Carlos Gutierrez of Berkeley thought his health care troubles were over when he received a letter from his county’s social service agency in May telling him he qualified for Medi-Cal.
The 34-year-old single father of two had been without health insurance for months after losing his job as a trainer in car rental sales. He’d applied for health coverage through Covered California — the state’s health insurance exchange — and when the letter about Medi-Cal arrived he felt relieved.
Finally, Gutierrez thought, he’d be able to take his teenage son and daughter for checkups he’d avoided because he couldn’t afford the doctor’s fees. And he’d be able to see someone about the nagging pain in his abdomen where he’d had his gall bladder removed the year before.
The county letter said he’d receive follow-up information soon. But that information never came.
Five months later, Gutierrez is still waiting for confirmation that his family has Medi-Cal, and his abdominal pain is worse.
“There are days when it’s unbearable,” he said, explaining that he’s afraid to go to the emergency room because he doesn’t want to go into debt. “I just don’t know what to do at this point. I’m just hoping and waiting and praying that something happens.”
Across the state, hundreds of thousands of other people are also awaiting confirmation that they are covered by Medi-Cal, the state’s health insurance program for low-income and disabled people. As of Sept. 23, 250,000 applicants were still waiting for their applications to be processed, according to California’s Department of Health Care Services. For some applicants, the wait has dragged on for months, leaving them in a state of limbo where they either have to forgo needed treatment or take on debt to get medical care.
The state said it is working hard to address the backlog, which it blames on computer glitches and an unprecedented surge in new Medi-Cal enrollments under the Affordable Care Act, which broadened eligibility criteria. The pending applications are down from 900,000 in May. Many of those remaining are thought to be duplicates or denials, according to a letter earlier this month from the Department of Health Care Services to the federal Centers for Medicare and Medicaid Services. The state has successfully enrolled 2.3 million new people in Medi-Cal under the Affordable Care Act, the letter states.
“We will continue our joint work with the counties to process these cases, and we expect more progress in the coming weeks,” department spokesman Anthony Cava said in an email. “With a program the size of Medi-Cal, there has always been — and will always be — a number of individuals who are pending enrollment.”
But some advocates say the state’s progress is not good enough. On Sept.17, a coalition of legal services organizations and community health care advocates filed suit against California claiming it is breaking the law by not processing Medi-Cal applications within 45 days, the time limit required under state law. The lawsuit, filed in Alameda Superior Court, lists four applicants caught in the backlog.
One applicant, 26-year-old Ebony Pickett of Los Angeles, delivered a premature baby following months of anxiety over medical bills while waiting to get Medi-Cal during her pregnancy, the lawsuit states. Another applicant, 55-year-old Groto Ni of Oakland who suffers from Hepatitis B and other health problems, became so depressed from the consequences of being uninsured that he wanted to die, the lawsuit said. Both applicants only received Medi-Cal after legal advocates stepped in to help them.
“This is a real problem affecting real people, it’s not just about numbers and statistics,” said Lucy Quacinella, the lead attorney in the case. “The situation has to be corrected. It’s not enough to say, ‘We’re working on it.’ (State officials) have to comply with the law.”
Waiting for Medi-Cal coverage can have deadly consequences.
Frances Rivera of Visalia, also named in the lawsuit, lost her 48-year-old son Robert Cribbs Jr. to a pulmonary embolism after he went without medical tests and treatment while his Medi-Cal application was pending, she said. Cribbs applied for Medi-Cal in early January, and still hadn’t received confirmation of his eligibility when he died on April 6.
In June, Rivera began receiving letters stating Cribbs had been granted Medi-Cal, retroactive to February. She’s convinced her son would still be alive if he’d received the determination sooner.
“That was very, very heartbreaking, to get this in the mail knowing it’s too late to help him,” Rivera said. “Had we gotten it sooner we could have went in (to the hospital) and said, ‘I have Medi-Cal, I have these problems. Can you please run these tests and see what’s causing them?’”
Often, those waiting for Medi-Cal have already submitted the income information and documents required of them, Quacinella said. However, the state waits to verify applicant income independently, before granting Medi-Cal, she said. The lawsuit argues that legally the state should grant Medi-Cal first and then seek to verify income.
Quacinella said she fears the backlog will balloon once open enrollment for Covered California begins again later this year.
“We need to get our house in order,” she said. “There is a solution to this problem and the solution is to follow the law.”
Income verification isn’t the only issue holding applications back. Joy Dockter, an attorney with Central California Legal Services, said she’s seen a variety of reasons for processing delays, including human and computer errors.
One client, Andrew Skaf, a college student, applied for coverage last fall. His case stayed pending for months because of a miscommunication between computer systems, Dockter said.
In March, the then 21-year-old was diagnosed with cancer. Without insurance and with very little income, he spent weeks trying to find a doctor who would see him. His parents had to put $8,000 on credit cards to pay for surgery and treatment, he said.
“It was a lot of anxiety,” Skaff said, who finally got coverage in May. “Without my parents I would have been out of luck. There’s no way I could have paid for that myself.”
Norman Williams, a spokesman for the Department of Health Care Services, said Medi-Cal applicants who need immediate medical care can visit their county human services agency for help expediting their application. However, advocates say many Medi-Cal applicants don’t know that that option exists and it doesn’t help people who don’t have emergency medical needs.
Medi-Cal will reimburse the cost of care after a pending application is approved, Williams said. But in some cases, patients may still be left with debt. Skaf said Medi-Cal’s reimbursement of his bills didn’t cover everything and he was still left with $2,000 of debt.
Some hospitals also provide temporary coverage for up to two months for children, parent or caretaker relatives, pregnant women, foster-care youth and adults newly eligible for Medi-Cal. Hospitals taking part in this program, known as the Hospital Presumptive Eligibility program are listed here.
Some advocates said they have noticed a drop in the number of people waiting for Medi-Cal. Amy Chen, a staff attorney with Bay Area Legal Aid in Oakland, said her office is now seeing more patients with cases that have been pending just a couple of months, rather than since the early part of the year.
“This does appear to be consistent with the state’s claims that the backlog is resolving and that the remaining numbers on the backlog are people who’ve applied more recently,” she said in an email. “However, I would point out that waiting for Medi-Cal for 2-3 months is still a hardship for someone with pressing health needs.”
This story has been updated.