Medi-Cal’s annual spending now stands at , serving low-income residents, more than a third of Californians. Of those, about 1.5 million are immigrants living in the U.S. without authorization, costing an estimated $6.4 billion, according to the Department of Health Care Services. They have been gradually added to the program as the state lifted legal residency as an eligibility requirement for , in 2020, in 2022, and all in January.

As California’s public insurance roll swells, advocates for immigrants praise the Golden State for an expansion that has helped reduce the uninsured rate to a . Providers and hospitals, however, caution that the state hasn’t expanded its workforce adequately or increased Medi-Cal payments sufficiently, leaving some enrollees unable to find providers to see them in a timely manner — if at all.

“Coverage does not necessarily mean access,” said Isabel Becerra, CEO and president of the Coalition of Orange County Community Health Centers, during an Oct. 2 in Los Angeles. “There’s a workforce shortage. We’re all fighting for those doctors. We’re fighting with each other for those doctors.”

Though the state has raised Medi-Cal payments for primary care, maternity care, and mental health services to 87.5% of what Medicare pays, private insurance still tends to pay more, according to the .

A ballot initiative approved this month guarantees that revenue from a tax on managed-care plans goes toward raising the pay of health care providers who serve Medi-Cal patients.

Some believe the next chapter for covering immigrants will require more than Medi-Cal.

Democratic state Assembly member Joaquin Arambula in 2022 proposed legislation to allow uninsured unauthorized residents who earn more than 138% of the federal poverty level to apply for state-subsidized health coverage through Covered California, the state’s health exchange. The bill, however, died in committee this year.

The final installment of the “Faces of Medi-Cal” series looks at how Medi-Cal has affected its newest enrollees. They include Vanessa López Zamora, who is finally getting treated for hepatitis and cirrhosis but has trouble seeing a gastroenterologist close to home; Douglas Lopez, an entertainment park worker who credits dental coverage for boosting his well-being; and Daniel Garcia, who suffers from gout but has given up his search for a primary care provider. All spoke to ºÚÁϳԹÏÍø News in Spanish after recently becoming eligible for Medi-Cal.

‘Started Feeling Sick a Long Time Ago’

In March, Vanessa López Zamora’s stomach had swollen so much it looked like she was pregnant. She had been vomiting and in pain for days.

She went to her local emergency room, at Kaweah Health Medical Center, but it didn’t have a specialist available, she said. So, the 31-year-old was transferred by ambulance to Adventist Health Bakersfield, about 80 miles from her home in Visalia.

Doctors diagnosed her with hepatitis A and C and cirrhosis, which had caused internal injuries to her liver and esophagus, she said. She spent four days in the hospital and for further treatment got a referral to a gastroenterologist, whom she can see as a new Medi-Cal enrollee — an option she couldn’t afford in the past when she had stomach pains and nausea.

“It’s been a very long process because I started feeling sick a long time ago.” said López Zamora, an accountant at a local radio station in Visalia in the San Joaquin Valley. “My girls are very little, and if I can’t get the necessary treatment, I won’t know how much time I have left.”

López Zamora, who came to California from Mexico City when she was 8 years old, is grateful for the care she initially received.

But she’s also frustrated.

The gastroenterologist the hospital referred her to is in Bakersfield — a tough journey for López Zamora, who doesn’t drive and can’t afford to travel to another city.

Limited access to specialists — from gastroenterologists to cardiologists — has been a long-standing challenge for many Medi-Cal patients, especially those in rural areas or regions facing staff shortages. The San Joaquin Valley, where López Zamora lives, has the in the state, according to the California Health Care Foundation.

Michael Bowman, a spokesperson for Anthem Blue Cross, her Medi-Cal plan, said in an email that Anthem has a broad network of specialists that serve Medi-Cal beneficiaries, including more than 100 gastroenterologists within 20 miles of Visalia.

She is treating her cirrhosis with medication and diet, but in August her gastroenterologist in Bakerfield discovered signs of a precancerous condition in the stomach.

López Zamora said she is searching for a specialist closer to home. For now, she relies on her mother, who must take the day off work, to get to appointments or she takes the bus. She tried using transportation provided by Medi-Cal but was left stranded at the hospital. And she has rescheduled her appointments twice.

“They drove me up but didn’t take me back because they couldn’t find an Uber,” she said.

‘A Very Simple Process’

Medi-Cal gave Douglas Lopez the dental treatment he couldn’t afford.

The 33-year-old earned minimum wage as a cleaner in an entertainment park in 2022, and the emergency Medi-Cal plan he signed up for covered only emergency extractions.

That year, Lopez experienced a sharp pain in his back teeth when he ate his beloved coconut-and-tamarind candy balls from his native Guatemala.

A dentist told him that he needed several filings and three root canals. He began treatment, but the bills became more expensive: $150 the first session, then $200, then $300.

“I couldn’t afford it,” recalled Lopez, who lives in Fullerton. “I had to pay rent and food.”

Worried he would lose teeth, he stopped eating anything that would cause him pain.

In January, Orange County automatically enrolled Lopez in Molina Healthcare’s Medi-Cal plan when the state expanded insurance eligibility for unauthorized residents ages 26-49. The coverage has transformed his care, he said.

So far, Lopez has seen a dentist six times, for a cleaning, three root canals, two filings, and X-rays. And Medi-Cal has footed the bill.

Lopez’s experience contrasts with that of many other Medi-Cal enrollees, to get the care they need. The UCLA Center for Health Policy Research found that saw Medi-Cal patients of all ages, according to data from 2019 to 2021. Often those dentists limit the number of Medi-Cal patients they will see; only 15% of adult enrollees might get dental care in a given year.

Lopez said Medi-Cal has come through for him.

“It was a very simple process. I was so excited to search for a dentist,” Lopez said. “The fear of losing my teeth because I wasn’t getting treatment disappeared.”

‘Something That You Can’t Even Use’

Last year, the stabbing pain in Daniel Garcia’s arm and foot got so bad that the 39-year-old went to the ER.

Garcia has gout, a type of inflammatory arthritis that can cause intense pain and swelling in his joints. When he became eligible for Medi-Cal coverage this year, he thought he could finally see a doctor for treatment.

But the Los Angeles County resident said he hasn’t been able to find a primary care provider willing to take his Molina Healthcare insurance.

“It’s frustrating because you have something that you can’t even use,” said Garcia, who has been unable to get an annual physical. “I’ve called, and they say they don’t take my insurance.”

Molina declined to comment on Garcia’s case and didn’t respond to questions about its primary care network.

Nearly people in California live in a total of 611 primary care shortage areas, according to a KFF analysis, which found the state would need to add 881 practitioners to close this gap.

Garcia, a construction worker, said he read that he could manage his arthritis by changing his eating habits. He now eats healthier and has cut back on sugar and Coke. As for the pain, he eases it with ibuprofen. He has given up looking for a provider.

Keeping patients out of the ER, which can be as primary care, is one of the arguments for expanding Medi-Cal. Studies have shown that not only does expanding health coverage lead to lower rates of ER visits, but expanding coverage also leads to patients using preventive care more, said Drishti Pillai, immigrant health policy director at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

“It can help save health care costs because conditions are no longer going untreated for a long time, in which case they may become more complex and expensive to treat,” Pillai said.

This article is part of “,” a series exploring the impact of the state’s safety-net health program on enrollees.

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referred the 75-year-old to a dentist about 20 miles away in San Francisco, but his tooth decayed while he waited months for authorization to cover the procedure. In the end, his tooth was pulled.

It was the sixth time in a decade Moske had lost a tooth for lack of dental care, he said. The behavioral health peer specialist wears a denture that must be removed at mealtime, making eating a chore. He often struggles to mash food between his gums, and he limits his diet to things he can easily chew. Nuts and steak, for instance, are off the table. It can be embarrassing to sit down for a meal with clients or colleagues.

“I feel like I give off the impression of somebody who doesn’t take care of himself, and I do take care of myself,” Moske said. “I try very hard. So, when I go out, I try not to smile.”

California is among a growing number of states that provide to adults enrolled in Medicaid, and some lawmakers want to add more dental cleanings, examinations, and implants to the safety-net program. Yet many dentists don’t accept Medi-Cal, the state’s Medicaid program, so new benefits would offer no guarantee that patients could get care.

The UCLA Center for Health Policy Research found that saw Medi-Cal patients of all ages, according to data from 2019 to 2021. Often those dentists limit the number of Medi-Cal patients they will see, meaning only 15% of adults might get dental care in any given year, said Elizabeth Mertz, a dentistry professor and medical sociologist at the University of California-San Francisco.

“The issue is you have coverage that is useless,” Mertz said. “The state does provide coverage, but almost no dentist will accept it.”

One of the through the California Legislature would expand Medi-Cal coverage of dental implants — artificial tooth roots implanted into the jawbone that support artificial teeth — and crowns, giving patients with broken or missing teeth more options.

Currently, Medi-Cal covers implants only when “exceptional medical conditions are documented,” according to the guide. It’s unclear how many private dental plans cover implants, but preliminary research has shown about half of individuals enrolled in a PPO plan nationwide have some type of coverage, said Mike Adelberg, executive director at the National Association of Dental Plans.

Under the bill, introduced by Democratic Sen. Aisha Wahab, Medi-Cal patients could qualify for an implant if their dentist determines it is the best option to replace a missing tooth.

“If you need an implant, you should be able to get it, especially our most vulnerable,” Wahab said. “The poorest of the poor in California deserve this.”

The Senate passed the bill unanimously in May, and a vote is pending in the Assembly Appropriations Committee. Elana Ross, a spokesperson for Democratic Gov. Gavin Newsom, declined to comment on the bill.

Four in 10 U.S. adults have had permanent teeth pulled, according to an . The that low-income older adults are at higher risk for tooth loss, which can cause discomfort and affect eating and speaking. The fix can be prosthetic devices, such as bridges and dentures, or replacement teeth, but they can be costly, especially for those without insurance or on government programs with limited benefits.

While the alternatives might be a better fit for some patients, implants are “the standard of care,” said Sohail Saghezchi, director of UCSF’s oral surgery residency program.

“They’re not able to eat everything that they want, and, a lot of times, foods like vegetables and fruits are harder to eat,” he said.

The Department of Health Care Services, which oversees Medi-Cal, estimates it would cost between $4 billion and $7 billion a year for about 1.5 million implants — a price tag Wahab fears could be problematic since Newsom in June signed a state budget closing an estimated .

The cost of an implant varies widely. DHCS estimates it would reimburse dentists between $3,000 and $4,500 for each implant surgery. FAIR Health, a national nonprofit that estimates health costs, reported a median charge for a typical implant in California between October 2022 and September 2023 ranged from about $4,000 to $4,800. Location matters, too. In San Franciso, for example, an implant is closer to $8,000, Saghezchi said.

“Reimbursement rates need to cover the costs of providing the service,” said Alicia Malaby, a spokesperson at the California Dental Association. “As with any Medi-Cal benefit, coverage is not meaningful unless the state is willing to fully invest in it to ensure people can actually access the care they need.”

The California Dental Association, which does not support the current bill, has raised concerns about the invasiveness of implant surgery, which requires regular follow-up appointments. It’s to require Medi-Cal to cover a standard two teeth cleanings and examinations a year for people 21 and older, as opposed to one.

DHCS spokesperson Leah Myers said the state has increased to dentists since the passage of Proposition 56 in 2016 and created a web-based app to enlist more dentists. More than 14,000 dentists — about 40% — were enrolled in the Medi-Cal program, as of July, according to the latest numbers published by the Dental Board.

But for people such as Moske, finding a dentist and getting needed care feels impossible. In most of California, 3 in 4 Medi-Cal patients 21 and up didn’t have a dental appointment in 2023, .

