The Medi-Cal mess: Will ’Obamacare' fix things?

About 160,000 people in the Sacramento area are uninsured, even though they could be signed up for the state’s low-income health-care 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 3 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 11 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 people 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 Phillips, 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, “where 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 they could receive 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.

“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, a birth certificate and other forms must be handed over to the county in order 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 Patient Protection and 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 percent 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.

In all, the Affordable Care Act will increase the number of Californians eligible for Medi-Cal by more than a million people statewide.

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 the county’s Health and Human Services Department. “We’re forecasting that 30 to 50 percent 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 that they can sign up.

Although county governments have substantial financial incentives 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.

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 Health Net and Molina Healthcare. 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,” 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.

Pan recently authored legislation that could improve some of Medi-Cal’s shortcomings and increase public transparency. 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 to improve health-care 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 health care 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.