Low-income people in Fresno County have to be poorer than people who live any place else in the state to get free medical care. But that could change with the release of a cost-of-living study this month, say advocates for the poor.
The study was prompted by a lawsuit contesting the county's eligibility rules for its Medically Indigent Services Program. It found that to live at a subsistence level takes $1,284 a month for a single adult -- more than twice the $509 monthly income limit the county currently has for someone to be eligible for entirely free medical care.
Fresno County hasn't changed eligibility levels in 14 years.
Changing the limits could shake up the county's relationship with Community Medical Centers, which has a 30-year contract with the county to provide care for indigent patients and jail inmates. A higher income cut-off would allow more people -- particularly the working poor -- to receive services.
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Regardless of its effect on enrollment, however, Fresno County's eligibility should be based on a reasonable evaluation of what it costs to live in the county, said Jen Flory, an attorney for the Western Center on Law and Poverty, a Los Angeles-based law firm that specializes in litigation for the low-income.
Flory represents David Piercy, a Clovis man who sued the county in 2008 when he was denied help to pay for epilepsy drugs because his monthly income was $24 above the county's cut-off.
"I am hoping the income level will be raised significantly so more people can access the program," Flory said.
Fresno County Counsel Kevin Briggs said the eligibility issues are in front of the court. "It would be inappropriate for me to comment on them now," he said.
Fresno County's eligibility levels -- at 56% of the federal poverty level -- are the lowest in the state, said Joel Diringer, who recently completed a study of the county's medically indigent program as a consultant for Fresno Healthy Community Access Partners, a nonprofit organization that works to improve access to health care.
Raising the eligibility level would be "a good step and an important step" for the program, he said.
Dr. Edward Moreno, the county's health director, said he will provide the Board of Supervisors on Feb. 23 with a report that will "deal with the medically indigent services program." Because of the litigation, Moreno said he could not comment on what the report would propose.
The push to loosen eligibility levels in Fresno County comes as counties statewide struggle to pay for the care. Most of the funding is from vehicle license fees, which dwindled in the past two years and remain low, as fewer cars are being sold. At the same time, more people need the help in the economic downturn.
In fiscal year 2007-08, the latest for which figures are available, there were 10,331 people in Fresno County's program. The county covers people between the ages of 21 and 64, including undocumented citizens. The health services mirror those of Medi-Cal, the state-federal insurance program for the poor.
If the eligibility limit was set to the federal poverty level, there would be about 40,000 adults eligible to have their health-care needs covered, said Diringer. Not all would apply, however, he said.
This fiscal year, Fresno County will pay nearly $19.8 million to Community for indigent and inmate care.
Community is aware that the county is looking at eligibility levels for the medically indigent program, but it will wait to see what action the county takes before commenting on how it might affect patient volumes, said John Zelezny, senior vice president of communication.
Community's contract can be renegotiated if the number of indigent patients increases by more than 10%, Moreno said.
Counties have the flexibility to determine eligibility and the scope of benefits for the medically indigent, but by law they are required to provide health services to uninsured adults who don't have Medi-Cal or Medicare and do not have the ability to pay for health care themselves.
This fall, for example, Stanislaus County decided to charge more adults a "share of cost," similar to a deductible paid by people with private insurance. People who never before had paid a share of cost now suddenly have bills -- some in the hundreds of dollars. The eligibility level remained unchanged at 200% of the federal poverty level, which in 2009 was $903 for a single adult.
"We're trying to do the best we can to provide medical care with limited resources," said Mary Ann Lee, managing director of the Stanislaus County Health Services Agency.
But attorney Flory said the law is on the side of the low-income. Rulings have tended to favor the position that counties have a responsibility to pay for the care -- and cannot deny services based on rigid income limits, she said.
Results of Fresno County's subsistence study make it clear that the current eligibility limits are too low, Flory said.
The study said the subsistence level for housing for a single adult in Fresno County is $600 a month, including utilities. The cost of food is another $197; transportation is $123; clothing and household supplies are $109; and subsistence health-care costs are $255 a month.
Fresno County caps income for the medical indigent program at $764 a month for a single adult. An adult with an income of up to to $509 a month gets total free care, while people with incomes between $510 and $764 get services -- but pay a share of cost, based on their incomes.
Flory said people like her client, David Piercy, don't have money at the end of the month to pay for health care.
The lawsuit, filed in Fresno County Superior Court, seeks to have the county's eligibility limits based on what it costs to subsist in the community, and that the eligibility income limit not be inflexible.
Piercy lived on $788 a month. But the county would not waver from its income limit to help him, she said.
He applied for the medical indigent program after insurance ended when he was laid off from a job as a medical assistant at Community Regional Medical Center in January 2008. He couldn't afford $1,200 a month for the drugs he needed to control epileptic seizures, he said.
But when he applied for help, Piercy said he was told: "You make $24 too much to get the medicine."
He didn't know day-to-day or week-to-week if he would have the medicine to prevent seizures, Piercy said. Family helped pay for about a two-week supply and pharmacies worked with him. But he suffered panic attacks and depression.
"I can't imagine people who have heart drugs or dialysis that get turned away," he said.
Piercy is a student at Fresno City College and hopes to get into the nursing program. He now has Medi-Cal because of his disability. The part of the lawsuit asking that he be put on the medical indigent program is moot. He is asking for monetary damages of an unspecified amount.
But not everyone who is poor is eligible to get Medi-Cal, the state-federal insurance program for the elderly, disabled and low-income families. Mostly, Piercy wants the county to change its eligibility rules so others can receive services. He represents the group of people who are denied because of income limits, said Yolonda Reeves, an attorney at Central California Legal Services, who is a co-counsel on the case.
Reeves and Flory said the lawsuit with the county was put on hold until the county could complete the cost-of-living study and make a report.