C A L I FOR N I A california H EALTH C ARE Health Care Almanac F OU NDATION regional markets issue brief december 2009 California’s Safety Net: The Role of Counties in Overseeing Care Introduction public or private providers, such as University of California All 58 California counties bear significant responsibility (UC) hospital systems, private hospitals, community health for assuring “safety-net” health care services for their centers, and health plans to provide care for their most lowest-income residents. But how health care services vulnerable residents. for low-income people are financed and delivered differs This study revealed a number of often related factors that significantly among the counties, with varying degrees of appear to shape the role that counties assume, including: county involvement. This variation reflects the state’s size ▶▶ State and local funding levels; and diversity, including differences in residents’ race and ethnicity, income, and insurance status, and the counties’ ▶▶ Degree of financial control desired; different political climates and health care infrastructures. ▶▶ Extent to which a county is urban or rural; Moreover, meeting their obligation to provide care for indigent residents1 recently has become more difficult for the ▶▶ Political environment, including the existence counties: The current economic recession has led to a greater of political champions; and need for services obtained through the health care safety net ▶▶ Extent to which county facilities serve as as people lose their jobs and health coverage, while state and major employers. local budgets to support the safety net face increased strain.2 This issue brief presents findings from a study by the These factors play out in diverse ways, with no single Center for Studying Health System Change (HSC) that factor or formula emerging to explain or predict a county’s made site visits to six California regions: San Francisco safety-net role. The study’s findings suggest that counties that Bay Area, Sacramento, Fresno, Los Angeles, Riverside/ play the most extensive roles have significant opportunities San Bernardino, and San Diego. The study explored the role to help coordinate safety-net services through providers and that 11 counties in these regions play in the health care safety managed care plans and to improve access to care. net, the factors that shape their roles, and the impact of these roles on care delivery for low-income people.3 Some counties County Safety-Net Roles: The Context operate their own hospitals and/or clinics and may have California counties have long been health care providers of local, publicly-operated health plans that provide Medicaid last resort to their poorest and most vulnerable residents, but (Medi-Cal in California) managed care services.4 Instead of county boards of supervisors have discretion to determine operating county facilities, some counties contract with other who is eligible, how much to spend, what services to cover, HSC’s Six-Community Market Study In fall 2008, a team of researchers from the Center for Studying Health System Change (HSC) conducted site visits to six California communities to study those markets’ local health care systems and to gain insights into regional characteristics in health care affordability, access, and quality. The six markets — Fresno, Los Angeles, San Francisco Bay Area, Riverside/San Bernardino, Sacramento, and San Diego — reflect a range of economic, demographic, health care delivery, and financing Placer El Dorado conditions. Approximately 300 interviews were conducted between October and Yolo Sacramento December 2008 in the six communities with representatives of hospitals, physician Marin Bay Area Contra organizations, health plans, major employers, benefit consultants, insurance Costa San Francisco Alameda Mariposa San Mateo brokers, community health centers, state and local policymakers, and other Madera Fresno stakeholder organizations. This issue brief is based on responses from representatives of safety-net hospitals, community health centers, Tulare Kings consumer advocacy organizations, community health center associations, local health departments, state and local policymakers, local medically indigent services program San Bernardino Los offices, local Medi-Cal enrollment offices and managed Angeles care plans, and other experts on the local health care Riverside safety net. A two-person research team conducted each San interview, and notes were transcribed and jointly reviewed Diego for quality and validation purposes. The interview responses were coded and analyzed using ATLAS.ti, a qualitative data management software tool. Note: This brief analyzed data from 11 of the 18 counties in the six market regions. ▶▶ access the entire regional markets series here. and how to deliver care.5, 6 In larger California counties, this Over the past few decades, counties have had to adapt obligation is carried out by operating a Medically Indigent to substantial changes in state policy and funding related Services Program (MISP) that provides inpatient, emergency, to care for low-income residents. State budget deficits in and some level of outpatient medical services to uninsured the early 1990s prompted a significant shift in financial adults (and, in some counties, to children as well). Income responsibility for health and social services from state to eligibility for MISP varies; many counties set MISP eligibility county governments. The