"Medically indigent" adults, who lost their Medi-Cal eligibility in 1982 because of state and federal budget cutbacks, continue to suffer more life-threatening illnesses than needy adults who did not lose their insurance, according to a study by UCLA Medical Center researchers.
In a follow-up report on the health status of 164 Los Angeles County adults a year after their termination from Medi-Cal, the researchers also found that some of these individuals still were receiving inadequate medical care, often because of difficulties they encountered at overburdened county health facilities. Previously, these patients could obtain medical care at facilities of their choice.
The study, published in today's New England Journal of Medicine, expands on a six-month study on the same patients that appeared in the same journal in August, 1984.
It found that the lack of access to treatment or uncoordinated medical care contributed to at least four of the seven deaths among the medically indigent adults during the year. In a comparison group of 94 indigent patients who did not lose their insurance, there was only one death--from lung cancer--and it was not related to quality of care.
"After our first study, a lot of people said the findings reflected a temporary phenomenon," said Dr. Nicole Lurie, the principal author of both studies. "Now it is clear that the problems did not go away in any way, shape, or form."
In an interview, Lurie added: "Government has a responsibility to evaluate major policy changes such as this to see whether adverse effects are occurring. We need better ways to identify people likely to fall through the cracks of the health care system so that we can help them."
Robert C. Gates, director of the county Department of Health Services, acknowledged that problems identified by the follow-up study are more likely to be related to shortcomings in the county medical system than to the transition period. "This gives me greater cause for reflection," he said. Gates said he had not seen the study but would review it closely.
In 1982, the California Legislature terminated benefits for 270,000 medically indigent adults, including 86,000 in Los Angeles County. Those affected were needy individuals who were not eligible for other federal assistance programs.
The state at the time made counties responsible for their health care and provided block grants to cover 70% of the estimated cost.
After six months, about 25% of the study's patients, particularly those with high blood pressure, developed such a "high risk of dying" that the researchers intervened for "ethical reasons" by helping them obtain care or regain some form of insurance, usually Medi-Cal. The health of some of these patients subsequently improved.
But a year after the loss of insurance, four patients were so sick that they needed to be hospitalized immediately, according to Lurie.
The majority of the patients in the study had serious health problems, such as high blood pressure or diabetes or both. They had all been attending UCLA outpatient clinics before they lost their Medi-Cal eligibility in November, 1982. The researchers followed them through early 1984, when the study ended.
Only 40% of the patients who lost their insurance were satisfied with their medical care after one year, in contrast to 97% before their loss of benefits and 60% after six months, according to the study. Three-quarters of those who did not obtain care when needed cited cost as the reason.
By comparison, of 94 patients who kept their insurance and continued to receive their medical care at UCLA, 86% reported satisfactory medical care at the one-year follow-up.
After one year, 50% of the medically indigent had a primary doctor, compared to 40% at six months, 92% at the beginning of the study and 94% in the control group.
Lurie, now an assistant professor of medicine at the University of Minnesota's Hennepin County Medical Center in Minneapolis, gave several examples of the problems patients encountered.
One with epilepsy had continuous seizures at home for 2 1/2 days after he ran out of medicines--because his wife believed that an emergency room would not care for him if they could not pay. "She eventually begged a pharmacist for a few pills and shoved them down his throat between seizures," Lurie explained.
One of the patients who died was a young diabetic man who became "horribly debilitated." He regularly attended a county medical clinic but saw a different doctor each time. Lurie said failure to coordinate his care "probably contributed" to his deterioration and death.
The transfer of responsibility to the counties was estimated to have saved the state $30 million to $60 million a year, $11 million to $24 million of this savings was in Los Angeles County.
But last year, the state gave back to the counties an additional $50 million for care of the medically indigent, after publication of the first UCLA study and subsequent hearings on the problems of the medically indigent throughout the state.
Charged $20 to $30
During the one-year study period, medically indigent patients were usually charged $20 to $30 by the county for an outpatient or emergency department visit.
While financial screening to reduce charges was theoretically available, it was "poorly publicized" and most patients were unaware of it, according to the UCLA report. The county claims it is now doing a better job publicizing the program. But it is still being sued by public-interest groups because of alleged deficiencies.
The study was funded by the Robert Wood Johnson Foundation of New Jersey, which finances research on health care issues.