Los Angeles aims to make Obamacare universal in more than just name
On a sunny weekday morning just east of downtown Los Angeles, a crowd of about 75 people rallied outside the LA County/USC Medical Center. They toted signs with slogans like “Healthcare is a Human Right” and “Salud Para Todos” (“Health for All”).
“How can we say we live in a just and humane society,” said one speaker, “without providing for the sickest and most vulnerable among us?”
This wasn’t 2009, when the Affordable Care Act was a hot point of debate. It happened just last week. The activists organized the rally to urge the LA County board of supervisors to increase funding to a program called Healthy Way LA that is spearheading an experiment to cover those who are uninsured or can’t afford or qualify for Obamacare.
If it works, the concept could revolutionize healthcare in American cities – if it can handle the problems of scale for millions of patients and funding from strapped municipal budgets.
A bridge for the uninsured
While the Affordable Care Act has reduced the ranks of the uninsured across the country, it was never designed to provide fully universal health coverage. Estimates show that 31 million people nationwide will stay uninsured.
Los Angeles, with its massive low-income population and largest concentration of immigrants anywhere in the country, may be the epicenter of the continuing uninsured crisis in America. Somewhere around one million county residents will remain uninsured even after the law changes.
“You have one million people in a county without access to primary health benefits, there’s a very good chance that you’ll have a lot of sick people, who will get other people sick,” says Tom Holler of OneLA, a faith-based coalition pushing for more funding for the uninsured.
The question the protesters were tackling is this: how do cities and states fill the gap between the people who are covered by Obamacare and those who aren’t?
“In our view, the Affordable Care Act makes huge strides to reduce the uninsured,” said Anthony Wright of Health Access California. “Now it’s more feasible for states and counties to finish the job.”
The creator of ‘medical homes’
In Los Angeles, Dr Mitchell Katz heads the county Department of Health Services. He has his own vision for how to cover those that Obamacare failed to capture: using existing community health centers and clinics to provide low-cost primary and preventive care to any uninsured individual who enrolls. He calls these “medical homes.”
The medical home acts like a primary care doctor: it collects the medical records of uninsured patients, develops long-term relationships with them and refers them to specialists when necessary. The promise is to provide a steady supply of healthcare, keeping patients from waiting so long that they wait for catastrophic illness and only use emergency rooms to see a doctor at all.
“If you have one place you can go to repeatedly that knows you, has your case history, can give you care inside or outside their facility, you’re more inclined to use primary care and preventive services,” says Tangerine Brigham, who ran the managed care services division and helped design HealthySF, and followed Mitchell Katz south to do the same for Los Angeles.
The medical home concept is a hybrid. It has elements of socialized medicine, where mostly public dollars supports universal clinics. It also has elements of managed care – the private-sector option that many Americans are familiar with from their healthcare plans through work.
“Just being able to make an appointment is almost a revolutionary idea in public healthcare,” says Shana Alex Lavarreda, Director of Health Insurance Studies at UCLA’s Center for Health Policy Research.
Katz has some experience with this idea of medical homes: he came to Los Angeles from San Francisco, where he built Healthy SF, a successful program whose ambition is to provide universal healthcare, rather than universal health insurance. The program was successful. “It really did establish something close to universal access to healthcare within the borders of San Francisco,” said Anthony Wright of Health Access California.
If Katz can scale up his concept, and replicate that success in Los Angeles, the nation’s second-largest city, he believes he will have a proven model for any city to follow.
Still, it won’t be easy. Cost is one barrier. So far, while the medical home model at HealthySF has improved patient outcomes and increased coverage, “that’s not translating into the medical system spending less money overall,” Lavarreda says.
Part of the problem is that it’s hard to track a population that tends to favor emergency rooms instead of regular doctors; another problem is that medical homes may be just too new to prove they save money on long-term healthcare costs.
A supplement to Obamacare
Katz’s LA experiment is not a replacement for Obamacare; it’s a supplement to it. Healthy Way LA, the vehicle for bringing the medical home concept to the county, grew out of a statewide low-income health program designed as a bridge to the launch of Obamacare this year.
Healthy Way LA enrolled over 300,000 county residents at nearly two dozen community clinics at the time. Many of these patients eventually passed into Medicaid, following its expansion under Obamacare.
