Health Care Access Report

Securing the Counties’ Health Care Safety Net for All Residents

Despite the significant gains in terms of health coverage, access, and utilization made since implementation of the Affordable Care Act (ACA), racial health disparity remains omnipresent in California. While a radical force for change in many respects, the ACA’s reforms were largely built atop our pre-existing health care system, inheriting its disparities. Because health disparity drivers abound in and outside our health care system – undermining our state’s well-being – agents advancing health equity become even more vital.

  • The ACA helped increase capacity at community health centers
  • Improved health care access was important in driving down the rate of preventable hospital stays – a highly-disparate and costly event – for people of color in California
  • Black, Latino, and indigenous Californians continue to struggle with health care access and outcome disparities even after ACA implementation
  • The level of support that California counties lend their individual safety net programs is fundamental in a statewide pursuit of health equity

INTERACTIVE

Los Angeles County’s health care access disparities are similar to those seen statewide, yet its performance on most indicators is poor – with especially poor access to a usual source of care.  While the ACA benefitted L.A. County more than many others – due to its size and high level of need – it continues to face many access barriers and challenges. Residents and leaders have taken the initiative, advocating for innovations such as a county safety net program offering comprehensive health care to impoverished residents regardless of immigration status via community health centers.

Riverside County’s expansiveness can make accessing health care difficult – particularly for its low-income residents of color. Riverside is generally lower-performing on health care access measures than the state as a whole and pairs it with high levels of disparity in some key indicators.  The ACA period brought a marked increase in community health centers countywide but the county is heavily reliant on these few dozen CHCs and a handful of hospitals to provide limited safety net health care services to uninsured Riverside County residents, regardless of immigration status.

Merced County’s high rate of poverty combined with ACA-era eligibility expansion means that over half of all county residents now qualify for Medi-Cal. They are primarily served by the county’s community health centers – centers struggling to attract health care providers while serving an ever-growing number of patients and without the benefit of a county-funded safety net program to underwrite these efforts.  Merced’s poor health care access performance cuts across all groups, meaning racial disparities here are comparatively lower than other counties but point to systemic challenges.

Timelapse Map

Community Health Centers
Clinics in 2011
Clinics opened between 2012 and 2015

2011

Los Angeles

Clinics

There were community health centers located across Los Angeles County when the ACA came into effect.

People of Color +
People in Poverty (#)

Office of Statewide Health Planning and Development (2011-2015); AMERICAN COMMUNITY SURVEY 5-YEAR ESTIMATES TABLES DP05, S1701 (2012-2016)

Los Angeles County had a significant increase of community health center sites during the ACA years, going from 248 sites to 341 – a 38 percent increase. These CHCs serve a huge proportion of county residents – a pattern that accelerated with a 21 percent increase from 2011-15. The more than 1.5 million CHC patients countywide are, disproportionately, Indigenous people and people of color, with 62 percent identifying as Latino (of any race), 10 percent as Black, 7 percent as Asian/Pacific Islander.

Los Angeles County’s rate of uninsured adults and children during this time dropped to historic lows but disparities in coverage persisted.  Likewise, the county had a stark reduction in preventable hospitalizations across all racial & ethnic groups – but these gains were not enough to erase the substantial, stubborn disparities in this measure.

Riverside County saw the largest percentage increase of CHC sites of any of our three counties with 15 new sites added during the ACA years, an increase of 71 percent. Yet, this fact reflects an inadequate starting point – as even with the new additions there are still only 36 tightly-bunched sites serving a county with more than 2.4 million residents.

Nonetheless, CHCs in the county did show a significant (52 percent) leap in the number of patients served during these years. Those using CHCs are much more likely to be people of color than the overall county population. In 2015, 58 percent of Riverside County CHC patients identified as Latino (of any race), 6 percent as Black, 3 percent as Native American, and 2 percent as Asian/Pacific Islander.

