Home Health Insurance California’s Large Medicaid Program Works for Some, however Fails Many Others

California’s Large Medicaid Program Works for Some, however Fails Many Others

California’s Large Medicaid Program Works for Some, however Fails Many Others

Newborns. Former inmates. Faculty college students. Expectant mothers. Folks with disabilities. Foster children. Homeless folks. Single dads.

Your neighbor. Your co-worker.


California’s Medicaid program, referred to as Medi-Cal, serves a whopping 15.4 million folks, providing care from cradle to grave: Half of all births are coated by Medi-Cal, as are greater than half of all stays in nursing properties.

All the things about Medi-Cal is huge, from its upcoming fiscal 12 months funds of $139 billion to the expansive checklist of advantages and companies it presents. The way in which this system works — or doesn’t — may spell life or loss of life for a lot of enrollees.

“It’s important, from the only pregnant mother, to the extraordinarily frail aged inhabitants that wants a nursing house,” mentioned Jennifer Kent, former director of the state Division of Well being Care Companies, which administers Medi-Cal. “If it weren’t for Medi-Cal, so many individuals would both be useless or could be severely compromised.”

In a brand new sequence, California Healthline will make clear Medi-Cal’s successes and failures via the experiences of its enrollees. They embody Stephanie Lammers, who can’t get her troubling belly signs checked at a clinic 50 miles from her small Calaveras County city as a result of the transportation Medi-Cal is meant to supply 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 combat to maintain his therapy going.

Medi-Cal is at a important 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 take care of uncommon genetic issues. Roughly half of enrollees are Hispanic, and, subsequent 12 months, California will turn out to be the primary state to develop eligibility to all immigrants who qualify, no matter their authorized standing.

Medi-Cal can also be endeavor a number of new initiatives that purpose to save lots of 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 exterior the standard realm of medication, together with serving to some enrollees pay for lease and purchase groceries.

“Persons are watching California,” mentioned Cindy Mann, who served as federal Medicaid director underneath former President Barack Obama. “What the state is doing is formidable and really aggressive. It makes a major mark on well being care and well being coverage, not simply due to the dimensions and breadth of its program, however by being very complete.”

However solely a sliver of enrollees will get the brand new social companies, whilst many sufferers battle to acquire primary care or get in to see their medical doctors. In actuality, the kind of care you get in Medi-Cal is determined by the place you reside and which insurer offers your advantages.

Meaning this system is working for some, however failing for a lot of others.

In case you are 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 ever had problem seeing the proper 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? Both approach, please take into account sharing your expertise with us.

Listed here are snapshots of sufferers who’ve used this system at a important time of their life.

Stephanie Lammers stands in the front door of her house and looks directly towards the camera. Her dog is visible in the window beside her.
Stephanie Lammers says the journey service offered by her Medi-Cal well being plan is so unhealthy that she stopped making an attempt to make use of it a few 12 months in the past, after it left her within the lurch a number of occasions. “I simply don’t go to the physician anymore,” she says.(Wealthy Pedroncelli for KHN)

‘I Simply Don’t Go to the Physician Anymore’

When Stephanie Lammers leans over to placed on her footwear, it feels as if she’s squishing one thing inside her stomach, she mentioned.

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. However 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 issue 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 sequence of mini-strokes and stress-related seizures. And he or she hasn’t been to a podiatrist in two years, regardless that her toes are twisted over each other and cling down, inflicting her to journey. She’s usually in excruciating ache when she walks.

Stephanie Lammers pets her dog, who is standing on its hind legs with its front paws on her shoulders, visibly jubilant from the affection.
Stephanie Lammers, pictured together with her canine, Shinook, has horrible ache in her toes. She incessantly journeys as a result of her toes cross over each other and cling down, however she hasn’t seen a podiatrist in two years. (Wealthy Pedroncelli for KHN)

Medi-Cal is meant to supply free transportation to enrollees who can’t in any other case get to their appointments.

However Lammers, whose well being plan is California Well being & Wellness, owned by Centene, the nation’s largest industrial Medicaid insurer, stopped utilizing its journey service almost a 12 months in the past, after she missed dozens of appointments as a result of drivers simply didn’t present up, she mentioned. She was getting threatening letters from medical doctors’ workplaces over the no-shows.

As soon as she needed to hitchhike greater than 30 miles house from a counseling appointment. On different events, Lammers mentioned, she didn’t obtain the reimbursement she was owed for arranging her personal rides.

“I simply don’t go to the physician anymore,” Lammers mentioned. “If I’m going to the physician, my boyfriend has to take the day without work work, and if he takes the day without work work, we’ve no cash.”

Over the past three months of 2022, Lammers canceled 5 appointments she had scheduled for the diagnostic belly procedures as a result of her boyfriend needed to work every time and couldn’t take her. She lastly stopped rescheduling.

California Well being & Wellness contracts with Modivcare, a Denver-based medical transportation firm that’s no stranger to affected person complaints and lawsuits.

Earlier than she gave up on the journey service, Lammers mentioned, she would name California Well being & Wellness to attempt to resolve the difficulty, solely to be advised that Modivcare was a separate firm. “I’m like, ‘When you guys employed them and put them accountable for transportation, who oversees their screw-ups?’”

Courtney Schwyzer, a member of a authorized help group representing Lammers on varied Medi-Cal issues, mentioned the failure of medical journey companies is a systemic downside. In late February, Schwyzer and her fellow attorneys filed a petition in court docket that she hopes will pressure the state Division of Well being Care Companies to deal with the issue.

California Well being & Wellness spokesperson Darrel Ng mentioned the corporate displays the standard of its contractors, however a scarcity of transportation suppliers in rural areas “has created distinctive challenges.”

