Obamacare and the docs

In his 2012 book, It’s Enough to Make You Sick, about the American health-care system, Chico neurosurgeon Jeff Lobosky warns that the Affordable Care Act has serious problems.

To mention just one flaw Lobosky sees: The ACA moves millions of low-income people into Medicaid (Medi-Cal in California), but there aren’t even enough doctors for current Medicaid patients. “It will get them a card,” he said in an interview, “but it won’t get them care.”

As of Jan. 31, more than 1.6 million Californians had signed up for either Covered California health-insurance plans or low-cost or no-cost Medi-Cal. Locally, some of those patients are finding health care, but many aren’t.

Julie Light is one of the lucky ones. A part-time substitute teacher, the Corning woman had been getting care at a local clinic that accepted cash payments on a sliding scale. When she signed up for Obamacare insurance, she continued to use the clinic.

On her one visit since getting her insurance card, she saw a physician assistant and got some lab work done. Her co-pay was $3.

The clinics are rapidly filling up, however, as more and more people obtain ACA coverage. In Chico, Northern Valley Indian Health’s East Avenue clinic is seeing six to eight new patients a day, Beya Villegas, its site manager, reported in a phone interview. The clinic is “close to capacity,” she said, and the pressure to see more people “has taken a toll on the clinic. … I wonder where patients will go when we fill up.”

The Chico Children’s Center, the pediatric clinic formerly run by Enloe Medical System but now part of NVIH, is similarly filled up. “We’re probably booked out six weeks for some providers,” Villegas said.

The number of patients these clinics can see depends on the number of providers—doctors, physician assistants, nurse practitioners—on staff. But it’s not easy to find qualified people who want to work in a clinic setting. “God, no,” Villegas said. “Normally it takes six months to a year [to fill an opening].”

The largest federally qualified clinic in the Chico area is the Ampla facility on Cohasset Road, which offers dental as well as medical care. It recently underwent a major remodeling and expansion, but even so, it’s now at capacity.

That doesn’t seem to faze Ampla’s Yuba City-based CEO, Benjamin H. Flores. Ampla has 12 clinics spread among rural towns such as Orland, Willows and Gridley, and many of them are not yet at capacity. Besides, Flores said during a phone interview, “We will continue growing and expanding services as demand requires.”

Flores’ optimism echoes that of Anthony Wright, executive director of the consumer-advocacy group Health Access. The hope, he told the California Health Report last June, is that “[i]f you create a lot more paying customers by getting them insured … the market will adjust in terms of having more [doctors] there.”

Maybe so, maybe not. Richard Thorp, who in addition to being a primary-care doctor in Paradise is president of the California Medical Association, points out that the historic problem with Medi-Cal—its low rate of reimburse-ment—has been carried forward under the ACA.

An office visit is valued at $23 or $24, he said, “about what you’d pay for an extra-large pizza.” The rates are so low, he added, that every Medi-Cal patient is a money loser for his or her doctor.

The rates under Covered California’s insurance plans aren’t any better, Thorp said. The most affordable “bronze” plan reimburses at 70 percent of the same insurance company’s commercial rate, which in turn is lower than the Medicare reimbursement rate.

Is it any wonder, he asked, that doctors aren’t eager to accept new Medi-Cal and Covered California patients? “Doctors are in business,” he said. “They have significant overhead. They have to make decisions that enable them to stay in business.”

California has faced a shortage of primary-care doctors since long before implementation of the ACA. This is especially true in rural areas, where many old-style family docs are retiring and not being replaced. Unfortunately, most young doctors are not attracted to working in small towns.

Indeed, most young doctors aren’t attracted to being family doctors, period. A specialist’s hours are better and so is the pay.

The trend is to make increased use of doctor surrogates—physician assistants and nurse practitioners—to compensate for the physician shortage by handling uncomplicated cases under a doctor’s supervision. This is especially true in clinics, where a team model is often used to provide the most efficient and effective care possible.

Even if the shortage of primary-care physicians is solved—a huge “if”—it won’t make specialists any more willing to accept Medi-Cal or ACA patients.

Just recently, Lobosky and his partners at Northstate Neurosurgical Associates received five or six referrals from the Redding area in one week. All were Medi-Cal patients who had been turned away by local neurosurgeons.

As the Redding doctors knew, the NNA neurosurgeons are the only ones in the area who accept Medi-Cal. In these cases, however, they too turned away the patients. They can barely afford to take Chico’s Medi-Cal patients, Lobosky explained.

Is Obamacare going to work? He’s doubtful. “Obamacare is counting on the doctors to say, “Oh, screw it. I’ll see them. The costs are going up, up, up, and they’re going to stick it to the docs and hospitals.”

If Obamacare fails, he said, one group will benefit: supporters of a single-payer system, or Medicare for all. “But it’s far too early to tell,” he said.

In contrast, Ampla’s Flores is upbeat. “For us, it’s an exciting time,” he said.

Independent reporting for this story was made possible through a grant from HealthyCal.org.