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"Advocacy for the"

March 1993 issue of Poverty & Race

The Orange County Health Care Organizing and Action Project: Research and Legal

by Carole Harris, Ivette Pena, James Meeker, Nieves Rubio, and Howard Waitzkin

The Orange County Health Care Organizing and Action Project aims to identify and to remove obstacles exper-ienced by poor people seeking health care in Orange County, California. Home to the fantasy world of Disney-land and the opulent luxury of Newport Beach, this county is one of the richest in the United States. Yet it also presents an example of severe barriers to health access within a locality widely recognized for its affluence.

The Local Access Problem

Orange County provides minimal health services for its poor and unin-sured. About 500,000 uninsured people live in the County. An additional 60,000 are poor and have public coverage such as Medi-Cal or the County-administered Medical Services for Indigents (MSI) program. The County government op-erates no public hospital nor any general medical clinic for anyone over the age of six and ranks 56th among California's 58 counties in per capita expenditures on health care. After the 1992-93 County budget was approved, the reimbursement rate for the MSI program dropped to an average of 5 cents on the dollar. Fewer and fewer private hospitals are willing to care for uninsured or publicly insured patients, and the County medical associ-ation reports that only 7% of member physicians are willing to accept a patient with Medi-Cal or MSI.

Our Project has focused on those persons eligible for the County-run MSI program. In 1983, the California legisla-ture transferred to its counties responsi-bility to care for a category of patients it no longer chose to include in the Medi--Cal program: adults between the ages of 21 and 65 who meet the financial eligi-bility requirements of Medi-Cal and who do not have access to other resources for medical care. Orange County met its newly imposed state-mandated responsi-bility by creating the MSI Program. With this program, the County also sought to satisfy its responsibilities under Section 17000 of the State Welfare and Institutions Code, which requires coun-ties to "relieve and support all ... indigent persons and those incapacitated by age, disease or accident." MSI purports to have created a unique private/public relationship with health care providers.

MSI works as follows: 1) the County government certifies indigent patients' financial eligibility (financial eligibility standards for MSI were incorporated from the guidelines used in the state Medi-Cal program); 2) it then instructs them to obtain medical care from private providers; 3) these providers, in turn, are told to bill the County for the patient's care. The County employs a fiscal inter-mediary, American Insurance Admini-strators (AIA), to process all medical bills submitted by private providers who treat MSI patients. However, AIA will only pay a bill if it is within MSI's "scope of services." That scope is limited to treatment that is "medically necessary to protect life, or prevent significant dis-ability, or to prevent serious deteriora-tion of health."

Research Efforts

When planning this Project, we con-ceived it as a follow-up to research done by a team from the University of Cali-fornia, Irvine (UCI) and the Orange County Task Force for Indigent Health Care. Our research assistant, with guid-ance from the research group and the litigation director of the Public Lave Center of Orange County (PLC), worked to identify patients who experienced bar-riers to access under the County's MS] program.

We quickly learned that there was a paucity of information about the MS] program. We found no regulations and could not determine how the fiscal intermediary and the medical review board it many instances made decisions about coverage.

The Health Care Agency of Orange County had established a special telephone number (the MSI Hotline) the patients and providers could call to inquire about the program and obtain tentative answers to coverage questions, We found that the Hotline was consistently busy during business hours. One provider's secretary called the number 12 times during a four-week period before she was able to talk to someone at MSI

The research assistant introduced the Project to the medical community b) meeting with MSI intake workers at different community clinics and hospital, with large MSI constituencies. She talked to them about our Project and our desire to help prospective MSI patient. through the application process and wit; any problems they might subsequently encounter. Several of these providers re-ferred appropriate MSI patients to our Project.

As a result of our work, we were able to identify six broad barriers that prevent access to health care in Orange County 1) cumbersome eligibility processing, including extensive paperwork, delays, registration at designated application, sites, and too few application sites, excessive waiting times for needed med-ical services, 3) burdensome patient co--payment and deposit policies, 4) narrow range of medical services provided, 5) language and cultural barriers, and 6) small number of participating MSI pro-viders.

Advocacy Strategies

In an effort to remove these barriers to health care, our Project developed several strategies. In order to educate newcomers to the subject of health law in Orange County, we wrote a memo-randum that outlines MSI's history and some of its problems.

We also assembled a packet of docu-ments to be used by advocates. Those materials include a brief reporting form for providers, a more detailed question-naire in English and Spanish for patients (which complements ongoing local re-search on access), a demand letter, a model legal brief, a research memorandum regarding the procedure for bring-ing a civil writ, and two research memo-randa discussing substantive bases to challenge health care access barriers. Finally, we prepared a list of the clients helped by our Project with a description of their problems and our interventions on their behalf.

