Newborns. Former inmates. College college students. Expectant mothers. People with disabilities. Foster children. Homeless folks. Single dads.
Your neighbor. Your co-worker.
You.
California’s Medicaid program, known as Medi-Cal, serves a whopping 15.4 million folks, providing care from cradle to grave: Half of all births are lined by Medi-Cal, as are greater than half of all stays in nursing properties.
Everything about Medi-Cal is huge, from its upcoming fiscal 12 months finances of $139 billion to the expansive checklist of advantages and companies it provides. The approach this system works — or doesn’t — may spell life or loss of life for a lot of enrollees.
“It’s critical, from the single pregnant mom, to the extremely frail elderly population that needs a nursing home,” stated Jennifer Kent, former director of the state Department of Health Care Services, which administers Medi-Cal. “If it weren’t for Medi-Cal, so many people would either be dead or would be severely compromised.”
In a brand new collection, California Healthline will make clear Medi-Cal’s successes and failures by way of the experiences of its enrollees. They embody Stephanie Lammers, who can’t get her troubling stomach signs checked at a clinic 50 miles from her small Calaveras County city as a result of the transportation Medi-Cal is meant to offer isn’t reliable; Carolina Morga Tapia, a Fresno girl who credit Medi-Cal with serving to her have 5 wholesome kids; and Lucas Moreno Ramirez, a Los Angeles County man with stage 4 lung most cancers who needed to struggle to maintain his remedy going.
Medi-Cal is at a vital juncture because it makes an attempt to serve the wants of a various affected person inhabitants with a dizzying array of medical wants — from childhood vaccinations and most cancers screenings to state-of-the-art look after uncommon genetic issues. Roughly half of enrollees are Hispanic, and, subsequent 12 months, California will turn into the primary state to increase eligibility to all immigrants who qualify, no matter their authorized standing.
Medi-Cal can also be enterprise a number of new initiatives that intention to avoid wasting taxpayer cash and enhance high quality. State officers are demanding that the 23 well being insurers that serve most Medi-Cal sufferers present higher care — or face vital penalties, together with potential expulsion from this system.
The state can also be including progressive social companies that fall outdoors the normal realm of drugs, together with serving to some enrollees pay for lease and purchase groceries.
“People are watching California,” stated Cindy Mann, who served as federal Medicaid director beneath former President Barack Obama. “What the state is doing is ambitious and very aggressive. It makes a significant mark on health care and health policy, not just because of the size and breadth of its program, but by being very comprehensive.”
But solely a sliver of enrollees will get the brand new social companies, at the same time as many sufferers wrestle to acquire primary care or get in to see their medical doctors. In actuality, the kind of care you get in Medi-Cal will depend on the place you reside and which insurer supplies your advantages.
That means this system is working for some, however failing for a lot of others.
If you might be in Medi-Cal, we want to hear from you, whether or not you reside in an enormous metropolis or a rural area, no matter your age, race, or ethnicity, and no matter your medical, dental, or psychological well being situation. Have you had problem seeing the fitting physician for what ails you, even to the purpose of placing your life in danger? Or did Medi-Cal present excellent care, maybe sparing you severe hurt or incapacity? Either approach, please take into account sharing your expertise with us.
Here are snapshots of sufferers who’ve used this system at a vital time of their life.
‘I Just Don’t Go to the Doctor Anymore’
When Stephanie Lammers leans over to placed on her sneakers, it feels as if she’s squishing one thing inside her stomach, she stated.
Lammers, 53, has been affected by frequent bouts of nausea, ache, and bloating for six months.
Her gastroenterologist needs to carry out diagnostic procedures, together with a colonoscopy and, if something exhibits up, a biopsy. But Lammers, who lives in a motel together with her boyfriend and teenage daughter within the Gold Rush city of San Andreas, doesn’t have a working automotive and might’t readily get to the clinic — which is 50 miles away.
For Lammers, like many Medi-Cal enrollees who reside in rural areas, lack of transportation is a significant obstacle to acquiring care. The downside is especially acute for sufferers who have to see specialists.
