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On Valley Edition: 'Gap' Widens Between Medi-Cal & Employer-based Insurance

Jul 15, 2015

A new study from the UCLA Health Policy Institute indicates that the access gap between Medi-Cal recipients and those with private, employer-sponsored coverage continues to grow. And those with Medi-Cal benefits in the Central Valley do even worse, facing even greater challenges in finding and retaining a doctor than those with the same benefits in wealthier parts of the state. 

We recently spoke with one of the study's authors, UCLA professor Shana Alex Charles about the study's findings, as well as how to improve the numbers in the future.

Q: What is the main conclusion of your research?

A: Medi-Cal is not keeping up with private job based coverage in giving good access to care, both on the outcome side and the status side but also really on the actual realized side of access and potential access for its enrollees. So there's still some work for Medi-Cal to do in order to be equivalent in coverage to private industry. 

Q: What do we see in different parts of the state as far as access to care?

A: Well, comparing different parts of the state with each other we found some good data, but not necessarily surprising data. Which means that current trends that we've seen continuing, where the parts of the state that are wealthier, the Bay Area region - end being the best access to care. And then the not as wealthy parts of the state, which would include the Fresno area, the Central Valley end up having worse access to care, even within the Medi-Cal population. 

Q: Your study shows that Medi-Cal enrollees were twice as likely to not have a usual source of care other than the emergency room, and three times as likely to have trouble finding a doctor. Can you talk about what that means?

"Health insurance doesn't mean anything unless it gets you good health care." - UCLA professor Shana Alex Charles

A: These two words, potential and realized access are very important, and that's why we want to look at it. The fact is, health insurance doesn't mean anything unless it gets you good health care. That's the point of health insurance. The point of giving free public Medi-Cal to people who can't afford private health insurance or don't have jobs that offer it is to try and give them the same kind of health care that everybody else gets. And so Medi-Cal is not reaching that potential at this point. With the potential access to care we talk about when they need care that they know they can get it, Medi-Cal has problems there.

As you mentioned with people saying their usual source of care is the emergency room, what that shows us is that they don't have a regular doctor that they know they can go to. They just have to rely on the most expensive, costly in terms of time and effort and difficult area of care like the emergency care. And then the second area which is the realized access, would be whether or not they can go see a doctor or find a doctor. And people on Medi-Cal having issues with that means they are not bale to have good continuity of care over time, a provider who knows their history over time, and who is able to look at them more holistically. The emergency rooms are great for specific situations but they're not good at being able to take are of people over time in a continuum of care. 

Q: Is this a problem that is unique in any way? Is it unique to California or is this across the board in other states that have Medicaid programs?

A: In terms of data, the only data that we have for this report is for California. We didn't look at any other states, but I will say that when you did look at Medicaid overall, another report that was done by a sister agency of ours did look at Medicaid nationally, comparing access to care for job-based coverage on a more national level and they actually found fewer differences than we did. There are other states that are doing a better job of it than California currently is. I think that we really need to take a look at our existing provider network and being able to give people the health care that the Medi-Cal program is supposed to be providing.

Q: You mentioned that the results aren't all that surprising given that the poorer parts of the state are where we see a majority of these problems, or see the problem at its most severe. Was there anything surprising in your analysis?

Well I think where we were surprised a little bit was the difference between children and adults. In this case it was a pleasant surprise in that children seem to have better access to care in that the Medi-Cal coverage access looked more similar to the job based coverage access than it did for adults. It might be a a factor of, that there are more children in the Medi-Cal program, it's a very large focus of the program, and in this state we have done an even better job of getting children enrolled where they have a higher percentage of having insurance in the first place. So it's good that for kids the system is doing better than it is for adults, but it does show where the focus can be in the future in terms of trying to improve access to care for adults. 

Q: You're using data from 2012 and 2013. Would you expect to see any changes in the next data set given the Medi-Cal expansion and other efforts along those lines?

"We're probably going to see even more use of the ER as a usual source of care as people try to navigate and find their own doctors." - UCLA professor Shana Alex Charles

What we're expecting to see is even more exaggeration of the patterns that we've already seen. This is an expectation. The hope would be that we would see a reduction in those patterns, that we would see increasing access to care for the Medi-Cal population as more and more people got into the program and as the population expanded in 2014. But honestly from the anecdotal evidence so far and from the issues of people who are newly enrolled in a program, trying to maneuver within the health system that they haven't had before, we're probably going to see even more use of the ER as a usual source of care as people try to navigate and find their own doctors, and worse problems, but hopefully that will not be the case. 

Q: You talk about the effort to close the access gap between Medi-Cal and employer sponsored coverage. I know your study doesn't get so much into the solutions side, but is it as simple as simply increasing provider premiums and state support for providers, or is it more complicated than that in some way? 

A: Even increasing premium support is very complicated. The state has had a history of trying to reduce provider payments over the last decade or so. In fact, the courts had to step in and stop those reductions and stop those reductions because that's historically been a way that California has looked to try and balance its budget, to cut payments to Medi-Cal providers.

"Providers are feeling like they're being asked to do more with less, and they were already working at below costs to begin with." - UCLA professor Shana Alex Charles
"[In LA] the strong focus has been on trying to attach a provider to a new enrollee as soon as they enroll. So not just giving someone a card and "saying ok, now you go out and find a provider." - UCLA professor Shana Alex Charles

Even if we could get that, it would be very difficult just to get that, but the problem is honestly is that as a system, health insurance in this state has undergone transformations that have highlighted where the fracture points are. And I think providers are feeling like they're being asked to do more with less, and they were already working at below costs to begin with. Which is leading to all these big consolidations as so many providers don't want to try to go it alone and even big companies are feeling that they want to merge to cover their own bases and to integrate.

The problem here is as you say, there are no simple solutions. If we were able to graduate 10,000 more doctors who all suddenly agreed to take Medi-Cal patients, I still think the problem wouldn't necessarily be solved overnight.  So it's something that will remain to be fixed as the years go on. I do think great steps have been made. I know in Los Angeles County on the local level, the strong focus has been on trying to attach a provider to a new enrollee as soon as they enroll. So not just giving someone a card and "saying ok, now you go out and find a provider," but at the point of enrollment, identifying "here is the hospital you're going to be affiliated with, here is the doctor's office, you can choose this doctor or not," and starting that from the enrollment process side. And I think if we link that statewide, if we can get access to care and that second step be part of a actual enrollment process, I think that would really go a long way to helping people use the health care system effectively. 

Editor's note: The UCLA report was funded by the non-profit California HealthCare Foundation, which is also a funder of Valley Public Radio.