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Few Sources of Care for Uninsured in Inland Empire

One in four residents is uninsured in the Inland Empire, which includes Riverside and San Bernardino counties, the fourth and fifth most populous counties in the state, according to a study released last month by the UCLA Center for Health Policy Research.

The Inland Empire, whose economy relied heavily upon new construction, has been hit hard by the recession and now has one of California’s highest rates of uninsured residents.

“It is one of the worst,” said Shana Lavarreda, lead researcher of the UCLA study and director of health insurance studies at the UCLA Center. “The San Joaquin Valley as a region is the worst, but there are a number of counties in the ‘bad’ range. San Bernardino and Riverside counties are not doing well.

Lavarreda said data show that the impact of the unemployment rate in the Inland Empire was much greater than other parts of the state. The unemployment rate in recent months has been hovering around 15% in the Inland Empire.

“Every county has a requirement … to provide services to the uninsured,” said Bradley Gilbert, CEO of the not-for-profit Inland Empire Health Plan and a member of the Riverside County Access to Care Coalition. “But (in the Inland Empire) they are covering a fraction of the population we’re talking about.”

For both counties, only 30,000 to 40,000 people are enrolled in medically indigent adult programs — a fraction of the more than one million who don’t have insurance, he said.

Ordinarily, federally qualified health centers and their associated clinics would help provide services to the increasing number of uninsured, but they are relatively few and far between in the region, which spans a vast territory approximately the size of Maine.

Patrick Petre, administrator of Arrowhead Regional Medical Center, said the hospital, which is owned and operated by San Bernardino County, has been affected by the spike in uninsured.

“We’ve seen a huge impact in the emergency room volume,” he said. “Arrowhead has the second-busiest emergency room in the state based on daily visits.”

Unprecedented Number of Uninsured

Lavarreda said there was not a direct correlation between job loss and the number of uninsured, which indicates that public health coverage in the region absorbed some individuals who may have lost their jobs and along with them, their employer’s insurance coverage.

Still, the numbers are alarming.

Between 2007 and 2009, the number of Inland Empire residents without insurance increased by 271,000.

Of the two counties, Riverside County has the highest percentage of uninsured — 28%.  In San Bernardino County, the rate is 25.1%.

“The increase in uninsured from 2007 to 2009 is the largest we’ve ever seen,” Lavarreda said. “The 2008-2009 economy was certainly unprecedented in terms of insurance loss in the time period we’ve been collecting data.”

In the two counties, there was a five-percentage-point increase between 2007 and 2009, a dramatic rise according to researchers.

“We used to say half a percent change or a percent change was a big increase,” Lavarreda said.

Too few FQHCs

Local experts worry that a shortage of federally qualified health centers could compound the issue. Such centers provide care to underserved areas or uninsured populations. Along with county clinics and hospital emergency rooms, which are legally obligated to provide care to those who seek care, regardless of insurance status, these centers are on the front lines of treating people who are underinsured or lack coverage.

Each federally qualified health center may operate several health clinics in a given area. Because the Inland Empire has so few clinics, people who would normally be served at FQHCs often end up in hospital emergency departments, one of the most expensive places to deliver health care.

“The problem is we do not have a lot of federally qualified health centers,” Gilbert said. “For counties our size with 25% uninsured, we really have a significant deficit of entities able to provide care for the uninsured. There are significant access issues.”

Between the two counties, there are five federally qualified health centers, which operate 12 sites, Gilbert said. Of those sites, nine are in Riverside County and three are in San Bernardino County.

In addition, Riverside County operates 11 primary care clinics. San Bernardino County has only four primary care clinics.

Geographic Hurdles

One of the areas that Gilbert identified as having the most severe shortage of health centers is the High Desert, a region stretching from the Cajon Pass in western San Bernardino County east to the Arizona and Nevada borders.

In particular, he said the area surrounding Hesperia, Victorville, Barstow and Adelanto in the High Desert is of particular concern because it has no federally qualified health centers, but a population of several hundred thousand lives there.

“I think there’s less access in San Bernardino County than in Riverside County,” Gilbert said. “The entire High Desert has no dedicated entity for primary care of uninsured people.”

Like San Bernardino County, Riverside County, which is also large in size, varies from having large urban and suburban areas in the west to isolated, rural areas in the east.

“I can tell you that we have five federally qualified entities with a total of 12 sites, but four of those sites are clustered in one area in far eastern Riverside County,” Gilbert said. “They are in an area of need, but that tells you the other eight sites are spread across a huge geography.”

The sheer size of the two counties poses a challenge for providing adequate access to care for residents.

“It’s really the worst of both worlds,” Gilbert said of the shortage of federally qualified health centers and the growing number of uninsured.

The Temecula-Murrieta area in southwest Riverside County is another area where access to care is an issue. The area has seen rapid population growth in recent years, but only has one community clinic.

Parts of the Inland Empire have been grappling with a shortage of hospital beds and at one medical facility, an outdoor tent was erected to deal with emergency department overcrowding.

“We could use more,” Gilbert said of federally qualified health centers.

The region has one federally qualified health center for every 828,623 people, more than twice the state average of 327,094. There are 113 federally qualified health centers statewide, according to research by the Henry J. Kaiser Family Foundation. There is hope that the counties will get more federally qualified sites in the next round of federal grant money, he said. But each entity that applies will be facing stiff competition since it is up against every other locale that has applied, he said.

Gilbert says he’s been tracking the issue because the goal is to create continuity in care for people, and “we see the federally qualified health centers and county clinics as key partners for IEHP.”

Petre acknowledged that Arrowhead Regional Medical Center has shouldered the burden of caring for San Bernardino County’s uninsured.

One approach in the future could be to run more clinics out of Arrowhead, he said.

“We certainly wish we had more clinics in outlying areas,” he said. “Geography is a real challenge for out county.”

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