When Moske testified in support of the implant bill in June, he took out his denture, held it up to show lawmakers, and opened his mouth.

“I’m here to show you something,” Moske said. “Please don’t be offended. These are the teeth I lost.”

After Moske had finished speaking, Assembly member Reggie Jones-Sawyer (D-Los Angeles) turned to his fellow members and removed his own denture.

“I know exactly what you went through,” he said. “I have dental insurance from the city of Los Angeles and the state of California and still had problems getting things covered. I thank you for being brave enough to let people know.”

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Ahmeir’s preschool teacher relayed her concerns to his mother, Kanika Thornton, who was already worried about Ahmeir’s refusal to eat anything but yogurt, Chef Boyardee spaghetti, oatmeal, and applesauce. He also sometimes hit himself and others to cope with the frustration of not being able to communicate, she said.

Thornton took her son, who is on Medi-Cal, California’s Medicaid program, which covers low-income families, to his pediatrician. Then he was evaluated by a school district official, a speech therapist, and the pediatrician — again. Along the way, Thornton consulted teachers, case managers, and social service workers.

Ten months later, she still doesn’t have an accurate diagnosis for Ahmeir.

“I felt like I failed my child, and I don’t want to feel that,” said Thornton, 30, who has been juggling Ahmeir’s behavior and appointments on top of her pregnancy and caring for her two other children.

“Some days I don’t eat because he doesn’t eat,” said Thornton from her home in Alameda County in the San Francisco Bay Area. “I don’t want to hurt my unborn child. So I try to eat some crackers and cheese and stuff, but I don’t eat a meal because he doesn’t eat a meal.”

Seeking a diagnosis for a child’s behavioral problems can be challenging for any family as they navigate complicated medical and educational systems that don’t communicate effectively with parents, let alone each other.

A common obstacle families face is landing an appointment with one of a limited number of developmental specialists. It is particularly difficult for families with Medi-Cal, whose access to specialists is even more restricted than for patients with private insurance.

As they await their turn, they boomerang among counselors, therapists, and school officials who address isolated symptoms, often without making progress toward an overall diagnosis.

Obtaining a timely diagnosis for autism, anxiety, attention-deficit/hyperactivity disorder, or other behavioral disorders is important for children and their parents, said Christina Buysse, a clinical associate professor in developmental and behavioral pediatrics at Stanford University.

“Parent stress levels go down when a child is diagnosed early,” because they learn how to manage their child’s behaviors, she said.

Intervening early can also help retrain a child’s brain quickly and avoid lifelong consequences of developmental delays, said Adiaha Spinks-Franklin, president of the Society for Developmental and Behavioral Pediatrics.

“A speech and language delay at the age of 2 can put a child at risk of reading comprehension problems in the third grade,” she said.

Buysse is likely the right type of medical specialist for Ahmeir. As a developmental-behavioral pediatrician, she can often unify different symptoms into one diagnosis, and she knows what kind of therapy or medication patients need.

The Society for Developmental and Behavioral Pediatrics reports that there are actively certified developmental specialists in the nation.

“There just aren’t enough of us,” Buysse said, and some developmental specialists don’t accept Medicaid patients because they believe the reimbursement rates aren’t adequate.

Thornton didn’t know her son needed to see a developmental specialist, and he had never been referred to one, despite his many medical appointments. Once she learned about this type of specialist in May, she asked his pediatrician for a referral.

Alameda Health System, which provides Ahmeir’s primary care, “does not have a developmental-behavioral pediatrician on staff at this time,” said Porshia Mack, the system’s associate chief medical officer of ambulatory services.

“We have made efforts to hire them, but recruiting and retaining pediatric subspecialists is difficult for all health systems, and public safety-net systems in particular,” she said.

Karina Rivera, a spokesperson for the Alameda Alliance for Health, Thornton’s Medi-Cal managed care plan, provided a list of nine developmental-behavioral pediatricians she said are in the plan’s network.

However, the only two in Alameda County work for Kaiser Permanente, which “is a closed system,” acknowledged Donna Carey, interim chief medical officer of the Alameda Alliance. In practice, that means “even if they have a developmental pediatrician, we don’t have access to that pediatrician,” she said.

The other seven specialists are in surrounding counties, which could pose transportation challenges for Thornton and other patients.

The Alameda Alliance for Health met state requirements for patient access to specialists in the most recent review of its network, in 2022, said Department of Health Care Services spokesperson Griselda Melgoza. The plan “was found compliant with all time or distance standards,” she said.

However, after learning from California Healthline that the plan considers Kaiser Permanente specialists part of its network, the department contacted the insurer to inquire, and will work with it “to ensure member-facing materials accurately represent their current network,” Melgoza said.

A month after starting preschool in fall 2023, Ahmeir was evaluated for speech delay through his school district. His pediatrician also began ordering tests to understand his eating habits.

But Thornton believes Ahmeir’s symptoms aren’t isolated problems that can be addressed in a piecemeal fashion. “It’s just something else. It’s his development,” she said. “I know a tantrum, but he doesn’t get tantrums. He will hit people. That’s a no-go.”

In addition to addressing medical concerns, a developmental specialist could help parents like Thornton understand what school districts offer and how to expedite school evaluations, Spinks-Franklin said. Ahmeir faces a six- to eight-month wait for a comprehensive evaluation through his school district for additional services, Thornton said.

It’s common for parents to get confused about what a school district can and can’t do for kids with developmental disabilities, said Corina Samaniego, who works at Family Resource Navigators, an organization that helps parents like Thornton in Alameda County. For instance, Samaniego said, school districts cannot provide medical diagnoses of autism, nor the therapy to address it.

Ahmeir has made significant improvement with speech therapy provided through the school district, Thornton said, and now speaks in full sentences more often. But she remains frustrated that she does not have a diagnosis that explains his persistent symptoms, especially his reluctance to eat and difficulty expressing emotions.

Thornton believes she has done everything she can to help him. She has even created elaborate food landscapes for Ahmeir with dinosaur-shaped chicken nuggets, mashed potato volcanoes, gravy lava, and broccoli trees — only to have him turn his head away.

As of late May, she continued to seek advice from teachers and counselors while she waited for an appointment with a specialist.

“I try to stay strong for my son and do the best I can and be there for him, talk to him, teach him things,” she said. “It’s been really tough.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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But meth is almost as easy to come by as a hazy IPA or locally grown weed.

Quinn Coburn knows the lifestyle well. He has used meth most of his adult life, and has done five stints in jail for dealing . Now 56, Coburn wants to get sober for good, and he says an experimental program through Medi-Cal, California’s Medicaid program, which covers low-income people, is helping.

As part of an innovative approach called “,” Coburn pees in a cup and gets paid for it — as long as the sample is clean of stimulants.

In the coming fiscal year, the state is expected to allocate $61 million to the experiment, which targets addiction to stimulants such as meth and cocaine. It is part of a broader Medi-Cal initiative , which provides social and behavioral health services, including addiction treatment, to some of the state’s sickest and most vulnerable patients.

Since April 2023, 19 counties have enrolled a total of about 2,700 patients, including Coburn, according to the state Department of Health Care Services.

“It’s that little something that’s holding me accountable,” said Coburn, a former construction worker who has tried repeatedly to kick his habit. He is also motivated to stay clean to fight criminal charges for possession of drugs and firearms, which he vociferously denies.

Coburn received $10 for each clean urine test he provided the first week of the program. Participants get a little more money in successive weeks: $11.50 per test in week two, $13 in week three, up to $26.50 per test.

They can earn as much as . As of mid-May, Coburn had completed 20 weeks and made $521.50.

Participants receive at least six months of additional behavioral health treatment after the urine testing ends.

The state has poured significant into curbing opioid addiction and , but the use of stimulants is also exploding in California. According to the state Department of Health Care Services, the rate of Californians dying from them .

Although the cutting-edge treatment and other drugs, California has prioritized stimulants. To qualify, patients must have moderate to severe stimulant use disorder, which includes symptoms such as strong cravings for the drug and prioritizing it over personal health and well-being.

Substance use experts say incentive programs that reward participants, even in a small way, can have a powerful effect with meth users in particular, and a indicates they can lead to long-term abstinence.

“The way stimulants work on the brain is different than how opiates or alcohol works on the brain,” said John Duff, lead program director at Common Goals, an outpatient drug and alcohol counseling center in Grass Valley, where Coburn receives treatment.

“The reward system in the brain is more activated with amphetamine users, so getting $10 or $20 at a time is more enticing than sitting in group therapy,” Duff said.

Duff acknowledged he was skeptical of the multimillion-dollar price tag for an experimental program. “You’re talking about a lot of money,” he said. “It was a hard sell.”

What convinced him? “People are showing up, consistently. To get off stimulants, it’s proving to be very effective.”

California was the first state to cover this approach as a benefit in its Medicaid program, according to the Department of Health Care Services, though other states have since followed, .

Participants in Nevada County must show up twice a week to provide a urine sample, tapering to once a week for the second half of treatment. Every time the sample is free of stimulants, they get paid via a retail gift card — even if the sample is positive for other kinds of drugs, including opioids.

Though participants can collect the money after each clean test, many opt for a lump sum after completing the 24-week program, Duff said. They can choose gift cards from companies such as Walmart, Bath & Body Works, Petco, Subway, and Hotels.com.

Charlie Abernathybettis — Coburn’s substance use disorder counselor, who helps run the program for Nevada County — said not everyone consistently produces a clean urine test, and he has devised a system to stop people from rigging their results.

For example, he uses blue toilet cleaner to prevent patients from watering down their urine, and has dismantled a spigot on the bathroom faucet to keep them from using warm water for the same purpose.

If participants fail, there are no consequences. They simply don’t get paid that day, and can show up and try again.

“We aren’t going to change behavior by penalizing people for their addiction,” Abernathybettis said, noting the ultimate goal is to transition participants into long-term treatment. “Hopefully you feel comfortable here and I can convince you to sign up for outpatient treatment.”

Abernathybettis has employed a tough love approach to addiction therapy that has helped keep Coburn sober and accountable since he started in January. “It’s different this time,” Coburn said as he lit a cigarette on a sunny afternoon in April. “I have support now. I know my life is on the line.”

Growing up in the Bay Area, Coburn never quite felt like he fit in. He was adopted at an early age and dropped out of high school. His erratic home life set him on a course of hard drug use and crime, including manufacturing and selling drugs, he said.

“When I first did crank, it made me feel like I was human for the first time. All my phobias about being antisocial left me,” Coburn said, using a street name for meth.

Coburn escaped to the solitude of the mountains, trees, and rivers that define the rural landscape in Grass Valley, but the area was also rife with drugs.

Construction accidents in 2012 left him in excruciating pain — and unable to work.

Coburn fell deeper into the drug scene, as both a user and a manufacturer. “You wouldn’t believe the market up here for it — more than you can even imagine,” he said. “It’s not an excuse, but I had no way to make a living.”

Financially strapped, he rented a cheap, converted garage from another local drug dealer, he said. Law enforcement officers raided the house in October, and authorities found a gun and large amounts of fentanyl and heroin. Coburn, who faces up to 30 years in prison, vigorously defends himself, saying the drugs and weapons were not his. “All the other ones I did. Not this one,” he said.

Coburn is also in an outpatient addiction program and is active in Alcoholics Anonymous, sometimes attending multiple meetings a day.

Every week, the small payments from the Medi-Cal experiment feel like small wins, he said.

He is planning to take his $599 as a lump sum and give it to his foster parents, with whom he is living as he fights his criminal charges.

“It’s the least I can do for them letting me stay with them and get better,” Coburn said, choking back tears. “I’m not giving up.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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“What I’m hearing is that you’re a self-starter,” he told one participant, who had taken up gardening but yearned for a community with which to share the hobby.

Cordero, 48, is guiding the discussion at Holding Hope, a weekly therapy group for people struggling with mental health. Anyone receiving mental health services through Solano County can participate.

