ANAHEIM, Calif. — When Fabiola Ortiz heard California had granted health coverage to poor children lacking legal immigration status, she felt grateful. Since arriving in the U.S. illegally 12 years ago, she has taken her two youngest children to the doctor only for required school physicals and relied on home remedies for everything else.
“The truth is that we really need insurance,” the 46-year-old Anaheim resident said. “For the children, it will be a big help.”
The coverage under Medi-Cal, the state’s version of Medicaid, is expected to result in more preventive care and better long-term health for an estimated 170,000 children who have long relied on safety-net clinics and emergency rooms. But while many policymakers, advocates and researchers celebrated the budget deal announced by Gov. Jerry Brown last month, they also said the new coverage is limited because it doesn’t guarantee access to doctors and doesn’t include adults.
“This is an important investment,” said Claire D. Brindis, director of the University of California San Francisco’s Institute for Health Policy Studies. “But it is not the full solution.”
About 1.16 million low-income adults are in California illegally and ineligible for comprehensive Medi-Cal services, though they may qualify for pregnancy and emergency care. In many areas of the state, they can get county-based coverage, but it also is not comprehensive and can’t be used in other counties.This KHN story also ran in the Orange County Register. It can be republished for free (details).
Orange County, where Ortiz lives, doesn’t offer such coverage. She wishes the state would allow her and her oldest son to sign up for Medi-Cal, too. He is 22 and has heart problems that have landed him in the emergency room about three times a year. She has to pay out-of-pocket for his regular visits to a cardiologist.
State Sen. Ricardo Lara, a Democrat from Bell Gardens, has proposed legislation that could extend Medi-Cal to low-income adults living in the state illegally, depending on available funding. The bill also requests a waiver from the federal government enabling higher-income immigrants to buy unsubsidized insurance through the state’s insurance marketplace.
In the meantime, Aracely Patchett, an administrator at Central City Community Health Center in Anaheim, where Ortiz gets care, said the new health coverage will enable her staff to refer the children to specialists. “Not being able to provide the care they deserve has been frustrating,” she said.
And Carmela Castellano-Garcia, president of the California Primary Care Association, said having the children covered will boost community health centers’ bottom line because many centers until now have been serving this population at a loss.
“These victories just fuel the fire continuing forward,” she said. “These incremental steps are very critical.”
Health researcher Laurel Lucia said she isn’t surprised that the state decided, for now, to cover children because there are fewer of them than adults and they are less costly. In addition, providing them with preventive care is a good long-term investment for the state, said Lucia, health care program manager at the University of California Berkeley Center for Labor Research and Education.
Also, Lucia said, “there is more sympathy toward kids.”
The children’s insurance will only help health and immigration advocates in their fight to cover everyone, said Wendy Lazarus, co-president of The Children’s Partnership, a nonprofit child advocacy organization.
“It is a hugely important step forward for the state and something we can build on,” she said. “Momentum is really building in California to finish the job and cover all residents, regardless of age.”
Opponents said California shouldn’t force its citizens to pay for health care for people here illegally.
“We’re talking about transferring tens of millions of dollars from taxpayers–citizens and lawful permanent residents–to those who have flouted our nation’s immigration laws and are now laying claim to the property of others,” said John C. Eastman, a law professor at Chapman University in Orange.
Eastman said the magnet for illegal immigration was already large enough in California. “Governor Brown and the Democrats in the state legislature have now made that magnet even larger,” he said.
The children will enter a Medi-Cal system that has more than 12 million enrollees and is struggling to ensure access to care. About 2.3 million people have joined the Medi-Cal rolls since the beginning of 2014, when the Affordable Care Act took full effect. About half the children in the state are now on Medi-Cal.
The California State Auditor recently found that the state had failed to ensure that Californians in Medi-Cal managed care could find doctors. And last year, the auditors said that only half of children enrolled in Medi-Cal were receiving dental care. Their audit cited insufficient numbers of dentists in some areas due to low reimbursement rates.
