Rural healthcare in California is fighting an uphill battle–for better access, improved transportation, more coverage and reimbursement, and against doctor shortages. But there is cause for hope, agreed a panel of health care providers and journalists at an event co-presented by the California Wellness Foundation in front of a full house at Fresno’s Café Revue.
Moderator Michelle Levander, director of the California Endowment Health Journalism fellowships, opened the discussion by presenting some bleak statistics about the inequalities of healthcare in the Central Valley. In the region’s poorer zip codes, the rate of premature death is double that of its higher-income zip codes. And the range in life expectancy from poorer to wealthier areas is as wide as 21 years. “These are really issues of a shared destiny,” said Levander.
Dr. Marcia Sablan’s patients at her clinic in rural Firebaugh–50 miles from Fresno–deal with transportation issues and specialist shortages on a daily basis. Take “a common, everyday care of gallbladder disease,” said Sablan. A patient with private insurance will have his or her gallbladder removed in a week or two. Someone with Medi-Cal will have the procedure in a few months, after a few trips back and forth to Fresno (which winds up costing about $100 per trip). And someone without insurance, who has to see the doctor at the local safety-net clinic, won’t get an appointment for “months and months.”
Gallbladder disease isn’t usually fatal, but Sablan frequently sees patients whose lives are put at greater risk as a result of delays in treatment of such problems. One, a 30-year-old woman, learned she was pregnant just before a sarcoma was discovered growing on her leg. She died after spending two months waiting to be transferred to a hospital that could treat her while she was pregnant. “I’m ashamed of our medical care situation,” said Sablan. No one can say she would have been saved elsewhere, “but at least she would have had a chance.”
San Joaquin Valley-based community health reporter Rebecca Plevin has found that transportation is “a huge issue” for the doctors and patients she meets, from a pregnant woman who had to take an hour-long ambulance ride after her contractions started to school nurses who report students who are unable to get the glasses they need. “There are clinics that will bring in specialists to avoid patients traveling,” said Plevin, “but it’s still a big barrier.” And although there is a strong network of local clinics and many access points to healthcare, it’s often difficult for patients to get to where they need to go–and to be able to afford to take off work for appointments.
Policy changes are also affecting healthcare in the region. For example, the Healthy Kids Program–a children’s insurance program intended for children who didn’t qualify for state-funded healthcare programs due to immigration status and family income–lost its funding last year. Sablan pointed to a stopgap in the form of Medi-Cal’s gateway program for children without immunization or physicals–but it only covers children for a month.
Herrmann Spetzler, the CEO of Open Door Community Health Centers in northern California’s Humboldt and Del Norte counties, offered one possible solution: telemedicine. It’s “a tool for getting over the mountains and getting that care that we need, or that connection to urban areas where the centers of excellence are always going to be,” he said. Telemedicine connects his clinics to doctors at UCSF and UC Davis, among other places. In the case of an eight-year-old girl with an undiagnosed seizure disorder, her caretaker, her local pediatrician, and two specialists in Los Angeles and Phoenix were able to analyze her condition together thanks to the technology.
“We are all over the state, because no longer is the geography an issue,” said Spetzler, who thinks that telemedicine is the future of rural healthcare. “It’s an economic development opportunity that this next generation of medical providers will have at their fingertips.” He added, “We can focus totally on the woe of how poor the distribution of healthcare resources is between rural and urban [communities]. Or we can look at what opportunities we have to go ahead and use modern technology.”
Technology also helps address the perennial problem of recruiting doctors to rural areas, said Spetzler. His clinics have one infectious disease doctor, but she meets regularly via telemedicine with three other rural doctors–who can even be on call to relieve her while she’s on vacation.
Pipeline programs are addressing this issue in the San Joaquin Valley, said Plevin. One is the Doctors Academy, which tries to increase interest among middle and high school students in joining the medical professions, encouraging them to go on to study medicine in college and beyond–and to return to the Valley. UC Merced and UC Davis also have a new program that studies the needs of the area and trains students to work there, while UCSF Fresno brings students to the Valley for their residency. The idea is to “train doctors who will be familiar with the needs of the Valley and who will want to stay here and practice here,” she said.
These programs are the answer, and our hope for the future, added Sablan.
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*Photos by Esteban Cortez