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Lawsuit forces changes in indigent healthcare program
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Published: Apr 6, 2011, 2:50 AM

A revision to the county’s medically indigent adult healthcare program, forced by a lawsuit, will make free or low-cost healthcare available to more county adults, affect payment schedules for many existing participants, and raise county costs.

“The impact to the patients varies,” said Mary Ann Lee, managing director of the Stanislaus County Health Agency. “For some patients, they’ll be eligible, based on approval, that aren’t eligible now. For some patients, they’ll be contributing more to their costs of care, and yet others will contribute less or won’t have to contribute to the costs of their care.”

The new policy, effective May 1, will see individuals who earn from 0 to 116 percent of the federal poverty limit – $902.50 per month for a family of one – qualify for no-cost healthcare.  Those earning 117 to 223 percent of the federal poverty limit will qualify for a hardship eligibility, by which they may participate in the program by covering a share of medical costs.

The cost sharing works like a monthly deductible, equal to the amount one earns over the no-cost income limit – $1,047 per month for a family of one. Should a patient earn $1,147 monthly, he or she will be responsible for the first $100 of monthly MIA costs, while the program will pay for any further expenses. Services will not be delayed if payment cannot be made at the time of service; payment arrangements will be made available.

Currently, only those earning 0-49 percent of the federal poverty limit receive no-cost care, while those earning 50 percent to 129 percent pay co-pays. Those earning 130 percent to 200 percent of the federal poverty limit qualify for a lower share of cost, and those above 223 percent are not qualified.

The expanded services will cost Stanislaus County between $130,000 and $205,000, based on staff projections. The extra costs must be paid with county dollars; no extra state funding is available, as the program is funded through dwindling sales tax and vehicle license fee realignment revenue.

 

Program changes driven by legal action

For the six months following Oct. 1, 2009, the eligibility limits were tighter yet in a cost savings effort – only those earning up to 33 percent of the federal poverty level qualified for no-cost help, those between 33 and 65 percent of the federal poverty level paid co-pays, and those earning up to 200 percent of the federal poverty level were responsible for share of cost payments.

But the Western Center on Law and Poverty challenged that policy in early 2010, arguing that the policy should consider an individual’s ability to pay in determining eligibility. The WCLP was successful in suing both San Diego and Fresno on the same issue, with courts compelling the cities to consider local cost of living factors.

In response, the Board of Supervisors reversed their decision on April 1, 2010, reinstating the income standards and cost sharing policies which were previously in effect while a cost of living study was undertaken by county staff and examined by outside consultants. That study ultimately resulted in the newly adopted eligibility requirements

“Based on the cost of living study, we were able to make recommendations that were based on local ability to pay,” Lee said.

To contact Alex Cantatore, e-mail acantatore@turlockjournal.com or call 634-9141 ext. 2005.
Costa, Gray propose congressional bill to address critical physician shortage in rural areas
Costa and Gray
San Joaquin Valley congressional members Rep. Jim Costa, D-Fresno, left, and Rep. Adam Gray, D-Merced, are shown discussing their bill H.R. 2106 in a virtual press conference on Tuesday.
Published: Apr 2, 2025, 4:48 AM

BY TIM SHEEHAN

CV Journalism Collaborative

Two San Joaquin Valley congressional representatives have introduced a bill that could help address the vast shortage of doctors in the region, particularly in underserved areas. 

Rep. Jim Costa, D-Fresno, and Rep. Adam Gray, D-Merced, say the Medical Education Act would, if passed, establish a program of grants to support expanded medical education programs in underserved areas of the nation.

The Valley could be one of the key areas that would benefit from the legislation. California has about 90 primary care doctors per 100,000 residents statewide, the federal Health Resources & Services Administration reported in November 2024. 

That’s more than the ratio in some states, and less than some others. The nationwide ratio is about 84 doctors per 100,000 residents.

But in the San Joaquin Valley, home to about 4.3 million people, doctors are much more scarce – about 47 primary care physicians per 100,000 residents, according to Dr. Tom Utecht, chief medical officer at the Fresno-based Community Health System.

That number is “a little over half of what is necessary to take care of a population,” Utecht said Tuesday in a video press conference. “We have the lowest physicians-per-capita rate in all of California, in the San Joaquin Valley.”

Introduced last month, the Medical Education Act is something of a placeholder for the time being until the Congressional Research Service can weigh in with financial estimates of what is needed in different parts of the country, Costa said. 

A companion version was introduced in March in the U.S. Senate by Sen. Tim Kaine, D-West Virginia, and Sen. Alex Padilla, D-Los Angeles.

