Obamacare Nears, but Hurdles Remain for the Needy in OC

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Beginning in January, about 280,000 lower-income, medically uninsured residents of Orange County could qualify for coverage under Obamacare, but it’s unclear whether the clinics serving poor residents will be ready to accommodate an influx of new patients or even whether the people who qualify will sign up.

Implementing the next step of the new health care reform law, officially known as the Patient Protection and Affordable Care Act or ACA, “is a huge endeavor,” said Isabel Becerra, CEO of the Coalition of Orange County Community Health Centers, whose 67 clinics form the county’s medical safety net.

Key provisions affecting uninsured people begin in January and include the expansion of Medi-Cal to people who were not eligible before because they were childless or had too high an income.

Under the ACA, a single person may now earn up to 138 percent of the federal poverty figure, approximately $15,856. An adult heading a family of four could qualify with a salary as high as $32,499.

Also scheduled to begin in January is a newly created health purchasing exchange for people who make too much to meet Medi-Cal income restrictions. Purchasers earning up to 400 percent of the federal poverty level will be eligible for tax credits or subsidies, depending on their incomes.

First Challenge: Signing Up People

A number of complicating factors threaten to thwart some of the health law’s intentions, which aim to expand coverage in addition to instituting medical reforms.

First, Gov. Jerry Brown waited until the last week in June to sign the legislation expanding Medi-Cal under the ACA, which significantly reduced the time available for outreach to low-income residents who don’t know much about the law because of language and cultural barriers. Making matters worse, a number of Orange County community organizations failed to win grants that would fund outreach efforts.

In another development, the Obama Administration announced last week it will postpone a requirement for large employers to provide insurance. At this point, the delay is not expected to affect the Medi-Cal expansion or exchange directly, but it reveals just how complicated the implementation of reforms is proving to be.

Meanwhile, it’s not certain that everyone who qualifies for medical coverage under the ACA will want it. One big reason is that families with a mix of legal and undocumented residents may be hesitant to step forward to enroll members who qualify for fear of running afoul of immigration authorities.

An estimated 90,000 people in Orange County will not gain coverage under the ACA, largely because they are not legal residents, though some people may simply be priced out of the exchange. Patients have to be legal residents for at least five years to qualify for the Medi-Cal expansion, with fewer than five years allowed for the exchange.

And some people may choose to opt out of coverage and instead pay fines, which initially will be light.

Becerra said patients who fail to secure coverage under the ACA likely will continue to seek care where they go now — for-profit medical centers also known as “bodega clinics,” nonprofit community health centers and, in worst cases, emergency rooms.

Dealing With Possible Doctor Shortage

But even if sign-up for Medi-Cal and the exchange goes well, safety net providers have a host of questions about what happens next.

Many are questioning whether there will be enough primary doctors for all the newly insured patients seeking care.

Community clinics that serve lower-income patients have already increased their patient loads in response to the economic downturn of the last few years, and many are at capacity. Countywide, the number of patients served annually at community clinics hit 300,000 in 2011, up from 186,000 six years ago.

“We need to find the dollars to find more doctors,” Becerra said.

Those clinics with the means have already begun adding to their staff in preparation for 2014. “We think there will be more demand for our services, so we recruited another full-time physician who will start in September,” said Barry Ross, chairman of the St. Jude Neighborhood Health Centers, whose two clinics serve low-income people in Buena Park and Fullerton.

Concern about shortages has led Share Our Selves, which runs clinics in three locations in Orange County, to rely more on nurse practitioners, said executive director Karen McGlinn. Nurse practitioners are specially qualified nurses with advanced training who manage daily patient care under a physician’s oversight.

Private Competition

Another concern for community clinics is that under the ACA’s Medi-Cal expansion, reimbursement rates to primary care physicians will equal those for Medicare. This upgrade means that private practices, driven by better reimbursements, could lure newly insured patients from the clinics, leaving them to serve uninsured patients only — a financially unstable arrangement.

Becerra said that private practices are already setting up offices in Orange County in anticipation of newly insured patients. In response, 10 clinics in her coalition have formed a network in order to remain competitive. The Coalition of Orange County Community Health Centers expects to leverage its combined scope of services to secure contracts with CalOptima, the county’s administrator of public coverage programs.

Meanwhile, Ed Gerber, executive director of Lestonnac Free Clinic in Orange, said he worries that if other community clinics take in more paying patients as a result of the ACA, Lestonnac will end up with more uninsured patients than it can handle.

“I’m hoping we’re not the only clinic left to take care of the uninsured. I on my own cannot handle all the uninsured of Orange County,” said Gerber. “In a sense, the ACA is dismantling the safety net.”

Innovation Leads to Better Coverage

But others in the field disagree.

Ross of St. Jude neighborhood clinics feels “very positive” about the law, “because it will insure more people. … It will provide more comprehensive benefits with a focus on prevention. It is encouraging electronic records and communication that should improve quality,” he said. “All of those things are positive.”

Ellen Ahn, executive director of Korean Community Services, which operates the KCS Health Center in Buena Park, also lauded Obamacare.

“I think it’s a great thing,” she said. Under the current system, a large number of Korean small-business owners and recent immigrants lack insurance, and as a result they may not go to a doctor until it’s too late to treat a disease, she said.

Dr. Korey Jorgensen of the Laguna Beach Community Clinic expressed a similar view, saying that a 22-year-old patient recently came in with a testicular mass. The patient couldn’t afford insurance, and he was not able to capitalize on the ACA’s provision to allow young people to stay on their parents’ plans until age 26, because his parents didn’t have insurance. On the other hand, his income was too high for Medi-Cal.

“In that situation, under the health care act, he would have his insurance paid for by the government. For a person like that, the ACA is a godsend. There are thousands of people like that right here in the OC,” Jorgensen said.

Correction: A previous version of this article misspelled the name of Ed Gerber, executive director of Lestonnac Free Clinic in Orange. We regret the error.

Amy DePaul is a Voice of OC contributing writer and lecturer in the UC Irvine literary journalism program. You can reach her directly at depaula@uci.edu

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