by John M. Gonzales, Senior Writer, CHCF Center for Health Reporting.

The Santa Cruz County Health Clinic on California’s Central Coast serves as a laboratory for the issues facing health reform’s rollout: the working poor come not only for treatment, but to navigate the intricacies of the new public health system.

Carol Ann Huboi, 57, is among the fortunate, already signed up for a state-administered precursor to health reform’s coverage expansion called the “Bridge to Reform.”

The program allows California counties to enroll low-come residents in a health plan that is largely paid for by the federal government.

Kimberly Barrett, 49, could qualify for the same program, but has yet to enroll, and her bill will be footed solely by county indigent funds.

“It takes work to get into the program,” said Barrett, who said she suffers from a debilitating case of sciatica and has trouble getting to the Santa Cruz County Health Clinic. “Five minutes late, and you’ve lost your appointment.”

While California’s health providers are concerned that new Affordable Care Act enrollees will overwhelm their systems, a troubling flipside has also taken hold. They are equally worried about patients like Barrett: those who don’t enroll.

These qualified but unreached California residents could number more than a million, according to estimates by the state Legislative Analyst’s Office. Without health reform coverage, they will seek medical care where they always have: county safety net clinics and emergency rooms.

Governor Jerry Brown is in conflict with the counties, pointing to health reform as the reason to slash indigent patient funds that pay for their care.

“We need that indigent care money,” said Giang Nguyen, director of the Santa Cruz County Heath Services Agency, as the disagreement heated up. “The state somehow believes after 2014 [when reform is in full swing] there will not be any indigent patients left. That is not true.”

California has already enrolled more than 500,000 residents in the Bridge to Reform, a head start on the 1.4 million patient Medi-Cal expansion created by President Obama’s Affordable Care Act.

The Bridge program has a different name in most every county. In Santa Cruz, it is called Medi-Cruz Advantage, and has covered 2,200 patients. Still, approximately 10,000 county residents who qualify for the program remain un-enrolled, said Nguyen.

Gov. Brown and the Democratic majority in Sacramento agreed in budget negotiations last month that county indigent funds would be reduced by $300 million in 2014, when health reform is fully implemented.

From there, reductions over the next two years will end up in the $2-billion range. They will be adjusted according to a pair of methods the counties have agreed to and can choose from.

A county can choose to receive 40 percent of their previous indigent care funding, or it can pick a “true-up mechanism” in which it must pay back to the state 80 percent of any indigent care funding it does not use.

Anthony Wright, executive director of Health Access California, a health care consumer advocacy coalition, said the poorest, hardest-to-reach patients will be on uncertain ground.

“There is going to be a mix of people who will fall though the cracks. And that’s why we need a safety net that survives, and thrives,” Wright said.

The state will take the fiscal and administrative lead in implementing health reform coverage expansion, unlike the Bridge program, which is run by the counties.

“The state cannot afford to both assume the costs of coverage, and continue its level of funding for county health care programs,” concluded Brown in his budget summary.

But other experts, including state-contracted evaluators of the health-reform transition, said there are significant bumps in the road.

First among those is the large segment of California’s population that will not qualify for health reform benefits: undocumented immigrants.

Unless they have insurance through an employer, these 2.5 million unauthorized residents will have no choice but to remain indigent care patients.

Even if President Obama’s immigration reform proposal becomes law, they would not qualify for health reform benefits for at least eight years.

“What happens to a county like L.A. County, where you have [hundreds of thousands of] undocumented immigrants who will still come to the county for care?” asked Dylan Roby, one of several experts at the UCLA Center for Health Policy Research undertaking an evaluation of health reform for the state.

It also remains to be seen how Bridge patients will be administratively transferred into health reform, Roby said. Proof of income and legal residency for the program’s half a million enrollees must be transferred from county enrollment systems to a state-supervised system beholden to a slew of new federal rules around reform.

Data “could be somewhat outdated,” Roby said. “There’s lots of movement on income.”

In addition to the qualifying standards, the realities of low-income life get in the way of enrollment.

Huboi, who suffers from the nerve disease neuropathy and also receives mental heath services with her Bridge plan, said jumping through administrative hoops makes staying eligible for the plan a “crapshoot.”

She is running thin on the patience needed to sit in waiting rooms with her documents, only to be told no one is available to meet her and she must come back another day.

An artist by trade, Huboi said enough patients are already enrolled in the program – so many that waits to see a physician can go on for weeks.

“I’ve gone to the ER before, rather than wait to be seen here,” she said.

Barrett said she was told after recent county-paid surgery on her back that the Bridge program was still open and she would qualify.

But she lost various odd jobs, then ended up in a homeless shelter where she has been unable to focus on anything but hasty trips to the clinic when her sciatica flares up.

She remains un-enrolled.

“I heard it was part of health reform,” she said. “There’s a lot it will pay for . . . Who do I see to try to get in?”

The CHCF Center for Health Reporting ( partners with news organizations to cover California health policy. Located at the University of Southern California’s Annenberg School for Communication and Journalism, it is funded by the non-profit California HealthCare Foundation.

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