IMPACT OF THE 2009-2010 CALIFORNIA BUDGET CRISIS ON PUBLIC
HEALTH AFFECTING MEDICALLY INDIGENT WOMEN
Jennifer Marie Whitby
B.A., California State University, Sacramento, 2008
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2010
IMPACT OF THE 2009-2010 CALIFORNIA BUDGET CRISIS ON PUBLIC
HEALTH AFFECTING MEDICALLY INDIGENT WOMEN
A Project
by
Jennifer Marie Whitby
Approved by:
____________________________, Committee Chair
Teiahsha Bankhead, PhD, L.C.S.W.
____________________________
Date
ii
Student: Jennifer Marie Whitby
I certify that this student has met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library
and credit is to be awarded for the Project.
________________________, Division Chair
Robin Carter, DPA, L.C.S.W.
Division of Social Work
iii
_______________________
Date
Abstract
of
IMPACT OF THE 2009-2010 CALIFORNIA BUDGET CRISIS ON PUBLIC
HEALTH AFFECTING MEDICALLY INDIGENT WOMEN
by
Jennifer Marie Whitby
This qualitative exploratory study examines the impacts of the 2009-2010 budget crisis
on public health agencies that provide physical health services to medically indigent
women. The purpose of the study was to explore the fiscal impacts on public health
agencies in Sacramento County and the degree to which medically indigent women are
affected. The researcher conducted 12 face-to-face interviews with administrators from
local public health agencies. Analysis of the findings from the experiential narratives
resulted into common themes, namely, longer wait periods, increase in caseload; the
impact on preventative services; and the long-term effects of the budget crisis.
iv
Implications for future research, social work practice, policy, and practice are explored.
_____________________________, Committee Chair
Teiahsha Bankhead, PhD, L.C.S.W.
_____________________________
Date
v
DEDICATION
I dedicate this project to my husband, my life partner, my Baby. You have always
been the shining light that sheds tremendous love and encouragement even in the
darkest of times. You have been my rock, my pillar, and my support. I love you baby!
vi
ACKNOWLEDGMENTS
This project became a reality through the countless support and help that I have
received in my life. Most of all, I give all praises to God without whose presence,
mercy, and guidance, nothing is possible.
I would like to thank Dr. Teiahsha Bankhead, my thesis advisor, for helping me
complete the final phase in my MSW career. Many thanks to Prof. John Davis for his
kind words and classic jokes in the classroom and halls that brought a smile to my face
and made my days bright.
I heartily acknowledge Dr. Susan Eggman for her compassion and dedication to the
profession and her students. She has always inspired me. She has made a lasting
impression on my heart. I will forever be grateful to her. I will never forget the
encouragements and care to help me realize my personal and professional goals.
To all my friends, especially, Melissa, Renee, Kelli and Cheryl, my constant support
through the trial and tribulations over the years, much love and many thanks.
To my family for their continuous love and support, my appreciation for you goes
beyond words. To my dad Todd and my father Mike, thank you for always encouraging
me to do my best. To my father-in-law Rick, though we struggled with Plate Tectonics
he never gave up on my education. Thank you for the small talks and words of
encouragement. More significantly, my dearest mother Peggy, my best friend,
confidant, and no. 1 fan, thank you and much love! You have been by my side,
believing in me every step of the way and I will be forever grateful. I love you!
vii
TABLE OF CONTENTS
Page
Dedication .................................................................................................................... vi
Acknowledgments...................................................................................................... vii
Chapter
1. THE PROBLEM ......................................................................................................1
Introduction ....................................................................................................... 1
Background of the Problem ............................................................................. 2
Statement of the Research Problem .................................................................. 3
Purpose of the Study ..........................................................................................4
Theoretical Framework ......................................................................................4
Definition of Terms............................................................................................6
Assumptions.......................................................................................................7
Justification ........................................................................................................7
Limitations .........................................................................................................7
Summary……………………………………………………………………… 8
2. REVIEW OF THE LITTERATURE .......................................................................9
Introduction ........................................................................................................9
How Does California Compare ..........................................................................9
Proposition 13 ..................................................................................................10
Medi-Cal ..........................................................................................................10
Prenatal Care ....................................................................................................12
viii
Hospitals ..........................................................................................................14
Clinics ..............................................................................................................15
Preventative Care .............................................................................................16
Immunization Services.....................................................................................17
Title X ..............................................................................................................17
California’s Safety Net ....................................................................................19
Women in Need ...............................................................................................21
Elderly Women ................................................................................................23
Sacramento Demographics ..............................................................................25
Emergency Care ...............................................................................................27
Sacramento County Clinics..............................................................................28
Sacramento Health Care Improvement Project................................................29
Summary ..........................................................................................................29
3. METHODS ............................................................................................................32
Introduction ......................................................................................................32
Collaborative Elements ....................................................................................32
Research Design...............................................................................................32
Measurements ..................................................................................................33
Sampling Plan ..................................................................................................34
Instrumentation ................................................................................................34
Data Collection ................................................................................................35
Data Analysis ...................................................................................................35
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Human Subjects ...............................................................................................36
Summary ..........................................................................................................37
4. FINDINGS .............................................................................................................38
Introduction ......................................................................................................38
Demographics ..................................................................................................38
Presentation of the Findings.............................................................................39
Longer Wait Periods ........................................................................................40
Increased Caseload...........................................................................................41
Cuts to Preventative Services...........................................................................44
Long Term Effects of the Budget Crisis ..........................................................46
Summary ..........................................................................................................47
5. CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS .................50
Introduction ......................................................................................................50
Conclusions to the Study .................................................................................50
Barriers to the Research Process ......................................................................54
Implications for Future Policy .........................................................................56
Implications for Social Work Practice .............................................................57
Implications for Practitioners ...........................................................................57
Summary ..........................................................................................................57
Appendix A: Approval by the Committee for the Protection
of Human Subjects .................................................................................59
Appendix B: Informed Consent Forms .......................................................................61
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Appendix C: Interview Questions for Health Administrative Professionals/Staff ............. 66
Appendix D: Interview Questions for Clients ..................................................................... 71
Appendix E: List of Resources ...................................................................................75
References ....................................................................................................................77
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1
Chapter 1
THE PROBLEM
Introduction
The 2009-2010 current budget crisis in California raises numerous questions and
concerns about the impacts it might have on public health care services for
Sacramento’s most indigent women. The issues surrounding access to health care are
magnified by California’s rising unemployment rate, exorbitant costs of private health
insurance, and cuts to public health care. California’s historical and recent budgetary
actions have complicated the health care system at the state and local level (Kelch,
2005).
Being a woman and sharing in the struggles of obtaining insurance, I have a deep
interest in this topic. As a full-time graduate student with limited financial resources, I
am often faced with health dilemmas. Though my health is considered good at this
point, I still require regular check-ups. I am cognizant of the possibilities of getting
involved in a car accident or facing a major health crisis and not having the financial
resources to obtain the needed services. I currently suffer from migraines. On one
occasion I had a prescription for the migraines that was covered through my spouse’s
employer-based health plan; however he was recently laid off from his job and
subsequently lost our health coverage. I have since depleted my prescription and cannot
get it refilled because of the exorbitant cost. It is a very helpless and frustrating feeling.
This topic is meaningful in other ways as well. In the coming months I hope to
obtain my Master’s degree of Social Work. As a social worker, I pledge to serve the
2
underserved, vulnerable and disenfranchised populations. I commit to ensure that my
clients are getting their needs met and are treated with respect and dignity. I will
advocate for policy and social change through research which will be an effective
vehicle for the needed change. With such task at hand as a social worker, I need to be
knowledgeable of the complex issues facing my prospective clients.
The 2009-2010 budget calls for additional cuts from the Proposition 99 funding
stream and will affect programs supporting prenatal care and health and wellness
(Health Access, 2009). Proposition 13 and Proposition 99 have impacted health care
funding for the uninsured. The passage of Proposition 13 in 1975 drastically reduced
local revenues derived from property taxes by 52 percent (Kelch, 2005). Proposition 13
limited revenues acquired through property taxes to one percent of the property value.
The loss in revenues had a direct impact on the amount of monies appropriated for
public health. Proposition 99 was passed by California residents in 1988 and was
intended to provide new funding for public health through the taxation of tobacco
products. Unfortunately this funding stream has been on a steady decline as less money
is being spent on tobacco products (Kelch, 2005). Both propositions are small
examples of the complex nature and impact of the budget crisis on people’s welfare.
Evidently, reform is much needed.
Background of the Problem
Each year the state legislature enacts a budget that delineates the state’s revenues and
expenditures for the following year. When the state has more expenditures than
incoming revenue it has no choice but to cut funding from its programs. The current
3
budget crisis called for numerous cuts to many very important programs and adversely
affected the low-income and vulnerable residents in California (California Budget
Project, October, 2009 & Health Access, 2009). The California Budget Project (CBP)
(1996) argued that, “The annual state budget reflects the priorities and values of the
Governor and the Legislature for the upcoming year” (p. 1). Deep cuts to public health
care, as a result of the current budget crisis, attest then to what is deemed important, or
unimportant, to the Governor and the Legislature.
Many of the clinics and agencies that offer public health services to the medically
indigent have already felt the effects since the enacted budget in July 2009. Funding
streams to these agencies have been drastically reduced resulting in reductions of staff
and their hours of operations, longer wait periods for the clients, and a decline in
services for women (Tu, Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009).
Women’s health is a complex issue due to the specific needs of the population, and
the policies surrounding access to health care. Since women typically have lower
incomes than men, they are more likely to be affected by health-related policies and the
rising costs of private health care. These factors increase the disproportionate rate at
which women utilize public health clinics (Wyn, & Ojeda, 2003). Medically indigent
women are in desperate need of health care, and the enacted cuts only amplify the
problem.
Statement of the Research Problem
The massive budget shortfall appears to be affecting one of the most vulnerable
segments of the population, medically indigent women. Systemic changes to public
4
health care need to take place so that women’s health is not jeopardized. Reductions in
funding for public health may place women’s health at risk and will likely prove to be
more costly for the government in the end.
Purpose of the Study
The purpose of this research study is to explore the consequences in health services
when medically indigent women are unable to access health care. This is an
exploratory study which is qualitative in nature based on information received from face
to face interviews with the representatives of agencies and the medically indigent
clients. This study will explore and discuss the effects of the budget crisis on medically
indigent women and their access to care through Sacramento public health agencies.
Agencies were identified through a systematic approach and contacted to schedule
face to face interviews regarding the changes in services. Clients from these agencies
were identified with the permission of the selected agency. In the end, this study will
provide the reader a glimpse into the negative impacts of the state budget on the health
care and the lives of the target population. It will demonstrate the importance of
women’s health and the need for adequate public health services within agencies that
support medically indigent women.
