County Budget Slashes Medical Services to Poor

Despite impassioned pleas from county doctors and health care providers, the Board of Supervisors on Wednesday adopted a $3.39-billion budget for 1990-91 that increases overall spending but dramatically cuts medical services to poor people.

“This budget is a needs nightmare,” said Supervisor Don R. Roth, who chairs the five-member board. “We’ve been forced to say no to just about everybody.”

With millions of dollars on the line, the session was by turns contentious, theatrical and openly confrontational as health care officials made a last-ditch effort to persuade the supervisors to dig into county funds for indigent health care. The supervisors, arguing that their budget was too tight to accommodate those needs, unanimously approved the county staff’s proposed budget without making a single amendment.

The budget combines higher fees to cities, school districts and other governmental entities with immediate cuts to indigent health care, expected to total $13.6 million but which could range anywhere from $9.2 million to $17 million. State lawmakers are still debating the precise funding formula.

Poor people will suffer the worst under Wednesday’s cuts, though virtually all county programs were held below what officials say is necessary to keep pace with Orange County’s growing population.

Emergency rooms may close, infectious diseases such as measles may become harder to fight and waiting lines at clinics may grow longer, representatives of doctors, hospitals and nonprofit agencies warned. And, without aid from the state before the end of the year, programs that help the homeless, distribute food stamps and provide shelter for troubled youths may also fall victim to the budget crunch.

“This has been a very difficult year for us,” County Administrative Officer Ernie Schneider told the supervisors. “This year’s budget is very lean.”

Although the overall county budget increases by $320 million, much of that is in the form of state reimbursement for services that the county government is obligated to perform under state law. Often the reimbursement amounts to less than the actual cost of providing the service, and as a result, budget planners had to parcel out cuts to some programs and hold down increases in others even as the budget grew.

Supervisors made the cuts through clenched teeth, however, and spent much of the Wednesday session blaming the county’s budget woes on its representation in Sacramento.

When Chauncey Alexander, representing the United Way Health Care Task Force, suggested that the supervisors join with health care advocates in “doing something special with our state legislators,” Supervisor Roger R. Stanton agreed.

“I’d like to do something ‘special’ with them too,” Stanton said, “with the exception of a couple that are enlightened.”

The state budget, approved late last month, passed along about $29 million in cuts to Orange County and sent local officials into a frenzy as they scrambled to make up the shortfall, which compounded a deficit of about $25 million that the county already faced.

The state authorized new fees to help counties deal with the cuts, but those fees involved problems as well: Cities and school districts, which will pick up most of the higher costs, have raised objections and even threatened retaliation.

Despite those threats, the county has gone ahead with plans to begin assessing one of those fees, a property tax levy that is expected to raise $14 million. A second fee, for booking inmates into county jails, has been deferred, but the supervisors are expected to approve it in November.

The new fees are only intended to pay for the cost of administering those services, however.

To temporarily offset a $3.7-million state cut in mental health funds and an $800,000 reduction in public health money, the supervisors dipped into the general fund for $2.1 million to carry the programs until December in the hope that additional money will somehow be found.

But despite pleas from doctors, hospital officials and a public interest lawyer who argued that the county had a legal duty to the poor, supervisors declined to bail out the program receiving the deepest cut, the Indigent Medical Services.

IMS--a state-funded program that cares for 24,000 of the county’s working poor--was expected to lose perhaps $13.6 million--55% of its funding--because of the state cuts.

In personal visits this week and again at Wednesday’s meeting, hospital leaders implored the supervisors to apportion a share of the new fees to all programs cut by the state. Medical centers that contracted with the county to provide indigent care last year were reimbursed only 22 cents on the dollar for their expenses, hospital officials said. With the budget cuts, they probably will receive fewer than 11 cents on the dollar, which may lead some hospitals to close their emergency rooms.

“If the state cuts in the Indigent Medical Services program are passed through to the providers of health services, it will threaten an already troubled health system and endanger the safety of all residents of Orange County,” said S. Russell Inglish, regional vice president of the Hospital Council of Southern California. “Only the Board of Supervisors can avoid deepening the current crisis.”

The supervisors bristled at being cast as the villains in the budget debate, and when Alexander asked members of the audience who support health care to stand and be counted, members of the board jumped to their feet as well.

“County staff, why don’t you stand too?” Roth urged. They did, leaving virtually the entire audience standing.

That gesture of solidarity was overshadowed by several testy exchanges, however, with health care leaders urging the supervisors to back their stated commitment to health care with county dollars to fund it.

“The Orange County Board of Supervisors should go on the record and confirm that medical care for the indigent in Orange County is their responsibility,” said Dr. Robert T. Miner, president of the Orange County Medical Assn.

“It’s easy to come out and attack. You don’t need any facts,” Supervisor Harriett M. Wieder lashed back. “We’re not looking for brownie points or a pat on the head, but come up with something constructive.”

Wieder’s remarks were echoed by her colleagues, who accused the doctors of doing too little to aid indigent patients and who defended the county budget cuts as a problem created by the state.

Indeed, even as Wednesday’s budget debate was under way, the exact extent of the cuts to Orange County’s Indigent Medical Services program was again being complicated by activity in Sacramento.

County officials previously had estimated that the county’s share of the state reduction would amount to $13.6 million, but they reported Wednesday that members of the Assembly are still haggling over the formula by which the state cuts will be apportioned. The final Orange County cut to indigent medical care could end up anywhere from $9.2 million to $17 million, officials said.

Doctors and hospital leaders say it may take several months before the IMS cuts have a visible impact.

At UCI Medical Center in Orange, which took care of 10,000 IMS patients last year, Deputy Executive Director Herb Spiwak estimated that the already deficit-ridden hospital could lose $4 million in reimbursements this year as a result of the IMS cuts.

Spiwak said he will not reduce emergency services but will begin reviewing all other hospital programs for cuts to counter the state reduction.

Sounding disgusted with the supervisors’ Wednesday, he added: “You know what I see there? A lot of finger pointing. The county to the state. The county to physicians. . . .”

“I don’t think health is the supervisors’ priority,” Spiwak continued. “And I don’t think they understand it”--especially the need for adequate reimbursement for in-patients.

Late Thursday, Dr. Peter Abbott, with the California Department of Health Services, suggested that Orange County could lose its 1990-91 share from the new state tobacco tax--Proposition 99--if it failed to use local funds to restore state cuts in indigent medical care.

“If in Orange County the decision not to put replacement money in the IMS programs means the county will not meet the ‘maintenance of effort’ required under Proposition 99 . . . the county potentially is in jeopardy of losing its tobacco tax money,” he said. Money from the tobacco tax goes to finance a variety of health care programs in the state.

Maintenance of effort is a technical phrase meaning that counties must not reduce the amount of funds for indigent health care or make cuts in the benefits.

But Herb Rosenzweig, a top Health Care Agency official who supervises the IMS program, did not believe that Orange County’s $16.2 million in tobacco tax funds this year would be threatened.

“Aw, he’s just blowing steam,” Rosenzweig responded. He noted that the “maintenance of effort” rule looks at Orange County’s history of supporting health care.