Medi-Cal, health-care reform and the ER collide

Nearly a third of Sacramento ER visits are paid for with Medi-Cal. Can we afford to add millions more low-income residents to the rolls and truly improve preventative care?

An hour before midnight inside the UC Davis Medical Center ER waiting room, a man with a tube protruding from his arm shuffles over to a wall socket and pulls his cellphone from its charger. As he turns, he catches the attention of a dejected-looking family, then jokes: “They’ll let you in if you’re having a heart attack. Your heart stop, they’ll let you right in!”

The family members smile.

The ER is about one-third full. It’s quiet, save for the buzz of TVs and about half of the two dozen or so middle- and lower-class people waiting who haven’t begun to doze off.

The intercom crackles to life and calls another patient into triage. His mother, an old woman in a red Christmas sweatshirt, sighs. Just moments before, she had given him permission to step out for a smoke.

If this December night is representative of most of last year, then 42 percent of the patients going through this ER on Stockton Boulevard in south Sacramento will be covered under Medi-Cal, California’s version of Medicare. That number is higher than most hospital emergency rooms in the region.

And it’s also more than the state and county averages. In fact, according to data provided by the Office of Statewide Health Planning and Development, Medi-Cal was the No. 1 means for paying for Sacramento County ER visits in 2011, at 30.88 percent.

Medi-Cal in the ER has been trending upward since 2006 in Sac County, which boasts payment frequencies higher than those at ERs in Los Angeles, San Diego and San Francisco counties.

These patients in Sacramento ERs also belie state averages: only 20 percent, or one in five California residents (some 7.7 million people), are covered under Medi-Cal, which serves low-income Californians, seniors and persons with disabilities, according to the California Department of Health Care Services.

The program, funded in equal parts by the state and federal governments, has proven difficult for California to pay for, with its increasingly tightening budget. DHCS reports show that in 2012 alone, the Golden State was on the hook for about $17 billion in Medi-Cal coverage, which is more than 19 percent of California’s general fund.

And the tab is about to get bigger.

The federal Affordable Care Act, or Obamacare, is set to go into effect in less than a year, expanding Medi-Cal eligibility to millions more uninsured Californians. While there are no concrete numbers surrounding future coverage, it is estimated that hundreds of thousands of Californians will sign up for Medi-Cal in the first year alone; the UC Berkeley Labor Center estimates that between 750,000 and 910,000 of the 1.4 million Californians to be newly eligible for Medi-Cal as a result of Obamacare will sign up for the program by 2019, along with up to a half-million of the estimated 2.5 million residents currently eligible but not enrolled.

People need health insurance, sure, but can California actually afford to insure people? And, even if it can, will Medi-Cal patients just end up in the emergency room instead of at a primary-care physician’s office?

The state Legislative Analyst’s Office says the Obamacare price tag will be in the low hundreds of millions annually during its first few years, and a study released this month by the UC Berkeley Labor Center has provided estimates in the same ballpark.

However, this same study suggests that the costs to California will be minimal, with the federal government perhaps picking up more than 85 percent of Medi-Cal expenses.

According to Laurel Lucia, one of the study’s authors, the added coverage for Californians won’t be the only perk.

“This program will be putting billions of federal dollars into the California economy,” said Lucia, noting that the Medi-Cal expansion, paired with enrollment growth for those already eligible, could inject up to $3.5 billion from the federal government into the state in 2014 alone.

Anthony Cava, with the state Department of Health Care Services, noted that there will be other benefits with the expansion of health coverage and preventative care for lower-income Californians. Again, however, these benefits cannot yet be specifically quantified.

“Regular preventive care has proven to decrease health-care costs,” he explained, “including costs associated with hospital admissions, emergency care and the costly treatment of chronic conditions.”

So while experts predict a spike in ER visits once Obamacare goes into effect, state officials are looking to win the long game, providing a portion of the 7.3 million uninsured Californians with Medi-Cal coverage with the hope that they will actively take part in preventative care.

Studies on Oregon’s Medicaid State Plan suggest they will: newly covered low-income Oregon residents have been found to be 70 percent more likely to have a usual place of care and 55 percent more likely to have a regular doctor than those not covered.

Of course, Medi-Cal won’t cover everyone. The California HealthCare Foundation reports that the percentage of uninsured in the state has been on a slow rise since the economic crisis kicked off in 2008; the uninsured currently make up 22 percent of the state population. For many who do not qualify, there are options, such as county indigent-care programs and the Low Income Health Program. But those are dwindling, too.

And for the rest?

For instance: California is home to about a quarter of the estimated 11.1 million illegal immigrants living in the United States. Whether or not this portion of the population should be eligible for medical benefits has long been hotly debated. As it stands, Medi-Cal applicants must provide identification, Social Security numbers and immigration status. However, applicants are not required to answer questions regarding their immigration status during the screening process.

Meanwhile, “Federal law requires states to provide emergency care to undocumented immigrants,” said Cava.

Minority communities also sometimes disproportionately end up in the ER and forgo preventive care. Here in Sacramento County, for instance, black residents make up 10 percent of the population, but in 2011, accounted for nearly 20 percent of emergency-room visits.

So, while Obamacare is coming and is set to provide many low-income Californians with much-needed healthcare coverage with seemingly little cost to the state, there’s still much work to be done. And concerns with the future of the U.S. health-care system remain.