Do We Save Lives or Count Bodies? : If counties can opt out of health services, urban areas will attract even more of the state’s poor and uninsured.

Imagine a diabetic without insulin, collapsing and dying on the street because no health provider is willing to give care. This could happen if Assembly Bill 154 becomes law. The legislation introduced by Assemblyman Bernie Richter (R-Chico) proposes to amend California’s welfare code to relieve counties from their current financial burden of providing services for all “incompetent, poor, indigent persons and those incapacitated by age, disease, or accident.” County health officers would end up counting bodies instead of saving lives.

The pressure to downsize county health departments is not new and the burden of providing care to growing numbers of uninsured people has outstripped several counties’ budgets. Officials in small counties and those most impacted by the downturns in the state’s economy resent the intrusiveness of state mandates that they provide this care. The continued bad economy and the realignment of the state budget, which eliminated funding for such county programs, fueled the move to dismantle state mandates. Many county supervisors had to choose between the public safety or public health. Though county health providers recognized the severe limitations of providing services to the indigent, they also recognized the huge social cost of not protecting residents from communicable diseases and destroying the health safety net for the poor.

Steve Thompson of the California Medical Assn. has criticized AB 154 for departing from California’s tradition of requiring counties to be the safety-net providers for their own poor. C. Duane Dauner, president of the California Assn. of Hospitals and Health Systems, provides a more sobering analysis of the negative effect on California’s health system: Immediate impacts, he says, would include reduced access to essential health services, greater incidence of death and disease and shifting of costs from the government to private providers. Critics of this bill share a real fear that large urban counties would become even greater magnets for the uninsured and underinsured. Los Angeles County, with its six large publicly owned hospitals and extensive network of health centers, would be forced to share these limited resources with surrounding counties that opt out of providing services. Los Angeles supervisors would have to choose between further restricting eligibility for needed public-health programs like prenatal care or pressuring the state for more money.

There is no doubt that unfunded and underfunded mandates, both by Congress and by the state Legislature, are an issue for county and municipal governments. But we must not be shortsighted in eliminating services for the poor. Infectious diseases like tuberculosis place us all at risk. County health programs are needed not only to monitor the outbreak of these diseases but also to mobilize the state and federal resources for effective treatment. As attractive as private-sector solutions may be, we must remember that government plays an equally important role in providing services when markets fail. Private-sector providers facing greater pressure from lower profit margins cannot absorb all of the indigent. In California, we once wisely decided that all counties must share in this burden because illness and disease do not recognize county boundaries. To allow supervisors the option of not providing services to the poor is to invite chaos, disease and death, a long-run cost we all will share.