Newborns. Former inmates. Faculty college students. Expectant mothers. Folks with disabilities. Foster children. Homeless folks. Single dads.

Your neighbor. Your co-worker.

You.

California’s Medicaid program, referred to as Medi-Cal, serves a whopping 15.4 million folks, providing care from cradle to grave: Half of all births are coated by Medi-Cal, as are greater than half of all stays in nursing properties.

Every little thing about Medi-Cal is very large, from its upcoming fiscal yr funds of $139 billion to the expansive checklist of advantages and providers it provides. The way in which this system works — or doesn’t — might spell life or demise for a lot of enrollees.

“It’s essential, from the only pregnant mother, to the extraordinarily frail aged inhabitants that wants a nursing dwelling,” stated Jennifer Kent, former director of the state Division of Well being Care Providers, which administers Medi-Cal. “If it weren’t for Medi-Cal, so many individuals would both be lifeless or can be severely compromised.”

In a brand new collection, California Healthline will make clear Medi-Cal’s successes and failures by way of the experiences of its enrollees. They embrace Stephanie Lammers, who can’t get her troubling stomach signs checked at a clinic 50 miles from her small Calaveras County city as a result of the transportation Medi-Cal is meant to offer isn’t reliable; Carolina Morga Tapia, a Fresno lady who credit Medi-Cal with serving to her have 5 wholesome kids; and Lucas Moreno Ramirez, a Los Angeles County man with stage 4 lung most cancers who needed to combat to maintain his therapy going.

Medi-Cal is at a essential juncture because it makes an attempt to serve the wants of a various affected person inhabitants with a dizzying array of medical wants — from childhood vaccinations and most cancers screenings to state-of-the-art look after uncommon genetic problems. Roughly half of enrollees are Hispanic, and, subsequent yr, California will turn out to be the primary state to increase eligibility to all immigrants who qualify, no matter their authorized standing.

Medi-Cal can be enterprise a number of new initiatives that goal to avoid wasting taxpayer cash and enhance high quality. State officers are demanding that the 23 well being insurers that serve most Medi-Cal sufferers present higher care — or face important penalties, together with potential expulsion from this system.

The state can be including revolutionary social providers that fall exterior the standard realm of medication, together with serving to some enrollees pay for hire and purchase groceries.

“Persons are watching California,” stated Cindy Mann, who served as federal Medicaid director beneath former President Barack Obama. “What the state is doing is formidable and really aggressive. It makes a big mark on well being care and well being coverage, not simply due to the dimensions and breadth of its program, however by being very complete.”

However solely a sliver of enrollees will get the brand new social providers, whilst many sufferers wrestle to acquire primary care or get in to see their docs. In actuality, the kind of care you get in Medi-Cal is dependent upon the place you reside and which insurer gives your advantages.

Meaning this system is working for some, however failing for a lot of others.

If you’re in Medi-Cal, we wish to hear from you, whether or not you reside in an enormous metropolis or a rural area, no matter your age, race, or ethnicity, and no matter your medical, dental, or psychological well being situation. Have you ever had issue seeing the fitting physician for what ails you, even to the purpose of placing your life in danger? Or did Medi-Cal present excellent care, maybe sparing you critical hurt or incapacity? Both means, please take into account sharing your expertise with us.

Listed here are snapshots of sufferers who’ve used this system at a essential time of their life.

‘I Simply Don’t Go to the Physician Anymore’

When Stephanie Lammers leans over to placed on her sneakers, it feels as if she’s squishing one thing inside her stomach, she stated.

Lammers, 53, has been affected by frequent bouts of nausea, ache, and bloating for six months.

Her gastroenterologist desires to carry out diagnostic procedures, together with a colonoscopy and, if something exhibits up, a biopsy. However Lammers, who lives in a motel together with her boyfriend and teenage daughter within the Gold Rush city of San Andreas, doesn’t have a working automotive and might’t readily get to the clinic — which is 50 miles away.

For Lammers, like many Medi-Cal enrollees who reside in rural areas, lack of transportation is a significant obstacle to acquiring care. The issue is especially acute for sufferers who must see specialists.

