Working In These Times
Making Health Care Reform Work: A Perspective from California Doctors
LOS ANGELES—At a conference convened by the organization Reporting on Health at the University of Southern California this week, doctors and health care experts shed light on labor-related aspects of the health care field as the sweeping health care reform legislation is set to take effect after being upheld by the U.S. Supreme Court.
They provided a window into the workplace stresses and challenges doctors themselves have faced in our tumultuous and trouble-plagued health care system, and also the health care needs and challenges of low-income workers.
Marcia Sablan, a doctor in the tiny northern California town of Firebaugh, embodies both of these narratives. Marcia is one of many doctors who depended on a federal program that helps people afford medical school in exchange for working in under-served rural districts. After her residency at the University of Hawaii, she was assigned to Firebaugh, in the agricultural valley of Fresno County, with a population then of just over 3,000. She was accompanied by her husband, also a doctor and the first native of Saipan to graduate from a U.S. medical school.
Panelists at the conference noted that such programs will be increasingly important if the government wants to encourage more doctors to go into general primary care rather than becoming specialists. Specialists make an estimated $3.5 million more over their lifetimes, yet there will be an estimated shortage of 30,000 primary care doctors in coming years especially as more people become insured under the new health care law.
Sablan arrived in Firebaugh in 1981 and eventually founded her own private practice there, where she primarily serves low-income Latino farmworkers, about half of them immigrants, including many uninsured people who may or may not end up insured under the health care bill reforms. Doctors and experts at the USC conference echoed the widespread concern that due to the way the health care reform bill and Supreme Court decision played out, people living under the poverty line may not get insurance under the new law. That’s because the insurance exchanges and subsidies the law mandates are designated for people who make more than the poverty line, while people making below the poverty line (including childless adults —a change from the past) are all supposed to be covered by Medicaid.
States are ordered to expand their Medicaid programs to cover people making up to 133 percent of the poverty line, but the mandate doesn't have strong teeth since it is unclear if or how the federal government can punish states that don't expand their Medicaid programs to cover the newly eligible people. Many states say they cannot afford their share of the expansion plus the extra costs expected when currently eligible but un-enrolled people “come out of the woodwork” thanks to the publicity around the reform law.
Sablan notes that she never asks her patients about immigration status—she is not required to under California’s Medicaid law—and she typically charges a $50 fee which most patients pay out of pocket.
“Undocumented workers know not to leave a trail, not to leave bills,” she said.
But when her patients need specialty care, the seasonal nature of farm work can cause serious problems. Many of them do have insurance during the months they are employed, but not during the off-months, she said. In her early years in Firebaugh, many of the locals were migrant workers living in labor camps who returned to Mexico or otherwise left Firebaugh for half the year. But the labor camps have been demolished and now many farmworkers have bought homes and live year-round in the town with their families, even as they continue to depend on seasonal agricultural wages. Hence an illness or injury that keeps them away from work for days or weeks during the crucial seasonal employment period is especially devastating financially.
“What does an agricultural-based seasonal economy mean to a doctor practicing there?” Sablan asked, noting that Firebaugh’s population now numbers 6,741: 88 percent Latino, 22 percent living below the poverty line, more than a third unemployed and almost two-thirds without a high school diploma. “It means people have insurance and Medi-Cal (California’s version of Medicaid) at certain seasons of the year. But we know diseases don’t work like that. So this is a huge problem for us—seasonal workers have a very difficult time keeping up with chronic diseases.”
From a health perspective, Sablan is glad to see the valley’s once-thriving cotton industry decline, she said, since it involves heavy pesticide use that raised serious health problems for workers and other residents. Once she treated victims of what was known as the worst pesticide-poisoning case in state history—28 workers critically poisoned after being ordered to return to a field too soon after it had been sprayed with phosphates. Now almonds and pistachios are the main crops in the area, grown mostly by huge industrial farms. (Meanwhile a sustainable cotton project has been in the works.)
Sablan hopes the health care reform law will indeed result in better preventative care for low-income and currently uninsured people. She cites the case of one patient, a 54-year-old farmworker who had a heart attack and was prescribed medication which, at $400 a week, he could never afford. Also suffering from diabetes and lacking medication, he eventually had another heart attack and ending up needing permanent dialysis by age 60.
“When you think about the Obama plan, think about [the farmworker] – do we want to be upstream or downstream?” in health care spending, she asked. “Someone paid for him to be in the hospital two times and on dialysis, which costs about a million dollars a year. He’s totally disabled now, unable to work, from what should have been a preventable situation.”
Despite such challenges, Sablan and her husband feel lucky to work in an environment where they have treated three generations of patients —it gives them a sense of personal connection and continuity that other doctors say they lack when forced to see up to 30 patients a day, in the common “fee for service” health care model.
Dr. Ken Kim described the challenges of working in a typical profit-driven, urban system. He and other internists were disgusted to see how badly many of their patients were faring under the standard health care model. He described multiple diabetic patients with legs amputated because they were shuffled between specialists, waiting for months for appointments, while a “pin-sized” wound became infected and festered. And he described elderly patients unable to comply with a doctor’s orders because they lacked a ride to the clinic or couldn’t open medicine bottles with arthritic hands or ate high-sodium meals as shut-ins. Doctors and nurses want to help such patients with personalized care, he indicated, but the fee-for-service model and other aspects of the traditional insurance system create so much time pressure that patients fall through the cracks.
So Kim and other doctors formed an “accountable care organization” (ACO) wherein insurance companies like Blue Cross pay the organization a flat fee to provide care for a certain group of the insurance companies’ enrollees. Kim said that after floundering at first, the company, CareMore, where he now serves as chief medical officer, was able to provide holistic, preventative care to a patient base of mostly ailing senior citizens by subverting the fee for service model, focusing on prevention and making sure the various nurses and doctors working with a given patient communicate and develop a cohesive plan. He said that under their organization rates of hospital readmissions, amputations, mortality and other indicators have decreased drastically. Many hope this type of accountable care organization will become more common under the health reform law.
While the general public is obviously confused about the implications of the health care reform bill, doctors and health care experts are also uncertain about how the law will play out and what it will mean for their own work lives and those of their patients.