Increasing Access to Care for
the Medically Underserved:
Four County Models
Annette Gardner, PhD, MPH
Institute for Health Policy Studies
University of California, San Francisco
March 3, 2007
How many of us
think of access:
“Uh oh, your coverage doesn’t
seem to include illness.”
Access or getting the health
care one needs
 Key barriers: linguistic,
cultural, ethnic, geographic,
economic, institutional
 Insurance matters uninsured delay seeking
care
 There is no one solution consider a “holistic”
approach
California Counties Where the Action is At
 Bear significant responsibility
(Section 17000)
 Willing and able to undertake
coverage expansions, e.g., CHIs
 Vulnerable - sustainability is a
key issue
Presentation Objectives
 Describe barriers and opportunities to
expanding access to care in 4
counties (Fresno, Humboldt, Santa
Cruz and Solano)
 Increase understanding of access
initiatives underway/proposed
 Describe strategies for financing,
planning and implementing access
initiatives, e.g., access coalitions
 Describe efforts to expand county
capacity, e.g., IT, integrated services
Study Approach
 Interviews with representatives from
4 counties comparable to Sonoma,
including:
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County health agency official
Access coalition director
Provider representative
Medi-Cal plan representative
 Gather information on:
Access and policy issues
Key stakeholders and their roles
Access activities (type, funding)
Models for planning, financing,
implementing access activities
 IT
 Effort to integrate services, achieve costsavings
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Study Findings:
Key Determinants
 Four different, four similar
counties: (see handout)
 Rural/suburban
 Size (< 1M people)
 Programs for the medically indigent: 2 CMSP
(Humboldt, Solano) and 2 MISP (Fresno,
Santa Cruz)
 Range of uninsured, from 7% (Solano) to
18% (Fresno)
 Medi-Cal model: 2 COHS (Santa Cruz,
Solano), 1 FFS (Humboldt) and Medi-Cal
managed care (Fresno, 2-Plan)
 Health care delivery systems: county-run
services (Solano and Santa Cruz) vs. noncounty services (Fresno and Humboldt)
Barriers to Care: Access Issues
 Commonalities exist:
 Lack of insurance (and care) for
low-income adults
 Lack of specialty care (mental
health, dental care)
 Differences:
 Geographic barriers
 Target populations, i.e. farm workers,
elderly
 Services, I.e. existence of county-run
health care facilities, lack of hospital
care
Policy Issues That Impede Counties
 Lack of flexibility/control over
existing programs, such as MediCal, CMSP/MISP, Medicare
 Rising medical costs
 Insuring the undocumented
 Low commitment to expanding
coverage
 Low reimbursement for services
County Access InitiativesObservations
 All counties are undertaking access
initiatives, ranging from coverage
expansions to service expansions
 There is some diversity within each
type of initiative, e.g., activities to
attract providers, coverage of different
adult populations
 Children are addressed - adults are in
the “proposed” stage
 IT systems/applications vary,
piecemeal
 Efforts underway to integrate MH in
primary care settings
Financing Access Initiatives
 Multiple funding sources - public
(federal, state and local) and
private (foundations, United
Way, providers)
 Tend to be piece-meal, project
driven
 One study county, Sonoma, has
sustainable funding (Tobacco
Settlement funding)
Vehicle for Change: Access Coalitions
 All 4 study counties have an
organization to plan and undertake
access initiatives:
 Vary in age/maturity
 Vary slightly in membership emphasize broad-based
participation of leadership
 Recognized as lead agency in 3 of
4 counties
 Capacity - can staff/support
county-wide access initiatives
 Wear multiple “hats” - convener,
planning body, implementation
 Rely on grant funding
Four Access Coalitions
Coalition
Launch
Date
Fresno Healthy Community’s Access
Partners (HCAP)
2003
Community Health Alliance of
Humboldt-Del Norte (CHA)
2000
Health Improvement Partnership of
Santa Cruz County (HIP)
2003
Solano Coalition for Better Health
1988
Access Coalitions: Factors for Success
 High stakeholder commitment and
involvement, particularly by top
leadership - “culture of collaboration”
 Strong partnership with county
 Track record of accomplishments
 Agreement on coalition goals
 Established relationships among
stakeholders
 Staff support to convene, coordinate,
and facilitate stakeholders and
capacity to plan and implement
access initiatives
The Future:
County IT Capacity
 Uneven, piece-meal
 One commonality - adoption of
One-e-App to streamline
enrollment in public programs
 Some progress in developing
centralized data systems
(Humboldt, Santa Cruz)
 Varied adoption of TM, electronic
exchange systems, such as
HRE/HER
The Future:
Integrated Systems of Care
 Integration of behavioral health
services in primary care settings
(Prop 63)
 Other:
 Frequent Users project (Solano)
 IT in tandem with insurance
coverage (Santa Cruz)
 TM mental health services in
multiple settings (Humboldt)
The Future:
Cost-effective Systems of Care
 Limited activity - strategies
emerging:
 Shared risk funding model among
providers (Santa Cruz)
 Registries that have potential to
morph into county-wide initiatives
(Humboldt, Santa Cruz)
 Included as part of Coalition goals
(Fresno)
 Leveraging of funding (Solano)
Summary
 Counties can address intractable
problems in innovative ways - have
the means and the motivation
 Access coalitions may be critical in
overcoming barriers, undertaking
activities that individual
organizations could not do
otherwise
 Though counties vary, they can
adopt similar approaches to
reducing the barriers to health care
Acknowledgements
Funded by
the California Program on Access to Care,
University of California,
Office of the President
Contact Information
Annette Gardner, PhD, MPH
Institute for Health Policy Studies,
University of California, San Francisco
(415) 514-1543
Email: annette.gardner@ucsf.edu
Panel:
Four County Models
County/coalition descriptions
Realistic expectations - what can counties do?
Opportunities?
Strengthening stakeholder relationships-strategies?
Advice for Sonoma County?
Panel Participants
 Norma Forbes, Fresno Healthy
Community’s Access Partners
(HCAP)
 Allan Katz, Community Health
Alliance of Humboldt-Del Norte,
Inc. (CHA)
 Eleanor Littman, Health
Improvement Partnership of
Santa Cruz County (HIP)
 Patrick Hughes, Solano Coalition
for Better Health