After San Diego ear, nose and throat physician Ted Mazer recently billed the state's medical insurance program for the poor for a tonsillectomy, he got a check for $168, too little to cover surgical costs. The balance came out of his pocket.

Now legislators have cut the rates even further, leaving Mazer resolved to shut his doors to new Medi-Cal patients. Almost every other specialist in his field countywide has already done the same, he said.

"I am the last guy I know of still taking [Medi-Cal] on a regular basis," he said. "I am seeing patients from the Riverside and Orange County lines all the way down to the border."

Statewide, many other doctors report that they too are abandoning Medi-Cal, even those who had stuck with it for years out of a sense of professional responsibility.

In response, San Francisco Mayor Gavin Newsom is expected to announce in Sacramento on Tuesday that a coalition of local governments and healthcare providers plans to file suit to force a rollback of the 10% cut in fees paid to doctors that was approved by legislators in February.

Patients and their caretakers say the scarcity of Medi-Cal doctors is already potentially dangerous.

It took downtown Los Angeles resident Liliana Ramirez more than six months to get an appointment with a physician willing to fit medical braces on her 7-year-old son, Angelo, a Medi-Cal recipient with spina bifida. Now, Angelo needs a urologist to treat a bladder problem, and Ramirez has spent weeks trying to get an appointment, she said.

"It feels like a gamble with his health," Ramirez said. "There is fluid going back to his kidney. And he only has one kidney, which is already halfway gone. . . . I am grateful for the system, but it is getting harder and harder to get in to see a doctor."

Half the state's doctors were refusing Medi-Cal patients eight years ago, just after rates were last increased. Refusal rates were sharply higher among certain specialists. Medical costs have risen since then, but state officials have stopped assessing whether enough doctors are participating in the program.



Numbers no longer work

Reimbursement rates, doctors say, already are so low that a patient office visit nets only $24. Some clinics say the numbers simply don't work anymore. The result: Thousands of patients guaranteed healthcare under state law can't get in to a doctor's office, so they don't go or they sit for hours in an emergency room.

Experts warn that things may get much worse.

Chris Perrone, an analyst who tracks Medi-Cal issues for the California Healthcare Foundation, said Medi-Cal risks are becoming so unattractive to doctors that the program could soon "fall off the edge."

When lawmakers began to address the state's multibillion-dollar budget shortfall, Medi-Cal was the first program to be targeted with major cuts because of its size.

Funded jointly by the state and federal government, Medi-Cal is California's second-biggest expenditure after education. It is projected to cost $38 billion next year, with about $15 billion drawn from the state's general fund. The program serves 6.7 million poor, elderly and disabled people.

The projected savings from the cuts, say state officials: more than $500 million annually.

The Legislature's nonpartisan budget analyst, Elizabeth G. Hill, had advised against the cut because it could discourage so many doctors from taking Medi-Cal that patients would be forced into emergency rooms, where treatment is far more costly. The state will also lose hundreds of millions of dollars in matching federal funds.

"This is not being done lightly," said Sandra Shewry, director of the state Department of Health Care Services. "It is not a preferred policy direction so much as responsible management, given the resources of the state."

Shewry said Gov. Arnold Schwarzenegger had no choice after lawmakers earlier this year rejected his proposal for universal healthcare, which would have included a substantial boost in rates paid to Medi-Cal doctors, funded by billions of dollars in new fees.



A 'hidden tax'