MORENO VALLEY, Calif. — Jennifer Vargas’ path toward becoming a doctor took her from UCLA to Guadalajara before it ultimately led back home, to California’s vast Inland Empire east of Los Angeles.

When the Chino Hills, Calif. native graduated from medical school in Mexico, her first choice for residency training was Riverside County’s public medical center, which serves among the fastest growing and most medically deprived parts of California.

It was just what she wanted:  To serve a vulnerable patient population facing high barriers to care, particularly immigrant patients from Mexico who would benefit from a Spanish-speaking physician.

“It offered the best fit for me,” said Vargas, 32, a second-year resident in family medicine at Riverside County Regional Medical Center.

The Inland Empire – a region roughly the size of Maine, including both Riverside and San Bernardino counties — needs hundreds more like her. Officials have launched a muscular effort to educate physicians locally and entice doctors from the outside to settle in Southern California’s interior, miles from the famously alluring coast.

They’re trying to do more than fix a doctor shortage. They’re attempting to train and attract the right kind of physicians — mainly primary care providers who relate to disadvantaged patients and want to treat them in their communities, before they become critically or chronically ill.

Some see it as an experiment with lessons for other underserved regions of the country – a way to spread out and diversify the next generation of doctors.

“Today, our country is largely training the sons and daughters of wealthy people to be physicians,” said G. Richard Olds, dean of the University of California, Riverside, School of Medicine. “You wonder why we have a problem with people not serving in underserved communities; it’s because they don’t know what an underserved community looks like.”

He’s looking for students who grew up in the Inland Empire and want to stay. He also wants people who speak English as a second language, or who were the first in their families to attend college.

The Inland Empire has for decades been short of physicians as newcomers poured in. Its population swelled from 1.6 million in 1980 to 4.4 million today. In 2011, it had 43 primary care physicians per 100,000 population, a supply roughly half the level recommended by experts, according to a study published last year by the California Healthcare Foundation.

Now, with the expansion of health insurance and Medi-Cal through the Affordable Care Act, many more new patients have spilled into the system.

The flow of patients seeking primary care services at  the 12 family care clinics run by Riverside County rose 8 percent to 161,000 during the year ended last June 30, said Dr. Geoffrey Leung, the system’s chief of family medicine.

Volume has continued to rise since then and now is only limited by the system’s capacity.

“If we had more providers, we would have more patients,” Leung said.

A Bagful Of Drugs, A Long List of Ailments

On a recent Friday morning, Maria Avelino Ibarra arrived at Riverside County main campus in Moreno Valley after an hour-long bus ride.

Ibarra, a 50-year-old Corona resident with diabetes, had come to renew her insulin prescription and get treatment for pain in her right knee, which she injured in a fall last year.

But as Dr. Bakr Khalifa Al Omrani, a second-year medical resident, quizzed her about her recent medical history, she added more ailments to the list, including chronic headaches, stomach problems and high cholesterol.

As she spoke, Ibarra pulled out a square-foot size zip-lock bag with 15 medication bottles and set them on a small counter in the exam room.

“Okay, I will not be able to deal with all of the problems today,” Khalifa told her through a Spanish translator listening in by phone. “Is your knee the most urgent problem?”

It was. Khalifa tried to flex her knee, which bent only to about 90 degrees before causing sharp pain.

The appointment lasted 35 minutes, about twice as long as primary care visits usually do. It’s a common problem: Because patients have gone without care so long, doctors have to spend more time sorting out their problems. That, in turn, lengthens wait times for other patients seeking appointments.

Thinking Creatively

The shortage of doctors, and the pent-up demand for care, is a problem with deep roots.

Historically, the region has not cultivated young physicians. The Inland Empire is below the state average in producing high school graduates who go to college. And until the UC Riverside program was founded in 2013, the region had only one medical school, at Loma Linda University.

To top it off, Olds said, there aren’t enough slots to train medical residents in the region.

All of these obstacles narrow the pipeline of available doctors. “Where you come from is about 40 percent of the decision” of where to practice, the dean said. “And another 40 percent is where you completed residency.”

In addition, the Inland Empire has hardly been an attractive destination for doctors from the outside.

USE OUR CONTENT

This story can be republished for free (details).

This post has been updated to reflect the subject’s 2016 insurance coverage. Click here to read.

With the deadline looming to re-enroll in California’s insurance exchange, Kuei Lin Liu faced a tough question: Do I want to go through this all over again?

After a year of bureaucratic snags, data glitches and inexplicably dropped coverage, Liu wondered whether Covered California was worth the effort.

“I’m so frustrated right now,” she said. “I spent the last year trying to work out this mess.”

