California counties provide ‘dramatically different’ care to uninsured

A new report from advocacy group Health Access found “striking” differences in how counties are approaching California’s estimated 3 million uninsured residents.

For the state’s uninsured, access to care depends on who they are and which county they live in, according to the report, whose authors contacted county officials throughout the state with a set of questions. The report found that eligibility for the care programs varies widely from county to county, in large part because of differing income and immigration status requirements. The survey also underscores the tremendous changes that have occurred under health reform — thousands of people who once utilized these institutions are now insured.

“We wanted to spotlight California’s uneven safety net to spur action at both the county and state levels,” said Health Access executive director Anthony Wright in an interview with Reporting on Health. “If you have a lot of programs and virtually no one is in them, there needs to be a change, and we need to be responsive to the remaining uninsured that exist and aren’t being served.”

Even under health reform, many Californians still don’t have insurance coverage. Some of the uninsured are eligible for Medi-Cal, the state’s Medicaid program, but not enrolled, while others are ineligible for subsidized coverage through exchange plans. Many of the remaining uninsured are undocumented and excluded from federally funded coverage under the Affordable Care Act. While community clinics and hospitals’ charity care provide some assistance, county safety net systems still play a crucial role.

“Otherwise, uninured individuals will show up for care — sometimes too late — in their emergency rooms, which drives up costs and makes the health delivery system less efficient for everyone else,” the Health Access report states.

The analysis found wide gaps between the eligibility requirements for free or reduced cost care throughout the state. Forty-three counties set income eligibility at 200 percent of the federal poverty line. Six set it below the 200 percent line, and nine set it above, often with some cost-sharing required.

Ten counties – Alameda, Los Angeles, Riverside, San Francisco, San Mateo, Santa Clara, Santa Cruz, Kern and Ventura provide care regardless of immigration status. (Fresno has done so in the past and is set to continue, and Contra Costa offers care to undocumented children.)  Undocumented immigrants in the remaining counties must seek care through emergency rooms, community clinics or hospital charity care programs.  

The report delves into more details for Fresno, a county that tried to end its medically indigent program for its undocumented residents but put a temporary stay on that move due in part to the community’s response. Last week, Fresno Bee reporter Barbara Anderson wrote an updated account of the county’s decision to provide specialty medical care for undocumented immigrants and the poor “by deferring repayment of road funds to the state.”

The Health Access report provides a useful chart detailing the number of people enrolled in many California counties’ indigent care services before the ACA rollout and then again in late 2014. As more and more formerly uninsured residents secured coverage through expanded Medi-Cal or exchange plans, those numbers fell dramatically across the board— some programs that once served thousands were now seeing no one on the date surveyed.

“While this outcome was expected, it provides further evidence that the ACA enrollment efforts worked — that people who were relying on the safety net are now getting comprehensive coverage and care,” according to the report. “However there is continued need for a safety net that survives and thrives.”

The county-by-county data provided in the report is useful for reporters looking to examine how their region’s safety net is faring under reform. For example, reporter Courtenay Edelhart of The Bakersfield Californian used the report to determine Kern County provided care for just 30 people in its indigent care program last year, down from 9,121 before the ACA was fully implemented. The county has clinics that provide care for undocumented immigrants.

For counties that don’t provide coverage above the federal poverty level or exclude undocumented immigrants, those low figures could mean something different: none of the remaining uninsured meet their eligibility requirements.  

But broad eligibility doesn’t necessarily mean a county is providing care for everyone, Wright cautioned.

“Even if you say you cover the undocumented, if you only have a couple dozen folks in your indigent care program, there’s an opportunity to take another look,” Wright said. “Why aren’t you meeting the need in your county? Is there some other eligibility issue?”

Most counties have not made significant changes to their programs since the ACA rollout, opting to wait and see how health reform affected their populations, and how the state would change indigent care funding under AB 85. The legislation reallocates money that had supported county health programs. Some counties, though, did reduce benefits, such as dropping mental health, vision care and dental. Still others eased eligibility requirements.

Some counties — such as Los Angeles — have used the ACA as an opportunity to provide safety net programs though a “medical home” approach. Last year, Los Angeles launched My Health LA, which assigns previously uninsured patients to a community clinic, with the hospital system providing specialty care and hospitalization services. The program, detailed in The Los Angeles Times, includes undocumented immigrants.

“Ultimately, the new, post-ACA context provides new opportunities for counties to redesign safety net programs,” the report concluded.

Photo by Neon Tommy via Flickr.