A former member, Cordero is now the group’s volunteer peer leader. He initially joined in 2020 while dealing with mental illness and substance use — and found that sharing with others who had been through similar trials could be deeply healing.

“Not all of us are going to speak about” pain, said Cordero, who is covered by Medi-Cal, California’s Medicaid program, which insures low-income people. “But when one does, another does, and then next week another does, and it becomes like a connective tissue.”

These groups can offer essential support in a public system beset by workforce shortages, Cordero said. Two are run entirely by peer leaders, who help build trust by sharing personal experiences, said Cheryl Akoni, a marriage and family therapist who works for Solano County and leads Holding Hope alongside Cordero.

“You’re amongst your peers,” Akoni said. “You’re amongst people who have lived and shared experiences that you often might not get with your therapist because we have to keep our boundaries.”

In California, mental health care for Medi-Cal enrollees is provided by managed care insurers and . Among its services, Solano County Behavioral Health provides case management and appointments with therapists and psychiatrists, plus five groups, ranging from Holding Hope to a journaling collective.

In 2022, California counties to use Medicaid dollars to pay peer support leaders for their work, a benefit 51 of the state’s 58 counties have adopted, according to the state Department of Health Care Services. To qualify, individuals must undergo training and get certified by the California Mental Health Services Authority.

Cordero isn’t yet getting paid for his work with Holding Hope. He said he’s building experience as a volunteer and plans to seek his certification when the next training takes place.

Cordero’s family immigrated to California from the Philippines, and the tension between his American and Filipino identities caused anxiety as a child, he said. He first thought about killing himself around age 13 and didn’t feel he could be honest about his mental health with his family.

“I had American problems for my parents and family who had a traditional Filipino paradigm,” he said.

Cordero was diagnosed with borderline personality disorder in his 20s and was addicted to marijuana and methamphetamine throughout his adult life. Amid these challenges, Cordero took human services courses at Solano Community College and started to speak to high school classes about mental health and addiction. When that program ended, the loss of structure was destabilizing, he said.

“I just dove headlong into substance abuse,” Cordero said.

He missed his daughters’ school graduations. His diabetes went untreated, and his addiction grew more severe.

During the covid-19 pandemic, social distancing restrictions made it difficult for Cordero to obtain illegal drugs. He experienced severe withdrawal symptoms, along with a blood infection and complications from his untreated diabetes. This resulted in a series of hospital visits — and it was during one of these that Cordero was enrolled in Medi-Cal.

After he recovered, Cordero contacted Solano County seeking mental health treatment. He was told there would be a wait for a therapist due to covid-19 and staffing shortages but was encouraged to attend Holding Hope in the meantime.

He quickly took to sharing in the group, and after about a year of his attending, its former leader encouraged Cordero to assume a bigger role, he said.

“It was great to talk, and I can ramble forever,” Cordero recalled. “She said, ‘I think you can do better than that.’”

He started leading the group with Akoni in January.

Not every person who seeks mental health help is ready for or needs a therapist, but for those who do, groups and peer support can provide connection and community as they wait, said Emery Cowan, director of Solano County Behavioral Health.

At least 90% of the city and county behavioral health agencies who responded to a survey commissioned by the County Behavioral Health Directors Association of California in 2021 recruiting psychiatrists, licensed clinical social workers, and licensed marriage and family therapists.

The counties pointed to multiple staffing challenges: They generally can’t offer salaries comparable to the private sector; don’t appeal to applicants who want to work remotely or have flexible schedules; and have trouble finding and keeping providers with the training and experience to handle the complex patient population.

Cordero was paired with a psychiatrist right after his intake appointment. He finally added his name to the waitlist for a therapist in 2022 and said it took about a year to get matched with someone.

Solano County Behavioral Health relies on Medi-Cal-certified peer leaders and volunteer peer leaders, like Cordero, who run groups, help clients prepare for appointments, and .

“They’ve lived that experience, they know how hard it is, they’re more willing to do it because they want to help people just like them,” Cowan said. “They were that person.”

Cowan and Cordero acknowledge that group therapy isn’t for everyone. Discussing personal challenges or traumatic incidents in front of a group can be intimidating, and some people need more individualized care.

But for those who are a good fit, there is community to be found.

At the recent gathering of Holding Hope, participants discussed relationships and loneliness. Cordero shared that he still finds it difficult to maintain close bonds with family and friends, and that he feels lonely.

He repeatedly encouraged his peers to reframe negative thoughts and experiences, explaining that anguish can start feeling comfortable, almost like a routine, and that breaking out of that routine can feel challenging.

To emphasize his point, Cordero circled back to a particular phrase several times over the hour: “The path to pain is a well-carved path.”

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Somewhat by accident, Bloomer, 26, found Priya Kalyan-Masih six months into her pregnancy. Kalyan-Masih is a doula, a professional childbirth companion who provides emotional support, physical comfort, and education to women before, during, and after pregnancy. Bloomer hadn’t realized Medi-Cal would cover the service until she visited an informational fair near her home in the High Desert region of Southern California.

Medi-Cal, California’s Medicaid program for low-income residents, started offering the benefit in January — but doulas have wrestled with the program’s bureaucratic requirements and what they say is insufficient pay.

“Priya really listened to me. Out of all my births, this was the most peaceful and stress-free,” said Bloomer, who is a student working part-time as an in-home caregiver and at a detox center. “The fact that I didn’t have to pay anything out-of-pocket was life-changing.”

Having Kalyan-Masih at her side was critical for Bloomer because her partner — now fiancé — was imprisoned a few weeks after she found out she was pregnant, which would have meant she’d have to navigate her pregnancy and delivery without him.

Across the country, doulas are being enlisted to combat rising maternal mortality rates. In 2021, the most recent year for which data is available, about 1,200 women in the U.S. died from pregnancy complications either during pregnancy or within six weeks afterward, about 60% more deaths than were reported two years earlier, according to the .

The numbers are starkest for Black women and their children. In 2021, Black women died at more than 2½ times the rate of white women.

Doulas are distinct from the medical team and act as advocates for birthing parents. A published this year found that doula care was associated with reductions in cesarean sections, epidural use, length of labor, premature deliveries, and maternal stress.

During Bloomer’s pregnancy, Kalyan-Masih assisted with strategies such as mapping a birth plan and coaching Bloomer on breathing techniques to ease her anxiety.

Less than a year after Bloomer moved from Texas to be with her fiancé, Tim Smith, he was arrested for firearm possession while on probation for drug-related charges. That left Bloomer in Victorville, on the edge of the Mojave Desert, far from friends and family.

In Smith’s absence, Bloomer was grateful for Kalyan-Masih’s companionship and reminders to take care of herself, she said.

But what meant the most was Kalyan-Masih’s willingness to weave Smith into the birth without judgment, she said. Kalyan-Masih acted as his eyes and ears at the hospital in June, running around with Bloomer’s phone so Smith could meet his newborn daughter, Tiara, via FaceTime.

“It meant everything. I mean, I’m locked up and I saw the baby before Mia did,” Smith recalled, laughing. “Priya made everything possible. She held the phone. She was running around when the baby came out. She made it feel like I was there.”

Smith met Tiara in person when he was released a month later.

Kalyan-Masih’s presence also led to a noticeable difference in how medical staff treated her, Bloomer said.

During her previous deliveries, she felt the medical professionals had been pushy and dismissive. For example, when her son Thaddeus was born last year, she said, doctors pressured her to get an epidural against her wishes after Smith left the room to grab her lunch.

“When I had Priya in the room, they were more attentive to my needs and didn’t treat me like my opinion didn’t matter,” Bloomer said. “It wasn’t an argument or debate. It was just like, ‘OK, that’s what we’re doing.’”

Medi-Cal covers up to 11 doula visits before and after pregnancy, and support during labor and delivery — and patients can petition for extra postpartum visits. Doulas can also be for providing support during and after miscarriages or abortions.

“I always explain it as obstetricians and midwives are the ones catching babies, and doulas catch Mom,” said Kalyan-Masih, who is a medical doctor by training and a doula since January.

Kalyan-Masih is pleased with California’s investment in doula services but said it has been a challenge to maneuver Medi-Cal’s administrative requirements, like acquiring business licenses.

Samsarah Morgan, a doula and founder of the Oakland Better Birth Foundation, said the business license fees, in addition to Medi-Cal’s reimbursement rates, prevent some doulas from participating in the program.

The state pays doulas fixed rates per visit, adding up to $1,154 if patients schedule the standard number of nine visits before and after birth, in addition to labor and delivery. Doulas can make up to $2,078 through Medi-Cal if patients schedule additional postpartum visits. The $1,154 rate is more than in 2022, and Morgan said that she’s grateful for the increase — but that it’s still not enough.

In her own practice, most clients pay $2,500 to $3,500, typically out-of-pocket since, in her experience, many private insurance plans don’t cover doula services, she said.

“I want to work with clients who are on Medi-Cal, but I also need to pay my bills,” Morgan said.

Griselda Melgoza, a spokesperson for the Department of Health Care Services, which administers Medi-Cal, said the department pays doulas the same as other providers — including doctors, nurses, and physician assistants — for the same services. The department has proposed rate increases for doula services next year, which would vary by type of delivery. A doula who provides the standard nine visits and attends a vaginal delivery, for example, would be paid $2,180, 89% more than the current rate.

Preliminary data shows that 50 doula claims were processed statewide as of July 31 and that claims from that time frame are still coming in, Melgoza said. She added that the department is working to make the benefit more accessible. In November, for instance, it eliminated most referral requirements, removing a hurdle for patients.

Bloomer said she wishes she had been able to work with a doula during previous pregnancies, especially when she was carrying Lucas, her first child, at age 19.

At the time, she didn’t know what questions to ask or what to expect, including how to cope with postpartum depression.

“With a doula, I would have been more informed,” Bloomer said as 6-month-old Tiara babbled on her lap. “I would have felt more empowered. I would have had the kind of support that would have made me a better mom.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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Her blood sugar was plummeting, and the beep came from a attached to her abdomen. The small but powerful device alerts Voros when her blood sugar is dangerously high or low.

“My blood sugar is at 64. It’s too low and still dropping,” Voros, 32, said on a bright October afternoon. She checks the monitor up to 80 times a day to help prevent complications from Type 1 diabetes.

But the monitor means little without the supplies that make it work, including a receiver, a sensor, and a transmitter — some of which must be replaced every 10 to 30 days. Voros also has an insulin pump, which delivers a steady supply of that hormone to her body, and it requires supplies too.

Until recently, Voros — who is covered by Medi-Cal, California’s Medicaid program for people with low incomes or disabilities — spent countless hours on the phone with her endocrinologists, her Medi-Cal insurer Health Net, and a medical supply company to obtain separate approvals for each item. At times, her authorizations expired too quickly, leaving her short on supplies and forcing her to ration and seek donations on social media from other diabetes patients.

Last year, she received only enough supplies to last six months.

“I’ve had to put in hundreds of hours over the phone in the past few years, and I’ve changed my insurance group twice because of this,” Voros said before slugging apple juice in her studio apartment in the Mission Hills neighborhood, a suburban neighborhood in the San Fernando Valley. “It’s exhausting. It makes you want to give up. But I can’t. I’ll literally die.”

Starting in October, Medi-Cal began that have caused life-threatening delays for Voros and others with diabetes.

Previously, authorizations for medications and supplies lasted six months, though for some patients, like Voros, they expired sooner. Under the new rules, authorizations are supposed to last one year from the date of approval and can include all needed supplies — ending the scramble to secure separate authorizations for each piece of equipment. Patients can receive 90 days’ worth of supplies and medications at once.

The state is also formalizing a policy that allows patients to obtain approvals from their health care providers by phone or video.

