Santa Cruz County Grand Jury • 2008-2009

Health Care for Low-Income Families in Santa Cruz County

Published: June 30, 2008 24 pages
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Note: Missing finding numbers detected: F31, F32, F33, F34, F35, F36, F37, F38, F39, F40, F41, F42, F43, F52, F53, F54, F55, F56, F57, F58, F59

Findings 42 findings

F1
A Promise Kept 23 Conclusions 2. Since the most pressing concern today is from where the money will come to maintain Medicare and Medicaid services for those who qualify under today’s system, extending it to include low-income families is not being discussed. 3. Santa Cruz County public, non-profit, and for-profit medical resources have worked together to make health care more accessible to low-income families. Commendation 1. The Human Services Department and the Health Services Agency are to be commended for ongoing focus on the delivery of adequate health care services to Santa Cruz County residents. Health Insurance Coverage 2000-2001 Grand Jury Recommendation 3: The Healthy Families Program should include parents in its coverage. Premiums should be set at more affordable levels in order to accelerate enrollment of families without insurance. Coverage should be maintained during short periods of seasonal unemployment. The Central Coast Alliance for Health should approach local employers to continue premium payments for families during short periods of seasonal unemployment to keep insurance coverage from lapsing. It should continue to expand the participation of specialists in its programs. County Response: This recommendation has been implemented. 2007-2008 Grand Jury Findings 12. The Healthy Families Program does not include parents in its coverage. Healthy Families insurance premiums vary depending on the health plan selected. Families receive a discounted premium if they select the local Community Provider Plan, which is the Central Coast Alliance for Health (the Alliance) in Santa Cruz County. The Alliance’s maximum monthly premium for a family with three or more children is $36 (or $108 per quarter). 13. Recent local funding contributions to the Healthy Kids program, which came primarily from Sutter Santa Cruz and Dominican Hospital, will allow the Alliance to move 295 children off the waiting list and into enrollment. 14. Seasonal unemployment only affects the eligibility of adults in a family receiving Medi-Cal. The Alliance reports that their Medi-Cal membership fluctuates by about five percent each year according to the growing season and migration of Medi-Cal recipients out of the area. Typically, a seasonal employee becomes eligible for Medi- Cal when the work season ends or slows down because the worker’s income decreases. When an individual’s work hours increase again, Medi-Cal eligibility could be lost due to the corresponding increase in income. Thus, an individual may 24 A Promise Kept qualify during periods of little work or unemployment but no longer qualify for Medi- Cal when working full-time. 15. Medi-Cal has no provision for continued eligibility if an adult no longer meets the criteria. However, children can maintain Medi-Cal eligibility for 12 months even if the adults in the family are terminated due to an increase in income or assets. 16. Although families pay no premiums for the Medi-Cal program, there are premiums associated with the Healthy Families and Healthy Kids programs. However, regardless of changes in family income, once a child is deemed eligible for Healthy Families or Healthy Kids, that child remains eligible for 12 months unless he or she becomes eligible for no-cost Medi-Cal, is covered by other health insurance, or turns 19. Children also lose Healthy Kids eligibility and coverage when they move out of Santa Cruz County. 17. In 2000, the Santa Cruz County population was 255,602. In 2007, the population increased slightly to an estimated 264,125 (3.3 percent). But the supply of health care specialists for Alliance programs has increased by almost 30 percent since that year. In 2000, the Alliance had an average of 499 specialists available to serve Santa Cruz County residents. As of March 2008, 697 specialists are available. 18. The Alliance collaborates with over 60 community coalitions and organizations to promote its programs, including the Santa Cruz County Human Services Department. It also promotes health care resources to the public at events, such as farmers’ markets, health fairs, community block parties, and other festivals. In addition, the Alliance publishes a provider bulletin in which providers are urged to encourage their Healthy Families and Healthy Kids patients to stay enrolled and thereby continue their health care coverage. 19. In March 2008, at California’s annual Medi-Cal Quality Conference, Central Coast Alliance for Health tied for first place with Health Plan of San Francisco, winning the Gold Award for the highest rate of preventive care services among all 39 Medi-Cal health plans in California. The Alliance also won a second place Silver Award for member satisfaction. Conclusions 4. Because Healthy Families is a state and federally funded health plan, Santa Cruz County cannot change the eligibility requirements for the program. 5. The 2000-2001 report recommended, “Coverage should be maintained during short periods of seasonal unemployment.” But, in fact, qualifying seasonal workers are covered while unemployed. They risk losing coverage when employed because their income may exceed guidelines. That issue has not been addressed by Medi-Cal or any county agency. 6. A public/private partnership exists in the county to provide affordable access to health care for low-income individuals and families. A Promise Kept 25
F2
While the County has pursued a goal of consolidating categorical health plans and simplifying eligibility requirements, there is no published plan or public commission in place to oversee it.
F3
Eligibility requirements for health plans have not been simplified in any significant 22 A Promise Kept way, but the County has structured resources to guide applicants through the maze of health services and health insurance programs that are offered by non-profits and various government agencies.
F4
