As part of a massive coverage expansion under the Affordable Care Act, millions of people have been allowed to sign up for California's health insurance plan for the poor for nearly two years.
The program, known as Medi-Cal, now serves more than 12.5 million people, nearly 1 out of every 3 Californians. But there have been persistent concerns about the quality of care, with questions about whether patients can find doctors and get the help they need.
Now a new analysis adds weight to those worries.
In the first study of its kind, UC Davis researchers found that compared with patients with other kinds of insurance, cancer patients with Medi-Cal were generally less likely to have their cancers caught at early stages, receive recommended treatments and be alive five years after diagnosis.
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"The aggregate finding that struck me, and continues to strike me, is that the Medi-Cal members seem to have little or no advantage over the uninsured," said Dr. Kenneth W. Kizer, who wrote the study as director of UC Davis' Institute for Population Health Improvement.
Starting in January 2014, Medi-Cal was greatly expanded under the Affordable Care Act, and the program now costs $91 billion. But Medi-Cal did not seem to confer the same benefits as having other kinds of insurance — and often was little better than having no insurance whatsoever, the study found.
Researchers reviewed data on treatments and survival rates for nearly 700,000 cases of breast, colon, rectal, lung and prostate cancers from 2004 to 2012 in California. The analysis is believed to be the first to examine cancer care and outcomes by insurance type.
Some of the findings appear related to Medi-Cal's problem of connecting patients with doctors, in part because of the program's lower payment rates. Those rates, among the lowest in the nation, discourage doctors from taking on more patients.
The UC Davis study found 27% of Medi-Cal patients with breast cancer were diagnosed at a late stage, compared with 12% of those privately insured.
"It doesn't surprise me at all," said Christopher Perrone of the California HealthCare Foundation. Making sure enough doctors agree to accept Medi-Cal patients has been a major problem for the program, he said. Plus, Medi-Cal has recently come under fire for other access issues. A recent state audit found that provider directories were riddled with errors and that the state wasn't properly checking that the health plans that treat Medi-Cal patients were serving them properly.
Experts say that worse health outcomes for the Medi-Cal population can also be attributed, at least in part, to demographic characteristics, such as patients having lower incomes and fewer resources, or suffering from other health problems.
But the study also revealed disparities in care that were harder to explain.
Breast-conserving surgery is considered a best practice for patients with early-stage breast cancer. The analysis revealed that 52% of Medi-Cal patients received the recommended treatment, while 60% of privately insured patients did. Similarly, 65% of Medi-Cal breast cancer patients received radiation therapy with the surgery — also considered a best practice — while 72% of those privately insured did.
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"When it comes to the quality of care, that's in the hands of providers," said Kizer, who formerly served as director of the state's Department of Health Care Services, which oversees Medi-Cal. "You can't explain that very well on the basis of socioeconomic or demographic things, so it raises questions about why Medi-Cal beneficiaries are not receiving the recommended treatments."
The study also found a 22% five-year survival rate among Medi-Cal patients diagnosed with Stage 4 breast cancer and a 31% rate for those privately insured. The difference was linked to the lower quality of care, Kizer speculated.
Health Care Services spokesman Anthony Cava said that Medi-Cal officials are reviewing the UC Davis study. "The data are an important tool to support our ongoing quality improvement efforts on health outcomes," he said.
Cava said he'd like to see similar data covering the years since implementation of the Affordable Care Act in 2014. The Medi-Cal program has grown dramatically in that period, with costs climbing 73% since 2013. Many say that has worsened Medi-Cal access problems, with too many new patients and not enough doctors willing to see them.
But the department has also been moving more Medi-Cal patients into managed-care plans, which are groups of doctors who contract with the state to provide and coordinate care. The shift is intended to improve patient care and could address some of the problems revealed by the study, because the plans have contracts requiring timely care, Perrone said.
The study also found that patients who received care through the Department of Veterans Affairs were often more likely to receive recommended treatments and have better outcomes than those with other insurance types. But they also often had the longest intervals between diagnosis and the beginning of treatment.
Kizer couldn't explain the delay. But he said it's possible that it didn't affect patient outcomes much because cancer is a slow-developing disease and that quick care may not be as important as the best care.
"What it does point to is that if you get the right treatment, your likelihood of a good outcome is much better," Kizer said.
Other findings in the UC Davis study include:
- 39% of Medi-Cal patients were diagnosed at an early stage of breast cancer, compared with 61% of those privately insured;
- Medi-Cal and uninsured patients were the most likely to have colon cancer diagnosed at Stage 4 at 32% and 29%, respectively, and VA patients were the least likely, at 15%, while the overall percentage of patients diagnosed at Stage 4 was 20%;
- 57% of Medi-Cal patients diagnosed with Stage 3 colon cancer had favorable five-year survival rates, compared with 71% of those privately insured;
- Medi-Cal patients were diagnosed with Stage 4 prostate cancer more than three times as often as patients with private insurance, 19% compared with 6%;
- 31% of Medi-Cal patients were diagnosed with rectal cancer at Stage 4, while only 14% of privately insured patients were diagnosed that late.