By Hannah Esqueda
While Medi-Cal expansion has helped provide first-time health insurance to residents throughout the Central San Joaquin Valley, patients living in rural communities still face tremendous obstacles to actually receiving care.
Building a professional pipeline
Chief among the roadblocks to proper health care access has been the area’s limited supply of primary care physicians or PCPs. The Central San Joaquin Valley is considered a Primary Care Shortage Area by California’s Office of Statewide Health Planning and Development, with deficits so severe much of the local population is further classified as “medically underserved.”
In a study by the California HealthCare Foundation, many Valley communities reported startling statistics of 40 or fewer physicians to every 100,000 patients, less than half the state recommended average of 80 PCPs to every 100,000 residents.
The issue is often compounded in local rural communities, whose markets have traditionally been less of a draw for physicians and other medical staff. Local physician groups frequently cite the competitiveness and quality of life in larger markets like Los Angeles or the Bay Area as top problems in recruiting physicians to the Valley, a problem that has seen little resolution despite the changes under the Affordable Care Act (ACA).
Theoretically, residents living in underserved communities have access to care through the recently expanded Medi-Cal program under the ACA, but in reality, health professionals warn there still aren’t enough doctors accepting those payments.
“Medi-Cal expansion has not necessarily meant a change in access,” said Dr. Katherine Flores, director of the Latino Center for Medical Education and Research at UCSF Fresno. “It still doesn’t solve the problem of getting good health care.”
Since its creation, the UCSF Fresno Latino Center has sought to create a pipeline of medical professionals in the Central San Joaquin Valley through both internal educational programs and partnerships with local school districts. Among the most successful ventures has been the Doctors Academy program which operates as a “school within a school” at three area high schools, including those in the local farming towns of Caruthers and Selma.
Since 2007, the program has helped to recruit, educate and support hundreds of teens interested in pursuing a career in the medical field. By starting youth on this career path early, Flores said the program aims to help build up a locally-bred workforce who will be more closely connected to the rural populations they serve.
“We’re hopeful that these kids who are born and raised and nurtured in these communities will have that much more incentive to come back after they graduate,” she said.
These efforts seem to be working and the Academy has maintained a 100 percent acceptance rate to four-year universities and 98 percent matriculation rate. Anecdotal evidence has also shown dozens of alumni moving back to the Valley to pursue careers in the medical field, Flores said.
“We’re trying to build a network of alumni relationships here,” she said. “The Valley is really a culture of its own and it helps these kids to connect with past participants.”
Long wait times frustrate patients, advocates
But while efforts to build a professional pipeline of local physicians are showing long-term promise, Valley Medi-Cal patients are still left struggling with more immediate needs.
The chronic shortage of PCPs coupled with the growing patient population throughout the Valley has led to exceptionally long wait times for residents attempting to utilize their newfound medical coverage.
“If someone does have full-scope Medi-Cal, it’s still a lengthy process for them to get services, because even though they might have the benefits and they want to schedule an appointment, some clinics have appointments out for two to three months,” said Ilse Gallardo, Health and Wellness program manager with Centro La Familia Advocacy Services in Fresno County.
Since 1972 the local nonprofit group has provided social services and Medi-Cal enrollment assistance to underserved and rural populations. The organization has built on these same deep ties to the community to navigate clients through the expanded Medi-Cal program since ACA took effect, however, Gallardo said the group now faces an uphill battle between limited local resources and growing patient demand.
Beyond the normal enrollment work, she and one other staff member are responsible for maintaining contact with the agencies multitude of clients and assessing additional needs. This frequently entails working directly with local health clinic partners like Clinica Sierra Vista to try and make earlier appointments.
“Once they call and make these appointments and they get that [2-3 month] time frame, they will call [Centro La Familia] and see what kind of options they have,” Gallardo said.
The agency is not always able to coordinate earlier appointments, however, and all too often patients are left with the option of either going to the emergency room or suffering through the issue at home.
“When you’re calling to make an appointment with a doctor for a stomach ache, you don’t want to wait a few months to get in,” Gallardo said. “But if they go to the emergency room, they have to wait all day and they likely won’t be admitted. From there a lot of [patients] just kind of lose hope.”
With a majority of Centro La Familia’s client-base being Hispanic, Gallardo said she has heard of some turning to home remedies in hopes of treating or managing a health condition. These methods are less than ideal, especially since most clients haven’t seen a physician in years.
“Some individuals will never use the benefits because they’re not used to it and they don’t want to wait for those long appointment times,” she said. “Others will be more determined [to see a doctor], especially if they have a chronic condition and need medications for it.”
While this reality is far from the hopeful future once promised by Medi-Cal expansion, Gallardo said she is still encouraged by the steady number of rural patients enrolling in coverage. Centro La Familia averages a few hundred new rural clients each month through its weekly rural events in communities like Mendota, Selma, Orange Cove, Parlier, and Firebaugh.
“We’re hardly in the office because we’re doing these community events,” Gallardo said. “They’re still really important because you do get a lot of people who can’t make it all the way out to Fresno and these communities may be easier for them to get to.”
Valley rural clinic scene sees expansion
Meeting patients where they live and work has become increasingly important as the insured rural patient population has grown and health care groups are quickly maneuvering to expand their footprint in many of the Valley’s previously underserved communities.
Construction of rural clinic sites has increased in the Valley over the last few years, with more than a dozen facilities opening or expanding since 2015. The trend has captivated both Federally-Qualified Health Centers (FQHC) and local hospital groups alike, with particular interest seen in the more rural regions of Kings and Tulare Counties.
FQHC group Family HealthCare Network has opened numerous clinics in many of the region’s smaller farming towns recently, with additional sites scheduled to come online in the next few years. The group has also actively partnered with Tulare County’s Health and Human Services Agency (HHSA), with several of the HHSA officials posted at rural clinics throughout the area.
These remote service sites enable the county to meet patients in their home communities and better serve their immediate needs, said Vienna Barnes, division manager for Self-Sufficiency at the county.
Tulare County currently has 234,000 residents – 51 percent of its total population – enrolled in Medi-Cal, a sharp increase from the 165,000 individuals – 36 percent – enrolled prior to the ACA and Medi-Cal expansion, she said.
Such a huge jump in enrollment has reinforced the need for expanded health infrastructure, and Barnes said the county has met a lot of success through its rural site model. Outreach efforts at community events have also helped spread the word, with the county averaging more than a hundred Medi-Cal enrollments per event.
“We’ve had this model for a number of years and so far have seen a good response from the community,” she said. “We’re a very rural community so we’re always looking for access points in the community.”
In the future, Barnes said county staff will also continue to work with health group partners to identify infrastructure and access needs in the smaller rural communities – meeting patients needs where and how they’re most needed.
Hannah Esqueda’s reporting on the Central San Joaquin Valley’s rural health care scene was undertaken as a USC Center for Health Journalism California Fellow.