When Derek Longwell needs to see one of the specialists that help him live with spina bifida, it’s a five-hour trip.
Longwell, 21, lives in Shingletown, in rural Shasta County, and his specialists are in Stanford.
With his mother, Wendy Longwell, at the wheel, Longwell will be making the trip nearly every week this summer to manage his condition, a birth defect that causes spinal malformations.
One thing, of many, on Wendy Longwell’s mind as she drives through the pine trees will be whether the state department that manages her son’s health insurance is providing equal and fair access to her child and others like him.
Should patients in rural California have to drive four times as far to see a neurologist as someone who lives in Los Angeles? Should your access to health care depend on your zip code?
California is struggling to answer those questions as it creates access standards for its low-income health program, Medi-Cal. The federal Medicaid program, which partially funds Medi-Cal, is requiring states to have access requirements, and California plans to have them in place by July 2018.
Some states are creating one standard for all, and others are proposing tiered systems based on where patients live. California is blending these approaches and has proposed a statewide standard for access to primary-care doctors and a tiered system for specialty care.
The California Department of Health Care Services, which runs Medi-Cal, is pushing for a three-tiered system of access for specialists and some mental health professionals, whose offices are fewer and far between in some stretches of the state.
Medi-Cal enrollees who live in Los Angeles County would have the best access to care, having to travel only 15 miles or 30 minutes to an appointment with a specialist.
Those in mid-sized counties, with less than 4 million people but more than 200,000, could have to travel 30 miles or 60 minutes to a specialist.
And Medi-Cal patients in the state’s smallest counties, with fewer than 200,000 residents, could have to travel 60 miles or 90 minutes. That’s four times the distance or three times the time of the Los Angeles County requirement.
“What we have found is that varying areas of the state have different levels and types of providers, so we are establishing specific standards that can be met in those distinct geographic areas,” Health Care Services spokesman Anthony Cava said.
More than a quarter of Californians—about 10.7 million people—are enrolled in a Medi-Cal managed care plan and would be affected by these new standards.
Advocacy groups across California that represent doctors, children, low-income residents and people of color, have expressed concern about the tiered system, saying that it could be confusing for patients and increase health disparities in rural regions.
“We are extremely concerned about the proposal to establish different specialty care standards for consumers in different counties,” the advocacy group Children Now wrote to the department in February. “We believe it creates a bad precedent to establish standards that effectively burdens rural residents by allowing much less stringent network standards. We are concerned that this creates unequal and inequitable access to care based on geography.”
The Health Care Services department received a number of comments questioning the proposal earlier this year—from the California Medical Association, California Pan-Ethnic Health Network and the Western Center on Law & Poverty, among others. The agency expects to issue a final proposal this month, Cava said. It remains unclear whether it will alter or remove the tiers based on the comments from advocates.
Advocates are also trying to get the California legislature to weigh in on the matter. Assembly bill 205 and Senate bill 171, which are waiting to be addressed by legislative committees, are intended to make the process of creating access standards more collaborative, said Linda Nguy, policy advocate at the Western Center.
“There should be a stakeholder process involved,” she said. “We’d like to continue working with (the Health Care Services department) in order to make it more consumer friendly.”
Nguy worries that a three-tiered system could be confusing for Californians, especially those who move across county lines. The net result could be that people take longer to find a doctor or end up going without, she said.
“We would prefer a statewide standard, because it’s just easier to understand,” Nguy said.
“We certainly understand there are differences throughout the state and that some places are more rural, but there can be exceptions for those areas that won’t be able to meet that standard.”
The Health Care Services department can require health plans that don’t meet its access standards to allow patients to see out-of-network doctors or pay for transportation to physicians that are farther away, for example.
Some advocates, including Mike Odeh, director of health policy for Children Now, also oppose the tiered system on philosophical grounds.
“Is the need any less urgent for someone just because they live in a rural community?” he said. “I get the reasons why you would say that in a rural area it’s harder to find providers, but from a justice and equity point of view, I don’t think it’s the direction we want California to head.”
Wendy Longwell understands the issue is complicated, and she often prefers to drive a few hours longer to make sure her son sees the best specialist.
But a number of families in her region don’t have the resources to do that. Putting them, and the rest of rural California, in the bottom tier of an access plan will result in them getting poorer care, she said.
“A tiered system is going to make it harder for us to access the doctors that we need for our kids,” she said.