Now, with the nonprofit Madera, California, hospital bankrupt and shuttered, St. Agnes looms as a dark knight, pushing to liquidate the hospital to get a loan it made to Madera paid back — even if that means dashing the hopes of the community activists, political leaders, and health care officials that the hospital can still reopen.

A pivotal moment in the case could come July 25, when a bankruptcy judge in Fresno will hear arguments on whether the Madera hospital should be allowed to spend its dwindling cash reserves on things such as building maintenance, security, utilities, and the salaries of its three top executives.

The hospital wants to run a skeletal operation while it seeks a buyer and develops a reopening plan. But the federal bankruptcy court in Fresno has authorized it to spend money only through July 29. If the judge doesn’t think the hospital has a viable plan, he may refuse an extension, which would likely mean liquidation.

Problems like Madera’s are common among other small, financially challenged hospitals in California and nationwide. They typically have low patient volumes and rely disproportionately on payments from Medicaid and Medicare, which constrains revenue and makes it difficult to attract talent or invest in cutting-edge equipment. Add to the mix a crushing surge in expenses stemming from the covid-19 pandemic, and dozens of such facilities are struggling to survive. Two others, both in California, have filed for bankruptcy this year.

Yet Madera had problems that were all of its own making. The hospital made money on patients insured by Medi-Cal, the state safety-net insurance program that pays notoriously low rates, according to financial data filed with state regulators. But it lost money on its commercially insured patients due to low volume and bad deals with insurance providers. It also failed to seek covid relief funds in a timely manner. A state hospital bailout fund came too late.

Plus, Madera had no backup plan when St. Agnes and its parent company, the hospital chain Trinity Health, walked away from a proposed merger with the troubled hospital late last year, giving virtually no notice and scant explanation. Their move shocked and infuriated officials, former employees, and community advocates in Madera and Sacramento.

In a brief December press release, St. Agnes and Trinity blamed their decision on “complex circumstances” and “additional conditions” imposed by state Attorney General Rob Bonta. But industry experts said Bonta had agreed to most of what St. Agnes asked for and were baffled as to why they walked away from the deal.

The spectacle of St. Agnes and Trinity now pushing in court for the liquidation of tiny Madera has drawn Bonta’s ire.

“For Trinity, it was always about profit, not the health of the Madera community,” Bonta told KFF Health News in a statement. “They are now attempting to use their position as Madera’s biggest creditor to extract every dollar possible, instead of keeping the community’s interests at heart.”

Bonta said his office had “offered maximum flexibility to Trinity in recognition of Madera’s financial circumstances.”

An agricultural area of 2,150 square miles and home to nearly 160,000 people, Madera County is 60% Hispanic, and more than one-fifth of its residents live below the poverty line, according to census data.

A Community Left in the Lurch

Jennifer Lara, a former Madera Community Hospital nursing assistant, said she and colleagues had been looking forward to positive change after the anticipated merger with St. Agnes. “We were floored when we found out the hospital was closing,” she said. “We didn’t think anything other than the hospital continuing on was going to happen.”

St. Agnes and Trinity declined to comment. The longtime CEO of St. Agnes, Nancy Hollingsworth, retired in May amid a reorganization that made the hospital part of a regional group based in Idaho. It’s unclear whether her departure was related to the collapse of the Madera deal. Hollingsworth could not be reached for comment.

St. Agnes’ considerable leverage in the bankruptcy case is the result of a $15.4 million loan it extended to Madera during merger talks last year. Madera has since repaid $8 million, leaving a debt of over $7 million, which still makes St. Agnes its largest creditor.

St. Agnes, one of 88 hospitals belonging to Trinity, a multistate, Catholic, nonprofit health system headquartered in Livonia, Michigan, argued in a recent bankruptcy court filing that Madera still has made no significant progress finding a buyer, more than four months after filing for Chapter 11 bankruptcy protection on March 10, and should not be allowed to continue spending money “without a serious path forward to either sell or mothball the hospital.”

The hospital has been talking to three potential partners, “one of whom is late to the game,” said Riley Walter, Madera’s bankruptcy lawyer.

Mohammad Ashraf, a cardiologist and member of the executive committee of Madera’s medical staff, said the first two entities in question, whom he declined to identify, are management service organizations, not hospital groups. “They don’t want to spend any money to buy it. They just want to run it,” he said.

Without a convincing strategy for the future of Madera Community Hospital, the end of the bankruptcy case could come quickly.

Ranjit S. Rajpal, a Madera cardiologist for over 40 years, said the closure of the hospital is bad news for patients who need time-sensitive care, such as for heart attacks, strokes, or other traumas, and who now must travel greater distances to get it.

And the closure will exacerbate existing health inequities for people who face challenges getting care because of immigration status, language barriers, lack of transportation, or other socioeconomic factors, he said. “Those disparities will be compounded as time goes by.”

Community leaders and the hospital’s leadership hold out hope for reopening. The hospital has applied for $80 million from California’s new, $300 million loan fund for distressed hospitals. Hospital leaders must produce a reopening plan by July 31, but even if it does, it’s unlikely to get the full requested amount: Sixteen hospitals have already applied for loans totaling over $385 million, said Joe DeAnda, spokesperson for the California State Treasurer’s Office.

“They’re not going to give a quarter of their total fund to one hospital that doesn’t even have a partner,” said Glenn Melnick, a health economist at the University of Southern California who authored an analysis commissioned by the AG’s office of the proposed St. Agnes-Madera merger. “Eighteen months ago, the ask would have been a lot smaller.”

Even if Madera Community Hospital finds a viable partner and gets the funding it needs, reopening would be daunting and expensive. The hospital would need to hire hundreds of nurses, technicians, and other staffers in a tight and expensive health care labor market and find a way to avoid the financial problems that landed it in bankruptcy.

“Some things an acute care hospital offers are profitable, and others are not,” said Jay Varney, Madera County’s administrative officer, whose role is akin to a CEO. “It doesn’t make much sense to have it reopen like it was and have it go bankrupt again.”

‘Running Out of Time’

Reopening the facility with all the services it provided before is not the only option. Baldwin Moy, an attorney for California Rural Legal Assistance, a community advocacy group, said he and colleagues have been arguing for the court to allow Madera additional time either to find a buyer or for the county “to put together a package that can reopen the emergency room with some stripped-down clinical operation.” But, Moy said, they are “running out of time.”

Karen Paolinelli, the hospital’s CEO, said the current suitors are interested in reopening it as an acute care facility that “may or may not have all services that were previously offered by Madera Hospital on day one.”

If the hospital can hold out for a few more months, it says, it can collect $23.5 million owed by the state for “provider fees,” and possibly an additional $10 million from the Federal Emergency Management Agency. Those payments would more than cover the hospital’s entire debt of $30 million. But the amount and timing of payments are unclear.

Paolinelli, voicing a common industry complaint, said the hospital has a disproportionately high number of Medi-Cal patients and Medi-Cal rates do not cover the cost of providing care. But state data shows that Madera received enough supplemental payments to earn nearly $15 million from Medi-Cal in 2021, though it lost over $11 million treating Medicare patients. Madera also lost about $6.8 million on commercially insured patients in 2021, the state data shows. Commercial insurance payments covered only 59.5% of what it cost to care for those patients. That compares with a statewide average of 156%, according to Melnick.

Paolinelli said Madera tried to negotiate better rates with commercial health plans but “does not have much leverage with the payors.” She added that many residents of Madera who get commercial insurance through their employers choose Kaiser Permanente, whose nearest acute care hospital is in Fresno, 20 miles away.

State Democratic Sen. Anna Caballero, whose district includes parts of Madera, Merced, and Fresno counties, said that if Madera Community Hospital were to successfully reopen, more people with commercial insurance would have to choose it over other hospitals outside the county, which they had not been doing frequently.

“The county and the city may need to say, ‘If you need hospitalization, you need to go to Madera, and there will be no copay, but if you go out of the county, there’s a copay you have to pay,’” Caballero said.

But with no clear path to reopening yet in sight, Caballero said, that discussion is premature.

Melissa Montalvo covers Latino communities for The Fresno Bee as part of the Central Valley News Collaborative, a partnership that includes The Fresno Bee, Vida en el Valle, Valley Public Radio, and Radio Bilingüe. This article is part of the Central Valley News Collaborative, which is supported by the Central Valley Community Foundation with technology and training support from Microsoft Corp.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Ahora, después que el hospital sin fines de lucro de Madera cerrara y se declarara en bancarrota, la situación no podría ser más distinta.

