January 17, 2003

Commentary

Gimmicks, Tricks and Evasions

By James Santiago Grisolía, MD

“There are no gimmicks. No tricks. No evasions,” claimed Governor Gray Davis when presenting his state budget proposals.

The first gimmick was his understating the budget deficit while running for re-election ($24 billion), followed now by what many consider to be an overstatement of the deficit ($35 to as much as $60 billion), presumably to scare Republicans in the state legislature to agree to tax increases. The tricks include his methods for closing the budget gap, and the evasions include the impacts of all this for Latino families.

Health care takes the largest hit in his proposed cuts, with a 34% drop from the 2002-2003 budget. MediCal takes a $3 billion dollar hit, with an additional loss of $3 billion in Federal matching funds. He proposes to cut payments to doctors 15%, dropping MediCal reimbursements from 42nd in the nation to dead last.

This means that if you have MediCal, doctors will not be able to afford to take care of you. The average follow-up visit will pay the doctor less than 19 dollars, less than pizza and soft drinks for your family. He or she must pay their malpractice insurance, all their secretaries and staff, office rent and utilities. No wonder they won’t see you; these low payments will even begin closing the community clinics.

Recently, the County Medical Society surveyed all doctors in San Diego. Doctors are leaving San Diego due to the low managed care payments, and new cuts in MediCal will only speed up the exodus. Of those that stay, 26% of all doctors and 44% of surgeons are planning to stop seeing MediCal. These trends are worse among physicians who speak Spanish and those that practice in South County.

New rules for eligibility are already depriving 500,000 Californians of MediCal benefits, increasing the number of the uninsured. This, plus the low doctor payments will force many people to put off health care until their problems become severe enough to go to the emergency room. The ERs will become more overcrowded so that even if you have “good” insurance, you and your family will have to wait longer for care if you have a true emergency.

Many benefits will also be cut from the program, including dental for adults, medical supplies like diabetes test strips, prosthetics (people with amputations won’t have a leg left to stand on!), medical equipment like wheelchairs and potty chairs to keep weak patients from soiling themselves at home, hearing aids, and hospice care.

Another trick is transferring many responsibilities to the counties. These include nursing home care, mental health, drug and alcohol services, migratory worker programs, rural health services and many others. Although new tax revenues to the counties are supposed to make these transfers budget-neutral, the revenues are fixed, whereas many of the responsibilities are open-ended, putting San Diego and other counties at risk for bankruptcy.

Where did this budget nightmare come from? More than many states, California depends on personal income tax. The boom years of the 90’s brought in big surpluses, while the dot.com bust has dropped state revenues dramatically. Mindful of this boom-bust cycle, state legislators spent some of the surplus to one-time projects like building new roads and schools. But about half of the money was committed to ongoing programs, and the energy crisis wiped out all the state’s reserves.

In solving this crisis, California is hamstrung by prior ballot initiatives. Our state constitution says the budget must always balance, eliminating the option of running a deficit during a recession, which could stimulate the economy. Prior propositions require certain percentages to be spent on certain areas, including education.

Worse, the budget and any tax increases must pass by a 2/3 majority in both the Assembly and the state Senate, meaning that both the Democratic majority and a few Republicans must agree on a solution. Democrats don’t want to cut medical programs and education, while Republicans want to hold the line on tax increases.

To prevent future crises, Denise Moreno Ducheny and other state legislators say we must restructure the state tax system to soften this boom-bust cycle and come up with a better reserve system. But we must get out of the current crisis first. The California Medical Association and other health groups are trying to preserve access for Latinos and all California families.

Cutting health care is shortsighted. By losing federal matching funds, they cost us one dollar in human suffering for every 50 cents saved to the state of California. The half million Californians who lose routine and preventive care will end up needing more expensive hospital care, costing us money and lives in the long run. By reducing medical and dental care, these budget cuts threaten our families and our hope for the future.

Dr Grisolía is Chief of Neurology at Scripps-Mercy Hospital, Communications Chair for the SD County Medical Society, and a Trustee of the California Medical Association.

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