ACA promises insurance, but can it promise care?

By Daniel Weintraub

The Affordable Care Act promises to bring insurance to millions of Californians who don’t have it now. But will it bring them health care?

The law expands the Medi-Cal program for the poor and offers subsidies for low-income and middle-class people to buy private coverage through a new online marketplace known as Covered California.

That assistance is expected to provide insurance to at least 2.5 million people, many of whom have depended on free clinics and hospital emergency rooms for their care. Now, in theory, they will have regular doctors, and many have unmet health issues that require attention.

But California already faces a shortage of family doctors, and some fear that the influx of new patients could overwhelm the physician workforce.

“It’s important to keep in mind that insurance does not equal access to care,” said Dr. Brennan Cassidy, a Newport Beach physician and former president of the California Medical Association.

California has about 22,000 primary care doctors, or about 60 for every 100,000 residents, the minimum number recommended by the Council on Graduate Medical Education to provide adequate access to patients.

Orange County has about 6,000 doctors, and about a third practice primary care. That’s about 65 primary care doctors for every 100,000 county residents.

But the bigger problem, statewide and in Orange County, is where those doctors practice.

Statewide, fewer doctors practice in rural areas or in poor communities, making it even more difficult for people in those places to get care.

The problem is especially acute in Medi-Cal, the state program that provides free care to the poor. California’s program has some of the lowest costs per patient of any state, but that is largely because the state pays doctors so little to care for Medi-Cal patients.

The result: fewer and fewer doctors accept patients through the program, and finding one near home can sometimes be impossible. Compounding the problem is the fact that low-income people also often have limited transportation options, making a trip across town to reach a doctor’s office impractical.

The shortage of doctors in Medi-Cal is a longstanding problem, but the same issue might also affect consumers who buy coverage through the state’s Covered California. While the state has established minimum standards for the doctor networks in the plans sold by the insurance companies through the new exchange, some of the plans are going to have fewer doctors than similar coverage available on the private market.

“We might not have this problem if the insurance companies and Medi-Cal would contract with all the doctors who want to be part of their networks,” said Assemblyman Richard Pan, a Sacramento Democrat and practicing pediatrician.

But the problem is cost. The fewer doctors in a network, the less an insurance company, or a public health care plan, has to pay to contract with its providers. If they contracted with more doctors, that would likely drive up the cost of their coverage, making it less affordable. So it’s a trade-off.

For Medi-Cal, at least, the Affordable Care Act addresses the shortage by increasing reimbursements to the level the federal government pays for doctors who see Medicare patients. In California, that will mean a doubling of rates for many visits and procedures, and sometimes more. But the feds will pay for the higher reimbursements for only two years.

California is also trying to address the problem by ramping up two new medical schools at UC Merced and UC Riverside. Both will have a focus on serving rural areas and low-income people.

Increasingly, that is also the mission of the family medicine program at UC Irvine.

“We have embraced a mission” to serve the poor, said Dr. Charles Vega, who directs the residency program for family medicine at UCI. The school does not have the funding to increase the number of doctors it trains – about nine per year in family medicine – but those doctors are working out of the UC Irvine Family Health Center in Santa Ana. After that exposure, many will continue to practice in low-income communities once they end their training.

In the long term, though, the answer come in asking doctors to delegate some of their duties to other professionals. The state is rolling out a pilot program in which paramedics will do some health screenings and follow-ups with people in their communities. And there is pressure to allow nurse practitioners to practice in California without a doctor’s supervision, which they do in many states. A bill in the Legislature to allow that was shot down by the medical community this year, but the issue won’t be going away.

Something will have to give. Without significant change throughout the system, it is difficult to see how California is going to fulfill the promise of bringing affordable care, not just insurance coverage, to the millions who don’t have access to it today.

Daniel Weintraub has covered public policy in California for 25 years. He is editor of the California Health Report at Reach him at

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