St. Agnes está impulsando la liquidación de los bienes del hospital para recuperar un préstamo que le hizo a Madera, aunque signifique acabar con las esperanzas de los activistas comunitarios, líderes políticos y funcionarios de salud que esperan que el centro de salud todavía pueda reabrir.

Un momento crucial en el caso podría ocurrir el 25 de julio, cuando el juez de un tribunal de bancarrota de Fresno escuche argumentos sobre si se debería permitir que el hospital de Madera gaste sus escasas reservas de efectivo para cubrir el mantenimiento del edificio, costos de seguridad, servicios públicos y los salarios de sus tres ejecutivos.

El hospital quiere mantener una operación con un mínimo de personal mientras busca un comprador y desarrolla su plan de reapertura. Pero el tribunal federal de bancarrota de Fresno le permitió gastar dinero solo hasta el 29 de julio. Si el juez piensa que el plan del hospital no es viable, podría rechazar una extensión, lo cual probablemente significaría la liquidación.

Problemas como el de Madera son comunes en otros hospitales pequeños con situaciones financieras precarias en California, y en todo el país. Por lo general, estos hospitales tienen un bajo volumen de pacientes y dependen desproporcionadamente de los pagos de Medicaid y Medicare, lo cual limita los ingresos y la posibilidad de atraer talento o invertir en equipos de última generación.

A esto se le suman los gastos abrumadores ocasionados por la pandemia de covid-19. Docenas de estos hospitales luchan por sobrevivir; otros dos, también en California, se declararon en bancarrota este año.

Sin embargo, Madera también tenía problemas generados internamente. El hospital ganó dinero con pacientes asegurados por Medi-Cal, el programa de seguro para californianos de bajos ingresos cuyas tarifas son notoriamente bajas, según datos financieros presentados ante los reguladores estatales. Pero perdió dinero con pacientes cubiertos por seguros comerciales, debido al bajo volumen y a acuerdos no favorables con los proveedores de seguros.

Y no recurrió de manera oportuna a programas de asistencia financiera durante la pandemia de covid. Un fondo de rescate estatal para el hospital llegó demasiado tarde.

Además, Madera no contaba con un plan de contingencia cuando St. Agnes y su compañía matriz, la cadena de hospitales Trinity Health, abandonaron su propuesta de fusionarse con el hospital a fines del año pasado, prácticamente sin aviso y con pocas explicaciones. Esta decisión conmocionó y enfureció a los funcionarios, ex empleados y defensores comunitarios en Madera y Sacramento.

En un breve comunicado de prensa en diciembre, St. Agnes y Trinity atribuyeron su decisión a “circunstancias complejas” y “condiciones adicionales” impuestas por el fiscal general estatal Rob Bonta. Pero expertos en la industria dijeron que Bonta había aceptado la mayor parte de lo que pedía St. Agnes y que las razones por las que abandonaron el acuerdo eran un misterio.

El hecho de que St. Agnes y Trinity ahora estén impulsando la liquidación del pequeño hospital ha provocado la ira de Bonta.

“Lo importante para Trinity siempre ha sido el dinero y no la salud de la comunidad de Madera”, dijo Bonta a KFF Health News en un comunicado. “Ahora están tratando de usar su posición como el mayor acreedor de Madera para extraer cada dólar posible, en lugar de tener en cuenta los intereses de la comunidad”.

Bonta dijo que le había “ofrecido la máxima flexibilidad a Trinity en reconocimiento a las circunstancias financieras de Madera”.

Madera es una zona agrícola de 2,150 millas cuadradas con una población de casi 160,000 personas. El condado es 60% hispano y más de una quinta parte de sus residentes viven por debajo de la línea de pobreza, según datos del censo.

Una comunidad abandonada

Jennifer Lara, ex asistente de enfermería del Madera Community Hospital, dijo que ella y sus colegas esperaban cambios positivos después de la esperada fusión con St. Agnes. “Cuando nos enteramos de que el hospital iba a cerrar, no lo podíamos creer”, dijo. “Solo pensamos que el hospital iba a continuar”.

St. Agnes y Trinity se negaron a hacer comentarios. Nancy Hollingsworth, directora ejecutiva de St. Agnes por muchos años, se jubiló en mayo en medio de una reorganización de la compañía que hizo al hospital parte de un grupo regional con sede en Idaho. No está claro si su salida estuvo relacionada con lo que pasó con el acuerdo con Madera. No se pudo contactar a Hollingsworth para un comentario.

La considerable ventaja de St. Agnes en el caso de bancarrota es el resultado de un préstamo de $15.4 millones que le otorgó a Madera durante las conversaciones sobre la fusión el año pasado. Desde entonces, Madera pagó $8 millones, dejando una deuda de más de $7 millones. St. Agnes sigue siendo su mayor acreedor.

St. Agnes, uno de los 88 hospitales pertenecientes a Trinity, un sistema de salud sin fines de lucro católico y multiestatal con sede en Livonia, Michigan, argumentó recientemente en un documento para el tribunal de bancarrota que Madera todavía no ha hecho avances significativos en su búsqueda de un comprador, más de cuatro meses después de solicitar la protección por bancarrota del Capítulo 11 el 10 de marzo, y que no se le debe permitir seguir gastando dinero “sin un camino serio hacia la venta o el cierre del hospital”.

El hospital ha estado hablando con tres socios potenciales, “uno de los cuales llega tarde al juego”, dijo Riley Walter, abogado de Madera especialista en bancarrotas.

Mohammad Ashraf, cardiólogo y miembro del comité ejecutivo del personal médico de Madera, dijo que las dos primeras entidades en cuestión, a las que se negó a identificar, son organizaciones de servicios de gestión, no grupos hospitalarios. “No quieren gastar dinero para comprarlo. Solo quieren ejecutarlo”, dijo.

Sin una estrategia convincente para el futuro de Madera Community Hospital, el final del caso de bancarrota podría llegar rápidamente.

Ranjit S. Rajpal, cardiólogo de Madera durante más de 40 años, dijo que el cierre del hospital es una mala noticia para los pacientes que necesitan atención de urgencia, como aquellos que sufren un ataque cardíaco, un accidente cerebrovascular u otros traumas, y que ahora deben viajar más lejos para recibir atención.

Y el cierre profundizará las desigualdades de salud existentes para las personas que enfrentan desafíos para recibir atención debido a su estatus migratorio, barreras de idioma, falta de transporte u otros factores socioeconómicos, dijo. “Esas disparidades se agravarán con el tiempo”.

Los líderes comunitarios y la dirección del hospital tienen la esperanza de reabrir. El hospital ha solicitado $80 millones del nuevo fondo de préstamo de $300 millones de California para hospitales en apuros.

Los líderes de los hospitales deben diseñar un plan de reapertura antes del 31 de julio, pero incluso si lo hacen, es poco probable que obtengan el monto total solicitado: 16 hospitales ya pidieron préstamos por un total de más de $385 millones, dijo Joe DeAnda, vocero de la Oficina del Tesorero del Estado de California.

“No van a dar una cuarta parte del total de su fondo a un hospital que ni siquiera tiene un socio”, dijo Glenn Melnick, economista de salud de la Universidad del Sur de California y autor de un análisis sobre la propuesta de fusión de St. Agnes y Madera encargado por la oficina del Procurador General. “Hace dieciocho meses, la demanda habría sido mucho menor”.

Incluso si Madera Community Hospital encuentra un socio viable y obtiene los fondos que necesita, la reapertura sería difícil y costosa. El hospital tendría que contratar a cientos de enfermeros, técnicos y otro personal en un mercado laboral de atención de salud limitado y caro, y encontrar la manera de evitar los problemas financieros que lo llevaron a la bancarrota.

“Algunas cosas que ofrece un hospital de cuidados intensivos son rentables y otras no”, dijo Jay Varney, oficial administrativo del condado de Madera, cuyo trabajo es similar al de un director ejecutivo. “No tiene mucho sentido que se vuelva a abrir como estaba y que quiebre de nuevo”.

“Se está acabando el tiempo”

Reabrir el hospital con todos los servicios que brindaba antes no es la única opción.

Baldwin Moy, abogado de California Rural Legal Assistance, un grupo de defensa de la comunidad, dijo que él y sus colegas han estado abogando para que el tribunal le otorgue a Madera tiempo adicional para encontrar un comprador o para que el condado “reúna fondos para reabrir la sala de emergencias con una operación clínica simplificada”. Pero “se les está acabando el tiempo”, dijo Moy.

Karen Paolinelli, directora ejecutiva del hospital, dijo que los postulantes actuales están interesados ​​en reabrirlo como un centro de cuidados intensivos que “tendría o no todos los servicios que ofrecía el hospital de Madera antes”.