Theoretical Framework
In this study, the researcher finds that the social theory of Karl Marx serves as an
appropriate theoretical framework in order to better understand the motivation and
inspiration behind this study. Having witnessed the seeming endemic oppression of the
lower social classes, Marx argued that one’s political, ethical, philosophical, religious,
5
and ideological views were influenced by social and economic class (McClelland,
2000). Furthermore, for him, the social class that possesses material goods, such as
wealth, will intellectually dominate the public media such as the communications media
and the political arena (McClelland, 2000). His idea supports the truth on the dynamics
of our society. In the United States, as a capitalist country, there are essentially three
class systems: the upper class, the middle class, and the lower class. The upper class
tends to oversee and influence policies that typically benefit them. Financial
corporations and legal institutions, where the upper class members are mainly found,
lobby intensely for their interests before lawmakers who make policies for the society,
which translated into the major interests of the upper class. Karl Marx believed that the
dominant culture in its effort to retain control in society utilizes systems, such as
religion and government, to reinforce the status quo, or their dominance in power. In
addition, he argued that when people feel abandoned and helpless, they become
withdrawn and succumb to social institutions such as government (McClelland, 2000).
In essence, when people feel as though they cannot compete against the dominant
culture or status quo, they surrender to the oppression. Medically indigent women are
vulnerable, oppressed, and controlled by the values, views, and monetary goods of the
dominant culture. Applied to the situation on current health policies, this subordinate
population is vulnerable because they do not have monetary goods or political power to
affect change.
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Definition of Terms
To help the reader understand the discussion better, the following terms which are
often used in this study are clearly defined in their meanings.
Agency/Clinic: public organization partially or completely funded by Sacramento
County that offers health services to the general public.
Budget: an attempt to itemize future income and expenses of a given entity for a
given time. For instance, this study discusses the 2009-2010 California budget.
Budget crisis: it describes California’s economic climate due to the lack of income
and revenues needed to support the various programs which the state of California
serves. For instance, California does not have enough income or revenues to financially
pay for services and expenditures of the medically indigent women.
Low income: income that is 200% or more below the federal poverty line (FPL).
Federal poverty guidelines are issued each year by the Department of Health and
Human Services and are used to determine financial eligibility for certain federal
programs.
Medically indigent: it describes a segment of the population that is without private or
public health insurance and cannot afford to pay for medical care.
Public health: government-funded health services offered to the general public for
the purposes of prevention, health education, and control of illness and disease.
Underinsured: it describes minimal coverage in insurance payment. For instance, an
insurance plan may cover only one procedure but not another, thus rendering an
incomplete and possibly ineffective solution or treatment.
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Uninsured: not covered by insurance.
Women: for purposes of this study, this term is used to describe women who are 18
years and older.
Assumptions
This study assumes that not all women have equal access to health care. It should
also be assumed that the political arena plays a major role in implementing policies that
may inherently affect vulnerable populations. Arguably, the current economic crisis has
affected health care services for medically indigent women. Furthermore, it is
anticipated that the overall viability of the clinics and the quality of care provided to
medically indigent women will be threatened as funding streams are drastically reduced
and possibly eliminated due to the current budget crisis.
Justification
This study will provide a further understanding of California’s current economic
crisis and its effects on poor women who lack health care. It is vital to recognize the
limitations and risks that are imposed on vulnerable populations due to decisions made
as regards the state budget. This study may have implications for the current and future
state budgets. It may also have implications for the rationale of clinics and the
medically indigent women they serve.
Limitations
This research is being conducted solely in Sacramento, California. Therefore,
findings of the study cannot be generalized to unduly apply to any other area. Given the
fact that the budget crisis is occurring now, it is difficult to determine the long term
8
effects of the economic crisis and the impact it may have on public health care and the
target population. At this point, there is limited research on how the agencies and
medically indigent women will be affected.
Summary
This introductory chapter outlined the issues surrounding the 2009-2010 budget
crisis and its direct impact on Sacramento’s medically indigent women. It indicated that
the purpose of the study focused on exploring the effects of the budget crisis on
women’s health. The next chapter broadens the base towards understanding the crisis
situation through a pertinent review of the literature on the given topic.
9
Chapter 2
REVIEW OF THE LITERATURE
Introduction
On July 28, 2009 California State Governor Arnold Schwarzenegger approved the
2009-2010 fiscal budget. The budget crisis of 2008-2009 was large and more complex
than California has endured, but sadly, the consequences of the 2009-2010 budget were
more drastic than the previous year’s budget (California Budget Project, May, 2009).
This was the largest deficit the state had encountered and the ramifications undoubtedly
affected California’s most vulnerable residents (Health Access, 2009). The budget
crisis presented challenges and placed vulnerable low-income women’s health at risk.
Drastic program changes were made as a result of the $60 billion shortfall.
Health
care lost over $2 billion and the loss in funding largely impacted the public health care
system in California. The enacted cuts eliminated or reduced funding for low income
residents, clinics, providers and rural and minority communities (Health Access, 2009).
How Does California Compare
The Public Policy Institute of California assessed California’s health services by
exploring the similarities and differences between California and other states, such as
New York, Illinois, Florida and Texas with regard to revenues and expenditures. Data
pertaining to the 2001-2002 fiscal year reported that California and these states shared a
large diverse population and a large percentage of poor people. Though these states are
similar in many ways, the data also revealed a few major differences. One of the
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biggest reported differences between California and other states was the legislation
regarding income taxes and property taxes (Gordon, Alderete, Murphy, Sonstelie, &
Zhang, 2007).
Proposition 13
California relies on revenues generated mainly through income taxes and less on
property taxes, while other states depend heavily on property taxes and less on income
taxes (Gordon, et al., 2007). California voters passed Proposition 13 in 1978 placing a
cap on property taxes. Property taxes could not exceed one percent of the full cash
value of the property (Cal-Tax Research, 1993). According to the California Budget
Project (CBP) (2004), California had suffered a steep decline in revenues due to drastic
tax cuts in 1991. CBP (May, 2009) also suggested the state had lost approximately $12
billion between 1993 and 2008 from tax cuts (California Budget Project, May, 2009).
In essence, the decrease in income taxes and property taxes likely contributed to
California’s economic crisis. With the rise in unemployment, many people have lost
their homes. In turn, the housing market has plummeted and property taxes have been
on the decline. These factors have created a larger deficit and may play a major role in
California’s budget crisis.
Medi-Cal
Medi-Cal, one of the largest federally funded programs stemming from Medicare,
supplies health care to medically indigent women. Medi-Cal has faced major changes
as a result of the budget crisis. In order to close the historically massive budget gap of
$60 billion, California legislation instituted drastic cuts to health care and Medi-Cal.
11
The 2009-2010 budget called for a decrease in Medi-Cal coverage for nearly two
million adults (Health Access, 2009, & California Budget Project, May, 2009). MediCal eligibility, preventative programs such as prenatal care and vaccinations, hospitals
and clinics will feel the devastation from the financial breakdown of the Medi-Cal
program. California’s recessional economy has intensified the need for public
assistance (County Welfare Directors Association of California, California State
Association of Counties, 2009, & California Budget Project, May, 2009). For example,
as more employees become laid off, they will lose their employer-based coverage. The
consequences of this may require the once covered employee to pay the high cost of
private health care, seek out public health care or go without until they can hopefully
obtain employment that includes health insurance benefits.
Payments made to counties for the purposes of reviewing applications and
determining Medi-Cal eligibility were considerably reduced by $85.3 million (Health
Access, 2009). The reduction in payments will likely impact the number of employees
undergoing the application review process. The delay in reviewing the applications
may leave more indigent women without health care for longer periods of time. In
addition, counties that offer individual assistance to clients with the Medi-Cal
application process lost $4.6 million (Health Access, 2009). The decrease in funding
will inevitably change the eligibility process for many prospective Medi-Cal recipients.
The application process is perplexing and not easily understood. Without the assistance
from county employees, many prospective Medi-Cal recipients may feel defeated and
overwhelmed by the challenging process. This may inhibit countless applicants from
12
completing the application and obtaining health care. Along with the cuts to Medi-Cal
eligibility, preventative programs supported by Medi-Cal funding streams were
impacted.
Prenatal Care
Programs servicing low-income pregnant women may have to reduce the number of
clients they serve due to the decrease of Medi-Cal funds. Access for Infants and
Mothers (AIM), a program providing low-income pregnant women with prenatal care
services lost $4.9 million from tobacco taxes established through Proposition 99 (Health
Access, 2009). Not only is the reduction of Medi-Cal funding affecting this program
but the revenue streams from Proposition 99 have been on a steady decline since 1989
as tobacco sales decrease and therefore, have not been able to keep up with the financial
demand to support the services (Ta & Wulsin, 2005; Kelch, 2005). This will drastically
impact the health care needs of women and their unborn children.
The Maternal, Child and Adolescent Health (MCAH) grant operates as a financial
umbrella to various programs, such as Black Infant Health (BIH), that serve women,
children and families. Programs such as these help to educate, provide quality health
care and offer resources to low-income and uninsured pregnant women. Resources
such as BIH are unique to specific ethnic groups as they strive to provide culturally
appropriate services to women and their families. BIH attempts to reduce the disturbing
infant mortality rate among African American infants by providing indigent pregnant
African American women proper education and health care during their pregnancies
(California Health and Human Services Agency, 2009).
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The 2009 budget slashed nearly $18.5 million from the Maternal, Child and
Adolescent Health (MCAH) grant (Health Access, 2009). In addition, the General Fund
will not provide funding to the grant which supported 58 counties and three city health
departments due to the decrease in state revenues (California Health and Human
Services Agency, 2009). These services not only help to achieve proper health for
pregnant women by providing preventative health services but also promote a healthy
pregnancy to ensure their infants are born healthy. BIH recognizes the importance of
family planning and provides education and counseling to their clients to prevent
unwanted pregnancies (Partners In Care Foundation, 2009). The BIH program lost $3
million due to the budget crisis (California State Association of Counties, 2009).
Resources such as Black Infant Health are culturally competent and highly respected
due to their ability to provide specialized services.
Prenatal care is crucial in terms of women having a successful pregnancy. Women
of all income levels are more likely to develop complications during their pregnancies
and deliver at risk infants if they do not engage in prenatal services (Francis et al.,
2009). When compared to upper class white women, low income women and women
of color have a higher probability of developing complications during their pregnancy
and delivering premature, low birth weight infants (Franci, Berger, Giardini, Steinman,
& Kim, 2009). The infant mortality rate is also much higher for this population
(Francis, et al., 2009). Research suggests that there is an increase in the likelihood of
infant mortality, low birth weight and premature birth if the mother does not obtain
prenatal care during her pregnancy (Adequacy of prenatal-care utilization -California,
14
1989-1994, 1996). With the establishment of clinics, some pressure from the hospitals
is relieved. Clinics play a key role in supporting women’s health with the delivery of its
services that are easily accessible to their clients, especially indigent women.
