This has been a tough year if you’re a California kid who needs medical care.


In February, President Obama expanded federal funding for the Healthy Families program, which provides health care to children whose parents earn too much money to qualify for Medi-Cal.  The increased support couldn’t have come at a better time, as it extended coverage to many children at a time when their parents were getting laid off and losing health insurance.  


But surprisingly, state lawmakers cut the program in July to help reduce California’s deficit, risking care for nearly 1 million kids served by the program. Thankfully, state legislators eventually came up with a solution – taxing managed care plans – to replace the cuts and keep eligible children enrolled.


Now, the access to health care for these kids is being threatened again.  Blue Cross of California, which contracts with the state to provide Healthy Families insurance, has slashed reimbursements in half , forcing doctors out of the program.  


What does this mean?  It means that in some rural areas, such as Humboldt County, thousands of children enrolled in Healthy Families can no longer see their regular doctor. So, families have to drive their children more than a half-hour to visit a doctor or they end up in the local emergency room, which are already stretched beyond capacity. And if this continues, we can expect pediatricians to close their doors and move away.


Unfortunately, this type of problem is all too familiar. For years, Medi-Cal recipients have endured similar obstacles. Low reimbursement rates mean only about one-third of the state’s physicians can afford to treat Medi-Cal patients.


Last week, the California Medical Association filed a complaint with the state Department of Managed Health Care asking for an investigation of Blue Cross. State law requires providers of the Healthy Families program to have physicians available within 15 miles or 30-minutes’ travel of recipients.


However, in or near Humboldt County’s three main towns, there are no primary care physicians who serve Healthy Families patients through Blue Cross. In letters to doctors in the area, Blue Cross claimed Healthy Families patients could see non-contracted physicians. But those doctors are not likely to accommodate new patients because Blue Cross’s reimbursements are shockingly low.
This is the result of new contracts Blue Cross required of its physicians beginning Sept. 1. Part of the new agreement included sharply reduced reimbursements – as much as 50 percent – for seeing Healthy Families patients. Those rates don’t cover costs, meaning that doctors have to pay out of pocket to see these patients, while Blue Cross prospers.


It might come as a surprise to learn our state does not set the reimbursement rates by Healthy Families. Rather, it pays the insurers based on how many Healthy Families’ contracts it has. In the case of Blue Cross, it appears the insurer is profiting at the peril of its own patients, who in turn have greater barriers to getting care. Taxpayers are not getting what we are paying for.


One of the facts of rural life is that patients have few choices. Blue Cross, for instance, dominates the Humboldt County market. It provides care to the 3,400 of the 3,579 children in the county enrolled in Healthy Families.


That makes it particularly important for the state to enforce the rules with insurers. But ensuring access is one of many areas in which the Department of Managed Health Care has failed its mandate.  


State law requires managed care plans, such as Blue Cross, to contract with a certain number of physicians to meet the need of its patients. The idea behind the law is to prevent exactly what is happening in Humboldt County; when there are only a few doctors to serve large numbers of patients, access to care is either delayed or denied.


State regulators have failed to hold managed care plans accountable to these network adequacy standards, and so the restricted access to care in Humboldt County is not unusual or isolated; it is increasingly common.


It is time for DMHC to step up and uphold the state’s access-to-care standards. Without them, there’s no reason to expect that poor children will get the health care they need – and the health care the state’s lawmakers have decided they deserve.


We know that Healthy Families saves the state money by making sure children can see doctors when they need to. This safeguards public health, prevents unnecessary and expensive visits to overcrowded emergency rooms and helps kids grow up healthy, happy and successful. And healthy, successful children have a better chance to grow up the productive citizens and taxpayers of tomorrow.