Si el hospital pudiera resistir unos meses más, dice, podría cobrar $23.5 millones que debe el estado en “tarifas de proveedores” y posiblemente $10 millones más de la Agencia Federal para el Manejo de Emergencias (FEMA). Esos pagos cubrirían con creces la deuda total del hospital de $30 millones. Pero la cantidad y fecha de los pagos no están claros.

Paolinelli, al expresar una queja común de la industria, dijo que el hospital tiene una cantidad desproporcionadamente alta de pacientes de Medi-Cal y que las tarifas que tiene este programa no cubren el costo de brindar atención.

Pero los datos estatales muestran que Madera recibió pagos suplementarios que suman casi $15 millones de Medi-Cal en 2021, aunque perdió más de $11 millones en el tratamiento de pacientes de Medicare. Madera también perdió alrededor de $6.8 millones en pacientes con seguros comerciales en 2021, según muestran los datos estatales. Los pagos de seguros comerciales cubrieron solo el 59.5% de lo que costó atender a esos pacientes. Eso se compara con un promedio estatal de 156%, según Melnick.

Paolinelli dijo que Madera trató de negociar mejores tarifas con los planes de salud comerciales, pero “no tienen mucha influencia sobre los proveedores”. Agregó que muchos residentes de Madera que obtienen un seguro comercial a través de sus empleadores eligen Kaiser Permanente, cuyo hospital de atención aguda más cercano está en Fresno, a 20 millas de distancia.

La senadora estatal demócrata Anna Caballero, cuyo distrito incluye partes de los condados de Madera, Merced y Fresno, dijo que si Madera Community Hospital reabriera con éxito, más personas con seguro comercial tendrían que elegirlo en lugar de ir a otros hospitales fuera del condado, algo que no habían estado haciendo con frecuencia.

“El condado y la ciudad van a tener que decir: ‘Si necesitas hospitalización, debes ir a Madera y no habrá copago, pero si sales del condado, tendrás un copago”, dijo Caballero.

Pero sin un plan claro para la reapertura, esa discusión es prematura, agregó.

Melissa Montalvo cubre las comunidades latinas para The Fresno Bee como parte de Central Valley News Collaborative, una asociación que incluye The Fresno Bee, Vida en el Valle, Valley Public Radio y Radio Bilingüe. Este artículo es parte de Central Valley News Collaborative, que cuenta con el respaldo de Central Valley Community Foundation con tecnología y soporte de capacitación de Microsoft Corp.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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About three weeks before his May move, Tennison called the agency that administers Medi-Cal in Contra Costa County, where Walnut Creek is located, to inform them he’d be moving to San Joaquin County.

Little did he suspect his transfer would get tangled in red tape, disrupt his care, and saddle him with two bills totaling nearly $1,700 after he was removed from his old plan without notice before his new one in Stockton took effect.

Medi-Cal members who move counties are often bumped temporarily from managed care insurance plans into traditional Medi-Cal, also known as “fee for service,” in which the state pays providers directly for each service rendered. But managed care practitioners who don’t participate in traditional Medi-Cal have no way to get paid when they see such patients, and they sometimes bill them directly — even though that’s prohibited.

Medi-Cal is a statewide program, but it is administered by the counties, which have separate government bureaucracies and different approaches to care: Some have just one county-operated Medi-Cal plan. Others have only commercial health plans, which are paid by the state to manage the care of Medi-Cal patients. Many have one of each.

Traveling from Walnut Creek to Stockton takes a little more than an hour by car, but as far as Tennison is concerned, the two cities might as well be on opposite sides of the planet.

Tennison, 63, needed a smooth health care transition. With severe chronic pain in his back, shoulders, and neck, he requires regular physical therapy and monitoring by an orthopedist, as well as multiple pain medications. He also has carpal tunnel syndrome and Type 2 diabetes.

Because of miscommunication and confusion surrounding his move, several physical therapy appointments he’d made for June 2022 were canceled, and he had to wait nearly two months for new ones.

“To me the whole issue is the confusion,” Tennison said. “Right hand and left hand, nobody talks to each other, and nobody talked to me.”

The first hint of trouble came when he called Contra Costa County Employment & Human Services in late April 2022 to report his upcoming move and was told the new county had to initiate the transfer — only to hear from a worker at San Joaquin’s Human Services Agency that it was the other way around.

They were both wrong: Medi-Cal members who move can inform either county.

Tennison persuaded a Medi-Cal worker in San Joaquin County to initiate the transfer. He also filed a notice of his move online, which Medi-Cal workers in Contra Costa processed and flagged for a June 2 transfer date, said Marla Stuart, director of the county’s Employment & Human Services Department.

They set that date, Stuart said, because they believed Tennison might have some medical appointments in May under his Contra Costa Anthem Blue Cross plan.

Medi-Cal workers in San Joaquin County, however, set a move date of May 5, which overrode Contra Costa’s June 2 date and bumped Tennison from his Anthem plan for most of May, according to Stuart.

“If anybody had called me to verify any of this, I definitely would have told them May 5 was the wrong date,” said Tennison, who moved to Stockton on May 17.

“There were good intentions all around,” said Stuart. “It’s unfortunate what happened.”

Being cut from Anthem left Tennison with fee-for-service Medi-Cal, a rapidly shrinking part of the program.

He discovered it only in mid-July, when he called the Office of the Ombudsman for managed care Medi-Cal to complain about two bills he’d received — one for $886.92 from his orthopedic surgeon and another for $795 from his physical therapist.

He had seen both providers in May, when he thought he was still covered by Anthem. But he wasn’t, and they billed him directly, despite signed agreements and a state law that prohibit billing patients for services covered by Medi-Cal.

The bills caught Tennison by surprise, because the ombudsman had told him in early June that he had still been on Anthem through May, he said.

“To me, that’s how insurance works: One insurance ends, the other begins,” he said.

When Medi-Cal patients are between health plans and temporarily in fee for service, it theoretically ensures they have ongoing access to health care. But in practice, that’s not always the case.

“Because the state is pushing most Medi-Cal members into managed care, fewer providers are accepting fee for service,” said Hillary Hansen, an attorney with Legal Services of Northern California who is handling Tennison’s case.

The prohibition against billing Medi-Cal patients is spottily enforced, Hansen said. And although the patients are not legally required to pay, she said, their credit rating can suffer if they don’t. Michael Bowman, a spokesperson for Anthem, said the company regularly communicates with its providers to ensure compliance with the terms of their contracts and Medi-Cal rules.

Hansen is not confident Tennison’s bills will be paid anytime soon. After legal aid lawyers sent a letter to state officials about improper Medi-Cal billing, and later met with them about it, the officials instructed them to have their clients submit reimbursement claims.

But the reimbursement rules require that patients have already paid the bills, and Medi-Cal beneficiaries typically can’t afford that, Hansen said.

Tennison submitted his reimbursement form in May and is waiting to hear back. “Getting medical care should not be this difficult,” he said. “Here it is a year later, and I’m still trying to work this out.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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El centro comunitario de rehabilitación de 60 camas en Santa Fe Springs, administrado por los Centros para el Abuso de Alcohol y Drogas de Los Ángeles, cuenta con una sala de desintoxicación, médicos y enfermeras, consejeros especializados en abuso de sustancias, terapeutas certificados y otros profesionales in situ.

Ofrece terapia grupal así como individual y familiar, y apoya el uso de medicamentos como la buprenorfina y la naltrexona, terapias de primera línea cada vez más populares para el tratamiento de adicciones.

Willard Sexton, empleado y ex-paciente de Allen House, dice que la parte más importante de su trabajo son las conversaciones diarias con cada residente. La mayoría de ellos, como él, llegaron al centro de tratamiento directamente desde la cárcel, y él sabe mejor que nadie lo difícil que es dejar de consumir.

“Se parece al duelo o a perder a un ser querido”, dice Sexton, de 35 años. “La droga fue su mejor amigo durante mucho tiempo”. Interactuar con los residentes, dice Sexton, lo ayuda en su propio proceso de recuperación.

En un momento en el que el uso de drogas está entre las crisis de salud pública más graves del país, una visita a Allen House ofrece lecciones clave. La adicción es una enfermedad crónica que requiere vigilancia constante, no existe una solución única y las recaídas son parte del proceso de recuperación.

Los programas de apoyo entre pares son fundamentales en la terapia para superar la adicción, ya que aquellos que han pasado por el difícil camino de la dependencia a la sobriedad comprenden la mentalidad de los pacientes a un nivel más profundo.

