By Thadeus Greenson, Grant Scott-Goforth and Heidi Walters
In many ways, Jude Ehrlich is the face of federal health reform on the northern California coast. The good face, anyway. The 44-year-old McKinleyville man never used to have much trouble getting health insurance. He had employee-offered plans until 2000, when he started his own small business and purchased his own policy, which helped cover his treatments for psoriasis, psoriatic arthritis, migraines and other health problems.
But paying for the Blue Cross policy increasingly became a challenge, especially as his computer repair and consulting business slogged through the recession and his monthly insurance premiums steadily climbed to $400. Eventually, Ehrlich found himself unable to keep up, and he let his policy lapse. When he was on better financial footing a few months later, he tried to reinstate it.
“And they denied me, giving me a bunch of excuses,” said Ehrlich, who was born deaf after his mother contracted rubella while he was still in the womb. “I then got a letter from them at one point saying that they would not cover me because I was deaf. I was shocked.”
For the first time in his life, Ehrlich was denied insurance due to a “pre-existing condition.” Ultimately, Ehrlich enrolled in the federal Pre-Existing Condition Insurance Plan with a $300 monthly premium. The policy wasn’t terrible — it allowed him to see his primary care provider with $20 co-pays — but it had some major problems. When Ehrlich needed a $4,000 colonoscopy, the federal plan chipped in just $600. He continues to make $20 monthly payments on the $3,400 balance.
So, when California unveiled its insurance exchange marketplace under the Affordable Care Act, known as Obamacare, Ehrlich quickly got onto Covered California’s website. He learned that he didn’t need to purchase a policy — he qualified for Medi-Cal thanks to new, expanded eligibility requirements.
“So far, it has been great,” Ehrlich said. “I pay exactly nothing, based on my income. No co-pay for doctor visits, no co-pay on (prescriptions). No monthly premiums. So far the coverage and service has been much better than what I have had in the past.”
Ehrlich’s story illustrates much of what has gone right with Obamacare. A man once denied reasonable coverage due to a pre-existing condition is now getting affordable care. But Ehrlich is only a small part of a complex picture emerging as the ACA continues to roll out in California, leaving a flurry of frustrations, successes and questions.
If the ACA is some kind of healthcare superhighway, then a Humboldt County-run call center on Fifth Street in Eureka is one of its onramps. On a recent Thursday afternoon, eligibility workers sat in neat cubicles with large computer monitors to help them guide callers through a maze of programs. While the center serves as a point of first contact for folks looking to enroll in a variety of state programs, it’s also one of the places Obamacare touches down locally.
Widely hailed as the most significant overhaul of the nation’s health-care system since the passage of Medicare in 1965, the ACA touches almost every aspect of health-care delivery in the United States. It mandates that most Americans get health insurance, threatening fines for those who try to skirt the law. It prohibits insurance companies from denying policies to people with pre-existing conditions, like Ehrlich, or from dumping folks who get sick. It also mandates that plans provide coverage for some mental-health and addiction services, on par with coverage of physical ailments.
But the biggest changes come in a three-tiered approach to getting more people insured. First, the act greatly expands eligibility for Medicaid, the federal health insurance program for the poor that covers more than 50 million Americans. In California, that means expanding Medi-Cal to cover folks making up to 138 percent of the federal poverty level — about $15,800 for an individual this year. Single adults are now eligible for Medi-Cal enrollment, opening the insurance door to millions of poor residents. On the second tier, people making too much to qualify for Medi-Cal, but less than four times the federal poverty level, are entitled to government subsidies to help pay their insurance premiums. Finally, the new law creates health insurance marketplaces, also known as exchanges, that offer standard, government-regulated plans. Open enrollment for the plans runs through the end of this month. After that, most people will have to wait until next year for coverage.
Covered California, the Golden State’s exchange, is designed to act as a large funnel. When someone calls a hotline number, he or she is quickly screened to determine eligibility for subsidies or Medi-Cal. If eligible, the operator seamlessly transfers the caller to a regional center — like the one on Fifth Street in Eureka — where local operators are waiting to help with enrollment in Medi-Cal and, if eligible, other state services. The system, which sees insurance companies, counties and the state as working in partnership with high-tech digital infrastructure, is designed to break down barriers, making it easier for people to enter the system. “It’s really a commitment for improved customer service — a commitment that there be no wrong door,” said Kathy Young, social services director at the Humboldt County Department of Health and Human Services.
