Dr. Del Morris has seen both sides of the canyon that separates health care for the well-to-do and the poor.
He practiced in a Seattle-area clinic where everyone was employed and insured. "I call it my yuppie practice," he said.
Today, he is medical director for the Health Services Agency in Stanislaus County, where an estimated 150,000 people -- nearly a third of the population -- do not have private health insurance.
"I've seen the well-insured. I've seen the world from different sides," Morris said.
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Nationally, there are 47 million people without health insurance, and tens of millions more who may be a paycheck away from losing coverage.
Who's at risk? The working poor and even middle-class men and women whose employers don't offer health insurance; young people stretching a budget by gambling that they will stay healthy; or just people who got sick, lost their job and their health benefits along with it.
Only a small percentage are homeless or substance abusers.
For these people, the county- operated clinics and nonprofit systems such as Golden Valley Health Centers are a fraying lifeline.
"When people talk about this being the greatest health care system in the world, they are not talking about this system, these patients," Morris said.
Stanislaus County goes well beyond the state mandate to treat the medically indigent adult population. The Health Services Agency and the clinics it operates also serve Medi-Cal, Medicare, medically indigent and uninsured patients.
But the system is strained to the breaking point, hemorrhaging millions of dollars of red ink that threatens funding for areas such as law enforcement, justice administration, parks, planning and community development, and animal services.
The county's health care crisis is echoed throughout the San Joaquin Valley, the state and the nation. Politicians at the federal and state levels, presidential contenders and Sacramento legislators are grappling with possible solutions.
The problems are particularly acute in the San Joaquin Valley, where a variety of interrelated factors converge to make health care access difficult and expensive:
California has a shortage of doctors, and the valley is worse off than the rest of the state. The shortage includes primary care doctors but is most severe for specialists.
California's reimbursement rate for Medi-Cal patients is one of the lowest in the nation. The rates are determined according to a state's per capita income, and California's is high. But the San Joaquin Valley lags far behind. Medi-Cal is California's version of the federal Medicaid program, which is administered by the states. It provides health care reimbursement for the uninsured who qualify under the financial guidelines.
The Northern San Joaquin Valley suffers more than its share of chronic disease. Stan- islaus County ranks near the bottom (the worst) of the state's 58 counties for coronary heart disease, diabetes, cancer, sexually transmitted diseases and infant deaths.
"When you look at the numbers, there is an enormous burden of chronic disease," said John Walker, Stanislaus County public health officer.
The Northern San Joaquin Valley demographics are rapidly changing. Stanislaus County's population has doubled since 1980, and the birth rate is more than double the death rate. About 52 percent of the babies born in Stanislaus County are eligible for Medi-Cal, according to HSA officials.
About 22 percent of Stanislaus County residents were eligible for Medi-Cal as of April. In San Joaquin County, eligibility was 21.3 percent, and almost 29 percent in Merced County. Statewide, the number was less than 18 percent. More than 300,000 people in the three counties were eligible for Medi-Cal as of April.
A mishmash of insurance programs for the poor, each with its own requirements and qualifications, makes it difficult for patients to understand and take advantage of them. Sometimes, a patient's status may change in the middle of treatment, making him or her ineligible or resulting in more time-consuming red tape, or children may qualify for coverage while their parents do not.
Cost vs. reimbursement
The dysfunctional health care system is expensive.
Stanislaus County last year spent $46.22 million on its clinic system, most of it reimbursed through federal and state programs and private insurance. But the rising costs have taken a toll on the county's $280 million general fund.
The county clinic system is struggling with a $10.6 million deficit even after a recent boost in federal reimbursement rates for low-income patients.
The Board of Supervisors is cutting clinic services, such as eliminating lab and radiology services, and reducing clinic hours.
More than two-thirds of the patients who come into the county health care clinics are poor. Medi-Cal patients make up 60 percent of the nearly 80,000 patients seen in the course of a year. An additional 10 percent are medically indigent, meaning they don't qualify for any in- surance coverage. The cost of their care is picked up by the county. The remaining patient population includes Medicare patients and privately insured patients.
Medi-Cal patients could go to a private practice physician -- if they could find one who would take them. Outside of the county Health Services Agency and a network of nonprofit private health clinics, Medi-Cal patients are not received with open arms.
That's because the program is a money-losing proposition for private practice doctors.
Physicians get roughly 30 percent of the costs of care from Medi-Cal, said Dr. C.V. Allen, a semiretired doctor and medical administrator in Modesto. The level of reimbursement varies depending on the service.
Most doctors in Modesto see some Medi-Cal patients, he said, and all the hospitals take a certain number of "no-pay" patients.
"I can't blame the doctors for filling their appointments with patients who can pay," acknowledged Morris, the county clinic medical director.
Given the shortage of doctors and the growing number of Medi-Cal patients, a doctor who announces that he or she is taking new Medi-Cal patients would be inundated with patients, said Debra Riordan, legislative analyst for the Central Valley Health Policy Institute at California State University, Fresno.
"He can't afford to serve them, because he wouldn't have enough private-pay patients to make his practice work," she said.
It's a vicious cycle
Dr. Eric Ramos was in private practice before joining the Del Puerto Health Center in Patterson as medical director. Medical practices have to meet expenses for office staff, nurses, supplies and malpractice insurance, he said.
Ramos said the reimbursement was $27 when a Medi-Cal patient came to the private practice with the flu. If he or she was a new patient, the cost of creating a chart, the examination and other expenses was $50 to $60.
"It's no incentive at all," he said of the Medi-Cal payments. "You can make it up in volume, but that decreases the quality of the care you give."
Without access, patients wait until a problem is severe, and then they show up in a hospital emergency room.
That's part of what Mary Ann Lee, managing director of the HSA, describes as a vicious cycle: The patient is hospitalized without insurance, and the hospital shifts the cost to its insured patients. That forces up insurance rates for employers, who eventually drop health insurance coverage for their workers. Those uninsured workers put off health care visits until a problem is acute and then show up in the emergency room, starting the cycle again.
Dr. Seang Seng is a veteran county physician. He did much to extend medical care to Cambodian refugees who came to Modesto in the 1980s.
Because of county budget cuts, Seng was not accepting new Medi-Cal patients earlier this year. Instead, he reserved space for medically indigent patients and others who have no coverage, he said. Seng said he doesn't think the county clinics are being overly restrictive. They just need to be economically viable to survive.
"Imagine if we didn't have this system," the doctor said. "Where are these patients going to go?"
Bee staff writer Ken Carlson contributed to this report.
Bee staff writer Tim Moran can be reached at firstname.lastname@example.org or 578-2349.