This year, San Diego County accepted $50 million from the federal government to launch a new program to improve health care for the county’s poorest uninsured residents.
Under the program the county started in July, poor singles and couples can now get health care benefits similar to Medi-Cal, the state’s safety net program that used to be only for poor, disabled people and families with children.
Over the next two years, the infusion of federal dollars will improve care for thousands of people in San Diego who earn less than 133 percent of the federal poverty level, about $1,207 a month for a single person.
Before, they could only get treatment if they needed urgent care. The new program will provide them with a primary doctor, preventive care and regular checkups.
Those changes represent a dramatic shift in San Diego County, which has long resisted having to pay for even basic emergency treatment for the poor.
The new program, called the Low Income Health Program, came at the urging of the federal government. It offered to pay up to half the cost for counties to enroll as many people as possible between now and 2014. That’s when the new federal health care law will shift people enrolled in the program onto Medi-Cal, and the federal government will assume the full cost of covering them.
San Diego County officials have historically been  reluctant to provide medical care on the county’s dime, and courts have repeatedly had to order the county to do more. But this time county officials have jumped at the new program because it’ll improve care while allowing the county to split the cost.
They have already enrolled nearly 15,000 people in the program – including 3,000 who were previously enrolled in County Medical Services, the county’s program of last resort that covers emergency care and is fully funded from county coffers. The shift has allowed them to begin passing the cost of treating the poor to the federal government.
Unlike some of California’s large counties, however, San Diego did not go as far as it could have to improve health care for low-income residents.
It rejected millions more in federal dollars that would have allowed it to improve care for people who earned too much to qualify for the Medi-Cal program but still were too poor to afford their own health care.
In 2007, the county accepted $13 million in annual federal grants that allowed it to do that. It provided specialized treatment to thousands of people with diabetes or hypertension. County officials trumpeted the program as evidence of their commitment to treating people who couldn’t afford their own care.
This year the feds offered San Diego County millions more to keep the program going.
But the county turned that money down. Instead it shifted about 9,000 of the poorest people from that program onto the new one, left a few hundred with higher incomes in place, and stopped allowing new people to enroll.
Michael Workman, a county spokesman, said in an email that given the county’s limited resources, it was focusing on expanding treatment for the neediest, lowest-income people in San Diego.
Under the original program for people with higher incomes, the county was allowed to set strict rules for who qualified. It enrolled people with diabetes and hypertension who earned up to twice the federal poverty level.
But now, the federal government wants local agencies to enroll as many poor uninsured people as possible in health programs to make it easier to transition them onto government-subsidized health plans when the new health care law takes effect in 2014.
So it told the county that if it accepted the federal money for the more moderately poor, it could no longer restrict that program to just diabetics.
That meant the county faced the possibility of thousands more people getting coverage. The county would have had to pay for half, committing it to spending potentially millions more depending on the number of people it sought to enroll.
“San Diego was moving from a small program where they had a targeted population of just the diabetics,” said Dylan Roby, a researcher at the University of California, Los Angeles who is evaluating the state’s new health programs. “Then when the new [program] came along, all of a sudden they were told you have to expand it to everybody in your county, not just diabetics.” That was a daunting prospect, Roby said.
So the county has opted only to expand coverage for the county’s poorest.
Still, Roby said the county’s decision not to accept money for both programs could have consequences later on. The federal grants are intended to start enrolling people in government health care programs now in order to reduce the workload for doing so when the federal health care law takes full force in two years.
The longer people remain uninsured after the law takes effect, Roby said, the longer they’re likely to fall back on the county’s last-resort program for emergency care and be an unnecessary drain on county coffers.
Steven Escoboza, president of the Hospital Association of San Diego and Imperial Counties, said hospital officials prefer treating patients receiving Medi-Cal benefits over patients on the county’s last-resort program because the county reimburses them at a higher rate.
But they also understand that the county may lack the ability to launch both federally subsidized programs at once, he said.
“We’re pushing to open the doors as much as possible,” he said. “But their approach is incremental.”
Correction: In our original version of this story, we called the county’s new health care program for low-income people Medi-Cal. It’s not. It provides health care benefits like Medi-Cal’s, but it’s actually called the Low Income Health Program. The people participating in the program will be formally enrolled in Medi-Cal in 2014.
Adrian Florido is a reporter for voiceofsandiego.org. He covers San Diego’s neighborhoods. What should he write about next?
Contact him directly at email@example.com  or at 619.325.0528.
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