San Diego County Medical Services Program Under Review for Accessibility Reforms
TL/DR –
San Diego County spends about $1 million annually on healthcare for a small group of people who do not qualify for other government health programs. The county’s health care program for the medically indigent, County Medical Services, served fewer than 40 people in its most recent fiscal year, down from around 19,000 in 2009 following the Affordable Care Act and expansion of Medi-Cal. Despite this decrease, there is renewed focus on the program due to federal cuts and work requirements for Medicaid, with labor unions proposing to fund the program via a sales tax increase, and county supervisors considering reforms to make it more accessible.
San Diego County’s Healthcare Program for Indigent Faces Revamp
San Diego County annually allocates approximately $1 million for the healthcare of individuals not eligible for other government programs. This program, mandated by state law, is designed for medically indigent individuals. However, with the Affordable Care Act and the expansion of Medi-Cal, California’s Medicaid program, such county programs have largely become redundant.
In 2009, the County Medical Services of San Diego funded the healthcare for nearly 19,000 people. This number dramatically reduced to fewer than 40 in the recent fiscal year. With the new Medicaid cuts and work requirements passed last summer, this medically-indigent program is facing renewed scrutiny.
Local labor unions, advocating for a countywide sales-tax ballot measure, propose using part of the tax revenue to increase funding for County Medical Services. Democratic county supervisors are now requesting a comprehensive review to identify potential reforms for increasing accessibility.
The proposed tax surcharge of half a cent is estimated to generate around $360 million in new annual revenue. Approximately $4 million of this would be directed towards County Medical Services, according to election documentation filed by two county labor unions and a coalition of nonprofit leaders.
A coalition spearheaded by SEIU Local 221, the largest labor union for county workers, along with the county firefighters’ union and Children First San Diego, is gathering signatures to get the tax hike on the ballot. If successful, the citizens-led measure would need a simple majority in November to pass.
SEIU 221 president Crystal Irving states that more funding is necessary to counter federal legislation. As per new federal rules, the county is expected to lose about 75,000 residents from Medi-Cal coverage due to immigration status and an additional 327,000 individuals will face new work requirements.
Proposed Changes in County Medical Services
For the County Medical Services to accommodate the increased need effectively, some changes are necessary. Currently, to enroll in San Diego’s program, residents must put a lien on their home, a criterion not present in other counties. Income limits for eligibility are also considerably lower than those in counties like San Francisco, Los Angeles, and Sacramento. Enrollment is also limited to U.S. citizens, not a requirement in other large counties.
County supervisors have proposed a review of the program, calling for eliminating the lien requirement and reforming income limits. However, no mention has been made of changing citizenship requirements.
In addition, Supervisor Monica Montgomery Steppe has initiated an effort to explore the possibility of setting up county-run primary care clinics for anyone who loses health insurance due to federal cuts and stricter eligibility.
County Medical Services Operations
County Medical Services is not a formal health insurance program. Instead, it pays for participants’ healthcare on a short-term basis. The county contracts with a list of providers who have long been part of the program and provide medical care to participants. However, administrative costs account for 79% of all spending on the program, far exceeding the usual healthcare system’s administrative costs, which usually account for up to 40% of total spending.
Between 2020 and 2025, the county spent an average of $1.1 million annually on the program, according to county data. Of this, around $413,000 was spent on actual patient care, with the remainder allocated to administrative costs.
Comparative Analysis
The program, not meant to provide long-term medical care, sees high turnover. Generally, only about two people are enrolled at any one time. Income limits for the program are lower in San Diego County than in comparable California counties. For instance, San Francisco’s Healthy San Francisco program permits individuals earning up to 500% of the federal poverty level, compared to San Diego’s limit of 165% of the federal poverty level.
Despite these restrictions, enrollment in similar programs varies widely across communities. For example, Los Angeles County’s Ability to Pay program provided healthcare to 500,000 people last year, with 24,000 new participants, despite having an income limit of just 200% of the federal poverty level.
Democratic supervisors seek reforms to make County Medical Services a reliable alternative for those who can’t access Medi-Cal. The changes to social safety-net programs pose significant fiscal challenges for the county, which estimates a need for an additional $200-$300 million annually by 2028 to maintain current staffing and programs, due to changes and cuts passed last year.
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