EDITORIAL: How to spend California’s cigarette tax. And don’t forget women’s health

May 05--Between Congress and Sacramento, it is now clear that the capacity to play politics with health insurance is boundless. Not so the resilience of those who most need coverage.

A week-and-a-half ago -- as Washington plotted another cruel shot at the Affordable Care Act and state lawmakers fought over a cigarette tax windfall -- a clinic that for 30 years had been a refuge for Sacramento-area women quietly closed, thanks to a scenario that is all too familiar to Medi-Cal providers.

Women's Health Specialists, like Planned Parenthood, California's better-known family planning nonprofit, had offered subsidized contraception, STD testing, legal abortion and other reproductive health services. About 80 percent of its clients paid via Medi-Cal, which is to say they were mostly low income.

Like Planned Parenthood, Women's Health served people who were often young, homeless or in crisis despite sometimes violent ideological and religious opposition. In the end, however, what shuttered Women's Health Specialists wasn't the poverty of the 10,000 patients it served annually or the picketing of its staffers.

It was the difficulty it encountered in paying its nurse practitioners and doctors, due largely to California's rock-bottom reimbursement rates for Medi-Cal providers. When a physician only gets paid $50 for a $100 doctor's visit -- or $300 for a $1,500 surgical procedure -- the arithmetic eventually speaks for itself.

Low reimbursement rates have been a chronic complaint among doctors who take Medi-Cal patients. California's rates haven't appreciably risen since the recession, though the need for Medi-Cal providers has grown exponentially since eligibility was expanded under Obamacare.

More than a third of the state, 14 million people and counting, are insured under Medi-Cal, which is what Medicaid is called in California. But finding doctors willing to endure the program's red tape and often meager scale of payment is notoriously difficult.

Frustration this year is especially intense because a voter initiative passed in November -- Proposition 56 -- had promised a solution. A $2-per-pack bump in the tobacco tax, pushed over the finish line by doctors, dentists, Planned Parenthood and other providers, was supposed to generate more than $1 billion in desperately needed new Medi-Cal funding. That, in turn, was supposed to underwrite an increase in reimbursement rates and encourage more doctors to accept Medi-Cal.

Instead, events have conspired to create a fresh health insurance skirmish between providers who want and need those higher rates and Gov. Jerry Brown, who, for a variety of also good reasons, wants to use the Proposition 56 money to buttress Medi-Cal's overall budget.

Brown, as usual, is pushing fiscal prudence. Republicans in Congress so far have been unable to completely gut the Affordable Care Act, but the disgraceful replacement voted on by the House this week makes it clear that even if it means never being able to look at themselves in the mirror again, they're still trying. Given the volatility of the Trump administration, it's wise not to take anything for granted.

If worse actually were to come to worst, California would lose about $24 billion in federal funds over the next decade for millions of patients insured through the Obamacare Medicaid expansion. And even if nothing changes, those millions of patients are still growing. More than 164,000 Californians are expected to be added to the Medi-Cal caseload in this state by 2018.

So it's understandable that Brown would want to maximize flexibility and reserve the option to use the Proposition 56 money to secure the overall Medi-Cal system. The problem is, the shortage of Medi-Cal doctors is too serious to put it off anymore.

California's push to get Medi-Cal patients into managed care has beggared independent physicians such as those at Women's Health Specialists and other such specialty clinics, which, whatever their mission, often are viewed by the poor as the only alternative to expensive emergency room visits. Even doctors who take Medi-Cal Managed Care, where the rates are typically a bit higher, often take only a limited number of such patients, fearing that Medi-Cal reimbursement alone won't support their practice.

Dental reimbursements are so far below the national average in California that a 2014 state audit found that five counties had no Denti-Cal providers and 11 others were refusing to take new patients. Last year, fewer than half the children on Denti-Cal and fewer than 1 in 10 adults got any preventative dental care.

That has to change. Surely the state can do some of both -- boosting the overall system but also bumping up reimbursement in a targeted manner. Certainly dentists should get a rate hike, and money should be set aside for specialty providers such as Women's Health Specialists, which is still struggling to operate three desperately needed clinics in rural Northern California, and Planned Parenthood, which is under congressional attack. Some of the money also should be used to fully restore dental, vision, speech therapy and some other benefits cut during the recession.

Like it or not, voters passed Proposition 56 in the hope that it would improve access to care in the program that insures, now, a third of California. Given the onslaught in Washington against the values that unite us, this is no time to fight over the fine print.

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