Lammers’ dermatologist and eye physician are over an hour away from San Andreas, the county seat of Calaveras County, about 125 miles northeast of San Francisco. She isn’t seeing a neurologist, regardless of a collection of mini-strokes and stress-related seizures. And he or she hasn’t been to a podiatrist in two years, though her toes are twisted over each other and grasp down, inflicting her to journey. She’s usually in excruciating ache when she walks.

Medi-Cal is meant to offer free transportation to enrollees who can’t in any other case get to their appointments.

However Lammers, whose well being plan is California Well being & Wellness, owned by Centene, the nation’s largest business Medicaid insurer, stopped utilizing its experience service practically a yr in the past, after she missed dozens of appointments as a result of drivers simply didn’t present up, she stated. She was getting threatening letters from docs’ workplaces over the no-shows.

As soon as she needed to hitchhike greater than 30 miles dwelling from a counseling appointment. On different events, Lammers stated, she didn’t obtain the reimbursement she was owed for arranging her personal rides.

“I simply don’t go to the physician anymore,” Lammers stated. “If I am going to the physician, my boyfriend has to take the time without work work, and if he takes the time without work work, we’ve no cash.”

Over the past three months of 2022, Lammers canceled 5 appointments she had scheduled for the diagnostic stomach procedures as a result of her boyfriend needed to work every time and couldn’t take her. She lastly stopped rescheduling.

California Well being & Wellness contracts with Modivcare, a Denver-based medical transportation firm that’s no stranger to affected person complaints and lawsuits.

Earlier than she gave up on the experience service, Lammers stated, she would name California Well being & Wellness to attempt to resolve the difficulty, solely to be instructed that Modivcare was a separate firm. “I’m like, ‘Should you guys employed them and put them in control of transportation, who oversees their screw-ups?’”

Courtney Schwyzer, a member of a authorized help workforce representing Lammers on varied Medi-Cal issues, stated the failure of medical experience providers is a systemic downside. In late February, Schwyzer and her fellow attorneys filed a petition in courtroom that she hopes will pressure the state Division of Well being Care Providers to handle the issue.

California Well being & Wellness spokesperson Darrel Ng stated the corporate screens the standard of its contractors, however a scarcity of transportation suppliers in rural areas “has created distinctive challenges.”

Modivcare gives greater than 4 million rides for Medi-Cal recipients yearly, and greater than 99% are with out criticism, stated Melody Lai, an organization spokesperson.

Lammers, who’s unemployed and attempting to begin a customized craft enterprise referred to as Stuff by Steph, stated docs have warned her that if she doesn’t cut back her stress degree, it might shorten her life. However arranging medical care is essentially the most worrying factor in her life proper now, so she doesn’t attempt anymore.

“So as to maintain from dying, I’ve to not go to the physician,” she stated.

‘It’s a Blessing’

Medi-Cal helped save the lifetime of Carolina Morga Tapia, a 30-year-old, full-time mom of 5 who lives together with her household amid almond groves in an agricultural enclave of Fresno.

9 years in the past, a bacterial an infection triggered untimely labor through the twenty fifth week of her second being pregnant, and Morga Tapia virtually died. She spiked a fever, bled profusely, and wanted rapid transfusions and emergency surgical procedure. After a number of days in essential care, she totally recovered.

However the docs couldn’t cease the untimely delivery, and her child got here out weighing simply 1 pound. She and her husband, David Nuñez, named her Milagros Guadalupe, and he or she died 4 days later, on Sept. 13, 2013 — a Friday.

In every of her subsequent pregnancies, Medi-Cal paid for Morga Tapia to get pictures of artificial progesterone, supposed to forestall one other preterm delivery. These pictures — one per week for about 20 weeks — can value a mean of greater than $10,000 per being pregnant.

Morga Tapia and Nuñez, a development employee, signed up for Medi-Cal when she was pregnant together with her first youngster greater than a decade in the past. They’ve been on the identical Anthem Blue Cross Medi-Cal plan ever since.

“It saves some huge cash, and it’s a blessing to have that further assist.”

Morga Tapia

The plan paid for prenatal care by way of all six of Morga Tapia’s pregnancies, and it has offered all of the medical and dental care the household wants, she stated.

“With out Medi-Cal, we must be paying for all of our kids,” stated Morga Tapia. “It saves some huge cash, and it’s a blessing to have that further assist.”

Her kids, 4 ladies and a boy, vary in age from 1 to 10. All of them go to the identical kids’s clinic and see the identical pediatrician.