Meanwhile, because immigrants living here illegally have long been excluded from coverage, getting them to sign up won’t necessarily be easy.
“We have a big challenge ahead of us to dispel the perception that undocumented people are forever left out,” said Daniel Zingale, senior vice president at The California Endowment, which has invested heavily in the campaign dubbed “Health for All” to cover all immigrants.
Zingale said community clinics, faith-based groups and the ethnic media will likely play a big role in educating families about the new coverage.
Experience has shown that even when immigrants living here illegally qualify for coverage, they may not apply. UC researchers found that many adults under 30 who were granted temporary legal status and became eligible for Medi-Cal were still likely to remain uninsured. That’s because they weren’t aware of their eligibility or were worried about the effect on relatives in the country without legal permission.
Jacqueline Curiel, a Santa Ana-based administrator for the AltaMed Health Services Corp. Community Health Center, said many people fear that enrolling their children in public programs could hurt the family’s chances of getting legal status. She said her staff has a tough job assuring patients that it won’t affect their immigration cases.
“There is a lot of distrust,” Curiel said.
Curiel said she is hopeful that the parents will soon be eligible for comprehensive Medi-Cal. But even if California’s policymakers don’t opt to cover adults, immigrant families are better off than in the past.
“We’ve made large strides,” she said.
Blue Shield of California Foundation helps fund KHN coverage in California.
Dr. Kendra Fleagle Gorlitsky recalls the anguish she used to feel performing CPR on elderly, terminally ill patients.
“I felt like I was beating up people up at the end of their life,” she says.
It looks nothing like what people see on TV. In real life, ribs often break and few survive the ordeal.
Gorlitsky now teaches medicine at the University of Southern California and says these early clinical experiences have stayed with her.
“I would be doing the CPR with tears coming down sometimes, and saying, ‘I’m sorry, I’m sorry, goodbye.’ Because I knew it very likely was not going to be successful. It just seemed a terrible way to end someone’s life.”
Gorlitsky wants something different for herself and for her loved ones. And most other doctors do too: A Stanford University study shows almost 90 percent of doctors would forego resuscitation and aggressive treatment if facing a terminal illness.
It was about 10 years ago, after a colleague had died swiftly and peacefully, that Dr. Ken Murray first noticed doctors die differently than the rest of us.
“He had died at home, and it occurred to me that I couldn’t remember any of our colleagues who had actually died in the hospital,” Murray says. “That struck me as quite odd, because I know that most people do die in hospitals.”
Murray began talking about it with other doctors.This story is part of a partnership that includes Southern California Public Radio, NPR and Kaiser Health News. It can be republished for free. (details)
“And I said, ‘Have you noticed this phenomenon?’ They thought about it, and they said, ‘You know? You’re right.’ ”
In 2011, Murray, a retired family practice physician in Los Angeles, shared his observations in an article that quickly went viral. The essay, “How Doctors Die,” told the world that doctors are more likely to die at home with less aggressive care than most people get at the end of their lives. That’s Murray’s plan, too.
“I fit with the vast majority that want to have a gentle death, and don’t want extraordinary measures taken when they have no meaning,” Murray says.
A majority of seniors report feeling the same way. Yet, they often die while hooked up to life support. And only about one in 10 doctors report having conversations with their patients about death.
One reason for the disconnect, says Dr. Babak Goldman, is that too few doctors are trained to talk about death with their patients. “We’re trained to prolong life,” he says.
Goldman is a palliative care specialist at Providence Saint Joseph’s Medical Center in Burbank, Calif., and he says that having the tough talk may feel like a doctor is letting a family down.
“I think it’s sometimes easier to give hope than to give reality,” Goldman says.
Goldman read Murray’s essay as part of his residency. Goldman too would prefer to die without heroic measures, he says, and knowing how doctors die is important information for patients.
“If they know that this is what we’d want for ourselves and for our own families, that goes a long way,” he says.
In addition, Medicare does not pay doctors for end-of-life planning meetings with patients.