state now allocates realignment at below 200 percent of the federal poverty guideline funds — sales tax revenues and vehicle license fees — directly ($21,660 for an individual in 2009). The majority of county to the counties for this purpose, with different formulas MISPs do not cover undocumented immigrants.7 The determining how much each county receives. Within the 34 smaller and/or predominantly rural counties in California same time frame, the state began a significant expansion of participate in the state’s County Medical Services Program, managed care for Medi-Cal in an effort to control program which provides services — similar to those included in the costs, and removed county responsibility for funding a Medi-Cal program — for adult residents with incomes of portion of the program. Counties nonetheless played a key up to 200 percent of the federal poverty guideline.8 role early on in the development of the public Medi-Cal 2 ©2009 California HealthCare Foundation managed care plans implemented in many counties, through Table 1. Indicators of California Counties’ Safety-Net Roles County-Owned County-Owned Public Entity Medi-Cal local, publicly-operated Medi-Cal managed care plans (or Market Region/County Hospital(s) Clinics Managed Care Plan Bay Area local initiatives) and county-organized health systems.9 More Alameda County 4 4 4 recently, California counties have experienced an erosion San Francisco County 4 4 4 of funds for providing health care to low-income people, fresno Fresno County relative to costs.10 An ongoing economic recession and related Madera County state and local budget crises have led to declining state tax Tulare County 4 Los Angeles revenues for realignment funding, to cuts in Medi-Cal and Los Angeles County 4 4 4 Children’s Health Insurance Programs, and to decreases in Riverside/San Bernadino Riverside County 4 4 4 counties’ own funds for safety-net care. San Bernardino County 4 4 4 Sacramento Variety of County Safety-Net Roles Placer County 4 Sacramento County 4 A county’s role in the safety net varies according to the extent San Diego to which it directly provides health services for low-income San Diego County Source: Authors’ analysis of data collected from 2008 study site visits. people or, instead, contracts with private organizations to serve MISP enrollees and other low-income county residents. Some counties directly operate health services (typically, the present study — San Francisco, Alameda, Los Angeles, administered by the local health department) through Riverside, and San Bernardino — own at least one hospital. ownership of hospitals and clinics, and through the creation Counties that do not own a hospital contract with private of local, publicly-operated Medi-Cal managed care plans as a hospitals in order to care for the MISP population. Two means of maintaining Medi-Cal patients at county facilities counties — San Diego and Sacramento — contract with (e.g., San Francisco, Alameda, Los Angeles, San Bernardino, UC hospitals as well. Also, some counties have health care and Riverside counties). Other, usually smaller, counties play districts, which are governed by an elected body separate a less direct role in the safety net, either owning no hospitals from the local government and have the authority to impose or clinics, not having local, publicly operated Medi-Cal plans property taxes to pay for the operation of a hospital. These (e.g., Fresno, Madera, and San Diego counties), or owning districts are not technically county-owned entities, and so only one or two of the three types of health care entities may not have the same mission of serving the uninsured (e.g., Sacramento, Placer, and Tulare counties).11 See Table 1 and indigent that county-owned public hospitals do, but for a comparison of these roles among counties included in in the counties of San Bernardino, Riverside, and Tulare this study. respondents indicated that they serve a significant proportion of low-income people. Hospital Care County hospitals assume responsibility for providing Clinic Care inpatient, emergency, and outpatient specialty services for Eight of the counties in this study operate their own primary patients regardless of their ability to pay. These patients care clinics: the five counties that own at least one hospital, include Medi-Cal beneficiaries, MISP enrollees, and other plus Sacramento, Placer, and Tulare. County clinics serve the uninsured people. Many counties statewide provide this MISP population as well as, typically, other uninsured and care in hospitals they own and operate: Five counties in Medi-Cal patients. All of the regions in the study also have 3 ©2009 California HealthCare Foundation private, nonprofit community health centers (CHCs) that effective political champions; and whether county facilities treat uninsured and Medi-Cal patients. Many CHCs and serve as major employers, including related union influence. some county clinics have become federally qualified health These factors carry different significance across counties centers (FQHCs), a designation that enables them to receive and, while some patterns emerge, no single formula can fully federal grants and enhanced Medi-Cal reimbursement, or predict or explain an individual county’s role in providing they have qualified as FQHC look-alikes that do not receive safety-net care. For instance, Fresno and Madera counties, grant funding but are entitled to enhanced Medi-Cal which are predominantly