“Before, California’s requirements were four pages long, and now it’s just a little more than a page,” said Lisa Murdock, chief advocacy officer for the American Diabetes Association, who helped push for the changes. “This is a really important step forward. It means not having to constantly guess how blood sugars are doing.”

Over the past two years, the state also started making continuous glucose monitors and related supplies available to many more people, including all patients with , a chronic autoimmune disease that attacks insulin-producing cells in the pancreas, and those with , , and , or chronic low blood sugar. Before last year, the monitors were available to only some patients on a case-by-case basis, according to the state Department of Health Care Services, which administers Medi-Cal.

The enhanced coverage extends to newer, more advanced devices, such as the popular , which retail for about $700 on Amazon for a 30-day supply without insurance. Medi-Cal pays for the same equipment.

Diabetes and prediabetes are . About have been diagnosed with diabetes. The Department of Health Care Services says about 1.2 million Medi-Cal enrollees have the disease, according to the latest data available.

Before these changes, Medi-Cal recipients had a harder time securing medication and supplies than people with private insurance, Murdock said.

“Diabetes is a really heartbreaking and costly disease, and to take care of themselves, people with diabetes need easy access to insulin, but also the supplies to manage the disease,” she said.

Patient advocates and state health officials say the changes will save money and lives by giving those with diabetes more control over their blood sugar, and by preventing complications such as organ failure and foot and toe amputations.

This expansion in coverage “improves access and member outcomes, reduces hospitalizations and comorbidities, and improves members’ quality of life with better disease management and less finger sticks,” said Ann Carroll, a Medi-Cal spokesperson. The state, she said, wants to ensure all diabetes patients get “the care they need to lead healthy, fulfilling lives.”

Before Voros got her monitor about three years ago, she had to visit an emergency room and was hospitalized with . She also lost nerve function in her stomach — which prevents digestion of high-fiber foods like vegetables — as her disease advanced.

“I haven’t had to go to the intensive care unit in almost two years. It has literally saved my life,” she said.

But the bureaucratic hurdles that kept Voros from getting supplies for her monitor were a constant source of stress. That’s changing since she switched to a new medical supply company and Medi-Cal has debuted its new preauthorization process, amid a broader revamp of its pharmacy system.

Getting her supplies on time means peace of mind, Voros said.

“I used to be so afraid to go to sleep at night because of the seizures I’d get from low blood sugar,” she said. “I’ve been really close to death, but now I feel better than I ever have.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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Johnson, 58, said her ordeal started in September 2022, when she went for a CT scan of her abdomen after a bout of covid-19. Though Johnson warned the lab she was allergic to iodine, she believes the lab tech used it in an injection, triggering an allergic reaction. She spent the next three weeks in the hospital, feeling as if her body was on fire.

When she was discharged to her home at the base of the San Jacinto Mountains in Riverside County, Johnson said, her quality of life deteriorated and her frustration mounted as she waited for her Medi-Cal plan to get her assessed by a specialist. She could barely walk or stand, she could no longer cook for herself, and sometimes she couldn’t even lift her leg high enough to step into the tub.

“I would never wish this on anybody,” Johnson said while rocking back and forth on the couch to still the pain. “You don’t know if you should cry, or just say OK, I can make it through this. It messes with you mentally.”

Johnson said her primary care doctor told her he wasn’t sure what triggered the pain but suspects it was compounded by the lingering effects of covid. Johnson, who is diabetic, developed neuropathy, a type of nerve damage, possibly after the allergic reaction caused her blood sugar levels to skyrocket, her doctor told her.

He referred Johnson, who receives care through California’s Medicaid program for low-income people, to an endocrinologist in March. But Johnson said she was not offered timely appointments, and it took more than six months, four referrals, multiple complaints to her health plan, and a legal aid group’s help to finally snag a phone call with an endocrinologist in mid-September.

Access to specialists — from gastroenterologists to cardiologists — has been a long-standing challenge for many Medi-Cal patients, especially those in rural areas or regions facing staff shortages. The Inland Empire, where Johnson lives, has the of specialists in the state, according to the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The state Department of Managed Health Care, which regulates most Medi-Cal health plans, requires plans to get patients in to see specialists within 15 business days, unless a longer waiting time would not harm the patient’s health. But the timeline often looks very different in reality.

“It’s hard to get a specialist to contract for Medi-Cal patients. Period,” said Amanda Simmons, executive vice president of Integrated Health Partners of Southern California, a nonprofit organization that represents community health clinics. “Specialists don’t want to do it because reimbursement rates are so low.”

Johnson said she made her first call in March to the endocrinologist assigned by her Medi-Cal insurer, Inland Empire Health Plan, and that the office offered her an appointment several months out. Over the next four months, she received three more referrals, but she said she got a similar response each time she called. When Johnson objected to the lengthy wait times, requesting earlier appointments, she was told there was no availability and that her condition wasn’t urgent.

“They told me it wasn’t important,” Johnson said. “And I asked, ‘How would you know? You’ve never seen me.’”

Esther Iverson, director of provider communications for the plan, declined to speak about Johnson’s case but said the plan makes every effort to meet the 15-day requirement. It can be challenging to meet the standard, she said, due to a lack of available physicians — especially for certain specialties, such as endocrinology and pain management.

She pointed to the nationwide physician shortage, which is more pronounced in rural areas, including parts of San Bernardino and Riverside counties, where the plan operates. She also noted that many physicians decided to leave the field or retire early due to burnout from the covid pandemic.

At the same time, she said, the plan’s enrollment ballooned to as eligibility expanded in recent years. Statewide, Californians are enrolled in Medi-Cal.

“The highest priority for us is timely access to quality care,” Iverson said.

During her quest, Johnson enlisted the help of , which provides free legal representation to low-income residents. They called the plan multiple times to request earlier appointments but got mired in bureaucratic delays and waiting periods.

In one instance in August, after the insurer told Johnson it couldn’t meet the 15-day time frame, her legal representative, Mariane Gantino, filed an appeal, arguing that Johnson’s request was urgent. The insurer’s medical director responded within a few hours denying the claim, saying the plan concluded that her case was not urgent and that a delay would not cause a serious threat to her health.

“I’m so burned out after dealing with this for so long,” Johnson said in mid-September. “Why do they have the 15-day law if there aren’t going to be any consequences?”

A few days later, Johnson finally received the call she had been waiting for: an offer of a phone appointment with an endocrinologist, on Sept. 18. During the appointment, the doctor adjusted her diabetes and other medications but didn’t directly address her pain, she said.

“I’m in the same position,” Johnson said. “I’m still in pain. What’s next?”

Over the years, Johnson has worked a variety of jobs — from driving eighteen-wheelers cross-country to weaving hair — but her most consistent work was as a caregiver, including to her six children, 21 grandchildren, and three great-grandkids, with another great-grandchild on the way. Now, because of her extreme pain, the roles have been reversed. A daughter and granddaughter who live with her have become her full-time caregivers.

“I can’t do nothing. I can’t take care of my grandkids like I used to,” said Johnson, who sleeps most of the day and wakes up only when her pain medication wears off. “I was planning to take care of the new baby that’s coming. I probably can’t even hold her now.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

This <a target="_blank" href="/aging/medicaid-specialist-shortage-wait-pain-riverside-county/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Bullied and ostracized, Wrangell started repressing those feelings in middle school and kept them bottled up for a long time. That led to decades of sadness, isolation, and even a couple of suicide attempts. What gnawed at Wrangell was gender dysphoria, a condition widely acknowledged in the medical community, which causes severe distress to people whose gender identity does not match their sex assigned at birth.

“It’s a sense of wrongness, like someone attached an arm to my head badly, and it just punches me in the face every time,” said Wrangell, 38, who grew up and still lives in this idyllic central California beach community. Facial and body hair is particularly upsetting: “I see my face in the mirror, and anytime I have to deal with hair, it is uncomfortable. I hate seeing it.”

Wrangell is nonbinary, meaning neither a man nor a woman, and uses the pronouns they and them. For over three years, they have been undergoing gender transition treatments to take on more feminine physical traits. These treatments have included genital transformation, known as ; hormone replacement therapy using estradiol; and electrolysis hair removal for their face, neck, and chest.

All of it is paid for by Medi-Cal, California’s version of the federal Medicaid insurance program for people with low incomes. California law and all other state-regulated health plans to cover gender-affirming care that is deemed medically necessary. But therein lies the rub.

Wrangell, an enrollee of the Central California Alliance for Health, the only Medi-Cal health plan in Santa Cruz, said it has been laborious to get the care they need. They contend with seemingly endless paperwork and phone calls to prove what they’ve already established — that their need for treatments is real and ongoing.

“There is a joke among the trans community, where they are always asking for letters, along the lines of, ‘Oh, did they think I stopped being trans or did the hair magically go away?’” Wrangell said.

And it requires a lot of work to find and vet the scant number of gender-affirming care providers who take Medi-Cal patients, Wrangell said.

Over 1.6 million people ages 13 and older in the U.S. , according to the UCLA School of Law’s , which conducts legal and policy research on gender identity and sexual orientation. Data from the institute shows an estimated in the U.S. are enrolled in Medicaid, including 164,000 in states where transgender care is covered. Of those, 36,000 are in California, one of 25 states, plus Washington, D.C., whose Medicaid policies cover gender-affirming care.

“I think there’s a lot of pressure in society to fit into a very narrow set of narratives, and I don’t think honestly that works for most people,” Wrangell said. “For some people, it’s so ill-fitting, it’s disastrous.”

A shows they disproportionately experience physical abuse, economic hardship, and mental health problems. And research finds gender-affirming care can their quality of life.

But as Wrangell has learned, coverage and care are not the same thing. Hair removal, their top priority, has been hard to get. After 2½ years of electrolysis treatment, they’ve had roughly only about half the total number of hours their electrologist said they needed.

Permanently removing the facial hair of a transgender person assigned male at birth can require of electrolysis spread over several years. For those paying out of their own pockets, the cost would easily reach tens of thousands of dollars. That doesn’t include the cost of facial, bottom, and body-shaping surgeries.

Wrangell said their health plan has limited the number of sessions it authorizes at a time, requiring constant reauthorization.

Dennis Hsieh, deputy chief medical officer of the Central California Alliance for Health, said the health plan recently updated its policy to allow 50% more electrolysis in a three-month period and eliminate a rule to submit photos of relevant body parts.

Hsieh acknowledged a shortage of providers and said the alliance contracts with clinicians across several counties to provide more options.

To a large extent, the challenges transgender people encounter seeking care are the same ones many people face in the “terror dome of U.S. health care,” said Kellan Baker, the executive director of the Washington, D.C.-based , which conducts research and education on topics of concern to gay, bisexual, and transgender people. “There are a lot of people in a lot of circumstances who cannot get medically necessary care for their conditions, whether that’s gender dysphoria or cancer or diabetes.”

Legal aid lawyers and transgender activists say another big reason for denials or delays in gender-affirming care, especially hair removal, is that many people in the medical world still think of it as cosmetic.

Medi-Cal, like most commercial insurance plans, does not cover cosmetic treatments. “But if it’s affecting your mental health, and it’s affecting your life opportunities, and it’s affecting your ability to get a job, and it’s affecting your ability to get housing, is that cosmetic?” asked Elana Redfield, the federal policy director at the Williams Institute.

Despite their travails in obtaining care, Wrangell said, the treatment is improving their life. The estradiol, they said, makes them feel “way more relaxed, much less on edge all the time.” And Wrangell feels good about an uncommon bottom surgery they got last October, but they are facing more paperwork for a needed follow-up operation.

They are frustrated about all the red tape they’ve encountered, precisely because the treatments are helping. “This is working,” Wrangell said. “Please finish it.”

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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 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 that it was the other way around.

They were : 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 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 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 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.”