Lammers’ dermatologist and eye physician are over an hour away from San Andreas, the county seat of Calaveras County, about 125 miles northeast of San Francisco. She isn’t seeing a neurologist, regardless of a collection of mini-strokes and stress-related seizures. And she hasn’t been to a podiatrist in two years, though her toes are twisted over each other and cling down, inflicting her to journey. She’s usually in excruciating ache when she walks.
Medi-Cal is meant to offer free transportation to enrollees who can’t in any other case get to their appointments.
But Lammers, whose well being plan is California Health & Wellness, owned by Centene, the nation’s largest business Medicaid insurer, stopped utilizing its experience service practically a 12 months in the past, after she missed dozens of appointments as a result of drivers simply didn’t present up, she stated. She was getting threatening letters from medical doctors’ places of work over the no-shows.
Once she needed to hitchhike greater than 30 miles dwelling from a counseling appointment. On different events, Lammers stated, she didn’t obtain the reimbursement she was owed for arranging her personal rides.
“I just don’t go to the doctor anymore,” Lammers stated. “If I go to the doctor, my boyfriend has to take the day off work, and if he takes the day off work, we have no money.”
During the final three months of 2022, Lammers canceled 5 appointments she had scheduled for the diagnostic stomach procedures as a result of her boyfriend needed to work every time and couldn’t take her. She lastly stopped rescheduling.
California Health & Wellness contracts with Modivcare, a Denver-based medical transportation firm that’s no stranger to affected person complaints and lawsuits.
Before she gave up on the experience service, Lammers stated, she would name California Health & Wellness to attempt to resolve the problem, solely to be informed that Modivcare was a separate firm. “I’m like, ‘If you guys hired them and put them in charge of transportation, who oversees their screw-ups?’”
Courtney Schwyzer, a member of a authorized support workforce representing Lammers on varied Medi-Cal issues, stated the failure of medical experience companies is a systemic downside. In late February, Schwyzer and her fellow attorneys filed a petition in courtroom that she hopes will drive the state Department of Health Care Services to handle the issue.
California Health & Wellness spokesperson Darrel Ng stated the corporate displays the standard of its contractors, however a scarcity of transportation suppliers in rural areas “has created unique challenges.”
Modivcare supplies greater than 4 million rides for Medi-Cal recipients yearly, and greater than 99% are with out grievance, stated Melody Lai, an organization spokesperson.
Lammers, who’s unemployed and attempting to start out a customized craft enterprise known as Stuff by Steph, stated medical doctors have warned her that if she doesn’t scale back her stress stage, it may shorten her life. But arranging medical care is probably the most irritating factor in her life proper now, so she doesn’t attempt anymore.
“In order to keep from dying, I have to not go to the doctor,” she stated.
‘It’s a Blessing’
Medi-Cal helped save the lifetime of Carolina Morga Tapia, a 30-year-old, full-time mom of 5 who lives together with her household amid almond groves in an agricultural enclave of Fresno.
Nine years in the past, a bacterial an infection triggered untimely labor throughout the twenty fifth week of her second being pregnant, and Morga Tapia nearly died. She spiked a fever, bled profusely, and wanted speedy transfusions and emergency surgical procedure. After a number of days in vital care, she absolutely recovered.
But the medical doctors couldn’t cease the untimely delivery, and her child got here out weighing simply 1 pound. She and her husband, David Nuñez, named her Milagros Guadalupe, and she or he died 4 days later, on Sept. 13, 2013 — a Friday.
In every of her subsequent pregnancies, Medi-Cal paid for Morga Tapia to get photographs of artificial progesterone, supposed to forestall one other preterm delivery. Those photographs — one every week for about 20 weeks — can value a median of greater than $10,000 per being pregnant.
Morga Tapia and Nuñez, a development employee, signed up for Medi-Cal when she was pregnant together with her first little one greater than a decade in the past. They’ve been on the identical Anthem Blue Cross Medi-Cal plan ever since.
“It saves a lot of money, and it’s a blessing to have that extra help.”
Morga Tapia
The plan paid for prenatal care by way of all six of Morga Tapia’s pregnancies, and it has supplied all of the medical and dental care the household wants, she stated.