Y lo más importante para las personas que se sienten desalentadas y atrapadas en la adicción es recordar que hay esperanza. “La recuperación es posible”, dice Michelle Doty Cabrera, directora ejecutiva de la County Behavioral Health Directors Association de California. “Todos los días, personas empiezan un tratamiento y logran superar sus trastornos por uso de sustancias”.

Las sobredosis de drogas matan a casi tantos californianos como el cáncer de pulmón, más que la diabetes y entre dos y tres veces más que los accidentes automovilísticos, según un informe de California Health Policy Strategies, una empresa de consultoría de Sacramento.

El reporte demostró que en 2021 hubo aproximadamente 11 veces más muertes relacionadas con el fentanilo que en 2017, lo cual representa más de la mitad de las muertes por sobredosis en ese año. Y la adicción puede arruinar la vida de una persona, sin acabar con ella.

Aún así puede ser difícil encontrar servicios de atención adecuados para los trastornos por uso de sustancias. Los expertos dicen que no hay suficientes camas disponibles en los centros de tratamiento residenciales. La escasez de trabajadores de salud causada por la pandemia ha afectado el mundo de tratamiento de la adicción a drogas.

Algunos operadores de rehabilitación sin escrúpulos, más enfocados en hacer dinero que en ayudar a la gente, se aprovechan de las personas desesperadas por encontrar cualquier solución. Las compañías de seguros de salud en muchos casos niegan las solicitudes de tratamiento o proponen alternativas más baratas.

Algunos centros de tratamiento se niegan a recetar medicamentos para la adicción cuya eficacia ha sido demostrada. En California, médicos, enfermeras registradas y otros proveedores de salud con la capacitación necesaria pueden recetar estos medicamentos, pero muy pocos parecen poder o estar dispuestos a hacerlo, aunque esto podría cambiar ahora que la ley federal ya no les exige obtener un permiso especial.

Una página en el sitio web de la Administración de Servicios de Abuso de Sustancias y Salud Mental (www.samhsa.gov) permite encontrar médicos en tu área que recetan buprenorfina.

No existe una solución única para la adicción. El tratamiento puede diferir según la sustancia: opioides, alcohol o metanfetamina, por ejemplo. Y las personas con adicciones provienen de todos los ámbitos de la vida: algunas acaban de salir de la cárcel o de situación de calle, o pueden tener afecciones mentales o médicas graves que requieren atención adicional. Otras pueden gozar de buena salud y tener trabajos estables y seguro médico. Si una clínica trata de venderte un programa de tratamiento estandarizado, no es un lugar serio.

Y si alguien te dice que después de hacer su programa tú o tu ser querido estarán curados para siempre de la adicción, aléjate lo más posible de ese lugar. Para muchas personas, la adicción es una afección crónica que va y viene durante muchos años. Muy a menudo, el sistema de salud salva a los pacientes de sobredosis y los da de alta sin seguimiento.

“Si habláramos sobre el tratamiento de otras enfermedades crónicas, como la diabetes o el asma, de la misma manera que solemos abordar el tratamiento del uso de sustancias, la gente pensaría que estamos locos o haría una demanda por negligencia médica”, dice Bradley Stein, psiquiatra e investigador principal de políticas médicas en la RAND Corporation.

Encontrar el tratamiento adecuado para ti o para un ser querido requiere investigación.

Para determinar si se necesita un programa residencial o ambulatorio hay que considerar varios factores. A las personas que requieren protección de un traficante o de una situación doméstica peligrosa, o que necesitan desintoxicación o tienen problemas de salud mental o médicos, además de su adicción, generalmente se les recomienda un entorno residencial, dice Randolph Holmes, director médico de los Centros para el Abuso de Alcohol y Drogas de Los Angeles.

Los programas ambulatorios son más adecuados para personas con vidas estables y buena salud, o que estén en transición a un tratamiento residencial, agrega Holmes.

El costo del tratamiento puede variar ampliamente según la duración y las circunstancias del paciente. En algunos casos, puede llegar a costar decenas o cientos de miles de dólares.

En internet hay varios recursos para ubicar centros de tratamiento de adicciones en tu área. La Administración de Servicios de Abuso de Sustancias y Salud Mental ofrece un localizador de tratamientos en www.findtreatment.gov, o puedes llamar a su línea de ayuda al 800-662-HELP (4347). Shatterproof (www.shatterproof.org) es otra fuente para encontrar tratamiento.

En California, el Departamento de Servicios de Salud publica una lista de líneas de ayuda para uso de sustancias organizadas por condado.

Si tienes Medi-Cal, la versión de California del programa federal de Medicaid para residentes de bajos ingresos, tu condado es un buen punto de partida. Esta cobertura te brinda varias opciones, al menos en las zonas más pobladas. Casi todos los pacientes de los Centros para el Abuso de Alcohol y Drogas de Los Ángeles, por ejemplo, son afiliados de Medi-Cal.

Si tienes un seguro médico comercial,  averigua primero con tu plan de salud.

Las leyes de paridad exigen que las aseguradoras cubran el tratamiento por uso de sustancias, aunque es común que estas encuentren razones para no cubrir el tratamiento recomendado por un proveedor de salud.

Si tu seguro te niega el tratamiento que crees que necesitas, puedes apelar la decisión. El Departamento de Cuidado de Salud Administrada (www.dmhc.ca.gov), el principal regulador estatal de planes de salud,  tiene una línea de ayuda (888-466-2219) que puede ayudarte a apelar tu caso. También puedes hacerlo en línea. Si el departamento no regula tu plan, puede guiarte en la dirección correcta.

Y recuerda que la recuperación es un compromiso a largo plazo.

Cuando Sexton comenzó a consumir a sus 20s, eligió la metanfetamina. Más tarde comenzó a fumarla con heroína y fentanilo mezclados, dice.

Hace varios años, Sexton pasó 45 días en rehabilitación residencial y logró “limpiarse”. Entonces empezó a salir con una mujer adicta a la heroína. Pensó que la ayudaría a estar sobria, pero terminó drogándose con ella. Aterrizó en la cárcel durante dos meses, y un juez le ordenó volver al tratamiento residencial por consumo de drogas.

Sexton dice que continúa buscando activamente su recuperación, incluso mientras ayuda a otros a hacer lo mismo. “Hay baches en el camino, pero me siento como si estuviera en una Range Rover”, dice. “No voy a derramar mi café”.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The 60-bed safety-net residential treatment center in Santa Fe Springs, run by Los Angeles Centers for Alcohol and Drug Abuse, has a dedicated detox room, on-site physicians and nurses, substance abuse counselors, licensed therapists, and other practitioners. It offers group counseling as well as individual and family therapy, and it endorses the use of medications for addiction treatment, such as buprenorphine and naltrexone, which are increasingly considered the gold standard.

Willard Sexton, a staff member and former Allen House patient, says the most important part of his job is speaking with each resident daily. Most of them, like him, came to treatment straight from jail or prison, and he knows as well as anybody how stressful it is to stop using.

“It’s similar to grief and loss,” says Sexton, 35. “The drug was their best friend for a long time.” Interacting with them, he says, helps him in his own ongoing recovery.

At a time when drug use is among the nation’s gravest public health crises, a visit to the Allen House offers key lessons: Addiction is a chronic illness requiring constant vigilance, there’s no one-and-done solution, and relapses are part of the journey to recovery. Peer mentoring is an invaluable element of drug counseling, since people who have plodded the difficult path from dependence to sobriety understand the mindset of patients on a visceral level.

And most importantly for those who feel despair in the grip of addiction, there is hope. “Recovery happens,” says Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California. “Every single day people come into treatment and succeed in addressing their substance use disorders.”

Drug-related overdoses kill almost as many Californians as lung cancer, more than diabetes, and two to three times as many as car accidents, according to a report by California Health Policy Strategies, a Sacramento consulting group. The report showed there were about 11 times as many fentanyl-related deaths in 2021 as in 2017, accounting for more than half of overdose fatalities. And addiction can ruin lives even if it doesn’t end them.

But proper care for substance use disorders can still be hard to find. Experts in the field say residential treatment beds are in short supply. A pandemic-driven shortage of health care workers has hit the drug treatment world. Unscrupulous operators, with an eye on their bottom lines, may take advantage of people desperate for any answer. Commercial insurers often deny treatment requests or propose cheaper alternatives.

Some treatment programs shun anti-addiction medications that have proven effective. Physicians, nurse practitioners, and other providers with the requisite training can prescribe these drugs in California, but too few seem willing or able to do so — though that could change now that federal law no longer requires them to get a special waiver.

