Clinton’s Health Plan : Health Plan: A User’s Guide : Reform Will Affect All Americans : THE POOR : ‘MediCal is not all that people believe it is’

Sherri Smith never thought it could happen to a solid middle-class woman like herself.

But last spring, the 24-year-old Los Angeles native became a MediCal recipient and joined the ranks of some 5 million poor Californians who receive free health care benefits at a total annual cost to the federal and state governments of $14 billion.

MediCal is California’s version of Medicaid, which provides a safety net for about 31 million of the poorest Americans at a cost of more than $118 billion a year. But MediCal coverage is often second-class: Many doctors refuse to treat MediCal patients, and pharmacies sometimes decline to fill their prescriptions.

Under President Clinton’s health care reform program, MediCal recipients would receive the same kind of insurance as other Americans, eliminating many of the barriers that now make it difficult for them to get care.

But this new status would come to her at a price. Instead of getting her care free, she would have to make a $10 co-payment for each doctor’s visit, just like all other persons enrolled in the low-cost health care plan.

Smith grew up in a financially secure, if not affluent, family in Hawthorne. She graduated from high school, married a book distributor, had three kids, worked as a business manager, attended college and was living a comfortable life in Los Angeles.

When the five-year marriage broke up last year, everything began unraveling. One of her children had a serious vision problem and, because she had no insurance, Smith began pouring money into medical care.

“Financially, it just broke me,” she said.

Then Smith lost her job, couldn’t pay the rent and soon found that she was among the city’s homeless.

“It was horrible,” she said, “because I’ve never understood what it was like to struggle like this. I never knew what it was like to be this broke.”

Once Smith was turned away from a private hospital because she had no insurance and no money for treatment for Anza, her 2-year-old girl with pneumonia. Smith spent hours on buses traveling to Los Angeles County-UCLA Medical Center to get help.

Finally, she became desperate enough last winter to apply for welfare and MediCal.

Smith and her children became eligible for MediCal benefits last spring, but she soon learned that her health care problems were far from solved. First of all, there was the task of finding a pediatrician who would accept MediCal’s payment rate, which many physicians find substandard.

“I started in the phone book under physicians,” said Smith, “and tried to find a pediatrician who accepted MediCal.”

She got to the letter K before she found one.

Smith also found that MediCal pays for only generic drugs and that prescriptions for other drugs must be returned to doctors for substitutions. Likewise, she discovered that MediCal would not pay for a $58 prescription medication for her thyroid condition.

“So I just didn’t fill it,” Smith said.

MediCal officials explain that some prescriptions require special paperwork and that pharmacists occasionally refuse to fill the orders rather than complete the forms.

Smith also found that MediCal dental benefits pay for root canal work only if the defective tooth is causing a broader medical disorder. She is currently neglecting a tooth that needs such treatment.

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But her most pressing concern has been MediCal’s refusal to pay for an eye operation for Anza. Smith said that specialists have recommended the operation so that the child will be better able to focus an eye that wanders so severely that it is dysfunctional. But MediCal refuses to pay for such operations on the grounds that they are cosmetic, Smith said.

Turned down by MediCal, Smith applied to California Children’s Services, a state agency that aids severely handicapped children. That agency approved payment for the operation.

“MediCal,” said Smith, “is not all that people believe it is.”

Under the President’s plan, Smith could join any low-cost health plan available to all individuals in her region. Her health care card would be no different from anyone else’s. The government would pay her premium and deductibles, and it would continue to provide some supplemental services now available to her under MediCal, such as transportation to the doctor and vision care.

And if Smith was turned down for a medical procedure she thought she deserved--such as the eye operation for her daughter--she could appeal to an ombudsman employed by her regional health alliance.

Although Smith is not familiar with Clinton’s health care plan, she doubts that it would hurt her. “I don’t think it could get much worse,” she said.