Thousands of poor and undocumented residents in Fresno County are at risk of losing their health care, an unintended and painfully ironic consequence of the Affordable Care Act.
While the federal government will soon bankroll a major expansion of medical services, new coverage will not extend to everyone, and in many cases it will come at the expense of health programs that serve those without insurance.
Under a plan set forth in the state budget approved on Friday, Fresno County stands to lose money it gets to fund a $20.7 million-a-year program that provides care for the uninsured. Although the program, run by Community Regional Medical Center, will see less demand as more people get federally backed coverage, at least 6,000 enrollees, and likely thousands more, will still need care.
These are non-U.S. citizens who don't qualify for coverage under the Affordable Care Act as well as those who don't sign up for coverage or experience delays in getting it.
"The county has supported care for the indigent and undocumented for years, but I don't know if that will continue considering we'll have to pull dollars from other resources," said county Supervisor Henry Perea.
The Board of Supervisors, which makes spending decisions for the county, is yet to take up the issue of what to do for those who will need care if and when the county's program for the uninsured loses funding.
The county could find other money to preserve the contracted services from Community Regional. Or the county could try to create a new, less-expensive health program for those without insurance.
Many, including Margarita Rocha, the executive director of the community advocacy group Centro La Familia in Fresno, say they worry about the county not moving forward to help those passed over by the Affordable Care Act.
"When I drive down the street coming to work, I see people in wheelchairs with limbs missing, and I suspect this is connected to poor treatment or not enough treatment. It's my opinion that this situation will get worse," Rocha said.
Health funds cut
The cut to the county's uninsured health program is implicit in the state budget, which was approved by the Legislature Friday and now awaits Gov. Jerry Brown's likely signature.
At the governor's request, the budget reduces health funds for counties. The thinking is that counties will have fewer uninsured to deal with under the Affordable Care Act.
On Jan. 1, the federal government will begin paying for more people to enroll in Medi-Cal, the state's low-income, health care program. The federal government will also subsidize private coverage for many who don't qualify for Medi-Cal.
Consequently, counties are slated to get $300 million less collectively for health programs over the next 12 months. Each county takes a share of the hit.
In the following budget year — the first full year with the Medi-Cal expansion — counties are slated to receive even less state health funds. A budget trailer bill, approved by the Legislature on Saturday, gives counties two ways to determine their cut.
Counties can either collect 40% of what they have historically received or opt for a complex formula, designed primarily for counties with public hospitals, that allots money based on historical costs, revenues and projected savings.
Neither alternative bodes well for Fresno County.
"The governor is saying your costs should go down, and in reality they should," said Donna Taylor, the county's former behavioral health director who is now consulting on the Affordable Care Act. "But that's not the way this county works."
Fresno County's unique way of contracting care for its uninsured — which comes at a fixed rate no matter how many people receive service — makes it unlikely that the county will recoup its costs.
Choosing the state's first option, getting 40% of what the county has historically received, would leave the county shy of the contract's nearly $21 million annual price tag. And choosing the second option, which factors expenses and savings, would short the county because the formula would understate the county's real costs.
"We've been working with (Fresno) County, their delegation, the Department of Finance and the Legislature, trying to figure out a way to help," said Farrah McDaid Ting, an analyst with the lobbying organization California State Association of Counties.
Community Regional Medical Center, meanwhile, has not shown a willingness to renegotiate a less-expensive health program for the county, even as the number of uninsured in the program — and hence the medical group's expenses — will likely drop with the Affordable Care Act.
This is largely because of the high cost the medical group has historically incurred. Community Regional has reported that it spends up to four times more to run the program than it collects from the county. The medical group is bound by a 30-year-contract, started in 1996, to provide the service.
The program serves about 20,000 people a year at the medical group's Fresno campus and countywide clinics, according to county officials.
While many of the patients will qualify for federal coverage starting Jan. 1, county officials estimate that 6,000 undocumented people won't and will need to get care elsewhere.
Thousands more who don't sign up for federal coverage or are in between insurance plans will likely need medical attention at some point as well.
"There's going to be a continued need in Fresno for a safety net. There's no doubt about it," said Anthony Wright, executive director of the statewide advocacy Health Access California.
Wright added that when the uninsured have few options for care, they'll show up at hospital emergency rooms where services are more costly and the individual's health, by this stage, is usually much worse.
"We hope that Fresno steps up and makes sure it can maintain its safety net," he said.
The state budget trailer bill passed Saturday contains one provision that could allow Fresno County to receive more money to help its uninsured. The provision, pushed by the California State Association of Counties, allows counties to petition the state if they don't think they're fairly compensated for health programs.
Taylor, the consultant for Fresno County, said the county would likely exercise this option, though she acknowledged success was far from certain.
The most likely scenario to play out under the budget plan, she said, would land the county about $16 million of state health funds in the first full year of the Medi-Cal expansion, instead of the $41 million the county currently spends each year. (The totals include a required county match.)
Making matters worse, this money is not only meant to go toward uninsured programs but public health, which includes animal control, infectious disease response and environmental disasters.
"We have a lot of work to do to figure out how we're going to provide health care to our indigent," Taylor said.
Ultimately, Taylor said it will be up to the Board of Supervisors to try to stretch state dollars or tap funds from other accounts to provide for the uninsured, most of whom will be undocumented.
Supervisor Perea has committed to finding this money, but other board members have not been as vocal on the topic.
Taylor said she's not sure what the supervisors will do: "For this community, this is a big political issue."
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