Most Riverside residents did not have as pronounced a reduction in preventable hospitalization as they did statewide – and Native Americans here had larger increases in such visits than seen statewide.  In the reverse of the CHC scenario above, however, this partly reflects a positive starting point – as some racial/ethnic groups in Riverside outperform their statewide rate in this measure.

Merced County’s safety net capacity did not accelerate at the pace needed to keep up with the 34,000 residents who gained coverage via Medi-Cal expansion. In fact, Merced County gained only two community health centers during the ACA years – leaving the county with 18 sites as of 2015. Those CHCs saw 109,000 patients – a rather incredible 40 percent of all county residents.  Yet this represents only an 11 percent increase in patients seen over this timeframe – far below the increase in our other spotlight counties – demonstrating the CHCs’ vital role as the county’s primary care providers predated the ACA years.

These community health centers disproportionately serve Merced’s people of color. In 2015, 72 percent of the county’s CHC patients identified as Latino (of any race), 4 percent as Asian/Pacific Islander, 3 percent as Black, and 1 percent as Native American.

The county made steep declines in the rate of preventable hospitalizations for most Merced County residents – outpacing the state and our other spotlight counties – though, for reasons that are presently unclear, the county’s Native American residents did considerably worse over this timeframe.

Indicator
  • Patients by Race
  • Patients by Ethnicity

OFFICE OF STATEWIDE HEALTH AND PLANNING (2015)

Indicator
  • Health Insurance
  • Preventable Hospitalizations


COUNTY FINDINGS

Los Angeles County did not passively rely on the ACA’s coverage expansions to improve health equity in the county. Advocates and officials created a new county-run program, My Health LA, to serve county residents ineligible for Medi-Cal by assigning them to a local community health center for care, where they can access a range of primary care options free of cost. Critically, the program is available to residents regardless of immigration status. By 2015, My Health LA was serving more than 140,000 county residents – a full 94 percent of whom identify as Latino.

Barriers to equitable health care access in the county remain. They include high housing costs; a transit network that can make utilizing available health safety net services difficult; and the challenge CHCs experience attracting and retaining high-level providers.

Fortunately, local health advocates have demonstrated the leadership to take on these challenges. They continue to push for making My Health LA’s innovative services available to more residents. Countywide, a host of campaigns are bringing together philanthropies, service organizations, health advocates, and officials to work on issues ranging from improving the health workforce pipeline to expanding programs for justice-system-involved Angelenos to creating a new Center for Health Equity.

Riverside County’s safety net program remains wide but shallow in the wake of the ACA. While eligibility standards are relatively-generous, it fails to cover primary care – leaving its participants eligible for only late-stage emergency care via its hospital network. County contributions to safety net care stayed relatively stable over this timeframe while the state contribution dropped considerably.  As a result, the program’s well-being depends more than ever on county financial support, but the Board of Supervisors has yet to refocus scarce resources on populations and services that could advance health equity.

One of the biggest local barriers to equitable health care access is the disconnect between low-income county residents’ health needs and available services – exacerbated by a lack of affordable, accessible transportation. The uncoordinated, underfunded transit network—particularly in rural areas—leads to patients delaying needed care and waiting until emergencies to finally seek out costly transit to care sites.

These challenges have spurred health advocates to band together to press the County and local transit providers to better integrate transit lines with health care providers in far-flung parts of the Riverside County. Recognizing this challenge, local CHCs have begun innovative transportation programs to bring needy patients from remote areas to the care they need.

In the wake of Medi-Cal eligibility expansion in 2014, Merced County effectively shuttered its existing safety net health program. For those lacking coverage (such as undocumented adults), there is no real safety net—they must pay out of pocket or delay care until being hospitalized with an emergency. This blinkered approach may reduce the county’s outlays, but at the cost of reducing access to care for undocumented residents.

