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Thelma Frieson makes a follow up appointment for her son as she carries her nephew, Sirerik Agreda, 2, as her grandson, Oren Frieson, 6, watches at La Clinica Fruitvale Village in Oakland, Calif. La Clinica is one of the larger community health centers serving patients in Alameda, Solano and Contra Costa Counties. (Laura A. Oda/Bay Area News Group)

OAKLAND -- Long before President Barack Obama made universal health coverage a national priority, Alameda County earned accolades with its mission to ensure decent medical care for all its nearly 1.5 million residents. A tax hike approved by voters a decade ago fortified an expansive safety net of public hospitals and primary care clinics.

So why are local health leaders so worried as the new federal law takes effect in January? An arcane state funding formula, they say, will soon penalize the county for its commitment to treating everyone, including the poor and immigrants denied health insurance because they are in the country illegally.

"This is really quite devastating," said Alameda County Supervisor Wilma Chan. "People will have to wait longer. People might be turned away. I know the clinics are thinking of doing layoffs."

A liberal Bay Area county that positioned itself as one of Obamacare's California standard-bearers, beating out most others in laying the groundwork and pre-enrolling the poor, is now running into problems because of its generosity.

"Alameda County voters have decided that a viable safety net for our most vulnerable community is a basic human right," said Alex Briscoe, director of the Alameda County Health Care Services Agency.


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But that voter and taxpayer contribution is counting against Alameda County as the state is about to take away $11 million in health care funds and could grab more than $30 million in the coming fiscal year. The cuts are based on the state's expectation -- Briscoe says an overly rosy one -- that expanding federal benefits will lessen the burden on urban hospitals and nonprofit clinics because more people will qualify for free or low-cost care through Medi-Cal.

Since 1991, state health care funding has been channeled into counties from a pot of state sales tax revenue and vehicle license fees. But Gov. Jerry Brown signed a law in June that orders counties to cough up 60 percent of their annual allotment or submit to a complicated formula that puts Alameda County at a disadvantage.

The state's reasoning is that the growing population of insured patients will be a boon to medical providers. Yet local providers anticipate about 150,000 Alameda County residents will remain uninsured because they do not or cannot sign up for Covered California, the state's version of the new federal health exchange. As many as 60,000 are immigrants without documentation whom the county is determined to keep caring for despite their exclusion, by law, from signing up for health insurance. Alameda County's mission to leave no one untreated contrasts with counties such as neighboring Contra Costa, which explicitly denies county-supported care to immigrants here illegally.

Chan and Supervisor Keith Carson have said they are particularly disturbed that the state appears to be penalizing them for chipping in too much to bolster the health care system.

"We did everything we could," Chan said. "This is exactly what the governor wanted the counties to do to be more self-reliant, ... but we're getting the most money taken away from us."

The county is the only one in the state where voters, in 2004, approved a tax hike that supports the health care safety net.

Three-quarters of the money from Measure A, a half-cent sales tax, goes directly to the Alameda Health System, a public hospital consortium that includes Oakland's Highland Hospital and was formerly known as the Alameda County Medical Center. The remaining quarter subsidizes a few private hospitals that serve the vulnerable, such as Children's Hospital Oakland, but mostly funds a network of community-based clinics that offer primary care to thousands of residents from Berkeley to Fremont and Livermore.

Among the busiest is Oakland-based La Clinica de la Raza, where the director for three decades, Jane Garcia, said she has been waiting "her whole life" for a law like Obama's Affordable Care Act. She is also nervous, however, that state cutbacks could force uninsured clients to be turned away.

That's because many families who depend on doctors and nurses at La Clinica, as well as at Hayward-based Tiburcio Vasquez Health Center, and Asian Health Services, headquartered in Oakland Chinatown, are immigrants locked out of Medi-Cal and the Covered California exchange because of their legal status. Without insurance or subsidized care, Briscoe says many will end up resorting to emergency-room visits at Highland and other hospitals and be saddled with huge bills.

For at least the next six months, the clinics will get a lifeline from the county's general fund. On Tuesday, the Alameda County Board of Supervisors voted unanimously to backfill some of the lost state money until the questions over the funding formula get resolved. The county has also, for months, been sending delegations to lobby state officials to stanch the loss, and Chan said the bigger financial problems could emerge later if too few get insured and the formula dispute is not resolved.

As if that was not enough to worry about, Briscoe said what "keeps me up at night" is that the Measure A tax revenue that the safety net system relies on expires in 2019 unless voters approve it again. With a recently commissioned poll showing Alameda County voters support the measure, but also don't entirely understand it, a task force is debating whether it makes sense to take a renewal of the tax to voters as early as next year.

Matt O'Brien covers Alameda County. Contact him at 510-208-6429.