By Matthew Hansen, Naomi Elias and Emiliano Vazquez
RotaCare Coastside Clinic sits inside a county medical building off Highway 1 in Half Moon Bay. Unlike a standard doctor’s office, the clinic isn’t open every weekday or even for an eight-hour day. Instead, a rotating group of volunteer physicians, health educators and dentists provides free services once a week for two and a half hours.
But the condensed hours don’t lessen demand. Administrator Karen Larson estimates that the clinic treats an average of 30 to 35 patients a week. Most are low-income and unable to miss work, so they rarely seek care before their conditions have deteriorated.
“When they finally reach us, they are very ill,” Larson said. “The main problem for our population is that if they don’t work, they can get fired.” Whatever the issue, she said, “we don’t turn people away.”
This is the reality for many patients who frequent privately run community clinics in San Mateo County. While county-run medical facilities provide emergency care, the clinics are often more convenient options. From the flu and the common cold to scabies and cancer, these clinics diagnose and treat an array of ailments suffered by the region’s uninsured and underinsured populations.
The patients are as diverse as the issues they arrive with, everyone from undocumented workers to sick tourists to people whose high-deductible insurance plans only cover the most catastrophic injuries.
Interviews at three of the county’s community clinics — RotaCare Coastside, Samaritan House and Ravenswood Family Health Center — revealed that the Affordable Care Act is seen as a chance to curb long wait times, encourage sustained care, and more quickly catch and treat conditions that the medical staff now encounters in their advanced stages.
But whether the ACA will be implemented successfully remains an open question. Even with the benefits the law brings, including expanded access to private health insurance and increased eligibility for Medi-Cal, clinic administrators remain unsure of who they will see walk through their doors.
Even with the benefits the law brings … clinic administrators remain unsure of who they will see walk through their doors.
Some wonder if newly insured patients will seek health care elsewhere. Others, however, foresee free and low-cost community clinics playing a key role in emergency care long-term.
In the coming months, the low-income uninsured and underinsured populations that these clinics serve could see increased access to health care via more affordable private insurance through Covered California, the state’s Affordable Care Act-mandated insurance exchange. Yet many will instead find coverage through the expansion of Medi-Cal, California’s Medicaid system.
An additional 1 million to 2 million residents will become eligible for Medi-Cal under the ACA when coverage commences on Jan. 1, according to the California Department of Health Services.
The Medi-Cal expansion will encompass single childless adults between the ages of 19 and 64, and revise income levels for everyone: low-income Californians making roughly $15,850 a year as individuals or $32,500 per year as a family of four will qualify for the plan.
In October, 30,830 Californians enrolled in health care coverage through Covered California, with another 29,000 enrolling during the first two weeks of November. Though the numbers may initially seem underwhelming, they are expected to accelerate over the coming months.
Medi-Cal has also seen an increase in applicants; of the roughly 370,000 October applicants, about 72,000 have been deemed eligible for the Medi-Cal expansion.
With the expected increase in Medi-Cal enrollees, however, much attention has been paid to enrollment challenges for patients seeking Medicaid services. California ranked second-lowest in the number of physicians in the state who will accept new Medicaid patients, behind only New Jersey, according to a 2011 study.
Low reimbursement rates make doctors wary of participating in the program, according to the nonpartisan California Budget Project. Compared as a percentage of federal Medicare payments for the same service, California’s Medi-Cal payments to physicians were the third-lowest in the nation in 2012, paying for 51 percent, as compared with the national average of 66 percent.
When it comes time to find a doctor, 23 percent of adults with Medi-Cal coverage reported having difficulty locating a primary care doctor who took their insurance, while only 11 percent of the general insured population reported the same, according to the budget project.
In San Mateo County, efforts have been made to help Medi-Cal patients access care through a network of county-run clinics.
For now, though, many of San Mateo County’s private community clinics — medical resources of last resort for those who can’t access health care anywhere else — are bustling.
Treating the uninsured
In the past year, the Samaritan House, a multi-purpose community clinic with locations in San Mateo and Redwood City, reported seeing more than 9,400 medical and dental patients, all of whom were uninsured.
A spokeswoman for the clinic noted that while most of the patients are employed, high-cost health insurance plans and medications “pose barriers to obtaining quality care.”
Each year, Samaritan House clinics have served as a one-stop shop for up to 12,000 individuals, whose food, shelter and medical needs are assessed by case managers. The clinic promotes a “neighbor helping neighbor” approach, and private contributions, grants and gifts make up nearly 70 percent of its funding.
To offset operational costs, the clinic leverages the support of community partners. In the past year alone, Samaritan House’s combined clinics provided more than 3,600 hours worth of medical attention to uninsured patients.
Retired internist Dr. Burt McDowell said there is a shortage of primary care physicians at the Redwood City clinic.
“We’ve lost a couple doctors due to age and illness,” McDowell said. He and his wife Mimi McDowell, a nurse, are among 43 medical volunteers—largely retirees—who provide care at the clinics. McDowell said he sees five to eight patients in a single morning shift.
