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Secret shoppers find long waits and scarce openings in L.A. for psychiatric care with Medicaid

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Secret shoppers find long waits and scarce openings in L.A. for psychiatric care with Medicaid

Only 15% of phone calls seeking psychiatric appointments for Medicaid patients resulted in an appointment in Los Angeles, the lowest percentage out of four cities in a “secret shopper” audit, researchers found.

Los Angeles also had the longest wait times, with the median wait stretching 64 days — more than twice as long as in New York City or Chicago and nearly six times the median wait in Phoenix, secret shoppers found.

The findings, published Wednesday in a research letter in JAMA, underscore long-standing concerns about Medicaid recipients being unable to access psychiatric care when they need it.

Earlier research has found that psychiatrists are less likely than other physicians to accept Medicaid, a public insurance program serving people with low incomes. The headaches for would-be patients are exacerbated by what critics refer to as “ghost networks,” in which health insurers list medical providers in their directories who aren’t accepting new patients, don’t take their insurance or are otherwise inaccessible to patients.

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As a medical student at Weill Cornell Medical College trying to ensure follow-up for patients leaving the hospital, “one area in which I consistently was coming up against a wall was making outpatient mental health appointments,” said Dr. Diksha Brahmbhatt, who helped spearhead the audit and is now a resident physician at Brigham and Women’s Hospital in Boston.

For one young man on Medicaid, “it took about an hour and a half to try to get any appointment for him at all” — and it was scheduled about 40 days after his discharge, Brahmbhatt said.

Such experiences left her wondering, “What is the extent of this issue, especially in urban areas where we might expect access to actually be better for patients?”

To see what Medicaid patients might encounter when seeking psychiatric care, researchers from Weill Cornell Medical College randomly chose scores of “psychiatric prescribing clinicians” — psychiatrists, nurse practitioners and physician assistants — who were listed as accepting new patients by the biggest managed care plans for Medicaid patients in each city, then phoned to ask for the soonest available appointment.

They found that less than 18% of the listed clinicians they tried to contact were reachable, accepted Medicaid and could offer an appointment for a new patient on the insurance program. Even among those psychiatric providers able to schedule an appointment, waits could stretch up to six months.

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All in all, only 27.2% of offices they phoned had an appointment available for a Medicaid patient with either the intended provider or another one at the same practice. In L.A., that rate was only 15%, compared with 27.5% in Chicago, 30% in Phoenix and 36.3% in New York City. The typical waits were much longer in L.A. as well.

The JAMA letter did not speculate on why such appointments might be scarcer or waits longer in L.A. Brahmbhatt said that the study wasn’t designed to examine those differences and that the number of offices they called — 320 total — limited their ability to draw conclusions.

Health economist William L. Schpero, one of the researchers who performed the audit, said that “the access challenges we identified are likely the product of multiple factors,” including “inaccuracies in plan directories, clinician reluctance to participate in Medicaid, and an under-supply of psychiatric clinicians in some areas.”

“Which of those factors — among others — is primarily driving the relatively low appointment availability we found in L.A. requires additional research,” Schpero said.

Schpero and Brahmbhatt found that among the psychiatric providers with whom they could not make an appointment, 15.2% had phone numbers listed that were incorrect or out of service, and 35% didn’t answer the phone after two attempts.

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This is a patient population that “already faces a lot of barriers to getting the care that they need” and may already be grappling with mental health symptoms when they seek an appointment, Brahmbhatt said.

If they hit roadblocks, they are “that much more likely to then disengage from the healthcare system.”

In California, lawmakers are weighing a bill that would mandate that health insurers keep accurate listings or face fines. The bill, AB 236, would gradually phase in requirements for increasing accuracy in provider directories, starting with at least 60% next summer and increasing to at least 95% by July 2028. Fines for faulty listings could range up to $10,000 for every 1,000 people insured by a health plan, and those penalties could be adjusted upward with time.

“When Californians can’t find a provider, it leads to delayed or more expensive care,” said Katie Van Deynze, policy and legislative advocate at the consumer advocacy group Health Access California, which sponsored the legislation. “AB 236 puts health plans on a path of improvement, so patients no longer have to call through lists of outdated providers that have moved, retired, or are not accepting new patients.”

The California Department of Managed Health Care estimated in January that implementing the bill could cost up to $12 million annually for additional staffers, but a department spokesman said it was updating its estimate based on the latest version of the bill ahead of a Monday hearing.

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The January estimate was based on “additional workload to promulgate regulations and guidance, develop methodology and review plan documents for compliance” and other needed tasks to carry out requirements under the bill, department spokesperson Kevin Durawa said in an email.

