Tagged California Healthline

In Deep-Blue State, Millions in Reddish Heartland Are Counting On Medicaid

FRESNO, Calif. — In 2012, when Jerry Goodwin showed up at a clinic with intense pain and swelling in his legs, doctors called for an ambulance even though the hospital was across the street. That generated a $900 bill — just the beginning of a nearly three-year ordeal for Goodwin, who was uninsured.

Diagnosed with cellulitis and an irregular heartbeat, Goodwin managed to get his emergency care costs covered through the hospital but then faced month after month of bills for follow-up care and medications.

Finally, in 2015, he was able to sign up for Medicaid coverage, which was expanded under the Affordable Care Act to cover many single adults without children. “That was a big relief,” said Goodwin, 64.

Now Goodwin and people like him are worried all over again.

Under Republican efforts to repeal, replace or reform the health law, many people on Medicaid — the nation’s single-largest insurer, with 72 million beneficiaries — could see their coverage slashed. The biggest chunk of them — 13.5 million — live in California. The state predicted Wednesday it could lose $24 billion in federal funding annually by 2027 under the current GOP proposal.

Among the hardest hit regions would be the Central Valley, the state’s agricultural heartland, stretching hundreds of miles from Redding to Bakersfield. Toward the south, in Fresno County, about half the population of 985,000 relies on Medi-Cal, as California’s Medicaid program is known. In adjacent Tulare County, 55 percent of the more than 466,000 residents were enrolled in Medi-Cal as of January 2016.

Much has been said about the plight of conservative voters in the Midwest who rely on Medicaid, a program the Trump administration and congressional Republicans are determined to shrink. But despite its reputation as a deep-blue state, California also has several red — or reddish — counties in its interior with millions of low-income people who depend heavily on Medicaid. Many live in congressional districts represented by Republicans who want to scrap or change the Affordable Care Act, also known as Obamacare.

J. Luis Bautista, an internist at Bautista Medical Center in Fresno, examines farm worker Jose Gonzalez in February. Gonzalez says he is not ready to retire and needs his insurance to stay healthy. (Heidi de Marco/KHN)

The current Republican bill, the American Health Care Act, would cut Medicaid funding by 25 percent by 2026, covering 24 million fewer people than today, according to the Congressional Budget Office.

“These are remarkable estimates,” said John Capitman, the executive director at the Central Valley Health Policy Institute and a professor at California State University, Fresno, referring to the CBO projections. “The level of cuts are devastating, and for California and the Central Valley, this represents a huge loss.”

The bill faces opposition from the left and right and is undergoing last-minute changes in the run-up to a House floor vote Thursday. Despite several protests in the valley and around the state, at least half of Republican lawmakers in the state appear poised to support it; several others are noncommittal.

U.S. Rep. Devin Nunes, whose congressional district includes portions of Tulare and Fresno counties, likes the proposal, saying it will improve care for everyone, including current Medi-Cal participants.

“Medi-Cal is a broken healthcare system that’s been completely mismanaged by the State of California,” Nunes said in a recent statement.

Capitman said Medi-Cal is vital in the Central Valley because of its high poverty rate, uneven access to care and pockets with very poor health outcomes. Many of these communities also depend on the Prevention and Public Health Fund, which was established by the ACA to fight chronic diseases and also is in peril, he said.

The valley suffers high rates of diabetes, obesity and heart disease. The area has some of the country’s dirtiest air, triggering epidemic levels of asthma. Wage stagnation and high unemployment contribute to stress and poor mental health.

Some areas are far better off than others. Within 10 miles, Capitman said, you can find up to a 20-year difference in life expectancy. On average, life is much shorter for residents in Southwest Fresno, for instance, where heavy industry soils the air, homeless people camp on sidewalks, and fences cage in lots overgrown with grass and weeds.

Not far away, Petra Martinez, a former fieldworker, recently waited to see a doctor at a crowded downtown clinic. At 86, she receives coverage from both Medi-Cal and Medicare, the federal insurance program for the elderly. She needs medication for arthritis, epilepsy and diabetes, all of which is paid for her through her dual coverage.

[embedded content]

Though the proposed House bill seemingly would not shrink spending on people with dual coverage, she is wary of what lies down the road.

“I’d like to think that we [seniors] will be OK, that maybe we won’t be affected by whatever changes are coming, but who knows?” Martinez said. “I don’t want to have to ask my children for money to go to the doctor.”