rural and have low available reimbursement. CHCs in San Francisco, Alameda, funding and more conservative electorates, play relatively Los Angeles, and San Diego counties also receive county small direct roles in providing safety-net care. Yet Riverside funding to treat MISP patients. and San Bernardino counties also have relatively low funding and a conservative electorate, but the presence of political Medi-Cal Managed Care champions and the need to respond to particular geographic Most counties in the study have adopted one of three and economic realities have led these two counties to play Medi-Cal managed care models used in California. Most more direct roles. In another example, it is unusual for a large of these operate a two-plan model, in which the state California metropolitan county such as San Diego to play a contracts with a local public plan or local initiative, and relatively indirect role in the safety net, but its conservative with a commercial plan, and beneficiaries choose between political environment overcomes other factors and limits the them. The five counties in the study that have a public county’s participation. health plan — San Francisco, Alameda, Los Angeles, San Bernardino, and Riverside — also own hospitals and Available Funding clinics. Although Fresno and Tulare counties also operate Counties with more health care funding typically play under the two-plan model, they use two commercial plans more direct roles in the safety net because ownership, to serve Medi-Cal beneficiaries because no public managed operation, and support of hospitals, clinics, and health care plan exists there. Sacramento and San Diego counties plans require significant financial investment. Currently, operate under a geographic managed care model, in which state realignment dollars represent an important source of several commercial managed care plans compete for Medi- funding for county health care and are distributed based on Cal enrollees. Placer and Madera counties currently operate counties’ historical spending on health and social services. under the traditional fee-for-service delivery system. Madera The realignment payment formula has not been regularly is expected to join Fresno and Kings counties to form a updated to reflect demographic and socioeconomic changes regional two-plan model in October 2010.12 in county populations, however. Respondents and other reports indicate that the level of per capita realignment funds Factors that Influence Counties’ Safety-Net Roles a county receives varies significantly across counties, with San This study identified several significant factors that appear Francisco County receiving the highest, which is significantly to shape the role counties play in providing safety-net care: greater, for example, than what Riverside and San Bernardino available funding; policymakers’ desired level of financial counties receive.13 Counties that own hospitals also receive control; the extent to which the county is urban or rural; federal dollars through Disproportionate Share Hospital the county’s political environment, including the presence of (DSH) payments and Safety Net Care Pool (SNCP) funds, provided through a Medicaid waiver to help defray the costs 4 ©2009 California HealthCare Foundation of providing uncompensated care. The ability of counties to your patients were… and you restricted that more or less at generate their own funding for health care was significantly will.” hampered by California’s Proposition 13, passed by voters Among the counties in this study, Fresno, Sacramento, in 1978, which limits county property tax assessments to and San Diego have chosen to contract for hospital (and 1 percent of home values, reducing this revenue source to in some cases, clinic) services as a way to control what they less than half of previous levels.14 spend on health care. Fresno has a 30-year contract with A few counties have enacted their own fees to support the major hospital system in the community to provide their safety net: San Francisco imposes a fee on employers inpatient and outpatient care to the medically indigent, a that do not provide health insurance to their employees, to set annual amount which respondents reported covers less help support Healthy San Francisco, a program to improve than half of the actual costs of care. Sacramento County access to care for uninsured adults with incomes of up to contracts with UC Davis hospital, but has also started using 500 percent of the federal poverty level; Alameda County a third-party administrator to contract with other hospitals voters passed a half-cent sales tax to support the county at lower payment rates (although early reports indicated that hospital and safety-net clinics; and Los Angeles voters passed the county may not be realizing any savings). Even counties a tax to pay for trauma and other emergency department playing large roles are experimenting with the financial services.15 Also, four of the study counties — Los Angeles, ramifications of contracting with some private providers, San Francisco, Alameda, and San Diego — currently receive particularly CHCs. As one such county respondent funding from the SNCP to operate a Health Care Coverage explained, “We had to see if we could get more by purchasing Initiative to expand access to care for low-income, uninsured services or doing them ourselves.” adults. Perceptions of financial control also appear to affect a county’s desire to establish a