The Medi-Cal expansion could help ease the clinic’s patient load.
While the organization is “still assessing” the ACA’s impact on its clinics, according to Operations Manager Sharon Petersen, it is working alongside the county to enroll people in Medi-Cal and other government benefit programs.
Gateway to primary care
Along San Mateo County’s largely rural coast, where small communities sit amid farms, forests and ranches, access to primary care can be a challenge for uninsured patients. Long drives, late working hours and low incomes all conspire to make access a challenge for people seeking care. Some are simply not aware of the health benefits they are qualified to take.
Larson, of RotaCare Coastside, and Diana Roberts-Mitchell, the head of the clinic’s advisory council, are hoping the Affordable Care Act will help change this, while acknowledging that the law won’t affect everyone they currently treat at their clinic.
They want to get as many of their patients as possible funneled into some type of long-term health care program.
“Our goal is not to be a medical home for our patients,” Larson said. “We want to get them into the system.” This means that instead of relying on volunteer doctors at community clinics like RotaCare, patients will be able to access preventive care from primary care physicians.
In San Mateo County, a patient can “get into the system” several different ways, including Medi-Cal enrollment and the county’s own Access and Care for Everyone (ACE) program, which provides health coverage at county-run hospitals and clinics for people unable to qualify for Medi-Cal or other forms of insurance, such as undocumented workers.
The RotaCare clinic itself sits inside the county-run Coastside Clinic, where patients in the Medi-Cal and ACE programs can access primary care.
Nonetheless, there are still county residents who are not enrolled in any program. For these people, clinics like RotaCare Coastside are intended to be providers of last resort. “We are a safety net,” Roberts-Mitchell said. “We catch people who fall through the cracks.”
To reach the uninsured, RotaCare works with community organizations who can access tough-to-reach populations, such as farm workers and the chronically homeless.
Ben Ranz is an outreach coordinator at Puente de la Costa Sur, a community services center that works in rural areas of southern San Mateo County. He thinks health coverage is becoming a bigger priority within the farming communities he serves. “Farm workers and families are often living together in clusters,” he said. “Someone will get health benefits when they need it, and their neighbor will see that and be interested. It’s like a domino effect.”
In 2013, Puente has seen increases in enrollment in both Medi-Cal and the ACE program, according to their annual records.
RotaCare also works with local providers to help patients avoid expensive and time-consuming trips “over the hill” for necessities like prescriptions. For Rotacare, independent pharmacist Harish Odedra is one such partner. His Half Moon Bay Pharmacy offers discounted rates on medications for people who find current price points too high.
“We’ve seen all types of people,” Odedra said, “some of them are desperate.”
In the past, Larson said, RotaCare has served “a group of people who just don’t fit” in the traditional insurance or Medi-Cal systems. But neither she nor Roberts-Mitchell are sure what to expect when the Affordable Care Act goes into full effect in 2014.
Expanding in East Palo Alto
Ravenswood Family Health Center is a privately run community health clinic in East Palo Alto that aims to serve uninsured and underinsured area residents. Part of its funding is public, while the rest is covered by an array of grants, foundations and other philanthropic efforts.
The clinic is undergoing the lengthy certification process of becoming a credentialed partner under the ACA, while serving 23 percent of the population of East Palo Alto. Of its total patient population, Ravenswood says 47 percent are uninsured.
East Palo Alto has the highest percentage of uninsured residents of any city in San Mateo County, at 25.9 percent. The city also has the highest rate of unemployment in the county, at 13 percent, according to monthly labor force data for August.
“We always have an influx of new patients, because we’re a community health center. People know that we’re going to be here,” Ravenswood Director Kathleen Alexander said. “[And] we’re limited in space. Currently we’re at 11,000 patients.”
In the face of increased demand, Ravenswood is undergoing a physical expansion, which started before the ACA.
“We’re going to build a 38,000 square foot, two-story facility at the intersection of Bay Road and Pulgas. It’s the first place in East Palo Alto that will include medical care, dental care and behavioral health,” Alexander said. “In terms of what has really motivated portions of this plan, it’s the fact that the need has always exceeded capacity. The new facility can handle 22,000 patients.”
Judged a healthy county
San Mateo County itself is also preparing to expand to face the new demands of growing patient populations. A new county clinic is being built in the North Fair Oaks neighborhood of Redwood City to house three smaller clinics that will relocate there.
“The new facility will consolidate and add to the services currently provided at three separate clinics,” said Communications Officer Robin Thaw of the San Mateo County Health System. “Each of the three existing sites are inadequate to meet the health needs of our expanding patient population.”
The new clinic will open in mid-December, weeks before the health care policies brought about by the ACA will go into effect.
Overall, though, San Mateo County is considered a leader in health statewide.
A recent study by the Robert Wood Johnson Foundation ranked county health for each of California’s 58 counties. The report measured health factors like health behavior and clinical care against health outcomes, or quality and length of life, to determine which counties were healthiest.
In general, San Mateo County scored high, ranking third for health factors and fifth for health outcomes.