Expanding the Safety Net: Counties Adjust to Provide Health Care to Uninsured, Undocumented

Earlier this year, a woman came into Contra Costa County Supervisor Mitchoff’s office in northern California. She had a message for the supervisor, but didn’t speak English, so they got somebody to translate for her.

Through the interpreter, the woman told Mitchoff that if she hadn’t gone in for a check-up, she wouldn't have had her breast cancer detected and removed in time. “She wanted to tell me how grateful she was. The program saved her life,” said Mitchoff.

The woman is one of many undocumented immigrants who have recently become eligible for their county’s indigent care program --which offers health care to patients who cannot afford insurance and are not eligible for Medi-Cal-- as counties throughout California expand their program’s eligibility.

In 2014, more than 3 million low-income patients were enrolled in Medi-Cal. With only 10 counties serving the undocumented population at the time of enrollment, including San Francisco, San Mateo and Los Angeles, 3 million - mostly undocumented - people were left uninsured.

Counties throughout California are obligated to provide care to low-income patients that are not eligible for Medi-Cal, through indigent care programs and following the implementation of the Affordable Care Act in 2014, many patients left the indigent care programs as they were enrolled in Medi-Cal.  Many indigent care programs, became nearly obsolete as enrollment plummeted, but programs throughout California are now thriving as services are made available to undocumented immigrants.

Undocumented immigrants were previously left out of the majority of county indigent care programs and were left with the option to buy their own insurance - not affordable for many undocumented families, 80% of which live in poverty -  or emergency services, one of two services offered to undocumented immigrants through Medi-Cal, the other being pregnancy-related services. Emergency services often fall short, offering only on-the-spot treatment for symptoms of chronic illnesses that deteriorate without treatment.

Contra Costa County was one of many counties that saw enrollment drop because of their restrictive eligibility requirements that excluded undocumented immigrants or set the income eligibility at or right above the poverty line.  Enrollment in Contra Costa County‘s indigent care program went from 11,000 patients in 2013 to zero patients in 2014. The program, which offered primary and specialty care coverage to patients whose income is less than 300% of the federal poverty line, did not offer services to undocumented immigrants.  

“We knew there was still a need for coverage,” said Contra Costa County Supervisor, Federal Glover, referring to the nearly 19,000 undocumented immigrants living in Contra Costa County.

Last year, Contra Costa County’s board of supervisors voted to restore the program that  provided indigent care to undocumented immigrants prior to the recession. Contra Costa Cares provides preventative and primary health care services and is capped at 3,000 patients. Since it began in December, the one-year pilot program has already enrolled 2,700 undocumented patients, said Contra Costa County Supervisor Karen Mitchoff.

“The Affordable Care Act dramatically expanded [Medi-Cal] coverage which is good news and potentially provides some savings to county indigent care programs that were previously taking care of that population,” explains Anthony Wright, director of Health Access California. “That doesn’t mean that the county programs don’t have a purpose. There still is a significant remaining uninsured population and so there are a number of counties that have been trying to figure out how to adapt and reorient their safety net programs to respond to the needs of that population.”

In anticipation of the Medi-Cal expansion, Governor Jerry Brown signed AB 85 in 2013 to recoup $900 million of about $1.4 billion in safety net funds the counties were receiving from state vehicle licensing fees. However, many counties still have surplus funding that they are using to reorient their programs to include more people and offer more services.  

The County Medical Services Program (CMSP) - a county indigent care program that spans 35 mostly rural counties in Northern California - will use surplus funds to help fund a two-year pilot-project that will expand the program’s eligibility requirements and benefits starting May, said Kari Brownstein, administrative director of CMSP.

The changes will extend eligibility to undocumented immigrants and will offer up to three combined primary and specialty care visits, a range of diagnostics tests and up to $1,500 in prescription drug coverage each enrollment term.

“Counties have the obligation to provide indigent care, but they interpret it very widely. In terms of what they provide and who they provide such services to depending on income and immigration status,” said Wright.

Sacramento County also began providing care to undocumented immigrants in January of this year and similar to the other counties, provides limited services, however, Sacramento County Supervisor Phil Serna, said they are hoping to change that soon.

The county used $6 million of its general fund to start Healthy Partners which currently offers primary care, women’s health services and preventative care.

“The program is very limited and doesn’t have a robust specialty care element yet. We are looking to incorporate our primary health care center as a facility where specialty care can be administered. Orthopedics and surgeries [...] we have both the potential for the personnel as well as the facilities to make it happen,” said Serna.

Like Los Angeles County, many well-established county programs are looking to enhance their services. My Health L.A. offers a coverage-like program to more than 120,000 patients, including undocumented.

In addition to primary and specialty care services and prescription medicines, My Health L.A. will be rolling out access to substance abuse disorder services in July and are currently in the process of expanding their pharmacy network, said Amy Luftig Viste, program director for My Health L.A.

Mitchoff said that although it’s too early to tell whether or not Contra Costa Cares will be successful, the health care director will be recommending that the county contribute $250,000 in the next fiscal year to keep the program going.

“There are those out there who don’t think we should be providing services to undocumented  individuals and that’s for another discussion - a political discussion.  My issue is about health care in the community and when people are well, other people don’t get ill. It’s very simplistic,” said Mitchoff.