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RB Knights Landing 5.JPGCalifornia continues to extend a patchwork of safety-net programs for its poor and uninsured residents despite making progress in several of the state's 58 counties, according to a report released Thursday.

The report from the Health Access Foundation documents large disparities for the estimated 3 million to 4 million residents projected to remain uninsured even after the federal health care law is fully implemented.

The goal of the report is to provide a baseline for county officials as they weigh key decisions in the coming months about the level of services they extend to the indigent and uninsured.

Anthony Wright, executive director of Health Access California, said the pending county-by-county debate must center on "how we provide the services to our friends, our neighbors, or fellow Californians."

"We're very excited about the implementation of the Affordable Care Act as a transformational leap in improving coverage, but for those left out - including, but not exclusively, undocumented immigrants - the safety net is a widely divergent patchwork and could become more so if we do not actively engage in the next few weeks and months," Wright said.

Under the federal health care overhaul, subsidized coverage is not available for undocumented immigrants, one of the key populations that will likely remain uninsured. San Francisco, Fresno, Los Angeles and Riverside counties are among the handful that provide funding for undocumented immigrant care, according to the survey.

Other changes are being driven by the state budget.

In 2013-14, some $300 million will return to the state and counties must choose between a pair of funding formulas: Shifting 60 percent of health realignment money to the state and retaining the remainder for public health; or settling on a more complex agreement aimed at keeping public hospitals viable under the new health law.

State Sen. Ed Hernandez, D-West Covina, said despite the health care overhaul, he's convinced the state still has a two-tiered system.

"We have one for those who can afford it and have the means," said Hernandez, chairman of the Senate Health Committee. "And we have one for those who are poor and don't have access to health care."

"I really believe that if we're going to be successful in health-care reform, we have to look at addressing the neediest and the uninsured or the under-insured and more importantly the safety net, whether it's the community health centers or county health systems," he added.

PHOTO: UC Davis medical student and co-director Alexa Calfee examines patient Armando Garcia at the monthly medical clinic in Knights Landing on Feb. 19, 2012. Medical services are a hardship for many isolated, low-income families. The Sacramento Bee/Randall Benton.



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