The Supreme Court's validation of President Barack Obama's landmark health law set off a scramble across California to find enough primary care doctors and other professionals to serve an estimated 3 million newly insured patients by 2014.
California rates below average in the number of doctors per capita. But the state, and rural counties in particular, will face additional shortages as health reform slashes the ranks of its 7 million uninsured.
California has an unusually large number of doctors heading into their retirement years. It expects a higher-than-average rise in the health-intensive 65-and-older population. And it has one of the lowest reimbursement rates in the country for Medi-Cal, the state's primary program offering health coverage for the poor.
Especially for communities that are struggling with doctor shortages, the court's somewhat unexpected endorsement of the Affordable Care Act suddenly presents a steep challenge.
"The Affordable Care Act will add hundreds of thousands of people to the rolls of the insured. That's good," said Dr. G. Richard Olds, founding dean of the UC Riverside School of Medicine. "But where are the primary care physicians going to come from to serve that population?"
In Merced County, there are an estimated 13,400 people who will be newly eligible for Medi-Cal in 2014, according to a UCLA study, said Alan McKay, executive director of the Central California Alliance for Health, a nonprofit that manages the county's Medi-Cal care.
There are about 12,000 people in the county who are eligible for Medi-Cal but haven't enrolled, he said. Also, about 10,000 county residents would be eligible for health coverage through the Health Exchange.
Nearly one-third of Merced County's 250,000 residents are without health insurance because of high unemployment and a drop in income, according to a 2010 report by the UCLA Center for Health Policy Research.
McKay said these are people in the community who are putting off health care. Sometimes they're going to the emergency room for care, he said.
It is likely that large numbers of people will go to a primary care doctor once those individuals get health coverage, McKay said.
"All health care providers are kind of bracing for that wave," he said. "There will be a lot of people who will have coverage and we need to make sure that the medical work force is ready to meet that need."
His nonprofit is offering incentives to providers to be open on evenings and weekends to help them get ready for the increased demand for health care services, McKay said.
According to a 2009 study by the California HealthCare Foundation, only 16 of 58 California counties had sufficient primary care doctors, as measured against standards set by the American Medical Association. The Association of American Medical Colleges has warned that the nation could reach a shortfall of nearly 100,000 doctors by 2020.
Many of California's most acute shortages are in the Inland Empire and the San Joaquin Valley, where communities struggle to attract and retain doctors. These areas have some of California's highest uninsured rates -- exceeding 30 percent of residents in some counties, according to a 2009 UCLA study.
Dr. Jaipal Reddy, a primary care physician at Family Clinic of Merced, said there are many uninsured people who can't afford a primary care physician, but will be able to do so in 2014.
He said there definitely will be an increased demand. "How much it will be? I don't know," he said.
Lee Kemper, executive director of the County Medical Services Program, a consortium of 34 rural counties that are implementing the Medi-Cal expansion together, said a mixture of innovation and increased funding was key to meeting the demands of health reform -- now a mere 18 months away.
"We're going to have to get creative," Kemper said Friday. "Strike teams" of medical specialists from urban areas could be brought into rural hospitals and clinics on a set schedule, he said. And telematic health care systems could be strengthened to allow distant specialists to consult and treat patients online.
Kemper added that Medi-Cal reimbursement rates for doctors in rural areas must be increased so practitioners have incentive to set up shop in the far corners of the state. Statewide, barely more than half of primary care doctors are willing to see new Medi-Cal patients.
Dr. Nancy Adinolfi, a primary care physician at Children and Family Medical Care in Merced, said the private practice had to stop accepting new Medi-Cal patients four years ago because of the low reimbursement rates. "I simply couldn't afford to keep my business open," she said.
Adinolfi said she believes those who become eligible for Medi-Cal in 2014 will have a difficult time finding providers that accept Medi-Cal.
$700 million for state
The Affordable Care Act does provide some help on this front, sending $700 million to California so Medi-Cal reimbursement rates can rise to the level of Medicare payments for two years. But the health industry worries that the underlying problem won't go away, and that state and federal politicians will be tempted to cut Medicaid reimbursements even more.
State Senate Health Committee chairman Ed Hernandez, D-West Covina, plans to make augmenting the health care work force, which he said is inadequate, one of his top priorities.
"What good is it in 2014, when millions of uninsured Californians will gain coverage, when they don't have access to providers?" he asked.
One of his key proposals will be legislation to expand scope-of-practice definitions for health care providers such as nurse practitioners and physician assistants.
Janet Coffman, assistant professor of health policy at UC San Francisco, said California lags behind many states in this area because most residents live in urban areas where doctor shortages aren't as much of a problem. Because of the Affordable Care Act, she said, "I would say scope of practice is on the radar screen."
Hernandez, who said he is holding committee hearings on work force issues, will try to boost the number of medical students in the state and bring medical residency programs to underserved areas.
Even before the health law was passed in 2010, the shortage of primary care physicians in California catalyzed a far-flung campaign -- by educators, doctors, and government leaders -- to train new doctors in the state and encourage them to practice in underserved regions, including the Central Valley and the Inland Empire.
That drive led to plans for medical schools at UC Riverside and UC Merced, with an emphasis on primary care. Plans called for eventually enrolling 400 students at each school, aiming to coax graduates to stay in the region.
But the state budget crisis has delayed both projects. This fall, 11 students, all ethnic minority students from the Central Valley, will be enrolled in a UC Merced program with ties to UC Davis and UC San Francisco's Fresno program. Pending accreditation approval, UC Riverside hopes to open in 2013 with an initial class of 50.
"The (UC Merced San Joaquin Valley Program in Medical Education) is an immediate response to the physician shortage in the San Joaquin Valley," said Brandy Ramos Nikaido, spokeswoman for the program. "We are proud to be a part of addressing the need."
The program, also known as UC Merced PRIME, just celebrated its first year. As part of the program, students will spend their first two years at UC Davis. Their last two years will be spent working in clinics and hospitals in the Valley.
"Training physicians locally increases the likelihood that they will stay here (in the Valley)," she said.
Sun-Star reporter Yesenia Amaro contributed to this report.
The California HealthCare Foundation Center for Health Reporting produces in-depth reporting on California health policy. Attached to the USC Annenberg School for Communication & Journalism, the center is funded by the nonpartisan California HealthCare Foundation. John M. Gonzales, Lauren M. Whaley, Emily Bazar, Deborah Schoch and Richard Kipling contributed.