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Medi-Cal’s annual spending now stands at , serving low-income residents, more than a third of Californians. Of those, about 1.5 million are immigrants living in the U.S. without authorization, costing an estimated $6.4 billion, according to the Department of Health Care Services. They have been gradually added to the program as the state lifted legal residency as an eligibility requirement for , in 2020, in 2022, and all in January.

As California’s public insurance roll swells, advocates for immigrants praise the Golden State for an expansion that has helped reduce the uninsured rate to a . Providers and hospitals, however, caution that the state hasn’t expanded its workforce adequately or increased Medi-Cal payments sufficiently, leaving some enrollees unable to find providers to see them in a timely manner — if at all.

“Coverage does not necessarily mean access,” said Isabel Becerra, CEO and president of the Coalition of Orange County Community Health Centers, during an Oct. 2 in Los Angeles. “There’s a workforce shortage. We’re all fighting for those doctors. We’re fighting with each other for those doctors.”

Though the state has raised Medi-Cal payments for primary care, maternity care, and mental health services to 87.5% of what Medicare pays, private insurance still tends to pay more, according to the .

A ballot initiative approved this month guarantees that revenue from a tax on managed-care plans goes toward raising the pay of health care providers who serve Medi-Cal patients.

Some believe the next chapter for covering immigrants will require more than Medi-Cal.

Democratic state Assembly member Joaquin Arambula in 2022 proposed legislation to allow uninsured unauthorized residents who earn more than 138% of the federal poverty level to apply for state-subsidized health coverage through Covered California, the state’s health exchange. The bill, however, died in committee this year.

The final installment of the “Faces of Medi-Cal” series looks at how Medi-Cal has affected its newest enrollees. They include Vanessa López Zamora, who is finally getting treated for hepatitis and cirrhosis but has trouble seeing a gastroenterologist close to home; Douglas Lopez, an entertainment park worker who credits dental coverage for boosting his well-being; and Daniel Garcia, who suffers from gout but has given up his search for a primary care provider. All spoke to ºÚÁϳԹÏÍø News in Spanish after recently becoming eligible for Medi-Cal.

‘Started Feeling Sick a Long Time Ago’

In March, Vanessa López Zamora’s stomach had swollen so much it looked like she was pregnant. She had been vomiting and in pain for days.

She went to her local emergency room, at Kaweah Health Medical Center, but it didn’t have a specialist available, she said. So, the 31-year-old was transferred by ambulance to Adventist Health Bakersfield, about 80 miles from her home in Visalia.

Doctors diagnosed her with hepatitis A and C and cirrhosis, which had caused internal injuries to her liver and esophagus, she said. She spent four days in the hospital and for further treatment got a referral to a gastroenterologist, whom she can see as a new Medi-Cal enrollee — an option she couldn’t afford in the past when she had stomach pains and nausea.

“It’s been a very long process because I started feeling sick a long time ago.” said López Zamora, an accountant at a local radio station in Visalia in the San Joaquin Valley. “My girls are very little, and if I can’t get the necessary treatment, I won’t know how much time I have left.”

López Zamora, who came to California from Mexico City when she was 8 years old, is grateful for the care she initially received.

But she’s also frustrated.

The gastroenterologist the hospital referred her to is in Bakersfield — a tough journey for López Zamora, who doesn’t drive and can’t afford to travel to another city.

Limited access to specialists — from gastroenterologists to cardiologists — has been a long-standing challenge for many Medi-Cal patients, especially those in rural areas or regions facing staff shortages. The San Joaquin Valley, where López Zamora lives, has the in the state, according to the California Health Care Foundation.

Michael Bowman, a spokesperson for Anthem Blue Cross, her Medi-Cal plan, said in an email that Anthem has a broad network of specialists that serve Medi-Cal beneficiaries, including more than 100 gastroenterologists within 20 miles of Visalia.

She is treating her cirrhosis with medication and diet, but in August her gastroenterologist in Bakerfield discovered signs of a precancerous condition in the stomach.

López Zamora said she is searching for a specialist closer to home. For now, she relies on her mother, who must take the day off work, to get to appointments or she takes the bus. She tried using transportation provided by Medi-Cal but was left stranded at the hospital. And she has rescheduled her appointments twice.

“They drove me up but didn’t take me back because they couldn’t find an Uber,” she said.

‘A Very Simple Process’

Medi-Cal gave Douglas Lopez the dental treatment he couldn’t afford.

The 33-year-old earned minimum wage as a cleaner in an entertainment park in 2022, and the emergency Medi-Cal plan he signed up for covered only emergency extractions.

That year, Lopez experienced a sharp pain in his back teeth when he ate his beloved coconut-and-tamarind candy balls from his native Guatemala.

A dentist told him that he needed several filings and three root canals. He began treatment, but the bills became more expensive: $150 the first session, then $200, then $300.

“I couldn’t afford it,” recalled Lopez, who lives in Fullerton. “I had to pay rent and food.”

Worried he would lose teeth, he stopped eating anything that would cause him pain.

In January, Orange County automatically enrolled Lopez in Molina Healthcare’s Medi-Cal plan when the state expanded insurance eligibility for unauthorized residents ages 26-49. The coverage has transformed his care, he said.

So far, Lopez has seen a dentist six times, for a cleaning, three root canals, two filings, and X-rays. And Medi-Cal has footed the bill.

Lopez’s experience contrasts with that of many other Medi-Cal enrollees, to get the care they need. The UCLA Center for Health Policy Research found that saw Medi-Cal patients of all ages, according to data from 2019 to 2021. Often those dentists limit the number of Medi-Cal patients they will see; only 15% of adult enrollees might get dental care in a given year.

Lopez said Medi-Cal has come through for him.

“It was a very simple process. I was so excited to search for a dentist,” Lopez said. “The fear of losing my teeth because I wasn’t getting treatment disappeared.”

‘Something That You Can’t Even Use’

Last year, the stabbing pain in Daniel Garcia’s arm and foot got so bad that the 39-year-old went to the ER.

Garcia has gout, a type of inflammatory arthritis that can cause intense pain and swelling in his joints. When he became eligible for Medi-Cal coverage this year, he thought he could finally see a doctor for treatment.

But the Los Angeles County resident said he hasn’t been able to find a primary care provider willing to take his Molina Healthcare insurance.

“It’s frustrating because you have something that you can’t even use,” said Garcia, who has been unable to get an annual physical. “I’ve called, and they say they don’t take my insurance.”

Molina declined to comment on Garcia’s case and didn’t respond to questions about its primary care network.

Nearly people in California live in a total of 611 primary care shortage areas, according to a KFF analysis, which found the state would need to add 881 practitioners to close this gap.

Garcia, a construction worker, said he read that he could manage his arthritis by changing his eating habits. He now eats healthier and has cut back on sugar and Coke. As for the pain, he eases it with ibuprofen. He has given up looking for a provider.

Keeping patients out of the ER, which can be as primary care, is one of the arguments for expanding Medi-Cal. Studies have shown that not only does expanding health coverage lead to lower rates of ER visits, but expanding coverage also leads to patients using preventive care more, said Drishti Pillai, immigrant health policy director at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

“It can help save health care costs because conditions are no longer going untreated for a long time, in which case they may become more complex and expensive to treat,” Pillai said.

This article is part of “,” a series exploring the impact of the state’s safety-net health program on enrollees.

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referred the 75-year-old to a dentist about 20 miles away in San Francisco, but his tooth decayed while he waited months for authorization to cover the procedure. In the end, his tooth was pulled.

It was the sixth time in a decade Moske had lost a tooth for lack of dental care, he said. The behavioral health peer specialist wears a denture that must be removed at mealtime, making eating a chore. He often struggles to mash food between his gums, and he limits his diet to things he can easily chew. Nuts and steak, for instance, are off the table. It can be embarrassing to sit down for a meal with clients or colleagues.

“I feel like I give off the impression of somebody who doesn’t take care of himself, and I do take care of myself,” Moske said. “I try very hard. So, when I go out, I try not to smile.”

California is among a growing number of states that provide to adults enrolled in Medicaid, and some lawmakers want to add more dental cleanings, examinations, and implants to the safety-net program. Yet many dentists don’t accept Medi-Cal, the state’s Medicaid program, so new benefits would offer no guarantee that patients could get care.

The UCLA Center for Health Policy Research found that saw Medi-Cal patients of all ages, according to data from 2019 to 2021. Often those dentists limit the number of Medi-Cal patients they will see, meaning only 15% of adults might get dental care in any given year, said Elizabeth Mertz, a dentistry professor and medical sociologist at the University of California-San Francisco.

“The issue is you have coverage that is useless,” Mertz said. “The state does provide coverage, but almost no dentist will accept it.”

One of the through the California Legislature would expand Medi-Cal coverage of dental implants — artificial tooth roots implanted into the jawbone that support artificial teeth — and crowns, giving patients with broken or missing teeth more options.

Currently, Medi-Cal covers implants only when “exceptional medical conditions are documented,” according to the guide. It’s unclear how many private dental plans cover implants, but preliminary research has shown about half of individuals enrolled in a PPO plan nationwide have some type of coverage, said Mike Adelberg, executive director at the National Association of Dental Plans.

Under the bill, introduced by Democratic Sen. Aisha Wahab, Medi-Cal patients could qualify for an implant if their dentist determines it is the best option to replace a missing tooth.

“If you need an implant, you should be able to get it, especially our most vulnerable,” Wahab said. “The poorest of the poor in California deserve this.”

The Senate passed the bill unanimously in May, and a vote is pending in the Assembly Appropriations Committee. Elana Ross, a spokesperson for Democratic Gov. Gavin Newsom, declined to comment on the bill.

Four in 10 U.S. adults have had permanent teeth pulled, according to an . The that low-income older adults are at higher risk for tooth loss, which can cause discomfort and affect eating and speaking. The fix can be prosthetic devices, such as bridges and dentures, or replacement teeth, but they can be costly, especially for those without insurance or on government programs with limited benefits.

While the alternatives might be a better fit for some patients, implants are “the standard of care,” said Sohail Saghezchi, director of UCSF’s oral surgery residency program.

“They’re not able to eat everything that they want, and, a lot of times, foods like vegetables and fruits are harder to eat,” he said.

The Department of Health Care Services, which oversees Medi-Cal, estimates it would cost between $4 billion and $7 billion a year for about 1.5 million implants — a price tag Wahab fears could be problematic since Newsom in June signed a state budget closing an estimated .

The cost of an implant varies widely. DHCS estimates it would reimburse dentists between $3,000 and $4,500 for each implant surgery. FAIR Health, a national nonprofit that estimates health costs, reported a median charge for a typical implant in California between October 2022 and September 2023 ranged from about $4,000 to $4,800. Location matters, too. In San Franciso, for example, an implant is closer to $8,000, Saghezchi said.

“Reimbursement rates need to cover the costs of providing the service,” said Alicia Malaby, a spokesperson at the California Dental Association. “As with any Medi-Cal benefit, coverage is not meaningful unless the state is willing to fully invest in it to ensure people can actually access the care they need.”

The California Dental Association, which does not support the current bill, has raised concerns about the invasiveness of implant surgery, which requires regular follow-up appointments. It’s to require Medi-Cal to cover a standard two teeth cleanings and examinations a year for people 21 and older, as opposed to one.

DHCS spokesperson Leah Myers said the state has increased to dentists since the passage of Proposition 56 in 2016 and created a web-based app to enlist more dentists. More than 14,000 dentists — about 40% — were enrolled in the Medi-Cal program, as of July, according to the latest numbers published by the Dental Board.

But for people such as Moske, finding a dentist and getting needed care feels impossible. In most of California, 3 in 4 Medi-Cal patients 21 and up didn’t have a dental appointment in 2023, .

When Moske testified in support of the implant bill in June, he took out his denture, held it up to show lawmakers, and opened his mouth.

