California’s Massive Medicaid Program Works for Some, but Fails Many Others

Newborns. Former inmates. School college students. Expectant mothers. Folks with disabilities. Foster youngsters. Homeless folks. Single dads.

Your neighbor. Your co-worker.

You.

California’s Medicaid program, known as Medi-Cal, serves a whopping 15.4 million folks, providing care from cradle to grave: Half of all births are coated by Medi-Cal, as are greater than half of all stays in nursing houses.

Every little thing about Medi-Cal is huge, from its upcoming fiscal yr price range of $139 billion to the expansive listing of advantages and providers it gives. The best way this system works — or doesn’t — may spell life or loss of life for a lot of enrollees.

“It’s crucial, from the only pregnant mother, to the extraordinarily frail aged inhabitants that wants a nursing dwelling,” mentioned Jennifer Kent, former director of the state Division of Well being Care Providers, which administers Medi-Cal. “If it weren’t for Medi-Cal, so many individuals would both be useless or can be severely compromised.”

In a brand new sequence, California Healthline will make clear Medi-Cal’s successes and failures by way of the experiences of its enrollees. They embody Stephanie Lammers, who can’t get her troubling belly signs checked at a clinic 50 miles from her small Calaveras County city as a result of the transportation Medi-Cal is meant to supply isn’t reliable; Carolina Morga Tapia, a Fresno girl who credit Medi-Cal with serving to her have 5 wholesome youngsters; and Lucas Moreno Ramirez, a Los Angeles County man with stage 4 lung most cancers who needed to struggle to maintain his therapy going.

Medi-Cal is at a crucial juncture because it makes an attempt to serve the wants of a various affected person inhabitants with a dizzying array of medical wants — from childhood vaccinations and most cancers screenings to state-of-the-art take care of uncommon genetic issues. Roughly half of enrollees are Hispanic, and, subsequent yr, California will turn out to be the primary state to increase eligibility to all immigrants who qualify, no matter their authorized standing.

Medi-Cal can also be enterprise a number of new initiatives that purpose to save lots of taxpayer cash and enhance high quality. State officers are demanding that the 23 well being insurers that serve most Medi-Cal sufferers present higher care — or face important penalties, together with potential expulsion from this system.

The state can also be including modern social providers that fall outdoors the standard realm of drugs, together with serving to some enrollees pay for hire and purchase groceries.

“Persons are watching California,” mentioned Cindy Mann, who served as federal Medicaid director below former President Barack Obama. “What the state is doing is formidable and really aggressive. It makes a big mark on well being care and well being coverage, not simply due to the dimensions and breadth of its program, however by being very complete.”

However solely a sliver of enrollees will get the brand new social providers, at the same time as many sufferers battle to acquire primary care or get in to see their medical doctors. In actuality, the kind of care you get in Medi-Cal is determined by the place you reside and which insurer supplies your advantages.

Meaning this system is working for some, however failing for a lot of others.

In case you are in Medi-Cal, we wish to hear from you, whether or not you reside in an enormous metropolis or a rural area, no matter your age, race, or ethnicity, and no matter your medical, dental, or psychological well being situation. Have you ever had issue seeing the suitable physician for what ails you, even to the purpose of placing your life in danger? Or did Medi-Cal present excellent care, maybe sparing you severe hurt or incapacity? Both means, please think about sharing your expertise with us.

Listed below are snapshots of sufferers who’ve used this system at a crucial time of their life.

‘I Simply Don’t Go to the Physician Anymore’

When Stephanie Lammers leans over to placed on her sneakers, it feels as if she’s squishing one thing inside her stomach, she mentioned.

Lammers, 53, has been affected by frequent bouts of nausea, ache, and bloating for six months.

Her gastroenterologist needs to carry out diagnostic procedures, together with a colonoscopy and, if something reveals up, a biopsy. However Lammers, who lives in a motel together with her boyfriend and teenage daughter within the Gold Rush city of San Andreas, doesn’t have a working automobile and may’t readily get to the clinic — which is 50 miles away.

For Lammers, like many Medi-Cal enrollees who reside in rural areas, lack of transportation is a serious obstacle to acquiring care. The issue is especially acute for sufferers who must see specialists.

