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Counties and the Health Care Safety Net: Shocking Secrets Revealed!

Counties and the Health Care Safety Net: Shocking Secrets Revealed!

Picture of Barbara Feder Ostrov

Many journalists trying to cover their county's safety-net health care system find it confusing at first, what with its alphabet soup of DSH payments, FQHC and CHC clinics, SNCP funds and MISP programs.

That's why I wish I had this wonky but useful report from the California HealthCare Foundation, a nonpartisan health policy think tank, to guide me when I started out as a medical beat reporter on my newspaper's city desk. Those acronyms I just mentioned? All explained. It's important background knowledge, helping you ask intelligent questions when your local county health executive complains about budget cuts – or blithely promises that services won't be affected despite them.

The report, released in December 2009, is particularly timely given California's dire budget deficit, which is forcing cuts to health and welfare programs, and the current uncertain state of health reform, which could change how safety-net hospitals get paid.

"California's Safety Net: The Role of Counties In Overseeing Care"  obviously focuses on how California counties finance and provide health care for the poor, but since many of the programs that help pay for such care are federal, it's worth a look even if you aren't based in California.

Researchers from the Center for Studying Health System Change fanned out to Fresno, Los Angeles, San Francisco, Riverside, Sacramento and San Diego to examine how these counties operate their safety-net health systems and how they are faring given state and federal cuts to their programs. Counties are required to offer poor people a certain level of access to health care, but how they do and how much they pay for it is up to them.

Some counties outsource their care to private hospitals and clinics, reimbursing them with a combination of local, state and federal dollars. Others keep it "in-house," so to speak, setting up an extensive network of county health clinics and hospitals and even subsidized health insurance to care for the poor. Some counties take an in-between approach, perhaps funding a free clinic but outsourcing hospital care.

The report helpfully touches on some reasons why counties take the approaches they do: urban and rural counties operate differently, as do political conservative and liberal ones. And it raises some issues that are ripe for turning into stories:

1. A number of California counties have high-profile "champions" who are able to push for a larger government role in providing health care to the poor. San Francisco has one. Fresno? Not so much. Who are the champions in your county? Do people who advocate for health care for the poor have any real political power? If so, how do they exercise it?

2. County-owned hospitals may be major employers, helping them survive politically even if they're losing money. What's the situation in your county? How powerful are the health care unions that operate in your county and what role do they play in preserving safety-net programs in the midst of budget cuts?

3. The report notes that many California counties have shed their county hospitals in the past few decades, not necessarily because they were too expensive to run but that their costs weren't predictable. It's a lot simpler to offer a private hospital a fixed fee to care for the poor. If your county once had a county-run hospital but now doesn't, has access to care improved or gotten worse?   

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