Dr. J. Luis Bautista, an internist at the clinic, estimates he’s seen a 20 percent increase in patient visits since the rollout of the ACA in 2014. The majority of his patients are on Medi-Cal.

“These are the people who usually wait until they’re very sick to come,” Bautista said. “We’ve seen people with high blood pressure who come in when they already have eye problems and heart problems. … They waited too long.”

But since the ACA rolled out, he said, preventive visits seem to have increased.

Luis Bautista, an internist at Bautista Medical Center in Fresno, examines Kathy Macias, 53, while her mother, Connie Hernandez, 72, waits to be seen last month. Bautista says the majority of his patients are afraid of losing the health insurance they received under the Affordable Care Act. (Heidi de Marco/KHN)

Fifteen miles outside the city of Fresno is Sanger, a largely Latino town of 25,000 where almost a quarter of residents live in poverty, according to the U.S. Census.

Here a neighborhood of newer houses with commuter residents isn’t far from another that lacks sidewalks and is strewn with aging or abandoned businesses and chain stores.

On a recent day, a hairstylist was tending to a client in a downtown salon nestled among boutiques, cafes and other small businesses. The stylist said she and her two teenagers are on Medi-Cal — and so are most of the people she knows. A single mother, she said she works six days a week but can’t afford to buy health coverage.

The salon’s owner interjected that she doesn’t oppose greater restrictions on who gets Medi-Cal — but plans on the state’s insurance exchange should be more affordable, so people will be drawn to buying coverage.

The women asked that they and the business not be identified.

Less than an hour southeast of Fresno, Iliana Troncoza lives in the city of Tulare, part of a heavily agricultural county of the same name. The county has one of the lowest incomes per capita in California.

Troncoza, a 47-year-old homemaker who takes care of her ailing husband, gets her health care at Altura Centers for Health, which runs seven clinics in the city. The thought of Medi-Cal cutbacks fills her with anxiety. Both she and her daughter, a college freshman, rely on the program for coverage.

Iliana Troncoza, 47, of Tulare, said she had gone without health coverage for six years before qualifying for Medi-Cal under the expansion. Troncoza said that since qualifying for Medi-Cal, she has gone in for mammograms, ultrasounds and has been able to obtain medication for her depression and anxiety. “It’s horrible to think that our Medi-Cal depends on people who don’t understand our situation,” Troncoza said. (Heidi de Marco/KHN)

Troncoza had gone without coverage for six years before qualifying under the ACA expansion. She traveled to Jalisco, Mexico, to remove a breast cyst because couldn’t afford the procedure in the U.S. Now, in her city, she can receive mammograms and ultrasounds, and has been able to obtain medication for her depression and anxiety, she said.

“It’s horrible to think that our Medi-Cal depends on people who don’t understand our situation,” Troncoza said.

Graciela Soto, CEO of Altura clinic system, said 75 percent of its patients are on Medi-Cal and 9 percent of patients are uninsured, mostly because of their immigration status. It’s quite a difference from 2012, before the ACA was implemented, when 50 percent of patients were on Medi-Cal and 35 percent uninsured, she said.

“The Medicaid expansion was wonderful for our patients,” Soto said.

Through the ACA, Soto said, many young women were able to access free or affordable birth control. That’s important, she said, because Tulare County has among the highest teen pregnancy rates in the state.

The region has a large population of migrant farm workers, many of whom don’t qualify for Medi-Cal. But a substantial portion of Latinos do qualify, as do non-Hispanic whites like Goodwin.

Among whites, the need for mental health and substance abuse services is growing, research suggests. Drug overdoses, alcohol abuse and suicide have significantly contributed to rising death rates, according to a study out of the Center on Society and Health at Virginia Commonwealth University.

In Fresno County, for example, the rate at which middle-aged white adults are dying from accidental drug poisoning has tripled since 1990, according to the report.

Some residents have turned to activism in their efforts to preserve ACA coverage. In January, Greg Gomez, a councilman for the city of Farmersville in Tulare County, led a small-scale protest outside Nunes’ office in Visalia.

It wasn’t just about politics — it was personal. Three of Gomez’s children are covered by Medi-Cal.

“The monthly premium to get my whole family covered by my employer would be about $2,000,” said Gomez, a computer systems engineer for Tulare County and former president for the local chapter of the Service Employees International Union. “That is totally out of reach. That’s why we need Medi-Cal. And that’s the story of a lot of Tulare residents.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Insurance, Multimedia, Repeal And Replace Watch, The Health Law

GOP Bill’s Unheralded Changes In Rules Could Undermine Health Of Neediest

An under-the-radar provision in the Republican proposal to replace the Affordable Care Act would require the millions of Medicaid enrollees who signed up under the Obamacare expansion to renew their coverage every six months — twice as often as under current law.

