COMMENTARY ON HEALTH COVERAGE : Indigent Care Catastrophes Product of Dysfunctional System : The crisis affects everyone as doctors pass on costs to the insured. Health care should be a right, not a privilege.

Committing an additional $7.5 million to the indigent medical care program June 23 was a significant step for the Orange County Board of Supervisors and for those “working poor” residents who are desperately ill.

Even more significant, however, is that this Band-Aid on a low-priority health service illustrates the gaping wounds in the entire health care system, the inadequate public policies that guide it and the urgent necessity for basic changes.

The Indigent Medical Service Program, operated by the county with state allocations, is the end-of-the-line public medical service for some adults, those ages 21 to 64, who cannot afford to pay. It’s the slight-hearted governmental attempt to deal with the health emergencies of California’s marginal labor force, the low-paid and unemployed who are part of a vaster army of 5 million in California without health insurance.

A slight majority of people receiving service are men (55%) and almost half (44.7%) of them are between the ages of 21 and 34. Contrary to general impressions, nearly two-thirds (63.7%) of the IMS patients are white, although Latino patients have increased from 13.4% to 20.2% in the last two years. Asian patients account for nearly 10%.

Despite service limits, Orange County’s economic conditions are escalating the IMS patient load radically, now serving 1,700 to 2,300 patients per month.

When the United Way’s Health Care Task Force issued warnings in its prophetic 1987 report (“Orange County’s Health Care Crisis”), the IMS program was high on the list of endangered species. Since then, inadequate financing of the IMS program has contributed to periodic catastrophes for Orange County residents seeking medical services, illustrating cause and effect of dysfunctions of the health care system.

Cost Controls

The IMS program exemplifies the misplaced effort of the health industry to meet the chronic escalation of health care costs, principally through service reductions rather than at original sources.

The controls of preference have been restrictions on the “scope of service” and so-called “disincentives.”

The former simply establishes restrictive rules that do not allow people to qualify for service.

If you are poor and your medical need is not immediately “necessary to protect life, to prevent significant disability or to prevent serious deterioration of health,” you will not qualify. For example, you may have a broken leg set as an emergency under IMS rules, but you can’t qualify under those rules to have the cast removed.

Aside from the message “come back when you are worse,” this economic funneling of the poor has clogged the costly hospital emergency rooms and left thousands unserved each month despite the desperate efforts of Orange County’s 12 struggling community clinics. Hardly a rational, preventive or cost-reducing program.

The underfunded IMS also spills over to private health care programs by stimulating compensatory billing increases and “disincentives.” That means techniques to discourage use of medical services; increased deductibles if you have any insurance, advance payments required if you do not.

The net effect is to squeeze people from using the system, thus forcing last minute crisis care rather than encouraging prevention.

To enforce restrictions, there must be personnel to receive applications, qualifiers to review and approve, form-handlers and checkers and auditors. Paperwork accounts for 20% to 30% of the cost of health care in the nation.

If you are the lucky insured, the IMS program is part of the reason you pay 20% more for your health insurance. You are absorbing the difference between the public program payments to physicians and hospitals and the “usual and customary” costs.

Add the costs of extra layers of administration and paperwork required to meet legal restrictions and you have a beginning understanding of the cost-spiral in health care.

Cost Shifting

The shell game of cost-shifting went big time with the federal government in 1980 under the disguise of shifting power and decisions to local levels.

Actually it shifted costs to state, to county, to providers, and to you, increasing them along the way.

IMS, a spinoff from Medi-Cal in 1983, was cost-shifted from the state to the counties with 70% of the original financing. Until now, Orange County has never picked up any of the difference despite its obligations under the state Health and Welfare Institutions Code. The IMS program has never dealt with more than a quarter of the health problems of the Orange County residents unable to pay for health services.

Instead, another shift passed costs on to hospitals and physicians through a county contract, presumably to obtain an equitable distribution of low-paid IMS patients to local providers.

This was in lieu of the abdication of the county hospital, sold to the UCI Medical Center in July, 1976.

Unfortunately, the low IMS payments made hospitals and physicians the financiers of health care for the poor, with many opting out of the system or passing along costs to other patients.

Maldistribution

The IMS plan instead brought inequitable patient distribution because money, like water, seeks its own level.

UCI Medical Center, an educational institution, became the de facto county hospital, and along with Western Medical and Fountain Valley medical centers, treats most of the IMS patients that some hospitals opt not to serve.

The community clinics tend to ignore IMS and most physicians don’t take IMS referrals because the paperwork isn’t worth the payment.

Responsibility

The shifting responsibility between profit-making, nonprofit voluntary, governmental agencies and private providers has resulted in service fragmentation, protective policies, all acting to prevent a user-friendly health service.

But sick people cannot wait. United Way’s Health Care Task Force has demonstrated small advances can make big differences. Prenatal care is an example, because $1,000 spent in prevention saves $30,000 in costs for each child born impaired.

The problems illustrated by the IMS program will be magnified as the county inherits responsibility for all the health and social services programs under the state’s planned “realignment.” Next year Orange County will be staggering from the full extent of the terminal disease of the health system.

It is increasingly evident to Orange County residents that the health care crisis impacts everyone, no matter the class, color or condition.

Opinion polls repeatedly verify that most Americans are convinced that we must join the rest of the industrialized nations with a national health program providing comprehensive health services to all.

Public health programs are in the best interest of the total community.

When will equity, justice and reason prevail?

When most Orange County residents demand an economical, comprehensive health care system as a right, as available as electricity.