Equipped with that information, ad-vocates are able to accept cases, analyze them, and resolve them either informally or through litigation. PLC maintains a data base of lawyers and paralegal workers in Orange County who have ac-cepted pro bono cases or are interested in doing so. We identified attorneys and paralegals experienced in handling health law cases and others who have expressed a commitment to handle such cases in the future. When a patient comes to our office, we find an attorney and/or para-legal willing to accept the case, prepare a brief summary of the facts of the case, and send that information along with any necessary forms to the attorney. The attorney or paralegal then handles the Ease, at no cost to the client, until the access problem is resolved.

Clients accepted by PLC are given pri-ority, based on the specific MSI program barriers to be overcome. As specific bar-riers are targeted, individual cases are analyzed to determine whether they ful-fill the criteria necessary to challenge each barrier successfully. It is anticipated that these test cases will create change in most aspects of the processing, admini-stration, and funding of the County's MSI program.

Challenges and Obstacles

In carrying out this Project, we dis-covered that as advocates we needed to be creative when identifying health care cases. Often we first learned about a client's lack of access to health care when his or her medical bill was sent to a col-lection agency. Health care access issues commonly arise in the context of unemployment, housing, disability, or immigration cases.

The indigence of the MSI-eligible community means that clients frequently have complicated and multiple legal and/or health care problems. Advocates should be prepared to address those other problems or, at the very least, be aware of community resources to which the client may be referred for help.

Three obstacles arose in carrying out this Project that were unforeseen at the proposal stage. The first was a state-level legislative move to repeal the statutory basis for the MSI program. Early in the Summer of 1992, during the pre-budget discussions in Sacramento, there was a serious, but fortunately unsuccessful, move to repeal Section 17000. That de-velopment required all of us to work to-gether with other legal advocates, health care providers, and activists to prevent repeal. The battle introduced uncertainty into the Project because, if the statute were repealed, we would have no strong legal basis to argue that the County has a duty to provide health care to indigent clients.

Secondly, in the midst of our Project, the County government announced that it was planning a pilot project in which all indigent persons receiving Medi-Cal would be enrolled in a managed care plan. That proposal, known as Orange Prevention and Treatment Integrated Medical Assistance Program (OPTIMA) created uncertainty because many polio makers mistakenly assumed that the new program would address all access issue affecting the, medically indigent. They misunderstood that OPTIMA was de signed for Medi-Cal patients and did no include the MSI community. Some legislators argued that if OPTIMA were successful and the County achieved savings they would consider including the MS population in the OPTIMA program. However, even if the proposal obtained all necessary approvals, it would not be implemented until 1995. Especially be cause the County government does no plan to add local funds to the program it is unclear if OPTIMA will prove viable financially and if it actually will be made available to the MSI-eligible community

A third obstacle arose due to an expectation of structural change at the federal level in the provision of health care. Local policy makers and health care providers argued that it was no efficient to worry about the community, of medically indigent people until w knew whether our country would have new President and if so what his health care agenda would be. Now that Bill Clinton has taken office, local policy makers and providers are more hesitant to consider changing the health car delivery system. However, even under the Clinton Administration's proposal, (which, as of this writing, emphasize "managed competition') co-payment and exclusions are likely to leave substantial barriers to access intact. We also believe that local variability in access will persist, especially in areas where county governments have not assumed a com-mitment to delivering services for the medically needy.

Future Prospects and Applicability Beyond Orange County

We view our Project as a necessary step in a larger strategy to improve access to health care. In that process, we hope that the packet of research methods, in-struments, and legal documents we have prepared will prove useful for other ad-vocates around the country. Once advo-cates learn the requirements, goals, and problems of public insurance programs like MSI, they can challenge government agencies, health care providers, an policy makers to make such programs more efficient and responsive. More importantly, once advocates familiarize themselves with programs such as MS they can work to make the process c obtaining health care more manageable and less degrading for clients.

It is likely that local projects like ours will become increasingly needed, because of current trends that reinforce the important role of county governments i policy decisions about health-care access. Due to persistent federal and state budget deficits, recent decisions have emphasized greater decentralization of policy and funding decisions regarding heals care to county governments. These trends are likely to persist, especially if the Clinton Administration's national health program proposal does not create uni-form standards of access throughout the country.

Conditions in Orange County are not unique, and its regressive public policies regarding health-care access have gained both notoriety and a certain popularity among policy makers in other localities. Numerous counties which appear rela-tively wealthy based on overall demo-graphics have closed their public hos-pitals or have transferred them to private control. Further, due to budget crises in many parts of the nation, county governments have cut back their spending on public health and direct medical services.

In a country whose regressive policies have become well known and increas-ingly influential, our research and advo-cacy strategies have helped challenge a powerful assumption guiding the on-going decentralization of health policy decisions-that restrictive local policies can yield budgetary savings without maintaining or exacerbating access bar-riers. In addition to its impact on local access, our Project contributes to the current debate on decentralization of health policy decisions, a debate whose repercussions will continue to be felt nationally.

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