California's 58 counties, each operating its own health system under an established set of rules over the past several decades, are undergoing fundamental shifts in how they provide health care for low-income residents.
The rules are changing.
The two biggest vehicles of change are the Affordable Care Act and its Medicaid expansion. In addition, the relationship between state and county governments in California is being realigned, shifting responsibility and funding for physical and mental health care.
Any one of those vehicles alone would keep officials busy. Together, they make for tumultuous times in county health offices.
"There's certainly a lot going on at the county level right now," said Cathy Senderling-McDonald, deputy executive director of the County Welfare Directors Association of California.
"A lot of work went into getting ready for the Oct. 1 kickoff and there is a lot of continuing work toward the Jan. 1 go-live date. What I think we're seeing is that the work has paid off so far. I think counties are as ready as they can be at this point," Senderling-McDonald said.
Dylan Roby, a researcher at the UCLA Center for Health Policy Research, said county health systems will continue to have unique approaches, as they have for decades, but some shifts will be universal.
"County-based providers will need to compete for patients in Medi-Cal and Covered California," Roby said. "Each county will have to decide how to compete -- in partnerships or on their own. Insurance plans will now be making care decisions instead of the counties themselves." Medi-Cal is California's Medicaid program.
Demographic and political influences will continue to shape county governments, but new rules governing health care may change the decision-making chemistry in some counties.
Bridge to Reform Leads to Good Place
After years of debate about whether to build it, controversy around designing it and uncertainty about the solidity of terrain on the other side, California's "Bridge to Reform" leads to a good place for close to one million low-income Californians and the state officials charged with providing them health coverage, according to researchers and stakeholders.
"I think it's accurate to say the bridge worked for people in the Low Income Health Program. It's given us a huge head start on Medi-Cal expansion that other states didn't have," Senderling-McDonald said.
LIHP was part of California's 2010 Section 1115 Medicaid waiver, known as the "Bridge to Reform."
"It wasn't the only part of the bridge," Roby said, "but LIHP seems to be the most important as we move toward Jan. 1."
Fifty-three counties participated in LIHP and 886,000 Californians enrolled, Roby said during a webinar presentation last week. Roby co-wrote a UCLA safety-net study released last week that examined California's experiment with LIHPs.
The UCLA study, "Safety Net Delivery System Redesign in California: Innovations in the Low Income Health Program," surveyed LIHP program administrators and primary care providers within LIHP networks to assess system redesign efforts during LIHP. In addition, it examined 10 counties that participated in the Health Care Coverage Initiative program, a precursor to LIHP.
Senderling-McDonald said the value of LIHP continues to grow.
"In the last week and a half alone we've seen a significant increase in LIHP enrollments," Senderling-McDonald said. "Before LIHP expires in two or three months, it will get bigger.
"When people walk in our door -- actually or virtually -- we are finding large numbers qualify for LIHP. We can't say yet how many, but anecdotally, it seems that a large percentage of folks who are looking into coverage now will be eligible today for LIHP in counties that have them. Some counties have caps on LIHP enrollment, but I don't think most counties have hit those caps," Senderling-McDonald said.
Counties Still Responsible for Uninsured
One constant remains in this swirl of change: Counties will continue to be responsible for providing health coverage for uninsured and indigent Californians.
The County Welfare and Institutions Code, which requires counties to provide indigents access to health care, is not changing.
How counties meet this obligation will change, but not the need to meet it.
Counties will be making several decisions in coming weeks and months to determine how they'll care for indigent and uninsured -- known as "residually uninsured" -- after the ACA's individual mandate takes effect.
"There will be a big variation in how counties meet their Welfare and Institutions requirements," Roby predicted. "The remaining uninsured are still going to be a significant issue. Many will be eligible for coverage but not taking advantage for one reason or another.
And many won't be eligible because of immigration status," Roby said.
Nine California counties now provide care for undocumented immigrants. That number may change in 2014.
A report released last week by a consumer advocacy group showed a wide variation in indigent care among California counties. The Health Access report, California's Uneven Safety Net: A Survey of County Health Care, estimates as many as three million Californians will still be uninsured even after the ACA is fully implemented.
Counties have been reshaping their systems for months as part of a long-planned realignment of state and county responsibilities for health coverage. But more decisions are due soon to set the stage for new rules under national health care reform and expanded Medicaid coverage.
Counties are faced with a complex set of equations dealing with varying degrees of poverty measured against the federal poverty level, matching funding from federal and state coffers, differences between county-run health plans and private plans, and changes inherent in shifting from fee-for-service to managed care Medi-Cal.
"We've all been dealing with a lot of uncertainty to this point -- and that will certainly continue to some degree," Senderling-McDonald said. "But I think it's safe to say we're as ready as we can be at this point."