Santa Cruz County now uses One-e-App, a web-based system for connecting families with a range of publicly funded health and social service programs. Applicants, usually with the help of Certified Application Assistants or county eligibility workers, enter their personal information to learn about and apply for programs that best meet their family's needs. System administrators, supervisors, and case management staff, can run reports and determine eligibility.
F5
Santa Cruz County Health Care Outreach Coalition expands access to health care coverage for uninsured county residents, promotes awareness of government- funded health insurance programs and conducts outreach to schools, community-based organizations, businesses, faith-based organizations, childcare providers, and the general community.
F6
The Benefits Call Center was established in 2000 to provide an easily accessible source of information for Medi-Cal recipients and to ensure that recipients complete all program requirements to maintain their coverage.
F7
There is no new program, or expansion of an existing program, to extend health care to entire families instead of just individual members. California’s Medicare system, Medi-Cal, is governed by federal rules because it is mainly funded by the federal government. Medi-Cal has not acted to extend health care coverage to low-income families.
F8
In 2008, Medicare’s Hospital Insurance Trust Fund (HI) is scheduled to pay out more in hospital benefits and other expenditures than it receives in taxes and other dedicated revenues. Growing annual deficits are projected to exhaust HI reserves in
F9
Private health care providers, both physicians and dentists, have been recruited to treat patients who can’t afford to pay. They do this without remuneration as a community service.
F10
In order to simplify access to categorical health programs, the 2000-2001 Grand Jury recommended using the Central Coast Alliance for Health as a model for administering them. Health Services Agency determined it would accomplish the same goal to make those programs part of the Alliance where possible.
F11
Some Grand Jury recommendations hinged on the county becoming a demonstration site for the integrated provision of local health services subsidized by state and federal governments. This did not happen as explained in Demonstration Site Finding 1. A Promise Kept 23 Conclusions
F12
The Healthy Families Program does not include parents in its coverage. Healthy Families insurance premiums vary depending on the health plan selected. Families receive a discounted premium if they select the local Community Provider Plan, which is the Central Coast Alliance for Health (the Alliance) in Santa Cruz County. The Alliance’s maximum monthly premium for a family with three or more children is $36 (or $108 per quarter).
F13
Recent local funding contributions to the Healthy Kids program, which came primarily from Sutter Santa Cruz and Dominican Hospital, will allow the Alliance to move 295 children off the waiting list and into enrollment.
F14
Seasonal unemployment only affects the eligibility of adults in a family receiving Medi-Cal. The Alliance reports that their Medi-Cal membership fluctuates by about five percent each year according to the growing season and migration of Medi-Cal recipients out of the area. Typically, a seasonal employee becomes eligible for Medi- Cal when the work season ends or slows down because the worker’s income decreases. When an individual’s work hours increase again, Medi-Cal eligibility could be lost due to the corresponding increase in income. Thus, an individual may 24 A Promise Kept qualify during periods of little work or unemployment but no longer qualify for Medi- Cal when working full-time.
F15
Medi-Cal has no provision for continued eligibility if an adult no longer meets the criteria. However, children can maintain Medi-Cal eligibility for 12 months even if the adults in the family are terminated due to an increase in income or assets.
F16
Although families pay no premiums for the Medi-Cal program, there are premiums associated with the Healthy Families and Healthy Kids programs. However, regardless of changes in family income, once a child is deemed eligible for Healthy Families or Healthy Kids, that child remains eligible for 12 months unless he or she becomes eligible for no-cost Medi-Cal, is covered by other health insurance, or turns
F17
In 2000, the Santa Cruz County population was 255,602. In 2007, the population increased slightly to an estimated 264,125 (3.3 percent). But the supply of health care specialists for Alliance programs has increased by almost 30 percent since that year. In 2000, the Alliance had an average of 499 specialists available to serve Santa Cruz County residents. As of March 2008, 697 specialists are available.
F18
The Alliance collaborates with over 60 community coalitions and organizations to promote its programs, including the Santa Cruz County Human Services Department. It also promotes health care resources to the public at events, such as farmers’ markets, health fairs, community block parties, and other festivals. In addition, the Alliance publishes a provider bulletin in which providers are urged to encourage their Healthy Families and Healthy Kids patients to stay enrolled and thereby continue their health care coverage.
F19
Children also lose Healthy Kids eligibility and coverage when they move out of Santa Cruz County.
F20
A comprehensive approach is the most pressing need in the system. Along with counseling and medication, affordable housing, tenured living spaces, and job development are all necessary for proper treatment.
F21
While all “safety net clinics” are not geared toward families, they are putting forth their best efforts to meet the various needs of the uninsured and Medi-Cal patients in Santa Cruz County.
F22
In June of 2001 the Packard Foundation grant expired. In 2007-2008, funding for the Coalition for Health Care Outreach (Coalition) came from two sources, First 5 California (First 5) and Medi-Cal Administrative Activities.
F23
The budget for fiscal year was $403,000. First 5 funded $300,000, and the Coalition hopes to receive the additional $103,000 from Medi-Cal Administrative Activities.
F24
The County works as a middleman for both sources of Coalition funding. Medi-Cal Administrative Activities
F25
