The health care plight for L.A.'s poor

Medi-Cal has expanded but barriers still remain

Sitting in a one-bedroom home she shares with her sister and nephew near Thai Town in Los Angeles, Mercedes tearfully recounts the moment she was diagnosed with breast cancer. As she describes the scene in her doctor's office two years ago - it was just a routine mammogram - it becomes clear that the news of her disease was less traumatizing than the thought of having to pay for treatment. Mercedes is undocumented and uninsured.

"The first thing I said was, 'How much could this cost?' she said. "I didn't know where to go."

Mercedes, 48, arrived in the United States from Puebla, Mexico nine years ago with her brother and sister. She took jobs cleaning homes and caring for children. She asked that her full name not be used because of her immigration status.

Mercedes was diagnosed with breast cancer at an early stage and was told there was hope of it being completely removed. She paid out of pocket for initial testing. A couple months later she ended up at the emergency room with extreme pain in one of her breasts.


Living with cancer is difficult for anyone.

It is even harder when you are residing in a country where your legal status is "undocumented?" How can you hope to pay for medical treatments when you don't qualify for health insurance?

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Two months later Mercedes underwent surgery at LA County-University of Southern California Medical Center. A special Medi-Cal program, covering emergency treatment for those who would not otherwise qualify for government aid, paid her bills.

Whether or not health care should be provided to everyone living in the United States is part of an ongoing national debate fueled by President Obama's signing of the Affordable Care Act in 2010. The election of President Trump, who promised to repeal the bill entirely during his campaign, intensified the conversation. There have been several failed attempts to repeal and replace the Affordable Care Act in the past few months.

Insurance Stats of L.A.

Expanding Medicaid to more low-income patients is central to this national debate. According to a 2016 report, Medi-Cal, California's version of Medicaid, provides medical insurance to 37.8 percent of people living in LA County.

Medi-Cal plans are available in LA County through programs like Health Net and LA Care. Additionally, the Department of Health Services provides a program called My Health LA (MHLA) for those ineligible for Medi-Cal.

While Medi-Cal covers about one third of LA County, MHLA ensures care for more than 145,000 residents, and participants are not asked about their immigration status. Patients can only access care at county clinics and hospitals. It is a health care program - not an insurance plan.

Although Medi-Cal and other county programs have expanded, it still proves challenging for low-income patients to get to clinics. In an affluent area like Beverly Hills, there are about 16 clinics per 10,000 people. In East Los Angeles, there are less than two clinics per 10,000 people.

Dr. Greg Haroutunian, regional director of AltaMed Company, discusses the trouble with Medi-Cal, an insurance policy for low-income people in California. Click here if video does not play.

Dr. Greg Haroutunian, regional director for AltaMed Company, oversees more than 35 clinics in Los Angeles. AltaMed, established as a free clinic in East LA, is a health care system that serves Southern California. As a pediatrician for the company's Boyle Heights clinic, Haroutunian sees primarily low-income patients.

"Their life is a little more difficult than some other people," he says. "Sometimes they need transportation and they rely on somebody and they don't get it. They're not always technically savvy or able to call and cancel. Some of them have language barriers."

Government-funded health care services have expanded access for many people, including the poor. But patients and doctors alike say the quality of care remains low. The possible culprit: Medi-Cal and My Health LA are capped programs, meaning doctors receive a fixed rate for accepting patients, regardless of the number of times they see a patient or the services they provide.

For example, My Health LA pays providers $32 per patient, per month. Medi-Cal pays about $20 per patient, per month. This fixed rate is paid whether the doctor sees a patient 10 times that month or not at all.

Haroutunian is frustrated by capped health care programs because he says they encourage doctors to see patients less often.

"What they were trying to convince me to do is to prevent patients from coming to see me, that way I could collect the money without seeing them," Haroutunian said. "They're all encouraging fraud."

My Health LA's program director, Amy Luftig Viste, defends capped health care programs. She says they do not stand in the way of patients receiving adequate care, as long as clinics and hospitals are able to stay operational.