Hospitals
Public hospitals, also known as safety net hospitals, and private hospitals lost
approximately $100 million from cuts to Medi-Cal payments in 2009-2010 (California
State Budget, 2009). Many hospitals receive supplemental financial support through
the Distressed Hospital Fund (Health Access, 2009). The Distressed Hospital Fund
provides financial compensation to hospitals that specifically serve uninsured patients
(Health Access, 2009). Nearly 25 percent of women report public hospitals to be one of
their sources of care. One percent of women rely on hospitals for their primary source
of care (Wyn, Hastert, & Peckham, 2008). As hospitals bear the financial burden from
the cutbacks, indigent women relying on emergency services may be impacted. Wait
periods may increase and the quality of care may diminish. Furthermore, rural hospitals
that frequently act as the sole resource for emergency care to rural communities also
lost financial support (Health Access, 2009; California State Budget, 2009). Many lowincome indigent women lack the resources needed to obtain health care. Transportation
issues and inadequate income are just two of the many factors hindering indigent
women from accessing health care (Health Access, 2009). Clinics play a key role in
supporting women’s health and help to relieve some of the pressure from the hospitals.
15
Clinics
Community clinics providing programs such as the Expanded Access to Care
Program, Rural Health Services Development Program, Seasonal Agricultural and
Migratory Workers Program and Indian Health Program are deeply affected by the loss
of $35.1 million within the 2009-2010 fiscal year (Health Access, 2009, & California
Budget Project, October, 2009). The Expanded Access to Care Program operates in at
least 535 clinics and provides low-income families with preventative care such as
primary health and dental care. This program lost $13.5 million under the 2009-2010
budget (Health Access, 2009, & California Budget Project, October, 2009).
The Rural Health Services Development Program provides funding to rural primary
care centers to assist with primary and preventative health services. This program helps
to support approximately 109 clinics and provides care to patients in rural communities
who are typically older and poorer than residents residing in urban communities (Health
Access, 2009; California Budget Project, October, 2009; California Department of
Health Care Services, 2007). Unlike urban communities, residents residing in rural
areas are often at a disadvantage in terms of access to health care. Health care resources
are typically limited in rural communities and the climate and location of the rural areas
play a factor in the supply of physicians (California Department of Health Care
Services, 2007). This program lost $8.2 million in the 2009-2010 fiscal year (Health
Access, 2009, & California Budget Project, October, 2009, & California Department of
Health Care Services, 2007).
16
Seventy-four clinics participate in the Seasonal Agricultural and Migratory Workers
Program. This program provides care to agricultural workers and lost $6.9 million
(Health Access, 2009, & California Budget Project, October, 2009).
Lastly, the Indian Health Program provides services and aims to improve the health of
over 600,000 American Indians and American Natives in at least 75 clinics. This
program lost $6.5 million (Health Access, 2009, & California Budget Project, October,
2009). Primary and preventative health care is crucial to women’s health and it is
imperative that the state of California provide resources to assist in funding programs
that meet the needs of uninsured women of all ethnicities. California is an exceptional
state when it comes to welcoming diversity; however cuts to culturally appropriate
services will impact this population in a negative way. The clinics may be financially
burdened by the crisis but the women will have to bear the uncertainty surrounding their
health. As preventative services diminish in an effort to sustain the budgetary needs,
the quality of women’s health will become more unpredictable. Preventative care for
women’s health is an equally important health care service.
Preventative Care
Preventative services generally consist of prenatal care as well as postnatal care,
services surrounding postpartum and immunization. If preventative services are cut, the
state will undoubtedly foster a reactive system that will be more costly in the long run.
If women are not able to routinely access primary health care, chronic health conditions
will arise. The cost of treatment for chronic conditions outweighs the cost of
preventative care. In a climate such as the one facing California, the demands for
17
services will significantly increase. It is likely that many women will lose their jobs and
their employee-based health care. Unemployed women will depend upon public health
agencies for their health care needs (County Welfare Directors Association of
California & California State Association of Counties, 2009). Immunizations play a
key role in preventative care and are crucial to the health of medically indigent women.
Preventative care relies much on the role of immunization services for women, as it is
crucial to health maintenance of medically indigent women.
Immunization Services
Immunization services lost approximately $18 million due to budget cuts. This
service aids in preventing and controlling the spread of communicable diseases (Health
Access, 2009, & California Health and Human Services Agency, 2009). Immunizations
are crucial to medically underserved women. Cuts to this service may be detrimental to
single mothers who are working and raising children. Annual influenza immunizations
may prevent single mothers on a low, fixed income from missing work or having to pay
to go see a doctor. Cuts to immunization services will not only jeopardize women’s
health but it will also cost the state more money to treat women when they become ill
because they were not able to access routine immunizations. Programs such as Title X
assist low-income women in obtaining preventative care and other health related
services.
Title X
Since the 1970’s, indigent women have relied on Title X funding for services such as
birth control, pelvic examinations, cancer screening, breast examinations and pap smear
18
testing. Former President Nixon first introduced the federally funded program in the
1970’s encouraging low-income Americans to participate in family planning (Nelson,
2005; 2009). Funding from this program provides services such as physical
examinations, cancer screening, testing for HIV and other sexually transmitted diseases,
blood pressure and cholesterol checks and pregnancy testing for poor women (Nelson,
2005; 2009). In the last two decades, health centers that were partially funded through
the Title X program have avoided approximately 20 million unplanned pregnancies and
nine million abortions, aided in preventing 5.5 million adolescent pregnancies and
conducted 54.4 million breast exams along with 57.3 million Pap smear tests which
prompted the early detection of at least 55,000 cases of cervical cancer (Nelson, 2005;
2009).
Title X funding plays a vital role in providing family planning services to many lowincome women (Dalton, Jacobson, Berson-Grand, & Weisman, 2005). Reducing Title
X funding may increase the risk for unintended pregnancies, sexually transmitted
diseases (STD’s) and cancer (Dalton, Jacobson, Berson-Grand, & Weisman, 2005;
Nelson, 2005; 2009). Services are offered in many facets of the health care system
including health departments, community centers and private centers (Dalton, Jacobson,
Berson-Grand, & Weisman, 2005).
Clinics are often times the main source of care for reproductive health services.
They provide many of the basic services specific to women and are critically important
to indigent women who reside in rural communities. In 2006, six out of ten clinics were
partially funded by Title X (Frost, J., Sonfield, A., Benson-Gold, R., Ahmed, F., 2006).
19
Clinics receiving Title X funding are able to make improvements to their facilities,
educate their communities through outreach services and create programs that will
attract clients who are not already receiving family planning services. Though many
women are fortunate to receive such services, there are still many more women who are
left without them. Some of these obstacles include lack of health insurance, increases in
health care costs and changes to the system of care, such as the eligibility criteria (Frost,
Ranjit, Manzella, Darroch, & Audam, 2001).
Unfortunately, the funding for the various programs has not been able to withstand
the demand for services. With the increasing numbers of uninsured low-income women
in need of family planning services and the increase of cost for contraception, clinics
are struggling to provide adequate services. Funding for family planning has been
steadily decreasing each year since 2002. As of 2007, the Title X program was under
funded by $442 million (Dalton, Jacobson, Berson-Grand, & Weisman, 2005; 2009).
Clinics that operate within California’s safety net will be affected by the reduced
funding.
California’s Safety Net
Uninsured and low-income women have historically relied on public clinics and
hospitals to provide care when needed. California’s safety net consists of community
centers and clinics, public hospitals, for-profit and non-profit clinics and provides care
at little or no cost to millions of women residing in California each year (Gatchell,
Lavarreda, & Ponce, 2007; Wyn, Hastert, & Peckham, 2008; Saviano, Esq., 2009 ).
20
Public clinics and hospitals have banned together to create a safety-net that would
provide needed services to this population.
The safety net provides preventative services and routine care for long standing
illnesses to low-income and uninsured women who vary in age, ethnicity, race, culture,
language, family size, income, health need and social status. Much of the funding that
supports the safety net stems from Medi-Cal reimbursement and unfortunately, the
budget crisis includes a drastic reduction in Medi-Cal funding. Consequently, the safety
net is financially weakening and will most likely be unable to provide the extent of
services that were offered before the reduction in Medi-Cal funding. Given the fact that
these services are going to be impacted, there will likely be an increase in demand for
emergency care, which is ultimately more costly to provide (California Association of
Public Hospitals and Health Systems, 2009).
In essence, ignoring the problem will only exasperate the issue. Besides the basic
preventative health care needs, women have specialty needs that may routinely arise
and require medical attention such as gynecology services, reproduction and prenatal
care, pregnancy care, pap smear tests and mammograms, acute and chronic disorders
such as, reproductive disorders, arthritis, diabetes, heart disease, high blood pressure
and cancer (Kjerulff, Frick, Rhoades, & Hollenbeak, 2007).
Women who typically utilize clinics for services may develop chronic medical
conditions over time and will have no choice but to seek out medical attention through
emergency service at hospitals. This places hospitals in a vulnerable position
21
financially as they will ultimately endure the high cost of treatment services without
adequate reimbursement funding from Medi-Cal.
Many women who utilize the safety-net have incomes 200 percent below the federal
poverty level (Wyn, & Ojeda, 2003; Wyn, 2006; Holtby, Zahnd, Chia, Lordi, Grant, &
Rao, 2008). Some of the reasons women are uninsured include lack of income, job loss,
employer does not offer insurance, recent job change, citizenship or immigrant status or
they do not qualify for public health services (Wyn, & Ojeda, 2003). Other barriers that
inhibit indigent women from obtaining health insurance include lack of transportation,
communication barriers, limited services, lengthy waiting periods, odd hours of
operation at the clinics and patient’s uneasiness about their immigrant status (Family
PACT “Increasing access to health services”).
Women in Need
In 2001the California Health Interview Survey (CHIS) (2001) investigated the
barriers which low-income non-elderly women face when trying to access health care
(Wyn, & Ojeda, 2003). The survey’s aim was to explore the nature of the respondents’
insurance coverage and their current health condition. CHIS randomly selected 55,428
households from each county in California to participate in their study. They obtained
the data through random digital telephone surveys. One adult, one adolescent ages 1217 and one child under age 12 in each household were surveyed. The interviews which
were done in English, Spanish, Chinese (Mandarin and Cantonese dialects),
Vietnamese, Korean and Khmer took place between November 2000 and September
2001. The collected data was then compared to the 2000 Census.
22
Wyn and Ojeda (2003) reported information based on data collected by CHIS
regarding 25,558 women between the ages of 18-64. Their analysis of the data showed
that Latina women are almost three times more likely to be uninsured than white
women and had the highest probability of being uninsured compared to other ethnic
groups (Wyn, Hastert, & Peckham, 2008; Wyn, & Ojeda, 2003; Holtby, Zahnd, Chia,
Lordi, Grant, & Rao, 2008; Wyn, 2006; Wyn, Hasert, & Peckham, 2008; “Increasing
access to health services”; Chabot, Lewis, & Thiel de Bocanegra, 2009). Latina, Asian,
American Indian, and African-American women were all more likely to have fair to
poor health and as a result have a higher need of medical care than white women.
