Through the Medically Indigent Services Program, low-income adults who do not qualify for Medi-Cal can receive treatment and services at Community Regional Medical Center.
"You talk about people coming from outlying areas, and coming into Community Medical Center -- the way they do that is by ambulance," said Hamilton, deputy chief of programs at Clínica Sierra Vista.
"They get sick, they don't feel good, they have the flu, they have a headache, and they call the ambulance. They don't have the money to buy gas to come into town... And they end up in the ER, for a migraine for goodness sake."
The situation could be improved through implementation of a Low Income Health Program, Hamilton said. He urged the board not to scrap plans for the program, a new initiative made available through the Affordable Care Act and the state's "Bridge to Reform" Medicaid waiver that would use federal matching funds to expand and improve health care and coverage for the county's poor and uninsured.
"Certainly your costs would go down by providing this care -- how much, I don't know," he said.
Despite the pleas of Hamilton and other health and community advocates, the board, after almost three hours of discussion and testimony, voted 3-2 to withdraw the county's Low Income Health Program application from consideration by the State Department of Health Care Services.
Board chairman Phil Larson, vice chair Deborah Poochigian, and supervisor Judith Case voted to withdraw the application, while supervisors Henry Perea and Susan Anderson voted against its withdrawal.
With the vote, the county became the first in the state to withdraw its application for the program, which was intended to help counties prepare for the expansion of Medi-Cal that will come with the implementation of the federal health care law in 2014.
During the hearing, county health officer Dr. Ed Moreno praised the concept of the Low Income Health Program, saying it would create a medical home model for low-income patients, allowing them to get regular care for chronic conditions like diabetes, hypertension, heart disease and lung disease, and preventing them from landing in the emergency room or hospitalized.
But, he said, it would not be financially feasible for the county to implement it.
Under a contract signed about 15 years ago, the county pays the hospital about $20 million each year to provide the indigent and undocumented with medical care, which, according to the hospital, costs about $80 million. Hospital officials say they are unable to take on the added financial risk of another health program.
The county could have received as much as $28 million per year in federal matching funds for the Low Income Health Program. The undocumented would not be eligible for the program.
"We analyzed the financial risk of continuing the Medically Indigent Services Program, which we as a county have an obligation to provide and operate, and simultaneously create a new managed system of care -- in essence a new business of health care delivery, all with $20 million," Moreno said.
"Unfortunately, the meetings that we had with Community Regional Medical Center revealed that we are at a place where we have few local revenue funds to support indigent care, compared with other counties in the state."
Stephen Walter, Community's chief financial officer, said the hospital could not afford to take on the financial risks of the new program, given the current contract. The current program, he added, is working fine.
"In the MISP, patients are getting care," he said. "It is not the best organized care -- it would be much better to have one primary care physician, or a nurse practitioner, and all that -- but we do have a system in place right now that people are getting good care."
Supervisor Anderson, though, argued that the LIHP would improve people's access to medical care and reduce visits to the emergency room, drawing down the cost of care.
"Isn't it more expensive to do it the way we are doing it?" she said. "We could bring this extra money in and do it more efficiently."
After the meeting, health and community advocates decried the board's decision.
In Fresno -- which has high rates of poverty, and where 19.6 percent of adults are uninsured all or part of the year, according to UCLA -- advocates said the program would be a significant step toward improving regular access to medical care, especially in the rural communities.
Citing a recent UC Berkeley Labor Center report, they said the program would also create about 500 jobs.
Anthony Wright, executive director of Health Access, a statewide health care consumer advocacy organization, acknowledged that the county's ability to implment the Low Income Health Program was complicated by the contract with the hospital.
Still, he characterized the county's decision as a, "loss of real money to our health system and our economy."
"It means that you are not taking care of more people, and not taking care of them more efficiently, and with better health outcomes, by providing primary and preventitive care," he said.
Chris Schneider, executive director of Central California Legal Services, echoed advocates' concerns. In a letter sent last Friday to the Board of Supervisors, Schneider said he objected to the board's decision on legal grounds, and asked them to not communicate their decision to the state.
Their action, he said, would reduce the level of health care available to the medically indigent population, forego $56 million that would benefit the medically indigent in the region, and result in the loss of jobs and job opportunities, among other consequences.
Among his legal concerns, Schneider said withdrawing the funding application would have a disparate impact on the rural poor, who are predominantly minority, and would violate state and country laws that prohibit discrimination under any program or activity that receives any state or federal assistance.
He requested the board reconsider its vote, and take action on the item, "after considering the good of the public generally, but particularly the indigent population directly affected by this decision. It is insufficient to consider only the financial agreement and financial imapct on the County and Community Regional Medical Center."
On Monday morning, board chairman Larson said Schneider's letter would not change the board's decision or course of action.
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