"You are incentivized to bring in patients less," she says. But "less is more if you're meeting patient needs."

Luftig Viste believes patients shouldn't have to go to the doctor more than is necessary, which fee for service care encourages. When patients go to the doctor only when needed, or for yearly checkups, it cuts costs for everyone.

Doctors, patients, and policymakers alike are trying to find an equilibrium within the system that will benefit all.

Barriers to Access

Medical bills are one of the top 10 reasons Americans end up in debt. Wilma Ballew, 73, from the San Fernando Valley went to Palmdale Hospital suffering from a gallstone attack. Her bill: $11,000.

"I just stared at that bill and thought 'Oh my god.' At first I thought 'is this me? Am I supposed to pay that?'"

Mercedes in her room

Medicare and Medi-Cal covered Ballew's medical bill. Nonetheless, her activist mind immediately jumped to those without the same coverage.

"What if I didn't have Medicare or Medi-Cal? What if I didn't have that? But yet I still have the right to go into the ER and get supposedly taken care of."

Money isn't the only barrier to health care. Other barriers may include location, language, and culture, says Dr. Patrick Dowling, the chair of UCLA's department of family medicine.

Medi-Cal and MHLA have increased coverage for low-income patients, but just having a card isn't always enough. Clinics, emergency rooms, and urgent care can be miles away. It can also be challenging for patients to engage with their health care providers.

"There are 6 million Californians that live in what's called a health professional shortage area for primary care," Dowling explains. "We have a huge immigrant population in the state. Even if you have insurance and there's a place to go, you can't really engage with that provider."

Reforms Needed

Efforts to repeal and replace the Affordable Care Act failed just a couple weeks ago in Congress. But does that mean everyone's happy with it? We asked some people in Los Angeles what they think. Click here if video does not play.

Since the passage of the Affordable Care Act in 2010 the number of Medi-Cal recipient has increased in LA County. But the program is far from perfect.

Dowling is pleased that the country was able to pass something similar to universal health care. He says that industrialized democracies with universal care have thrived. "Those are the systems that work, that have the best outcomes, the best quality, the lowest cost per person."

Many European countries, such as France and Switzerland, have experienced shorter wait times, cheaper medication, and high quality care since providing people with universal health care.

Dowling wants the United States to keep pushing toward universal health care despite challenges. "That's going to be a real fight because that means people are going to get paid less."

Haroutunian also agrees that the country needs a universal health care system. "We're a filthy rich country, the richest by far than any other country in the world," he says. "And we can't afford healthcare for everybody? For kids, who are our future? Isn't that ridiculous?"

In Case of Emergency

For Mercedes, the greatest challenge in accessing health care is her immigration status, but she also faces language, cultural, and financial barriers. She was determined to pay for treatment using the little money she earned, but a friend convinced her otherwise, knowing the financial burden would eventually be too much.

"A friend I know said to me, 'You know what, Mercedes? Right now, yes, you can pay because you're working. But what happens the day they operate on you?'" The friend encouraged Mercedes to apply for Emergency Medi-Cal.

"I said, 'How does one get Medi-Cal? I don't know, they're not going to give it to me because I don't have papers.'"

Mercedes decided to test her luck and apply anyway. After submitting the application she was told she would have to wait until her paperwork was processed. But cancer doesn't wait.

"It started to hurt me more, the breast pain, and so I went to the emergency room. Then, you know what they told me? 'You need to apply for emergency Medi-Cal so we can operate on you here because it's very expensive.'"

After explaining that she had already submitted an application, she was given her Emergency Medi-Cal card that same day at the hospital.

Emergency Medi-Cal is available for patients in an emergency medical state who would otherwise be ineligible to receive government-funded health care. It can only be used for emergency treatment.

Mercedes' cancer is now in remission, though she will be returning to the hospital for more tests in September.

While the care she got was not easy to come by and leaves plenty of room for a focused debate on how to improve these types of government programs, Mercedes is grateful.

"Thank God they operated on me and I'm OK. Thank you my God."


Two L.A. County residents share their experiences with Medi-Cal.

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