At hundreds of safety-net hospitals and community clinics, momentous changes are unfolding as the health reform law takes effect.
The safety net faces a flood of new patients, as an estimated 1.4 million low-income Californians will become eligible for Medi-Cal, and an additional five million are expected to qualify for coverage through Covered California. Medi-Cal is California's Medicaid program, and Covered California is its health insurance exchange.
That influx of new patients has ignited concerns for safety-net providers in Los Angeles and the Central Valley, regions that have some of the state's largest undocumented populations.
Directors of clinic networks and health policy experts in these areas said a couple things are clear: Doctor shortages will be exacerbated with thousands of new residents seeking health insurance and, come Jan. 1, clinics will be better positioned to provide preventive and more coordinated care.
What is unclear, however, is how these clinics will stay afloat to provide care for millions of undocumented immigrants who will be left out of health reform.
One strategy is to position themselves as a provider of choice, which will bring in additional revenue from new Medi-Cal patients, and through the private insurance market, said Shannon McConville, a health policy expert and researcher for the Public Policy Institute of California. McConville in 2012 co-wrote an extensive report examining the role of the state's safety net called, "Access to the Health Care Safety Net in California."
"The safety net is crucial. Next to emergency rooms, they're the only services available for the unauthorized population," McConville said. "It's important that safety-net providers are able to balance serving the publicly insured and those low-income folks who are entering insurance, while also maintaining their mission to serve those who are outside of insurance coverage, which includes the unauthorized. That balancing act is going to be challenging."
California Has Nation's Largest Undocumented Population
After health care reforms are in place, between three and four million of California's seven million uninsured still will be without insurance, according to McConville. Undocumented immigrants, who are barred from participating in the exchange and are not eligible for the Medi-Cal expansion, will account for the largest portion of the uncovered.
"Unauthorized immigrants will constitute one of the single largest population subgroups projected to remain uninsured after the Affordable Care Act is implemented in California," the Public Policy Institute report found. "More than any other state, California is home to the largest estimated number of unauthorized immigrants -- about 2.6 million."
Some funding streams will grow and some will shrink under the ACA. For instance, some Disproportionate Share Hospital payments -- enhanced federal reimbursements, which in the past have cushioned the impact of providing care for those who can't afford it -- will be reduced. On the other hand, clinics will soon be able to bill Medi-Cal for services they provide to previously ineligible single, childless adults.
'It's Like Being on a Bullet Train.'
Despite all the uncertainty, safety-net experts say that while reform deadlines can be difficult, they are optimistic.
"We are extremely excited about the ACA, and we're working really hard to make sure all the pieces are in place for 2014. But with that, of course we are facing significant challenges," said Cynthia Carmona, director of government and external affairs for the Community Clinic Association of Los Angeles County, a network of 52 clinics. "Our biggest concern is the pace of change. It's like being on a bullet train. We can hardly see all the changes zooming past us, and we have to make sure we're compliant with all the new regulations."
In addition to big changes taking place in a short time, Carmona said clinics in her association face other significant changes, including a technological learning curve and doctor shortages.
"What's on our mind are the capacity questions," Carmona said. "We're not sure there are going to be enough doctors to take new patients after all these new folks get insurance. There is just never enough capacity, especially when you're talking about a place that's so huge like L.A. County."
"Getting up to speed on technology, implementing electronic health records, that is going to vastly help our capacity problems," she added.
Focus on Farmworkers in Central Valley
Concerns about provider shortages are mirrored in the Central Valley, which stretches from counties north of Sacramento to south of Fresno.
Cathy Frey -- CEO of the Central Valley Health Network, which includes 13 clinics -- said serving undocumented immigrants is her organization's primary mission.
"Because the Central Valley is dominated by the agricultural industry, we have a very large farmworker population, so a large number of health centers are actually federally designated as migrant health clinics," Frey said. "The health centers in the Central Valley are critical for the care of those who are undocumented."
Like clinic officials in Los Angeles and in San Francisco, Frey said her clinics are also worried about stable funding and about provider shortages.
"Workforce is going to be a huge issue," Frey said. "It's almost impossible to recruit providers to California, and it's doubly hard in the Central Valley."
Frey said providers in her network are educating the immigrant population about services for which they might be eligible.
"Our clinics are vital and we're certainly going to continue providing services for those who remain uninsured, whether that's due to immigration status or because they simply don't know how to enroll," she said. "We're working on educating our residents, and because of that, I think we're on our way to becoming a provider of choice."
Frey said her networks stress cultural competency, which includes offering services in multiple languages and informing undocumented parents that children born in the U.S. could be eligible for coverage.
"We're a patient home, a place where no matter our patients' immigration status, they can feel comfortable," Frey said. "And I think that competency is going to lead to more and more people seeking our services."
Study Suggests Policy Shift Would Increase Stability
"Undocumented and Uninsured," a study published last month by the UCLA Center for Health Policy Research, underscored concerns echoed by community clinic officials throughout the state.
The ACA "specifically excludes one group from all its provisions: the approximately 11 million undocumented immigrants residing in this country," the report stated. "Access to health care in California is significantly worse for undocumented immigrants."
Access is particularly problematic in California, researchers found. The study set forth some policy recommendations, including:
- Expanding insurance options to undocumented immigrants;
- Increasing access to high-value services such as specialty care through no- or low-cost care to the uninsured; and
- Maintaining and increasing subsidies to safety-net providers in communities with high volumes of immigrants.
Improving access to care and insurance coverage for the undocumented would improve financial stability for all safety-net providers where undocumented populations are clustered, the study concluded.
Jenny Rejeske, a health policy analyst for the National Immigration Law Center, said safety-net clinics will remain the most important source of care for the undocumented.
"The community health centers are hugely important. They're one of the most crucial parts of the health care safety net and they'll continue to be," Rejeske said. "Undocumented immigrants aren't going to be the only ones who continue to need the safety net."