In less than one year, Obamacare's promise to bring health care to perhaps 1 million more poor California residents will be tested.
The big day arrives Jan. 1, 2014, when Medi-Cal, a publicly funded health program for low-income and disabled residents, launches a huge statewide expansion.
But making a promise is one thing, and delivering is another.
In some places, it's difficult for many poor California residents to find a doctor who is able or willing to see them when they need one.
From the Bay Area to San Diego, from the sprawling Los Angeles basin to the sparsely populated rural north, many medical providers who see these patients say they are overwhelmed, a situation that could worsen when those newly covered by Medi-Cal arrive for care.
The epicenter is the Central Valley, where high rates of uninsured residents, coupled with persistent doctor shortages, create a potentially combustible brew that could thwart the health care law'ssuccess.
"We're not even talking about 2014," said Carmen Burgos of the nonprofit Greater Bakersfield Legal Assistance program. Burgos helps low-income Kern County residents access health care and dental services. "Good luck finding a doctor who takes Medi-Cal now."
More than 7 million Californians are covered under Medi-Cal, and expanding the program is a major piece of President Barack Obama's signature health care reform law, the Affordable Care Act.
From 2014 to 2019, about 1 million to 1.4 million more Californians will enroll in Medi-Cal as a result, according to estimates from UCLA and the University of California at Berkeley.
The Medi-Cal expansion will broaden eligibility by allowing applicants with higher incomes and those who previously were ineligible, such as childless adults, to get coverage.
State officials say there's sufficient access to Medi-Cal services and they are constantly monitoring to ensure recipients can get care.
"We do believe that the Medi-Cal provider network provides adequate access in California now," said Norman Williams, spokesman for the state Department of Health Care Services, which administers Medi-Cal. The state also is "adequately preparing for 2014 and the expansion."
But doctors and health care experts across the Golden State offer a grim portrait of access on the ground.
"We're experiencing provider shortages right now," said Alex Briscoe, director of the Health Care Services Agency in Alameda County.
He sees pressure points across the county, from less-populated areas to dense communities. "Patients often wait months to get access to care," he said.
Desperate parents overwhelm phone lines at Riverwalk Pediatric Clinic, a private practice in Bakersfield, searching for doctors who accept Medi-Cal, said pediatrician Hasmukh Amin. About half of the practice's 20,000 patients have Medi-Cal.
"We say no to 25 to 30 callers per day," Amin said. "We cannot handle any more volume. We are maxed out."
In Los Angeles County, more than 1 million people about one-third of them on Medi-Cal were seen at 174 health clinics in 2011, said Louise McCarthy, president of the Community Clinic Association of Los Angeles County. When asked whether there will be enough doctors to serve the growing population of Medi-Cal patients, she replied simply, "No."
Medi-Cal is California's version of the federal Medicaid program, and the Golden State ranks poorly in doctor participation compared with other states.
Two studies, including one in the journal Health Affairs in August, show that 57 percent of California doctors accept new Medi-Cal patients. That's the second-lowest rate in the nation after New Jersey.
In Nevada and Oregon, 75 percent and 80 percent, respectively, accept such patients.
The primary reason doctors say they don't participate is financial.
Here, too, California scores badly, with one of the nation's lowest payment rates, ranking 47th of 50.
"I would challenge any legislator, any politician to come to my community and see if a Medi-Cal patient can get the access to the care they need when they need it, without going to the emergency room," said Ted Mazer, an ear, nose and throat specialist in San Diego.
Mazer leads the California Medical Association's committee that focuses on Medi-Cal policy. The group represents more than 35,000 doctors.
He said doctors lose money providing care under Medi-Cal. For example, he said, Medicare, the federal health insurance program for people 65 and older, pays doctors about $76 for a regular, return office visit. One private insurance company pays about $71.
Medi-Cal? It pays $24, he said.
Low Medi-Cal rates are addressed, temporarily at least, by Obamacare. Starting in January and lasting two years, reimbursement rates for many primary care services in Medi-Cal will jump to Medicare levels, funded by the federal government.
In California, the change is dramatic. On average, fees will increase by 136 percent, according to the Kaiser Commission on Medicaid and the Uninsured.
"The payment increase is a significant incentive that we anticipate will help attract new primary care physicians to the Medi-Cal provider network," said Williams of the Department of Health Care Services.
Lack of choices
In some areas, Medi-Cal patients have no other choice than clinics, said Debbie Wood, coordinator of school health for the Bakersfield City School District, where nearly 90 percent of students live at or below the poverty level.
"They go to the clinics and they sit there for six, seven, eight hours. They may have an appointment at 8 a.m. and not be seen until 4 in the afternoon," she said.
While patients ultimately receive care at the clinics, they pay for the crowded conditions in other ways, Wood said.
"Many of our families are in agricultural work," she said. "If they miss a day, they don't get paid. So they go to the emergency room."
McCarthy, of the Los Angeles County clinic association, said clinics are working double-time to hire doctors and increase capacity, but isn't sure if the efforts will be enough.
"At a certain point, the clinics are going to need to say, 'I need to cap enrollment or cap my patient load,' " she said. "It's critical we take on new patients in a sustainable manner."
The CHCF Center for Health Reporting is an independent news organization that reports about health care issues. For more, go to www.centerforhealthreporting.org.