After 30 years of providing health services to undocumented immigrants, Fresno County says the Affordable Care Act makes it too costly to continue.
So the county is taking steps to end the program. It could be the first in the state among counties that offer services to everyone regardless of immigration status to end indigent health care for thousands of the undocumented.
According to a recent health-safety net report, Fresno and eight other counties provide health services to undocumented immigrant adults. But only Fresno is actively trying to eliminate the care, according to a survey of the counties last week by The Bee.
Fresno County is in court trying to terminate a 1984 injunction requiring it to care for the undocumented. The county says a $14 million cut in state funds for indigent care this year gives it no choice.
But advocates for undocumented immigrants say Fresno County wants out of more than the health-care business for the undocumented. The county is using the federal Affordable Care Act as a scapegoat to quit a $20 million indigent-care contract with Community Medical Centers, they say.
"This affects more than just the undocumented people," said R. Toma Tawatao, a lawyer with the nonprofit Western Center on Law & Poverty who is opposing the county's bid to get the undocumented injunction dissolved.
Fresno County contends the injunction covers only undocumented health services. But it has made no secret that the Community contract — which provides care for legal residents as well as undocumented immigrants — will have to end or change because of the reduction in state funds for indigent care.
The move comes as no surprise to Community Medical Centers, which expected the Board of Supervisors "might exercise its right to unilaterally end the contract," John Zelezny, senior vice president of communications, said Thursday.
But before that can happen, the 1984 injunction must be lifted, John Pomaville, the county's interim public health director, said last week. The soonest that could happen is Feb. 26 at the next scheduled hearing in Fresno County Superior Court.
The county had hoped its motion to quash the injunction would be approved on Dec. 19, but Judge Donald S. Black continued the hearing to Dec. 31 and allowed Clinica Sierra Vista, which operates community health centers in Fresno, to argue for the injunction to remain. Clinica took over clinics run by Sequoia Community Health Foundation, the original plaintiff, when it went bankrupt in 2008.
In the meantime, supervisors likely will weigh in on the injunction this month. Board Chairman Henry Perea said Thursday he doesn't support the county's action and wants a discussion on it.
Perea and other supervisors agree, however, that the county won't have enough money to pay for indigent care unless it moves money now allocated for other services. "Where do we start shifting those dollars to provide that care? I don't have that answer today," he said.
Supervisor Phil Larson said undocumented immigrants should be medically served, but the county's hands are tied. Larson said he blames the Affordable Care Act for stripping funding from indigent care.
The county says about 4,500 to 5,000 undocumented people remain uninsured today in the program. The health care for the indigent program costs about $5,000 per patient per year and to continue care for the undocumented would cost at least $25 million, Pomaville said.
Fresno County expects to get $18 million this year from the state for indigent and public-health services, he said. Last year, the county received $32 million.
The state's rationale for reducing funding: The county's indigent program will have less demand as more people get federally backed coverage, such as Medi-Cal, the state-federal insurance for the low-income.
The state considered the lower number of indigent patients but also per-patient costs when devising funding formulas, said Norman Williams, spokesman for the state Department of Health Care Services.
Tawatao said Fresno County has rushed to make financial assumptions that could affect thousands of people.
"I don't think they've made the showing or really spelled out exactly how the (state) realignment funds and also the ACA is going to result in the loss that absolutely requires them to make the cuts that they say they need to make," she said.
Other counties understand that the full effect of the Affordable Care Act, also known as Obamacare, is still unknown, Tawatao said. Open enrollment for federally subsidized individual health plans continues through March 31, she said.
The county's budget concerns must be weighed against the harm that could be caused by cutting off undocumented immigrants from health care, Tawatao said.
Supervisors said excluding undocumented immigrants from the county's indigent program would not leave them without health care. Clinica Sierra Vista provides primary care to anyone regardless of immigration status or ability to pay; and hospitals cannot deny care to anyone who comes to the emergency department, they said.
But Clinica CEO Stephen Schilling said his health centers offer only primary care. Patients who need specialists or special diagnostic tests are referred to providers outside the clinics. Indigent patients, including the undocumented, now have specialists through the county's the Medically Indigent Services Program, he said.
If the county contract ends, Schilling said his only option will be to send patients to emergency rooms for specialist care.
Under state statute, counties are supposed to set up indigent health programs. But the counties determine how to design the programs and whether to include undocumented immigrants.
According to the Health Access Foundation, a statewide health-care advocacy organization, a survey of county safety-net programs found nine counties provide services regardless of immigration status — Alameda, Fresno, Kern, Los Angeles, Riverside, San Francisco, San Mateo, Santa Clara and Santa Cruz.
Alameda County has decided to continue the current level of service to the undocumented, but not without financial sacrifice, said Alex Briscoe, health director. "We anticipate it will cost Alameda County approximately $15 million of additional net county costs," Briscoe said.
The decision was based on the belief that "health care is a basic human right to be provided regardless of immigrant status," he said.
Briscoe said he personally and professionally disagrees with Fresno County's effort to exclude undocumented immigrants from indigent health services, but understands the scarcity of resources to provide the care.
"As health reforms go down, health departments are having to make these painful choices," he said.
Anthony Wright, executive director of Health Access, said Thursday he was not aware of Fresno County's move to exclude undocumented immigrants, but it goes counter to the area's needs, he said: "These are folks who are a vital part of the Fresno community, commercially, culturally and they need to be included in the health-care system."
The reporter can be reached at (559) 441-6310, email@example.com or @beehealthwriter on Twitter.