A page on the website of the Substance Abuse and Mental Health Services Administration (www.samhsa.gov) allows you to find practitioners in your area who treat patients with buprenorphine.

There’s no one-size-fits-all solution for addiction. Treatment can differ depending on the substance — opioids, alcohol, or methamphetamine, for example. And people with substance use problems come from all walks of life: Some are straight off the streets or out of jail or may have serious mental or medical conditions that require additional care. Others may be otherwise healthy with good jobs and insurance. If a clinic tries to sell you on a standardized treatment program, cross the place off your list.

And if someone tells you that after one stint in their program you or a loved one will be drug-free for life, run the other way. For many people, addiction is a chronic condition that ebbs and flows over many years. Too often, patients in the throes of an overdose are revived and then discharged with no follow-up.

“If we talked about treating other chronic illnesses like diabetes or asthma in the same way we often approach treating substance use, people would think we were crazy or would sue the doctor for malpractice,” says Bradley Stein, a psychiatrist and senior physician policy researcher at the Rand Corp.

Finding the treatment that is right for you or a loved one will take legwork.

Whether it should be a residential or outpatient program depends on multiple factors. People who need to be shielded from exposure to a dealer or a toxic domestic situation, require detox, or have mental health or medical conditions on top of their drug use generally are better off in a residential setting, says Randolph Holmes, medical director of the Los Angeles Centers for Alcohol and Drug Abuse. Outpatient settings are more suitable for people with stable lives and better health or those transitioning from residential treatment, he says.

The cost of treatment can vary widely depending on duration and the patient’s circumstances. In some cases, it can reach tens or hundreds of thousands of dollars.

Various websites allow you to search for nearby addiction treatment. The Substance Abuse and Mental Health Services Administration has a treatment locator at www.findtreatment.gov, or you can call its help line at 800-662-HELP (4347). Shatterproof (www.shatterproof.org) is another source for finding treatment. In California, the Department of Health Care Services publishes a list of substance use help lines by county.

If you’re on Medi-Cal, California’s version of the federal Medicaid program for low-income residents, your county is a good place to start. It can point you to several options, at least in more populous areas. Almost all patients with the Los Angeles Centers for Alcohol and Drug Abuse, for example, are Medi-Cal enrollees.

If you have commercial insurance, call your health plan first. Parity laws require insurers to cover substance use treatment, though they often find reasons not to provide the treatment your provider recommends. If your plan denies you treatment you think you need, you can file an appeal. The Department of Managed Health Care (www.dmhc.ca.gov), the state’s primary health plan regulator, has a help line (888-466-2219) that can assist in appealing your case. Or you can do it online. If the department does not regulate your plan, it can steer you in the right direction.

And remember that recovery is a long-term commitment.

When Sexton first started using in his early 20s, his drug of choice was meth. He later started smoking it with heroin and fentanyl mixed in, he says.

Several years ago, Sexton spent 45 days in residential rehab and got clean. Then he started seeing a woman who was addicted to heroin. He thought he’d help her get sober but ended up doing drugs with her instead. He landed in jail for two months, and a judge ordered him back into residential drug treatment.

Sexton says he continues to actively pursue his recovery even as he helps others do the same. “There are bumps in the road, but I feel like I’m in a Range Rover,” he says. “I’m not going to spill my coffee.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“I anticipate that we will ask the bankruptcy judge to let our case proceed,” said David Millstein, an attorney representing the Milwaukee-based American Academy of Emergency Medicine Physician Group. “Among other things, Envision’s practices violate the law, are continuing, and need to be addressed.”

Envision said it filed under Chapter 11 in bankruptcy court in Houston hoping to liquidate most of its $7.7 billion in debt and restructure the business. So far, the company said, its plan has the support of creditors holding about 60% of its debt, and it expects support “to grow in coming days.” The Wall Street Journal first reported on May 9 that Envision was preparing to reorganize its business, having missed an interest payment in April and failing to report quarterly financial results by a March 31 deadline.

Envision spokesperson Aliese Polk declined to comment on the emergency physicians’ lawsuit but said the company is compliant with state laws. Polk said that other legal challenges to its business model “have proved meritless.”

The lawsuit does not ask for monetary damages, so the physician group would presumably not have a financial claim against Envision. Instead, the doctors seek a legal finding that the company’s alleged use of shell business structures to retain de facto ownership of ER staffing groups is illegal. A trial in San Francisco had been scheduled to start next January, but the date has been pushed back.

The doctors believe that a victory in their case would lead to a ban on that business strategy across California — not just in ERs run by Envision but also by TeamHealth, another private equity-owned medical staffing firm, and in other medical services the two companies provide, including anesthesiology, hospital-based medicine, and gynecology.

Many doctors, nurses, consumer advocates, and even some lawmakers, hope a legal victory would spur prosecutors and regulators in other states to take the issue of medical practices controlled by corporations more seriously.

Envision runs 467 emergency departments across the country and TeamHealth operates 511, according to Ivy Clinicians, a startup job search website for emergency physicians. Together, the two companies control more than 17% of emergency departments, the data shows.

Envision was acquired by the investment firm KKR in 2018 for $9.9 billion, making it the largest private equity deal in health care during that decade. The deal saddled Envision with about $7 billion in debt. Last September, analysts at S&P Global Ratings estimated that the company’s debt was 29 times its earnings in 2022, a staggeringly high figure that raised alarms about its ability to pay its obligations.

At the same time, Envision’s revenue picture has deteriorated. The federal No Surprises Act, which protects patients from unexpected bills sent by out-of-network providers, sapped a key source of revenue. The pandemic shrank patient volumes, and burnout among health care workers fueled staffing shortages that have jacked up labor costs. A fierce battle with insurance giant UnitedHealthcare over payments for patient care also hit Envision.

Envision said the bankruptcy process would allow it to shed about $5.6 billion in debt, which will either be canceled or exchanged for equity in the restructured company. Its ambulatory surgery affiliate, AMSURG, will become a separately owned firm.

Envision said it has “more than ample cash” to continue operating without interruption.

“The financial profile of the company is just not strong enough to manage the debt they have on the balance sheet, and I think that’s really what the bottom line is,” said David Peknay, a director at S&P Global Ratings.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

Es probable que en las próximas semanas escuches y veas mensajes públicos instándote a actualizar tu información de contacto. Hazles caso.

En algún momento entre ahora y la próxima primavera, es probable que recibas correspondencia de la agencia que administra Medi-Cal en tu condado para dejarte saber si todavía eres elegible para el seguro de salud, o para pedirte más información acerca de tu situación laboral, ingresos y cuántas personas componen tu núcleo familiar.

Lo más probable es que recibas una solicitud de información en un sobre de color amarillo brillante con un formulario de unas 20 páginas, unas seis semanas antes de que empiece tu mes de renovación.

Manténte alerta: Medi-Cal está advirtiendo sobre estafadores que han contactado a los afiliados y solicitado una cuota para ayudarles a renovar la cobertura. No caigas en esa trampa. No se requiere ningún pago para renovarla.

Pero asegúrate de abrir la correspondencia y responder a cualquier solicitud oficial de información personal. Y ten en cuenta que la actualización de tu información podría dejarte fuera de Medi-Cal, si tus ingresos han aumentado o si tienes acceso a otro seguro.

Si necesitas ayuda, especialmente con el intimidante formulario de renovación, sigue leyendo.

Medi-Cal, la versión de Medicaid en California, puso en marcha una iniciativa de 14 meses para reexaminar la elegibilidad de sus casi 15.8 millones de miembros. Esta medida forma parte de la “reducción” masiva que están emprendiendo todos los programas estatales de Medicaid después de tres años de pandemia durante los cuales sus listas de afiliados aumentaron. Los estados habían acordado no expulsar a nadie salvo en casos como fraude, fallecimiento o mudarse de estado, a cambio de financiación adicional federal.

Medicaid reanudó el 1 de abril las comprobaciones anuales de elegibilidad que habían sido la norma antes de la pandemia. Es la mayor reorganización en la cobertura sanitaria estadounidense desde la Ley de Cuidado de Salud a Bajo Precio (ACA), aunque con recortes  que van en sentido contrario: es probable que entre 8 y 24 millones de personas queden excluidas de Medicaid en todo el país, incluidos entre 2 y 3 millones en California.

Para reducir al mínimo el número de afiliados que se den de baja innecesariamente, el Departamento de Servicios de Atención de Salud de California, que gestiona Medi-Cal, ha puesto en marcha una campaña publicitaria y de divulgación de $25 millones que enviará notificaciones en 19 idiomas.