Single women are more susceptible to being uninsured than married women. Younger
women between the ages of 18-29 are more likely to be uninsured. The authors stated
this may be true due to the fact that this age group is least likely to be covered through
employment. The majority of uninsured women have family incomes at least 200
percent below the federal poverty level (Wyn, Hastert, & Peckham, 2008; Wyn, &
Ojeda, 2003; Holtby, Zahnd, Chia, Lordi, Grant, & Rao, 2008; Wyn, 2006; Wyn,
Hasert, & Peckham, 2008; “Increasing access to health services”; Chabot, Lewis, &
Thiel de Bocanegra, 2009).
Regarding specific ethnic groups, foreign born Latina women were more likely to
lack coverage than U.S. born Latina women. Mexicans and Central Americans were
more likely to be uninsured than other Latino group members and Korean women were
more at risk than other Asian group members to be uninsured (Holtby, Zahnd, Chia,
Lordi, Grant, & Rao, 2008). Just like the unmarried women, the elderly women who
23
may be widows also risk being neglected and badly affected in their health care by the
2009-2010 budget crisis.
Elderly Women
The California Endowment Center for Healthy Families funded a report on older
women and discussed the numerous obstacles and challenges that older and elderly
women face trying to access medical care while living in poverty (Estes, Goldberg, &
Fineman, 2007). As stated earlier, older and elderly women of color are more likely to
experience barriers to health care than white women (Estes, Goldberg, & Fineman,
2007).
Low-income older women ages 55-64 are reportedly at a greater risk for having
untreated health problems (Estes, Goldberg, & Fineman, 2007). This age group tends to
be in more need of health care due to health complications such as diabetes and
hypertension that tend to arise at an older age (Estes, Goldberg, & Fineman, 2007).
With a higher risk of medical complications, rising health costs and high costs of
prescriptions, many women in this age group are left untreated and vulnerable to major
health issues. Cuts to programs and agencies that provide services to this population
will only create more health related problems for older indigent women.
Women tend to need preventative care and treatment as they increase in age.
Agencies such as Family PACT and Every Woman Counts provide specialized services
such as treatment for sexually transmitted diseases, cervical dysplasia and screening for
breast cancer for older women but there is a continuing need for clinics that provide
primary care and specialize in women’s basic health needs.
24
Another age group at risk is women 65 years and older. Many of these women will
receive some sort of health insurance through Medicare as they become eligible by age,
but for elderly women who are uninsured with little financial resources they are
anguished by the financial burden to cover expenses that are not covered under
Medicare. A majority of women in this age group do not have the financial security to
obtain private health care and they must rely on the public health care system to support
their medical needs. Unfortunately, our system is not stable enough to help elderly
women and often times their medical needs go untreated. If this age group does not
receive proper medical care, by the time they become eligible for Medicare the state
will be spending more money in treatment costs for their untreated medical issues.
At this point, California is ill equipped to respond to current demands. The 20092010 budget called for deep cuts to Medi-cal and these cuts will likely impact the aging
population as well. As the older population grows, more and more elderly women are
going to be in need of medical care. By cutting programs and services, reducing staff
levels and ultimately closing clinics, California is relaying the message that the state
cannot care for the women who need these services (Estes, Goldberg, & Fineman,
2007).
Both the older and elderly populations are in dire need of preventative services. One
of the most common and important preventative service needed by this vulnerable
population is the annual influenza vaccine (Estes, Goldberg, & Fineman, 2007). As
people age, their immune systems can weaken. Older women rely heavily on the annual
influenza vaccine to prevent illness and possibly death. Older women with only Medi-
25
Cal coverage are at the greatest risk for not receiving the vaccination. It is sad to think
that one simple procedure such as getting the flu vaccination is restricted from so many
just because our government does not view public health as a priority.
Another preventative service that older women are in need of is routine mammogram
screening. Nearly half of uninsured women age 55-64 residing in California were not
screened for breast cancer compared to less than 12 percent of similarly aged insured
women (Estes, Goldberg, & Fineman, 2007). This statistic clearly portrays the risks
uninsured women face when they do not have access to routine preventative care.
If uninsured women are not vaccinated and provided treatment for basic and routine
care they may utilize the hospitals for emergency services when they become ill (Estes,
Goldberg, & Fineman, 2007). This is just one of the many examples of how the lack of
preventative care may ultimately lead to more costly treatments and procedures in the
long run. Sacramento County is at risk and may have to endure these consequences as
well.
Sacramento Demographics
As of January 2009, Sacramento County comprised of more than 1.4 million
residents (County of Sacramento, California, 2010). Slightly more than half of the
residents were female (U.S. Census Bureau: State and County QuickFacts, 2009).
According to 2007 U.S. Census Bureau statistics, nearly 63 percent of the population
was between the ages 18-64 years old and 11.1 percent was 65 years or older (Tu,
Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009).
26
Sacramento is one of the most diverse counties in California in terms of its racial and
ethnic make-up (Tu, Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009). The
ethnic population consisted of 59.7 percent White non Latino, 6.4 percent AfricanAmerican non-Latino, 18.9 percent Latino, 10.4 percent Asian non-Latino, 4.6 percent
other race non-Latino, 15.1 percent foreign-born and 28.5 limited/ non English speaking
adults (Tu, Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009).
As of 2005, 13.6 percent of Sacramento’s residents were below the federal poverty
line (County Welfare Directors Association of California and California State
Association of Counties, 2009). Approximately 25 percent reported incomes at 200
percent below the federal poverty line and as of January 2009 the unemployment rate
was 10.7 percent (Tu, Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009). Though
the 10.7 percent unemployment rate may seem fairly steep, Sacramento ranks somewhat
lower than the state average of 10.9 percent (Employment Development Department,
2009; Tu, Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009).
Sacramento’s median household income was approximately $57 thousand a year as
of 2007 compared to the state’s median household income of nearly $60 thousand a
year (U.S. Census Bureau: State and County QuickFacts, 2009). Nearly a quarter of
Sacramento residents have obtained higher education of at least a Bachelor’s degree
compared to the state average of 26 percent (U.S. Census Bureau: State and County
QuickFacts, 2009). Sacramento ranks slightly lower than the state average on
education status and income level (Tu, Felland, Ginsburg, Liebhaber, Cohen, &
Kemper, 2009).
27
Statistics for health insurance consisted of the following; 66.8 percent of the
Sacramento residents had private insurance; 9.4 percent had Medicare, 15.1 percent had
Medi-Cal or relied on other programs; and 8.6 percent were uninsured (Tu, Felland,
Ginsburg, Liebhaber, Cohen, & Kemper, 2009). Approximately 12 percent of
Sacramento residents reported fair/poor health status (Tu, Felland, Ginsburg, Liebhaber,
Cohen, & Kemper, 2009). Sacramento residents reported their health to be better on
average than California residents as a whole (Tu, Felland, Ginsburg, Liebhaber, Cohen,
& Kemper, 2009). Residents in Sacramento are less likely to be uninsured or have
Medi-Cal coverage and are more likely to have private health insurance than other
residents throughout California.
Between the diverse ethnic composition, educational and income levels, slightly
lower than state average unemployment rate and amount of residents who have
insurance Sacramento appears to be a desirable place to live. Despite the positives,
there is still room for improvement. The need for a county hospital is highlighted in the
possible influx of people for emergency care as subsidies to various health care
programs are cut. This becomes another pressure point for the California health care
system.
Emergency Care
As legislators and county officials attempt to restore the budget, the demand for
emergency care continues to rise in Sacramento. For many years, Sacramento County
contracted with UC Davis to provide health care for medically indigent patients (Tu,
Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009). In 2008 Sacramento County,
28
in hopes of reducing county costs, sought out a third party administrator to provide
services for medically needy patients and terminated their contract with UC Davis (Tu,
Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009). Though the county
anticipated a savings, the new contract had a negative impact on the budget (Tu,
Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009). County officials
underestimated the cost of integrating a third party administrator. The county estimated
the average cost for health services for one month and annualized that cost to get an
approximate figure for their annual budget. Faulty estimates placed an additional
financial burden on the budget and strain on the county.
While the county makes attempts to rectify the contract issue, patients will continue
to be served and will benefit from the additional choices in care providers. However, a
solution to mend the budgetary issues has not yet materialized (Lewis, 2009). If the
budget is not stabilized the quality of care may be jeopardized, services may be cut,
access to care may be restricted and indigent women may be vulnerable to significant
health issues.
Sacramento County Clinics
In February 2009, the county closed three part-time clinics, leaving three clinics
available for Sacramento’s medically indigent women (Tu, Felland, Ginsburg,
Liebhaber, Cohen, & Kemper, 2009). As the number of clinics decrease, the need for
care grows. In 2002, the Office of Statewide Health Planning and Development
(OSHPD) reported that 70 percent of the uninsured population who utilized community
clinics was women (Ta and Wulsin, 2005). With minimal staffing levels and limited
29
service hours, many indigent women will be forced to seek out care through the
emergency department. Emergency room staff will likely see an increase in case load
and chronic health related issues.
Sacramento Health Care Improvement Project
Numerous attempts have been made to address the dilemmas surrounding public
health. Various organizations, hospitals and clinics joined forces in 2007 through
Sacramento Health Care Improvement Project (SHIP) to reform Sacramento’s safety net
(Tu, Felland, Ginsburg, Liebhaber, Cohen, & Kemper, 2009). One of SHIP’s goals is to
recruit and retain specialized physicians within community clinics to serve indigent
residents who are in need of specialty care. Other goals include making services more
accessible, expanding clients’ options for providers and stabilizing the safety-net system
by providing consistent care for the medically needy (Tu, Felland, Ginsburg, Liebhaber,
Cohen, & Kemper, 2009). Programs such as SHIP offer hope to the medically indigent
population through collaboration and advocacy. Effective changes occur through a
team approach and may have long standing effects. SHIP has the opportunity to make
significant changes in Sacramento’s public health care system and ultimately the
legislature, paving the way for other counties and states.
Summary
This literature review attempted to broaden the knowledge base of the problem in
health care for the medically indigent women in Sacramento County with a review of
facts and figures based on evidence-based research. The review of literature attempts to
portray the adverse impact of budget cuts on health care of medically indigent women.
30
The literature presents the issues and offers the reader a better understanding of the
problem. The review covers a wide spectrum of women’s health care such as prenatal
care to care in hospitals and clinics, from preventative care to immunization services.
Moreover, the clients who are affected range from the women in need to elderly
women. With an overarching impact on the target population, there could emerge new
demographics at the Sacramento County with an abundance of clients in need of
emergency care. At this time, it is unclear as to the magnitude of the ramifications that
will materialize once this storm settles.
After presenting a brief background on California’s economic crisis and the budget
cuts on various social services programs, the chapter focused on the different programs
that have been negatively impacted. The massive reductions to Medi-Cal gradually led
to the closure or reduction of health care programs and medical institutions that serve
medically indigent women.
Prenatal care, preventative care, and immunization services are basic health care
needs. Hospitals and clinics are important institutions where health care services can be
provided (Saviano, 2009 & Frost, et al., 2001). By attending to medically indigent
women through maintenance of the programs and services for their health care needs,
the benefits may outweigh the costs in the long run. Otherwise, lacking in these types
of services, emergency care in hospitals becomes the main alternative. The effect could
be counterproductive in the long run.
