A CARE RE­VER­SAL

In an about-face from a 2009 de­ci­sion, Sacra­mento County wants to re­store health clinic ac­cess to peo­ple in U.S. il­le­gally

Los Angeles Times - - CALIFORNIA - By Soumya Kar­la­mangla

Fac­ing a $55-mil­lion deficit dur­ing the Great Re­ces­sion, Sacra­mento County of­fi­cials made a choice: To save money, they would close their free health clin­ics to peo­ple who en­tered the coun­try il­le­gally.

Six years later, they want to re­verse that de­ci­sion.

“The real in­tent of the Af­ford­able Care Act, po­lit­i­cal or not, is to see to it that we’re all cov­ered,” said Sacra­mento County Su­per­vi­sor Pa­trick Kennedy, who was elected last year af­ter cam­paign­ing to re­store clinic ac­cess for th­ese im­mi­grants.

“We know the right thing to do, and that’s of­fer a level of health­care that’s avail­able to ev­ery per­son in Sacra­mento County.”

Cal­i­for­nia law has long re­quired county gov­ern­ments to pro­vide health­care to their poor­est res­i­dents, but most have not in­ter­preted that to in­clude those who’ve en­tered the coun­try il­le­gally. But now that al­most all of the other peo­ple coun­ties once paid the tab for have in­sur­ance un­der Oba­macare, some of­fi­cials think they can af­ford to re­con­sider.

Health ad­vo­cates say it’s a smart fi­nan­cial move. Peo­ple who en­tered the coun­try il­le­gally are barred from sign­ing up for Oba­macare, and with­out in­sur­ance, they can gen­er­ally visit only emer­gency rooms or free clin­ics. Giv­ing them ac­cess to care

through other means can pre­vent the spread of dis­ease and save money by of­fer­ing less ex­pen­sive pri­mary care that can catch or stave off se­ri­ous ill­nesses that are more ex­pen­sive to treat, Kennedy said.

So Sacra­mento su­per­vi­sors are set to vote this week to begin of­fer­ing health­care to res­i­dents who en­tered the coun­try il­le­gally. How­ever, the plan they’ll prob­a­bly adopt is a mod­est one: a $5mil­lion in­vest­ment that would pro­vide limited care to less than a quar­ter of that pop­u­la­tion.

A sim­i­lar pro­posal is mov­ing through the Leg­is­la­ture. And though that bill, SB 4, was orig­i­nally in­tended to cover more than 1 mil­lion Cal­i­for­ni­ans in the coun­try il­le­gally, it had been sig­nif­i­cantly whit­tled down by the time it passed the Se­nate this month, with pro­vi­sions to cover only a few hun­dred thou­sand. Now it heads to the As­sem­bly.

Th­ese de­ci­sions ref lect public agen­cies’ con­tin­u­ing tight bud­gets, but they also speak to a cen­tral prob­lem with the Amer­i­can health­care sys­tem — one the Af­ford­able Care Act aims to cor­rect.

Even though pro­grams and ser­vices may im­prove the gen­eral public health, of­fi­cials are re­luc­tant to spend money on them un­less they de­liver im­me­di­ate benefits.

“Very few or­ga­ni­za­tions have an eco­nomic in­cen­tive to in­vest in in­ter­ven­tions that im­prove health in the long run,” said USC health econ­o­mist Glenn Mel­nick. “That’s a real weak­ness of our health­care sys­tem.”

Ad­vo­cates ar­gue that easy and early ac­cess to med­i­cal care will save money for the health sys­tem over­all. With­out cov­er­age, peo­ple de­velop se­ri­ous ill­nesses and end up in hos­pi­tal emer­gency rooms, gen­er­at­ing big bills, said Daniel Zin­gale of the Cal­i­for­nia En­dow­ment, which is lead­ing a cam­paign to ex­pand health cov­er­age to all Cal­i­for­ni­ans. Those costs ei­ther in­crease hos­pi­tal prices and then in­sur­ance pre­mi­ums, or are sub­si­dized by the fed­eral gov­ern­ment with tax­payer money, he said.

“We can pay for it in the emer­gency room set­ting, we can pay for it through [in­sur­ance] pre­mium in­creases, or we can pay for it in a way that makes the most sense,” Zin­gale said.

But the way Zin­gale thinks would make the most sense — in­sur­ance-like cov­er­age through a gov­ern­ment — is a huge in­vest­ment that many county of­fi­cials are un­will­ing to make.

In Sacra­mento County, pro­vid­ing com­pre­hen­sive cov­er­age — pri­mary, spe­cialty and hos­pi­tal care — to 15,000 of the county’s 50,000 un­doc­u­mented res­i­dents would cost from $41.9 mil­lion to $52.3 mil­lion, ac­cord­ing to county pro­jec­tions. Though of­fi­cials didn’t cal­cu­late the cost for cov­er­ing all 50,000, San Fran­cisco County ran a pro­gram of sim­i­lar size for $150 mil­lion an­nu­ally.