“I’m here to show you something,” Moske said. “Please don’t be offended. These are the teeth I lost.”

After Moske had finished speaking, Assembly member Reggie Jones-Sawyer (D-Los Angeles) turned to his fellow members and removed his own denture.

“I know exactly what you went through,” he said. “I have dental insurance from the city of Los Angeles and the state of California and still had problems getting things covered. I thank you for being brave enough to let people know.”

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Ahmeir’s preschool teacher relayed her concerns to his mother, Kanika Thornton, who was already worried about Ahmeir’s refusal to eat anything but yogurt, Chef Boyardee spaghetti, oatmeal, and applesauce. He also sometimes hit himself and others to cope with the frustration of not being able to communicate, she said.

Thornton took her son, who is on Medi-Cal, California’s Medicaid program, which covers low-income families, to his pediatrician. Then he was evaluated by a school district official, a speech therapist, and the pediatrician — again. Along the way, Thornton consulted teachers, case managers, and social service workers.

Ten months later, she still doesn’t have an accurate diagnosis for Ahmeir.

“I felt like I failed my child, and I don’t want to feel that,” said Thornton, 30, who has been juggling Ahmeir’s behavior and appointments on top of her pregnancy and caring for her two other children.

“Some days I don’t eat because he doesn’t eat,” said Thornton from her home in Alameda County in the San Francisco Bay Area. “I don’t want to hurt my unborn child. So I try to eat some crackers and cheese and stuff, but I don’t eat a meal because he doesn’t eat a meal.”

Seeking a diagnosis for a child’s behavioral problems can be challenging for any family as they navigate complicated medical and educational systems that don’t communicate effectively with parents, let alone each other.

A common obstacle families face is landing an appointment with one of a limited number of developmental specialists. It is particularly difficult for families with Medi-Cal, whose access to specialists is even more restricted than for patients with private insurance.

As they await their turn, they boomerang among counselors, therapists, and school officials who address isolated symptoms, often without making progress toward an overall diagnosis.

Obtaining a timely diagnosis for autism, anxiety, attention-deficit/hyperactivity disorder, or other behavioral disorders is important for children and their parents, said Christina Buysse, a clinical associate professor in developmental and behavioral pediatrics at Stanford University.

“Parent stress levels go down when a child is diagnosed early,” because they learn how to manage their child’s behaviors, she said.

Intervening early can also help retrain a child’s brain quickly and avoid lifelong consequences of developmental delays, said Adiaha Spinks-Franklin, president of the Society for Developmental and Behavioral Pediatrics.

“A speech and language delay at the age of 2 can put a child at risk of reading comprehension problems in the third grade,” she said.

Buysse is likely the right type of medical specialist for Ahmeir. As a developmental-behavioral pediatrician, she can often unify different symptoms into one diagnosis, and she knows what kind of therapy or medication patients need.

The Society for Developmental and Behavioral Pediatrics reports that there are actively certified developmental specialists in the nation.

“There just aren’t enough of us,” Buysse said, and some developmental specialists don’t accept Medicaid patients because they believe the reimbursement rates aren’t adequate.

Thornton didn’t know her son needed to see a developmental specialist, and he had never been referred to one, despite his many medical appointments. Once she learned about this type of specialist in May, she asked his pediatrician for a referral.

Alameda Health System, which provides Ahmeir’s primary care, “does not have a developmental-behavioral pediatrician on staff at this time,” said Porshia Mack, the system’s associate chief medical officer of ambulatory services.

“We have made efforts to hire them, but recruiting and retaining pediatric subspecialists is difficult for all health systems, and public safety-net systems in particular,” she said.

Karina Rivera, a spokesperson for the Alameda Alliance for Health, Thornton’s Medi-Cal managed care plan, provided a list of nine developmental-behavioral pediatricians she said are in the plan’s network.

However, the only two in Alameda County work for Kaiser Permanente, which “is a closed system,” acknowledged Donna Carey, interim chief medical officer of the Alameda Alliance. In practice, that means “even if they have a developmental pediatrician, we don’t have access to that pediatrician,” she said.

The other seven specialists are in surrounding counties, which could pose transportation challenges for Thornton and other patients.

The Alameda Alliance for Health met state requirements for patient access to specialists in the most recent review of its network, in 2022, said Department of Health Care Services spokesperson Griselda Melgoza. The plan “was found compliant with all time or distance standards,” she said.

However, after learning from California Healthline that the plan considers Kaiser Permanente specialists part of its network, the department contacted the insurer to inquire, and will work with it “to ensure member-facing materials accurately represent their current network,” Melgoza said.

A month after starting preschool in fall 2023, Ahmeir was evaluated for speech delay through his school district. His pediatrician also began ordering tests to understand his eating habits.

But Thornton believes Ahmeir’s symptoms aren’t isolated problems that can be addressed in a piecemeal fashion. “It’s just something else. It’s his development,” she said. “I know a tantrum, but he doesn’t get tantrums. He will hit people. That’s a no-go.”

In addition to addressing medical concerns, a developmental specialist could help parents like Thornton understand what school districts offer and how to expedite school evaluations, Spinks-Franklin said. Ahmeir faces a six- to eight-month wait for a comprehensive evaluation through his school district for additional services, Thornton said.

It’s common for parents to get confused about what a school district can and can’t do for kids with developmental disabilities, said Corina Samaniego, who works at Family Resource Navigators, an organization that helps parents like Thornton in Alameda County. For instance, Samaniego said, school districts cannot provide medical diagnoses of autism, nor the therapy to address it.

Ahmeir has made significant improvement with speech therapy provided through the school district, Thornton said, and now speaks in full sentences more often. But she remains frustrated that she does not have a diagnosis that explains his persistent symptoms, especially his reluctance to eat and difficulty expressing emotions.

Thornton believes she has done everything she can to help him. She has even created elaborate food landscapes for Ahmeir with dinosaur-shaped chicken nuggets, mashed potato volcanoes, gravy lava, and broccoli trees — only to have him turn his head away.

As of late May, she continued to seek advice from teachers and counselors while she waited for an appointment with a specialist.

“I try to stay strong for my son and do the best I can and be there for him, talk to him, teach him things,” she said. “It’s been really tough.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

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But meth is almost as easy to come by as a hazy IPA or locally grown weed.

Quinn Coburn knows the lifestyle well. He has used meth most of his adult life, and has done five stints in jail for dealing . Now 56, Coburn wants to get sober for good, and he says an experimental program through Medi-Cal, California’s Medicaid program, which covers low-income people, is helping.

As part of an innovative approach called “,” Coburn pees in a cup and gets paid for it — as long as the sample is clean of stimulants.

In the coming fiscal year, the state is expected to allocate $61 million to the experiment, which targets addiction to stimulants such as meth and cocaine. It is part of a broader Medi-Cal initiative , which provides social and behavioral health services, including addiction treatment, to some of the state’s sickest and most vulnerable patients.

Since April 2023, 19 counties have enrolled a total of about 2,700 patients, including Coburn, according to the state Department of Health Care Services.

“It’s that little something that’s holding me accountable,” said Coburn, a former construction worker who has tried repeatedly to kick his habit. He is also motivated to stay clean to fight criminal charges for possession of drugs and firearms, which he vociferously denies.

Coburn received $10 for each clean urine test he provided the first week of the program. Participants get a little more money in successive weeks: $11.50 per test in week two, $13 in week three, up to $26.50 per test.

They can earn as much as . As of mid-May, Coburn had completed 20 weeks and made $521.50.

Participants receive at least six months of additional behavioral health treatment after the urine testing ends.

The state has poured significant into curbing opioid addiction and , but the use of stimulants is also exploding in California. According to the state Department of Health Care Services, the rate of Californians dying from them .

Although the cutting-edge treatment and other drugs, California has prioritized stimulants. To qualify, patients must have moderate to severe stimulant use disorder, which includes symptoms such as strong cravings for the drug and prioritizing it over personal health and well-being.

Substance use experts say incentive programs that reward participants, even in a small way, can have a powerful effect with meth users in particular, and a indicates they can lead to long-term abstinence.

“The way stimulants work on the brain is different than how opiates or alcohol works on the brain,” said John Duff, lead program director at Common Goals, an outpatient drug and alcohol counseling center in Grass Valley, where Coburn receives treatment.

“The reward system in the brain is more activated with amphetamine users, so getting $10 or $20 at a time is more enticing than sitting in group therapy,” Duff said.

Duff acknowledged he was skeptical of the multimillion-dollar price tag for an experimental program. “You’re talking about a lot of money,” he said. “It was a hard sell.”

What convinced him? “People are showing up, consistently. To get off stimulants, it’s proving to be very effective.”

California was the first state to cover this approach as a benefit in its Medicaid program, according to the Department of Health Care Services, though other states have since followed, .

Participants in Nevada County must show up twice a week to provide a urine sample, tapering to once a week for the second half of treatment. Every time the sample is free of stimulants, they get paid via a retail gift card — even if the sample is positive for other kinds of drugs, including opioids.

Though participants can collect the money after each clean test, many opt for a lump sum after completing the 24-week program, Duff said. They can choose gift cards from companies such as Walmart, Bath & Body Works, Petco, Subway, and Hotels.com.

Charlie Abernathybettis — Coburn’s substance use disorder counselor, who helps run the program for Nevada County — said not everyone consistently produces a clean urine test, and he has devised a system to stop people from rigging their results.

For example, he uses blue toilet cleaner to prevent patients from watering down their urine, and has dismantled a spigot on the bathroom faucet to keep them from using warm water for the same purpose.

If participants fail, there are no consequences. They simply don’t get paid that day, and can show up and try again.

“We aren’t going to change behavior by penalizing people for their addiction,” Abernathybettis said, noting the ultimate goal is to transition participants into long-term treatment. “Hopefully you feel comfortable here and I can convince you to sign up for outpatient treatment.”

Abernathybettis has employed a tough love approach to addiction therapy that has helped keep Coburn sober and accountable since he started in January. “It’s different this time,” Coburn said as he lit a cigarette on a sunny afternoon in April. “I have support now. I know my life is on the line.”

Growing up in the Bay Area, Coburn never quite felt like he fit in. He was adopted at an early age and dropped out of high school. His erratic home life set him on a course of hard drug use and crime, including manufacturing and selling drugs, he said.

“When I first did crank, it made me feel like I was human for the first time. All my phobias about being antisocial left me,” Coburn said, using a street name for meth.

Coburn escaped to the solitude of the mountains, trees, and rivers that define the rural landscape in Grass Valley, but the area was also rife with drugs.

Construction accidents in 2012 left him in excruciating pain — and unable to work.

Coburn fell deeper into the drug scene, as both a user and a manufacturer. “You wouldn’t believe the market up here for it — more than you can even imagine,” he said. “It’s not an excuse, but I had no way to make a living.”

Financially strapped, he rented a cheap, converted garage from another local drug dealer, he said. Law enforcement officers raided the house in October, and authorities found a gun and large amounts of fentanyl and heroin. Coburn, who faces up to 30 years in prison, vigorously defends himself, saying the drugs and weapons were not his. “All the other ones I did. Not this one,” he said.

Coburn is also in an outpatient addiction program and is active in Alcoholics Anonymous, sometimes attending multiple meetings a day.

Every week, the small payments from the Medi-Cal experiment feel like small wins, he said.

He is planning to take his $599 as a lump sum and give it to his foster parents, with whom he is living as he fights his criminal charges.

“It’s the least I can do for them letting me stay with them and get better,” Coburn said, choking back tears. “I’m not giving up.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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“What I’m hearing is that you’re a self-starter,” he told one participant, who had taken up gardening but yearned for a community with which to share the hobby.

Cordero, 48, is guiding the discussion at Holding Hope, a weekly therapy group for people struggling with mental health. Anyone receiving mental health services through Solano County can participate.

