The medical system for the more than 300,000 people who rely on Medi-Cal in the Northern San Joaquin Valley suffers from a multitude of problems that add up to a dysfunctional system: a shortage of doctors, low payments for physicians treating Medi-Cal patients, a high incidence of chronic diseases, poverty and low education rates.
Some of the problems are national in scope: large numbers of uninsured patients, rapidly rising medical costs and a growing elderly population that requires more care.
Because of the complexity of the problem, there's no "magic bullet" solution. Efforts are under way on a variety of fronts, from federal and state medical reform proposals to local efforts to curb costs and reduce chronic disease.
The federal and state proposals are couched in the political arena, as presidential candidates jockey for advantage in primary campaigns, and Gov. Schwarzenegger and legislators battle for constituent groups in California.
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Those proposals are focused on the problem of the uninsured. They range from programs that would require uninsured residents to purchase discounted health coverage to universal health care that would eliminate insurance compa- nies in favor of a single-payer, government-administered program.
Each concept has vocal critics.
Labor and consumer groups say requiring residents to buy insurance provides a windfall for insurance companies at the expense of middle-income working families. Republicans and Democrats in the Legislature are battling over how much each stakeholder -- residents, employers and health care providers -- should invest for the coverage.
Insurance companies and conservatives say a government- administered single-payer program would create a huge bureaucracy with rising costs and higher taxes.
The details of the plans are fluid, as legislative negotiations and political campaigns play out.
San Joaquin Valley health care providers and observers watch and hope for relief.
"So far, it's politics," Stanislaus County Chief Executive Officer Rick Robinson said of efforts at reform in Sacramento. "I haven't seen anything with enough substance."
"The solution is not going to be a California solution," added Dr. John Walker, the county's public health officer. "It has to be a national solution. It will require sweeping reform."
"We need a system where everyone is blind to the payer source," said Mike Sullivan, CEO of Golden Valley Health Centers. "A single-payer system would at least be blind. Now, a doctor says, 'What kind of insurance do they have?' and then says, 'Send me the private insurance patients.' "
All of the California proposals have some merit, said Debra Riordan, legislative analyst for the Central Valley Health Policy Institute in Fresno.
"If I had to name one way to solve the problems, it would be some kind of single-payer plan, government-run," she said. "I don't see that happening in the near future. There is a lot of mistrust of government programs."
Riordan said the public struggles with the issues as well.
"We feel people should have access to care. What level of care is under constant discussion. It's difficult. Is it pragmatic, philosophical, ethical? It's difficult for Americans. The Europeans seem to have a handle on it.
"I don't know where it is going. It seems like we are spiraling down still."
Designation means more help
The Stanislaus County Health Services Agency received a federal designation in September that will help keep the doors open at the county clinics. The county's primary care clinics became Federally Qualified Health Centers, which will increase reimbursements for Medi-Cal and Medicare patient visits.
The enhanced federal reimbursements give Stanislaus County incentive to serve a larger number of Medi-Cal patients. But it's not likely to happen right away. The county first has to close a $10.6 million annual deficit in its health care budget.
"At this point, it would be premature to say we are going to be growing and expanding," said Mary Ann Lee, Health Services Agency director. "Our focus is on eliminating the deficit."
The county will seek grants from other government sources to fund health care projects, Lee said.
David Quackenbush, executive director of the Central Valley Health Network, an association of community health clinics in the valley, said that county health systems could do more to collaborate with other safety-net clinics.
"What the counties don't appreciate is that the federally funded health centers are willing to provide services the counties are providing," he said. "The counties should talk ... to see how they can partner."
County officials have urged private specialty practices in the community to accept more low-income patients.
Higher reimbursement rates for Medi-Cal patients could take the pressure off the crowded county clinics, said Dr. Del Morris, who oversees the clinic system. Private practice physicians in theory would be more willing to treat low-income patients if the reimbursement were closer to private insurance rates, he said.
Dr. Alan Yates, an ear, nose and throat specialist in Modesto, said health reform legislation to insure more Californians could convince specialists to open their doors. He believes that with the employer and individ-ual mandates, a greater number of valley residents would have insurance to pay for treatment.
Stanislaus County's public health department is attacking the problems of chronic disease with education and outreach programs to change the way people live.
"There are multiple factors. Clearly, there are lifestyle issues, diet and exercise," Walker said. "There are socioeconomic variables. Poverty is a significant factor. Education is a significant factor."
The county public health department is working with church groups, volunteer organizations, law enforcement and schools to educate the public about obesity, diabetes, infant mortality and substance abuse, said Walker, the county's public health officer.
Improvement won't happen overnight, he acknowledged. "It will take time, but we have some successes to encourage us," he said.
The county has task forces working on overall infant mortality and childhood obesity.
Putting hope in UC Merced
Attracting more doctors to the San Joaquin Valley will get a boost with the proposed University of California at Merced medical school.
"That's why we have been encouraging a medical school," said Riordan, the legislative analyst. "If they are home-grown, the chance of them staying and practicing here is greater. It would be grooming people toward the medical profession."
Morris agreed. "It's hopeful for the Central Valley. A rule of thumb is that doctors stay in the county they were trained," he said.
Stanislaus County's residency program, run through the University of California at Davis medical school, has produced more than 70 local doctors, according to officials.
The UC Merced medical school could channel more local students into medicine, said Richard Pan, associate professor of pediatrics at UC Davis. Pan has studied why doctors choose to practice in particular areas.
Some communities sponsor medical students in an effort to get more local doctors, Pan said.
Negative perceptions about an area can affect a young doctor's decision, Pan said, and a community can work at educating people on the positive aspects of a place. Investments in education, for instance, can be a part of that effort, he said.
Telemedicine, where doctors in another area can view test results for patients and recommend treatment, could help alleviate the shortage of specialists, Pan said.
The demographics will remain a challenge, as the valley's population continues to grow, said Robinson, the county CEO. "It's a very, very difficult demo-graphic. Very diverse, a large income span from wealthy to poor, and a birthrate per capita among the highest in the nation."