Growing pains: A look at the ACA in California

Dan Weintraub, editor in chief of the California Health Report, sat down with Capitol Weekly’s Alvin Chen at Weatherstone to discuss California healthcare developments, including Medi-Cal expansion, technology and the health-wealth disparity. Dan, a veteran California political reporter, previously worked for the Sacramento Bee, the Los Angeles Times and the Orange County Register.

Alvin Chen: Good afternoon, Dan.  California’s healthcare is undergoing a significant expansion.  Can you talk about who is now newly eligible and what part of California are difficult areas for patients to access healthcare?

Daniel Weintraub: The more dramatic expansion has been the Medi-Cal program in California.  It increased the income threshold from 100 percent to 137 percent of the poverty level, and it made Medi-Cal open to single people without children.

Difficult areas are particularly in inner city areas, and especially rural areas. There are very few doctors and hospitals that are open to Medi-Cal patients in rural parts of California, so that’s a big problem, but even in the inner cities where there are more doctors that serve Medi-Cal patients there are so many people eligible that those doctors are being overwhelmed. So even though there are millions more people with a Medi-Cal card, they don’t have access to doctors.  We heard stories about people who called five, six, or 10 doctors’ offices and being told that they don’t take Medi-Cal or they are not taking new patients.

AC: How will technology shape the future of California’s healthcare?  For example, there has been talk about skyping with your doctors, emailing pictures of wounds to doctors, etc.

DW: Technology like that is probably not going to revolutionize healthcare, but there is hope that it can help to alleviate the shortage of providers.  For instance, in the rural areas if somebody can have a video conference with a doctor and have essentially a face to face conversation they may be able to avoid having to travel long distances to the doctor’s office.  There is also technology that is being implemented to digitize people’s health records, and there is a lot of debate about whether that is really going to help or not, particularly a lot of people are uncomfortable with their doctor being tied to a computer or laptop while they are having a conversation.

Dan Weintraub, California Health Report

AC: Could you elaborate on the technology for health records?

DW: There is a plan to digitize health records, so instead of having everything in a paper file, everyone’s health records would be in a computer storage. A lot of that has already been done, but there are plans and mandates to make all those health record systems be able to talk to each other. There are places like Kaiser that were doing this long before the federal and state government start mandating it, and they have found that it is helpful particular when you are seeing more than one doctor, or doctor and a specialist, and your doctors can just call up your medical record and see what other doctors have said and what medications you are taking.

That can be particularly helpful with older patients, who are on a lot of medications, who sometimes go from doctor to doctor, and can get prescribed multiple medications. This way the health care folks can see exactly what medications people were taking and adjust to that, so there is a lot of hope that that will improve the provisional care.

But there are downsides to it, particularily overwhelming doctors with all these information and somehow the need to collect it, while also trying to have face to face conversations with their patients.

AC: Have people voiced security concerns over the computer records?

DW: Sure, as anything we’ve seen, any data base that’s out there can be hacked, even the most secure databases that the US government maintains can be hacked, and there are a lot of people who are concerned that their health records will be compromised and their personal information compromised if somebody gets into the system.

AC: How does wealth disparity in California affect healthcare?  Will the Medi-Cal expansion remedy that problem?

DW: Disparity in wealth and income is probably the biggest issue in California and all across the country.  Research shows that where you live tells us more about how healthy you are going to be and how long you are going to live than any other factor.  It’s probably true somewhere around 80 percent of the factors that affect your health and how long you live have nothing to do with doctors, hospitals, and insurance companies but the conditions in which you live and work.

Factors that are upstream from doctor’s office include anything from the house you live, the neighborhood you live in, the working conditions if you do work, your ability to move around without an automobile, whether your community is walkable or bikeable, your nutrition, the sleep you get, and probably most important — your daily stress.

And we know that the stress that comes from unrelenting poverty has a huge effect on people’s health, and probably contributes to the onset of chronic diseases, like obesity diabetes, hypertension, heart disease, which together are somewhere around 40 to 50 percent of healthcare costs in California.  Those diseases are avoidable with better living conditions and healthier behavior which is more than just about people making choices. You have to put people in a position where they can make the best choices for their health, and when you are on the edge of survival everyday, you are just trying to figure where your next meal is coming from, where you are going to sleep, whether you have a house or not. Considerations about healthy eating, smoking or drinking kind of go on the backburner when your very survival is at stake everyday.

Healthcare is necessary but think of it like taking a car to a mechanic.  The mechanic can fix your car, but once you take the car back, and you don’t maintain it, change the oil, and do the things you should do on a daily basis to keep your car in good condition, you are just going to bring the car right back to the mechanic.  Doctors can’t keep you healthy, they can sometimes fix something, but they can’t keep you healthy- that’s something we need to do ourselves and in our communities.

So until we start to improve the conditions in which people live, and improve the economy, and lift people out of poverty, we are probably not going to see significant changes in health outcomes no matter what we do with the insurance system, or no matter how many doctors we train and deploy.

AC: A common complaint from doctors is that reimbursements are too low for them to keep taking in Medi-Cal patients.  Why are the reimbursements rates low and is there a solution?

DW: One reason they are low is because the government only has so much money and they are trying to spread it among a lot of different priorities, from education to public safety to social benefits and healthcare. And California historically has tried to keep a lid on payments through Medi-Cal.

There is not much that can be done to increase those payments other than having more money in the Treasury to spread around, but there is some hope that by changing some of the rules that govern medicine, we might be able to serve everyone with providers who don’t necessary need to have years and years of medical school and medical degrees. So position assistants, nurse practitioners, nurse midwives, and a lot of medical professionals who are not doctors could be serving more patients under a doctor’s supervision if laws and rules would be changed.

AC: What do you think will be the next biggest debate or issue in the California healthcare system?

DW: Well I think the funding for Medi-Cal is going to be fought over this summer very soon, as the governor left a big hole in the budget on that issue and wants the Legislature to pass some taxes that will put the funding on a stable path going forward.

I think there will be continual debate about the private side of the Affordable Care Act and whether the insurance offered through Covered California, the new healthcare marketplace, is adequate. A lot of people are grumbling about the high out of pocket costs that people have to pay in the program, the high deductibles, and the more limited selection of doctors than people were used to under their old insurance. I think those issues in California are going to continue to pop up assuming the program survivals the political winds of Washington.

AC: Is California’s health care sustainable in the long run?

DW: Medi-Cal is definitely more sustainable than Social Security or public employment retirement benefits, especially because we just had a huge increase in patients in this program and the state is probably going to pass some laws to stabilize that funding.

The most recent increase is paid for by the federal government out of the Affordable Care Act. The federal government is paying 100 percent of the cost for the newly eligible for the first three years, and that’s going to decline after the three year period to 90 percent of that cost. Essentially california is getting probably 6 or 8 billion dollars worth of healthcare for a fraction of the cost-with only around 600 million to the state taxpayers-so that is a pretty good deal.

Probably the biggest red flag or trouble spot is the aging of the population because a disappropriate share of the cost of Medi-Cal goes to older adults and nursing home care.  Since most private insurances don’t pay for nursing home care, a lot of people when they get older spend down their assets until they qualify for Medi-Cal and they end up in nursing home paid for state taxpayers.