California’s Care Divide

Concierge medicine versus Medi-Cal California's doctor-patient great divide.


California’s health care system is increasingly divided between two contrasting health care business systems. These are high-cost concierge medicine and the essential safety net of Medi-Cal. This growing split is shaping health care experiences across the state. It is not surprising, therefore, that many of my friends and acquaintances have been complaining about their health care recently. 

Escalating costs, decreased face time with their physicians, obviously hurrying nurses and administrative staff, and difficulties scheduling tests and follow-up appointments are commonly discussed over coffee. Stories of bad experiences seem to abound. One was about a doctor saying they could move their patient through the system faster if they signed up for her ‘concierge services.’ Another was about a subspecialist who didn’t introduce themselves to new patients at a busy neighborhood public health clinic.

This got me thinking again about two aspects of the health care business in the United States, particularly in California, which has a population of almost 40 million. The first is known as Concierge medicine. In these practices, physicians charge substantial monthly or annual retainers, sometimes reaching as high as $20,000 per year. 

These services promise faster access, longer visits, and more personalized care. Some concierge practices bill insurance companies, especially for specialty services, lab tests, procedures, and imaging studies. Others, mainly in the realm of direct primary care (DPC), might not bill third-party insurers for some things. Patients pay either through their retainer or directly using a lower fee-for-service model.

Today, concierge services are provided by about 2% of U.S. physicians, but they are growing rapidly. Some studies show that these services reduce emergency department use and improve patient and physician satisfaction. One recent study showed that California, with its many wealth-concentrated urban and suburban neighborhoods, has the highest concentration and growth rate of concierge practices in the United States. Perhaps this is why people refer to them as “boutique” or “VIP” medicine.

A second aspect of the health care business is Medi-Cal, California’s Medicaid program that provides health insurance to low-income individuals and families. Eligibility is linked to the Federal Poverty Level. This corresponds to about fifteen million people, more than one-third of the state’s residents. According to the California Health Care Foundation, this means 3 in 7 children, 2 in 9 non-elderly adults, and 2 in 5 people with disabilities. It also includes 1.5 million Californians aged 65 and older (about 25% of the 6 million seniors living in California).

My own experience caring for patients with Medi-Cal coverage was, for the most part, nontraumatic. Perhaps this is because my department was in an academic center of the University of California, which did not distinguish between types of insurance. My team considered all our patients VIPs, regardless of insurance status, race, nationality, gender, social position, financial situation, sexual orientation, or education. For this, I am both grateful and proud.

Some criticisms of the Medi-Cal system, however, are long waits for appointments, the high administrative burdens of enrollment and eligibility, and patients feeling discriminated against because of cultural sensitivities, language barriers, and the stigma of their Medi-Cal status and financial conditions.

Thinking about these two contrasting health care business systems reminds me of the complexity of the health care delivery process. It makes me thankful that most of the health care providers I have known, from world-famous surgeons to newly hired and still inexperienced administrative assistants, remained true to their calling: to treat every patient equally, with respect, consideration, and the same level of care regardless of their circumstances.