As of June, AB 236 was backed by the National Union of Healthcare Workers and the National Multiple Sclerosis Society, among others, but opposed by industry groups including the California Assn. of Health Plans and the California Medical Assn.

Mary Ellen Grant, vice president of communications for the California Assn. of Health Plans, said its members understand the frustration that arises from inaccurate listings, but “AB 236 does nothing to address the root cause of the issue” and “simply places the full responsibility of provider directory accuracy onto health plans.”

Their accuracy is “largely reliant upon providers and medical groups maintaining their own accurate records and providing that information to health plans in a timely manner,” the group said. “The bill fails to acknowledge this shared responsibility” and is “unfairly punitive against health plans.”

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Can fire-resistant homes be sexy? ‘You be the judge,’ says this Palisades architect

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Can fire-resistant homes be sexy? ‘You be the judge,’ says this Palisades architect

At first glance, it looks like nothing more than a charming Spanish-revival, quintessentially Californian home — but this Pacific Palisades rebuild is constructed like a tank.

Every exterior wall of the steel-framed home is a foot-thick, fire-resistant barricade. The home is connected to a satellite fire monitoring service. Should a fire start in town, sturdy metal shutters descend to cover every window. An exterior sprinkler system can pump 40,000 gallons of water from giant tanks hidden behind the shrubs in the property’s yard. If the cameras and heat sensors around the house detect danger, the system can envelop the home in over 1,000 gallons of fire retardant and hundreds of gallons of fire-suppressing foam.

Palisades resident and architect Ardie Tavangarian is so confident in his design that he even asked the fire department if they could start a controlled fire on the property to test it all out. (They said no.)

Tavangarian built a career designing multimillion-dollar luxury homes in Los Angeles, but after the Palisades fire destroyed 13 of his works — including his family’s home — he found another calling: how to design a house that can handle what the Santa Monica Mountains throw at it. And how to do it quickly and affordably.

Water tanks form part of a backup water supply in a newly built fire-resistant home in Pacific Palisades.

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“Nature is so powerful,” he said, sitting on a couch in the new house, which he built for his adult twin daughters. “We are guests living in that environment and expecting, ‘Oh, nature is going to be really kind to me.’ No, it’s not. It does what it’s supposed to do.”

Tavangarian watched the Jan. 1 Lachman fire from his property not far from here; a week later that fire rekindled, grew into the Palisades fire, and burned through his house. But the painful details of the fire — the missteps of the fire department, the empty reservoir — didn’t matter when it came to deciding how to rebuild, he said. The reality is, many fires have burned in these mountains. Many more will.

A sprinkler on a roof.

A sprinkler on the roof is part of a house-wide sprinkler system.

For the architect, who has spent much of his 45-year career designing for luxury, hardening a home against wildfire has brought a new kind of luxury to his homes: peace of mind.

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It’s a sentiment that resonates with fire survivors: Tavangarian says he’s received considerable interest from other property owners in the Palisades looking to rebuild their houses.

The metal shutters and advanced outdoor sprinkler system are the flashiest parts of Tavangarian’s home hardening project, and the efficacy of these adaptations is still up for debate. Because the measures have not yet been widely adopted, there are few studies exploring how much or little they protect homes in real-world fires.

Ardie Tavangarian stands inside a house.

Architect Ardie Tavangarian inside the house he designed.

Anecdotal evidence has indicated the effectiveness of sprinklers can vary significantly based on the setup and the conditions during the fire. Extreme wind, for example, can make them less effective. Lab studies have generally found shutters can reduce the risk of windows shattering.

These measures aren’t cheap, either. Sprinkler systems can cost north of $100,000, for example. However, Tavangarian said when all was said and done, the home he built for his daughters cost around $700 per square foot — less than what Palisades residents said they expected to pay, but more than what Altadena residents expected for their rebuilds.

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Tavangarian also hopes to see insurers increasingly consider the home-hardening measures property owners take when writing policies, which he said could potentially offset the extra cost in a decade or less. As he explored getting insurance for the new home, one insurer quoted him $80,000 a year. After he convinced the company to visit the property, it lowered the quote to just $13,000, he said.

A living room inside a fire-resistant house, with metal heat shields drawn over the windows.

The house includes metal heat shields that can drop down if a fire approaches.

The home also has essentially all of the other less flashy — but much cheaper and well-proven — home hardening measures recommended by fire professionals: The underside of the roof’s overhang is closed off — a common place embers enter a home. The roof, where burning embers can accumulate, is made of fire-resistant material. The windows, vulnerable to shattering in extreme heat, are made of a toughened glass. There is virtually no vegetation within the first five feet of the home.

