The Supreme Court's validation of President Barack Obama's landmark health law sets off a scramble across California to find enough primary care doctors and other professionals to serve an estimated 3 million newly insured patients by 2014.
California already rates below average in the number of doctors per capita. But the state - rural counties in particular - will face additional headwinds as health reform slashes the ranks of its 7 million uninsured.
California has an unusually large number of doctors heading into their retirement years. It expects a much higher than average rise in the health-intensive 65-and-older population. And it has one of the lowest reimbursement rates in the country for Medi-Cal, the state's primary program offering health coverage for the poor.
Especially for communities that are already struggling with doctor shortages, the court's somewhat unexpected endorsement of the Affordable Care Act suddenly presents a steep challenge.
"The Affordable Care Act will add hundreds of thousands of people to the rolls of the insured. That's good," said Dr. G. Richard Olds, founding dean of the University of California, Riverside School of Medicine. "But where are the primary care physicians going to come from to serve that population?"
According to a 2009 study by the California HealthCare Foundation, only 16 of 58 California counties had sufficient primary care doctors as measured against standards set by the American Medical Association.
Many of California's most acute shortages are in the Inland Empire and the San Joaquin Valley, where communities struggle to attract and retain doctors. They also have some of California's highest uninsured rates - exceeding 30 percent of residents in some counties, according to a 2009 UCLA study.
Increases start in 2014
That could mean the same counties already fighting doctor shortages could see big increases in the insured starting in 2014.
Asked if local providers in San Luis Obispo County were numerous enough to accommodate the new patients created by health reform, county health officer Dr. Penny Borenstein had a definitive answer: "No. Simply.
"We may have the possibility of adding 10,000, 15,000, 25,000 people into the health care system who have not used it very much," she said.
Lee Kemper, executive director of the County Medical Services Program, a consortium of 34 rural counties that are implementing the Medi-Cal expansion together, said a mixture of innovation and increased funding was key to meeting the demands of health reform - now a mere 18 months away.
"We're going to have to get creative," Kemper said Friday. "Strike teams" of medical specialists from urban areas could be brought into rural hospitals and clinics on a set schedule, he said. And tele-health systems could be strengthened to allow far-away specialists to consult, and even treat patients, with an online connection.
Kemper added that Medi-Cal reimbursement rates for doctors in rural areas must be increased so practitioners have incentive to set up shop in the far corners of the state. Statewide, barely more than half of primary care doctors are willing to see new Medi-Cal patients.
James Hay, a family physician in Encinitas and president of the California Medical Association, is among those who decline Medi-Cal patients.
"In my office, we figure it probably costs us $50 to $55 to see any patient on average," he said. "If Medi-Cal pays us $23 to see a medical patient for a routine office visit. I would be spending $32 per visit to see that patient."
In California, Hay said, that's why much of Medi-Cal primary care is done in federally qualified clinics, which are paid a higher amount for patient care because they also have to cover certain tests and other costs.
Can those community clinics handle the new wave of Medi-Cal patients?
"Absolutely not," Hay said. "I think there will be a huge access problem."
Boost for Medi-Cal
The Affordable Care Act does provide some help on this front, sending $700 million to California so that Medi-Cal reimbursement rates rise to the level of Medicare payments for two years. But the health industry worries that the underlying problem won't go away, and that both state and federal politicians will be tempted to cut Medicaid reimbursements even more.
Senate Health Committee Chairman Ed Hernandez, D-West Covina, plans to make the health care workforce, which he said is currently inadequate, one of his top priorities.
"What good is it in 2014," when millions of uninsured Californians will gain coverage "when they don't have access to providers?" he asked.
One of his key but controversial proposals will be legislation to expand scope-of-practice definitions for some health care providers such as nurse practitioners and physician assistants.
Janet Coffman, assistant professor of health policy at the University of California, San Francisco, said California lags many states in this area because most residents live in urban areas where doctor shortages aren't as much of a problem. Because of the Affordable Care Act, she said, "I would say scope of practice is on the radar screen."
Hernandez, who said he is holding committee hearings on workforce issues, also will try to boost the number of medical students in the state and bring medical residency programs to underserved areas.
Putting program in place
Even before the health law was passed in 2010, the shortage of primary care physicians in California catalyzed a far-flung campaign - by educators, doctors and government leaders - to train new doctors in the state and encourage them to practice in underserved regions, including the Central Valley and the Inland Empire.
That drive led to plans for all-new medical schools at the Universities of California at Riverside and Merced, with an emphasis on primary care. Plans called for eventually enrolling 400 students at each school, both of them aiming to coax graduates to stay in the region.
But the state budget crisis has delayed both projects. This fall, 11 students, all ethnic minority students from the Central Valley area, will be enrolled in a UC Merced program with ties to UC Davis and UCSF-Fresno.
Pending accreditation approval, UC Riverside hopes to open in 2013 with an initial class of 50.
The California HealthCare Foundation Center for Health Reporting produces in-depth reporting on California health policy. Attached to the USC Annenberg School for Communication & Journalism, the center is funded by the nonpartisan California HealthCare Foundation.
John M. Gonzales, Lauren M. Whaley, Emily Bazar, Deborah Schoch and Richard Kipling contributed to this article.