Modivcare offers greater than 4 million rides for Medi-Cal recipients yearly, and greater than 99% are with out criticism, mentioned Melody Lai, an organization spokesperson.

Lammers, who’s unemployed and making an attempt to begin a customized craft enterprise referred to as Stuff by Steph, mentioned medical doctors have warned her that if she doesn’t cut back her stress stage, it may shorten her life. However arranging medical care is probably the most anxious factor in her life proper now, so she doesn’t attempt anymore.

“As a way to hold from dying, I’ve to not go to the physician,” she mentioned.

Carolina Morga Tapia stands outside, amid almond trees. The trees have no leaves, signaling the time of year.
Carolina Morga Tapia stands amid almond timber exterior her house in Fresno, California. She, her husband, and their 5 kids are enrolled in Medi-Cal, and he or she says she may be very proud of the care it has offered, together with emergency surgical procedure that saved her life after she fell gravely sick throughout her second being pregnant.(Heidi de Marco / KHN)

‘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.

9 years in the past, a bacterial an infection triggered untimely labor through the twenty fifth week of her second being pregnant, and Morga Tapia virtually died. She spiked a fever, bled profusely, and wanted fast transfusions and emergency surgical procedure. After a number of days in important care, she absolutely recovered.

However the medical doctors couldn’t cease the untimely beginning, and her child got here out weighing simply 1 pound. She and her husband, David Nuñez, named her Milagros Guadalupe, and he or she 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, meant to stop one other preterm beginning. These photographs — one per week for about 20 weeks — can value a mean 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 youngster greater than a decade in the past. They’ve been on the identical Anthem Blue Cross Medi-Cal plan ever since.

“It saves some huge cash, and it’s a blessing to have that additional assist.”

Morga Tapia

The plan paid for prenatal care via all six of Morga Tapia’s pregnancies, and it has offered all of the medical and dental care the household wants, she mentioned.

“With out Medi-Cal, we must be paying for all of our youngsters,” mentioned Morga Tapia. “It saves some huge cash, and it’s a blessing to have that additional assist.”

Her kids, 4 women and a boy, vary in age from 1 to 10. All of them 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 mentioned. She will get appointment reminders by way of 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 mentioned.

Her household’s expertise contrasts sharply with the state’s evaluation of their well being plan, based on 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, ladies’s well being, and continual illness administration, put Anthem Blue Cross within the lowest tier, and beneath par on a number of measures in quite a few counties, together with Fresno.

One other state report, launched in late January, detailed how shortly 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 mentioned in an announcement that the interval coated within the experiences coincided with the covid-19 pandemic, “when our security internet suppliers handled vital challenges with workforce and appointment availability.”

Morga Tapia doesn’t give the insurer low marks. “It’s completely different for everyone. I’ve wholesome household, and what Medi-Cal covers is de facto lucky for us,” she mentioned.

Lucas Moreno Ramirez sits at his kitchen table and looks directly at the camera. His medication is visible beside him.
Lucas Moreno Ramirez has late-stage lung most cancers, and in 2021, medical doctors gave him just a few months to reside. However the Los Angeles County man declined hospice and fought for a special therapy. Two years later, Moreno Ramirez continues to be alive and says his painful cough has subsided.(Heidi de Marco / KHN)

‘I Don’t Wish to Die But’

In late 2021, medical doctors gave Lucas Moreno Ramirez a number of months to reside.

Combating diabetes and late-stage lung most cancers, Moreno Ramirez suffered debilitating ache as he hacked and labored for breath. His medical doctors really helpful that he cease therapy and begin hospice care.

He felt as in the event that they had been giving up on him.

“They mentioned they’re going to present me opioids for my ache and assist me have a snug loss of life,” mentioned Moreno Ramirez, 68, who lives in Norwalk, in Los Angeles County. “I advised them I don’t consider in that. I don’t wish to die but.”

A former landscaper and manufacturing unit employee, Moreno Ramirez discovered he needed to be his personal advocate, preventing for the care he believed he deserved from Medi-Cal.

He mentioned 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 therapy with fewer uncomfortable side effects than chemotherapy.

“I consider in prayer,” he mentioned. “However I consider in science and medicine, too.”

The photograph shows a box of medication Lucas takes for his lung cancer. It is a white box with blue lettering that reads, "Albuterol Sulfate Inhalation Solution." A nebulizer compressor kit is also visible.
Lucas Moreno Ramirez has late-stage lung most cancers, and in 2021, medical doctors gave him just a few months to reside. However the Los Angeles County man declined hospice and fought for a special therapy. Two years later, Moreno Ramirez continues to be alive and says his painful cough has subsided.(Heidi de Marco / KHN)

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 almost 2.6 million members, related him with a care supervisor who labored with him to establish a special therapy referred to as Tagrisso and advocated for him to get it. 

Even with the brand new treatment, Moreno Ramirez’s coughing matches 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 advised the primary appointment could be in June 2023. So he switched medical doctors and scored an appointment almost six months sooner.

“My previous physician didn’t assist me. I didn’t belief him,” Moreno Ramirez mentioned. “He was all the time too busy for me. I advised my medical doctors, ‘Give me an opportunity.’”

Having taken his care into his personal fingers, he says he’s not in ache, his cough has subsided, and he feels looking forward to the longer term. “Now I really feel good,” he mentioned.

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 a long time, he mentioned.

“It’s important to rise up for your self and advocate,” mentioned Joann Pacelo, the care supervisor who helped Moreno Ramirez change medical doctors, get faster referrals to specialists, and get authorized for in-home nursing visits.

“Numerous occasions it’s troublesome with Medi-Cal as a result of the medical doctors are busy and the reimbursements are so low, however nobody must be denied the care they deserve.”

This story was produced by KHN, which publishes California Healthline, an editorially impartial service of the California Well being Care Basis.