A former member, Cordero is now the group’s volunteer peer leader. He initially joined in 2020 while dealing with mental illness and substance use — and found that sharing with others who had been through similar trials could be deeply healing.

“Not all of us are going to speak about” pain, said Cordero, who is covered by Medi-Cal, California’s Medicaid program, which insures low-income people. “But when one does, another does, and then next week another does, and it becomes like a connective tissue.”

These groups can offer essential support in a public system beset by workforce shortages, Cordero said. Two are run entirely by peer leaders, who help build trust by sharing personal experiences, said Cheryl Akoni, a marriage and family therapist who works for Solano County and leads Holding Hope alongside Cordero.

“You’re amongst your peers,” Akoni said. “You’re amongst people who have lived and shared experiences that you often might not get with your therapist because we have to keep our boundaries.”

In California, mental health care for Medi-Cal enrollees is provided by managed care insurers and . Among its services, Solano County Behavioral Health provides case management and appointments with therapists and psychiatrists, plus five groups, ranging from Holding Hope to a journaling collective.

In 2022, California counties to use Medicaid dollars to pay peer support leaders for their work, a benefit 51 of the state’s 58 counties have adopted, according to the state Department of Health Care Services. To qualify, individuals must undergo training and get certified by the California Mental Health Services Authority.

Cordero isn’t yet getting paid for his work with Holding Hope. He said he’s building experience as a volunteer and plans to seek his certification when the next training takes place.

Cordero’s family immigrated to California from the Philippines, and the tension between his American and Filipino identities caused anxiety as a child, he said. He first thought about killing himself around age 13 and didn’t feel he could be honest about his mental health with his family.

“I had American problems for my parents and family who had a traditional Filipino paradigm,” he said.

Cordero was diagnosed with borderline personality disorder in his 20s and was addicted to marijuana and methamphetamine throughout his adult life. Amid these challenges, Cordero took human services courses at Solano Community College and started to speak to high school classes about mental health and addiction. When that program ended, the loss of structure was destabilizing, he said.

“I just dove headlong into substance abuse,” Cordero said.

He missed his daughters’ school graduations. His diabetes went untreated, and his addiction grew more severe.

During the covid-19 pandemic, social distancing restrictions made it difficult for Cordero to obtain illegal drugs. He experienced severe withdrawal symptoms, along with a blood infection and complications from his untreated diabetes. This resulted in a series of hospital visits — and it was during one of these that Cordero was enrolled in Medi-Cal.

After he recovered, Cordero contacted Solano County seeking mental health treatment. He was told there would be a wait for a therapist due to covid-19 and staffing shortages but was encouraged to attend Holding Hope in the meantime.

He quickly took to sharing in the group, and after about a year of his attending, its former leader encouraged Cordero to assume a bigger role, he said.

“It was great to talk, and I can ramble forever,” Cordero recalled. “She said, ‘I think you can do better than that.’”

He started leading the group with Akoni in January.

Not every person who seeks mental health help is ready for or needs a therapist, but for those who do, groups and peer support can provide connection and community as they wait, said Emery Cowan, director of Solano County Behavioral Health.

At least 90% of the city and county behavioral health agencies who responded to a survey commissioned by the County Behavioral Health Directors Association of California in 2021 recruiting psychiatrists, licensed clinical social workers, and licensed marriage and family therapists.

The counties pointed to multiple staffing challenges: They generally can’t offer salaries comparable to the private sector; don’t appeal to applicants who want to work remotely or have flexible schedules; and have trouble finding and keeping providers with the training and experience to handle the complex patient population.

Cordero was paired with a psychiatrist right after his intake appointment. He finally added his name to the waitlist for a therapist in 2022 and said it took about a year to get matched with someone.

Solano County Behavioral Health relies on Medi-Cal-certified peer leaders and volunteer peer leaders, like Cordero, who run groups, help clients prepare for appointments, and .

“They’ve lived that experience, they know how hard it is, they’re more willing to do it because they want to help people just like them,” Cowan said. “They were that person.”

Cowan and Cordero acknowledge that group therapy isn’t for everyone. Discussing personal challenges or traumatic incidents in front of a group can be intimidating, and some people need more individualized care.

But for those who are a good fit, there is community to be found.

At the recent gathering of Holding Hope, participants discussed relationships and loneliness. Cordero shared that he still finds it difficult to maintain close bonds with family and friends, and that he feels lonely.

He repeatedly encouraged his peers to reframe negative thoughts and experiences, explaining that anguish can start feeling comfortable, almost like a routine, and that breaking out of that routine can feel challenging.

To emphasize his point, Cordero circled back to a particular phrase several times over the hour: “The path to pain is a well-carved path.”

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Somewhat by accident, Bloomer, 26, found Priya Kalyan-Masih six months into her pregnancy. Kalyan-Masih is a doula, a professional childbirth companion who provides emotional support, physical comfort, and education to women before, during, and after pregnancy. Bloomer hadn’t realized Medi-Cal would cover the service until she visited an informational fair near her home in the High Desert region of Southern California.

Medi-Cal, California’s Medicaid program for low-income residents, started offering the benefit in January — but doulas have wrestled with the program’s bureaucratic requirements and what they say is insufficient pay.

“Priya really listened to me. Out of all my births, this was the most peaceful and stress-free,” said Bloomer, who is a student working part-time as an in-home caregiver and at a detox center. “The fact that I didn’t have to pay anything out-of-pocket was life-changing.”

Having Kalyan-Masih at her side was critical for Bloomer because her partner — now fiancé — was imprisoned a few weeks after she found out she was pregnant, which would have meant she’d have to navigate her pregnancy and delivery without him.

Across the country, doulas are being enlisted to combat rising maternal mortality rates. In 2021, the most recent year for which data is available, about 1,200 women in the U.S. died from pregnancy complications either during pregnancy or within six weeks afterward, about 60% more deaths than were reported two years earlier, according to the .

The numbers are starkest for Black women and their children. In 2021, Black women died at more than 2½ times the rate of white women.

Doulas are distinct from the medical team and act as advocates for birthing parents. A published this year found that doula care was associated with reductions in cesarean sections, epidural use, length of labor, premature deliveries, and maternal stress.

During Bloomer’s pregnancy, Kalyan-Masih assisted with strategies such as mapping a birth plan and coaching Bloomer on breathing techniques to ease her anxiety.

Less than a year after Bloomer moved from Texas to be with her fiancé, Tim Smith, he was arrested for firearm possession while on probation for drug-related charges. That left Bloomer in Victorville, on the edge of the Mojave Desert, far from friends and family.

In Smith’s absence, Bloomer was grateful for Kalyan-Masih’s companionship and reminders to take care of herself, she said.

But what meant the most was Kalyan-Masih’s willingness to weave Smith into the birth without judgment, she said. Kalyan-Masih acted as his eyes and ears at the hospital in June, running around with Bloomer’s phone so Smith could meet his newborn daughter, Tiara, via FaceTime.

“It meant everything. I mean, I’m locked up and I saw the baby before Mia did,” Smith recalled, laughing. “Priya made everything possible. She held the phone. She was running around when the baby came out. She made it feel like I was there.”

Smith met Tiara in person when he was released a month later.

Kalyan-Masih’s presence also led to a noticeable difference in how medical staff treated her, Bloomer said.

During her previous deliveries, she felt the medical professionals had been pushy and dismissive. For example, when her son Thaddeus was born last year, she said, doctors pressured her to get an epidural against her wishes after Smith left the room to grab her lunch.

“When I had Priya in the room, they were more attentive to my needs and didn’t treat me like my opinion didn’t matter,” Bloomer said. “It wasn’t an argument or debate. It was just like, ‘OK, that’s what we’re doing.’”

Medi-Cal covers up to 11 doula visits before and after pregnancy, and support during labor and delivery — and patients can petition for extra postpartum visits. Doulas can also be for providing support during and after miscarriages or abortions.

“I always explain it as obstetricians and midwives are the ones catching babies, and doulas catch Mom,” said Kalyan-Masih, who is a medical doctor by training and a doula since January.

Kalyan-Masih is pleased with California’s investment in doula services but said it has been a challenge to maneuver Medi-Cal’s administrative requirements, like acquiring business licenses.

Samsarah Morgan, a doula and founder of the Oakland Better Birth Foundation, said the business license fees, in addition to Medi-Cal’s reimbursement rates, prevent some doulas from participating in the program.

The state pays doulas fixed rates per visit, adding up to $1,154 if patients schedule the standard number of nine visits before and after birth, in addition to labor and delivery. Doulas can make up to $2,078 through Medi-Cal if patients schedule additional postpartum visits. The $1,154 rate is more than in 2022, and Morgan said that she’s grateful for the increase — but that it’s still not enough.

In her own practice, most clients pay $2,500 to $3,500, typically out-of-pocket since, in her experience, many private insurance plans don’t cover doula services, she said.

“I want to work with clients who are on Medi-Cal, but I also need to pay my bills,” Morgan said.

Griselda Melgoza, a spokesperson for the Department of Health Care Services, which administers Medi-Cal, said the department pays doulas the same as other providers — including doctors, nurses, and physician assistants — for the same services. The department has proposed rate increases for doula services next year, which would vary by type of delivery. A doula who provides the standard nine visits and attends a vaginal delivery, for example, would be paid $2,180, 89% more than the current rate.

Preliminary data shows that 50 doula claims were processed statewide as of July 31 and that claims from that time frame are still coming in, Melgoza said. She added that the department is working to make the benefit more accessible. In November, for instance, it eliminated most referral requirements, removing a hurdle for patients.

Bloomer said she wishes she had been able to work with a doula during previous pregnancies, especially when she was carrying Lucas, her first child, at age 19.

At the time, she didn’t know what questions to ask or what to expect, including how to cope with postpartum depression.

“With a doula, I would have been more informed,” Bloomer said as 6-month-old Tiara babbled on her lap. “I would have felt more empowered. I would have had the kind of support that would have made me a better mom.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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Her blood sugar was plummeting, and the beep came from a attached to her abdomen. The small but powerful device alerts Voros when her blood sugar is dangerously high or low.

“My blood sugar is at 64. It’s too low and still dropping,” Voros, 32, said on a bright October afternoon. She checks the monitor up to 80 times a day to help prevent complications from Type 1 diabetes.

But the monitor means little without the supplies that make it work, including a receiver, a sensor, and a transmitter — some of which must be replaced every 10 to 30 days. Voros also has an insulin pump, which delivers a steady supply of that hormone to her body, and it requires supplies too.

Until recently, Voros — who is covered by Medi-Cal, California’s Medicaid program for people with low incomes or disabilities — spent countless hours on the phone with her endocrinologists, her Medi-Cal insurer Health Net, and a medical supply company to obtain separate approvals for each item. At times, her authorizations expired too quickly, leaving her short on supplies and forcing her to ration and seek donations on social media from other diabetes patients.

Last year, she received only enough supplies to last six months.

“I’ve had to put in hundreds of hours over the phone in the past few years, and I’ve changed my insurance group twice because of this,” Voros said before slugging apple juice in her studio apartment in the Mission Hills neighborhood, a suburban neighborhood in the San Fernando Valley. “It’s exhausting. It makes you want to give up. But I can’t. I’ll literally die.”

Starting in October, Medi-Cal began that have caused life-threatening delays for Voros and others with diabetes.

Previously, authorizations for medications and supplies lasted six months, though for some patients, like Voros, they expired sooner. Under the new rules, authorizations are supposed to last one year from the date of approval and can include all needed supplies — ending the scramble to secure separate authorizations for each piece of equipment. Patients can receive 90 days’ worth of supplies and medications at once.

The state is also formalizing a policy that allows patients to obtain approvals from their health care providers by phone or video.