Indigent uninsured women are in desperate need of health care. Their needs are
magnified during economic hardships such as the current budget crisis. Many women
31
may have relied on employer based insurance or Medi-Cal funding in order to get their
health needs met but in a recessional economy where unemployment is high and social
services are being slashed, women are forced to obtain health care through community
based clinics and hospitals. It is time for our system to take a proactive stance and form
a budget that is conducive to times such as this.
Through this qualitative research design, the researcher hopes to touch base with the
administrators representing health care agencies and the clients of health care services.
It is interesting to verify from their concrete life experiences how the budget cuts impact
them and the quality of their life. Their insights and voices could help the reader and the
policy makers in seeing a clearer picture of the situation. The review of literature which
anticipates the adverse impact of budget cuts on health care of women tends to clarify
the research problem in this study.
The plummeting economy has played a major role in the state budget deficit. The
loss of revenues from sales and property taxes force Sacramento County to make
complex and grueling decisions that affect its residents (California Budget Project,
2004; California Budget Project, May, 2009; Gordon et al., 2007). It is during times of
crisis that social service programs should be the first line of defense. It is hard to
believe that an industrialized country of this magnitude cannot provide its residents with
comprehensive public health care.
32
Chapter 3
METHODS
Introduction
The purpose of this chapter is to discuss the methods used to conduct this research.
To describe the methodology, this chapter contains subsections consisting of
collaborative elements, research design, variables, participants, sampling plan,
instrumentation, data collection, data analysis, and human subjects.
Collaborative Elements
This researcher along with two other researchers shared a common research subject
but differed in their subtopic interests. One researcher focused on undocumented
immigrants. The other centered the interest on children ages zero to five. This
researcher studied the impact of the budget crisis on medically indigent women. The
researchers collaborated throughout the project. They developed a common survey that
contained questions relevant for each selected population. Any crossover of subject
matter was due to the sharing of research data. Each researcher interviewed
representatives coming from a total of 12 agencies. Data reported in this study reflect
pertinent information which was obtained by the three researchers, not only by this
researcher, concerning women’s health.
Research Design
This research study is qualitative and exploratory in its design. A qualitative study
allows for a descriptive analysis of the topic and further exploration of its subsets
33
particularly through contacts with participants who share their experiential narratives.
Information for the study was obtained through interviews with target participants with
the use of questionnaires (Appendix C and D). Two sets of questionnaires were utilized
that were specific to the subjects being interviewed. One set with 38 questions
pertaining to the health agency was used for health administrators (Appendix C). The
other set with 26 questions was used for the clients (Appendix D) on their knowledge
and views on the budget cuts to public health.
Measurements
The instrument designed for agency administrators employed 36 open-ended
qualitative questions and two closed-ended questions. The questions intended to
measure the effects of the 2009-2010 budget crisis on the agencies. Five of the said
questions were ordinal and inquired about the demographics of the agency. The
questionnaire aimed to measure the methods utilized by the agencies in order to
continue serving clients. It examined the means by which agencies have adjusted their
programs in order to continue to serve their clients. Furthermore, this researcher
measured the financial impact of the crisis on the agencies in their ability to achieve
their objectives.
The instrument of measurement designed for the clients employed 17 open-ended
qualitative questions, four nominal questions, and five ordinal questions. These
questions intended to measure the types of health care programs which the client
utilized, the challenges they faced when accessing services and their experience with
regard to the change in services.
34
Sampling Plan
The agencies identified for this study were selected from the list of the Community
Services Directory (2007) which was published by the Community Services Planning
Council of Sacramento. A stratified sampling method was utilized to determine which
agencies would participate. Every other agency from the published list of health
agencies in the Community Services Directory was chosen and contacted via telephone
to inquire about whether the agency fit the criteria of providing services to low-income
populations, specifically women, and of receiving county/state funding. There were not
enough agencies available for interviews after the first sample as many agencies were
no longer operating, did not fit the criteria or were not available for interviews due to
personal reasons such as lack of staff or time. The list was exhausted and in the end 12
agencies were selected based on the set criteria and the availability of the
administrators.
During the telephone calls with the various agencies, the researchers initially
explained the purpose of the study being conducted and asked whether a Director,
Administrator or Secretary might be available and interested to be interviewed for the
study. Agency representatives were chosen based on the specific criteria. They should
have worked closely with the clients and had substantial knowledge about the services
offered by the agency, the history of agency or its funding streams.
Instrumentation
The instruments employed were two sets of questionnaires, one for health
administrators consisting of 38 questions, and the other for clients with 26 questions.
35
The questionnaire for the administrators focused on the effects of the 2009-2010 budget
crisis on the agency, such as program cuts, changes in services, staff reductions, and
changes in the hours of operations. The questionnaire for the clients asked basic
demographic questions and inquired about the client’s perception of public health care
and how the budget crisis had affected their health care needs. The three researchers
formulated the questionnaires in a collaborative work.
Data Collection
This researcher conducted interviews with health administrators from local public
health agencies over the telephone and through face to face interviews with the use of
the questionnaire specific to administrators (Appendix C). Agencies were contacted,
and interview times were scheduled. Some of the interviews dates were more difficult
to establish than others due to conflicting schedules between the researchers and
participants. The interviews averaged one and a half hours to two hours.
The participants were initially briefed about the study. Informed consent forms
(Appendix B) were presented to them for signing which indicated their consent to
participate voluntarily in the research study, their right to terminate the interview in any
case, and the assurance of safeguarding the confidentiality of their responses to the
questions.
Data Analysis
Data obtained from the interviews were analyzed in a collaborative manner by the
three researchers. Each researcher sorted out the information which pertained to one’s
36
particular subtopic of interest, namely, on undocumented immigrants, on children ages
zero to five, and on women’s health.
Human Subjects
An important element considered in this study was a careful consideration of the
human subjects or the participants in the research work. After having determined the
topic for the study and the intended human subjects, the researchers presented their
proposal and application for approval of human subjects to the Division of Social
Work’s Human Subjects Review Committee at California State University, Sacramento.
The application was reviewed and subsequently approved by the Review Committee
with its approval number 09-10-031 (Appendix A). The Committee determined this
study to be of minimal risk to the participants.
The participants who were interviewed over the phone verbally consented to
participate in the study. During the face to face interviews the informed consent form
was presented to each of them for signing. The consent form indicated the participant’s
willingness to voluntarily participate in the study research, their right to terminate the
interview and the assurance of keeping the responses to the questions asked
confidential.
Interviews began once a signed consent form from each participant had been
collected. Separate interview questions for each participant were used and signed
consent forms were kept separate from the interview form by placing the consent forms
in one envelope and the completed interview forms in another. There was not any
identifying information on the interview form. Therefore, each participant was able to
37
opt out of the interview at any time without penalty.
The participant’s information was stored in a locked cabinet in the researcher’s
place of residence. The researcher was the only one who had access to the secured
cabinet. Once the thesis is submitted and accepted by the California State University,
Sacramento Office of Graduate Studies, all the collected data for the research project
will be shredded and disposed of.
Summary
This chapter of the research study presented the methods used in identifying the
topic and the selection of the participants with the approval of the human subjects by
the Division of Social Work’s Review Committee. As a qualitative and exploratory
study, it explored the impacts of the 2009-2010 California budget crisis on public health
and medically indigent women based on the responses of the participants through
telephone and face to face interviews with the selected public health administrators and
clients within those agencies. Two sets of questions were directed to the specific group
in eliciting desired responses. In the next chapter, the findings from these interviews are
to be presented for subsequent analysis of the gathered data.
38
Chapter 4
FINDINGS
Introduction
This chapter presents the findings on the impacts of the budget crisis in California on
public health agencies that provide services to medically indigent women. As
mentioned previously, three researchers interviewed 12 participants who represented 12
health agencies that fit the two key categories set for the study. The agencies of the
participants provided services to low-income populations, especially women, and they
received state and/or county funding. The agencies were chosen from the Community
Services Directory.
This researcher focused on the impacts of the budget crisis on medically indigent
women. Interestingly, from the experiential narratives of the participants, four major
themes affecting the women with trailing effects on the employees and the agencies
surfaced. The themes included longer wait periods for the clients, increased caseloads
for the employees, adverse impacts on preventative services and the long-term effects of
the budget crisis itself on the medically indigent population.
Demographics
Two types of participants are prominent here: those who focused on the political
aspects of delivering public health care to the medically indigent population, and those
who delivered direct services to the medically indigent clients. There were initially 14
prospective participants in the list of respondents. They represented a broad range of
39
service providers as well as service recipients. The 14 interviewees included three
Executive Directors, two Program Managers, a Clinic Coordinator/Professor, a
Licensed Clinical Social Worker, a Director of Client Services, a Public Affairs
Director, a Chief Executive Officer, a Practice Manager, a Development Director, and
two clients. The two clients were both women aged 61 years and above. One reported
being of White/Caucasian descent, while the other reported being of African
American/Black descent.
After interviewing the two clients, the three researchers discussed the results of their
interviews with one another and decided that the clients did not meet the criteria. One
client had federal insurance that was secured while she was working for the state. The
other client reported that she had insurance through SSI and Medi-Cal. She did not
report any noticeable changes to her health care or prescriptions since the budget crisis.
With the two clients having been excluded, the final number of research participants
was reduced to 12. The questionnaire that was used may be found in Appendix B.
Presentation of the Findings
The findings from the research study are presented in the sections below and focused
on the impacts of the budget crisis on the medically indigent women as reported by the
participant-representatives of the agencies. The interview results are grouped together
into themes. Each respondent was respectively coded with an alphabetical letter.
Though the name of the participating agencies will remain confidential, there will be an
attempt to portray the impacts on the clients and agencies by describing the services and
population in which each agency serves.
40
Longer Wait Periods
The participants were asked about the quality of care which the patients received in
the context of the economic crisis which the County is experiencing. Question # 7 in the
questionnaire was presented to the respondents. Interestingly, 67% of the participants
responded that a clear adverse impact of the crisis on the clients was the longer wait
periods. One respondent, a Clinic Coordinator/Professor noted that in their agency,
their waiting list numbered 300-400 clients eager to get services. In another agency, a
Project Manager reported that with these longer wait periods clinics and Emergency
Departments of hospitals also accumulate long waiting periods.
To highlight the severity of the problem a Program Manager informed the
researchers that in their agency, previously patients were seen by an ear/nose/throat
(ENT) doctor within four weeks. With the crisis, the wait time has considerably
increased to eight months. Moreover, the respondent added that this intense wait period
led to “losing patients” in the process. For instance, it happened that once the patient
reached the top of the list to be seen, the agency was unable to contact the patient any
longer. The agency was unaware whether the patient had moved, changed their number
or sought out services elsewhere.
One agency representative reported their clinics were “over crowded.” He correlated
the increase in caseload with longer wait periods. A coping strategy by one agency that
was reported was to provide health services for a set amount of people each day.
Unfortunately, even a coping strategy such as this has a direct effect on the wait time
41
clients have to endure before they are seen. Depending on the nature and extent of their
illnesses, clients’ health may have been jeopardized by the lengthy wait periods.