To demonstrate the no-wrong-door approach, Young tells one of her favorite stories. A local woman phoned the call center not long ago and was enrolled in Medi-Cal without any income verification tests — operators simply accessed her tax information electronically. Then, after she’d enrolled, the woman said she was with a relative from Sacramento who was also looking to sign up for Medi-Cal. The operator told her to put the relative on the phone and signed her up with her local Sacramento office. The whole goal, as Young sees it, is to get as many eligible folks signed up as possible.
In Humboldt County, the need was great, with a large number of people living without health insurance, according to Herrmann Spetzler, CEO of Open Door Community Health Centers. “Almost half of the people in our greater Humboldt Bay Area did not have any kind of insurance,” Spetzler said. “Now, a pretty large subset of those people are getting insurance, and they are looking for their medical home.”
Statewide, 828,000 people had enrolled for coverage under Covered California as of Feb. 15, but the exchange isn’t releasing county-level data, so it remains unclear how many folks in Humboldt have signed on. What is clear, however, is that Medi-Cal enrollment is surging locally under Obamacare. According to the Department of Health and Human Services, the number of Medi-Cal cases granted in Humboldt County jumped more than 40 percent from December to January, increasing from 9,888 to 13,925, with the cases combining to bring coverage to some 27,699 people.
That’s more than 4,000 newly covered people looking to access health-care providers — an influx that threatens to strain the local system. “Expanding capacity is not as instant as giving people insurance cards,” Spetzler said.
If Ehrlich and his smile can be seen as what Obamacare got right, Catherine Markle sees the other side on a daily basis. Markle, the billing manager at Eureka Family Practice, said she’s been dealing with confused and frustrated patients since October, when Covered California began enrolling patients.
Only two major insurers are offering policies under the California exchange — Blue Shield and Anthem Blue Cross. When the companies came to negotiate with providers on the North Coast, they took a hard line, as they have throughout the state. Blue Shield offered reimbursements that were 30 to 50 percent less than they would pay doctors under traditional insurance plans, Markle said. Similarly, Anthem Blue Cross offered 10 to 65 percent reductions from its traditional reimbursement levels.
“These are major payers,” explained Markle. “They don’t have to give you a reason, and they don’t have to negotiate. They really kind of backed us into a corner and they wouldn’t negotiate. They said, ‘Take it or leave it,’ and we were forced to leave it.” It turns out that most providers on the North Coast decided to leave it, unable or unwilling to agree to huge reductions to their bottom lines. “As a business, that’s not something we were able to sign on for,” Markle said. “I tell patients, ‘Equate it to your salary for the year. Would you be able to survive taking a 65 percent pay cut?’ The answer is always no.”
The situation directly impacts two types of patients. First, there are the newly insured who will be setting out to find a primary-care doctor — their “medical home” — and will learn that the only major provider accepting their new insurance is the Open Door Community Health System. Then there are the patients who have long had a primary-care doctor but switched to a cheaper Covered California plan, not realizing the Blue Cross or Blue Shield exchange alternative is decidedly different than the plan they gave up. It’s this second group that’s most frustrating for Markle, as she’s the one tasked with telling longtime patients that Eureka Family Practice won’t take their new insurance. “I’ve had patients in tears and patients who are really angry,” she said. “It’s been awful and I feel terrible for our patients who are put in this position of non-coverage, really.”
Charles Minton, a retired RN, said he was stunned when his wife recently enrolled in Covered California, looking to replace her existing catastrophic insurance plan (which carries a $15,000 deductible) with an option that was cheaper and covered more services. Minton says she was looking forward to finding her medical home but was turned away again and again as she approached local providers. “Getting it accepted is a whole new thing I hadn’t even thought of,” Minton said. “Everyone took Blue Cross before.”
Markle said there is a workaround that she’s informing patients of, but — she warns — it comes with some risk. If a patient sees a provider that isn’t contracted with one of the state exchange plans, he or she can pay out of pocket and then apply for reimbursement for “out-of-network coverage,” which the plans offer for care they deem reasonable and customary. “It’s then kind of at the whim of the claims processor as to what they deem reasonable and customary,” Markle said.
While the problem seems to be acute in Humboldt County, it’s not unique. With Covered California, the insurance companies knew there would be a demand for their products so they could afford to offer lower reimbursement rates. Insurers figured they’d offer providers lower rates with the promise of scores of new patients. On the northern California coast, where primary-care doctors are in high demand, the prospect of new patients doesn’t provide much incentive. The same is true with many specialty practices.