public Medi-Cal health Financial Control plan. Public plans tend to serve a majority of Medi-Cal The amount of control a county wants to exercise over its beneficiaries in the market and reportedly steer enrollees, health care expenditures seems to be a factor in the size and and therefore Medi-Cal funds, to their own providers. The directness of its safety-net role. Because county facilities two-plan model arose in numerous counties as a result of a require increasing capital and operational investment as both political compromise between the counties and the state, in the demand for safety-net services and the costs of care rise, which the state wanted to contract with managed care plans counties that own facilities have less control over and less through competitive bidding and the counties wanted to predictability regarding how much they spend on health protect the historic funding streams of their county hospitals care compared to counties that solely contract with private and clinics. On the other hand, respondents indicated that providers and the UC system. Many California counties have Sacramento County — which owns clinics for the medically shed their county hospitals over the last few decades for this indigent but no longer a hospital — requested to operate reason.16 As one respondent explained, “It wasn’t hard for under a geographic Medi-Cal managed care model because boards of supervisors to see that if you ran a county hospital, they did not want the responsibility of creating a publicly- you would spend more of your local tax dollars. [Instead] you operated managed care plan that would be required under could fulfill your statutory responsibility through contracting other Medi-Cal managed care models. In that community, and, in that process, you had a great opportunity to say who the private not-for-profit community clinics argued that the 5 ©2009 California HealthCare Foundation geographic managed care model did not adequately protect organized networks of advocates for low-income people. In them financially.17 these counties, boards of supervisors and mayors can gain politically by using their hospitals as political “medals,” Urban or Rural Environment displaying them to constituents and stakeholders to show In some cases, the extent to which a county is largely urban what they have accomplished for the community. In or rural affects the safety-net role it plays. More urban addition, the progressive electorates in these counties have counties, such as San Francisco and Los Angeles, have more been willing to pass dedicated taxes to support the safety net. money for health care and play a larger, more direct role, The presence of a political champion to advocate while more rural, agricultural counties tend to have fewer for the safety net can also foster a larger role for the resources and play a smaller role. But as one respondent county. For example, the county administrative officer for explained, it is not solely a matter of available funds but San Bernardino County was previously CEO of the county also of political leverage: “Urban areas are the ones out there hospital and is collaborating with the county health officer really fighting and have the political power to influence to create an integrated primary care-based safety-net system. where the health care dollars go.” In San Francisco, the mayor (who also serves as the county Some rural counties, such as Fresno and Madera, executive) has been a major proponent of county health care assume smaller safety-net roles because contracting with facilities and improving access to care for the uninsured. Such existing providers allows them to offer a provider network political supporters also help protect safety-net funding from without making a capital investment. But in Riverside and local budget cuts. San Bernardino counties, where the population is widely In contrast, many other counties lack a supportive dispersed — geographically, San Bernardino is the largest political environment or political champions to advocate for county in the continental United States — the county safety-net health care. This is the case for Fresno County, governments assume a larger safety-net role because otherwise despite it being an agricultural area dependent on many low-income residents might not be able to obtain care low-wage, migrant workers. As one respondent put it, Fresno without traveling long distances. Because of the low number has no “political capital” with which to operate hospitals, of providers in Riverside and San Bernardino counties, clinics, or a local public Medi-Cal managed care plan. There, county-owned hospitals attract larger proportions of county supervisors reportedly prioritize public safety and commercially-insured patients than publicly-owned hospitals law enforcement over health care and spend a portion of usually do, which helps their financial stability. Other the county’s realignment funds on health care in county factors may also alter the typical urban/rural distinction: jails. Fresno also has the most restrictive MISP income Placer County, for example, is a rural area that lacks private eligibility in the state, enrolling uninsured adults with community health centers; as a result, the county found it incomes of only up to 63 percent of the federal poverty level. too difficult and expensive to get sufficient participation from Similarly, San Diego’s electorate is relatively conservative and private physicians, so it continues