Lammers’ dermatologist and eye physician are over an hour away from San Andreas, the county seat of Calaveras County, about 125 miles northeast of San Francisco. She isn’t seeing a neurologist, regardless of a sequence of mini-strokes and stress-related seizures. And he or she hasn’t been to a podiatrist in two years, though her toes are twisted over each other and hold down, inflicting her to journey. She’s typically in excruciating ache when she walks.

Medi-Cal is meant to supply free transportation to enrollees who can’t in any other case get to their appointments.

However Lammers, whose well being plan is California Well being & Wellness, owned by Centene, the nation’s largest industrial Medicaid insurer, stopped utilizing its trip service almost a yr in the past, after she missed dozens of appointments as a result of drivers simply didn’t present up, she mentioned. She was getting threatening letters from medical doctors’ workplaces over the no-shows.

As soon as she needed to hitchhike greater than 30 miles dwelling from a counseling appointment. On different events, Lammers mentioned, she didn’t obtain the reimbursement she was owed for arranging her personal rides.

“I simply don’t go to the physician anymore,” Lammers mentioned. “If I am going to the physician, my boyfriend has to take the time without work work, and if he takes the time without work work, we now have no cash.”

Over the last three months of 2022, Lammers canceled 5 appointments she had scheduled for the diagnostic belly procedures as a result of her boyfriend needed to work every time and couldn’t take her. She lastly stopped rescheduling.

California Well being & Wellness contracts with Modivcare, a Denver-based medical transportation firm that’s no stranger to affected person complaints and lawsuits.

Earlier than she gave up on the trip service, Lammers mentioned, she would name California Well being & Wellness to attempt to resolve the difficulty, solely to be instructed that Modivcare was a separate firm. “I’m like, ‘In case you guys employed them and put them accountable for transportation, who oversees their screw-ups?’”

Courtney Schwyzer, a member of a authorized assist workforce representing Lammers on varied Medi-Cal issues, mentioned the failure of medical trip providers is a systemic downside. In late February, Schwyzer and her fellow attorneys filed a petition in courtroom that she hopes will pressure the state Division of Well being Care Providers to handle the issue.

California Well being & Wellness spokesperson Darrel Ng mentioned the corporate displays the standard of its contractors, however a scarcity of transportation suppliers in rural areas “has created distinctive challenges.”

Modivcare supplies greater than 4 million rides for Medi-Cal recipients yearly, and greater than 99% are with out criticism, mentioned Melody Lai, an organization spokesperson.

Lammers, who’s unemployed and attempting to begin a customized craft enterprise known as Stuff by Steph, mentioned medical doctors have warned her that if she doesn’t scale back her stress degree, it may shorten her life. However arranging medical care is probably the most annoying factor in her life proper now, so she doesn’t strive anymore.

“With a purpose to hold from dying, I’ve to not go to the physician,” she mentioned.

‘It’s a Blessing’

Medi-Cal helped save the lifetime of Carolina Morga Tapia, a 30-year-old, full-time mom of 5 who lives together with her household amid almond groves in an agricultural enclave of Fresno.

9 years in the past, a bacterial an infection triggered untimely labor in the course of the twenty fifth week of her second being pregnant, and Morga Tapia virtually died. She spiked a fever, bled profusely, and wanted speedy transfusions and emergency surgical procedure. After a number of days in crucial care, she totally recovered.

However the medical doctors couldn’t cease the untimely delivery, and her child got here out weighing simply 1 pound. She and her husband, David Nuñez, named her Milagros Guadalupe, and she or he died 4 days later, on Sept. 13, 2013 — a Friday.

In every of her subsequent pregnancies, Medi-Cal paid for Morga Tapia to get pictures of artificial progesterone, meant to forestall one other preterm delivery. These pictures — one every week for about 20 weeks — can price a mean of greater than $10,000 per being pregnant.

Morga Tapia and Nuñez, a development employee, signed up for Medi-Cal when she was pregnant together with her first baby greater than a decade in the past. They’ve been on the identical Anthem Blue Cross Medi-Cal plan ever since.

“It saves some huge cash, and it’s a blessing to have that further assist.”

Morga Tapia

The plan paid for prenatal care by way of all six of Morga Tapia’s pregnancies, and it has supplied all of the medical and dental care the household wants, she mentioned.

“With out Medi-Cal, we must be paying for all of our kids,” mentioned Morga Tapia. “It saves some huge cash, and it’s a blessing to have that further assist.”