During the month of September, the Coalition completes a “time survey” to establish the annual cost of outreach activities in excess of what First 5 already pays. The federal government agency Medi-Cal Administrative Activities is billed that excess cost. The turnaround for payment is generally about three years.
F26
The County supports various organizations associated with the Coalition throughout the year and receives the money from Medi-Cal Administrative Activities. Many variables determine what work is being done and how it is being claimed. On average, the Coalition received approximately 75 percent of what they predicted in their budget from Medi-Cal Administrative Activities. The County then funds the remaining budget. First 5 California
F27
The State of California retains 20 percent of the money First 5 receives, and 80 percent is distributed to the 58 counties throughout California based on the number of children born in the county. Santa Cruz receives approximately $2,700,000 annually.
F28
First 5 has three established goals: healthy children, children learning and ready for school, and healthy families. Allowing for local decision-making, the First 5 Santa Cruz County Commission determines how to distribute funds based on a three-year strategic plan and annual contracts. Money provided to the Coalition by First Five has been designated as outreach funds. A Promise Kept 27
F29
First 5 reimburses the County for payments made to community agencies for contracted services.
F30
In the fall of 2008, First 5 will create a new three-year strategic plan. This may or may not result in continued funds for the Coalition for Health Care Outreach. Conclusion
F44
The Mental Health and Substance Abuse Services (Division), a division of the Santa Cruz County Health Services Agency, works with and through many groups to offer a wide range of mental health care services including emergency shelter, transitional A Promise Kept 31 housing, supported housing, dual diagnosis treatment, crisis intervention, case management, and peer support. Other services available to clients are assessment, counseling, medication support, and referrals. Spanish translation is offered, as is an Appeal Resolution Process for anyone who is denied assistance. The following is a partial list of these resources. Adult residential treatment is offered at • Transition House, 10 beds • Paloma House, 12 beds • Pioneer House, eight beds • Opal Cliffs, 15 beds • El Dorado Center, 16 beds • Darwin House, 15 beds • Front St., Inc., 11 beds • River Street Shelter, 20 beds reserved for people referred by County Mental Health Outpatient treatment and/or social rehabilitation are available at • North County Mental Health Center • South County Clinic • Community Support Services • Dominican Hospital Behavioral Health • Pioneer House Dual Diagnosis Day Program • Community Connection Academy • Front Street Day Rehabilitation Program Self help resources include • Mental Health Client Action Network • Mariposa Activity Center • Community Connection Mental Health Resource Center and Career Services • Community Support Services Community Organizers Program Ongoing services for the protection of low-income mentally ill residents include • Advocacy, Inc. (Patient Rights) • Public Guardian’s Office
F45
It is hard to retain staff; therefore, continual training programs are necessary. Many new employees come from the Cabrillo College Health Science/Community Health programs.
F46
Various federal, state, county and private agencies fund mental health treatment in our county. Mental health has made effective use of these grants and programs. Some of these sources (known as funding streams) are designated for specific and limited uses. Clients often present with a variety of issues and staff sometimes has difficulty matching funds to the specific needs of the client. Services offered to individuals and families will be further restricted by potential state and county budget cuts in the coming year.
F47
Training in cultural sensitivity is emphasized and employees are trained within their department as well as by outside resources. A Promise Kept
F48
Some families have difficulty acknowledging the existence of a mental health problem. This can be a cultural issue or a matter of pride. Successful mental health outreach and education programs have worked as a part of the network of general health services.
F49
Access to services is difficult for South County residents because most service sites are located in Santa Cruz. Public transit offers only a few routes and limited hours of operation. The Division is attempting to expand county services and to create more partnerships with community agencies in South County.
F50
The Division works with Senior Network Services but does not yet have an early intervention program for seniors.
F51
Among the ongoing concerns of the Division is the ever-present worry of patients exhibiting unexpected antisocial behavior. Conclusions
F60
Currently Santa Cruz County uses eight nearby counties in salary surveys: Monterey, Santa Clara, Alameda, Napa, Sonoma, Marin, Solano and San Mateo. For the most part, these are more similar to Santa Cruz than the nine counties formerly used in that they are not strictly agricultural and have living costs comparable to Santa Cruz.
F61
Recruiting and retaining physicians and other medical professionals is uniquely difficult in Santa Cruz County because it is labeled by Medicare as a rural county. The Medicare reimbursement rate is the same as Butte, Imperial and other counties with a much lower cost of living.
F62
The county health programs must compete with Dominican and Sutter for physicians and other medical professionals. Hospitals are in a unique position to pay higher salaries as their Medicare reimbursements are based on actual costs. A national Medicare study released in 2007 shows hospitals in Santa Cruz County have the highest labor costs in the country, which local health officials say means higher medical costs and insurance premiums for patients. This situation creates a difficult challenge when it comes to recruiting medical professionals.
F63
Salaries and working conditions for physicians and other medical professionals employed by the County are negotiated with the respective unions. Conclusions

Recommendations 41