An Executive Director for an agency that provided prenatal and gynecological
services to women and teens reported that their agency “had to close for a few days in
order to save money.” The patients were thus affected by the limited hours of operation
and had to endure longer wait periods to receive care.
A Public Affairs Director at an agency that provides reproductive health, prenatal
care, primary care services and health education, reported that patients had to wait
longer to get an appointment and that it had become significantly difficult to obtain an
appointment. Additionally, the respondent reported that the increase in patients
requiring services and the inability to hire more staff had also contributed to the lengthy
wait periods.
Another Executive Director of an agency that advocated to the Legislature and
policy makers on behalf of people in need of health care also reported that their agency
had seen an increase in wait periods for people seeking medical services within the
community.
Increased Caseload
Question # 6 pertained to how the agency’s program, employees or clients have been
affected by California’s current budget crisis. Of the 12 respondents, two-thirds (8)
reported an increase in caseloads. One agency that mainly provided services for the
undocumented population believed they had seen a remarkable increase in the number
of clients because of the fact that more people were losing their jobs, and subsequently,
42
their insurance. The agency noted that the increase in the number of their clients who
were mainly in the undocumented population stemmed from the fact that other public
health clinics had cut their services that were previously offered to undocumented
immigrants. It left these clients nowhere to go but to this particular agency whose
services were primarily aimed towards clientele who were undocumented. In a dominolike effect, there had been an increase in the number of undocumented clients at the
agency because former and current clients were referring other undocumented
individuals to this agency because of its commitment and objective to serve them.
Another agency that provided services primarily to low-income women reported that
more women who lost their insurance benefits tended to travel from other counties to
obtain services in Sacramento. With this movement of new clients, the agency
observed another possible reason for the increase in the caseloads of clients whose
origin have gone beyond the boundaries of the Sacramento County.
Another respondent, a Chief Executive Officer, reported that their agency’s increase
in medically indigent clients rose up to 5% in the last three months. An Executive
Director of an agency which provided health services to women and teens reported that
they had seen an increase in the number of clients who were Medi-Cal eligible.
Furthermore, the respondent reported that with the increase in the number of clients,
there was a corresponding rise in the number of their employees’ caseloads which, in
effect, has caused more stress for the employees as they were required to work more
efficiently. On the other hand, a Public Affairs Director reported that the increased
caseload has motivated their employees to work “harder and faster”.
43
One agency that provided physical and mental health services to the HIV and AIDS
population has also seen an increase in the number of clients requesting HIV/STD
testing. The Director of Client Services also reported that with the increase of clients
there was also an increased demand by clients for mental health treatment. This
noticeable increase in clients and clientele demands for treatment was attested by an
agency that recruited and placed volunteer physicians within the community to do
general and specific medical practices. The Program Manager of this agency associated
this phenomenon with the loss in county funding and the closures of county clinics.
Lastly, the representative of an agency that supported and advocated for public
health at the local and state levels reported that they too have seen an increase in
caseload as county clinics have closed. The respondent stated that the clinics that
remained open were becoming “over crowded” and “hundreds of people were being
turned away.”
With the reported information on case overloads by agencies, respondents indicated
that a number of medically indigent women were turned away. As more women are
denied the needed services, the risk of developing chronic health conditions may
intensify and prove to be fatal. As medically indigent women seek out other solutions to
get their medical needs met, emergency care costs may increase and become expensive
and demanding on the state budgetary needs. The intended cost-benefit moves through
the enacted budget may be more expensive in the long run and result in the loss of
innocent lives.
44
Of the four agencies (33%) that did not see an increase in their caseloads, one
respondent stated that they were not affected by the budget crisis because their funding
streams were not linked to funds that were getting cut by the budget. The other three
agencies specialized in specific care services compared to those agencies which
provided more general services to increasing number of clients.
Cuts to Preventative Services
Sixty-seven percent (8 out of 12) of the respondents reported that clients were being
impacted by the cuts to preventative services when asked if client eligibility had
changed (Question #3), if services may have been eliminated or reduced due to the
budget crisis (Question #23), and how female clients may have been impacted by the
elimination or reduction of services (Question #24).
Half of these respondents (4) reported that their female clients could no longer obtain
mammogram tests as preventative services unless they were 50 years old or older due to
the drastic cuts to public health. One reporting agency indicated that another
qualification to be able to obtain such a test must be a doctor’s notation of the client’s
concerns, such as a lump or mass in the breast. With such a requirement, the agency
representative reported that the employees felt “helpless” when they were not able to
provide preventative services. Another respondent indicated the inconsistencies in
preventative services which their agency was allowed to provide, for instance, as seen
in cases of birth control and mammogram tests. She remarked, saying, “Free birth
control is great but you cannot discriminate between breast exams.” She added that for
her, birth control was just as important as mammograms, and that she noted her
45
alarming concern about the consequences that this new policy would have on medically
indigent women.
The participant from an agency which specialized in attending to HIV and AIDS
patients commented, “Prevention is hugely important.” For her, prevention was a
significant key to decreasing the risk in the transmission of HIV virus. She also
reported that indigent women were the “most reluctant group to seek out services.” On
the other hand, those who sought out services at her agency received gynecology
services as well as free testing. The loss of preventative services impacted
undocumented immigrants as well since they could only receive care for communicable
diseases. Unfortunately, since other services for the undocumented clients have been
cut off with the closure of the clinics, the participant from the agency could not refer
this population to other clinics. A further alarming revelation from this respondent was
that among minority ethnic groups, “Hispanics move to AIDS faster than any other
group because they cannot get care.” Whether this trend was largely due to the fear that
many feel when trying to access services or because there were no longer services
available for this population is an interesting question to ask. The respondent reported
that the agency had a surplus in its budget and was therefore able to continue offering
preventative services but it was unsure as to what the next year’s budget would offer,
especially because the agency expected deeper cuts.
Four respondents did not report any concerns over preventative services. Three of
these agencies provided specialized services and the other agency stated that it was
doing well and was “currently growing” as it had recently hired employees and
46
relocated to a nicer building. This agency was recently accepted as a Federally
Qualified Health Center (FQHC) and was entitled to a wider range of grant funding and
enhanced reimbursement rates from Medicare and Medicaid. The respondent reported
that this new status allowed the agency to serve more clients without feeling the effects
of the budget crisis. Luckily, its clients could continue to benefit from this agency’s
services.
Long Term Effects of the Budget Crisis
Two important questions that were asked of the respondents were these: What may
be the long-term effects of the state’s current tightening of the budget in relation to
health care (Question # 8 ) and How may women’s health be impacted in the long run if
the services are cut (Question # 30)?
One respondent expressed fear at the likelihood of their agency being closed. Three
other respondents argued that the clinics and Emergency Department at the hospitals
would suffer the most, and that the public would have to supplement the rising costs of
social service programs, essentially through an increase in taxes. Another respondent
indicated that as people lose their jobs and employer-based insurance plans, they would
have to “look outside the typical medical model for help.”
One respondent feared that the current situation would get worse before it could get
better. Another respondent assumed that the decrease in preventative services would
increase the need for Emergency Room services. This may trigger more consequent
problems, including costs and quality of services. The agency that provided services
mainly for undocumented immigrants strongly believed that more people would become
47
sick and that health conditions would get worse due to the lack of services offered to
this population.
The representative of the agency that advocated for and supported public health on
the local and state levels noted the different adverse effects on the health care system.
He specified the negative impacts as the following; an increasingly ineffective system
of care in regards to the health care system, the Medi-Cal application process would
become more rigorous, and that the homeless would increasingly have difficulties in
accessing health care.
The participant from the agency that specialized in HIV and AIDS services feared
that their clinic would be forced to provide more generalized services and ultimately
lose their specialty component. One respondent who reported that their agency did well
despite the harsh economic conditions advised by saying, “Clinic administrators need to
learn how to be business savvy.” He recommended that clinics should seek out other
funding streams, such as grants and donations.
Summary
Overall, the representatives of agencies that were interviewed reported that they
were acutely aware of the budget crisis and the impact it has had on public health
agencies in Sacramento. The common themes among the respondents consisted of
longer wait periods among clients, increased caseloads for the employees, considerable
cuts to preventative services, and adverse long term effects on health care.
48
Two-thirds of the respondents (8 out of 12) reported that their clients had
experienced longer wait periods at their agency due to the closing of other clinics and
the increase in the number of people without private health insurance.
As to case overloads, two-thirds of the respondents replied that their caseloads had
increased significantly. One unexpected finding from all the participants was that the
quality of care in services has not diminished, despite the major adjustments
experienced by the employees. Many reported that their employees had to work more
diligently to meet the needs of these clients but that the quality of care remained the
same.
Cuts to preventative services were a concern for 67% of the respondents. Many felt
that this was a key component to maintaining good health and that the lack of
preventative care would ultimately place client’s health at risk. Respondents also
reported their concerns for the undocumented population as they now can only be
treated for communicable diseases.
The twelve respondents expressed concern about the long term effects of the budget
crisis. Many felt that the cuts to public health would create more health complications
for the medically indigent, while others feared that tax payers would end up paying the
ultimate price if social services were cut. In general, cuts to public health were
perceived to be detrimental to medically indigent women whether they had to wait
longer to receive care, were denied care such as mammogram testing or became more ill
due to the closure of county-funded clinics.
49
The following chapter will recap the important findings of the study. This researcher
will also discuss the implications for future research, policy, social work practice and
practitioners. There will also be a discussion pertaining to the limitations of the data
collection and in essence, what may be known about the non-responders.
50
Chapter 5
CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS
Introduction
This chapter discusses the conclusions of the study and its implications on various
aspects of social work, such as, future research, policy making, and social work
practice. Furthermore, it compares the themes found within the literature review and
the themes that emerged from the face-to-face interviews. The themes that surfaced
from the interviews on the impact of the budget crisis on health care agencies, their
employees, and the clients included longer wait periods for the clients, increased
caseload for employees, cuts to preventative services, and the long term effects of the
budget crisis on the targeted population. Moreover, this chapter discusses in detail the
limitations in the study and data collection due to the barriers that were present in the
course of the research process. Implications for future research is addressed as it relates
to the current budget crisis and its effect on public health agencies that provide health
related services to medically indigent women. This researcher is hopeful that through
an in depth discussion of the implications of this study for social work policy, social
work practice, and the practitioner, the reader will gain a richer understanding of the
issues pertaining to the budget crisis.
Conclusions to the Study
In an effort to address the magnitude of the 2009-2010 fiscal budget crisis in
California and the devastating effects it has had on the lives of medically indigent
51
women and the delivery of services by health care agencies, this researcher attempted to
embark on this study despite the barriers encountered in the process of selecting the
participants and the collection of data. Additionally, this study may act as a vehicle for
change through the promotion of awareness for the benefit of the target population and
the health care services in which they need.