“For me, this still comes back to the fact that we have a bud­get re­spon­si­bil­ity here,” Sacra­mento County Su­per­vi­sor Su­san Peters said at a re­cent hear­ing. “What­ever price tag it is, I want to know where the money is com­ing from.”

Su­per­vi­sors ac­knowl­edge that fund­ing th­ese pro­grams means less money for other city ser­vices, such as polic­ing, that can serve a broader swath of the com­mu­nity. Pro­vid­ing health­care to peo­ple who’ve en­tered the coun­try il­le­gally is also po­lit­i­cally un­pop­u­lar in many parts of Cal­i­for­nia, with only 11 of the state’s 58 coun­ties of­fer­ing some form of health­care to th­ese im­mi­grants.

It’s hard to make a fi­nan­cial ar­gu­ment as a med­i­cal provider or lo­cal gov­ern­ment for pro­grams that are sim­ply good for peo­ple’s health “be­cause the costs and benefits are not aligned,” said Steven Wal­lace, a pro­fes­sor of health pol­icy at UCLA.

For in­stance, if a clinic for unin­sured pa­tients in­vests in a can­cer screen­ing that catches a tu­mor early, it does a huge ser­vice for the pa­tient and saves money for the hos­pi­tal that might have had to pro­vide more ex­pen­sive treat­ment when the dis­ease grew worse. But the clinic has made no money off that in­vest­ment.

One of the main goals of the Af­ford­able Care Act is to fix many of th­ese mis­aligned fi­nan­cial in­cen­tives, which have of­ten been blamed for driv­ing up the na­tion’s health­care costs.

Doc­tors typ­i­cally haven’t prof­ited from a pa­tient not need­ing med­i­cal care. Tra­di­tion­ally, providers have been paid on a fee-for-ser­vice ba­sis re­gard­less of whether a pa­tient’s health im­proved. Now, many re­ceive a lump sum to take care of a pa­tient over a pe­riod of time, so they profit when they pre­vent them from get­ting sick, avoid­ing the need for more ex­pen­sive care.

In a sign of the grow­ing shift away from that fee-forser­vice model, fed­eral of­fi­cials an­nounced in Jan­uary that Medi­care, the gov­ern­ment’s big­gest health in­sur­ance pro­gram, would han­dle half its pay­ments based on qual­ity of care by 2018.

But that won’t change any­thing at the county gov­ern­ment level.

In Sacra­mento County, ex­pand­ing health cov­er­age to in­clude some un­doc­u­mented im­mi­grants may re­duce ER and free clinic vis­its but still “as a county ... you’re not sav­ing money in the county’s gen­eral fund bud­get,” Wal­lace said.

And fi­nances re­main tight for Sacra­mento County.

County gov­ern­ments lost money when the Af­ford­able Care Act was im­ple­mented, be­cause the state took back mil­lions in health fund­ing to fi­nance an ex­pan­sion of Medi-Cal, the state’s health pro­gram for the poor, which now in­sures mil­lions of low­in­come Cal­i­for­ni­ans who once re­ceived care through coun­ties. In Sacra­mento, fund­ing for their health pro­gram dropped from $42 mil­lion to $13 mil­lion, ac­cord­ing to of­fi­cials.

Hugo Mar­quez, who works in Sacra­mento, told su­per­vi­sors at a re­cent meet­ing that he’d ben­e­fit from county med­i­cal care. He has a her­nia and a mis­aligned spine for which he can’t af­ford treat­ment.

“The only thing I know is life here,” he said. “I work day to day, five days a week, eight hours, like the Amer­i­can dream.”

He’s wor­ried, he said, that he won’t be able to sup­port his wife and two kids if the in­juries get worse.

Su­per­vi­sor Phil Serna, the Sacra­mento County board chair­man, said he thinks health­care is es­sen­tial. He ac­knowl­edges that the pro­posed in­vest­ment is small but said he is happy the county is poised to take this first step.

“If we had un­lim­ited rev­enue, we would try to pro­vide un­lim­ited ser­vices, but that’s just not the case,” Serna said.

Le­zlie Ster­ling

AN­DREA TOR­RES

applauds at a Sacra­mento County work­shop that con­sid­ered op­tions for restor­ing health ac­cess to im­mi­grants.

Hec­tor Amezcua

AKIKO ASPILLAGA of San Fran­cisco reads a poem as back­ers of SB 4 rally at the Capitol. The bill nows heads to the As­sem­bly.

Le­zlie Ster­ling Sacra­mento Bee

BISHOP JAIME SOTO of the Sacra­mento Catholic Dio­cese waits to speak at a Sacra­mento County su­per­vi­sors work­shop on health clinic ac­cess for im­mi­grants.

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