to run its own clinics. particularly opposed to providing services to undocumented immigrants, prompting local leaders to run for office under Political Environment and Champions the banner of “fiscal responsibility” and the county to assume The counties of Los Angeles, San Francisco, and Alameda a more hands-off, smaller safety-net role. San Diego County appear to have assumed larger roles in the safety net in part did recently raise the income eligibility for its MISP from due to their politically progressive electorates and well- 135 percent to 165 percent of the federal poverty level, but 6 ©2009 California HealthCare Foundation only in the wake of lawsuits alleging the county was shirking this greater role can produce some benefits to low-income its responsibility to be the provider of last resort. residents in access to care and improved coordination of health care delivery, as discussed in this section. County Facilities as Major Employers, and Union Influence Public ownership of hospitals appears to help improve County-owned hospitals often serve as major employers access for low-income patients for some services.18 This is in a community, a factor that appears to help maintain a partially explained by these facilities’ mission to provide county’s large safety-net role. Respondents in Riverside and care to county residents regardless of their ability to pay, San Bernardino counties indicated that local government whereas county contracts with other hospitals typically only continues to play a strong role in the safety net because cover care for people who meet the county’s specific MISP health care is a major employer and economic driver in an eligibility criteria. Also, respondents observed that county area where construction and manufacturing jobs have dried hospitals, as well as some hospitals in the UC system, are up. As one respondent from Riverside County noted, “The more likely than private providers to take steps to improve only area where jobs are increasing in the Inland Empire [the access to specialty care, mental health services, and dental metropolitan area of Riverside and San Bernardino counties] care — services that are especially difficult for low-income is health care.” people to access. These facilities often operate outpatient Further, heavily unionized workforces tend to protect specialty clinics staffed with physicians and accept patients county facilities in order to preserve county jobs. Union regardless of their insurance coverage. influence contributed to Alameda County’s decision to Compared to specialty, dental, and mental health care, convert its county hospital into an independent public primary care is more available to low-income people across health authority (funded by the county but with a separate all the study counties, regardless of a county’s safety-net board and management structure) rather than into a separate role. While Sacramento, Alameda, and Tulare counties have district hospital, which would have potentially reduced union reduced the capacity of their county clinics over the last protections for workers. As one respondent explained, “There few years because of local budget deficits, county and other was pushback from unions and the more progressive elements community clinics in other counties have achieved or are in the political spectrum who thought that [converting to pursuing federally qualified or look-alike status to obtain a district hospital] was a move to privatize. What happened additional, and seemingly more stable, revenues. Indeed, was a compromise and the hospital stayed within the county increased federal funding for FQHCs over the past decade family.” Similarly, in Los Angeles, influential public employee has sparked significant growth of private community health unions supported the election of a new county supervisor centers across the counties. One of the reasons Alameda who has worked to slow the shift of medically indigent County contracts with FQHCs is to build upon county patients from county clinics to community health centers in clinic capacity and obtain a range of culturally competent an effort to reduce costs. services for its diverse uninsured population. For Medi-Cal beneficiaries, many respondents reported Impact of a County’s Safety-Net Role that public Medi-Cal managed care plans have helped Counties that play the largest direct safety-net role seem to improve access to care, whereas lack of a locally-developed have greater control over funding streams, and sometimes Medi-Cal managed care plan can generate concerns about more leverage with providers and Medi-Cal plans, than those access to and quality of care. Sacramento respondents with a more limited role. Study respondents indicated that expressed concern that the county does not receive 7 ©2009 California HealthCare Foundation information on whether access to and quality of care for programs with that goal. In San Diego County, for example, Medi-Cal beneficiaries are adequate because the participating policymakers commissioned an assessment of the capacity of commercial plans contract directly with the state. Fresno private safety-net providers and allocated funding to address County is working towards creating a regional, two-plan identified concerns, such as by implementing an information initiative with Kings and Madera counties, which local technology system to share patient information between policymakers expect will allow the three counties to more emergency