HUNTINGTON PARK, Calif. — The “bodega clinicas” that line the bustling commercial streets of immigrant neighborhoods around Los Angeles are wedged between money order kiosks and pawnshops. These storefront offices, staffed with Spanish-speaking medical providers, treat ailments for cash: a doctor’s visit is $20 to $40; a cardiology exam is $120; and at one bustling clinic, a
colonoscopy is advertised on an erasable board for $700.
County health officials describe the clinics as a parallel health care system, serving a vast number of uninsured Latino residents. Yet they say they have little understanding of who owns and operates them, how they are regulated and what quality of medical care they provide. Few of these low-rent corner clinics accept private insurance or participate in
Medicaid managed care plans.
“Someone has to figure out if there’s a basic level of competence,” said Dr. Patrick Dowling, the chairman of the family medicine department at the David Geffen School of Medicine at the University of California, Los Angeles.
Not that researchers have not tried. Dr. Dowling, for one, has canvassed the clinics for years to document physician shortages as part of his research for the state. What he and others found was that the owners were reluctant to answer questions. Indeed, multiple attempts in recent weeks to interview owners and employees at a half-dozen of the clinics in Southern California proved fruitless.
What is certain, however, is that despite their name, many of these clinics are actually private doctor’s offices, not licensed clinics, which are required to report regularly to federal and state oversight bodies.
It is a distinction that deeply concerns Kimberly Wyard, the chief executive of the
Northeast Valley Health Corporation, a nonprofit group that runs 13 accredited health clinics for low-income Southern Californians. “They are off the radar screen,” said Ms. Wyard of the bodega clinicas, “and it’s unclear what they’re doing.”
But with deadlines set by the federal Affordable Care Act quickly approaching, health officials in Los Angeles are vexed over whether to embrace the clinics and bring them — selectively and gingerly — into the network of tightly regulated public and nonprofit health centers that are driven more by mission than by profit to serve the uninsured.
Health officials see in the clinics an opportunity to fill persistent and profound gaps in the county’s strained safety net, including a chronic shortage of primary care physicians. By January 2014, up to two million uninsured Angelenos will need to enroll in Medicaid or buy insurance and find primary care.
Posted Jan. 08, 2013, at 11:57 a.m.
On New Year’s Day, President Barack Obama looked ahead to the post-fiscal cliff, deficit-reduction battles and declared: “I agree with Democrats and Republicans that the aging population and the rising cost of health care … [make] Medicare the biggest contributor to our deficit. I believe we’ve got to find ways to reform that program without hurting seniors who count on it to survive.”
The question — a tricky one for a president who won re-election in part by defending “Medicare as we know it” — is how to accomplish this feat.
Medicare as we know it is not sustainable.
Medicare cost $555 billion in 2012, according to the Congressional Budget Office. The CBO has projected that this number, already 15 percent of noninterest federal spending, will nearly double by 2022. Medicare’s trustees estimate that the hospital insurance fund supported by the payroll tax will run out of cash by 2024, but this is mainly a symbolic threat: The government will draw on general revenue to keep Medicare going. The real threat is that Medicare spending will crowd out other necessary federal endeavors, forcing undesirable cuts, substantially higher taxes, unsustainable borrowing — or some combination of the three.
There are two major reasons for Medicare’s rising costs. The first is the program’s design, often tweaked but left fundamentally intact since its creation in 1965, which basically pays doctors and hospitals fixed fees for whatever they do. At a time of rapid (and often beneficial) medical innovation, the dominant incentive has been to provide more, and more expensive, care. Hence the House Ways and Means Committee’s 1965 estimate that Medicare hospital insurance would cost $9 billion by 1990 fell short by $58 billion.
The second reason costs keep going up, of course, is the rising number of elderly eligible for Medicare, which is inevitable; the 50 million beneficiaries today will be 78 million in 2030.
The ultimate solution is structural: to limit growth in expenditures per beneficiary. Easier said than done. Liberals would empower the Independent Payments Advisory Board, or IPAB, to stop payment for treatments it deems not cost-effective. The idea hasn’t gotten very far, partly because Republicans denounce it as “rationing.” Conservatives favor “premium support,” which would subsidize seniors to shop among competing insurance plans, but Democrats, the president included, have tarred that idea as a skimpy “voucher.”
It’s unfortunate but not disastrous that no structural solution is, for the moment, politically possible. Not even their advocates can guarantee that a beefed-up IPAB or premium support would work as advertised. The effect of policy changes on health care costs is notoriously difficult to project.
Indeed, the past three years have seen an unexpected and so far unexplained slowing in Medicare spending’s rate of growth. This happy development doesn’t mean that there’s no problem — far from it. But it buys time to mitigate Medicare’s costs incrementally, while working out the partisan impasse over more fundamental reforms.
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