[Noozhawk's note: This article is part of a Noozhawk special project for The California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communcation & Journalism. On Saturday, Day 7.]
Thousands of local patients in Santa Barbara County will be newly eligible for health insurance once the Patient Protection and Affordable Care Act is implemented in January, and health-care providers are bracing for increased demand.
The rush of new patients likely won’t be met with many more primary-care physicians, however, even though the model pushed by the new law depends on preventive care.
Wait times for primary-care appointments can be weeks or even months now, so it’s not just the uninsured who head to the emergency room.
Even people with a local doctor will go to the ER when they get sick since they can’t usually get a last-minute appointment anywhere, said Dr. Brett Wilson, an emergency physician at Santa Barbara Cottage Hospital.
“There’s still kind of a finite amount of doctors," he said. "It's not like a new surge of doctors are coming out into the population and there are empty schedules to fill."
It’s difficult to recruit primary-care doctors, even in such a desirable location as Santa Barbara, said Kurt Ransohoff, CEO of Sansum Clinic. Sometimes they earn a quarter of what a specialist would, he said.
“It’s a combination of lifestyle and compensation, and the debt as medical school has gotten more and more expensive,” he told Noozhawk. “If you graduate with $250,000 of loans on top of your college loans, the choice of your career is driven oftentimes by the ability to pay off your loans.”
The 23 Sansum Clinic locations cover primary and specialty care in southern Santa Barbara County and accept Medi-Cal patients in addition to commercial insurance.
They do care for a smaller portion of Medi-Cal patients than the county’s Public Health Department clinics, the Santa Barbara Neighborhood Clinics and the local emergency rooms, but are preparing for the expansion of coverage.
“We’re planning on increasing our primary-care base because we think there’s a need, but they’re modest increases, not a revolutionary type of increase in levels of staffing,” Ransohoff said. "It will probably be a couple of primary-care doctors."
New eligibility rules mean that Santa Barbara County expects 25,000 more people to become eligible for the program on Jan. 1.
Public Health Department officials expect at least 6,000 to convert to Medi-Cal in the first year, which will put a lot of demand on local health-care facilities when more people get insurance.
“It does make you wonder who’s going to be taking care of all these patients, doesn’t it?” Ransohoff said.
If people have insurance for the first time in 10 years, or ever, they could require a huge amount of care and referrals, which will severely tax the health-care system until it stabilizes, said Dr. Takashi Wada, director of the county Public Health Department.
Patients of the county often need more complex care, as well, with five to 10 different health issues because of the effects of poverty and stressors associated with that.
“Down the road, I think it will be a lot better, but that first year is going to be a huge challenge for the whole system,” Wada said.
The Medi-Cal program will be available to all legal residents who earn at or below 138 percent of the federal poverty level, which amounts to $15,000 for an individual and $32,000 for a family of four.
That’s a change from only being offered to people with disabilities, mothers with young children, and low-income families with children.
At least 80 percent of the county-sponsored Medically Indigent Adult program participants will be eligible for Medi-Cal, according to the Public Health Department.
CenCal Health, the Medi-Cal administrator for Santa Barbara and San Luis Obispo counties, is preparing for 30,000 more people to become eligible over the 18-month period starting Jan. 1.
That will expand the existing program by 30 percent, CenCal CEO Bob Freeman said.
Freeman is confident that the county can deal with the increase since so many of the patients covered under the Medi-Cal expansion are already being seen by local doctors.
“According to our analysis, about 80 percent of these newly Medi-Cal-eligible individuals currently are receiving care from safety-net clinics, as either private-pay or no-pay patients,” he said.
As of now, 25 percent to 35 percent of Public Health clinic patients have no insurance, and that population includes a lot of working poor people who don’t get any coverage from their employers.
The county has seen a wider range of people come in as uninsured patients since the recession hit.
“It’s largely because so many working folks were losing their jobs in 2007, 2008 and 2009, and couldn’t afford to go on COBRA or had a total discomfort of going through that process,” said Elizabeth Snyder, deputy director of primary care for the Public Health Department.
“It’s a totally different face of who we would usually serve," she said. "Many of them still aren’t insured; they’re maybe in their mid- to late 50s, and stay with us much longer.”
There are also people who can’t afford private insurance but don’t qualify for Medi-Cal.
Young, healthy people who are no longer eligible for their parents’ insurance after age 26 often decide against buying their own plan. People in the medical world call them “young invincibles.”
Take Alisa Cullen, for example. A 35-year-old Santa Barbara woman, she showed up at the Santa Barbara Cottage Hospital emergency room with a bloody nose related to her anemia.
She had nicked herself shaving, and noticed it wasn’t clotting quickly enough, but that day’s never-ending bloody nose let her know her blood was thinner than usual.
“So I knew I couldn’t ignore it anymore,” she said.
Wilson, her attending physician in the emergency room, asked her why she didn’t have a doctor or clinic in town, or any form of insurance.
“I have never needed to go to the doctor often enough to justify the expense of having insurance,” she said.
Wilson noted, “You’ll hear that answer a lot.”
At 35, Cullen is not “super young,” but not old enough to feel like it was an expense she could afford, she said.
“I don’t care, because I see everyone, but you young healthy people need (a plan for) something catastrophic,” Wilson said. “The only way you’ll end up here is if something big happens.”
Even though more of these people will become eligible for insurance on Jan. 1, the county clinics and other providers are worried about financially covering patients who can’t get insurance.
Public Health officials are especially concerned about the lack of coverage for undocumented people, who aren’t citizens or lawfully present immigrants.
They’re left out of the health-care changes altogether, and clinics and counties will not be paid for providing care (since undocumented people can’t get any kind of insurance) even though federally qualified health centers are mandated to provide that care.
“So my concern is, is it going to work the way it should with all the people uninsured going to get insurance?” asked Sue Andersen, chief financial officer for Marian Regional Medical Center in Santa Maria. "We’re not convinced of that yet.
“It’s not like there is a hidden bucket of money somebody gives us to cover those patients.”
Other stories in the Safety Net series: