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Indigent Health Care Program Battered by Recession

New America Media, News Report, Annette Fuentes Posted: Feb 25, 2010

Californias county health care programs for the poor face growing demand from the newly unemployed and uninsured. At the same time, funding for services is evaporating in the economic downturn, raising alarms from public health officials and providers.

Called the County Medical Services Program (CMSP), it was created in 1983 when MediCal shed its coverage of indigent adults. It is considered the health care provider of last resort for people 18 to 64 who have no other insurance. And now more and more Californians are in need of its services.

Ive worked in the clinic system for 30 years, and were going through a time like weve never seen before, said Dr. William Walker, director of Contra Costa County Health Services. Its a meltdown of the American health care system.

In 34 mostly rural counties, (those with a population of 300,00 or fewer), CMSP is overseen by a governing board of county officials. In the states 24 other more populous counties, the program is administered by each county, which sets its own eligibility levels and services provided. Most offer a menu of services similar to MediCal, with some limitations. Some counties, like Alameda, Los Angeles and Kern, serve undocumented immigrants. Most others do not. Counties can contract with private clinics, or provide care at their own medical centers.

None of the programs receives federal or state funding. All depend upon whats called realignment funding, from vehicle registration fees and county sales tax. In the recession, both funding streams are drying up, say administrators.

All counties are suffering a loss of realignment funding, said Lee Kemper, executive director of the rural counties CMSP.

At the same time, more and more people are eligible for services, pressuring limited capacity.

Kemper said the program had built up a funding reserve through good budgeting, but that wont last. Were pretty good for this fiscal year through June 2010, he said. Then the following year we anticipate trouble.

Counties set CMSP eligibility at up to 200 percent of the federal poverty level and charge a co-pay for those who can afford it. In fiscal year 2006-2007, their programs served on average 42,000 patients a month and paid $205 million for services. But in the last two years, enrollments jumped.

Now, Kemper said, at least 53,000 people use the clinics every month, with some patients returning again and again. And because the program is temporary and people drop out, the total number of individuals served by CMSP clinics over the year has surpassed 100,000.

The largest increase in CMSP patients has been among those who have the lowest incomes and therefore arent charged a co-pay. What were talking about is people behind these numbers, said Kemper, who were affected by the economy, who lost hours or lost jobs.

Alameda Countys CMSP has seen similar growth in need, mostly from the newly unemployed, and a parallel drop in revenues to fund it. according to health services finance director Vana Chavez.

In fiscal year 2007-2008, Alamedas indigent health program served 56,000 unduplicated patients at the county medical center and a network of 25 community clinics. A year later, it served 60,200. Currently, she said, At any time we have between 60-65,00 enrolled, and that doesnt necessarily represent the need. But we dont take applications if we dont have the capacity.

Capacity is limited by funding and funding is plummeting, Chavez said.

In FY 2008-09, realignment revenues were down $16 million. This year, Chavez expects another $10.5 million drop because of the continued recession. The sales tax was taking a terrible header down, but these last two months, that is picking up, Chavez said. What is really taking a hit is the vehicle licensing fee. Nobody is buying cars.

Alameda also funds indigent and underserved patients through a half-cent sales tax approved by voters as Measure A. But that, too, has declined by 28 percent, Chavez said, and this year she expects the program reserves will be depleted. Weve done everything we can this year to try to save revenue. Were in a hiring freeze. Any discretionary spending is scrutinized, Chavez said. Ive worked in this capacity for 20 years and Ive never seen anything like this.

Contra Costa County has two programs for the uninsured one that sets eligibility at 300 percent of the federal poverty level, and one that sets it at 200 percent (which receives some federal funding). It serves CMSP patients at the County Regional Medical Center in Martinez and 11 county and private clinics. As elsewhere, the demand has climbed as the economy has tanked.

According to county director Walker, the demand is reflected in usage data from the hospital and clinics. Our inpatient discharges are up 8 percent from the hospital since the economy crashed. Emergency visits are up 33 percent, Walker said. At health centers around the county, utilization is up 13 percent in east county, and 12 percent in the central county. It doesnt take rocket science to figure out that people have lost their jobs and their health insurance.

Walker said he is astounded by the large number of people who had been covered by Kaiser or Blue Cross insurance and now find themselves unemployed and uninsured for the first time.

They have never been through this before, he said. They dont know where to turn. They may delay coming in, or be off their meds for while, he said. We had some people who were cut off in the middle of their chemotherapy because the insurance companies dont care what happened. Crazy stuff like that is happening.

Contra Costas budget is strained and faces more cuts from the state, Walker said, putting more stress on medically indigent services in terms of financing and physical capacity to serve more people. Were trying to hold the pieces together. We were hoping to keep it together until health reform takes effect, but it doesnt look like that is going to happen, he said.

Meanwhile, he is working to build partnerships with private health care providers, including Sutter Health Care, John Muir and Mt. Diablo medical centers to serve the uninsured. We have to figure out how we can all step up to the plate, Walker said.

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