departments and community health centers. Also, efficiently address reimbursement and provider network the Healthy San Diego collaboration draws private Medi-Cal issues and therefore improve access to care. managed care plans and providers together with the county Counties that assume a large safety-net role have greater and consumer advocates to address access and quality of care. control over funding, as well as over provider and Medi-Cal plan activities, which allows them to work toward a more Conclusion coordinated safety-net delivery system overall. Given The funding, politics, and market factors that shape a safety-net capacity limitations, these efforts typically county’s role in the safety net are varied and complex. involve reaching out beyond a county’s own providers to Examining those factors may help policymakers in their private entities. As a San Diego respondent observed, “My efforts to improve access to care for low-income people. impression is that in communities where there is a county County or other public ownership and operation of health hospital, because there is a locus there, they have formal care facilities, as well as locally developed Medi-Cal managed connections with other providers. And because the county care plans, appear to offer some benefits, including improved has skin in the game, they provide the support to make the access to specialty medical care and stronger coordination of connections.” services among both public and private providers. A key example of such coordination is in San Francisco, In responding to the challenges of the current economic where the health department combines different funding climate and of California’s ongoing budget crisis, counties streams and works with various providers to implement that assume the largest roles in their local health system will its Healthy San Francisco (HSF) program for uninsured have more tools — hospital systems, clinics, local public adults. HSF uses the San Francisco Health Plan, originally entity health plans — with which to address the problem of developed as the Medi-Cal local health plan initiative, as increased numbers of uninsured people. On the other hand, the third-party administrator, and contracts with public they are also at higher risk, as their finances and organizations providers, private hospitals, and community health centers are strained by budget shortfalls. Counties that instead rely to encourage use of primary care providers rather than more on contracting out services to private providers may emergency departments and to coordinate access to specialty save some money by doing so, but they may soon encounter care. In contrast, respondents in counties that assume smaller growing access problems if demand for safety-net services roles — particularly in the Central Valley (Fresno, Madera, overwhelms what the private safety net is willing or able to Tulare counties) — noted a lack of broad efforts to coordinate provide. Ongoing efforts to better coordinate services may health care delivery. help counties all along the spectrum, from those that operate Counties that play smaller safety-net roles, however, services directly to those that solely contract with private can still bring private organizations and policymakers providers. together to better coordinate safety-net services. Some of Similarly, national health care reform likely would affect these counties have established safety-net coalitions and counties differently. Counties having large safety-net roles 8 ©2009 California HealthCare Foundation might be better able to help low-income residents navigate About the authors Laurie E. Felland is a senior health researcher at the Center for Studying new opportunities for coverage and to help coordinate their Health System Change (HSC) in Washington, D.C. Aaron B. Katz is a care. Should federal legislation expand Medicaid eligibility, principal lecturer of health services and global health, and director of the local, publicly-operated Medi-Cal managed care plans global health leadership program, at the University of Washington, School could gain enrollment and county facilities could gain more of Public Health. He also serves as a senior consulting researcher at HSC. Medi-Cal patients and revenue. Alternatively, Medicaid or Johanna R. Lauer was a research assistant at HSC until August 2009. She is currently a graduate student at the University of Michigan School Medicare changes could eventually diminish public revenue of Public Health. HSC is a nonpartisan policy research organization that streams that county facilities currently rely upon to care for designs and conducts studies focused on the U.S. health care system to undocumented immigrants and others who likely will remain inform the thinking and decisions of policymakers in government and private uninsured. In that scenario, counties playing large safety-net industry. More information is available at www.hschange.org. roles could be left with costly infrastructures that are difficult to reorganize, whereas counties playing smaller roles may be About the Foundation more nimble in shifting resources in response to changes. For The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed example, if the need for medically indigent programs were in California. By promoting innovations in care and broader access to greatly reduced under federal reform legislation, counties information, our goal is to ensure that all Californians can get the care with small safety-net roles would be able to reallocate existing they need, when they need it, at a price they can afford. For more county contracts and funding to other local priorities. information, visit www.chcf.org. California Health Care Almanac is an online clearinghouse for key data and analysis examining the state’s health care system. For more information, go to www.chcf.org/topics/almanac. 