From a patient’s perspective, the situation can be daunting. Minton said he and his wife are holding onto both her old plan and the new one from Covered California until they get a better idea of what’s going on. The hope, he said, is that something changes with the state plan. “It looked like a great deal, and it could be if people only took it,” he said.
Manila’s Casey Schuetzle was an ideal candidate for the ACA: She’s 29, self-employed and had been uninsured since being kicked off her parents’ plan about five years ago. She’s also been dealing with a nasty shoulder problem that’s kept her from surfing.
In response to a survey on the North Coast Journal’s website, Schuetzle raved about the ACA: “The 2 months coming up to before I got my card have been the hardest for me physically,” she wrote. “But!!! I have it now, as we speak I’m in my car in SF to see a specialist and get the care I deserve … that everyone deserves. … I get to be honest with the shoulder specialist and not have to worry about pre-existing conditions that will shut the door in my face.”
But a couple of weeks later, her enthusiasm had turned to frustration. “Now that I’ve got insurance, there’s a whole new set of problems,” she said, explaining that she made the six-hour drive down to San Jose to see a shoulder specialist only to be turned away at the receptionist’s desk after learning that, while the doctor takes Anthem Blue Cross, he wouldn’t accept her Anthem Blue Cross. “I had no idea that I had to disclose I’m with Covered California,” she said. Finding an orthopedic surgeon that will accept her plan has been a nightmare. “Every time I call a freakin’ surgeon they say they take Anthem Blue Cross but they do not take it under Covered California,” she said.
Schuetzle’s frustration is partly balanced by the fact that her plan has worked well for her primary care and lowered her prescription costs. That’s because she was already a patient at Open Door, which is welcoming Covered California patients, according to its CEO Spetzler. “As far as I know, Open Door was the only substantial provider pool that was willing to accept these [Covered California] policies,” he said. “For us, the reason is we were seeing these patients anyway before they had insurance.”
Open Door has a policy of not turning anyone away, Spetzler said, so it accepts payments on a sliding scale from the uninsured and, often, no payment at all. “So, now, if they come to us with any kind of coverage at all, we’re better than we were,” Spetzler said. But can Open Door alone keep up with the avalanche of demand that seems to be looming on the northern California coast? Can it continue to be one of Humboldt County’s only large providers to accept Medi-Cal patients as thousands like Ehrlich join their ranks and all of the county’s Covered California patients like Schuetzle come knocking?
“The biggest single issue on the north coast is that the private-sector, primary-care capacity has shrunk radically,” Spetzler said. Last year, Open Door’s centers saw 45,500 patients, he said. That’s 1,000 more than they saw in 2012, and 3,000 more than 2011. “We are bulging at the seams,” Spetzler said, adding that Open Door will continue its policy of treating those in need and not turning people away. However, he said, there’s a push through the ACA for patients to find a medical home, a primary physician who can coordinate their care and serve as a point of entry for all their needs. Open Door can only provide that service to so many people. Spetzler estimates its Eureka facility is probably at capacity but centers in McKinleyville, Arcata and Willow Creek can probably take on some additional patients.
“We will make every accommodation for people,” he said. “We’ve always seen the people in Humboldt County who need to be seen.” But, Spetzler says, the county “needs a vibrant primary care group. … We really need to regroup and bring more providers into this community.”
It’s pouring rain in McKinleyville, and Jude Ehrlich is huddling under a redwood tree in his front yard to stay dry. He has nothing but good things to say about Obamacare and what it’s done for him. If he’d waited to get that colonoscopy it likely would have been covered, and he wouldn’t still be paying it off.
Looking out at the rain and patting his service dog, an energetic yellow lab, Ehrlich said the ACA has been a ray of sunshine in an otherwise pretty rough year. He’s been looking for work since April, having decided that his computer repair business isn’t worth the time as computer equipment keeps getting cheaper to buy and more costly to fix. People just throw away the broken stuff and replace it with something new, Ehrlich said.
But the job hunt has been tough. In total, he’s applied for more than 200 positions, trying to get someone to pay him for working the register at local gas stations, being a systems administrator at Humboldt State University or a range of other jobs. He’s had no luck. Recently, he fell behind on his house payments, so he took out a loan against his car to catch up. While Ehrlich is working toward certifications to bolster his resume, he’s living on a thin margin. Stress is building. But, at least he can rest assured that he can break his leg or suffer some other unfortunate accident without the medical bills costing him his house. “I’m covered,” he said.
This story was produced for the California Health Report in partnership with The North Coast Journal.