The 37-year-old Richmond resident first enrolled in the exchange last fall, when she left a senior accounting position at a big corporation and the benefits that came with it. With two daughters under 5 and a son due in May, Liu said going uninsured was not an option.

So Liu and her husband Qing Lin, a 45-year-old stay-at-home dad, signed up for a benefits-rich platinum plan from Blue Shield of California. With a projected income of about $90,000 from her tax prep business,  they were eligible for a subsidy that covered a third of their nearly $1,600-a-month premium.

The plan wasn’t as generous as the coverage at her accounting job, but having most of the year virtually free to spend with her family was, to her, a fair trade.

Then the hassles began, said Liu, a CPA and native of Taiwan who immigrated to the United States in 1997 to attend college.

After applying in November 2013 for the Blue Shield plan, she didn’t hear back. With no response from the exchange or the insurer by Dec. 28, she panicked. She had her insurance broker submit another application.

The New Year came and went with neither a confirmation nor a bill from Covered California or Blue Shield. She had to pay for an ultrasound out-of-pocket — about $600, said Liu, who goes by Cecily in English. Fearful of giving birth without insurance, she shelled out about $1,200 for an off-exchange policy with Blue Shield that started on Feb. 1.

Shortly afterward, Liu received confirmation that her Covered California plan was in effect. Blue Shield agreed to apply the payment she had already made on the off-exchange plan to the exchange plan — but that took another month. The reason: Blue Shield had separate payment systems for off- and on-exchange plans.

“I actually visited Blue Shield in El Dorado Hills, their corporate office, to try and make them move the payments,” said Liu’s broker, Kevin Knauss.

Liu thought her problems were behind her after the company applied the payment correctly. Then, in May, her son Nolan was born.

Knauss contacted Covered California the day after his birth to add him to the family policy. When the enrollment data was submitted to Blue Shield, however, the rest of the family’s coverage disappeared from the computer record. It was reinstated –except for Liu’s older daughter Larissa.

That problem eventually was corrected but the policy started on the wrong date.

Although Blue Shield covered the baby’s birth, Liu and Knauss had to hector the insurer and Covered California for two months to ensure Nolan and his siblings remained properly enrolled, they said. Liu even filed a complaint with the state Department of Managed Health Care.

“No one was willing to take responsibility. I told them… ‘You took my money and ran.’”

In late September, Knauss was checking online and noticed the family’s coverage seemed to have disappeared again.

After another round of calls they were back in the system. But all the stress resurfaced in November when the pediatrician’s biller called to say coverage couldn’t be verified for her younger daughter Fiona’s visit in July.

“It’s like history is repeating,” said an exasperated Liu, who fielded several similar calls in the summer, when she was trying to sign up her son. “It’s ridiculous.”

‘We can do better’

Neither Covered California nor Blue Shield would comment specifically on Liu’s case. But they and consumer advocates both underscored the need to improve “the customer experience.”

Covered California is “going to have to not just promise but provide a better experience for people in renewing and signing up for coverage,” said Anthony Wright, executive director of Health Access California, an advocacy group.

Despite glitches, Covered California’s first enrollment period, which started in October 2013, was a success compared to the rollout of its federal counterpart operating in 36 states, healthcare.gov. Enrollment this year began on Nov. 15 and runs until Feb. 15, and California’s exchange appears to be going more smoothly. In the first month, 144,178 people selected a health plan, nearly a third more than signed up in the first month in 2013, according to Covered California.

Exchange officials say they spent the summer making improvements, bolstering technological infrastructure and adding staff.

“I’m sure there are people who have had a negative experience that won’t come back,” said Roy Kennedy, a spokesman. “We ask that they come back and let us try to make it up to them. We know that we can do better.”

A Blue Shield spokesman said in an email that during the early implementation of the health reform law, “some customers did not experience the level of service they deserve.”

“We have and will continue to work closely with Covered California and our vendors to address these issues and streamline the process in 2015 and beyond,” said the spokesman, Sean Barry.

A Cautious Decision

For months, Liu went back and forth about whether to re-enroll.

She found herself thinking, “It’s just too much work. I don’t have time for that.”

If she took no action, she and her family would be automatically re-enrolled in their Blue Shield platinum policy. The pre-subsidy premium would be $1,699 a month, a $116 hike.

Days before the Dec. 21 deadline for coverage beginning in the New Year, Liu cautiously decided to give Covered California another try. Instead of a platinum plan, she picked a slightly less rich gold one because she doesn’t expect to need as much care as this year when she had the baby. She will pay $1,482—or $949 with the tax credit.

Liu’s hoping the switch proceeds without difficulties but if the service isn’t substantially better, she’s buying private insurance off exchange next time.

“I don’t want to deal with that headache again,” she said.

2015 Update

2016 Update

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).