilia said in a video statement. “I think as a mother I can never get used to this one. We have to call the ambulance because if they don’t get him the medicine he needs, he has more seizures every time. … With his new insurance, Medi-Cal, they don’t want to pay for his special care. And we can’t see the doctors he needs to see to control the seizures.”
“It would be wonderful if Analilia’s story was an outlier, but it’s far too routine,” Saenz said. “The general experience is one that’s been repeated millions and millions of times across the state.”