El departamento está recabando la ayuda de casi todos los que tienen contacto con los beneficiarios de Medi-Cal: oficinas del condado, planes de salud, proveedores médicos, grupos de defensoría y voluntarios. Y consiguió $146 millones en fondos suplementarios para ayudar a los condados a hacer frente al número sin precedentes de renovaciones.

Pero a algunos defensores de los pacientes, ejecutivos de planes de salud y administradores de clínicas comunitarias les preocupa que no sea suficiente para ayudar a todos los afiliados que podrían perder la cobertura si no se les puede localizar o no responden, especialmente personas que no tienen un domicilio fijo, las que viven en la calle, o las que tienen barreras de idioma o culturales.

Menos de dos meses antes del inicio de los ajustes, varios condados, entre ellos Fresno y Sacramento, informaron de la escasez de personal y de la necesidad de formar a trabajadores que cumplieran con los requisitos.

Laura Sheckler, directora adjunta de políticas de la Asociación de Atención Primaria de California, que representa a cerca de 1,300 clínicas comunitarias en todo el estado, dijo que los casi $60 millones en fondos estatales destinados a “navegadores” para ayudar a los afiliados de Medi-Cal no es suficiente para proporcionar toda la ayuda que se necesita. La asociación ha pedido a los legisladores otros $60 millones.

Algunos afiliados de Medi-Cal ya saben a qué atenerse. Anthony Kelley, padre soltero de 53 años, es uno de ellos. Kelley, que vive con su hijo de 14 años, Nicholas, en Pacifica, California, perdió temporalmente su trabajo como conductor para una empresa de hormigón en los primeros días de la pandemia y se inscribió en Medi-Cal.

Recuperó su trabajo un mes después, junto con el acceso a la cobertura médica patrocinada por su empleador, pero ha permanecido en Medi-Cal durante los últimos tres años. Su hijo ha estado en Medi-Cal desde que nació.

Cuando el condado de San Mateo envió a Kelley un formulario de renovación, llamó y le dijeron que sus $58,000 de ingresos anuales probablemente significaban que él y su hijo perderían la cobertura de Medi-Cal. Ahora está esperando que eso suceda.

“Es un fastidio para mi hijo”, dijo Kelley, quien agregó que teme que Nicholas pueda perder a sus médicos. “Pero ya lidiaremos con eso”.

Si tienes ansiedad o dudas sobre lo que debes hacer, no te preocupes. Hay ayuda disponible.

Puedes llamar o acudir a una oficina local de Medi-Cal para actualizar tus datos personales o solicitar ayuda. El Departamento de Servicios de Atención de Salud (www.dhcs.ca.gov) tiene una lista en su sitio web de todas las agencias de Medi-Cal de los condados, con direcciones, números de teléfono y enlaces. También puedes llamar al teléfono de ayuda de Medi-Cal (800-541-5555).

Si quieres evitar las largas filas o los tiempos de espera por teléfono, considera la posibilidad de abrir una cuenta en www.benefitscal.com o www.mybenefitscalwin.org. Esto te permitirá actualizar tu información personal y financiera en línea, y encontrar tu fecha de renovación.

Otro gran recurso es la Alianza de Consumidores de Salud (888-804-3536 o www.healthconsumer.org), que puede ayudarte con las complejidades de la renovación, o impugnar una decisión de cancelación que consideres injustificada.

Las clínicas comunitarias, que atienden a casi un tercio de los afiliados a Medi-Cal, suelen contar con asesores que pueden ayudarte a llenar formularios y responder a tus preguntas. L.A. Care, el mayor plan de salud de Medi-Cal, tiene 11 centros en el condado de Los Ángeles que ofrecen ayuda a cualquiera que la necesite, no solo a sus afiliados.

El condado de Fresno cuenta con 14 centros de este tipo. Consulta con tu plan de salud para obtener recursos similares.

En virtud de una ley estatal, la SB260, si se te da de baja de Medi-Cal pero tus ingresos son lo suficientemente bajos como para tener derecho a un subsidio a través de Covered California, el mercado de seguros del estado, se te inscribirá automáticamente en un plan que el mercado considere la mejor relación calidad-precio. Una vez notificada la selección del plan, tendrás 30 días para aceptarlo, elegir otro plan o rechazar la cobertura.

“Esto no tiene por qué ser un desastre para los beneficiarios de Medi-Cal”, indicó David Kane, abogado del Western Center on Law & Poverty.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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You will likely hear and see public messages over the coming weeks urging you to update your contact information. Heed them.

Then, sometime between now and next spring, you’ll probably receive mail from the agency that administers Medi-Cal in your county telling you if you are still eligible for the safety-net health insurance program or asking for more information about your employment status, income, and household size. An information request would likely come in a bright-yellow envelope containing a roughly 20-page form about six weeks before the start of your renewal month.

Be on the alert: Medi-Cal is warning about scammers who have been contacting enrollees and requesting a fee to help people renew coverage. Don’t fall for it. No payment is required to renew your coverage.

But be sure to open your mail and respond to any official request for personal information. And be aware that updating your information could push you off Medi-Cal if your income has risen or if you have access to other insurance.

If you need help with any of this, especially that daunting renewal form, keep reading.

Medi-Cal, the state’s version of the Medicaid health insurance program for low-income residents, has embarked on a 14-month effort to reexamine the eligibility of its nearly 15.8 million members. It is part of the massive “unwinding” being undertaken by all state Medicaid programs after three pandemic years during which their rolls swelled. States had agreed, in exchange for extra funding from the feds, not to boot anyone except in cases such as fraud, death, or a move out of state.

On April 1, Medicaid restarted the annual eligibility checks that had been the norm before the pandemic. It will be the biggest shake-up in U.S. health coverage since the Affordable Care Act, though it cuts the opposite way: Between 8 million and 24 million people will likely be bounced from Medicaid nationally, including an estimated 2 million to 3 million in California.

To minimize the number of enrollees dropped unnecessarily, California’s Department of Health Care Services, which runs Medi-Cal, has launched a $25 million advertising and outreach campaign that will send messages in 19 languages. The department is enlisting the assistance of nearly everyone who has contact with Medi-Cal enrollees: county offices, health plans, medical providers, advocacy groups, and volunteers. And it got $146 million in supplemental funding to help counties cope with the unprecedented number of renewal decisions.

But some patient advocates, health plan executives, and community clinic administrators worry it will not be enough to help all enrollees who could lose coverage if they can’t be reached or don’t respond — especially transient and homeless people and those with language or cultural barriers.

Less than two months before the start of the unwinding, multiple counties, including Fresno and Sacramento, reported staffing shortages and the need to train eligibility workers.

Laura Sheckler, deputy director of policy at the California Primary Care Association, which represents about 1,300 community clinics statewide, says the nearly $60 million in state funds earmarked for “navigators” to assist Medi-Cal enrollees is not enough for her group’s members to provide all the help that will be needed. The association has asked lawmakers for another $60 million.

Some Medi-Cal members already know where they stand. Anthony Kelley, a 53-year-old single dad, is one of them. Kelley, who lives with his 14-year-old son, Nicholas, in Pacifica, California, temporarily lost his job as a driver for a concrete company in the early days of the pandemic and signed up for Medi-Cal. He got his job back about a month later, along with access to employer-sponsored health coverage, but he has stayed on Medi-Cal for the past three years. His son has been on Medi-Cal since he was born.

When San Mateo County sent Kelley a renewal form, he called and was told his $58,000 annual income likely meant he and his son would lose Medi-Cal coverage. Now, he’s waiting for that to happen.

“It sucks for my son,” Kelley says, adding that he fears Nicholas could lose his doctors. “But we’ll deal with it.”

If you are anxious or uncertain about what you need to do, don’t fret. Help is available.

You can call or visit your local Medi-Cal office to update your personal information or ask for assistance. The Department of Health Care Services (www.dhcs.ca.gov) lists on its website all county Medi-Cal agencies, with addresses, phone numbers, and links. You can also call Medi-Cal’s help line (800-541-5555).

If you want to avoid potentially long lines or telephone hold times, consider signing up for an account at www.benefitscal.com or www.mybenefitscalwin.org. Doing so will allow you to update your personal and financial information online and find your renewal date.

Another great resource is the Health Consumer Alliance (888‑804‑3536 or www.healthconsumer.org), which can help you navigate the complexities of renewal, or contest a termination decision you think is unwarranted. Community clinics, which provide care for nearly one-third of Medi-Cal enrollees, often have navigators on-site who can help fill out forms and answer questions. L.A. Care, the largest Medi-Cal health plan, has 11 centers across Los Angeles County that will offer help to anyone who needs it, not just its members. Fresno County has 14 such centers. Check with your health plan for similar resources.

