Chinese American Medi-Cal patients find difficulties in accessing care

Is there a parallel between health insurance and health care access? With the wave of universal healthcare, 8 million people have signed up for health plans nationwide, including more than 3 million in California. Nearly 2 million of these have enrolled in Medi-Cal, California's version of the federal Medicaid program, commonly referred to as the “white card” in Chinese American communities. However, are these figures truly reflecting the outcome of the universal health care? Is the health care door really open to these two million “white card” holders?

The data provided by Covered California showed that, as of March 31 this year, there were 1.93 million people enrolled in the Medi-Cal program, nearly 1.4 million of which are new enrollees benefiting from the expansion of the federal Medicaid program. However, according to the data from California Department of Health Care Services (DHCS), the number of doctors in California that accept Medi-Cal patents did not increase correspondingly. Instead, it decreased from 109,000 in 2013 to 82,600 in 2014. 

The statistics from California HealthCare Foundation also show that only 57 percent of family practice physicians accept new Medi-Cal patients, while 76 percent of them are willing to accept new patients on private health care plans. Does the proportional imbalance between patients and physicians lead to difficulty accessing health care and result in poor quality care and other problems for Medi-Cal patients? 

To make matters worse, Gov. Jerry Brown signed a new budget on June 15 that, in spite of providing additional funding for new Medi-Cal enrollees, maintained a 10 percent cut in Medi-Cal reimbursement rates, which means doctors will continue to receive less for treating Medi-Cal patients. Even before the announcement of the latest budget, California's Medicaid reimbursement rates were already among the lowest in the nation.

Doctors reject Medi-Cal patients due to low rates

Lawrence Cheung, president of the San Francisco Medical Society, believed that the Affordable Care Act was a wise policy that has helped many people previously unable to afford health insurance get covered. 

However, the imbalance between the numbers of insured and available doctors has increased the workload of some doctors while also creating access problems for patients. And the state’s low Medi-Cal reimbursement rates discourage doctors from accepting such patients due to cost considerations.

Where can Medi-Cal patients go to see a doctor? While many new patients can get covered through the ACA, what happens if there is no doctor willing to accept them?

Dr. Cheung is a dermatologist. His clinic now accepts patients who bought insurance through the state health exchange Covered California, but not Medi-Cal patients. He saw many doctors rejecting Medi-Cal patients because the compensation does not cover the expenses.

Take his clinic as an example. Since the implementation of the ACA, the workload has increased by approximately 20 percent, and patient wait times have also increased from one month to six weeks in average. He believed wait times are an important criterion to measure the quality of health care.

Cheung explained that he needs to consider operation costs, such as rent and payroll expenses for nurses and staff in the clinic. He said that reimbursement for a Medi-Cal patient is only 70 percent of private insurance, which forces doctors to shorten examination times to compensate for the lower reimbursement rates, which means seeing more patients in a shorted period of time.

Cheung had to assign nurses or assistants to handle some of the cases due to the increased patient volumes. For example, when one of his patients had a problem after an appointment and couldn’t see him soon enough, Cheung would ask the patient to call a nurse or assistant directly to discuss the problem, saving time. 

Doctors selecting patients

Dr. Edward Ko, a family practice physician in Chinatown, acknowledged that he had to filter through and select Medi-Cal patients due to the increased number of patients. For example, he may no longer accept Medi-Cal patients with complicated health conditions.

Ko believes it’s inevitable doctors will choose patients in the future. The best doctors would only accept the patients with private insurance, allowing them to receive more reimbursement. Medi-Cal patients are inevitably situated at the bottom of this “food chain.”

Ko also said that due to the low reimbursement of the Medi-Cal program, patients are often rejected when referred to a specialist.

According to the Department of Health Care Services, there are only 43,760 specialists who signed up to accept Medi-Cal patients in 2014, which is only 37.5 percent of all registered specialists.

State denies health care access challenges

Dr. Cheung believed that it is not enough for universal health care to just provide affordable insurance – it’s also necessary that people with insurance can access a doctor when they are sick.

When asked about the decrease in the number of doctors accepting Medi-Cal patients, DHCS’s spokesperson Anthony Cava said that the big gap was largely caused by the ongoing process of figuring out which doctors will accept these patients.

Cava also denied that Medi-Cal patients have difficulty gaining access to health care. He said that the department has been authorized to take action if it is discovered that Medi-Cal patients have difficulty accessing providers. 

The asymmetry between the number of patients and the number of doctors is one reason patients are encountering difficulty accessing health care. However, the president of the San Francisco Health Commission, Ed Chow, said that universal health care is a long-term goal, and the Affordable Care Act has logged initial successes. 

Chow believes that issues such as a longer waiting times for a doctor appointment, the increase of doctors’ workloads, and the imbalance between the number of patients and the number of doctors are problems that have always existed but became more pronounced after the implementation of the ACA. He said that health care reform still has a long way to go. In implementing reform, the first step is for patients to obtain health insurance, and the next step is to make health insurance more affordable and improve health care quality.

Hospitals brace for challenge

Dr. Scott Huang, director of family practice at Excelsior Health Service in San Francisco, pointed out that community clinics treat a large number of Medi-Cal patients daily. As Medi-Cal patients do not need to pay or only pay small deductibles, some patients use care more intensively, resulting in an uneven distribution of limited resources.

For example, under normal circumstances, it takes a few days to recover from viral influenza, and patients do not need to return to the hospital for follow-ups every day. But some Medi-Cal patients make repeated appointments, which results in a waste of resources, causes other patients’ longer wait times, and reduces the efficiency of the health care system. He said that some Medi-Cal patients even make an appointment to see a doctor to get free condoms.

Since the implementation of Affordable Care Act, San Francisco Chinese Hospital, in the heart of Chinatown, had accepted 15 percent more Medi-Cal patients, according to Brenda Yee, CEO of the hospital. Despite the increase in patient volume, there is no problem with scheduling and operations at the hospital, she said, mainly because the hospital has a number of medical centers throughout the city, and therefore the workload is shared to a certain degree.

Chinese Hospital’s outpatient and innovation director, Jian Zhang, also observed that while the number of Medi-Cal patients did increase, the hospital was well prepared for that by increasing the number of doctors in three medical centers to ensure that the number of patients a doctor saw per day remained at 20 to 24, and the average examination time averaging 15 to 45, minutes depending on the patient's condition. Zhang said that the number of specialists who accepted Medi-Cal patients was indeed fewer than compared with private insurance, but that public hospitals such as San Francisco General Hospital and UCSF still accept Medi-Cal patients, albeit with slightly longer wait times. 

Zhang found that it is common for many new Medi-Cal enrollees to have high blood pressure or high cholesterol or other health issues due to a lack of health care access over a long period of time. In addition, many Medi-Cal patients do not understand why doctors ask them things such as regularly take medication, control their diet, and increase their exercise. In many cases, Zhang says doctors need to patiently explain and educate these Medi-Cal patients, which inevitably increases the workload of doctors.

Weiquing Yan, a 13-year-old Medi-Cal patient, came to a medical clinic in Daly City with his mother because of a finger infection. His mother, Hsiuqing Lin, said that they were happy to see that federal health care reform has enabled a lot of families who previously could not afford health insurance to see doctors. She did not feel that the imbalance between the numbers of patients and doctors had caused difficulty in gaining access to medical treatment. Lin explained that she and her family did not see doctors unless they felt sick. However, some of her friends have told her that it was rather troublesome to make an appointment to see a specialist due to the longer wait times.

This article was originally published in Sing Tao Daily USA, the most widely known and largest circulation Chinese newspaper in the Bay Area.