The number of people in Tuolumne and Calaveras counties enrolled in Medi-Cal, the state’s health insurance program for low-income and disabled people, could swell upward of 15 to 20 percent in coming days as a result of the Affordable Care Act.
The shift Jan. 1 reflects the addition of formerly uninsured working adults and their children, plus individuals and families whose employers have dropped their employee health care, and individuals transitioning from state and county funded medical programs to Medi-Cal.
The result will likely be a flood of patients leaving their doctors or pediatricians and going to Medi-Cal clinics.
Tuolumne County now has about 6,000 Medi-Cal recipients. After Jan. 1, Tuolumne County Public Health officials expect 7,545 people will be eligible for Medi-Cal.
In Calaveras County, Calaveras Works and Human Services Agency Program Manager Kathy Houle expects an additional 2,000 people countywide will be eligible for Medi-Cal or so-called “managed Medi-Cal” plans that are like traditional Medi-Cal but for people that fall in a higher-income range.
The Medi-Cal enrollees will include 1,300 people formerly on a state- and county-funded public health plan for residents of rural counties called Path2Health/County Medical Services Program.
Most of the others entering the Medi-Cal system have never been on government-funded insurance. Some of those people were formerly uninsured while others are workers whose employers have dropped their health plans.
Many adults in the latter group will buy insurance off the state’s health exchange, while their children will go on Medi-Cal. This would include those in a family of four earning over $32,496 but under $58,884.
The Affordable Care Act, among other things, raised the eligibility limit for Medi-Cal enrollment, opening the door to people formerly ineligible because their income was too high. It also removed the asset test for individuals and families whose income is at or below 138 percent of the federal poverty level.
Individuals who make $15,864 a year or less can enroll and a family of four making less than $32,496 can enroll for the Expanded Medi-Cal program.
As a result of all these changes, many people will have to switch doctors. That’s because some physicians won’t accept Medi-Cal because of its historically low reimbursement and onerous paperwork requirements, according to health experts.
Still others who enroll in the subsidized exchange insurance plans — Blue Shield of California and Anthem Blue Cross in this region — could lose their doctors if their doctors don’t take the policies.
Some Affordable Care Act critics say 70 percent of California physicians won’t take so-called “Obamacare patients.” Others say such claims are overstated.
“Talk about some panicking that’s going on. The families are really worried,” said Calaveras Works and Human Services Agency Program Manager Kathy Houle. “For those who are very sick ... it’s hard for people to understand.”
Dr. Todd Stolp, Tuolumne County Public Health Officer, said higher Medi-Cal reimbursements under the Affordable Care Act, and the fact so many people are being added to the Medi-Cal rolls, may force doctors to accept Medi-Cal and the exchange plans anyhow.
The billing and approval processes are also supposed to be streamlined, perhaps making Medi-Cal insurance more palatable.
“There is, understandably, a lot of skepticism among practitioners,” Stolp said.
When it comes to accepting Medi-Cal, family medical centers or health clinics aren’t as dis-incentivized as private practice doctors. As so-called “rural health providers” they already get reimbursed at a rate higher than a private doctor, said Calaveras County Public Health Officer Dr. Dean Kelaita.
That means many people who formerly went to a private practice doctor may find themselves seeing doctors at so-called “safety net clinics” in the near future.
In Calaveras County, Mark Twain Medical Center operates five family health clinics that accept Medi-Cal, but some private providers do not, Kelaita said. There are is also a MACT Clinic in San Andreas.
Tuolumne County clinics include the MACT Clinic in Sonora, the Mathiesen Memorial Clinic in Jamestown, the Tuolumne Me-Wuk Clinic in Sonora, the Tuolumne Me-Wuk Clinic in Tuolumne, and the Forest Road Health and Wellness Clinic in Sonora.
“In Tuolumne County, we’re very fortunate to have as many safety net clinics as we have,” Stolp said.
An example of how the shift will work: Children formerly seen at Foothill Pediatrics — part of Sonora Regional Medical Center’s contracted Sierra Physician Network — will be referred to the Forest Road Pediatric Health Clinic instead, according to Gail Witzlsteiner, Sonora Regional Medical Center spokeswoman.
Witzlsteiner said the Tuolumne County physicians not in the hospital’s network will determine individually if they’ll accept the new insurance. None returned phone calls for this story.
The emergency rooms at Sonora Regional Medical Center and Mark Twain Medical Center will continue to see Medi-Cal patients — a large part of their businesses already.
According the Office of Statewide Health Planning and Development, in 2011 Sonora Regional got 31 percent of its inpatient reimbursement from Medi-Cal and Mark Twain Medical Center reported 44 percent.