When asked if he felt he had compromised on design, comfort or aesthetics for the extra protection — one of the many concerns Californians have with the state’s draft “Zone Zero” requirements that may significantly limit vegetation within five feet of a home — Tavangarian simply said, “You be the judge.”

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Commentary: My toothache led to a painful discovery: The dental care system is full of cavities as you age

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Commentary: My toothache led to a painful discovery: The dental care system is full of cavities as you age

I had a nagging toothache recently, and it led to an even more painful revelation.

If you X-rayed the state of oral health care in the United States, particularly for people 65 and older, the picture would be full of cavities.

“It’s probably worse than you can even imagine,” said Elizabeth Mertz, a UC San Francisco professor and Healthforce Center researcher who studies barriers to dental care for seniors.

Mertz once referred to the snaggletoothed, gap-filled oral health care system — which isn’t really a system at all — as “a mess.”

But let me get back to my toothache, while I reach for some painkiller. It had been bothering me for a couple of weeks, so I went to see my dentist, hoping for the best and preparing for the worst, having had two extractions in less than two years.

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Let’s make it a trifecta.

My dentist said a molar needed to be yanked because of a cellular breakdown called resorption, and a periodontist in his office recommended a bone graft and probably an implant. The whole process would take several months and cost roughly the price of a swell vacation.

I’m lucky to have a great dentist and dental coverage through my employer, but as anyone with a private plan knows, dental insurance can barely be called insurance. It’s fine for cleanings and basic preventive routines. But for more complicated and expensive procedures — which multiply as you age — you can be on the hook for half the cost, if you’re covered at all, with annual payout caps in the $1,500 range.

“The No. 1 reason for delayed dental care,” said Mertz, “is out-of-pocket costs.”

So I wondered if cost-wise, it would be better to dump my medical and dental coverage and switch to a Medicare plan that costs extra — Medicare Advantage — but includes dental care options. Almost in unison, my two dentists advised against that because Medicare supplemental plans can be so limited.

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Sorting it all out can be confusing and time-consuming, and nobody warns you in advance that aging itself is a job, the benefits are lousy, and the specialty care you’ll need most — dental, vision, hearing and long-term care — are not covered in the basic package. It’s as if Medicare was designed by pranksters, and we’re paying the price now as the percentage of the 65-and-up population explodes.

So what are people supposed to do as they get older and their teeth get looser?

A retired friend told me that she and her husband don’t have dental insurance because it costs too much and covers too little, and it turns out they’re not alone. By some estimates, half of U.S. residents 65 and older have no dental insurance.

That’s actually not a bad option, said Mertz, given the cost of insurance premiums and co-pays, along with the caps. And even if you’ve got insurance, a lot of dentists don’t accept it because the reimbursements have stagnated as their costs have spiked.

But without insurance, a lot of people simply don’t go to the dentist until they have to, and that can be dangerous.

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“Dental problems are very clearly associated with diabetes,” as well as heart problems and other health issues, said Paul Glassman, associate dean of the California Northstate University dentistry school.

There is one other option, and Mertz referred to it as dental tourism, saying that Mexico and Costa Rica are popular destinations for U.S. residents.

“You can get a week’s vacation and dental work and still come out ahead of what you’d be paying in the U.S.,” she said.

Tijuana dentist Dr. Oscar Ceballos told me that roughly 80% of his patients are from north of the border, and come from as far away as Florida, Wisconsin and Alaska. He has patients in their 80s and 90s who have been returning for years because in the U.S. their insurance was expensive, the coverage was limited and out-of-pocket expenses were unaffordable.

“For example, a dental implant in California is around $3,000-$5,000,” Ceballos said. At his office, depending on the specifics, the same service “is like $1,500 to $2,500.” The cost is lower because personnel, office rent and other overhead costs are cheaper than in the U.S., Ceballos said.

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As we spoke by phone, Ceballos peeked into his waiting room and said three patients were from the U.S. He handed his cellphone to one of them, San Diegan John Lane, who said he’s been going south of the border for nine years.

“The primary reason is the quality of the care,” said Lane, who told me he refers to himself as 39, “with almost 40 years of additional” time on the clock.

Ceballos is “conscientious and he has facilities that are as clean and sterile and as medically up to date as anything you’d find in the U.S.,” said Lane, who had driven his wife down from San Diego for a new crown.

“The cost is 50% less than what it would be in the U.S.,” said Lane, and sometimes the savings is even greater than that.

Come this summer, Lane may be seeing even more Californians in Ceballos’ waiting room.