The youngsters, all in good well being, get routine checkups, vaccinations, and different preventive care, Morga Tapia stated. She will get appointment reminders through textual content and playing cards within the mail notifying her when it’s time for the youngsters’ vaccinations and wellness checks, in addition to her Pap smears, she stated.

Her household’s expertise contrasts sharply with the state’s evaluation of their well being plan, in keeping with a report on high quality of care in Medi-Cal issued late final yr. The report, which evaluated Medi-Cal well being plans on pediatric care, ladies’s well being, and power illness administration, put Anthem Blue Cross within the lowest tier, and under par on a number of measures in quite a few counties, together with Fresno.

One other state report, launched in late January, detailed how shortly insurers present appointments for his or her sufferers, and put Anthem Blue Cross’ Medi-Cal plan close to the underside of the heap.

Anthem Blue Cross spokesperson Michael Bowman stated in a press release that the interval coated within the reviews coincided with the covid-19 pandemic, “when our security web suppliers handled important challenges with workforce and appointment availability.”

Morga Tapia doesn’t give the insurer low marks. “It’s totally different for everyone. I’ve wholesome household, and what Medi-Cal covers is basically lucky for us,” she stated.

‘I Don’t Wish to Die But’

In late 2021, docs gave Lucas Moreno Ramirez a number of months to reside.

Combating diabetes and late-stage lung most cancers, Moreno Ramirez suffered debilitating ache as he hacked and labored for breath. His docs advisable that he cease therapy and begin hospice care.

He felt as in the event that they had been giving up on him.

“They stated they’re going to present me opioids for my ache and assist me have a snug demise,” stated Moreno Ramirez, 68, who lives in Norwalk, in Los Angeles County. “I instructed them I don’t imagine in that. I don’t wish to die but.”

A former landscaper and manufacturing facility employee, Moreno Ramirez realized he needed to be his personal advocate, combating for the care he believed he deserved from Medi-Cal.

He stated his Christian religion gave him power, and over the subsequent few months, Moreno Ramirez pushed this system and his docs to maintain battling his most cancers, utilizing a special therapy with fewer unwanted side effects than chemotherapy.

“I imagine in prayer,” he stated. “However I imagine in science and drugs, too.”

Moreno Ramirez is likely one of the roughly 1.6 million Californians enrolled in each Medicare, which covers people who find themselves 65 and older or have disabilities, and Medi-Cal, which kicks in to cowl the prices and advantages that Medicare doesn’t.

He additionally depends on his Medi-Cal insurer to assist him navigate the byzantine system. L.A. Care, the biggest Medi-Cal plan with practically 2.6 million members, related him with a care supervisor who labored with him to determine a special therapy referred to as Tagrisso and advocated for him to get it. 

Even with the brand new medicine, Moreno Ramirez’s coughing suits returned final yr, and his signs grew so painful he suspected the most cancers was rising. He requested to see his pulmonologist however was instructed the primary appointment can be in June 2023. So he switched docs and scored an appointment practically six months sooner.

“My previous physician didn’t assist me. I didn’t belief him,” Moreno Ramirez stated. “He was all the time too busy for me. I instructed my docs, ‘Give me an opportunity.’”

Having taken his care into his personal fingers, he says he’s not in ache, his cough has subsided, and he feels eager for the long run. “Now I really feel good,” he stated.

He has additionally sought extra consideration for his diabetes and obtained a steady glucose monitor to measure his blood sugar. It’s higher managed now than it has been in many years, he stated.

“You need to rise up for your self and advocate,” stated Joann Pacelo, the care supervisor who helped Moreno Ramirez change docs, get faster referrals to specialists, and get accredited for in-home nursing visits.

“Loads of instances it’s troublesome with Medi-Cal as a result of the docs are busy and the reimbursements are so low, however nobody ought to be denied the care they deserve.”

This story was produced by KHN, which publishes California Healthline, an editorially unbiased service of the California Well being Care Basis.

KHN (Kaiser Well being Information) is a nationwide newsroom that produces in-depth journalism about well being points. Along with Coverage Evaluation and Polling, KHN is likely one of the three main working packages at KFF (Kaiser Household Basis). KFF is an endowed nonprofit group offering data on well being points to the nation.

USE OUR CONTENT

This story might be republished without spending a dime (particulars).