Health provider access challenges abound in Merced County.  Particularly alarming was local CHCs inability to attract and retain physicians during the ACA years, even as those eligible for Medi-Cal skyrocketed countywide. In fact, the CHCs actually had fewer doctors to meet residents’ health needs—a trend completely out of step with the statewide one.  While there was an increase in the number of nurses in these CHCs, advanced care was harder than ever to access and specialty care was almost non-existent — problems all too common in many of the state’s more rural counties.

In 2017, officials and advocates banded together to press the Board of Supervisors to reinvest in a county safety net program—one that for the first time would serve all county residents, regardless of documentation status. While these Health4All efforts were dealt a blow by a October 2017 vote defeating the motion to fund such a program, the efforts illustrate the growing voice countywide making the case that the lack of a safety net program is undermining Merced County’s overall health and prosperity.

REPORT RECOMMENDATIONS

  1. Counties should prioritize their health safety nets.

    As our analysis has shown, in too many cases, counties have been content to coast, allowing state and federal programs (and dollars) to play the near-exclusive role in determining access for their residents. County leaders should listen to advocates’ arguments that there is a local stake in health equity too.

    Counties should make a concerted effort to make sure that their safety nets live up to their names. At a basic level, this will require additional resources – and beyond looking to leverage state and federal funding and grant opportunities, counties should commit significant local resources, including property tax revenues. Funds should be allocated after a needs-assessment determines which investments would do most to ameliorate the specific racial disparities in each county. Those counties that have already created promising programs in this regard should loosen restrictive income eligibility standards to make those benefits more widely available to vulnerable residents.

    Counties also should think broadly about how to address social determinants of health, understanding that effective access has many prerequisites and that low-income communities of color often labor under the burden of multiple, simultaneous disparities.

  2. Set a framework to guarantee health care access for all.

    Counties will need support and partnership from Sacramento to achieve health equity goals. First, the state should set a floor by creating a baseline standard requiring that every Californian receive primary care. This would involve a concomitant requirement that county programs extend eligibility regardless of immigration status. It would also mean the adoption of uniform standards for data and reporting, for both demographic and outcome data, to enable regulators and researchers to understand whether counties are meeting this requirement.

    Secondly, to allow even resource-poor counties to meet the goal, the state should adopt new funding allocation metrics to ensure that dollars are following need. Ensuring adequacy of funding might require the state to revisit how its budgets allocate existing health funding streams, such as the recently-passed Propositions 52 and 56, and explore new ones. Ultimately, the state should lead the way toward universal coverage. Until then, steps such as extending full-scope Medi-Cal coverage to all state residents, would go far toward reducing the disparities we have identified, and provide an important backstop to counties that lack the funding or political will to take on these challenges.

  3. Create incentives to widen the health care workforce pipeline for areas in need.

    The current workforce systems, in conjunction with local job market conditions across California, make it difficult for safety net providers in underserved areas in either rural or urban counties to develop, attract and retain a sufficient number of trained, culturally-competent health professionals. It is low-income communities of color, especially those with language needs, who are locked out as a result. Educational training and incentives such as loan forgiveness can help open avenues for historically-disadvantaged populations to enter a broad array of health professions and encourage them to remain working locally.

    While federal action may ultimately be required and while waiting for more supportive federal partners, the state’s new Future Health Workforce Commission can lead the way by studying the gaps in existing programs such as the Teaching Health Center program and the National Health Services Corps, and identifying potential state-level solutions.

  4. Improve data-gathering and analysis.

    Important gaps in the available health care access data remain – limiting the ability of advocates and leaders to improve our public systems. To help all stakeholders better understand the challenges and opportunities before them, we call on agencies that create and gather public health data to adopt the following best practices:

    • collect and make available data disaggregated by race, ethnicity, and national origin wherever possible, especially for the Asian American community;
    • prioritize data collection efforts to ensure that there is comprehensive, accurate information about the state of health access in Indigenous communities;
    • gather data about the experience, access, and outcomes of immigrants in our health systems, while being mindful of the potential for harm and distrust if questions are not asked appropriately; and
    • institute uniform data collection and reporting protocols for each county’s safety net program that abide by the above recommendations.
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