Public Comment

The War on Medi-Cal

By Anne Richardson
Thursday June 11, 2009 - 06:59:00 PM

Nine years ago, Medi-Cal saved my life. I was diagnosed with thyroid cancer, and could not pay for my care. Medi-Cal covered two surgeries, two hospital overnights, two diagnostic outpatient visits, an examination and consultation with a prominent oncologist, and the coordinative work and monitoring laboratory work of my primary care provider, who was proactive throughout the experience. My surgeon operated twice, because the foci of cancer in the second lobe were submicroscopic at the time of the first surgery, and he concluded from the slides he examined microscopically that this lobe was healthy. It is good surgical practice not to perform a complete thyroidectomy, when one lobe can remain and do the work of both. When, months later, the foci of carcinoma in the remaining lobe became microscopic, it was clear that this lobe, too, needed to be removed. I asked this well-thought-of young surgeon what motivated him to do such conscientious work for such a low rate of reimbursement under Medi-Cal, and he said, “ love.” Those were the high and palmy days of Medi-Cal, when increasing numbers of specialists were not taking Medi-Cal patients but the perception was, still, that the best doctors considered such a denial of service unconscionable. 

In the course of the Bush II years, Medi-Cal has fallen on evil days. Medi-Cal recipients are finding it terminally difficult to find doctors—specialists or primary care providers—to treat them; and in the medical profession and in the media, Medi-Cal is increasingly viewed as an encumbrance. The State of California proposes to cut the program in two areas: 10 percent deducted in reimbursement to providers, and the exclusion from coverage of “optional” categories of medical treatment. (A third way of shrinking the Medi-Cal footprint, that of tightening the eligibility criteria, was floated in a May 14 story in the San Francisco Chronicle, but it is doubtful that the means testing can be made more stringent than it is already, if applicants for the program are to be allowed enough income and resources to afford basic necessities.) 

Cutting 10 percent in Medi-Cal reimbursement, when this figure now ranks 42nd among Medicaid payments among the states, would hasten the flight of doctors and other health professionals, and cripple pharmacies, diagnostic laboratories and public hospitals. Perhaps the situation for pharmacies is most ominous. Many small independent pharmacies rely on their Medi-Cal compensation and, unable to make ends meet, would have to go out of business. To wipe out the skillful dispensation of medications would affect more Californians than solely the very poor on Medi-Cal. It would hollow out our staple idea that people should dutifully stay on their medications. 

It is equally disheartening to read the list of “optional benefits:” i.e., “adult dental, acupuncture, audiology and speech therapy, chiropractic, optometric and optician services, podiatry, psychology, and incontinence creams and washes” (Alameda-Contra Costa Medical Association Bulletin, April 2009). 

It should be considered that tooth decay can be mortal if it enters the bloodstream. And a biennial optician’s examination, normally covered by Medi-Cal, is the only chance most people get to be screened for glaucoma, retinitis or macular degeneration. Thus the distinction between “optional” and essential does not make medical sense. We are told that the federal governmant views the above categories as optional. Who decided that? Someone in the Bush administration? 

It should come as good news, for those who have a partiality for agitation, that more than mere hand-wringing has taken place in the community of those who deplore the cuts. 

In April 2008, the Gray Panthers of San Francisco, in a coalition of various groups, successfully sued the state in federal court to block the provider cuts. The ruling was appealed by the state in a hearing on February 18 of this year. The Panthers’ attorney, Lynn S. Carman of the Medicaid Defense Fund, argued on the basis of foundational “War on Poverty” legislation that for a state to run a poverty health program, the program must measure up to federal health standards, and that further emasculation of Medi-Cal would render it dysfunctional. The state’s defense was “States’ Rights.” The appeals court has yet to issue a ruling on that issue. The appeal process may reach the U. S. Supreme Court. So we have the Gray Panthers to thank that, in the words of a Chronicle writer on May14, the intention of cutting payment to providers is “mired in a lawsuit.” As regards the cuts in “optional” treatments, the Gray Panthers have filed a preliminary restraining order in a separate but complementary suit on a different legal basis. The state argues that the $10 billion in stimulus money it was expecting for July 1, 2010 will come to only $6.5 billion, and the shortfall will “trigger” the cuts in “optional” services. But the Panthers’ argument is 1) need and 2) that in the terms of the ARRA bill it is illegal to accept federal stimulus money while cutting ongoing education, health, or social services on the state or local level. 

My escape nine years ago from a slow, quiet and below-the-radar death has acquired for me visionary American themes. To be deprived of the triad of rights in The Declaration of Independence, to fail of protection from the cruel and all too usual punishment for being poor; to come short of equal treatment under the law: all these themes call up the immortal words of Dr. Martin Luther King, Jr. to the effect that “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” But with the Medi-Cal cuts poised to affect so many numbers of Californians, even if indirectly, we are no longer talking about inequality. We are all sadly coupled, ridden by the Social Darwinism that weeds the weak and lets predators take them out. This is in accord with brute nature, perhaps, but inhumane. Let us not try to accept the unacceptable. Let us insist on health justice for all our citizens. 


Anne Richardson is an East Bay Medicare and Medi-Cal recipient and a member of the San Francisco Gray Panthers.