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Obamacare Expansion A Bumpy Ride For Rural Health Clinics

By Kaiser Health News  
   August 03, 2016

After a more than two-year moratorium on nearly all new adult patients, a California community health center has reopened its doors this month. The facility’s director discusses the experience of adjusting to the changes wrought by the Affordable Care Act.

This article first appeared August 3, 2016 on the Kaiser Health News website

By Pauline Bartolone

A network of clinics that serves low-income patients in rural Northern California is finally finding balance after being deluged with newly insured patients under the Affordable Care Act.

After a more than two-year moratorium on nearly all new adult patients, the Redding-based Shasta Community Health Center has reopened its doors to some newcomers this month, and it will start accepting more new patients in September.

When Medi-Cal, California's version of Medicaid, was first expanded under the Affordable Care Act in early 2014, the number of people insured under the program doubled to around 40,000 people in the region served by Shasta Community Health. Not only did the clinics see new patients, but the demand for services soared from existing ones who were newly insured.

The clinic network already had a shortage of doctors and nurses. — a problem shared by many other rural health clinics in California.

"The … more new patients we brought in, the more stress on the providers, the more likely [they] were going to leave, the deeper the crisis went," said Shasta Community Health Center CEO C. Dean Germano. So he decided to close the network's five clinics to new adult Medi-Cal patients, though they continued to serve all of their existing patients and accepted new children.

During the moratorium, patients in the region had to travel long distances for primary care, or use the local emergency room, Germano said.

Shasta Community Health Center has since boosted its capacity to provide primary care. It has hired two physicians, created a family practice residency program and has a fellowship program for nurse practitioners and physician assistants. For every new primary care provider, the clinic network can add up to 1,200 new patients, Germano said. The system now serves about 60,000 people in the area.

California Healthline interviewed Germano about his health center's experience adjusting to the changes wrought by the Affordable Care Act. His comments have been edited for length and clarity.

Q: How did the ACA change the type of services you were giving or the type of care the patients needed?

Uninsured people tend to use the system much less and often at the worst possible places.

With the onset of coverage, you have all this relief to pent-up demand, people seeking more regular care and preventive [care], which often for the uninsured is not a priority. They tend to come in because they have acute issues or they have long-term chronic issues that have become complicated.

So [with] people gaining coverage, the uninsured are becoming much like our other insured populations — seeking care at the appropriate moments.

Q: Were you able to meet the demand for all these new services?

No, not at all. We quickly became overwhelmed, although there were a couple of things happening all at once. One was certainly the growth in Medicaid coverage, but at the very same time, the state of California expanded Medi-Cal managed care into 28 rural counties. We are one of them. We did not have Medi-Cal managed care prior to this.

We were assigned patients, then assigned more patients. We quickly reached a point where we could not take on more new adult patients to our practice. We had to essentially constrain and at one point close the practice to new adult Medicaid patients. We never closed the practice to uninsured patients because they don't have many options, as in the ER. We never close it to homeless or to children or to people with HIV. Interestingly enough, [it was] not a great business model because our best payers are the ones we closed to.

It was a very big hit [to] the community because adult patients had to go further afield to find services outside of the emergency room. Under managed care, it's [the health plan's] responsibility to find a medical home and some of the medical homes were 30 to 40 miles into the mountains. For patients who have transportation issues, there was no doubt that was a real imposition.


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Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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