“Without Medi-Cal, we would have to be paying for all of our children,” stated Morga Tapia. “It saves a lot of money, and it’s a blessing to have that extra help.”
Her kids, 4 ladies and a boy, vary in age from 1 to 10. They all go to the identical kids’s clinic and see the identical pediatrician.
The children, all in good well being, get routine checkups, vaccinations, and different preventive care, Morga Tapia stated. She will get appointment reminders through textual content and playing cards within the mail notifying her when it’s time for the youngsters’ vaccinations and wellness checks, in addition to her Pap smears, she stated.
Her household’s expertise contrasts sharply with the state’s evaluation of their well being plan, in accordance with a report on high quality of care in Medi-Cal issued late final 12 months. The report, which evaluated Medi-Cal well being plans on pediatric care, girls’s well being, and persistent illness administration, put Anthem Blue Cross within the lowest tier, and under par on a number of measures in quite a few counties, together with Fresno.
Another state report, launched in late January, detailed how rapidly insurers present appointments for his or her sufferers, and put Anthem Blue Cross’ Medi-Cal plan close to the underside of the heap.
Anthem Blue Cross spokesperson Michael Bowman stated in a press release that the interval lined within the reviews coincided with the covid-19 pandemic, “when our safety net providers dealt with significant challenges with workforce and appointment availability.”
Morga Tapia doesn’t give the insurer low marks. “It’s different for everybody. I have a good healthy family, and what Medi-Cal covers is really fortunate for us,” she stated.
‘I Don’t Want to Die Yet’
In late 2021, medical doctors gave Lucas Moreno Ramirez just a few months to reside.
Struggling with diabetes and late-stage lung most cancers, Moreno Ramirez suffered debilitating ache as he hacked and labored for breath. His medical doctors beneficial that he cease remedy and begin hospice care.
He felt as in the event that they have been giving up on him.
“They said they’re going to give me opioids for my pain and help me have a comfortable death,” stated Moreno Ramirez, 68, who lives in Norwalk, in Los Angeles County. “I told them I don’t believe in that. I don’t want to die yet.”
A former landscaper and manufacturing facility employee, Moreno Ramirez discovered he needed to be his personal advocate, preventing for the care he believed he deserved from Medi-Cal.
He stated his Christian religion gave him power, and over the following few months, Moreno Ramirez pushed this system and his medical doctors to maintain battling his most cancers, utilizing a special remedy with fewer unintended effects than chemotherapy.
“I believe in prayer,” he stated. “But I believe in science and medication, too.”
Moreno Ramirez is likely one of the roughly 1.6 million Californians enrolled in each Medicare, which covers people who find themselves 65 and older or have disabilities, and Medi-Cal, which kicks in to cowl the prices and advantages that Medicare doesn’t.
He additionally depends on his Medi-Cal insurer to assist him navigate the byzantine system. L.A. Care, the biggest Medi-Cal plan with practically 2.6 million members, linked him with a care supervisor who labored with him to establish a special remedy known as Tagrisso and advocated for him to get it.
Even with the brand new treatment, Moreno Ramirez’s coughing suits returned final 12 months, and his signs grew so painful he suspected the most cancers was rising. He requested to see his pulmonologist however was informed the primary appointment can be in June 2023. So he switched medical doctors and scored an appointment practically six months sooner.
“My old doctor didn’t help me. I didn’t trust him,” Moreno Ramirez stated. “He was always too busy for me. I told my doctors, ‘Give me a chance.’”
Having taken his care into his personal fingers, he says he’s not in ache, his cough has subsided, and he feels longing for the longer term. “Now I feel good,” he stated.
He has additionally sought extra consideration for his diabetes and acquired a steady glucose monitor to measure his blood sugar. It’s higher managed now than it has been in many years, he stated.
“You have to stand up for yourself and advocate,” stated Joann Pacelo, the care supervisor who helped Moreno Ramirez change medical doctors, get faster referrals to specialists, and get accepted for in-home nursing visits.
“A lot of times it’s difficult with Medi-Cal because the doctors are busy and the reimbursements are so low, but no one should be denied the care they deserve.”
This story was produced by KHN, which publishes California Healthline, an editorially unbiased service of the California Health Care Foundation.