Ex-Health Net member learns to deal with Medi-Cal

The coverage from the array of public and private insurance plans in this country is a recipe for dysfunction

There are a lot of people who resent having to buy health insurance under Obamacare. Presumably their only weakness is Kryptonite.

Then there are those who desire Obamacare coverage but have been forced out of the program and into plans for low-income people. They now face difficult choices because a growing number of doctors won't accept them as patients.

Kerry Reis is one such person. The Mar Vista resident enrolled in a Health Net plan offered through Obamacare as soon as the Covered California online exchange opened last year.

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FOR THE RECORD:

Covered California: In the Nov. 24 Business section, a column about patient eligibility for Medi-Cal, the state version of Medicaid, quoted a UCLA Health spokeswoman as saying its primary care physicians do not accept Medi-Cal patients. A senior manager said they do.
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He was pleased with the coverage. It provided a free annual physical and helped him afford the drugs he takes to manage his Type 2 diabetes, the most common form of the disease.

A few weeks ago, however, Reis, 57, received word from Covered California that he was out. Because his earnings had dipped low enough to make him eligible for Medi-Cal, he was being automatically switched to the public program intended as a safety net for low-income people.

Reis has been out of work since losing his job as a TV executive in 2011. He doesn't consider himself "poor" or "indigent."

"I did not request enrollment in Medi-Cal," Reis told me. "I do not think the state has any right to force any of its residents into a social services program at this level."

Actually, the state has no say in the matter.

It's one of the lesser-known aspects of the federal Affordable Care Act that anyone whose income drops below a certain level will be automatically shifted to Medicaid — or Medi-Cal in California.

They can still buy Obamacare coverage if they so choose, but they'd have to bear the full cost themselves. No subsidies would be available.

As a result, Medicaid is almost always their only choice.

In Reis' case, the original Health Net plan he bought through Covered California came with a price tag of $447.59 a month. But with subsidies, his monthly out-of-pocket cost was $28.59.

Medi-Cal will be even cheaper. In fact, Reis will pay nothing.

Thanks to Obamacare, newly eligible Medi-Cal members will have all costs paid by the federal government for at least the first three years. The state is responsible for half the costs of people who qualified for the program before Obamacare, even if they hadn't previously signed up.

The ranks of Medi-Cal members are rapidly swelling. It's now the country's largest Medicaid program, with more than 11 million members statewide.

But to control costs, Medi-Cal's compensation to doctors is among the lowest in the nation. As a result, many doctors no longer accept Medi-Cal members as patients. There are parts of California where people in the program simply have no access to healthcare.

There's also a stigma attached to Medi-Cal and other healthcare programs targeting low-income people. They're often are seen as insurance of last resort, providing substandard care and conditions.

A report on Medi-Cal last year by the California HealthCare Foundation found that the state ranked below the national average in "consumer experience," such as communication with doctors and receiving treatment in a timely fashion.

"Is it totally inadequate? No," said Michael B. Nichol, a professor of health policy at USC. "But it's not what most people would prefer."

This is why Reis is unhappy. His doctor in Santa Monica is part of the UCLA Health system and already has informed him that she won't accept Medi-Cal reimbursement.

In fact, a spokeswoman for UCLA Health told me that not one of the hundreds of primary care doctors at the system's facilities throughout the region will accept Medi-Cal patients.

So Reis will have to look elsewhere for healthcare. And he's deeply worried about what he'll find — if he can track down a doctor who will see him.

"I've heard that the care under Medi-Cal isn't the best in the world," Reis said.

Roy Kennedy, a spokesman for Covered California, said people in Reis' position "should speak with one of our enrollment counselors or certified licensed agents to see what options are available."

That probably wouldn't hurt. But unless you're ready to shoulder the full cost of insurance under Obamacare — that is, without subsidies — your options won't be plentiful.

It should be said: At least Medi-Cal is something. It might not provide the best or most convenient healthcare, but it's still better than being uninsured.

Yet again, however, it's clear that the hodgepodge of coverage provided by the dizzying array of public and private insurance plans in this country is a recipe for dysfunction and inefficiency, not to mention a healthcare system comprised of haves and sort-of-haves.

Health insurance is the art of risk management, and, as with all forms of insurance, the most effective way of providing comprehensive coverage at the lowest price is to pool all risk and share costs evenly among the population.

USC's Nichol said other countries do this in the form of single-payer health plans, supplemented by private insurance.

The United States, in its obsessive devotion to "free markets," forgoes the efficiencies of a robust single-payer system and remains committed to the idea that healthcare is first and foremost a for-profit business.

Nichol said he believes we'll find our way to a more enlightened healthcare system eventually.

"I just don't know if it will happen in my lifetime," he said.

In the meantime, it appears that people like Reis will have to be satisfied with whatever they get.

David Lazarus' column runs Tuesdays and Fridays. he also can be seen daily on KTLA-TV Channel 5 and followed on Twitter @Davidlaz. Send your tips or feedback to david.lazarus@latimes.com.

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