SACRAMENTO — With an outraged tone, Dr. Samuel Fink dismisses Gov. Arnold Schwarzenegger's proposal to tap physicians to help pay for universal healthcare.
"That makes about as much sense as taxing teachers to provide a better education, or taxing Assembly members or senators to pay for upkeep of the Capitol," said Fink, a Tarzana internist. "We're part of the solution, not the problem."
But Hector Flores, a family physician who practices in East Los Angeles, is in a minority that supports the governor's idea of collecting 2% of physicians' gross income to help pay for a $4-billion increase in Medi-Cal payments that the state makes to doctors who tend to the poor.
"Most of the physicians who complain about this aren't really serving the Medi-Cal or low-income population anyway," said Flores, whose 22-doctor office treats a large number of uninsured and poor patients. "These are the docs who don't mind paying $10,000 to join an exclusive club somewhere."
Represented by one of the Capitol's dominant lobbies, California's physicians are respected for their successful ability to forge a united front against incursions into their field. But this year, when healthcare is the central issue before the Legislature, the profession is practicing the political equivalent of defensive medicine, grappling with their increasingly divided membership as they try to ward off proposals that would hurt them economically.
Along with trying to block Schwarzenegger's proposed assessment, the California Medical Assn. is working to persuade Democratic lawmakers to increase Medi-Cal fees without placing a levy on doctors' incomes. The CMA, which represents about half of the state's physicians, also opposes a proposal to create a single government-run insurer out of concerns it would lead to low reimbursement rates like those from Medi-Cal.
All these efforts, critics charge, expose tensions that physicians prefer to downplay between their roles as patient advocates and as members of a lucrative profession.
"While lots of doctors would like to see everybody covered, when it gets down to who's going to pay, they seem no more eager than anyone else in this conversation," said Dr. Mark Smith, president of the California Health Care Foundation, an Oakland nonprofit philanthropy.
This year's debate over healthcare has exposed a number of other fissures: between doctors with profitable practices and those who tend to the poor; between those who are paid for services and those who work in managed care; and between those reluctant to tamper with the current system and those who want to discard it.
Though the governor's fee is strongly opposed by the CMA, the California Assn. of Physician Groups, another lobbying group that represents 150 managed-care entities that employ or contract doctors, has taken no position on the issue. Don Crane, the group's president, said the group "applauds and believes in the concept of shared responsibility." The phrase "shared responsibility" is Schwarzenegger's favored slogan for requiring everyone, including doctors, to make financial concessions in the name of universal care.
The rates Medi-Cal pays doctors to treat the poor are lower than in all but six other states and the District of Columbia, according to the Kaiser Family Foundation. The CMA dismissively noted in a report last year that Medi-Cal pays doctors $24 for an office visit, the cost of a large pizza. Over the last 12 months, 40% of California's doctors did not participate at all in the Medi-Cal program, making it especially hard for the poor to obtain medical care.
"The rates are so low that a lot of doctors just can't afford to see these patients," said Dr. Paul Urrea, a pediatric ophthalmologist from Monterey Park. Urrea, who practices at White Memorial Medical Center in Montebello, favors the governor's proposal.
But some California doctors say that even though they don't work much with Medi-Cal, they still provide substantial care for the poor. Dr. Richard Corlin, a Santa Monica gastroenterologist and former CMA president, said his practice provided $250,000 worth of free care to the Venice Family Clinic last year.
"Physicians and hospitals and, increasingly, pharmaceutical companies carry their share of the burden," he said. "Health plans don't. They don't provide a penny for medical education benefits, and they really don't provide uncompensated care to the poor."
There are 99,150 licensed physicians and osteopaths in California, according to state licensing boards. Nationally, the profession remains financially rewarding: In 2004, the median income for a family care doctor was $156,000, while the median income for a heart surgeon -- the wealthiest specialty -- stood at $428,000, according to the Medical Group Management Assn., a Colorado group.
Doctors say Schwarzenegger's 2% assessment is excessive because it would not be placed on a doctor's net income but on all office revenue. Many doctors say it would amount to at least 4% of their take-home pay.
