Mamie Stamps lives in a little blue house in Watts. Her 17 grandchildren call her Bear in the Big Blue House, after their favorite cartoon. The inside is cramped; framed pictures of her family plaster the room like wallpaper. Stamps lives alone here. Her kids have grown and moved out; her husband died in 1992.

Stamps is now retired. She worked for 20 years at Children Institute International, where she cared for abused children.

“I did everything for them that I did for my babies. Raised them. Did everything for them. You just fall in love with the kids,” Stamps paused and laughed, caught in a memory. “It was nice.”

Like many people in the area, Stamps lives on a fixed income; like many people in the area, Stamps suffers from multiple health problems, and; like many people in the area, she relies on Medi-Cal to help her with health care costs.

Stamps has an arrhythmia and stigmatism. Today, she spent six hours at the Watts Health Center on her regular check-ups for her eyes and heart.

“I depend on Medi-Cal,” said Stamps, as she pours a cup of ice tea from a plastic pitcher she removed from an avocado-colored refrigerator. “Shoot, I don’t know how many times a year I see the doctor. A lot of times, quite a few time.”

But in January 2012, Stamps’ health care bills will increase.

On March 24, Gov. Jerry Brown signed 13 bills into law, aimed to reduce California’s $26.6 billion budget deficit. Combined, the bills cut the budget by $11.2 billion. One of the bills, AB 97, affects Medi-Cal, California’s version of the federal Medicaid program.

Medi-Cal offers health insurance to the elderly, those below the poverty line and the disabled.

The governor’s office projects the cuts will save the state $557 million. Health care activists, however, say the cuts will significantly burden low-income communities.

“Medi-Cal covers the sickest and most vulnerable people in California,” said Jessica Rothharr, program director for budget advocacy for Health Access, a health care advocacy organization.

Many people on Medi-Cal are already having trouble making ends meet.

“For a lot of these families, they’re the first one to lose a job,” said Dr. Ricky Choi, pediatrician at H & M Human Services Community Healthy Center in Oakland. Choi is also the Chairman of the National Physician’s Alliance of California, a group that officially opposes the cuts. “They’re the first ones who can’t get their kids out of a struggling school; they’re the ones that are really bearing the brunt of the recession.”

The changes to Medi-Cal may seem small. But the little adjustments will add up to a big impact for many recipients.

AB 97 has many provisions, but there are three that health care activists see as especially pernicious: Increases in patients’ co-pays, an annual soft cap of 7 doctors visits, and; a 10 percent pay cut for providers.

Ultimately, opponents to the cuts argue, the plan will cost more than it saves.

Co-Pays equal prohibitive costs

Effective in the new year, Medi-Cal recipents will have to pay a $5 co-pay on doctor visits and medications (currently, both are free). Emergency room visits will now cost $50 up front, and inpatient care will run a person $100 a day.

This may not seem like a lot. But for Stamps, that means not buying as many groceries. That means not being able to buy her grandson a little gift when she sees him every Sunday for church.

“I like to buy him little trucks,” smiled Stamps, peering down into her hand through coke-bottle classes, as though she could see the truck. “I love the way he looks when I give him those.”

Choi sees first-hand how the poor already triage their resources. Ninety-nine percent of Choi’s patients are 200 percent bellow the poverty line.

“In some cases, they can’t even afford Christmas presents, let alone pay for additional co-pays and premiums,” said Choi. “These changes will be a significant burden to the low-income community.”

Rothharr says the increase in co-pays won’t bring in a lot of revenue. In fact, according to Rothharr, hospitals and doctors don’t even want the burden of collecting $5.

“This is just an additional barrier to care,” she said. “The way it saves money is not because of the income received. The way it saves money is by reducing the amount of care.”

People can’t afford to go to the doctor, so the volume of patients’ visits and prescriptions filled is reduced.

“It’s a pretty sneaky and immoral way to go about it,” Rothharr continued. “It’s reducing access to care, reducing utilization of care by those who need it most.”

The new $50 co-pay on ER visits will also cause problems. Many people on Medi-Cal don’t have that much money lying around. But if a person is truly in need of medical attention, ERs cannot turn them away under the federal law Emergency Medical Treatment and Active Labor Act (EMTALA).

