Caring for the Medically Indigent and Uninsured

The table is set for change, and healthcare professionals must help design the solutions.

HEADLINE IN THE SACRAMENTO BEE January 20, 2000:
Health Insurance Gap Expands: 300,000 More In State Go Without.

Four months ago I accepted the position of Medical Director for Primary Care Services for the County of Sacramento, Primary Care Clinics. What I found was a system of nine clinics spread around the county providing a variety of services to the County's General Assistance (welfare) population.

I also found a clinic system with services that were stretched thin, infrastructure that had not been replaced or updated for many years, and a staff that had been through a period of constant downsizing and cutbacks of services. Even so, the staff had been able to maintain a constant level of service to our community. These were things I expected to find when I took this position.

What I did not expect to find was how the clinics managed to provide these services with limited resources. I found a number of collaborative efforts and partnerships between the county and community-based healthcare organizations and individuals.

In the SPIRIT project, I found a partnership between the Sacramento-El Dorado Medical Society, the County, the four major healthcare systems (Kaiser, Mercy, Sutter and UC Davis) and area physicians that came together to meet a community need and provide selected services to patients with no other alternative.

At the Oak Park Community Center and Capital Health Center, I found a collaborative between the County, the community, Sutter Health and Mercy Healthcare systems to provide care for the uninsured. At the HOPE and Imani clinics, I found the County and UC Davis delivering services to the homeless and uninsured. These are only a few examples of the way the County clinics have partnered with the healthcare community.

My second surprise was that the Board of Supervisors supports restoration of clinic services. Through the efforts of community-based organizations like Sacramento ACT (Area Congregations Together), area physicians and hospitals, the Board unanimously funded the clinics to not only restore services cut in previous years, but to also enhance and expand new services. Furthermore, the new County Executive has placed a priority on the delivery of healthcare services to the population of patients managed by the County Clinic System.

Well, it all sounds like good news. However, the healthcare community is still faced with a challenge-the delivery of services to an ever-increasing population of uninsured patients from all walks of life. Meanwhile, employers are putting the onus for obtaining health insurance on workers; hospital and medical groups are unable to provide charity care due to a tight managed care market; and physicians cannot accept the uninsured because of decreasing incomes and increasing workloads.

What is the answer? I don't know, but I can see some potential avenues of help. First, the economy has been expanding at a phenomenal rate, providing state and local government with a budget surplus. Second, the recent tobacco settlement will make available millions of dollars to local government. Lastly, there is an increasing public dissatisfaction with the current healthcare system that is leading to scrutiny of managed care.

The table is set for change. No one knows how the change will evolve. What we do know is that we healthcare professionals (hospitals and physicians) must involve ourselves in designing solutions. If not, solutions will come from the government and private insurance side.

Now is the time for us to address these challenges collaboratively, with a focus on global solutions for all county residents, both insured and uninsured. Rather than fight our challenges individually, as a profession we need to be open to change and develop partnerships to make changes in healthcare that will benefit both the profession of medicine and all individuals that seek care.

I welcome your thoughts and suggestions.

beraa@dhhs.co.sacramento.ca.us