You've probably heard about California Gov. Arnold Schwarzenegger's medical budget cuts that took effect July 1. Certainly, some spending cuts need to be made in light of a statewide $16 billion shortfall.

What you may not realize is now that the Medi-Cal repayment cuts have taken place, the state's already fragile health-care system is in for some of the toughest times we've ever faced.

Leaders of organizations representing doctors and hospitals, along with an advocate for low-income people, recently discussed the potential impact of the cuts to the state's Medi-Cal system. Here are some of their thoughts:

Angela Gilliard, with the Western Center on Law and Poverty, said "cuts to Medi-Cal reduce preventive care for patients and eventually shift more patients to the state's already-crowded hospital emergency departments."

Noting that California doctors already receive the lowest Medicaid reimbursement rates in the country, Richard Frankenstein, president of the California Medical Association, said "the governor's cuts cause physicians to lose even more money by treating Medi-Cal patients."

What we're seeing here in the Barton HealthCare System is pretty straightforward. Our Community Clinic, which operates at a loss of about $1 million per year, accepts Medi-Cal patients. The clinic also accepts patients who have no insurance and charges on a sliding scale based on income. Many patients pay as little as $5 for a medical visit. Hence, the $1 million-plus loss per year.

With El Dorado County cutting its Family Planning Services at the end of June and now referring all their family-planning patients to Barton's Community Clinic, the clinic's patient load will significantly increase, putting our clinic over capacity.

Once the Community Clinic exceeds capacity, Medi-Cal patients begin using the hospital's emergency department as their medical choice of first resort. The emergency department is the most expensive setting in which to receive medical services, which drives up costs and reduces revenue.

When hospitals operate at a loss, they close. That's the bottom line.

And that's happened more than we care to hear about in the past 10 years. Ten California hospitals and 11 emergency departments have closed in the past decade.

Barton HealthCare System has taken great measures to make sure that we can financially withstand these reimbursement cuts so that our fellow residents and tourists will continue to have a stable community hospital.

However, with the current Medi-Cal reimbursement cuts, even more hospitals will be on the verge of closing, and that's not good for anyone in the state.

Jan Emerson, vice president of external affairs for the California Hospital Association, said the impact will not be limited to Medi-Cal recipients and providers.

"With these Medi-Cal cuts in place, you're going to see a complete meltdown of the health-care system in California," Emerson said. "This is not limited to people on Medi-Cal. All of us in California will be affected by these cuts."

As Barton's chief medical officer and an emergency-department physician, my first concern is treating patients regardless of their ability to pay. And like all physicians in the state, if our hospitals close, we have no where to treat people who need us.

An update as of July 7: "California's MediCal program has been underfunded for the last two decades and now ranks dead last among the 50 states in payments to health-care providers," said Suzanne Ness, regional vice president of the Hospital Council of Northern and Central California. "As of last week, the 10 percent across-the-board cuts that the Legislature and governor approved in February hit hospitals, doctors, dentists, pharmacists and ambulance services.

"The only hope in sight is an agreement on the state budget that provides additional revenue to reduce the cuts now in place," she said. "If not, be prepared to wait even longer in the emergency room, as there will be nowhere else to go."

- Clint Purvance, M.D., is chief medical officer for Barton HealthCare System.