Yet Obamacare advertising has been so successful that healthcare demand is booming in the county, even for the uninsured. “We’ve seen a 40% increase in patient volume over the past several months,” says Jim Mangia, CEO of St John’s Well Child and Family Center, a non-profit clinic in Los Angeles.
As a result, the Department of Health Services will relaunch Healthy Way LA this fall. Its goal is to cover all residents at no cost who remain uninsured after Obamacare, and whose income is less than 138% of the federal poverty level.
Under the relaunch, clinics will have enrollment specialists on site, so if they get walk-ins who could be eligible for Medicaid or other public health programs, they can register them on the spot. The county and nonprofit community clinics are working to determine the capitated rate, a finite pool of money that would be given to cover each individual member of the medical home. This should give clinics an incentive to reduce costs. There will be no exclusions based on immigration status.
Katz believes the managed-care relaunch will allow him to stretch scarce dollars, and views it as a first step toward universal care. But he told the Los Angeles board of supervisors in late March that the program would still likely serve only 100,000 patients to start, and the county has a budget of only $55m that it’s unlikely to scale up – even though healthcare advocates believe it should be triple the size at $165m.
That would be less than 1% of LA County’s $26bn budget, which is already running at a surplus – “budget dust in the scheme of things”, says Mangia, a strong advocate of the program.
The LA County budget will fuel further protests like the one last week, leading up to a critical May 20 board of supervisors meeting.
“We plan to impose tremendous grassroots and political pressure, and I think they’ll step up,” says Mangia. “Why wouldn’t we want to cover everyone? This would have a profound ripple effect across the country, for health care access, universal coverage and even immigration reform.”
The ‘medical home’ idea
Getting to that point means creating a program that can handle the health problems of a sprawling metropolis. Los Angeles County has interpreted a statewide mandate to cover the uninsured broadly, committing to help fund a program to cover everyone, including the undocumented.
That’s no small task. Los Angeles County includes 88 cities with over 10 million residents, dozens of languages, and at least 400,000 undocumented immigrants.
Analysts estimate there are anywhere from 800,000 to 1.2 million uninsured across Los Angeles County, including mixed immigration status families where some kids are covered and others are not. The county had to deal with the barrier of getting undocumented immigrants comfortable with using a publicly provided service without fear of deportation. And it’s difficult to even locate and communicate in the right language to LA’s uninsured, let alone provide them with continuing care.
“We were worried about whether it would translate,” Anthony Wright says. “We were wondering, what are you going to do to Mitch?”
“The magnitude and scale is completely different,” says Shana Alex Lavarreda of UCLA, who says she supports the program. “In San Francisco you had tens of thousands, here you have millions of uninsured to deal with.”
The undocumented and healthcare
The LA crowd took a particular interest in immigrants, both legal and undocumented, the latter of which are barred from obtaining Medicaid or using the Obamacare insurance exchanges, even to purchase health insurance with their own money.
A bill from state senator Ricardo Lara would allow the undocumented access to Medicaid and the insurance exchanges, using state money to evade the federal ban. But until that happens, and until immigration reform provides a path to citizenship, counties like Los Angeles have this enormous uninsured population to deal with.
With the undocumented comprising as much as half of the uninsured population in Los Angeles, the issue has echoes of the roiling immigration debate.
“Immigrants are such an important part of California’s economy and society, they need to be included in the health system,” said Anthony Wright of Health Access California.
“We’re dealing with segregated health care in America,” says Victoria Ortega, a program director at the community health center Clinica Romero, at the rally. “We didn’t tolerate it in the education system; we shouldn’t tolerate it in the health care system either.”
Graciela Villeda, an uninsured and undocumented resident, told the rally at LA County/USC Medical Center that she has gall stones, and that Healthy Way LA does not cover the surgery she would need to remove them. “She would have to be dying for the operation to be covered,” said Iliana Garcia, her daughter. Garcia added that her community in Boyle Heights has only two clinics for Healthy Way LA, and even many of those enrolled find the nearest clinic too far to access.
“These people deserve the same healthcare as anyone else,” said Dr Brownell Payne of Crenshaw Health Partners. “It doesn’t matter if you’re undocumented or the president. We all have red blood cells. This isn’t about money, it’s about taking care of our people.”