At the downtown L.A. garment factory where Graciela Villeda spends her days sewing clothes for little more than minimum-wage, the talk among her co-workers turned to health care on a recent day.
Two of her friends wanted to know whether she’d signed up for a new county program they’d learned about on the evening news. It provided health care to people like themselves: poor, uninsured immigrants living in the country illegally.
"I told them I was going to go to the clinic with my daughter to sign up, and that I’d bring them more information about it," Villeda said.
Like all unauthorized immigrants, Villeda and her friends are barred from benefits under the Affordable Care Act. So like many such immigrants who can’t afford insurance, they hope not to get sick. But when they have needed care, they’ve often relied on a last-resort option that can’t turn them away: emergency rooms.
Villeda has been a little luckier. Until recently she got care through an L.A. County program that reimburses clinics when uninsured immigrants like her showed up for care. But the care she got through the program, called Healthy Way L.A., was less than ideal, she said.
A year ago, Villeda discovered a lump in her breast. She went to a clinic, which sent her to a hospital for a mammogram. The hospital sent the results back to the clinic, which called Villeda and told her the mass appeared to be a harmless cyst. But it told her to go back to the hospital for an ultrasound, just to make sure. She did.
"And I never heard anything back," Villeda said. She hoped that was a good sign, but she admits she can’t say for sure. It’s not her only worry. Villeda suffers from painful gallstones, which the clinic also couldn’t treat. Whenever the pain has become unbearable, Villeda said, she’s gone to the ER.
County officials describe the kind of contact Villeda has had with the health care system as episodic, uncoordinated and expensive. They also say her story is typical of the kind of care many unauthorized immigrants get. It’s this kind of care that the new county program, My Health L.A., is trying to fix. It began on Oct. 1.
"We certainly believe that over time, this program will really promote a much stronger unified health care delivery system on a local level," said Tangerine Brigham, the county official in charge of My Health L.A.
Under the old program for such immigrants, Healthy Way L.A., patients could show up at any community clinic, and the county would reimburse the clinic for that visit. But the problem, Brigham said, was that patients often went to one clinic for one ailment, and to another for the next one. Doctors had no way of knowing what care the patient had already received, and they often duplicated treatment. Now officials have transformed that old model into the new program, which they believe will be better for the county’s bottom line and for patient care.
"They’re going to be actually developing a relationship with a clinic that’s their usual source of care, where a provider and a care team knows their medical history and can serve that person as effectively as possible," Brigham said.
The program works like this: A patient signs up for My Health L.A. at one of about 160 participating clinics countywide. (He or she must earn less than 138 percent of the federal poverty level and be ineligible for Medi-Cal). Then the patient must go to that clinic for all of his or her care.
Instead of getting reimbursed $94 each time it sees a patient, as it did under the old system, the clinic will get about $32 a month for each patient it signs up for the program, regardless of how often or intensively the patient actually uses the clinic’s services.
The clinic will be required to provide primary and preventive care, diagnostic and pharmacy services, and to refer the patient to county facilities for specialty care. The program will also include dental coverage.
Brigham said the county’s hope is that the new model will encourage clinics to keep their patients healthy, because the less often a patient has to visit, the more of that monthly $32 payment the clinic can use to care for other patients.
Immigrant advocates and the clinics themselves are pleased with the change.
"The My Health L.A. program is a very significant step up in the quality of care that immigrants will receive in Los Angeles," said Jim Mangia, CEO of the St. John's Well Child and Family Health Center in South Los Angeles.
Mangia is especially pleased with one major change under the new program. Under St. John's' contract with the old one, the county would only reimburse the clinic up to $600,000 a year. At $94 per visit, that meant the clinic was only paid for the first 6,400 patients, far fewer than it actually treats.
"We saw 18,000 uncompensated visits of undocumented folks last year," Mangia said.
But under My Health L.A., there’s no limit to the number of patients clinics can sign up. As of last week, Mangia said, St. John's had signed up close to 10,000 people, each of whom will generate a $32 monthly grant from the county. That’s close to $4 million a year to care for those patients.
"It means that everybody will have all of their diabetes medication. It means they’ll have all their diagnostic services that they need. It means they’ll see a doctor whenever they need to. It means they’ll actually have coverage," he said. And importantly, he said, the care will be coordinated mostly under one roof.
Mangia said he wants his clinic to sign up 23,000 patients for the program, a number that would generate nearly $9 million for St. John's each year.
Indeed, the rush is on to sign patients up at clinics countywide. There are estimated to be about a million immigrants without legal status in Los Angeles County, about 400,000 t0 700,000 of whom are uninsured. The county has budgeted $61 million for My Health L.A, which it expects to be enough to cover about 146,000 people.
Asked whether she feared that the new model could actually encourage clinics to sign people up but then skimp on their care in order to keep more of the revenue that patients generate, Brigham said she did not.
"Frankly, these clinics have been serving this population for 20 years," often at a financial loss, she said. Instead, she said, she believed the new model will give clinics the ability to treat patients more effectively and keep them out of emergency rooms.