Helping the Forgotten

Whenever she felt ill, Hilda Guzman did what many people without health insurance do. She ignored her symptoms in the hopes that they’d go away eventually.

The 27-year-old mother of three wanted to have a checkup and Pap smear. But with money tight--her husband’s employer doesn’t provide medical insurance and the family’s income is above the threshold for the state’s Medi-Cal program--preventive care was an unaffordable luxury.

“I just did without. It was too expensive,” she says. “The wait at hospital emergency rooms are too long.”

Then one day, Guzman got lucky. At a free immunization clinic at her daughter’s school, she picked up a flier about a community clinic that didn’t turn away anyone, and she promptly made an appointment.

“The experience was great. I got birth control and got everything done in one visit,” she says of her visit to the South Central Family Health Center. “I found out about other clinics in the area that I hadn’t known about. You have to dig, to do some research, to find out about these things.”

Working adults who make too much money to qualify for welfare and yet make too little to afford health insurance premiums are truly the forgotten segment of the state’s patchwork health care system. These are not only the poor. They are middle-class adults who are temporarily unemployed. They are employees of small businesses that don’t offer medical insurance. And they are young adults who are no longer covered by their parents’ insurance, but earn low wages or are in school.

Officials acknowledge that these are the people who don’t know where to go to find quality, low-cost care. And there is very little effort to reach out to them. The barriers to care seem insurmountable to many people. Besides having no money, some people can’t take the time away from their jobs to wait long hours at clinics. Others encounter language barriers.

The Search for Providers

With diligence, and perhaps some luck, however, this forgotten segment can find health care providers who will honor their patients’ inability to pay, says Teri Jolin, communications and development director for the Community Clinic Assn. of Los Angeles County.

“There really are numerous places and resources for the uninsured through community clinics and the county,” says Jolin.

While that appears true, the system still isn’t easy to enter, says E. Richard Brown, director of the UCLA Center for Health Policy Research.

“We provide a lot of barriers to people getting care and we don’t provide much guidance about where to go. Then we’re surprised when they go to unlicensed providers,” he says. “Private hospital emergency rooms will treat if it’s emergency care. If it’s not, it’s within their right to refer a person out some place. But they don’t necessarily give people a list of where to go for care.”

The state allocates about $3 billion to pay for health care for uninsured Californians, Brown says. But the money is funneled into a fragmented system that can be confusing.

“The policies differ a lot from one county to the next,” he says. “In L.A. County and most others that operate their own county hospitals, they have an open-door policy with respect to residency status. People concerned about their legal status are not discouraged from getting care.”

Californians can turn to one of three resources for quality low-cost health care. They are county health departments, community clinics and a few private doctors who will take patients on a sliding-scale fee structure.

Los Angeles County provides a toll-free line to refer callers to clinics under contract with the county to provide low-cost or free care. (For information, call [800] 427-8700 from 8 a.m. to 5 p.m. weekdays.) Information is available in English, Spanish and a number of other languages as well.

The “Ability to Pay” program also provides some dental care--a service that the county is attempting to expand.

A community clinic is defined as a nonprofit center that is licensed by the state in conformity with the state’s operating regulations and charges clients based on their ability to pay.

“The first, safe way is to go to licensed, free or community clinics,’ says Dr. Susan Fleischman, medical director of the Venice Community Clinic. “They all meet state licensure.”

Most community clinics will provide free care or will ask for a small payment depending on the patient’s ability to pay. Typically, at the first visit, clinic officials will ask some questions that will help them determine how much the family can pay. The fee can be as little as $5.

“It’s basically determined by the clinic staff,” Jolin says. “It’s not a particular formula. It’s taking into account a person’s individual circumstances. And many community clinics offer free care.”

A visit to a community clinic might also help a family determine if some members qualify for government assistance, such as the Healthy Families program for children, Jolin says.

Some May Qualify for Assistance

“What we’re really promoting is the idea that many of these individuals can apply for Medi-Cal and Healthy Families. Medi-Cal is the federal-state medical insurance program for the poor, while Healthy Families provides care to uninsured children of low-income families who don’t meet the Medi-Cal requirements. There are certain criteria to qualify for these programs. Patients should talk to someone at the community clinic about it. And many clinics are expert in assisting families with the [program] applications.”

If you’re unsure whether a clinic is reputable, you can ask several questions, including: Is the clinic licensed by the state? Do all the physicians in the clinic have a license from the California Medical Board?

In Los Angeles, you can also ask if the clinic is a member of the Community Clinic Assn. of Los Angeles County. This is an umbrella organization for 36 free and community clinics that meet the association’s criteria, says Jolin.

There are 107 free and community clinics in Los Angeles, however, and many of them are quality clinics, she says. Some of them may not be affiliated with the clinic association, though, because of the group’s requirement that members operate under an independent board of directors. Some community clinics are affiliated with hospitals or other organizations and are governed by those boards.

Individuals can also be referred to a clinic through a statewide network of community clinics called the California Primary Care Assn. The 275 clinics in this network also follow state rules that mandate they accept fees based on the ability to pay. Beginning in April, the association will begin airing a public service announcement featuring a toll-free hotline that can help callers find the nearest CPCA clinic.

To further investigate the credentials of a physician, you can ask where the person was educated and attended medical school. Consumers can also call the California Medical Board’s quality assurance hotline at (916) 263-2382. In large, busy clinics, don’t forget to find out a little bit about the person caring for you, Fleischman adds. Lots of people wear white coats in a clinic, but they aren’t all doctors, she notes. They may also be nurse practitioners, nurses, medical assistants--or someone who isn’t licensed at all. She advises patients to be assertive about finding out who is doing the care.

Community clinics provide a wide range of primary and preventive care, such as treating simple medical problems and providing immunizations, checkups and screening tests. Some clinics also provide vision and dental care. If patients need more complex procedures, such as surgery, they are usually referred to a county-run facility, Fleischman says.

It’s best to call and make an appointment to be seen. Appointments typically require anywhere from a few days’ to a few weeks’ advance notice, she says.

For individuals who are reluctant to use community clinics, another option is to locate a private physician. To be sure, the days when the neighborhood doctor’s office would take all patients, regardless of their ability to pay, are over. Few doctors today accept Medi-Cal patients and not many offer payment on a sliding scale.

Private Physicians a Possible Option

Nevertheless, a study in the recent Journal of the American Medical Assn. reported that private physicians provide care for about one-third of the nation’s uninsured. The study of 10,881 doctors nationwide also found that physicians in solo or two-person practices were more likely to offer free or discounted care than their colleagues in managed care.

Patients who have a long-standing relationship with a doctor but who one day find themselves without insurance should ask the doctor if they can receive basic care at a reduced fee or at no cost, Fleischman says.

“I think doctors do see patients without getting paid, but I don’t think it happens in the context of a cold call,” she says. “People go on and off insurance. They are employed and unemployed. I think some physicians feel some obligation to patients they have seen before.”

She believes that many private doctors do behind-the-scenes care for current patients who have fallen on hard economic times.

“The private sector does a huge amount of uncompensated care,” she said. “They don’t get much credit for doing it.”