Fresno County lags most of California in embracing President Barack Obama's health-care reform, meaning thousands of uninsured residents could face delays in getting new federally funded medical care next year.
County leaders say they can't afford to participate in a state program that already has begun integrating federal health care policy and signing people up for coverage.
While many counties will be ready to put their uninsured residents on federal rolls and assure them services come Jan. 1 -- when the Affordable Care Act starts in earnest -- Fresno County is yet to figure out its transition.
"The folks who need health care are just not going to get it," said former executive director of Fresno Metro Ministry Richard Yanes, who has been following federal reform efforts in Fresno County. "The process of taking an individual applicant through the system so that the individual is getting benefits is not easy to set up. And we're so far behind."
Next year's reforms require the county to confront another equally difficult issue: what to do about undocumented residents who won't qualify for new federal health care.
"Conversations that should be taking place now are just not," Yanes said.
Already, county officials have been hit with one lawsuit for not moving forward with the statewide transition program, dubbed the Bridge to Reform or Low-Income Health Program.
In a settlement with Central California Legal Services Inc., the county agreed to reconsider the transition program but the county has no obligation to adopt it.
Money already tied up
The county's lack of progress on federal health-care reform is tied to a tricky financial situation.
State money that the Board of Supervisors had wanted to use to launch the Low-Income Health Program, which 51 of 58 counties have adopted, already is locked up in care for the uninsured. The county pays Community Regional Medical Center $20 million annually for emergency and drop-in services for people who have no other medical option.
The Low-Income Health Program, by contrast, estimated to cost $28 million annually, would draw matching federal dollars to extend full health-care coverage to some 12,000 county residents -- temporarily. The coverage would end as residents are transitioned to the federal rolls Jan 1.
Since the Low Income Health Program would cover only a fraction of the county's uninsured, county supervisors have prioritized the safety-net contract over the state program. The county doesn't want to spend money on both.
County and hospital officials have discussed running dual programs, but can't make a deal.
"I'm disappointed we couldn't do a Low-Income Health Program," said Ed Moreno, director of the county's Department of Public Health, who had initially tried to start the program. "Unfortunately, we were not able to come to an understanding with the hospital on how to make that happen."
Other doubts have arisen about the Low-Income Health Program. Supervisor Judy Case has wondered whether the county would receive adequate federal reimbursement -- some counties have reported problems -- and she is concerned that costs of the program might escalate.
Most board members say the program is all but dead -- for now.
Moreno acknowledged that not having the Low-Income Health Program has meant forfeiting coverage for many county residents and likely will make preparations for next year's federal reform more difficult.
Behind the curve
The centerpiece of the Affordable Care Act is the expansion of health care scheduled for next January.
The legislation will allow the uninsured to get coverage either by buying it through newly created insurance exchanges or enrolling in federally expanded Medicaid, the joint federal-state health program for the poor.
In California, the expansion of Medicaid, also known as Medi-Cal, begins with the counties. Gov. Jerry Brown this month offered two possible scenarios for how counties will administer the expanded coverage. The state is yet to select which option to go with.
The first option asks counties to extend current Medi-Cal programs and cover all Californians with an income up to 138% of the federal poverty level, about $15,400 annually for an individual. More than 1.4 million people would be newly eligible statewide, according to the UCLA Center for Health Policy Research.
The tab for the new enrollees would be picked up by the federal government for three years and after that, the state would be asked to contribute.
The second scenario directs counties to continue their Low-Income Health Programs and offer coverage to roughly the same uninsured population but with counties -- not Medi-Cal -- coordinating the care. Terms for this option, including federal reimbursement, are yet to be worked out.
No matter which scenario is selected, Fresno County is behind the curve, say state and local health officials. The option that involves setting up a Low-Income Health Program, however, would require more work on the part of the county and make it harder to catch up.
"It's like Fresno (will be) flying the plane and building the plane at the same time. That's essentially how I think we're going to be operating, which is risky and prone to errors," said Norma Forbes, executive director of local health advocacy Fresno Healthy Community Access Partners.
Anthony Wright, executive director of state advocacy Health Access, described Fresno County's situation as a "scramble" to quickly do outreach to the uninsured, get health-care providers on board and coordinate financing.
County health officials say the state needs to decide how counties will proceed before they can completely assess their workload.
About 159,000 affected
About 159,000 people are uninsured in Fresno County, according to Sanja Kovacevic, deputy director of the county Department of Social Services.
The department has identified about 29,000 people who initially would be eligible for federally funded coverage. Most of the newly eligible will be families that are just above Medi-Cal's current income caps and low-income adults who don't have children. (Those with children currently get Medi-Cal.)
"I'll really be happy when the first of next year comes," said Connie Sanchez, 53, who works part-time at a Fresno discount store where she doesn't get enough hours to qualify for her employer's insurance.
She also has no children, meaning no Medi-Cal.
She has been sick recently, but because she has no coverage she hasn't had much choice for treatment beyond over-the-counter drugs.
"I'm sure that if I would have gotten medical attention, I would have gotten better sooner," she said. "And I still haven't gotten better. I have some wheezing in my throat."
Sanchez is happy that her ailment isn't too serious.
Reason to stay
County health officials want to keep the Community Regional Medical Center contract for many reasons. Providing a health-care option for undocumented residents is a big one.
Most others who receive services under the contract will be eligible for coverage elsewhere once the federal expansion rolls out.
But undocumented residents will not qualify for that new coverage -- nor are they currently eligible for Medi-Cal.
Community Regional estimates that about one-third of the patients it serves under the county contract are undocumented -- as many as 6,000 a year.
Counties are required to have some safety nets for anyone without coverage, so Fresno County -- which shuttered its county hospital, University Medical Center, in 1996 -- is motivated to keep its Community Regional contract.
But the county has pressed the hospital for cheaper contract terms since the demand for safety-net services is likely to fall off. Hospital officials counter that the $20 million cost covers only 25% of their expense and they've appeared unwilling to drop the price.
The contract was negotiated in 1996 and runs for 30 years.
While county officials acknowledge it's a good deal, state funding that pays for the contract eventually could dry up.
Officials with the state Department of Health Care Services say they're exploring ways to recoup money from counties as the federal and state governments pick up an increasing share of local health-care costs. How they will do this remains to be seen.
"The question is how much money is going to remain for the contract, and will it be adequate," Yanes said. "The county has been afraid to talk about this because there's going to have to be change, and the change is going to cost them money."
Staff writer Barbara Anderson contributed to this report. The reporter can be reached at (559) 441-6679, firstname.lastname@example.org or @KurtisInValley on Twitter. ___