Her youngsters, 4 ladies and a boy, vary in age from 1 to 10. All of them go to the identical youngsters’s clinic and see the identical pediatrician.

The youngsters, all in good well being, get routine checkups, vaccinations, and different preventive care, Morga Tapia mentioned. She will get appointment reminders by way of textual content and playing cards within the mail notifying her when it’s time for the children’ vaccinations and wellness checks, in addition to her Pap smears, she mentioned.

Her household’s expertise contrasts sharply with the state’s evaluation of their well being plan, based on a report on high quality of care in Medi-Cal issued late final yr. The report, which evaluated Medi-Cal well being plans on pediatric care, ladies’s well being, and power illness administration, put Anthem Blue Cross within the lowest tier, and beneath par on a number of measures in quite a few counties, together with Fresno.

One other state report, launched in late January, detailed how rapidly insurers present appointments for his or her sufferers, and put Anthem Blue Cross’ Medi-Cal plan close to the underside of the heap.

Anthem Blue Cross spokesperson Michael Bowman mentioned in a press release that the interval coated within the experiences coincided with the covid-19 pandemic, “when our security internet suppliers handled important challenges with workforce and appointment availability.”

Morga Tapia doesn’t give the insurer low marks. “It’s totally different for everyone. I’ve an excellent wholesome household, and what Medi-Cal covers is actually lucky for us,” she mentioned.

‘I Don’t Wish to Die But’

In late 2021, medical doctors gave Lucas Moreno Ramirez a number of months to reside.

Scuffling with diabetes and late-stage lung most cancers, Moreno Ramirez suffered debilitating ache as he hacked and labored for breath. His medical doctors really useful that he cease therapy and begin hospice care.

He felt as in the event that they had been giving up on him.

“They mentioned they’re going to present me opioids for my ache and assist me have a snug loss of life,” mentioned Moreno Ramirez, 68, who lives in Norwalk, in Los Angeles County. “I instructed them I don’t imagine in that. I don’t wish to die but.”

A former landscaper and manufacturing unit employee, Moreno Ramirez realized he needed to be his personal advocate, combating for the care he believed he deserved from Medi-Cal.

He mentioned his Christian religion gave him power, and over the following few months, Moreno Ramirez pushed this system and his medical doctors to maintain battling his most cancers, utilizing a distinct therapy with fewer uncomfortable side effects than chemotherapy.

“I imagine in prayer,” he mentioned. “However I imagine in science and medicine, too.”

Moreno Ramirez is without doubt one of the roughly 1.6 million Californians enrolled in each Medicare, which covers people who find themselves 65 and older or have disabilities, and Medi-Cal, which kicks in to cowl the prices and advantages that Medicare doesn’t.

He additionally depends on his Medi-Cal insurer to assist him navigate the byzantine system. L.A. Care, the most important Medi-Cal plan with almost 2.6 million members, related him with a care supervisor who labored with him to determine a distinct therapy known as Tagrisso and advocated for him to get it. 

Even with the brand new remedy, Moreno Ramirez’s coughing suits returned final yr, and his signs grew so painful he suspected the most cancers was rising. He requested to see his pulmonologist however was instructed the primary appointment can be in June 2023. So he switched medical doctors and scored an appointment almost six months sooner.

“My previous physician didn’t assist me. I didn’t belief him,” Moreno Ramirez mentioned. “He was all the time too busy for me. I instructed my medical doctors, ‘Give me an opportunity.’”

Having taken his care into his personal arms, he says he’s not in ache, his cough has subsided, and he feels eager for the long run. “Now I really feel good,” he mentioned.

He has additionally sought extra consideration for his diabetes and obtained a steady glucose monitor to measure his blood sugar. It’s higher managed now than it has been in many years, he mentioned.

“It’s important to arise for your self and advocate,” mentioned Joann Pacelo, the care supervisor who helped Moreno Ramirez change medical doctors, get faster referrals to specialists, and get accepted for in-home nursing visits.

“Lots of instances it’s troublesome with Medi-Cal as a result of the medical doctors are busy and the reimbursements are so low, however nobody must be denied the care they deserve.”

This story was produced by KHN, which publishes California Healthline, an editorially unbiased service of the California Well being Care Basis.