California was not alone in the economic crisis that impacted other states, the whole
country, and the other nations of the world have experienced this crisis. It shares with
other states, like New York, Illinois, Florida and Texas, in having diversified population
groups and economically poor people (Gordon, et al., 2007). These states relied on
income taxes and property taxes to boost their economic resources. However, California
was financially impacted with the passage of Proposition 13 in 1978 which put a cap on
the taxation of properties. The state suffered a tremendous loss in taxes, up to $12
billion between the fiscal years of 1993 to 2008 (California Budget Project, May, 2009).
Confronted with the unexpected loss, the legislators and policy makers scrambled for
solutions, now seen as quick-fix, through budget cuts on many services, particularly on
health care, with tremendous impacts, and damage to a very vulnerable population in
need of care and services, medically indigent women.
Medi-Cal was hit hard in the budget cuts, thus gradually paralyzing or numbing the
delivery of services in health care on the people (Health Access, 2009, & California
Budget Project, May, 2009). The medically indigent women were among the targeted
populations that were affected. Funding for prenatal care was drastically cut (Health
Access, 2009). Hospitals and clinics became limited in the provision of care and
52
services to their patients (California State Budget, 2009, & California Budget Project,
October, 2009). Preventative care and immunization services became limited (Health
Access, 2009, & California Health and Human Services Agency, 2009). Title X
screening services which were helpful for family planning methods were also affected
(Nelson, 2005, & National Family Planning and Reproductive Health Association,
2009). In essence, with the limits on Medi-Cal fund flow, California’s safety net
through its public clinics and hospitals began to crumble, therefore increasing the health
risk for medically indigent women due to the lack of proper health care.
Evidently, the vast population of the state felt the effects of the budget cuts.
However, it is troubling to witness that in such situation of crisis, the most vulnerable
sectors of society are often and continuously the ones most affected. Medically indigent
women, who need most of the health care services, sadly take the brunt of economic
losses. It is often taken for granted that women, of all ages, need preventative health
care services, and have specialty needs too.
This study, on the impact of the budget cuts, has its limitations. However, its
findings from the narratives of the selected participants confirm what many, especially
the medically indigent women, may have long desired to express. The results of the
study may serve as proof that those in power are making decisions without proper
consultation and consideration of those affected most. One may begin to question what
the reasoning was behind the actions on the fiscal budget. Furthermore, one may
question the priorities of those in power and to what extent their priorities are beneficial
53
to them versus the social and human capital of the state. Undeniably, health care needs
and social services are among the “first lines of defense” within a diverse society.
The research findings indicated that the budget cuts affected the proper functioning
of health care agencies, their employees, and their clients. These included the following:
(1) longer wait periods for clients to obtain health care services from agencies, (2)
increase in case loads among the employees, (3) cuts to preventative services, and (4)
the long term effects of the budget crisis on the lives of people who are in need of health
care services. Of the first three aspects, three-fourths or 67% of the respondents
indicated that they felt and suffered the impact of the budget crisis. What is worth
paying attention to is that although the employees of the affected agencies experienced
increases in case loads, they indicated that the quality of service delivery remained
constant. They also sustained their motivation to assist their clients.
The other 33% of the respondents noted that their agencies were not so much
affected financially due to other sources of funding such as grants for mental health
services, donations and fundraising. This did not mean that they did not feel the effects
of the budget crisis. On the fourth aspect, all the respondents agreed that the budget
crisis would have negative long term effects on everyone. The 33% group
acknowledged that they survived the initial waves of the problem, but they also felt
unsure as to what the future would bring them, their employees, and their clients. The
findings in this study presented data from the narrative reports of 12 participants.
Behind the given responses there is a call for action and change in reconsidering the
54
criteria and the priorities chosen for budgetary purposes. This study has considerable
implications for future research, policy, social work practice, and the practitioners.
Barriers to the Research Process
Multiple barriers emerged along the way while the three researchers attempted to
collect data from agency representatives and clients. One of the biggest barriers to the
research was the scarcity of available literature on the current budget crisis. Much of
the literature was still in the publication process as information was gathered about the
fiscal impacts on California’s safety net. There was also limited information about the
recent impacts on medically indigent women. Furthermore, literature pertaining to the
fiscal impact on the Sacramento County’s public health care system and its public
agencies was minimal.
Another difficulty encountered was in obtaining support for this research study from
the County itself. The three researchers met with the Director of Health and Human
Services and a number of her colleagues from Sacramento County at the beginning
phases of this research study. The researchers mentioned that their goal in the intended
studies was to discuss in detail the current budget crisis. The Director seemed pleased
with the chosen topics and even confirmed that the budget crisis had devastating effects
on Sacramento County’s public health care system, medically indigent women, children
ages 0-5, and the undocumented population. The Director further stated that she would
support the study and would write a letter of support to give to prospective agencies, on
the condition that the researchers obtained approval from the Sacramento County’s
Human Subjects Review Board. This posed as a dilemma to the researchers. They had
55
already obtained support and approval from the University’s Human Subjects Review
Board and were given the deadlines to complete their studies. Consequently, the
researchers were not able to obtain approval from the County’s Human Subjects Review
Board. As a result, there were a limited number of agencies available to participate in
the study. The County would not allow the researchers to collect data from the
County’s three primary clinics or their clients. This restriction affected the scope and
depth of the study in that the researchers were unable to get data from arguably the most
pertinent resource, the County. This researcher saw a significant implication for further
research on the need to obtain support from the Sacramento County’s Director of Health
and Human Services upon beginning a study on or related to this topic.
Moreover, it was very difficult to locate willing participants from agencies that
matched the criteria set. Several agencies referred this researcher to the county clinics.
Others reported that they did not have the time to meet or that they did not have the
information available for the study at hand. The lists which the researcher utilized to
contact agencies were not updated. Many of the agencies had already closed and/or
were no longer offering health services to the public.
Another critical issue arose when the representatives from the agency were
prescreened on the telephone about their agency’s experience with the effects of the
budget crisis. Many stated that their agency had not yet experienced layoffs, changes to
hours of operation, changes in client eligibility or changes to the number of clientele
seeking services. The representatives attributed this to the fact that the enacted cuts had
not yet affected the agencies, and that the agency’s current budget was supportive of
56
them. Quite a few representatives reported that they were receiving donations to help
supplement their budget or that they were able to access other loop holes, such as,
mental health funding to maintain financial stability within the agency. However, they
expected changes in the next year’s fiscal budget. Possibly, some agency
representatives had some ambivalence about participating in the study out of fear that
they may not be able to justly share information, especially since the budget crisis was
so current.
Lastly, this researcher was unable to interview clients because of the agencies’
commitment to HIPPA (Health Insurance Portability and Accountability Act)
regulations. This researcher had approval from the Human Subjects Review Board at
the California University of Sacramento’s Social Work Division. Still it made no
difference. This researcher was not asking for health information on the clients or for a
list of clients receiving care from that agency. The agencies were still very adamant that
the researcher should not make any contact with clients at the agency. This ruling
further limited the depth of the research data that may have been collected, assessed and
related to the current literature.
Implications for Future Policy
This researcher recommends that the agencies that receive county funding for the
purposes of providing health services to the medically indigent population be required
to participate actively in research that attempts to assess the quality and quantity of the
services rendered to the community. The public should have the right to be informed as
to how their tax dollars are spent and to what extent.
57
Research such as this would also enable policy makers to be kept abreast of the
effects of previously implemented policies so that, if needed, changes can be made at an
earlier stage in the implementation process. Counties should also be open to share in
the responsibility of conducting research about their own policies.
Implications for Social Work Practice
This study attempts to educate social workers about the effects of the budget crisis
on their medically indigent clients. In this way, they become more sensitive to how
clients may respond to the impacts of the budget crisis. This research also gives way to
advocacy opportunities for social workers on behalf of medically indigent women. If
social workers have a better understanding of health related policies and how they affect
their clients they may be more apt to advocate for their clients’ needs.
Implications for Practitioners
Practitioners may be interested in this research for several reasons. This research
study could inform them of the drastic changes to public health and the short term and
long term affects it may have on medically indigent women and the medically indigent
population as a whole. Furthermore, it could inform the practitioners of the needs of
this population and the best ways to provide care for them even in the current
circumstances. Practitioners can be politically involved as well by advocating for the
needs of their patients (Haynes, & Mickelson, 2010).
Summary
The needs of medically indigent women have been evident through the literature
review and the data collected from the agencies of health care services. The themes that
58
emerged as patterns from the data collection process pertained to longer wait periods,
increased caseload, cuts to preventative services, and the long term effects of the budget
crisis. The literature confirmed the validity of these themes by reporting that the effects
of the budget cuts increased the probability among medically indigent women becoming
more sickly and vulnerable not only to acute illnesses but chronic diseases as well
(Estes, Goldberg, & Fineman). In the long run, the budget crisis could possibly increase
the financial burdens placed on hospitals as they attempt to provide basic services to
women who cannot obtain services through a clinic (California Association of Public
Hospitals and Health Systems, 2009).
Lastly, after having seen the extent of the problem and the possible solutions to it,
this researcher discussed the implications of this study for future research, policy, and
social work practice. Many barriers presented themselves as this researcher attempted
to collect the data. The lack of support from the County, the possible ambivalence from
agency representatives and the inability to interview clients posed as obstacles.
However, this researcher hopes that policies could be implemented to create a vehicle of
change for future researchers who would want to explore the affects of the current
budget crisis or any other policy for that matter. Additionally, this researcher is hopeful
that through this study other social workers will be properly informed and made aware
of the significant issues relevant to medically indigent women and the medically
indigent population as a whole. Positive changes through advocacy for the medically
indigent can occur if social work practitioners are informed and consequently positively
and devotedly take up the cause of their clients.
59
APPENDIX A
Approval by the Committee for the Protection of Human Subjects
60
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
DIVISION OF SOCIAL WORK
TO: Jennifer Whitby
Date: October 27, 2009
FROM: Committee for the Protection of Human Subjects
RE: YOUR RECENT HUMAN SUBJECTS APPLICATION
We are writing on behalf of the Committee for the Protection of Human Subjects from
the Division of Social Work. Your proposed study, “The impacts of California budget
crisis on various health agencies” has been
__X_ approved as _ _
_EXEMPT _ __ NO RISK __X__ MINIMAL RISK.
Your human subjects approval number is: 09-10-031. Please use this number in
all official correspondence and written materials relative to your study. Your
approval expires one year from this date. Approval carries with it that you will
inform the Committee promptly should an adverse reaction occur, and that you
will make no modification in the protocol without prior approval of the
Committee.
The committee wishes you the best in your research.
Professors: Teiahsha Bankhead, Chrys Barranti, Andy Bein, Joyce Burris, Maria Dinis,
Susan Eggman, Serge Lee, Kisun Nam, Sue Taylor
Cc: Dr. Teiahsha Bankhead
61
APPENDIX B
Informed Consent Forms
62
Informed Consent Form for Health Administrative Professionals/Staff
I _________________________ consent to participate in this voluntary study
conducted by Jennifer Whitby, MSW student at Sacramento State University.
I understand the purpose of this research study is to explore the effects of the California
budget on public health agencies and how the agency and its clients may be affected.