“It means Emergency rooms will eat it,” said Rothharr. “It’s a horrible system and that’s why the hospitals were strongly opposed because what are they supposed to do?”

This undue strain on hospitals means worse care – especially in less affluent neighborhoods where uncompensated visits will be more common.

Caps on visits means less care for the most needy

Even if a Medi-Cal patient can fork over the five bucks for a visit, the cuts will cap the number of times he or she can see the doctor in a year.

Rothharr worries that this will deter people from seeking medical attention when symptoms first show – and when they might be able to be cured.

“What you’re doing is having those people decide which of those doctors visits to skip, which of their regular tests and checkups to skip,” she said.

This is especially difficult in people with chronic conditions who need regular checkups, such as diabetes, high cholesterol and cancer survivors.

“It is not workable, and what it means is that people are going to die,” said Rothharr.

Stamps has never thought about how many times she sees the doctor a year. But now she’s going to have to. Both her conditions require regular check-ups; she depends on them. Now she doesn’t know what she’ll do.

“I’d just have to suffer through it,” she said. “I can’t afford any private medicine.”

Both children and pregnant women are exempt from the seven-visit cap.

In the original proposal, Brown wanted a hard cap of 10 doctors visits – meaning that patients could not see a physician more than 10 times, no exceptions. The Committee on Budget ultimately compromised with the soft cap of seven.

A soft caps means that a doctor could see a patient more times if they self-certify that the visit was medically necessary.

“But what you’re asking the doctor to do is take a chance in seeing that patient in the hopes that Medi-Cal will agree and pay them,” said Rothharr.

If Medi-Cal will reimburse, the payments take months to receive.

“It transfers the burden of more paperwork on physician and provider,” explained Choi.

Ten percent provider pay cut, fewer doctors

Doctors in California aren’t required to see Medi-Cal patients. And now they’re less likely to than ever.

The new budget decreases the amount received from Medi-Cal by 10 percent.

“We’re already near the very bottom in terms of states that provide reimbursement,” said Choi.

Many providers simply won’t be able to keep their practice open at the lower rate. Others will limit the number of Medi-Cal patients they see. As a result, there will be fewer doctors for Medi-Cal patients – and more demand for the ones who are. It will also be harder for Medi-Cal recipients to find a doctor.

“This is concern for providers who are really honestly seeking to provide the best care they can for their patients,” said Choi. “Unfortunately, these cuts are going to make it harder to do the jobs that we feel passionate about doing.”

The true costs

Myrna Schnur is the co-convener of the Grey Panthers of Berkeley, a social service non-profit organization that advocates for social programs in bills facing Sacramento.

The Grey Panthers have been watching AB 97 closely.

“Not only is it immoral and horrifying, it is financial foolish to cut Medi-Cal,” said Schnur.

The Legislative Analyst’s Office, the nonpartisan fiscal advisor to the state, did not account for increased use of ERs and county clinics when calculating the savings of AB 97.

This oversight is why the American Association of Medical Assistants, the Association of Emergency Physicians and the National Physicians Alliance all went on record opposing this bill.

“It’s penny wise and pound foolish,” Rothharr said. “You’re not dealing with the underlying need for care.”

In addition to a rise of uncompensated care, patients will also be sicker when they do seek medical help. Not only will that cause unnecessary suffering, said Choi, but they’ll be more expensive to treat.

“While it might not show up in the budget or the books, quite frankly it’s going to increase the overall costs of health care in California,” said Choi.

The Grey Panthers see the cuts as a human rights issue. Cutting Medi-Cal is myopic, says Schnur, and further disenfranchises the already disenfranchised.

“We’ll see an increase in hunger, adding more stress to food banks,” said Schnur.

“Clearly, this will lead to a humanitarian disaster,” said Rothharr. “We are talking about California going backwards into something that looks a lot more like a third world country.”

Choi also sees Medi-Cal cuts as a justice issue. For example, the plan will cut vision services.

“If you can’t see, you can’t do very well in school,” he said.

Choi says the changes will affect his families at the clinic immediately.

“These people are already, bearing the brunt of this recession,” he said. “They are the least able to handle this accumulated impact of all these cuts in services.”

Stamps knows she will feel it.

“I budget my money closely,” she said. “I have to. It’s all I have.”