Under a state law, SB 260, if you are bumped off Medi-Cal but still have income low enough to qualify for an insurance subsidy through Covered California, the state’s insurance marketplace, you will be auto-enrolled in a plan the exchange deems to be the best value at the lowest cost. Once notified of the plan selection, you will have 30 days to accept it, choose another plan, or decline coverage altogether.

“This doesn’t need to be all doom and gloom for people who have Medi-Cal,” says David Kane, a senior attorney at the Western Center on Law & Poverty.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

Yet the law — meant to discipline doctors who give patients false information about covid-19 — is now in legal limbo after two federal judges issued conflicting rulings in recent lawsuits that say it violates free speech and is too vague for doctors to know what it bars them from telling patients.

In two of the lawsuits, Senior U.S. District Judge William Shubb in Sacramento issued a temporary halt on enforcing the law, but it applies only to the plaintiffs in those cases. Shubb said the law was “unconstitutionally vague,” in part because it “fails to provide a person of ordinary intelligence fair notice of what is prohibited.” His ruling last month clashed with one handed down in Santa Ana in December; in that case, U.S. District Judge Fred Slaughter refused to halt the law and said it was “likely to promote the health and safety of California covid-19 patients.”

The legal fight in the nation’s most populous state is to some extent a perpetuation of the pandemic-era tussle pitting supporters of public health guidelines against groups and individuals who resisted masking orders, school shutdowns, and vaccine mandates.

California’s covid misinformation law, which took effect Jan. 1, is being challenged by vaccine skeptics and civil liberties groups. Among those suing to get the law declared unconstitutional is a group founded by Robert F. Kennedy Jr., who has questioned the science and safety of vaccines for years.

But doubts about the law are not confined to those who have battled the scientific mainstream.

Dr. Leana Wen, a health policy professor at George Washington University who previously served as president of Planned Parenthood and as Baltimore’s health commissioner, wrote in an op-ed a few weeks before Newsom signed the law that it would exert “a chilling effect on medical practice, with widespread repercussions that could paradoxically worsen patient care.”

The Northern California affiliate of the American Civil Liberties Union has weighed in against the law on free speech grounds, though the national organization has affirmed the constitutionality of covid vaccine mandates.

“If doctors are scared of losing their licenses for giving advice that they think is helpful and appropriate, but they don’t quite know what the law means, they will be less likely to speak openly and frankly with their patients,” said Hannah Kieschnick, an attorney with the ACLU of Northern California.

The law establishes that doctors who give false information about covid to patients are engaging in unprofessional conduct, which could subject them to discipline by the Medical Board of California or the Osteopathic Medical Board of California.

Proponents of the law sought to crack down on what they believe are the most clear-cut cases: Doctors who tout treatments such as ivermectin, an anti-parasitic agent that is unproven as a covid treatment and can be dangerous; who exaggerate the risk of getting vaccinated compared with the dangers of the disease; or who spread unfounded theories about the vaccines, including that they can cause infertility or harm DNA.

But the law lacks such specifics, defining misinformation only as “false information that is contradicted by contemporary scientific consensus contrary to the standard of care.”

Michelle Mello, a professor of law and health policy at Stanford University, said the wording is confusing.

“On a matter like covid, science is changing all the time, so what does it mean to say there is scientific consensus?” she asked. “To me, there are lots of examples of statements that clearly, with no vagueness involved, meet the definition of the kind of conduct that the legislature was going after. The problem is that there are all kinds of other hypothetical things that people can say that don’t clearly violate it.”

Dr. Christine Cassel, a professor of medicine at the University of California-San Francisco, said she expects the law to be applied only in the most flagrant cases. “I trust scientists enough to know where there’s a legitimate dispute,” she said.

Cassel’s view mirrors Newsom’s rationale for signing the legislation despite his awareness of potential free speech concerns. “I am confident,” he wrote in his message to lawmakers, “that discussing emerging ideas or treatments including the subsequent risks and benefits does not constitute misinformation or disinformation under this bill’s criteria.”

Plaintiffs in the Santa Ana case, two doctors who have sometimes diverged from public health guidelines, appealed Slaughter’s ruling allowing the law to stand. The case has been combined in the 9th U.S. Circuit Court of Appeals with another case in which a San Diego judge declined to rule on a similar request to temporarily halt the law.

Newsom spokesperson Brandon Richards said in early February that the administration would not appeal the two Sacramento cases in which Shubb issued the narrow injunction. The plaintiffs’ lawyers had expected the state to appeal the decision, thinking all four lawsuits would then be decided by the appeals court, providing greater clarity for all parties.

Richard Jaffe, lead attorney in one of the Sacramento cases — brought by a doctor, Kennedy’s Children’s Health Defense, and a group called Physicians for Informed Consent — said Newsom’s decision not to appeal is “just going to increase the level of chaos in terms of who the law applies to.”

But the Newsom administration has decided to wait for the appeals court to rule on the other two judges’ decisions that left the law intact for now.

Jenin Younes, a lawyer with the New Civil Liberties Alliance who is lead counsel in the other Sacramento case in which Shubb issued his injunction, said Newsom may be calculating that “you’re in a stronger position going up on a win than on a loss.”

A victory for Newsom in the appeals court, Jaffe and others said, could dampen the impact of the two Sacramento cases.

Opponents of California’s covid misinformation law question why it is needed at all, since the medical boards already have authority to discipline doctors for unprofessional conduct. Yet only about 3% of the nearly 90,000 complaints the Medical Board of California received over a decade resulted in doctors being disciplined, according to a 2021 investigation by the Los Angeles Times.

That could be good news for doctors who worry the new law could constrain their ability to advise patients.

“I don’t see medical boards being particularly vigorous in policing physicians’ competence in general,” said Stanford’s Mello. “You have to be really bad to get their attention.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

Your neighbor. Your co-worker.

You.

California’s Medicaid program, called Medi-Cal, serves a whopping 15.4 million people, offering care from cradle to grave: Half of all births are covered by Medi-Cal, as are more than half of all stays in nursing homes.

Everything about Medi-Cal is massive, from its upcoming fiscal year budget of $139 billion to the expansive list of benefits and services it offers. The way the program works — or doesn’t — could spell life or death for many enrollees.

“It’s critical, from the single pregnant mom, to the extremely frail elderly population that needs a nursing home,” said Jennifer Kent, former director of the state Department of Health Care Services, which administers Medi-Cal. “If it weren’t for Medi-Cal, so many people would either be dead or would be severely compromised.”

In a new series, California Healthline will shed light on Medi-Cal’s successes and failures through the experiences of its enrollees. They include Stephanie Lammers, who can’t get her troubling abdominal symptoms checked at a clinic 50 miles from her small Calaveras County town because the transportation Medi-Cal is supposed to provide isn’t trustworthy; Carolina Morga Tapia, a Fresno woman who credits Medi-Cal with helping her have five healthy children; and Lucas Moreno Ramirez, a Los Angeles County man with stage 4 lung cancer who had to fight to keep his treatment going.

Medi-Cal is at a critical juncture as it attempts to serve the needs of a diverse patient population with a dizzying array of medical needs — from childhood vaccinations and cancer screenings to state-of-the-art care for rare genetic disorders. Roughly half of enrollees are Hispanic, and, next year, California will become the first state to expand eligibility to all immigrants who qualify, regardless of their legal status.

Medi-Cal is also undertaking several new initiatives that aim to save taxpayer money and improve quality. State officials are demanding that the 23 health insurers that serve most Medi-Cal patients provide better care — or face significant penalties, including potential expulsion from the program.

The state is also adding innovative social services that fall outside the traditional realm of medicine, including helping some enrollees pay for rent and buy groceries.

“People are watching California,” said Cindy Mann, who served as federal Medicaid director under former President Barack Obama. “What the state is doing is ambitious and very aggressive. It makes a significant mark on health care and health policy, not just because of the size and breadth of its program, but by being very comprehensive.”

But only a sliver of enrollees will get the new social services, even as many patients struggle to obtain basic care or get in to see their doctors. In reality, the type of care you get in Medi-Cal depends on where you live and which insurer provides your benefits.

That means the program is working for some, but failing for many others.

