In one of the largest expansions of health coverage to the uninsured, Los Angeles County is enrolling hundreds of thousands of residents in a publicly funded treatment program and setting the stage for the national healthcare overhaul.
The county hopes to register as many as 550,000 patients and is assigning them to medical clinics for services at no cost to them. At the same time, the county is transforming its healthcare system to be less focused on acute care and more on primary care. The changes are expected to reduce costs, streamline care and attract patients.
Under President Obama's controversial healthcare overhaul, millions more uninsured Californians will be eligible for Medicaid — the healthcare program for the poor — beginning in 2014. Even as the debate over the law continues in Washington, California is starting that expansion now and using federal dollars to do so. Altogether, the state expects to receive $2.3 billion to expand and modernize its Medicaid program, known as Medi-Cal, now available only to certain low-income residents.
In L.A. County, the stakes are high. In 2014, the newly insured county residents will be able to seek treatment wherever they want. To keep them with the county, health leaders recognize that they must make the system one of choice rather than of last resort. Otherwise, the only patients left will be illegal immigrants and others still ineligible for public coverage.
"Our survival depends on it," said Mitchell Katz, director of the county Department of Health Services. Unless the healthcare system improves, he said, "if people have choice, they won't choose us and the system will implode."
Health departments across the nation are watching L.A. County, where nearly one-quarter of the 9.8-million population is uninsured. If the county is successful in expanding coverage and revamping its healthcare system, observers say, it could become a model for others.
But that won't be easy.
"The scale here is just mind-boggling," said Andy Schneider, a consultant to the Kaiser Family Foundation. "And there are so many changes that have to occur simultaneously.... It's like trying to reorganize the health system of Michigan."
Health workers began signing patients up for a program called Healthy Way L.A. in July and so far have enrolled 24,000, many of whom are receiving services. County residents are eligible if they are between the ages of 19 and 64, citizens or permanent residents of five years and earn less than 133% of the federal poverty level (about $14,500 for an individual and $29,700 for a family of four).
The coverage is not insurance and cannot be used outside of L.A. County, but it does give patients the ability to receive free primary and specialty care, mental health services, chronic disease management, medication and emergency treatment. Most of the enrollment is being done when patients go to the county's network of hospitals and clinics.
Advocates are closely tracking the expansion and said they have found several problems, including lack of translated documents, delays in setting up appointments and extensive patient paperwork, said Barbara Siegel, managing attorney at Neighborhood Legal Services of Los Angeles.
"We have to get it right so that in 2014, the county continues to play that critical role in providing healthcare to our indigent population," she said.
Over the next two years, the county will pay half the cost for Healthy Way L.A. — or about $300 million — and the federal government will pay the other half. By 2014, when the patients become eligible for Medi-Cal, the federal government will pick up the entire tab, which will help bolster the financially strapped county's health system. The county also expects to receive about $300 million more for other changes.
"It's the county's job to provide care for the uninsured," Katz said. "If I have an opportunity to get half of that paid for by the federal government, I'd be a fool not to take it."
Healthy Way L.A. and other programs throughout the state will ensure that there isn't a flood of new patients or any delay in receiving federal dollars for their care in 2014, said Anthony Wright, executive director of the California advocacy group Health Access.
"We are taking this two years to get fully ramped up so we are ready on Day One," Wright said. "The more Los Angeles [County] enrolls people in the next two years, the more folks will be on the federal rather than the county dime."
Just three months in, county health officials are already encountering obstacles. Outdated technology and a lack of electronic records are causing delays and making it difficult for doctors to effectively manage care. And moving people away from urgent care has required a massive culture shift.
"Old habits are hard to break," said Ernest Espinoza, administrator of the El Monte Comprehensive Health Center. "Everyone was entrenched — both staff and patients."
One of those habits was using specialists as primary-care doctors. The county recently moved 4,000 patients — who were getting all their medical care from neurologists, cardiologists and other specialists — back to primary-care doctors. That makes more room for people who need specialists and decreases wait times for appointments, Katz said.
Perhaps the biggest change has been the creation of medical homes, clinics where patients receive consistent, comprehensive primary care by the same team of providers. The El Monte center, which has enrolled about 1,200 new patients in Healthy Way L.A., is one of the first in the county.
Administrators at the El Monte center are assigning patients to specific doctors, expanding clinic hours and allowing more same-day appointments. They are also urging patients to call the 24-hour nurse advice line, rather than go to a hospital emergency room, and they are offering health education classes and mental health services on site. The goal, Espinoza said, is to build a relationship with patients so they keep coming back.
Evan Ramirez, 50, is an uninsured cancer survivor who said she typically goes to the emergency room when she gets sick. But if she has to buy medicine, she said, "there isn't enough for food." Ramirez learned last week that she could enroll in Healthy Way L.A. and planned to return to the El Monte clinic with the remaining paperwork. "For me, it's a great benefit," said Ramirez, whose only income is from baby-sitting her grandchild.
Chee To, 60, who works as a caregiver and recently became covered under the new program, went to the clinic last week to follow up on her diabetes and high blood pressure. To said she liked seeing the same doctor twice. "If I see other doctors, they don't understand my medical condition as well," she said.
The clinic's adult medicine chief, Dennis Wong, said he is able to develop relationships with his patients and follow their progress. "That continuity is very important, not only for the patients but for us," he said.
The UCLA Center for Health Policy Research is evaluating Healthy Way L.A. Its associate director, Gerald Kominski, said it is too early to tell how it will turn out, noting that changing behavior is difficult.
"You are talking about a population that is accustomed to being uninsured," he said. "So they have had a lifetime of only seeking care when it is absolutely necessary and going to the emergency room."