Patching County Safety Nets While Working for Statewide Coverage for Uninsured

Health advocates hope California will extend health coverage to all remaining uninsured in the state — including undocumented immigrants. Efforts are underway to do that on several fronts — state legislation in Sacramento, federal regulation changes linked to President Obama’s executive order on immigration and lobbying to include provisions for the uninsured in the state’s new Medicaid waiver.

In the meantime, the estimated three million uninsured Californians continue to get sick and injured. Their care — as it has traditionally — falls to a variety of safety-net programs run by county governments.

The size and quality of that safety net varies greatly and is fraying at different places in California’s 58 counties. In general, county-run safety nets continue to serve the role of “providers of last resort,” according to Anthony Wright, executive director of Health Access California.

“We think we’re on the cusp of a victory — or victories — to have the uninsured covered with a statewide program,” Wright said. “With that in mind, we’re working to make these county programs serve as a bridge to a statewide solution.”

“I think we’re making progress on that,” Wright said.

In a webinar earlier this month, Health Access and the California Endowment offered an update on progress in efforts to mend the mesh in various counties since the release last month of a Health Access report — “Reorienting the Safety Net for the Remaining Uninsured.”

Maricela Rodriguez, program manager for California Endowment, said her organization is working with Health Access on county programs as part of the Endowment’s Health4All statewide campaign to provide coverage for all remaining uninsured.

Three ‘Flavors’ of Counties

County safety-net programs for indigent and uninsured Californians fall into one of three organizational models. “We refer to them as three flavors of counties — the public hospital counties, payer counties and the CMSP counties,” Wright said.

A dozen counties — mostly high-population urban counties — organize their safety-net offerings around public hospitals. They are:

  • Alameda;
  • Contra Costa;
  • Kern;
  • Los Angeles;
  • Monterey;
  • Riverside;
  • San Bernardino;
  • San Francisco;
  • San Joaquin;
  • San Mateo;
  • Santa Clara; and
  • Ventura.

Another dozen — known as “payer” or “Article 13” counties, after the section in the state constitution dealing with tax provisions that provide the funding — operate their own clinics or contract with local providers to care for the indigent and uninsured. They are:

  • Fresno;
  • Merced;
  • Orange;
  • Placer;
  • Sacramento;
  • San Diego;
  • San Luis Obispo;
  • Santa Barbara;
  • Santa Cruz;
  • Stanislaus;
  • Tulare; and
  • Yolo.

The rest of the state’s counties — many of them rural and more sparsely populated — are part of the County Medical Services Program, an agency created in the early 1980s, when California shifted responsibility for indigent care from the state to counties.

Sawait Hezchias-Seyoum, policy advocate for Health Access and co-author of the safety-net report, said there were three key findings in the survey of counties after the arrival of the ACA.

“Some counties adjusted their benefits but not the eligibility requirements,” Hezchias-Seyoum said. “We also found a lot of apprehension around realignment shifts from AB 85 and we saw that many counties are in a wait-and-see mode.”

The state Legislature two years ago passed a bill — AB 85 — establishing the framework for realigning state and county responsibilities for health care in response to changes brought on by the ACA.

Hezchias-Seyoum said CMSP county indigent programs eliminated optometry, mental health and substance abuse coverage, reduced dental coverage and shortened the term of eligibility to three months.

Five Counties Highlighted

The webinar highlighted progress in strengthening the safety net in five counties — Alameda, Contra Costa, Fresno, Los Angeles and Sacramento.

Two days before the webinar, the Fresno County Board of Supervisors voted to continue funding a revamped program for indigent care, featuring $5.6 million for specialty care. The county will pay for the health program by deferring repayment to the state for road restoration work.

Amparo Cid, director of the Fresno office of the California Rural Legal Assistance Foundation, called the vote a victory for health advocates.

“Grassroots advocacy and working together can make a big difference in people’s lives,” Cid said.

In Los Angeles County, the My Health LA program — also known as Mi Salud — began contracting providers this month to be paid on a capitated system.

“Very early on, our policymakers here in Los Angeles understood it was very important to have a program here for the undocumented,” said Sonya Vasquez, policy director for Community Health Councils, a Los Angeles health advocacy organization.

“With the amount of money the program has, it’s expected to be able to serve 146,000 people,” Vasquez said.

In several counties where health budgets were slashed in the bleak recession year of 2009, efforts are under way to re-establish care systems for uninsured.

Nenick Yu, advocacy consultant with Sacramento Building Healthy Communities, said newly elected supervisors are revisiting the idea in Sacramento.

In Contra Costa County, Alvaro Fuentes, executive director of the Community Clinic Consortium of Contra Costa and Solano County, said efforts are under way to create a primary care program for undocumented immigrants.

A few CMSP counties are also exploring the possibility of establishing programs for uninsured, according to Wright.

In Alameda County, health officials are working on long-range plans for uninsured programs after voters extended a 0.5% sales tax. Last summer, Alameda voters approved a 15-year extension of a safety-net tax to provide health care for undocumented immigrants.

Health Access last week published a report on the Alameda campaign by Bradley Cleveland, planning and health policy consultant with the San Mateo County Union Community Alliance and manager of the Alameda tax campaign.

‘Next Big Question’

“We have the ACA now and we’re moving ahead in many ways,” Wright said. “But the real question — the next big question — is what about all those people left out of the ACA? California could have as many as three million still uninsured — almost half of them because of immigration status.”

“County-run programs will continue to be the final word for now, but ultimately, we should be working toward a statewide or national solution,” Wright said.

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