California Dreamin’: We’ve Got No Primary Care Doctors But We’ll Implement Obamacare Anyway

All the leaves are brown
All the leaves are brown
And the sky is grey
And the sky is grey
Ive been for a walk
Ive been for a walk
On a winters day
On a winters day
Id be safe and warm
Id be safe and warm
If I was in l.a.
If I was in l.a.
California dreamin
California dreamin
On such a winters day

Lyrics to California Dreamin’

Californians are warm weather schemers and health reform dreamers, even as California suffers through its budgetary winter, with a deficit of $22 billion. Governor Jerry Brown has proposed $1.7 billion cuts in Medi-Cal and 10% decreases in payments to physicians and clinics.

California ranks 47th among states in Medicaid physician payment rates, and has only one primary care doctor for every 2000 Medicaid beneficiaries, The Golden State would need to recruit 350 new primary care physicians to add to existing 3379 primary practitioners to provide care under the Obama plan, which will increase demand for their services by 70% by 2014.

Here are the words of two policy types from the University of California and George Washington School of Public Health (Bindman, A. and Schnieder, A, “Catching a Wave – Implementing Health Care Reform in California, “ New England Journal of Medicine, April 21, 2010),

“Addressing this shortfall will be very difficult. There's not enough time between now and 2014 to train and deploy sufficient new primary care physicians. In addition, Medi-Cal patients are now highly concentrated among a relatively small percentage of providers: approximately 25% of primary care physicians provide more than 80% of the visits for Medi-Cal beneficiaries . Thus, much of this needed capacity will have to be developed from among physicians who now have little or no involvement with Medi-Cal patients.”

No matter. Dream on. California will provide coverage even if there are no doctors to provide care.

How will California execute this magic trick – coverage without access to doctors?

Well, first, the state plans to expand converge to the uninsured before 2014 on a county-by-county basis.

Two, California will use federal resources available under a waiver to invest in its public safety-net hospitals.

Third, California will expand its use of Medicaid managed care by mandating the enrollment of 320,000 elderly and disabled people.

Then, comes the authors’ caveat: “Meanwhile, other early signs in California are worrisome.”

Translated, this caveat means “No one has the faintest idea who will take care of 1.7 million new Medicaid beneficiaries coming on board in 2104?” No answers here, except somehow physicians will form partnerships with the state to “determine whether coverage expansion translate into access to care and improved population health.”

If this does not happen, add the authors, ”Missing this opportunity to collaborate on improving the population’s health could result in a wipeout of epic proportions.”

Indeed, a wipeout could occur. California is broke. The U.S. is broke. Primary doctors fear of going broke because California underpays them and now promises to overwork them.

For primary practitioners, this situation is, as Californian John Steinbeck, said, "The Winter of Our Discontent.” Californians can always dream. The weather is warm, and fantasies live on. As comedian Fred Allen, observed, “California is a wonderful place to live – if you happen to be an orange.”

Tweet: California is dreamin’ if it thinks he can implement Obamacare while providing care to millions of its new Medicaid beneficiaries.