Nora Zamichow wishes she had read Murray’s essay sooner. The Los Angeles-based freelance writer says she and her husband, Mark Saylor, likely would have made different treatment decisions for Saylor’s brain tumor if they had.
Zamichow says that an arduous regimen of chemotherapy and radiation left her 58-year-old husband unable to walk, and ultimately bedridden, in his final weeks.
“At no point,” she says, “did any doctor say to us, ‘You know, what about not treating?’ ”
Zamichow realized after reading Murray’s essay that doing less might have offered her husband more peace in his final days.
“What Ken’s article spelled out for me was, ‘Wait a minute, you know, we did not get the full range of options,’ ” she says.
But knowing how much medical intervention at the end of life might be most appropriate for a particular person requires wide-ranging conversations about death.
Murray says he hopes his essay will spur more physicians to initiate these difficult discussions with patients and families facing end-of-life choices.
With the Supreme Court decision, it appears the Affordable Care Act will stand, but that doesn’t mean the law’s troubles are over. NPR’s Renee Montagne talks to KHN’s Julie Rovner.
Now that we are midway through the year I thought it would be a good opportunity to look at our metrics at this point. What In Custodia Legis blog posts have been popular? What Law Library of Congress reports? What legislation?
The mix of the top ten new blog posts highlights both our foreign and U.S. law expertise. All three of the Women in History posts made the top ten. They were part of a series highlighting firsts from across the globe. Two items from the new Frequently Asked Legal Questions series also made the list. I was excited to see a post about a much-requested feature for Congress.gov, email alerts, at the top of the list. Overall traffic to In Custodia Legis was up 34% over the first six months of last year. Here is the list of top ten posts in order of popularity:
- Legislation Email Alerts on Congress.gov
- Treaties, Text, and Timely Updates – Congress.gov Spring Cleaning
- Women in History: Lawyers and Judges
- Women in History: Voting Rights
- Congress.gov Continues…
- Twenty Years of THOMAS
- FALQs: Freedom of Speech in France
- FALQs: Cuban Legal System
- Women in History: Elected Representatives
Jennifer recently blogged about our new Comprehensive Index of Legal Reports. The Law Library makes a lot of terrific foreign law reports freely available to the public. The most viewed reports at the year’s half birthday are:
- Firearms-Control Legislation and Policy: Australia
- Laws on Children Residing with Parents in Prison
- Sex Selection & Abortion: India
- Firearms-Control Legislation and Policy: Great Britain
- Children’s Rights: Canada
- Children’s Rights: China
- Citizenship Based on Birth in Country
- Children’s Rights: United Kingdom (England and Wales)
- Children’s Rights: International Laws
- Points-Based Immigration Systems: Canada
Putting more reports online is having a positive effect on our website as a whole. The total number of page views across Law.gov has more than doubled in the first six months of 2015 compared to the first six months of 2014.
Over on Congress.gov, almost all of the most-viewed legislation is from the current Congress (2015-2016) except H.R.83, which is from the 113th (2013-2014). If any of the legislation from the current Congress interests you, be sure to select it and click “Get alerts” to subscribe to email updates.
- H.R.213 – Fairness for High-Skilled Immigrants Act of 2015
- H.R.83 [113th] – Consolidated and Further Continuing Appropriations Act, 2015
- H.R.240 – Department of Homeland Security Appropriations Act, 2015
- S.1 – Keystone XL Pipeline Approval Act
- H.R.378 – Responsible Body Armor Possession Act
- H.R.2 – Medicare Access and CHIP Reauthorization Act of 2015
- H.R.1314 – Trade Act of 2015
- H.R.2232 – Vaccinate All Children Act of 2015
- H.R.1735 – National Defense Authorization Act for Fiscal Year 2016
- H.R.36 – Pain-Capable Unborn Child Protection Act
As Congress.gov continued to grow, the page views have grown as well. They have increased over 70% as compared to the first six months of 2014.
Are there other blog posts, reports, or legislation that you are surprised did not make the list?