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The number of people who lack health insurance has fallen substantially since the implementation of the federal health care law known as the Affordable Care Act.
That's been particularly true in the 30 states that expanded Medicaid. But in more than a dozen of those states, enrollment in the public insurance program for the poor has far eclipsed projections, straining budgets and an overburdened health care system.
Special correspondent Sarah Varney has our report from San Diego.
This story was produced in collaboration with our partner Kaiser Health News.
The Affordable Care Act unleashed a building boom of community health centers across the country. At a cost of $11 billion, more than 950 new health centers have opened, with hundreds more on the way, all meant to accommodate millions of new Medicaid patients. People like Lori Simpson.
LORI SIMPSON, Medicaid Patient:
Hi. How are you?
Good. How are you doing?
At age 58, after several worrisome decades without health insurance, she's finally getting treatment for her dangerously high blood pressure, as well as a thyroid disorder, and, after years of double vision, surgery for her eyes.
I have nine medications that I get every month, and mine comes to a little over $200. My husband, he's a diabetic, and his medication alone without doctors' visits or anything comes to over $400 a month.
And for that, how much do you have to pay?
We don't pay anything. It's all covered. It's just amazing.
Tilt a little bit this way.
Simpson goes to the Family Health Centers of San Diego, which saw an increase of 24,000 patients, almost overnight, after the Medicaid expansion.
DR. CHRIS GORDON, Family Health Centers of San Diego: Sit up straight. Breathe normally.
DR. Chris Gordon, the assistant medical director here, says it was a rush primary care clinics have been waiting for ever since President Obama signed the health law.
DR. CHRIS GORDON:
We have anticipated this for years, and have been planning for it. We have capacity to take on patients.
These are patients that haven't had access before because they just didn't have the financial means to get in.
And now, all of a sudden, they actually get to come in, get to spend time with somebody and get to feel, you know, like they're heard.
That's not to say there haven't been problems. Three million more people than expected have enrolled in Medicaid in California. Other states have also seen surges far beyond initial projections, including Kentucky, Michigan, Oregon, and Washington state.
As successful as California has been in enrolling millions in Medicaid and building new primary care clinics, patient advocates say the Medicaid expansion has exacerbated longstanding shortages in specialty care. Community clinic directors say it's often difficult to find cardiologists, orthopedists and other specialists to see their patients and that low-income Californians still face formidable hurdles when they need medical treatment.
For Alessandro Gonzales Gomez, the search for specialty care has been burdensome. Gomez spent years working as a car salesman and auto parts delivery driver. But now, at age 60 and living alone, he shuffles around his home in an Escondido trailer park, hampered by spells of dizziness.
The spells disrupt his daily prayers and curtail his driving. He's now insured under Medicaid. But most of the specialists he needs to see are an hour away.
ALESSANDRO GONZALES GOMEZ, Medicaid Patient:
On my way over there, I didn't feel well at all. I, all of a sudden, started getting dizzy again, so I turned around and just went and told them, 'I can't do this. It's too far.'
And I even asked for the director of the clinic, explained my problems. And she told me that that's the way it worked out, that there were only certain doctors that would contract with them.
ALESSANDRO GONZALES GOMEZ:
Doctor. How you doing?
DR. TED MAZER, Ear, Nose & Throat Surgeon: OK. Let's pull you up a chair right here.
One of the doctors he has managed to reach is Ted Mazer. Mazer is one of the few ears, nose, and throat surgeons in San Diego County who accepts Medicaid patients. He says the state isn't paying specialists enough to cover their costs.
DR. TED MAZER:
Certain surgeries, I can be out of the office for two hours, and we might get $300. My overhead is more than that. So, that's a loss.
Dr. Mazer sees only a limited number of Medicaid patients. But he often agrees to treat those like Qadir Khoshnaw, a 19-year-old in need of a complicated nose surgery.
MAN IN SURGICAL WARD:
OK. Lay your head back for me.
But Mazer says the state is failing to guarantee access to this type of care for all Medicaid patients.
If it was working, I wouldn't have patients coming here from Oceanside and Fallbrook and from the Mexican border and the Imperial County area and the Riverside border. I'm one office.
Why am I seeing all of those people? Because nobody else is available in their communities to see them. Why not? Because the rates are unacceptable, the hassles from the managed care plans, as well as the state, are unacceptable to most offices to deal with.
The complaints extend beyond San Diego. A withering state audit released this summer found that regulators couldn't verify if health plans had enough doctors in their Medicaid networks or if the distances patients had to drive were unreasonable.
The state's call centers were overwhelmed with phone representatives answering just half of all calls. And too often, those obstacles have forced patients to seek help in expensive emergency rooms. In a recent national survey, three out of four E.R. physicians said patient volume had increased, a pressing concern the Medicaid expansion was meant to address.
DR. CHRISTIAN TOMASZEWSKI, Medical Director, U.C. San Diego’s Emergency Department:
There's a lot of people here with chronic back pain.
Dr. Christian Tomaszewski, the medical director of U.C. San Diego's Emergency Department, says E.R. visits have increased 11 percent since the Medicaid expansion.
DR. CHRISTIAN TOMASZEWSKI:
A lot of these patients, what we're also noticing, are coming here looking for sub-specialty care. They need an orthopedist for a complicated fracture. They might need a head and neck doctor for some complicated throat problem. And they're using the emergency department as a gateway to have access to that kind of care.
At nearby Scripps Mercy Hospital, visits by new Medicaid patients are up 30 percent due to the health law, says Dr. Davis Cracroft, the hospital's medical director.
DR. DAVIS CRACROFT, Scripps Mercy Hospital:
They have insurance, they come for care, but the overall goal is to get them into a primary care doctor's office or get them the specialty care that they need. And oftentimes that's difficult for them to achieve.
JENNIFER KENT, Director, California Department of Health Care Services: We're committed to having the conversation with you about how it needs to be spent.
California's Medicaid program is a budgetary behemoth that falls to Jennifer Kent to manage. She's the California Department of Health Care Services director.
There's definitely growing pains as the system broadly has to stretch to accommodate the influx of enrollees.
Kent says the state is fixing its phone system and looks closely at complaints, but that problems with physician access are isolated and are being addressed.
We are struggling, just as every other state is, in terms of: How do we bring people into California, how do we grow primary care providers, and then, more importantly, how do we provide specialists in areas where there may not be specialists today?
California's governor, Democrat Jerry Brown, has championed the Medicaid expansion, but like other governors, he's leery of paying physicians more money just as the state confronts a drop in federal aid.
The federal government is currently paying for the entire Medicaid expansion. but, in 2020, federal support drops to 90 percent. Instead, he wants the state to spend its money revamping a system to better serve low-income patients, who are often sicker and can be hard to reach.
Despite the challenges, there is evidence progress is being made. A recent survey found that in states that expanded Medicaid, 93 percent of new enrollees are satisfied with their coverage.
Alessandro Gonzales Gomez says he will continue the long drives across the county…
Next week, I have to go to La Jolla.
… because his Medicaid card has opened up doors, even if those doors are often difficult to reach.
For the PBS NewsHour, I'm Sarah Varney in San Diego.
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