The closure of Madera Community Hospital represents a monumental challenge for health-care provision in Madera and the San Joaquin Valley as a whole. Its collapse is symptomatic of so many of the deep-seated problems facing California health care, particularly in rural and lower-income communities.

How did it happen? There are two answers: Medi-Cal, and (possibly) the abortion intransigence of state Attorney General Rob Bonta.

A huge percentage of Madera Community’s patients were Medi-Cal beneficiaries. Medi-Cal reimburses poorly as compared with private insurance, so poorly that many doctors lose money on every Medi-Cal patient they treat, particularly for certain fields like OB/GYN care. The financial challenge of Medi-Cal’s low reimbursement rates hugely contributed to Madera Community’s unprofitability and is at the core of the key public health challenges in the Valley.

Prenatal care is a good context for understanding Medi-Cal’s problems. Fewer doctors want to take pregnant Medi-Cal patients, because of the financial strain.

This results in fewer options for lower-income pregnant women. The care in the few remaining Medi-Cal-accepting clinics gets worse as patient visit times shrink from 20 to 15 to 10 minutes because doctors need to see more patients per hour to stay profitable. The time a patient must wait before she can get an appointment grows longer, as fewer clinics have fewer openings available.

As a result, almost one in four women in south Fresno get no prenatal care before delivery.

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Medi-Cal Poses Many Challenges

Medi-Cal is also massively difficult to work with. Rather than a single contract with “vanilla” Medi-Cal, providers must maintain contracts and credentialing processes with a host of “managed Medi-Cal” entities. Most of them are often county-specific. This multitude of payors with whom one must contract to care for the “Medi-Cal” population adds enormous complexity and cost.

Medi-Cal also has ticky-tacky rules that sometimes actively harm patient care. For example, there are certain categories of services for which a provider may not bill two services within the same service day. This can require patients to come on multiple days for services that could easily be provided in one visit. This is a hardship for lower-income patients who may depend on public transportation or have otherwise unreliable transportation.

Medi-Cal is also notorious for aggressively nitpicking a provider’s bill and not paying for services. Combined with their poor reimbursement rates, billing departments who deal with Medi-Cal find themselves spending 80% of their time chasing down 20% of their revenue.

Gov. Gavin Newsom takes every opportunity to pat himself on the back for his expansion of Medi-Cal eligibility. But this alone will not improve community health if doctors don’t want to take Medi-Cal, or if hospitals or clinics with large Medi-Cal populations can’t stay in business.

More Answers Needed From Bonta

Finally, a skeptical public deserves some answers from Bonta. Madera Community had reached an agreement to be taken over by Trinity Health, the large chain of Catholic hospitals that includes Saint Agnes Medical Center in Fresno. Trinity backed out of the deal following the AG’s office imposing certain conditions on the sale, immediately leading to Madera Community’s closure.

According to a Fresno Bee report from December, these conditions included “emergency reproductive health care services, notice and information to the public about nonemergency reproductive health care not provided, as well as information about alternative licensed providers and transportation options.”

As a Catholic hospital, Saint Agnes does not perform or provide formal referrals for abortions or certain contraceptive services, all of which could fall under the California rubric of “reproductive health care.” Saint Agnes’ CEO Nancy Hollingsworth affirmed that Trinity withdrew from the deal because of Mr. Bonta’s new conditions, though she did not specify which conditions were at fault.

It would be a disgrace if Mr. Bonta (a fierce proponent of legal abortion) were so obstinate as to insist that Saint Agnes abandon its moral principles as a term of the merger. The people of Madera County deserve to know if Attorney General Bonta preferred that there be no general hospital in Madera, rather than a Catholic one.

About the Author

John Gerardi is the executive director of Right to Life Central California and CEO of Obria Medical Clinics of Central California.

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