Patient Flow Enewsletter
Volume 1, Issue 3
Thursday, February 26, 2004
Faced with a startling budget shortfall, California Gov. Arnold Schwarzenegger has said that he will contain health care costs by dramatically restructuring Medi-Cal, the state's free health care program for poor and uninsured residents. While the changes may help curb costs, experts fear they will also end free medical care for thousands of Californians, thereby clogging already overcrowded emergency rooms and putting even more stress on the local providers and institutions that make up the state's health care safety net.
Particularly hard hit could be San Diego County, where hospitals provided more than $325 million in uncompensated care in 2002, and where nearly 340,000 Medi-Cal recipients reside.
Over the past few decades, the county's role in caring for safety net patients has substantially diminished, with the county selling its public hospital to the University of California at San Diego and gradually reducing its financial contributions for health care services. Instead, the county has chiefly relied on the private sector to tend to its growing safety net population. While this has fueled a spirit of cooperation among local private and public entities, it has also left the community struggling to meet the health care needs of low income and uninsured residents.
As the former health director for San Diego County, Robert K. Ross, M.D., helped strengthen San Diego's extensive patchwork of safety net services and is recognized as an innovator in bringing diverse groups together. Now president and CEO of The California Endowment, the state's largest health foundation, which is dedicated to improving access to care for the poor and uninsured, Dr. Ross shared his thoughts on the safety net in San Diego, and the need to bring people of differing viewpoints together.
Interview: Robert K. Ross, M.D.
Q. You've been a close observer of the safety net in San Diego for more than 10 years. How has it changed?
A. I think the last decade has brought greater awareness of the importance of the safety net in general, and much greater recognition of the importance of public- and private- sector partnerships and roles. Throughout the entire state, the capacity and ability of our community health centers as a vibrant component of the safety net is better than 10 years ago. That's the upside. But the downside is that the resources allocated to improving safety net services - which were terrible in '93 and much better in '98 - are now shrinking again because of the state's fiscal crisis and what's happened with the economy. And throughout California, the ability of public hospitals to provide and deliver cost-effective services is far more precarious due to a combination of factors. So the safety net story seems to be one of bad news, good news, bad news.
Q. San Diego has seen many providers cooperate to provide safety net services to the community. How did you help foster partnerships among providers and community organizations in order to fill voids in the safety net?
A. The political culture in San Diego clearly called for the private sector to steer public and community health, so we had no option other than figuring out how to work in partnership. We quickly learned that we were going to have to be creative and bring many players together in a routine, systematic way. This meant involving hospital councils, health advocates, community clinics, legal aid services, doctors, county officials, and many others. We disagreed and fought like cats and dogs, but at least we had an institutionalized structure, which was called Healthy San Diego, for discussing problems. Eventually we formed personal relationships, and levels of trust, and consensus. Through this stakeholder group, we always seemed to find another way of solving issues that held incentives for the different members of the group. It took time to bring everyone along, more than a year and a half, but it was well worth the investment. When we would bring our recommendations to the county board of supervisors, the list of supporters generally included all the stakeholders, which of course made the board's job a lot easier.
Q. Every community faces obstacles in making safety net populations aware of the primary care services available to them. Besides language barriers, what other barriers or cultural biases exist in communities?
A. The bureaucracy - long lines, too many forms, rude people who aren't helpful, that sort of thing. It's particularly problematic if you are dealing with an immigrant population or the undocumented, who have an inherent fear of these systems. A few years ago I participated in a workshop on the confusing web of federal and state programs for the uninsured where we looked at a typical family who needed health services and needed to get to self-sufficiency. We identified their needs and put all the forms that they would need to fill out in one book. It was something like 800 pages between Medi-Cal, social services applications, medical histories, documentation, job training programs, etc. It illustrates the enormity of the bureaucracy and greatly undermines the notion that we're there to help. We need to improve on that.
Q. Is there one safety net population that is particularly underserved?
A. Absolutely - the undocumented migrant population in the U.S. It's truly an invisible population that deserves some serious public policy attention and action. The California Endowment is working with migrant farm workers, for example, and we know that this is a population that is overlooked at every level. We've done a study of their health needs and their status is terrible: nearly all uninsured, many never having been to an eye doctor or dentist in their lives. There are 44 million uninsured people in America, but then there are all of these workers, too. I know that some say we should stick to taking care of our own citizens, but this is a huge group of people who are helping to feed this nation and they are being overlooked and need our attention.
Q. You have been a strong advocate for engaging the business community in safety net issues. How did you do that in San Diego?
A. First off, we recognized that the private sector - particularly the hospitals and health systems - were not only safety net providers, they were also major employers and business leaders. So we worked to mobilize the health care "businesses" to assume their leadership role and serve as ambassadors to the rest of the business community. They educated non-health business leaders about health issues through the Chamber of Commerce, which in San Diego is very active in shaping local policy. It often resulted in the local Chamber supporting various health initiatives, which continues to this day.
Q. What other community stakeholders need to be engaged in order for a community to strengthen its safety net?
A. There are many examples, but three entities quickly spring to mind: the sheriff's department, the district attorney, and the court system. They all wield enormous power; they all involved generally popular leaders in San Diego; and they all have a soft spot for safety net prevention efforts such as drug treatment, mental health services, after-school programs, and others. They were consistently helpful in supporting our efforts and all became partners that we utilized for health initiatives.
Q. Without a public hospital, how have other hospitals in San Diego coped with increased numbers of patients in the emergency department?
A. It has been and remains a significant problem. The sheer number of uninsured patients combined with paltry reimbursement rates leads to a controlled, slow rage. Every hospital has had health care consultants come in and look at their processes and every major hospital has churned through staff because the pressure is enormous to try to meet financial margins amidst rising numbers of uninsured patients coming to the hospital. It's a boiling pot and it's going to boil over unless something is done very, very soon at the state and federal levels. That's why I support the work that Urgent Matters is doing, as well as The California Endowment's own efforts on this issue. We need to call attention to the incredible strain that hospitals, patients, providers and everyone else is under because of our nation's lack of action.
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Robert Ross, M.D.
President and CEO
The California Endowment
Los Angeles, CA