“Before, California’s requirements were four pages long, and now it’s just a little more than a page,” said Lisa Murdock, chief advocacy officer for the American Diabetes Association, who helped push for the changes. “This is a really important step forward. It means not having to constantly guess how blood sugars are doing.”

Over the past two years, the state also started making continuous glucose monitors and related supplies available to many more people, including all patients with , a chronic autoimmune disease that attacks insulin-producing cells in the pancreas, and those with , , and , or chronic low blood sugar. Before last year, the monitors were available to only some patients on a case-by-case basis, according to the state Department of Health Care Services, which administers Medi-Cal.

The enhanced coverage extends to newer, more advanced devices, such as the popular , which retail for about $700 on Amazon for a 30-day supply without insurance. Medi-Cal pays for the same equipment.

Diabetes and prediabetes are . About have been diagnosed with diabetes. The Department of Health Care Services says about 1.2 million Medi-Cal enrollees have the disease, according to the latest data available.

Before these changes, Medi-Cal recipients had a harder time securing medication and supplies than people with private insurance, Murdock said.

“Diabetes is a really heartbreaking and costly disease, and to take care of themselves, people with diabetes need easy access to insulin, but also the supplies to manage the disease,” she said.

Patient advocates and state health officials say the changes will save money and lives by giving those with diabetes more control over their blood sugar, and by preventing complications such as organ failure and foot and toe amputations.

This expansion in coverage “improves access and member outcomes, reduces hospitalizations and comorbidities, and improves members’ quality of life with better disease management and less finger sticks,” said Ann Carroll, a Medi-Cal spokesperson. The state, she said, wants to ensure all diabetes patients get “the care they need to lead healthy, fulfilling lives.”

Before Voros got her monitor about three years ago, she had to visit an emergency room and was hospitalized with . She also lost nerve function in her stomach — which prevents digestion of high-fiber foods like vegetables — as her disease advanced.

“I haven’t had to go to the intensive care unit in almost two years. It has literally saved my life,” she said.

But the bureaucratic hurdles that kept Voros from getting supplies for her monitor were a constant source of stress. That’s changing since she switched to a new medical supply company and Medi-Cal has debuted its new preauthorization process, amid a broader revamp of its pharmacy system.

Getting her supplies on time means peace of mind, Voros said.

“I used to be so afraid to go to sleep at night because of the seizures I’d get from low blood sugar,” she said. “I’ve been really close to death, but now I feel better than I ever have.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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Johnson, 58, said her ordeal started in September 2022, when she went for a CT scan of her abdomen after a bout of covid-19. Though Johnson warned the lab she was allergic to iodine, she believes the lab tech used it in an injection, triggering an allergic reaction. She spent the next three weeks in the hospital, feeling as if her body was on fire.

When she was discharged to her home at the base of the San Jacinto Mountains in Riverside County, Johnson said, her quality of life deteriorated and her frustration mounted as she waited for her Medi-Cal plan to get her assessed by a specialist. She could barely walk or stand, she could no longer cook for herself, and sometimes she couldn’t even lift her leg high enough to step into the tub.

“I would never wish this on anybody,” Johnson said while rocking back and forth on the couch to still the pain. “You don’t know if you should cry, or just say OK, I can make it through this. It messes with you mentally.”

Johnson said her primary care doctor told her he wasn’t sure what triggered the pain but suspects it was compounded by the lingering effects of covid. Johnson, who is diabetic, developed neuropathy, a type of nerve damage, possibly after the allergic reaction caused her blood sugar levels to skyrocket, her doctor told her.

He referred Johnson, who receives care through California’s Medicaid program for low-income people, to an endocrinologist in March. But Johnson said she was not offered timely appointments, and it took more than six months, four referrals, multiple complaints to her health plan, and a legal aid group’s help to finally snag a phone call with an endocrinologist in mid-September.

Access to specialists — from gastroenterologists to cardiologists — has been a long-standing challenge for many Medi-Cal patients, especially those in rural areas or regions facing staff shortages. The Inland Empire, where Johnson lives, has the of specialists in the state, according to the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The state Department of Managed Health Care, which regulates most Medi-Cal health plans, requires plans to get patients in to see specialists within 15 business days, unless a longer waiting time would not harm the patient’s health. But the timeline often looks very different in reality.

“It’s hard to get a specialist to contract for Medi-Cal patients. Period,” said Amanda Simmons, executive vice president of Integrated Health Partners of Southern California, a nonprofit organization that represents community health clinics. “Specialists don’t want to do it because reimbursement rates are so low.”

Johnson said she made her first call in March to the endocrinologist assigned by her Medi-Cal insurer, Inland Empire Health Plan, and that the office offered her an appointment several months out. Over the next four months, she received three more referrals, but she said she got a similar response each time she called. When Johnson objected to the lengthy wait times, requesting earlier appointments, she was told there was no availability and that her condition wasn’t urgent.

“They told me it wasn’t important,” Johnson said. “And I asked, ‘How would you know? You’ve never seen me.’”

Esther Iverson, director of provider communications for the plan, declined to speak about Johnson’s case but said the plan makes every effort to meet the 15-day requirement. It can be challenging to meet the standard, she said, due to a lack of available physicians — especially for certain specialties, such as endocrinology and pain management.

She pointed to the nationwide physician shortage, which is more pronounced in rural areas, including parts of San Bernardino and Riverside counties, where the plan operates. She also noted that many physicians decided to leave the field or retire early due to burnout from the covid pandemic.

At the same time, she said, the plan’s enrollment ballooned to as eligibility expanded in recent years. Statewide, Californians are enrolled in Medi-Cal.

“The highest priority for us is timely access to quality care,” Iverson said.

During her quest, Johnson enlisted the help of , which provides free legal representation to low-income residents. They called the plan multiple times to request earlier appointments but got mired in bureaucratic delays and waiting periods.

In one instance in August, after the insurer told Johnson it couldn’t meet the 15-day time frame, her legal representative, Mariane Gantino, filed an appeal, arguing that Johnson’s request was urgent. The insurer’s medical director responded within a few hours denying the claim, saying the plan concluded that her case was not urgent and that a delay would not cause a serious threat to her health.

“I’m so burned out after dealing with this for so long,” Johnson said in mid-September. “Why do they have the 15-day law if there aren’t going to be any consequences?”

A few days later, Johnson finally received the call she had been waiting for: an offer of a phone appointment with an endocrinologist, on Sept. 18. During the appointment, the doctor adjusted her diabetes and other medications but didn’t directly address her pain, she said.

“I’m in the same position,” Johnson said. “I’m still in pain. What’s next?”

Over the years, Johnson has worked a variety of jobs — from driving eighteen-wheelers cross-country to weaving hair — but her most consistent work was as a caregiver, including to her six children, 21 grandchildren, and three great-grandkids, with another great-grandchild on the way. Now, because of her extreme pain, the roles have been reversed. A daughter and granddaughter who live with her have become her full-time caregivers.

“I can’t do nothing. I can’t take care of my grandkids like I used to,” said Johnson, who sleeps most of the day and wakes up only when her pain medication wears off. “I was planning to take care of the new baby that’s coming. I probably can’t even hold her now.”

This article is part of “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

This <a target="_blank" href="/aging/medicaid-specialist-shortage-wait-pain-riverside-county/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Bullied and ostracized, Wrangell started repressing those feelings in middle school and kept them bottled up for a long time. That led to decades of sadness, isolation, and even a couple of suicide attempts. What gnawed at Wrangell was gender dysphoria, a condition widely acknowledged in the medical community, which causes severe distress to people whose gender identity does not match their sex assigned at birth.

“It’s a sense of wrongness, like someone attached an arm to my head badly, and it just punches me in the face every time,” said Wrangell, 38, who grew up and still lives in this idyllic central California beach community. Facial and body hair is particularly upsetting: “I see my face in the mirror, and anytime I have to deal with hair, it is uncomfortable. I hate seeing it.”

Wrangell is nonbinary, meaning neither a man nor a woman, and uses the pronouns they and them. For over three years, they have been undergoing gender transition treatments to take on more feminine physical traits. These treatments have included genital transformation, known as ; hormone replacement therapy using estradiol; and electrolysis hair removal for their face, neck, and chest.

All of it is paid for by Medi-Cal, California’s version of the federal Medicaid insurance program for people with low incomes. California law and all other state-regulated health plans to cover gender-affirming care that is deemed medically necessary. But therein lies the rub.

Wrangell, an enrollee of the Central California Alliance for Health, the only Medi-Cal health plan in Santa Cruz, said it has been laborious to get the care they need. They contend with seemingly endless paperwork and phone calls to prove what they’ve already established — that their need for treatments is real and ongoing.

“There is a joke among the trans community, where they are always asking for letters, along the lines of, ‘Oh, did they think I stopped being trans or did the hair magically go away?’” Wrangell said.

And it requires a lot of work to find and vet the scant number of gender-affirming care providers who take Medi-Cal patients, Wrangell said.

Over 1.6 million people ages 13 and older in the U.S. , according to the UCLA School of Law’s , which conducts legal and policy research on gender identity and sexual orientation. Data from the institute shows an estimated in the U.S. are enrolled in Medicaid, including 164,000 in states where transgender care is covered. Of those, 36,000 are in California, one of 25 states, plus Washington, D.C., whose Medicaid policies cover gender-affirming care.

“I think there’s a lot of pressure in society to fit into a very narrow set of narratives, and I don’t think honestly that works for most people,” Wrangell said. “For some people, it’s so ill-fitting, it’s disastrous.”

A shows they disproportionately experience physical abuse, economic hardship, and mental health problems. And research finds gender-affirming care can their quality of life.

But as Wrangell has learned, coverage and care are not the same thing. Hair removal, their top priority, has been hard to get. After 2½ years of electrolysis treatment, they’ve had roughly only about half the total number of hours their electrologist said they needed.

Permanently removing the facial hair of a transgender person assigned male at birth can require of electrolysis spread over several years. For those paying out of their own pockets, the cost would easily reach tens of thousands of dollars. That doesn’t include the cost of facial, bottom, and body-shaping surgeries.

Wrangell said their health plan has limited the number of sessions it authorizes at a time, requiring constant reauthorization.

Dennis Hsieh, deputy chief medical officer of the Central California Alliance for Health, said the health plan recently updated its policy to allow 50% more electrolysis in a three-month period and eliminate a rule to submit photos of relevant body parts.

Hsieh acknowledged a shortage of providers and said the alliance contracts with clinicians across several counties to provide more options.

To a large extent, the challenges transgender people encounter seeking care are the same ones many people face in the “terror dome of U.S. health care,” said Kellan Baker, the executive director of the Washington, D.C.-based , which conducts research and education on topics of concern to gay, bisexual, and transgender people. “There are a lot of people in a lot of circumstances who cannot get medically necessary care for their conditions, whether that’s gender dysphoria or cancer or diabetes.”

Legal aid lawyers and transgender activists say another big reason for denials or delays in gender-affirming care, especially hair removal, is that many people in the medical world still think of it as cosmetic.

Medi-Cal, like most commercial insurance plans, does not cover cosmetic treatments. “But if it’s affecting your mental health, and it’s affecting your life opportunities, and it’s affecting your ability to get a job, and it’s affecting your ability to get housing, is that cosmetic?” asked Elana Redfield, the federal policy director at the Williams Institute.

Despite their travails in obtaining care, Wrangell said, the treatment is improving their life. The estradiol, they said, makes them feel “way more relaxed, much less on edge all the time.” And Wrangell feels good about an uncommon bottom surgery they got last October, but they are facing more paperwork for a needed follow-up operation.

They are frustrated about all the red tape they’ve encountered, precisely because the treatments are helping. “This is working,” Wrangell said. “Please finish it.”

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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 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 that it was the other way around.

They were : 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 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 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 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.”

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