Getting primary medical care when you're poor or uninsured is challenging everywhere. In some places in California, people can at least tap into extensive county services and flourishing networks of federally financed community clinics.
But not in Sacramento County.
Health care leaders here describe the county's network of primary care for the poor and uninsured including people who don't get health insurance through their employers or can't afford it on their own as "fragmented," "frayed" and two to three decades behind the times.
Once operating six public clinics for the poor and uninsured, Sacramento County now has one. Nonprofit community clinics, which form the backbone of primary care for the poor in other counties, are few and far between.
Given the options, the estimated 444,000 Sacramentans who have Medi-Cal or no health insurance at all nearly a third of all county residents often struggle to get primary care. More and more, they end up in emergency rooms.
"Things are uniquely bad in Sacramento County compared to other counties in the state," said Jonathan Porteus, chief executive officer of The Effort, Sacramento's fastest-growing chain of nonprofit clinics.
Alameda County, which like Sacramento is home to a diverse population of just over 1.4 million, has four times more county-run clinics. As of 2010, Alameda also had nearly three times more federally funded community clinics, employing five times more clinicians and providing over six times more primary care visits per year, a Bee analysis of data from the California Office of Statewide Health Planning and Development shows.
A recent analysis by the Sacramento research firm Valley Vision determined that, unless you count emergency rooms as primary care clinics, Sacramento County's doctor deficit for low-income patients leaves 113,000 to 142,000 residents with no physician to serve them.
Private doctors treat some patients with Medi-Cal coverage, but given California's rock-bottom payment rates, most doctors who do accept Medi-Cal patients take only a handful.
What that means for many low-income patients is that, yes, if you have a heart attack, you can go to the emergency room. But "once your heart attack has resolved and now you need the medication to prevent the next one, and a stress test too bad," said Patricia Samuelson, medical director of the MercyClinic Norwood in Del Paso Heights.
Karen and Michael Brandt of Del Paso Heights have navigated Sacramento's system for years, with mixed results.
Michael, 50, once an aspiring horticulturist, is among the luckier ones.
He qualifies for Medi-Cal due to disability stemming from a stroke, and he found a doctor (Samuelson) in his neighborhood to take him.
Still, in Sacramento's labyrinthine Medi-Cal system, Brandt hits glitches.
Last week, his newest Medi-Cal card hadn't arrived in time for him to pick up prescriptions for a toe infection. He sat barefoot in his living room, on hold on the phone trying to sort it out, blood seeping out around the nails of his big toes.
His wife has run a tougher road. Karen Brandt, 48, has been uninsured since her last child turned 18 five years ago, disqualifying her from Medi-Cal. She cares for her husband and mother in the Brandts' two-bedroom home, earning about $880 a month via the state's In-Home Supportive Services program.
She used to go to the county's Del Paso Heights public clinic, but it closed. She said she tried independent clinics, but had to arrive early and wait all day, and felt she couldn't leave her husband alone that long.
A little over a year ago, suffering from asthma and fearing her unexplained weight loss could mean cancer, she tried the county's only remaining public clinic on Broadway. But her co-pay would have been $230, she said, and she couldn't afford that.
So Karen Brandt did without. When her asthma flared up, she borrowed her husband's inhaler. Finally, months later, she was able to get free care at MercyClinic Norwood, where she learned she does not have cancer.
"It just really puts you in the kind of place where you either go to the doctor or have a roof over your head," she said. "You've got to pick which is better."
Free clinics mostly full
The Brandts' bumpy ride mirrors what Valley Vision researchers found across the county when they studied the experiences of poor and uninsured Sacramentans in 2010.
Medi-Cal works for some patients and stymies others. It covers only certain categories of low-income people: pregnant women, parents of underage kids and the disabled. It leaves out lots of people who can't afford private insurance premiums.
Uninsured residents can try the county clinic, but that mainly serves people earning less than $620 a month. The free clinics run by UC Davis and Mercy are mostly full.
The weakness of Sacramento's system of primary care for the poor and uninsured has existed for decades, hidden in the shadows of a world-class private health care system, local health care leaders say.
"You've got four very strong hospital systems which dominate and make this one of the best places, by some measures I've seen, in the country for health care if you've got employer-provided insurance," said Marty Keale, executive director of the Capitol Community Health Network, an association of local clinics.
But Sacramento's medical landscape is vastly different for those without private coverage. "I'd say it's the opposite end of the scale," Keale said. "It's one of the worst."
The problem evolved gradually.
Alameda County, considered by many to be a model in health care for the poor, has for decades contracted with community health centers to provide some primary care services, helping them gain strength.
But until recently Sacramento County went it alone, meeting its legal obligation to treat the very poorest residents but not encouraging nonprofit clinics in the community to build a broader system of care.
For their part, the independent clinics in town mostly stayed small and didn't go after federal dollars the surest way for nonprofit health centers to grow and survive.
Clinics that meet strict requirements can compete to become federally qualified health centers (FQHCs). They then get extra government money each year in exchange for treating the uninsured.
La Clínica, Alameda County's biggest chain of nonprofit health centers, gained FQHC status when the federal program started in the 1970s. Now it operates 29 sites in three counties and gets an annual federal grant of around $5 million. An additional six FQHCs in the county qualify for the annual grants.
In Sacramento, The Effort is the only clinic group yet to win full federal status, which it did in 2009. In proportion with its size, it gets a federal grant of around $650,000.
Recession widened gap
The gap in local services widened as the 2008 recession took hold and drove tens of thousands of Sacramentans into unemployment. Within two years, the county shuttered five of its six primary care clinics to close budget deficits.
President Barack Obama's health care reform plan set the wheels in motion to get millions of people newly insured by 2014, including an estimated 167,000 in Sacramento County a potential tsunami of fresh demand that has pushed area politicians and health care administrators to take notice.
Local community clinics are expanding. The Effort has grown to five full-service health centers and plans to add four more by mid-2013.
Four other clinics the Sacramento Native American Health Center, Midtown Medical Center for Children and Families, Health for All, and Health and Life Organization have earned a federal status that brings higher Medi-Cal payment rates, though not an annual grant like The Effort gets.
The Sierra Health Foundation has brought together local groups, including county staff, to try to quantify Sacramento's health care needs and create a plan to fill them.
Still, real change will hinge on strong county leadership, said Keale and other leaders.
"You would need the county supervisors to be interested in medical care for the poor, which I don't think they are," said Glennah Trochet, who served 18 years as medical director of the county clinics and then county health officer before resigning amid concerns about funding cuts last year.
Ted Wolter, chief of staff to Supervisor Roberta MacGlashan, said since the county clinic closures there's fresh interest among officials to seek new strategies to care for the poor. Supervisors' staff members have been meeting with local health care providers to try to improve the Medi-Cal system.
That said, Wolter added, "The top priority of the board has been and continues to be providing the top quality of law enforcement that we can."