Every year, San Diego County spends about a million dollars paying for the health care of a narrow group of people who don’t qualify for other government health care programs. All California counties have a program like this for people deemed medically indigent, as required under state law. But a fter the passage of the Affordable Care Act and the expansion of Medi-Cal, California’s Medicaid program, many county programs became mostly obsolete. In San Diego County, its County Medical Services paid for the health care of about 19,000 people in 2009, the year before the ACA became law. In its most recent fiscal year, it served a total of fewer than 40. At any given time, it has only about two people enrolled. But with cuts and new work requirements for Medicaid passed by Congress last summer, the medically-indigent program is getting renewed focus. Labor unions promoting a countywide sales-tax ballot measure have been looking to use some of the revenue from such a tax hike to boost funding for County Medical Services. And now two Democratic county supervisors are calling for a comprehensive review of the program to identify reforms to make it more accessible. The Board of Supervisors is scheduled to vote on a review at their meeting Tuesday. The program is among a list of county social safety-net programs that could benefit from $360 million in new annual revenue that backers of the ballot measure say a half-cent tax surcharge, if passed, would generate for the county. About $4 million of that would be steered toward County Medical Services, according to election paperwork filed by two county labor unions and a coalition of nonprofit leaders. SEIU Local 221, the largest labor union for county workers, is leading the sales tax ballot effort. It’s joined by the county firefighters’ union and Children First San Diego, a political action committee helmed by leaders of the YMCA of San Diego County and Jewish Family Service of San Diego, two of the region’s biggest social services providers. The coalition is currently gathering signatures to get the tax hike on the ballot. Such a citizens-led measure, if put to voters, would need support from a simple majority in November in order to pass. SEIU 221 president Crystal Irving said more money is needed for County Medical Services to counter federal legislation. Under new federal rules, the county estimates about 75,000 residents will lose Medi-Cal coverage because of their immigration status. Another 327,000 of the county’s roughly 854,000 Medi-Cal recipients will be subject to new work requirements. “Providing dedicated funding to the county’s healthcare program of last resort for the uninsured — funding Washington can’t take away and local politicians can’t divert — ensures working families and kids have somewhere to turn when they get sick,” Irving said. But a well-funded County Medical Services capable of shouldering that burden will require some changes. As it’s currently set up, San Diego County’s is the most restrictive medically-indigent program among California’s biggest counties. To enroll, residents must have a lien put on their home — a requirement that does not exist in other big counties across the state. No other asset, like a car, can be subject to the lien. Income limits for the county’s program are far lower than those seen in counties like San Francisco, Los Angeles and Sacramento. And enrollment is limited to U.S. citizens, a requirement that doesn’t exist in other large counties. “With all of these restrictions, the question then becomes: Why even have it in the first place if nobody can access it and you put so many restrictions on it?” said Ana Alvarez, an organizer with Health Access California, a health care advocacy group that tracks county indigent care programs. The supervisors’ proposal for a review of the program specifically calls for county staff to draft recommendations for eliminating the lien requirement and reforming income limits. But it makes no mention of changing citizenship requirements. “San Diego must explore every tool to keep hospitals open and emergency care available,” Supervisor Terra Lawson-Remer said in a statement. “That means taking a hard look at solutions like reforming the CMS, changing the criteria and building a safety net that works when Washington walks away.” In recent months, Supervisor Monica Montgomery Steppe has separately launched an effort to explore having the county set up primary care clinics for anyone who loses health insurance as a result of federal cuts and stricter eligibility. That program would be distinct from County Medical Services. Ariel Gibbs, a spokesperson for Montgomery Steppe, said the primary care clinics — known as the Safety Net Bridge Program — could solve the more immediate problem of people losing their Medicaid coverage. But reforming County Medical Services is a longer-term priority that supervisors need to get started on now, Gibbs said. How it works County Medical Services is not a formal health insurance program like Medi-Cal. Instead, the county pays for participants’ health care on a short-term basis. That usually consists of one-time medical needs, not preventative care, said Tim McClain, a spokesperson for the county’s Health and Human Services Agency, which administers the program. But the program will pay for a wide range of health care, from primary care, dental and vision to emergency medical services and prescription drugs. In other counties, similar programs compliment public safety-net hospitals, which San Diego County does not have. Instead, the county has contracts with a set list of providers who have long participated in the program and provide medical care to participants, McClain said. The burden of those administrative costs — which made up 79% of all spending for the program in the county’s last fiscal year — far exceeds what is seen in the broader health care system, where administrative costs often account for up to 40% of total spending. Between 2020 and 2025, the county spent on average $1.1 million on the program each year, according to county data shared by McClain. Of that, an average of $413,000 was spent on actual care for patients. The rest of the money went to administrative costs. In response to questions about the county’s spending on the program, Supervisor Joel Anderson said he’s asked a new fiscal transparency and accountability subcommittee formed by supervisors to look into it. “He believes programs like this are exactly what the subcommittee should be taking a closer look at,” said Matthew Phy, a spokesperson for Anderson. Supervisors Paloma Aguirre and Jim Desmond did not respond to requests for comment. How it compares Since the program isn’t designed to provide long-term medical care, turnover is considerable, McClain said. County data bear that out: A cumulative 39 people were enrolled in the program at some point during the last fiscal year, but in general only about two were enrolled at any given time. Apart from citizenship and lien requirements, income limits for the program are far lower in San Diego County than they are in comparable California counties. In San Diego County, program participants can’t make more than 165% of the federal poverty level. That is $26,000 a year for a single person and $53,000 for a family of four. Income limits are far higher elsewhere, including in counties with similarly high costs of living. In San Francisco, its Healthy San Francisco program allows for people to make up to 500% of the federal poverty level, about $78,000 for a single person and $161,000 for a family of four. Sacramento County’s program has a limit of 400% of the federal poverty line, and Contra Costa County’s program has a 300% income limit. But in other communities, enrollment still varies widely, regardless of income restrictions. Contra Costa County’s program had about 3,000 people enrolled in it as of January, Alvarez said. Sacramento County’s program, which has less restrictive income limits, had zero people enrolled as of January, said Elizabeth Zelidon, a spokesperson for the county’s Department of Public Health. In Los Angeles County, 500,000 people got health care last year through the medically indigent program, known there as the Ability to Pay program, with 24,000 of them new participants, according to the L.A. County Department of Health Services. Yet its income limit is just 200% of the federal poverty level, and participants do not have to be citizens. Alvarez said county-by-county enrollment comes down to how much a county works to expand enrollment and publicizes its program in the community — in particular among undocumented immigrants who might be ineligible to enroll in Medicaid if they make too much money. Democratic supervisors say they want reforms to make County Medical Services a “durable” alternative for people who can’t get Medi-Cal, according to the proposal supervisors will consider Tuesday. Federal changes to social safety-net programs like Medicaid are posing major fiscal challenges to the county that go beyond County Medical Services. By 2028, the county estimates it will need anywhere between $200 million and $300 million a year in order to maintain current staffing and programs as a result of safety-net program changes and cuts that Congress passed last year. The unions promoting a sales-tax ballot measure have cited those new costs to justify their pursuit. ...read more read less