Outline of Alameda County’s Health Care System for the Medically Indigent

Alameda County Re-Entry Task Force October 11, 2007

Dr. Tony Iton, County Health Officer & PH Director

The Context

The Medically Uninsured

Our Broken Our Broken Health Care Health Care

System in CASystem in CA

6.5 Million Uninsured6.5 Million Uninsured

20% of Population20% of PopulationSource: California Health Interview Survey, 2005

Change in Uninsured Rates 2001 to 2005, Alameda County

2001 2003 2005

0-18 years 19,000 24,000 19,000

19 years and older

108,000 149,000 148,000

Total Uninsured

127,000 173,000 166,000

Total Population 1,449,00 1,466,000 1,475,000

% Uninsured 9% 12% 11%

Source: California Health Interview Survey 2001, 2003, 2005. Due to rounding, numbers may not add to 100%.

Healthy Families/CHIP

1%

Medicare & Medicaid

3%

Medicare, Medicare & Others

7%

Other public1%

Privately purchased

7%

Medicaid9%

Uninsured11%

Employment-based61%

Fig. 1. Types of Health Coverage Among Alameda County Residents (total = 1,475,000)

Source: California Health Interview Survey, 2005.

58,000

3,000

60,000

44,000

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

No usual source ofcare

Emergencyroom/Urgent

care,Some otherplace/No one

place

Communityclinic/governmentclinic/community

hospital

Doctor'soffice/HMO/Kaiser

Usual Source of Care Among the Uninsured, Alameda County (n= 166,000)

Source: California Health Interview Survey, 2005. Note that numbers may not add to 100% due to rounding.

Non Working Family

16%

Full Time Employed

Family66%

Self Employed

Family13%

Part Time Employed

Family5%

Source: California Health Interview Survey, 2005

84% of the Uninsured Work

The Situation in Alameda County

Environmental Health

Environmental Health

HCSA Administration/Indigent Health

HCSA Administration/Indigent Health

Behavioral Health Care

Services

Behavioral Health Care

Services

Public Health Services

Public Health Services

AdministrationIndigent Health Care Services

Environmental Health Services

Vector Control Services

Cross-Departmental/Cross-Jurisdictional

Health Services

Administration/Infrastructure

Support

24 Hour Services

AncillariesDay Treatment

Outreach

Outpatient Services

Referral Services

Support Services

Family Health Services

Office of the Director/

Health Officer

Administrative Services

Public Health Nursing Emergency

Medical Services

Communicable Disease

Control & Prevention

Office of AIDS

Alameda County Health Care Services Agency

U.C. Cooperative Extension

Community Health

Services

Administration

HCSA Indigent Care Spending ~ $96 million in 2007

Indigent Health Care Services

County Medically Indigent Services Program

•Alameda County Medical Center

•Primary Care CBOs

Other private providers

Juvenile Justice Medical Services

$

$72,397,851

$15,766,890

$ 5,255,000

$ 2,898,690

$96,318,433

The Safety Net

Serves: uninsured, underinsured, and portion of the Medi-Cal population (123,000).

Comprised of: ACMC (3 hospitals and three outpt. clinics), 10 community-based clinics, and Health Care for the Homeless

AHS LaC TVWO Ax

Highland Hospital

W E N

TC

JGPH FH

Safety Net Payor Mix

Medicare13%

CMSP20%

Private5%

Other5%

Medi-Cal57%

Major Payor Sources Medi-Cal and County General Funds (CMSP) However, Medi-Cal covers less than ½ of the

poor. Must be categorically linked or disabled. States are desperately looking for ways to

decrease spending on Medicaid thus passing the financial burden down to counties.

Alas working poor, homeless adult singles, new immigrants are left out and must depend entirely on the safety net.

CCLHO Proposal To CDCR Receivership

Brief Context CCLHO approached by Mr. Bob Sillen, Receiver

for CDCR’s medical system (California Prison Health Care Receivership Corporation or CPR), to draft a proposal to help strengthen public health in California’s prisons. (Seek Foundation support?)

CCLHO has been working diligently over the past few years to reinvigorate a joint CDCR-DHS-CCLHO committee on communicable disease policies and control within CDCR.

CPR has engaged several health care medical informatics experts and intends to enhance the availability of electronic health data, electronic registries, & telemedicine within CDCR.

Brief Context (cont.) Several innovative city-based programs have been

developed including LA’s Going Home--Los Angeles program and Oakland’s Project Choice.

Several counties (LA, San Diego, Riverside, San Bernardino, and Alameda) have been involved in an effort organized by Regional Congregations and Neighborhood Organizations (RCNO) to develop a Public Health Reentry Initiative to provide a seamless system of support for parolees who are seeking solutions to their health needs.

Kern and San Diego counties HIV and mental illness case management programs for re-entering prisoners.

The Status Quo

High Prevalence of PH Problems DHS study reveals that the prevalence of

hepatitis C in California prisons is 34%, hepatitis B (past infection) is 28%, hepatitis B current/chronic infection is 3.5%, and HIV prevalence is 1.8%.

Estimates of prisoners with serious mental health suggest rates as high as 20%, while substance abuse rates are estimated to be 85%.

Other diseases of special interest include coccidiomycosis for which specific surveillance strategies within CDCR may be indicated.

 

Missed Opportunities

There are 5 clear intervention points in the cycle of incarceration and re-entry into communities:

1. County Jail; 2. Prison Intake; 3. Incarceration; 4. Anticipating Release; 5. Re-Entry To Counties.

During this cycle, effective health assessment, record keeping, appropriate intervention, and inter-agency communication, is critical to optimize the use of the scarce health resources devoted to this population.

Recommendation 1

Establish a robust and competent public health infrastructure within CDCR

Recommendation 2

Work in partnership with CDCR to develop an electronic “Continuity of Care Record” (CCR), accessible to county public health departments (and DPH), that would serve as an electronic “health passport” for prisoners upon release

Recommendation 3

Establish within CDCR a pre-release screening, education, and discharge coordination process, which may include a pre-release health curriculum, community health directory, electronic transmission of medical records to receiving county, and vouchers for establishing health access in the accepting communities.

Recommendation 4

Develop a standardized medical screening at intake and pre-release that screens for chronic disease as well as communicable disease and other diseases of particular public health significance, such as hepatitis C, chronic/carrier Hepatitis B, HIV, and TB.

Recommendation 5

Work with CCLHO, CHEAC to advocate for simple reactivation of Medi-Cal benefits for those re-entering prisoners whose Medi-Cal was suspended at incarceration.

Based on discussions with health officers, knowledgeable local and state public health department staff, CDCR medical staff, Receiver’s medical staff, and community based organizations involved in prison health and re-entry issues, and given the ongoing internal initiatives that CDCR is already pursuing under the Receiver’s tenure, it is CCLHO’s conclusion that Recommendation 2 provides the greatest opportunity for CCLHO and CDCR

collaboration.