At this point, the legislation does not specify how much money will ultimately be sought or how grants would be structured.

Costa said the shortage of doctors in the region “is combined with language barriers, cultural barriers and distances … and that would really go for rural parts of our country regardless where folks live.”

“If you live in rural areas, it’s just more difficult to have access to good quality health care,” he added.

Costa said the legislation, if it can survive a Republican-controlled House and Senate and a Republican president, “would be transformative because it would invest expanded resources to minority-serving institutions and colleges located in rural and underserved areas to establish schools of medicine and osteopathic medicine.”

The bill would also create an avenue for more historically Black colleges and universities, as well as Hispanic-serving institutions, to establish medical education programs, Costa said.

Gray noted that when he was in the state Legislature, he and colleagues “worked to get hundreds of millions of dollars in funding to expand the UC Merced campus, to ultimately secure the funding to put the first medical education building up on campus.”

Gray added that the UC San Francisco’s medical education program in Fresno “is an important part of creating the (medical) workforce of the future for the valley, but more importantly, solving this access to care issue that plagues Valley communities.”

At UC Merced, director of medical education Dr. Margo Vener said there has been a surge of interest in the university’s program that funnels students through an undergraduate program for their bachelor of science degree through a medical school degree in collaboration with UC San Francisco.

“All the students that we are enrolling are from the Valley and for the Valley, because they want to really make a difference in promoting health in their communities,” Vener said. That, she added, is likely to eventually translate to those would-be doctors to stay in the Valley to practice medicine.

“The data suggests that two factors really strongly influence where physicians stay to practice,” Vener said. “One of them is where they’re from, which, of course, is why we’re recruiting students from the Valley for the Valley just to stay (and) be doctors for their community. And the other factor is where you went to residency. Those are the two biggest drivers.”

That’s something that was underscored by Dr. Kenny Banh, assistant dean of undergraduate education at UCSF Fresno. “Regional campuses such as UC Merced and UCSF Fresno not only grow doctors, but they take those doctors, physicians and medical students from their communities in the region, and train them in those regions to go back to be physicians in those areas,” he said.

While the costs of the Costa-Gray legislation are yet to be determined, Banh said there are also costs associated with doing nothing to expand medical education.

“There’s health care costs, regardless of how we work it, if we don’t invest in having an adequate supply of physicians,” Banh said. “There’s a cost on the human that can’t access care” and doesn’t get to a doctor until a condition is not treatable “or with significantly worse morbidity and mortality outcomes.”

“And that cost is borne by health systems taxpayers, one way or the other,” Banh added.

But even if the Costa-Gray bill were to pass in this congressional session, the payoff of home-grown medical schools producing a bumper crop of physicians in the Valley or other deprived parts of the country would be years down the road.

“I think it’s really important to understand why we need to invest now for our future, because it takes so darn long” for a student to go from being a college freshman to a practicing doctor, surgeon or specialist, UC Merced’s Vener said. 

After a four-year bachelor’s degree, a student must then complete four years of medical school, which in turn is followed by a residency of three to five years.

“Then often people will do a fellowship to become, for example, a cardiologist or a gastroenterologist or something like that,” she added.

“If you start investing in just one student now, it’s going to take such a long time before they really are there to take care of you at that moment when you need them to be your gastroenterologist, your cardiologist, your emergency physician, or, dare I say, your family doctor,” Vener said.

That, she said, is why it’s also necessary to expand residency programs that can attract would-be physicians into the region in hopes that they will remain once they complete their training. “We need those doctors now, and that’s why this effort is important,” Vener said, “because this is what will both inspire people to stay, but also inspire people to really come and embrace the communities and serve them.”

In a related development, state Assemblymember Esmeralda Soria, D-Fresno, recently introduced a bill for the University of California system to develop a comprehensive funding plan for expanding the current SJV Prime+ BS-to-MD partnership between UC San Francisco and UC Merced, with the goal of transitioning the program to a fully independent medical school operated by UC Merced.

“We have seen firsthand the impacts of medical workforce shortages throughout the Central Valley,” Soria said in a prepared statement. “AB 58 would help ensure the Legislature is equipped with the information needed to secure appropriate funding for the medical education provided for our community at UC Merced.”

— Tim Sheehan is the Health Care Reporting Fellow at the nonprofit Central Valley Journalism Collaborative. The fellowship is supported by a grant from the Fresno State Institute for Media and Public Trust. Contact Sheehan at tim@cvlocaljournalism.org.