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“Proposed funding cuts to the Medi-Cal Dental program would have devastating impacts on our state’s most vulnerable residents,” said dentist Robert Hanlon, president of the California Dental Assn.

Dental student Somkene Okwuego smiles after completing her work on patient Jimmy Stewart, 83, who receives affordable dental work at the Ostrow School of Dentistry of USC on the USC campus in Los Angeles on February 26, 2026.

(Genaro Molina / Los Angeles Times)

Under Proposition 56’s tobacco tax in 2016, supplemental reimbursements to dentists have been in place, but those increases could be wiped out under a budget-cutting proposal. Only about 40% of the state’s dentists accept Medi-Cal payments as it is, and Hanlon told me a CDA survey indicates that half would stop accepting Medi-Cal patients and many others will accept fewer patients.

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“It’s appalling that when the cost of providing healthcare is at an all-time high, the state is considering cutting program funding back to 1990s levels,” Hanlon said. “These cuts … will force patients to forgo or delay basic dental care, driving completely preventable emergencies into already overcrowded emergency departments.”

Somkene Okwuego, who as a child in South L.A. was occasionally a patient at USC’s Herman Ostrow School of Dentistry clinic, will graduate from the school in just a few months.

I first wrote about Okwuego three years ago, after she got an undergrad degree in gerontology, and she told me a few days ago that many of her dental patients are elderly and have Medi-Cal or no insurance at all. She has also worked at a Skid Row dental clinic, and plans after graduation to work at a clinic where dental care is free or discounted.

Okwuego said “fixing the smiles” of her patients is a privilege and boosts their self-image, which can help “when they’re trying to get jobs.” When I dropped by to see her Thursday, she was with 83-year-old patient Jimmy Stewart.

Stewart, an Army veteran, told me he had trouble getting dental care at the VA and had gone years without seeing a dentist before a friend recommended the Ostrow clinic. He said he’s had extractions and top-quality restorative care at USC, with the work covered by his Medi-Cal insurance.

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I told Stewart there could be some Medi-Cal cuts in the works this summer.

“I’d be screwed,” he said.

Him and a lot of other people.

steve.lopez@latimes.com

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Diablo Canyon clears last California permit hurdle to keep running

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Diablo Canyon clears last California permit hurdle to keep running

Central Coast Water authorities approved waste discharge permits for Diablo Canyon nuclear plant Thursday, making it nearly certain it will remain running through 2030, and potentially through 2045.

The Pacific Gas & Electric-owned plant was originally supposed to shut down in 2025, but lawmakers extended that deadline by five years in 2022, fearing power shortages if a plant that provides about 9 percent the state’s electricity were to shut off.

In December, Diablo Canyon received a key permit from the California Coastal Commission through an agreement that involved PG&E giving up about 12,000 acres of nearby land for conservation in exchange for the loss of marine life caused by the plant’s operations.

Today’s 6-0 vote by the Central Coast Regional Water Board approved PG&E’s plans to limit discharges of pollutants into the water and continue to run its “once-through cooling system.” The cooling technology flushes ocean water through the plant to absorb heat and discharges it, killing what the Coastal Commission estimated to be two billion fish each year.

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The board also granted the plant a certification under the Clean Water Act, the last state regulatory hurdle the facility needed to clear before the federal Nuclear Regulatory Commission (NRC) is allowed to renew its permit through 2045.

The new regional water board permit made several changes since the last one was issued in 1990. One was a first-time limit on the chemical tributyltin-10, a toxic, internationally-banned compound added to paint to prevent organisms from growing on ship hulls.

Additional changes stemmed from a 2025 Supreme Court ruling that said if pollutant permits like this one impose specific water quality requirements, they must also specify how to meet them.

The plant’s biggest water quality impact is the heated water it discharges into the ocean, and that part of the permit remains unchanged. Radioactive waste from the plant is regulated not by the state but by the NRC.

California state law only allows the plant to remain open to 2030, but some lawmakers and regulators have already expressed interest in another extension given growing electricity demand and the plant’s role in providing carbon-free power to the grid.

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Some board members raised concerns about granting a certification that would allow the NRC to reauthorize the plant’s permits through 2045.

“There’s every reason to think the California entities responsible for making the decision about continuing operation, namely the California [Independent System Operator] and the Energy Commission, all of them are sort of leaning toward continuing to operate this facility,” said boardmember Dominic Roques. “I’d like us to be consistent with state law at least, and imply that we are consistent with ending operation at five years.”

Other board members noted that regulators could revisit the permits in five years or sooner if state and federal laws changes, and the board ultimately approved the permit.

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