Fhoto: Hannah Norman/KHN Illustration
San Diego podiatrist Dr. John Chisholm recalls the jolt some of his patients felt in 2009 when Medi-Cal, the government-funded health insurance in California for low-income people, eliminated coverage for podiatry care and several other benefits for adults due to a massive budget shortfall engendered by the Great Recession.
Chisholm calls that cut “the Big One,” and for some of his low-income patients, the consequences were catastrophic. Many of them had diabetes and could no longer afford the foot care so vital for people with the disease, which can constrict blood flow and cause serious nerve damage in the feet. Those patients stopped coming to see him.
He would see them again only when he was called to the emergency room to perform amputations on those whose disease raged unchecked.
“For so many of the working poor, losing this coverage was absolutely devastating,” Chisholm said. “It resulted in people having to choose between the basic necessities of life and going to the doctor. I saw a lot of hurt.”
This month, Medi-Cal restored podiatry and several other adult health benefits eliminated more than a decade ago, including eyeglasses and speech therapy, as well as hearing exams, hearing devices and other related services. The state’s 2019-20 budget provides $17.4 million to pay for the coverage.
About 13 million Californians — including 7 million adults — are covered by Medi-Cal, the state’s version of Medicaid.
“Millions now have access to these types of health care they didn’t have before,” said Anthony Wright, executive director of Sacramento-based Health Access California, a consumer advocacy group. “And we’ve seen that services such as podiatry, audiology and speech therapy are clearly medically necessary.”
Some health activists wonder why it took the state so long to restore the benefits. “A lot of these recession-related cuts came on the backs of the poor. Yet when the economic recovery came, we didn’t see their restoration,” said Linda Nguy, a policy advocate at the Western Center on Law and Poverty. “The low-income people who needed the medical services the most were the first to see them cut and the last to have them returned.”
Anthony Cava, a spokesperson for California’s Department of Health Care Services, said the recently reinstated benefits are just the latest in an incremental restoration of care for the state’s low-income adult population. Acupuncture was brought back in 2016, and full dental benefits were restored in 2018, he said.
Raquel Serrano, a 67-year-old Fresno farm laborer, will become one of the many to take advantage of Medi-Cal’s resurrected benefits. Serrano learned she had diabetes a decade ago but signed up for Medi-Cal only recently. For years, she drank sugary soda with every meal and hot chocolate with bread at bedtime.
“My parents didn’t have the education about diabetes,” said Serrano’s son, Jose, the eldest of six children. “Soda was something we had on the table for breakfast, lunch and dinner. We drank soda, not water.” Now, he said, his mother will be able to see a podiatrist, get eyeglasses and fix her damaged teeth. “We think this will add years to her life,” he said.
Proponents of the restored benefits say the state will save money by providing foot care for people with diabetes, such as Serrano. A 2017 analysis by UCLA researchers estimated that the use of preventive podiatric services saved Medi-Cal up to $97 million in 2014, attributable to avoided hospital admissions and amputations.
Lower-limb amputations increased across California by a staggering 31% from 2010 to 2016, according to state hospital data reported by inewsource, a San Diego-based nonprofit investigative journalism organization.
Chisholm attributes the rise, in part, to the elimination of podiatric benefits for Medi-Cal patients. “We can’t say for sure,” he said, “but California suffered an avalanche of amputations after these cuts. Those are compelling numbers.”
Chisholm, who runs two podiatry offices in the working-class San Diego suburbs of National City and Chula Vista, said one elderly Latina woman who had been coming to him for years was unable to pay out-of-pocket after Medi-Cal stopped covering her treatments in 2009, so he offered to treat her for free.
But for some reason, whether shame or some bureaucratic confusion, she stopped coming anyway, he said. Chisholm lost track of her, until one day he was summoned to the emergency room to perform a below-the-knee amputation. She was the patient.
Though the benefits are now restored, many activists wonder if patients who need to see podiatrists, audiologists or speech therapists will be able to get appointments.
“Many of these providers have not worked with Medi-Cal for years, so it could be a challenge to accommodate all these patients,” said Nadereh Pourat, associate director of the UCLA Center for Health Policy Research.
Chisholm said California has recently reduced the amount of paperwork required by health care providers to be reimbursed for services they offer to Medi-Cal patients. “It used to be a bureaucratic nightmare, including paperwork and documentation, to get the government to reimburse you for even the simplest procedures,” he said. “But that has improved, along with the rates for reimbursements.”
Many California doctors have long declined to treat patients enrolled in Medi-Cal because of the program’s low payment rates, but the state has raised those rates — in some cases quite substantially — in each of the past two years.
But the latest restoration of Medi-Cal benefits is so new that many doctors and patients still don’t fully understand it.
Native Spanish speakers face an additional complication, said J. Luis Bautista, who runs two Central Valley clinics that serve primarily Latino patients, many of whom are on Medi-Cal. “What patients hear on the news and read on the internet is different. They’re not sure which services are covered and which aren’t,” Bautista said.
Chisholm said that despite efforts by his office and podiatrist trade groups to spread the word about the reinstated benefits, it has been slow to reach the public — and even some health care workers. Just recently, he overheard a receptionist in one of his offices turn away a Medi-Cal patient who had walked in seeking an appointment.
“I heard her tell the man, ‘No, we don’t take Medi-Cal,’ and I walked out of my office and said, ‘Yes, we do,’” Chisholm recalled. “This woman had been to all the meetings, she’d gotten the memos, it just didn’t click. But we got the patient in.”
