In the three-ring circus of healthcare reform showmanship, county health service budgets are stretched dangerously thin as they provide the safety net for a growing number of uninsured.

More than 20 percent of California’s residents have no health insurance, according to a 2008 California HealthCare Foundation Snapshot. These 6.6 million people make up the largest number and percentage of uninsured in the country. The figures are climbing higher as companies lay off employees or cut benefits to offset rising healthcare premiums.

These uninsured of all ages, races and economic background – the majority of them employed – turn to county-administered Medi-Cal programs to pay the bill for emergency room visits.

Counties act as the ringmasters, administering mental health, drug, alcohol and disease prevention services while operating hospitals, clinics and health centers. Administrators must learn to be contortionists, caught between the competing demands of the state to freeze or lower costs while the federal government mandates expansion of benefits.

“The state’s chronic underfunding of health programs strains the ability of counties to meet accountability standards,” reads the California State Association of Counties 2009 health platform. “Freezing health program funding also shifts costs to counties and increases the county share of program costs, while at the same time running contrary to constitutional provisions.”

That role isn’t going to change anytime soon.

“Counties are already the default health reform mechanism,” according to Micah Weinberg, Senior Research Fellow for the California Program at the New America Foundation.

 “Even if Washington passes healthcare reform, it will simply build on the infrastructure already in place so counties will continue to be the delivery system for expanding coverage,” Weinberg says.

The National Association of Counties supports the idea of universal health insurance coverage with some caveats.  “Existing public health insurance systems should be strengthened and expanded, including Medicare, Medicaid and the State Children’s Health Insurance Program (SCHIP),” reads a NACo white paper on healthcare.

Because no two counties are alike, however, expanded coverage needs to be as flexible as possible, NACo argues. That means fewer mandates and full Medicaid safety net funding along with resources to implement and train staff on electronic health records management.

Prevention has taken the spotlight in the healthcare debate. Pilot programs like the California Coverage Initiative, which is using $180 million in matching federal funds to “radically redesign” how the uninsured and underinsured receive medical care, focus on chronic disease management in 10 counties, including Ventura, San Diego, Kern, Contra Costa and San Francisco.  

One of the experiments is the Innovative Care Clinic at San Mateo Medical Center in Santa Clara County. The $20 million pilot provides comprehensive primary and preventive health care to more than 4,000 self-employed and low-wage earners from their choice of a network of public and private clinics based on a shared responsibility model. Costs are split between employer, employee and the community. Although the county faced challenges getting reimbursed, “inreach” recruiting patients was more than twice the target, showing the need for coordinated care.

The program started in 2007 and runs through 2010, but initial data by Insure the Uninsured project concluded “ many counties believe they will save money and create positive externalities like increased productivity or improved quality of life for their enrollees.”

If the UCLA study planned for the end of the test period confirms these trends, prevention and efficient long-term care service delivery by counties could help reform reach a wider audience.

JT Long can be reached at