Editors Note: Another Health Affairs Blog post published today also discusses the California health care system and how the Affordable Care Act will affect the way the state meets the needs of low-income patients.
Many low-income patients have had little or no choice about where they obtain health care. But this will change when the Affordable Care Act’s subsidies begin in 2014. When this happens, according to a recently published report, low-income patients may turn out to be vigorous health care shoppers who will not be shy about leaving their current providers and who will look beyond price in choosing new ones. This will pose a significant challenge to community clinics and health centers and other safety net providers.
Those conclusions emerge from a survey of the health care experiences and expectations of low-income Californians. The survey, performed by Langer Research Associates for the Blue Shield of California Foundation (BSCF), included phone interviews in English and Spanish with Californians aged 19-64 with incomes below 200 percent of the federal poverty level – about $45,000 for a family of four. Between March 25 and April 11 of this year, researchers conducted 1,005 interviews, which offered a statistically representative sample of the roughly six and a half million Californians in this population.
“There is a changing paradigm coming for this low-income population” in California and elsewhere, Gary Langer, the research firm’s founder and president, said at a June 23 briefing on the study sponsored by BSCF and Health Affairs. “Currently many patients in this population lack choice. They are safety net patients cared for by safety net providers who have too often not needed to be concerned specifically with meeting the needs of the population,” but instead have had to be been concerned with “meeting the needs of the funders and authorities who set up these programs.” Safety net care “has not necessarily been as client-focused a business in terms of service and satisfaction as it will need to be in the future,” when the ACA enables low-income Americans “to go shopping for their care,” Langer said.
Almost half – 44 percent – of low-income Californians said they currently have no choice of where they go for care, according to the BSCF survey. More than nine in ten have a place to go when they need medical care, although almost half reported they have no regular personal doctor. A plurality – 44 percent – get their care at a clinic, but significant numbers get their care at doctors’ offices (28 percent), Kaiser Permanente (12 percent), and hospital emergency rooms (10 percent).
Among those who said they have no choice of where to go for care, most – nearly six in ten – said cost is the main factor that limits where they can go. But among those who do have a choice, just 12 percent reported that they chose the least expensive option. “It’s an important point to know if you’re a health care provider as you position yourself in the future,” Langer said. For this later group, convenience (39 percent) and referrals from friends and family members (33 percent) significantly outranked cost as the main reason why they chose their current providers.
Nearly six in ten low-income Californians said they would be interested in changing providers if they had insurance, as they will in 2014, and many of these respondents also indicated that they would take factors other than price into consideration. About a third said cost would be the most important factor in their choice of a new provider in an Affordable Care Act world, but another third prioritized being able to see the same doctor each time they visit. The remaining third identified convenience (19 percent) and a short wait (11 percent) as the most important factors.
Of those who do not have a personal doctor and want one, 86 percent said they would be interested in changing providers. Other groups expressing high levels of interest in changing included the uninsured (73 percent); those who say their care has deteriorated at their current facility (72 percent); and those who rate their current care as less than “very good” (69 percent).
Fewer than half of low-income Californians (48 percent) rated their current care as “very good” or “excellent,” while 42 percent said their care was “good” and 9 percent rated their current care as “not so good” or “poor.” As Langer pointed out, this is comparable to the 55 percent of all Americans who rate their care as “very good” or “excellent” or the 40 percent Americans in families with incomes below $25,000 who rate their care that highly.
“There are two takeaways from this,” said Langer. “One is that the safety net providers in California are doing a good job in providing basic, acceptable care to this population. The other is that they could be doing better, in that the ‘good’ population people who are not particularly enthusiastic about their care are inclined to look elsewhere.” The biggest determinants of satisfaction with current care were the cleanliness of the facility and the courtesy of the staff, followed closely by communication with one’s physician, convenience, and the sense that “people like you” are welcome at the facility.
Nearly two-thirds of patients who currently receive care at a clinic said they are interested in moving. Speaking at the briefing, Louise McCarthy, President and CEO of the Community Clinic Association of Los Angeles, outlined the stakes for her members and for clinics in the rest of California in the post-2014 world. Of the 830,000 patients who visit Los Angeles County’s community clinics each year, 87 percent have incomes under 200 percent of the poverty level, and only 38 percent are insured, just above the 34.5 percent threshold of insured patients that research shows clinics need to remain viable.
When people get insurance under the Affordable Care Act, does that mean that they then leave our networks and leave L.A.’s community clinics with only the uninsured?” McCarthy asked. After 2014, there will remain 800,000 uninsured people in LA County, but “we cannot be the system solely for the uninsured, because we will not be open tomorrow if that’s the case,” she stressed.
Health Affairs Editor-in-Chief and event moderator Susan Dentzer emphasized the importance of the topics raised at the briefing. Citing research published in Health Affairs, Dentzer noted that after full implementation of the Affordable Care Act, variable incomes among low-income Americans could cause more than 20 million people a year to shift back and forth between Medicaid and subsidized coverage through state insurance exchanges. “If you think about the lives of individuals who might, in a given year, have their insurance change, but yet very much want the kinds of things that Gary Langer and his colleagues identified in the survey – stability in a relationship with a personal physician, for some of them a medical home it really drives home in spades why it is so important for the policy world, as well as clinics and other providers, to come to grips with these issues.”
The survey also included other interesting findings: .
- A health-stressed population likely to increase utilization. Only a third of low-income Californians ranked their health as excellent or very good, compared to 57 percent of all Californians and 52 percent of all Americans. “This is a health-stressed population,” Langer said. “However, it is a population that is no more likely than state-wide or national populations to get care … This suggests an underutilization of care by this population because of the nature of their relationship to the system: they’re not particularly satisfied with their care, they are less likely to go and get care. Once they have insurance, and they have a choice and develop a greater satisfaction with and relationship to the system, we might see their utilization of care move up to be in line with their health status, which is not good, and this could stress the system.”
- One size does not fit all. People’s priorities varied markedly among groups. For example, 47 percent of low-income Californians said that finding a doctor who explained things well was their chief priority related to the doctor-patient relationship; only 32 percent prioritized finding a physician who would take their opinions and concerns into account, and 19 percent cited time spent with the physician as their chief priority. But looking one level down, non-citizens, non-English speakers, Latinos, and the least educated were more concerned with finding a physician who explains things well, while citizens, whites, and those with more education were more concerned with finding a doctor who would take their concerns into account. . In a separate question, 59 percent of low-income Californians said they would prefer to have an equal say in health care decisions. However, a perhaps surprisingly large minority of respondents, 39 percent, said they preferred the more traditional model of leaving these decisions primarily up to health care professionals. Again, citizens, white, and those with more education disproportionately preferred to participate in decisions regarding their health care, while non-English speakers, Latinos, the uninsured, and those with less education preferred the more traditional model of leaving those decisions primarily to doctors and nurses.
Another briefing panelist, Kavita Patel, said the BSCF report’s findings on patient preferences would be crucial for policymakers, as well as for other groups such as payers, insurers, and providers. To “bend the curve” of health care costs, it is necessary to structure benefit design and payment reform around patient values, said Patel, and she recalled the dearth of rigorous evidence on patient preferences that she faced as a congressional staffer. Patel is managing director for clinical transformation and delivery at the Engelberg Center for Health Care Reform at the Brookings Institution. She served in the Obama White House as director of policy for the Office of Intergovernmental Affairs and Public Engagement, and on Capitol Hill as Deputy Staff Director for the Senate Health, Education, Labor and Pensions Committee.
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