If you are in Medi-Cal, we would like to hear from you, whether you live in a big city or a rural region, regardless of your age, race, or ethnicity, and whatever your medical, dental, or mental health condition. Have you had difficulty seeing the right doctor for what ails you, even to the point of putting your life at risk? Or did Medi-Cal provide good care, perhaps sparing you serious harm or disability? Either way, please consider sharing your experience with us.

Here are snapshots of patients who have used the program at a critical time in their life.

‘I Just Don’t Go to the Doctor Anymore’

When Stephanie Lammers leans over to put on her shoes, it feels as if she’s squishing something inside her abdomen, she said.

Lammers, 53, has been suffering from frequent bouts of nausea, pain, and bloating for six months.

Her gastroenterologist wants to perform diagnostic procedures, including a colonoscopy and, if anything shows up, a biopsy. But Lammers, who lives in a motel with her boyfriend and teenage daughter in the Gold Rush town of San Andreas, doesn’t have a working car and can’t readily get to the clinic — which is 50 miles away.

For Lammers, like many Medi-Cal enrollees who live in rural areas, lack of transportation is a major impediment to obtaining care. The problem is particularly acute for patients who need to see specialists.

Lammers’ dermatologist and eye doctor are over an hour away from San Andreas, the county seat of Calaveras County, about 125 miles northeast of San Francisco. She isn’t seeing a neurologist, despite a series of mini-strokes and stress-related seizures. And she hasn’t been to a podiatrist in two years, even though her toes are twisted over one another and hang down, causing her to trip. She’s often in excruciating pain when she walks.

Medi-Cal is supposed to provide free transportation to enrollees who can’t otherwise get to their appointments.

But Lammers, whose health plan is California Health & Wellness, owned by Centene, the nation’s largest commercial Medicaid insurer, stopped using its ride service nearly a year ago, after she missed dozens of appointments because drivers just didn’t show up, she said. She was getting threatening letters from doctors’ offices over the no-shows.

Once she had to hitchhike more than 30 miles home from a counseling appointment. On other occasions, Lammers said, she did not receive the reimbursement she was owed for arranging her own rides.

“I just don’t go to the doctor anymore,” Lammers said. “If I go to the doctor, my boyfriend has to take the day off work, and if he takes the day off work, we have no money.”

During the last three months of 2022, Lammers canceled five appointments she had scheduled for the diagnostic abdominal procedures because her boyfriend had to work each time and couldn’t take her. She finally stopped rescheduling.

California Health & Wellness contracts with Modivcare, a Denver-based medical transportation company that is no stranger to patient complaints and lawsuits.

Before she gave up on the ride service, Lammers said, she would call California Health & Wellness to try to resolve the issue, only to be told that Modivcare was a separate company. “I’m like, ‘If you guys hired them and put them in charge of transportation, who oversees their screw-ups?’”

Courtney Schwyzer, a member of a legal aid team representing Lammers on various Medi-Cal matters, said the failure of medical ride services is a systemic problem. In late February, Schwyzer and her fellow attorneys filed a petition in court that she hopes will force the state Department of Health Care Services to address the problem.

California Health & Wellness spokesperson Darrel Ng said the company monitors the quality of its contractors, but a shortage of transportation providers in rural areas “has created unique challenges.”

Modivcare provides more than 4 million rides for Medi-Cal recipients annually, and more than 99% are without complaint, said Melody Lai, a company spokesperson.

Lammers, who is unemployed and trying to start a custom craft business called Stuff by Steph, said doctors have warned her that if she doesn’t reduce her stress level, it could shorten her life. But arranging medical care is the most stressful thing in her life right now, so she doesn’t try anymore.

“In order to keep from dying, I have to not go to the doctor,” she said.

‘It’s a Blessing’

Medi-Cal helped save the life of Carolina Morga Tapia, a 30-year-old, full-time mother of five who lives with her family amid almond groves in an agricultural enclave of Fresno.

Nine years ago, a bacterial infection triggered premature labor during the 25th week of her second pregnancy, and Morga Tapia almost died. She spiked a fever, bled profusely, and needed immediate transfusions and emergency surgery. After several days in critical care, she fully recovered.

But the doctors could not stop the premature birth, and her baby came out weighing just 1 pound. She and her husband, David Nuñez, named her Milagros Guadalupe, and she died four days later, on Sept. 13, 2013 — a Friday.

In each of her subsequent pregnancies, Medi-Cal paid for Morga Tapia to get shots of synthetic progesterone, intended to prevent another preterm birth. Those shots — one a week for about 20 weeks — can cost an average of more than $10,000 per pregnancy.

Morga Tapia and Nuñez, a construction worker, signed up for Medi-Cal when she was pregnant with her first child more than a decade ago. They’ve been on the same Anthem Blue Cross Medi-Cal plan ever since.

“It saves a lot of money, and it’s a blessing to have that extra help.”

Morga Tapia

The plan paid for prenatal care through all six of Morga Tapia’s pregnancies, and it has provided all the medical and dental care the family needs, she said.

“Without Medi-Cal, we would have to be paying for all of our children,” said Morga Tapia. “It saves a lot of money, and it’s a blessing to have that extra help.”

Her children, four girls and a boy, range in age from 1 to 10. They all go to the same children’s clinic and see the same pediatrician.

The kids, all in good health, get routine checkups, vaccinations, and other preventive care, Morga Tapia said. She gets appointment reminders via text and cards in the mail notifying her when it’s time for the kids’ vaccinations and wellness checks, as well as her Pap smears, she said.

Her family’s experience contrasts sharply with the state’s assessment of their health plan, according to a report on quality of care in Medi-Cal issued late last year. The report, which evaluated Medi-Cal health plans on pediatric care, women’s health, and chronic disease management, put Anthem Blue Cross in the lowest tier, and below par on multiple measures in numerous counties, including Fresno.

Another state report, released in late January, detailed how quickly insurers provide appointments for their patients, and put Anthem Blue Cross’ Medi-Cal plan near the bottom of the heap.

Anthem Blue Cross spokesperson Michael Bowman said in a statement that the period covered in the reports coincided with the covid-19 pandemic, “when our safety net providers dealt with significant challenges with workforce and appointment availability.”

Morga Tapia doesn’t give the insurer low marks. “It’s different for everybody. I have a good healthy family, and what Medi-Cal covers is really fortunate for us,” she said.

‘I Don’t Want to Die Yet’

In late 2021, doctors gave Lucas Moreno Ramirez a few months to live.

Struggling with diabetes and late-stage lung cancer, Moreno Ramirez suffered debilitating pain as he hacked and labored for breath. His doctors recommended that he stop treatment and start hospice care.

He felt as if they were giving up on him.

“They said they’re going to give me opioids for my pain and help me have a comfortable death,” said Moreno Ramirez, 68, who lives in Norwalk, in Los Angeles County. “I told them I don’t believe in that. I don’t want to die yet.”

A former landscaper and factory worker, Moreno Ramirez learned he had to be his own advocate, fighting for the care he believed he deserved from Medi-Cal.

He said his Christian faith gave him strength, and over the next few months, Moreno Ramirez pushed the program and his doctors to keep battling his cancer, using a different treatment with fewer side effects than chemotherapy.

“I believe in prayer,” he said. “But I believe in science and medication, too.”

Moreno Ramirez is one of the roughly 1.6 million Californians enrolled in both Medicare, which covers people who are 65 and older or have disabilities, and Medi-Cal, which kicks in to cover the costs and benefits that Medicare doesn’t.

He also relies on his Medi-Cal insurer to help him navigate the byzantine system. L.A. Care, the largest Medi-Cal plan with nearly 2.6 million members, connected him with a care manager who worked with him to identify a different treatment called Tagrisso and advocated for him to get it. 

Even with the new medication, Moreno Ramirez’s coughing fits returned last year, and his symptoms grew so painful he suspected the cancer was growing. He asked to see his pulmonologist but was told the first appointment would be in June 2023. So he switched doctors and scored an appointment nearly six months sooner.

“My old doctor didn’t help me. I didn’t trust him,” Moreno Ramirez said. “He was always too busy for me. I told my doctors, ‘Give me a chance.’”

Having taken his care into his own hands, he says he’s not in pain, his cough has subsided, and he feels hopeful for the future. “Now I feel good,” he said.

He has also sought more attention for his diabetes and received a continuous glucose monitor to measure his blood sugar. It’s better controlled now than it has been in decades, he said.

“You have to stand up for yourself and advocate,” said Joann Pacelo, the care manager who helped Moreno Ramirez change doctors, get quicker referrals to specialists, and get approved for in-home nursing visits.

“A lot of times it’s difficult with Medi-Cal because the doctors are busy and the reimbursements are so low, but no one should be denied the care they deserve.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).