I understand this survey may take approximately 60 minutes and that I may choose a
confidential and comfortable setting for the survey to take place.
I am aware there is no risk of discomfort involved as I will only be asked questions
about the agency itself.
I understand the benefits from participating in this research study may help educate and
inform the researcher, State of California residents, policy makers, public health
agencies and ultimately, the clients they serve.
I fully understand that my interview will be coded with a number in order to
differentiate my responses from other participant responses. I also understand that a
master list of all identifying information will be kept in a safe and secure location that
will be locked in a cabinet at the researcher’s home at all times except for when the
researcher is accessing the data for research purposes.
I understand that I am not being forced to participate in this study and that my
participation is strictly voluntary. It has been explained to me that I can refuse to
participate and withdrawal from this interview at any time up to the time this research
study is finalized by the Graduate Studies Department at California State University,
Sacramento. I may withdraw my information without any consequences or penalties
being placed upon me or the agency.
63
I have read and understand this consent form and understand my rights as a participant.
I would like to voluntarily consent to this research study. I understand that I can request
and will receive a copy of this consent form at any time I wish.
_________________________
Signature of Participant
Jennifer Whitby, MSW Student
Email: jw123@saclink.csus.edu
Phone: (555) 555-5555
Teiahsha Bankhead, Ph.D., LCSW
Graduate Program Director
Email: bankhead@csus.edu
Phone: (916) 278-7177
______________________
Date
64
Informed Consent Form for Client Participants
I _________________________ consent to participate in this voluntary study
conducted by Jennifer Whitby, MSW student at Sacramento State University.
I understand the purpose of this research study is to explore the effects of the California
budget on public health agencies and how the agency and its clients may be affected.
I understand this survey may take approximately 60 minutes and that I may choose a
confidential and comfortable setting for the survey to take place.
I am aware there is minimal risk of discomfort involved because I will be asked
questions that relate to women’s health services and my feelings about how my services
might be impacted by the budget crisis
I understand the benefits from participating in this research study may help educate and
inform the researcher, State of California residents, policy makers, public health
agencies and ultimately, the clients they serve.
I fully understand that my interview will be coded with a number in order to
differentiate my responses from other participant responses. I also understand that a
master list of all identifying information will be kept in a safe and secure location that
will be locked in a cabinet at the researcher’s home at all times except for when the
researcher is accessing the data for research purposes.
I understand that I am not being forced to participate in this study and that my
participation is strictly voluntary. It has been explained to me that I can refuse to
participate and withdrawal from this interview without any consequences at any time up
to the time this research study is finalized by the Graduate Studies Department at
65
California State University, Sacramento. I may withdraw my information without any
consequences or penalties being placed upon me or the agency.
I have read and understand this consent form and understand my rights as a participant.
I would like to voluntarily consent to this research study. I understand that I can request
and will receive a copy of this consent form at any time I wish.
I have been provided with a list of therapists that I may contact at my own expense if I
feel bothered or upset for any reason after I participate in this interview.
_________________________
Signature of Participant
Jennifer Whitby, MSW Student
Email: jw123@saclink.csus.edu
Phone: (555) 555-5555
Teiahsha Bankhead, Ph.D., LCSW
Graduate Program Director
Email: bankhead@csus.edu
Phone: (916) 278-7177
______________________
Date
66
APPENDIX C
Interview Questions for Health Administrative Professionals/Staff
67
1. Please describe the top 3-5 programs/services this agency offers.
2. Please describe the specific populations that benefit from each of these programs.
3. Has client eligibility for health services changed as a result of California’s current
budget crisis?
4. How does your agency prioritize which programs or services to keep and which
programs to cut?
5. In relation to California’s current budget crisis, which programs within your agency
have been (negatively) impacted the most?
6. How has California’s budget crisis impacted the employees of this agency? (i.e. Have
employment rates, case loads, and the number of out-referrals changed within the last
12 months? What has been the impact of these changes to employees?)
7. How has the quality of care for patients been impacted due to the state’s budget cuts
and decreased funding?
8. What may be the long-term effects of the state’s current tightening of the budget in
relation to health care?
9. What was your annual budget for 2008-2009?
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Less than $50,000
$50,001-$100,000
$100,001-$300,000
$300,001-$500,000
$500,001-$700,000
$$700,001-$900,000
$900,001-$2,000,000
$2,000,001-$3,000,000
$3,000,000 +
Unknown
68
10. What is your annual budget for 2009-2010?
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Less than $50,000
$50,001-$100,000
$100,001-$300,000
$300,001-$500,000
$500,001-$700,000
$$700,001-$900,000
$900,001-$2,000,000
$2,000,001-$3,000,000
$3,000,000 +
Unknown
11. Approximately how many patients does your agency currently serve?
_____
_____
_____
_____
_____
100-200
301-400
401-500
501-600
601-700
_____
_____
_____
_____
_____
701-800
801-900
901-1,000
1,000 +
Unknown
Children Ages 0-5 Population: (The next section of questions will request information
that is specific to this age group.)
12. What type of insurance, if any, does a child need in order to be seen at this agency?
13. How have eligibility requirements for children ages zero to five been affected by the
budget crisis?
14. Has this agency seen any changes in outreach services provided to inform
potentially eligible participants during the current budget crisis?
15. What services/programs does this agency provide for families with children zero to
five years of age?
16. Which services do children zero to five seek most frequently at this agency?
17. How have these services been affected by the current economic situation?
18. How has this agency prioritized its services in order to insure children can receive
the care they need during the budget crisis?
19. How do you believe children’s health will be affected in the future due to the recent
budget crisis?
69
Women’s Health: (The next section of questions will request information that is
specific to this group of people.)
20. How long has this agency provided services specific to women? (Please check the
best response.)
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
1-10 years
11-20 years
21-30 years
31-40 years
41-50 years
51-60 years
61-70 years
71-80 years
81 + years
Unknown
21. What is the age range of women who seek out services at this agency? (Please check
all that apply to the agency.)
_____ 0-17 years
_____ 18-24 years
_____ 25-30 years
_____ 31-40 years
_____ 41-50 years
_____ 51-60 years
_____ 61 & above
22. Please describe the services and/or programs this agency offers specifically for
women’s health.
23. How have services specific to women's health been eliminated or reduced due to the
recent budget crisis?
24. How have eligibility requirements for women seeking health services been affected
as a result of current the budget crisis?
25. How have female patients/clients been impacted by the elimination or reduction of
services?
26. How have employees who specialize in women’s health been impacted by the
current budget crisis?
70
27. How has the budget crisis impacted your decision-making and the agency’s
priorities surrounding programs geared towards women’s health?
28. How may women’s health be impacted in the long run if the services are cut?
Undocumented Immigrant Population: (The next section of questions will request
information that is specific to this group of people.)
29. Please describe the top five programs and/or services this agency offers specifically
to undocumented immigrants.
30. How do undocumented immigrants receive information regarding the services this
agency provides?
31. What types of insurance does this population require in order to receive services
from this agency?
32. What challenges does this population face when gaining access to health care
services at this agency?
33. How do agency employees respond to the needs of undocumented immigrants
seeking services?
34. What health needs does this population present that the agency has difficulty
managing?
35. How have the programs and/or services offered to undocumented immigrants been
impacted by the current economic situation?
36. How is the undocumented immigrant population’s ability to receive adequate care
being impacted by any funding cuts within the agency?
37. Where is the agency’s location within the county?
38. What is your job title within the agency?
Today’s Date: _______________
Interviewer/Researcher: _______________
71
APPENDIX D
Interview Questions for Clients
72
Children Ages Zero to Five: (The following questions request information that is
specific to this group of health care recipients.)
1. Do you have health care coverage for your child?
*If yes, what types of coverage do you have? (Continue to question 2)
*If no, for what reasons do you not have health coverage? (Skip to question 3).
2. What health care programs does your child utilize?
3. Which two programs do you feel are the most important/beneficial for your child?
4. What challenges are you facing in accessing or maintaining health care for your
child?
5. How do you believe the current economic situation is impacting your child’s access
to health care?
6. How do you believe the current economic situation is impacting the quality of care
your child is receiving?
Women: (The following questions request information that is specific to this group
of health care recipients.)
7. What types of health services do you feel are most important to women?
8. What are some barriers to health care and medical services women may face?
9. What types of programs specific to women’s health do you use?
10. As a woman, do you feel that you receive quality health care that meets your
specific health needs? Please explain.
11. Please describe any changes in your ability to obtain health coverage and/or medical
services in the past 5 years.
Undocumented Immigrants: (The following questions request information that is
specific to this group of health care recipients.)
12. Please describe any health coverage or benefit you receive. If you do not have
health coverage, explain why.
73
13. What types of medical services or health programs do you use?
14. Do you use emergency care or primary care for your health needs? Please explain.
15. Do you feel that the medical care you receive is adequate? Please explain.
16. How does health care in the U.S. today compare to the health care you received in
your home country?
17. Please describe any changes in your ability to obtain medical services or care in the
last 5 years.
18. In what ways is the health care you receive being impacted by the California’s
current economic situation?
DEMOGRAPHICS:
Please respond and check the section that best applies to you.
19. Age:
_____
_____
_____
18-24
25-30
31-40
_____
41-50
_____
51-60
_____
61 & above
20. Sex/Gender:
_____
Female
_____
Male
_____
Decline to Answer
21. Ethnic Identification:
_____
_____
_____
_____
_____
_____
African American/Black
Asian/Pacific Islander
Latino/Hispanic
White/Caucasian
Other
Decline to Answer
22. Citizenship Status:
_____
_____
_____
_____
_____
_____
U.S. Citizen
Non-citizen of U.S. (Undocumented Immigrant)
Work Visa
International Student Visa
Other
Decline to Answer
_____
Decline to
74
23. Number of family members in your household:
24. Number of children ages 0-5 in your household:
25. Number of adult women in your household:
26. Yearly Income: ___________
Today’s Date: _______________
Interviewer/Researcher: _______________
75
APPENDIX E
List of Resources
76
Sacramento County Mental Health
Offers mental health services, support and referrals for adults and children.
(916) 875-7070.
Family Service Agency
Family Service Agency, located near Watt and Folsom Blvd provides counseling for
children, adults and families. MediCal is accepted and a sliding fee is provided based on
monthly income. MediCal clients please call (916) 875-1055, all others may call (916)
368-3080.
Yolo County Mental Health
Provides mental health services as well as drug/alcohol rehabilitation and other services.
West Sacramento: (916) 375-6350. Woodland: (530) 666-8630.
New Pathways (formerly Catholic Social Services)
Provides counseling for children, adults and families of all denominations. Their
standard fee is $70, but they also offer a sliding fee based on income. They are located
on Newman court in Sacramento.
(916) 452-1218.
Family Study Center
The Family Study Center offers counseling for adults, children and families. They do
offer a sliding fee based on income. They are located on X Street in Sacramento.
(916) 456-4412.
La Familia Counseling Center
La Familia offers free short and long term counseling for all ethnicities. Located on 34th
Street in Sacramento.
(916) 452-3601
77
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