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June 4, 2013
Editorial: State can't take risks with county public health

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(June 4 -- By the Editorial Board)

Protecting public health is a basic government function. County health officers track illnesses and deaths from West Nile virus to hospital infections to food-borne contamination. They conduct vaccination campaigns and restaurant inspections. They respond to outbreaks and disasters.

Unfortunately, this essential public health function is being lost in the budget battle between Gov. Jerry Brown and the counties in the jostling over preparing for the federal Affordable Care Act. The governor wants the state to take back the bulk of a $1.5 billion block grant (so-called "county health realignment funds") that goes to counties for the medically indigent and for public health.

Counties, justifiably, are up in arms. Yet legislative leaders have sent no clear signal where they stand. As the June 15 budget deadline approaches, that should change. Senate President Pro Tem Darrell Steinberg, D-Sacramento, and Assembly Speaker John A. Pérez, D-Los Angeles, need to step up.

Brown is right that under federal health care reform, many of the uninsured who now fall back on county care will be covered after Jan. 1 either under an expanded Medi-Cal paid for by federal dollars or in the exchange of private insurers with federal subsidies. Counties won't need as much money to cover the medically indigent.

The best estimates so far are that of 6 million uninsured Californians, 2 million to 3 million of them will get insurance coverage under the Affordable Care Act. Some 3 million to 4 million, however, will remain uninsured.

The governor is justified in wanting to reduce the amount that goes to counties for covering the medically indigent - so counties have an incentive to get people enrolled in Medi-Cal and the exchange. At the same time, counties are justified in wanting to ensure they can care for the remaining uninsured and continue basic public health functions.

In 2013-14, Brown would take $900 million of the $1.5 billion block grant. After that, he would take $1.3 billion. That's too much.

Counties historically have spent more than half of the grant on public health, according to the California State Association of Counties - though there is variation among them. If Brown sweeps the bulk of the funds, counties will have to choose between covering the remaining uninsured or continuing basic public health functions, when they should be doing both.

Sacramento County, for example, struggles to allocate health realignment funds between the equally compelling needs of public health and indigent health care. Of $43.5 million this year, it spends $25.5 million on indigent care (58 percent) and the rest on public health (including health care in the jails).

The governor wants to allocate the block grant based on actual county costs for the remaining uninsured, which is fine for the part dealing with indigent care. But what about public health?

In a compromise, the counties have proposed a formula that would reserve 30 percent of the block grant for public health. The rest would be divided between the counties, for caring for the remaining uninsured, and the state - with a true-up at the end of each year to make sure that counties get money only for actual services to uninsured individuals. This would take effect in 2015-16 - providing a transition.

The Legislature, a co-equal branch of government, needs to jump into the fray, sending the message that public health is important.

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