That change would inevitably push many people out of coverage, at least temporarily, experts say, and help GOP leaders phase out Medicaid expansion — a key goal of the pending legislation.

“That’s designed to move people off those rolls as soon as possible,” said Ken Jacobs, chairman of the University of California, Berkeley, Center for Labor Research and Education.

The proposal to cut renewal time in half is among other changes that seem only procedural but could have a profound effect on Medicaid enrollees’ health, pocketbooks and ability to get — and keep — coverage.

Another proposal would eliminate the ability of new Medicaid enrollees to request retroactive coverage for up to three months before the month they apply, which they can do under the current law — assuming they were eligible during that previous period.

Use Our Content

Health care experts and advocates fear that could potentially saddle people on Medicaid with unaffordable medical bills, shortchange providers and raise costs throughout the health care system.

“These are changes to fundamental pieces of the Medicaid program,” said Cathy Senderling-McDonald, deputy executive director of the County Welfare Directors Association of California in Sacramento, which represents human services directors from the state’s 58 counties.

“They could result in people delaying their health care or having to pay out-of-pocket and not having any hope for reimbursement at all,” she said.

But Michael Cannon, director of Health Policy Studies at the libertarian Cato Institute, said some of these changes would prevent fraud and keep ineligible people from obtaining benefits, thus saving taxpayer money.

“It’s so hard to eliminate fraud in Medicaid, because someone always benefits from it,” he said. “They don’t want to give that up.”

The expansion of Medicaid — the federal-state health care program for people with low incomes, known as Medi-Cal in California — would be phased out under the Republicans’ plan starting in 2020.

The expansion, adopted by 31 states and the District of Columbia, added more than 11 million people to the rolls, including about 3.7 million in Medi-Cal. The federal government picks up a much higher proportion of the cost for this population than for traditional Medicaid enrollees.

In the GOP plan, people already covered under the expansion would continue to be funded by the federal government after Jan. 1, 2020, but if states opted to sign up new enrollees under the expansion criteria after that date, they wouldn’t receive the more generous federal funding for them.

And those who remained in the program after 2020 but later lost eligibility would not draw the more generous federal funding for expansion enrollees if they became eligible again and re-enrolled at a later date.

In California, the potential loss of federal dollars caused by the rollback of the expansion would be massive. The state Legislative Analyst’s Office estimated last month that the Golden State is slated to receive more than $17 billion from the federal government for the Medi-Cal expansion in 2017-18.

“We’re talking about a big shift in costs to the state of California and potentially a major loss in coverage,” said UC Berkeley’s Jacobs.

The GOP legislation, which is scheduled for a vote on the House floor on Thursday, would impose the new renewal requirement on expansion enrollees starting Oct. 1.

“They’re saying to states that do the expansion, ‘We’ll cover people who are continuously in the program, but we’ll make it really hard for people to be continuously in the program,’” Jacobs said.

Wolf Faulkins, a resident of Mariposa, Calif., who enrolled in Medi-Cal in 2014 as a result of the expansion, said the proposed rule change regarding renewal would add one more layer to Medi-Cal’s already considerable bureaucratic requirements, none of them logical or simple.

“If I were more of a senior citizen than I am now, I would be overwhelmed” by it, Faulkins, 61, said. “I would not be a happy camper.” But he would complete the extra paperwork, he added, because his Medi-Cal coverage keeps him alive: Among other things, he has a heart condition and high blood pressure as well as knee and hand ailments.

Senderling-McDonald said the new paperwork will lead some enrollees to drop out for two reasons: Either they’re no longer eligible, or they’re eligible but the new bureaucratic hurdle stops them.

Faulkins agreed. Even though he would jump through the necessary hoops to keep his coverage, some others probably wouldn’t, he guessed. “There are people who are just going to say, ‘It’s important, but it’s too overwhelming. There’s no one to advocate for me. There’s no one to help me figure this out, ” he said. “People are just going to get frustrated and say no.”

The new renewal time frame has a precedent in California, which adopted a semiannual reporting requirement in 2003 for some enrollees that lasted about a decade. Though it was less cumbersome than the regular annual renewals, it nonetheless resulted in people dropping from the rolls, Senderling-McDonald said.