9 ©2009 California HealthCare Foundation Endnotes 9. A few California counties outside of this study operate under a 1. California Welfare and Institutions Code § 17000: “Every county and county-organized health system model, in which a sole public health every city and county shall relieve and support all incompetent, poor, plan contracts with a network of providers to deliver care. Federal indigent persons, and those incapacitated by age, disease, or accident, legislation placed limits on the number of counties that could have a lawfully resident therein, when such persons are not supported and single county-organized health system and the number of enrollees that relieved by their relatives or friends, by their own means, or by state could be covered by them. See also Kelch, Deborah Reidy. Caring for hospitals or other state or private institutions.” Medically Indigent Adults in California: A History. California HealthCare Foundation, Oakland, CA, June 2005. Draper, Debra A. and Marsha 2. California Association of Public Hospitals and Health Systems. Growing R. Gold. September/October 2000. “Customizing Medicaid Managed Numbers of Patients Seek Care at California’s Public Hospitals as Economy Care — California Style.” Health Affairs 19 (5). Declines. CAPH Report. Oakland, CA, 2009; Colliver, V. September 9, 2009. “Newly Uninsured Up 50 Percent at Community Clinics,” 1 0. Kelch, Deborah Reidy, op. cit., 2005. San Francisco Chronicle. September 9, 2009. 1 1. See also Kelch, Deborah Reidy. The Crucial Role of Counties in the Health 3. The six regions are: Bay Area (San Francisco, Alameda, Marin, San Mateo, of Californians: An Overview. California HealthCare Foundation, Oakland, and Contra Costa counties), Sacramento (Sacramento, Placer, Yolo, and CA, July 2004. El Dorado counties), Fresno (Fresno, Madera, Tulare, Kings, and Mariposa 1 2. Department of Health Care Services, Medi-Cal Managed Care Division. counties), Los Angeles, Riverside/San Bernardino, and San Diego. This Quarterly Update to the Legislature: Medi-Cal Managed Care Program, analysis focuses on the 11 counties where interviews on the safety net were January through March 2009. conducted, which did not include Marin, San Mateo, Contra Costa, Yolo, El Dorado, Kings, and Mariposa counties. 1 3. Hines, Lora. August 23, 2009. “Inland Area Shortchanged on State Funds to Cover Health Care for the Poor.” The Press Enterprise. 4. Local Initiative (LI) health plans (in two-plan counties) and County Organized Health Systems (COHSs) are public agencies that can be 1 4. California State Board of Equalization. California Property Tax: An chartered by county boards of supervisors. LIs and COHSs are licensed Overview. Publication 29, August 2009. as health care service plans under state law but are not legal agencies or 1 5. Christianson, Jon B., et al. San Francisco Bay Area: Downturn Stresses departments of the county. County officials typically appoint and serve Historically Stable Safety Net. California Health Care Foundation, on the governing bodies of LIs and COHSs to varying degrees, but Oakland, CA, July 2009. counties have no legal risk or financial obligation related to the provision of Medi-Cal managed care by LIs and COHSs. 1 6. Brown, Richard E. Public Medicine in Crisis: Public Hospitals in California. California Policy Seminar, Monograph No. 11. Institute of Governmental 5. The board of supervisors is the governing body in California counties. It is Studies, University of California, Berkeley, 1981. typically composed of five or more members, each representing a separate district within the county. 1 7. Calvan, Bobby Caina. “Community Clinics Want County to Help Change System,” The Sacramento Bee, January 28, 2009. 6. National Health Law Program. State and Local Responsibility for Indigent Health Care: California. 1997. 1 8. Thorpe, Kenneth E., and Charles Brecher. Summer 1987. “Improved Access to Care for the Uninsured Poor in Large Cities: Do Public 7. Blue Sky Consulting Group. County Programs for the Medically Indigent Hospitals Make a Difference?” Journal of Health Politics, Policy and in California. California HealthCare Foundation, Oakland, CA, Law, 12 (2). Bindman, Andrew B., Dennis Keane, and Nicole Lurie. October 2009 (www.chcf.org/topics/view.cfm?itemID=134110). December 12, 1990. “A Public Hospital Closes: Impact on Patients’ 8. In addition to MISPs, virtually all of the counties studied operate other Access to Care and Health Status.” JAMA, 265 (22). programs to improve access to care or health insurance coverage for other low-income people, using federal, state, local, and/or private funding. For example, seven of the counties operate Healthy Kids programs, which provide insurance to low-income children who do not qualify for Medi-Cal or for the Children’s Health Insurance Program (CHIP), using state funding and philanthropy, and four of the counties also operate Health Care Coverage Initiatives to expand access to care for medically indigent adults with funding from a state Medicaid waiver. 10 ©2009 California HealthCare Foundation