But others charge that it is the door-to-door sales technique that is undermining the program.
Last year, health inspectors were "absolutely inundated with complaints" about salesmen, said Theresa Franco, an investigating supervisor in the attorney general's office.
Franco, who worked undercover as a door-to-door saleswoman, said she discovered that salespeople were paying $400 to county welfare workers for the latest government microfiche listing the names and addresses as well as other private information about eligible Medi-Cal beneficiaries.
The sales representatives use these lists--often duplicated and resold to other marketing agents--to target their victims, Franco said. "To get in the front door, they used any kind of scam, any kind of story, anything and everything, because for every person they enroll, they are paid $40 to $50," Franco said. One 21-year-old salesman with no more than a high school diploma was making $50,000 a year, she said.
The salesmen frequently victimize Spanish-speaking people by telling them they will lose their Medi-Cal benefits or be investigated by the government if they do not sign up for a health plan, Franco said.
"It's very sad," she said. "They are poor people, and all they want to do is go down the street to see their doctor. They have no idea what these salesmen are doing to them."
By law, state health officials have the discretion to ban door-to-door solicitations. Most states do not allow it, relying instead on government officials to inform Medi-Cal beneficiaries in neutral terms about the advantages of various private health plans during welfare eligibility and recertification interviews.
But in California, door-to-door marketing accounts for 82% of all enrollments.
"It makes the program viable," said Stolmack, a state health official in charge of the managed-care program.
"We keep reassessing the need for it . . . and when it's no longer necessary we will promptly discontinue it," Stolmack said, "because it's just not the best way to promote the integrity of this program."
Trish Riley, executive director of the National Academy for State Health Policy in Maine, which has published a guide to Medicaid managed-care programs, said she knows of no other state that allows door-to-door marketing of health plans.
Ironically, she said it was California's pioneering efforts with managed care during the early 1970s that gave door-to-door marketing "a black eye" and discouraged many states from permitting the practice.
The early program in California, which enrolled 160,000 people in 27 prepaid health plans, was racked by scandal that has been well documented in scathing reports by the state auditor general and during congressional hearings.
In a review of the early program, the Hastings Law Journal concluded: "Massive enrollment fraud and poor-quality services characterized . . . many plans. Numerous reports alleged widespread profiteering, conflict of interest and mismanagement" by the private plans and by state health officials.
Some plans boasted annual profits ranging up to 2,500%. One plan enlisted doctors by offering either a Cadillac or a Mercedes-Benz as a bonus. Numerous Medi-Cal recipients reported enrollment inducements such as free fried chicken or tickets to sporting events.
"As long as door-to-door solicitation is the sole or primary method of securing new plan members, enrollment abuse will be the rule rather than the exception," the article concluded.
Legislative reforms have been enacted to safeguard against many abuses that occurred during the 1970s, but critics say that serious, widespread enrollment problems are continuing because door-to-door marketing is still permitted. Furthermore, they decry recent state legislation that will permit the private plans, beginning in 1994, to offer incentives for enrollment such as crates of free diapers and caseloads of infant formula.
Opening the door ever so slightly to program inducements "is a slippery slope," warned attorney Deborah Garvey. "It muddies the issue for people trying to decide whether to enroll on the merits of the plan." She pointed out that the services offered and the locations of clinics and hospitals can vary from plan to plan.
As a Legal Aid attorney in East Los Angeles, Garvey said that she alerted state health authorities to about 100 complaints of unfair enrollment tactics by door-to-door salesmen during the last year.
Stolmack at the state health department said that three marketing representatives have been terminated from the program during the last year for improper sales tactics, but no financial or administrative sanctions have been applied to any plan for marketing violations.
He asserted that most critics of the program have unfairly criticized managed care based upon their encounters with a small, unrepresentative sample of problem cases.