By Sandra Celedon
(corrected: 2-8-14)
On Dec. 31, 2013, Fresno County subtly attempted to overturn a permanent injunction issued in 1983 that requires the county to provide medical care to all poor Fresno residents. The county asked a Fresno judge over the holidays, without initial notice to the public or interested parties, to relieve it of the responsibility to care for low-income Fresnans.
The county is required by law to provide medical care for low-income people who have no other source of care. In the past, the county fulfilled its responsibility by providing services at the old Valley Medical Center located on Kings Canyon Road and Cedar Avenue. In 1996, Community Regional Medical Centers (CRMC) took over the care of low-income Fresnans via a $20 million annual contract that it signed with the county. Since then, the CRMC has operated the county Medically Indigent Services Program (MISP). The program provides basic medical services to people—especially those with complex chronic medical conditions—who would otherwise have no access to medical care.
The county asserts that the implementation of the Affordable Care Act (ACA) will cover all uninsured individuals currently served by the MISP and that the only people who will remain uninsured are undocumented Fresnans, who the county is not obliged to serve under state law, and therefore the injunction should be dissolved. The county also projects it will lose $14 million in funding due to the state’s shifting of realignment dollars.
“Without this funding, the county is unable to continue the MISP, unless other public health programs are cut,” said Fresno attorney Jerome Behrens, who represents the county. Behrens states that the county just learned about this shift in funding six months ago and that is why ending the permanent injunction was a matter of urgency.
During the New Year’s Eve hearing, Clinica Sierra Vista asked to intervene in the matter before the court. Clinica Sierra Vista—a federally qualified health center—took over the operation of Sequoia Community Health Foundation in 2008. Sequoia Community Health Foundation was the original plaintiff in the 1983 injunction.
Clinica Sierra Vista’s attorney, R. Mona Tawatao, asked the court for a continuation of the case because Clinica Sierra Vista first learned of the matter on Dec. 19 and did not have time to prepare. Tawatoa stated that “if the county ends the provision of medical services, thousands of people will be affected and the county is mandated by law to hold public hearings before ending care for thousands of Fresnans.”
Fresno County Superior Court Judge Donald S. Black granted Clinica Sierra Vista’s request for a continuation. Black set a new hearing date for Feb. 26 and questioned the county’s decision to wait “until the 11th hour” to bring up this matter.
Advocates who gathered outside the B.F. Sisk Courthouse questioned the county’s actions and urged the Fresno County Board of Supervisors to live up to what they believe is their moral and legal obligation to continue and improve the provision of medical care for uninsured Fresnans. They believe that medical care should be made available as a matter of public policy on general welfare, economic and humanitarian grounds to all Fresnans, lawful or undocumented.
Veronica Garibay, co-director of the Leadership Council for Justice and Accountability, stated that “the county’s attempt to leave poor Fresnans without nonemergency and preventative medical care will have long-range medical and social consequences.” She questions why the county would do this when the Board announced at its Jan. 14 board meeting that it expected to receive $28 million in state funding to maintain indigent care services.
Advocates emphasized that the Medically Indigent Services Program serves as a safety net program of last resort for people whose financial, social, physical, mental or geographic conditions limit or complicate their access to mainstream care and related supportive services. “The program not only serves the needs of low income and vulnerable people but it also provides the basic framework for protecting the health, safety, and well-being of the entire community,” said Ana Palomares, Health & Wellness Program Supervisor at Centro La Familia Advocacy Services. “This is a matter of public health.”
The implementation of the Affordable Care Act provides new and more affordable coverage options for thousands of Fresnans. Beginning in January 2014, thousands of low- and middle-income Fresnans gained access to coverage under the Medi-Cal expansion and through premium assistance offered through Covered CA, the new health insurance exchange. But Palomares argues that the ACA is not a universal health care policy and many Fresnans will be left uninsured due to barriers to enrollment that include challenges in the enrollment process, lack of required documentation, lack of affordable options, and ineligibility to participate in the federal law. “Many of the remaining uninsured will not only include undocumented individuals, it will include people experiencing homelessness and/or mental illness. The ACA recognizes that a significant number of people will remain uninsured and that a robust safety net is essential to care for the remaining uninsured,” Palomares said.
According to a report published by the UCLA Center for Health Policy Research, almost three-quarters of the remaining uninsured in California will be U.S. citizens or lawfully present immigrants and more than half will be low income.
“The county’s argument that the MISP program should be dismantled because it is no longer necessary or will serve only undocumented Fresnans is not entirely accurate,” Garibay said. “In fact, the full impact of the ACA will not be known until the full implementation of all ACA provisions in 2019. The county’s action to do away with or scale back the program is premature at best.”
Advocates argue that many state statutes mandate, authorize and protect the provision of medical care and other public assistance to those living in poverty who are uninsured. “The law requires that the county provide nonemergency medical care to all poverty-stricken residents,” said Garibay.
She says that “Fresno County’s attempt to deny healthcare services to poor Fresnans, especially those who are undocumented, will create an unhealthy and potentially non-productive second class of community residents who will be conditioned to access expensive episodic emergency care instead of preventative primary care services.”
“In regards to undocumented Fresnans, no federal decision has precluded the granting of state or local public assistance to immigrants, lawful or undocumented, nor would such a presumption be justified,” stated Garibay. “American values of justice and generosity call for fair treatment of all individuals in need.
“In fact, undocumented Fresnans as a group are very deserving of public assistance in the form of medical care because of their contributions to this county’s economic growth and social stability,” added Garibay. “We cannot deny the fact that our agricultural, service, and hospitality industries are sustained by the hard labor of undocumented Fresnans.”
Advocates say that the reality in Fresno is that healthcare has been a low priority for the Board of Supervisors. Fresno is one of only a few California counties that uses a portion of its realignment dollars to fund prison health services and refused to set up a low-income health program for indigent care.
In 2011, 2012 and, finally, in 2013, the county relinquished the option to bring $50 million in funding from the federal government to the county. The funding was designed to help move thousands of poor adults from county indigent programs into the state Medi-Cal expansion, thus saving the county millions of dollars in MISP care. The Board voted to leave this money on the table despite overwhelming opposition. Fresno County became one of only five counties in the state to turn down these federal dollars.
Advocates are urging the county to invest in the safety net and provide healthcare to all Fresnans. “If the county does not invest in the safety net homeless, poor and undocumented people to suffer without basic medical care,” said Veronica Garibay. “The Board of Supervisors should continue to provide medical care for the remaining uninsured. This will require true leadership and the political will to care for our poorest and most vulnerable community members.”
The county’s next steps will largely depend on the outcome of the Feb. 26 court hearing.
*****
Correction (February 8, 2014): The original quote in the paragraph below was mistakenly attributed to Ana Palomares. The quote has been changed and attributed correctly to Veronica Garibay.
Advocates are urging the county to invest in the safety net and provide healthcare to all Fresnans. “If the county does not invest in the safety net homeless, poor and undocumented people to suffer without basic medical care,” said Veronica Garibay. “The Board of Supervisors should continue to provide medical care for the remaining uninsured. This will require true leadership and the political will to care for our poorest and most vulnerable community members.”
*****
Sandra Celedon is a public health advocate and president of the Calwa Political Action Committee. Contact her at calwapac@gmail.com.
Get Involved: Veronica Garibay and Ana Palomares are part of the Fresno Building Healthy Communities Prevention Action Team, which is working to improve access to healthcare for all Fresnans. For more information or to get involved, e-mail info@fresnobhc.org.