But the Cato Institute’s Cannon believes six-month renewals are reasonable. “The savings from removing ineligible people would justify the paperwork involved,” he said.

The paperwork imposed by these changes could be the least of the headaches for Medicaid beneficiaries.

Retroactive benefits, for example, are extremely valuable for new Medicaid enrollees who face medical bills during a gap in coverage, and losing them could cause financial pain.

“If they have had health expenses, like having to pay for a prescription out-of-pocket or a doctor’s visit, or a woman goes into labor uninsured, they can say to the county, ‘I had medical bills. Can you see if I was eligible during that time?’” said Senderling-McDonald.

Pregnant women are among the most frequent beneficiaries because they often don’t know that they’re pregnant right away, she added.

The GOP bill would end this, and would allow coverage to begin only the month in which enrollees apply. This provision would affect all Medicaid applicants and, like the change in renewal time, would begin Oct. 1.

Some experts believe the proposed change would increase medical debt for consumers hit with massive bills, and for providers who ultimately won’t get paid for their services.

The three-month retroactive rule is “a big deal for hospitals as well as people, because it keeps them from being saddled with medical debt,” said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities in Washington, D.C.

Senderling-McDonald warned that as more consumers racked up medical debt, the cost of it would shift to other people. “If someone has to declare bankruptcy when they are hit with bills they can’t pay, everybody else takes the hit for it,” she said. “They’re going to raise insurance rates or costs of care for everybody. People who have coverage through employers or the private market could see their rates go up.”

Cannon agreed that providers will get hit with more unpaid bills, but said that this provision would save the federal government money. “States have taxing authority and can fund these benefits themselves if they want to,” he said. “If they don’t, that should tell us something — that they don’t value these benefits that much.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Cost and Quality, Health Industry, Insurance, Medicaid, Repeal And Replace Watch, The Health Law

Tags:

Many Californians Could Be Priced Out Of Exchange Coverage, Analysis Finds

The average 40 percent drop in subsidies proposed under the GOP health care bill would put coverage out of reach for many Californians on the state exchange, according to a preliminary analysis released Tuesday.

People living in pricey cities like San Francisco, as well as the elderly and those with low incomes, would be most seriously affected, the Covered California analysis shows. That’s because the Affordable Care Act takes into account income and location, whereas the Republican bill offers flat-rate tax credits based only on age (up to $75,000 in income for an individual).

The Covered California analysis provides some stark comparisons:

  • Under the ACA, also known as Obamacare, a 62-year-old living in San Francisco making $20,000 a year would pay $84 a month with a tax credit for silver plan coverage (the second-least-costly plan). Under the GOP plan, that person would pay $668.
  • A San Francisco family of four earning $41,000 a year would pay $346 more in premiums per month under the GOP plan for coverage similar to an Obamacare silver plan.
  • A 27-year-old making $30,000 a year in San Francisco would pay $9 per month less under the GOP plan than for Obamacare coverage. A 62-year-old would pay $460 more.

In Los Angeles, many people would pay less under the GOP plan vs. Obamacare, especially young people and families, according to the analysis. That’s because health care there is much less expensive. All beneficiaries making at least $50,000 a year would pay much less in premiums under the GOP plan, because it offers tax credits to more affluent people who don’t qualify for them under Obamacare.

Use Our Content

The analysis came a day after the Congressional Budget Office released a report saying that the GOP’s plan, the American Health Care Act, would cut government subsidies for older and low-income consumers and cause an estimated 24 million Americans to lose their coverage by 2026.

Covered California has approximately 1.5 million enrollees, who benefited from $4.2 billion in premium subsidies last year, said Peter V. Lee, Covered California’s executive director, at Tuesday’s monthly board meeting. Ninety percent of exchange enrollees receive subsidies to help them cover the costs of their premiums.

Covered California’s calculations show that in 2016 the average subsidy for an individual was worth $3,500. Meanwhile, households received an average of $5,300 per year in subsidies. Twelve percent of households got subsidies worth about $10,000.

“That [$10,000] wasn’t a gift, it wasn’t extra money,” Lee said in a media call Tuesday. “It was given to them because without it they would have not been able to afford coverage.”

Ignoring income and geography means poor people would be worse off, Lee said.

Since 2014, the ACA has helped lower California’s uninsured rate from almost 17 percent to 7.1 percent, through both Covered California and an expansion of Medi-Cal, the state’s Medicaid program.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Repeal And Replace Watch, The Health Law

Tags: , ,