Opinion ID: 1401176
Heading Depth: 2
Heading Rank: 2

Heading: The Effect of Section 17000.5 Upon the Obligation of Counties to Provide Health Care

Text: Section 17000.5, subdivision (a), states in relevant part: [A]ny county may adopt a general assistance standard of aid, including the value of in-kind aid which includes, but is not limited to, the monthly actuarial value of up to forty dollars ($40) per month of medical care, that is 62 percent of a guideline that is equal to the 1991 federal official poverty line.... This subdivision is not intended to either limit or expand the extent of the duty of counties to provide health care. The County contends that, by including medical care within section 17000.5's standard of aid, the Legislature defined the [s]ection 17000 population to whom the County owes a duty to provide health care once [s]ection 17000.5's safe harbor has been invoked. In other words, according to the County, section 17000.5 permits counties to limit medical care to those residents eligible for general assistance, and to satisfy its obligation to provide medical care to that limited class of residents either by furnishing such care and deducting $40 from general assistance grants, or simply by declining to take the $40 deduction. Plaintiffs, on the other hand, assert that the County's construction of section 17000.5 is unsupported by the language of the statute and conflicts with the last sentence of subdivision (a), which expressly states that the statute was not intended to limit a county's duty to provide health care under section 17000. Our role in construing a statute is to ascertain the Legislature's intent so as to effectuate the purpose of the law. ( People v. Snook (1997) 16 Cal.4th 1210, 1215, 69 Cal.Rptr.2d 615, 947 P.2d 808.) In determining intent, we look first to the words of the statute, giving the language its usual, ordinary meaning. If there is no ambiguity in the language, we presume the Legislature meant what it said, and the plain meaning of the statute governs. (Ibid.) The words, however, must be read in context, considering the nature and purpose of the statutory scheme. ( Torres v. Automobile Club of Southern California (1997) 15 Cal.4th 771, 777, 63 Cal.Rptr.2d 859, 937 P.2d 290.) Section 17000.5, subdivision (a), provides that a county may adopt a general assistance standard of aid, including the value of in-kind aid which includes, but is not limited to, the monthly actuarial value of up to forty dollars ($40) per month of medical care.... The statute specifies that the value of in-kind aid may be included in the general assistance standard of aid. The statute further provides that this value of in-kind aid includes a portion of the actuarial value of medical care, thereby clarifying that medical care is among the types of in-kind aid that may be included for this purpose. (See Gardner v. County of Los Angeles, supra, 34 Cal.App.4th at pp. 213-227, 40 Cal.Rptr.2d 271 [reaching a contrary conclusion before the 1996 amendment to section 17000.5].) Read in context, the reference in subdivision (a) to $40 per month places a cap upon the value of in-kind medical care that may be included in the general assistance standard of aid. Contrary to the County's assertion, nothing in the actual language of section 17000.5, subdivision (a), either establishes the level of medical care that a county must provide to its residents or defines the class of residents eligible for such care. The last sentence of section 17000.5, subdivision (a), affirmatively demonstrates that the absence of any such language reflects a legislative purpose to preclude the interpretation advanced by the County: This subdivision is not intended to either limit or expand the extent of the duty of counties to provide health care. Accordingly, a county's duty to provide health care remains the same as it existed before the 1996 amendment to section 17000.5 added the reference to medical care. After the effective date of the amendment, however, a county may include the value of the medical care it provides, up to a maximum of $40 per month, in the general assistance standard of aid calculated pursuant to section 17000.5. The Court of Appeal agreed with the County's position that the plain language of section 17000.5 establishes the full extent of the obligation of counties to provide health care. In reaching this conclusion, the Court of Appeal stated in full: Prior appellate decisions have established that a county may satisfy its section 17000 obligations through grants computed according to the formula described in section 17000.5 or, in whole or in part, through in-kind aid. [Citation] Revised section 17000.5 establishes that in-kind aid `includes, but is not limited to, the monthly actuarial value of up to forty dollars ($40) per month of medical care.' Hence, as with other types of in-kind aid, counties may either discontinue medical care for those receiving GA [general assistance] benefits set according to section 17000.5 or continue to provide such [benefits] and deduct up to $40 from the GA grant levels. There is no other reasonable interpretation. The concluding sentence of section 17000.5, subdivision (a), which indicates the subdivision `is not intended to either limit or expand the extent of the duty of counties to provide health care[,]' merely explains that section 17000.5 does not define the counties' duty to provide health care but provides an alternate means of satisfying it. As set forth above, we discern a different  and, in our view, more reasonable  interpretation of section 17000.5, subdivision (a). By selectively quoting from the statute, the Court of Appeal determined that this provision establishes that in-kind aid `includes ... up to forty dollars ($40) per month of medical care.' From this premise, the Court of Appeal concluded that payment of $40 representing in-kind medical care completely satisfies a county's statutory obligation to provide medical care. The statute, however, does not establish what in-kind aid `includes.' Rather, it establishes what the general assistance standard of aid may include; it is the value of in-kind aid that may be included in calculating general assistance payments pursuant to this section. Furthermore, the statute's reference to $40 per month does not establish the extent of a county's obligation to provide medical care, as the Court of Appeal determined, but rather specifies the maximum value of in-kind medical aid that may be included in the general assistance standard of aid and deducted from the cash grants. The Court of Appeal's statement that the last sentence of subdivision (a) merely explains that section 17000.5 does not define the counties' duty to provide health care but provides an alternate means of satisfying it, is internally inconsistent. If section 17000.5 specified that a county could satisfy its duty to provide health care by including $40 per month in its general assistance standard of aid, the statute would define the county's duty to provide health care. Indeed, the County contends that its adoption of the standard of aid set forth in section 17000.5, subdivision (a), satisfies the totality of the [County's] Section 17000 obligation to furnish medical care. By adding the last sentence to subdivision (a), however, the Legislature expressly and clearly disclaimed any intention that section 17000.5 would affect the duty of counties to provide health care. The Court of Appeal's interpretation renders this sentence surplusage, in contravention of the principle that, if possible, significance should be given to every word, phrase, sentence, and part of a statute. ( Woosley v. State of California (1992) 3 Cal.4th 758, 775-776, 13 Cal.Rptr.2d 30, 838 P.2d 758.) The County further contends that subdivision (b) of section 17000.5 establishes the scope of its obligation to provide health care pursuant to section 17000. This subdivision states: The adoption of a standard of aid pursuant to [section 17000.5] shall constitute a sufficient standard of aid. The only standard of aid to which section 17000.5 refers, however, is a general assistance standard of aid. (§ 17000.5, subd. (a).) Our decision in County of San Diego, supra, 15 Cal.4th at pages 92-104, 61 Cal.Rptr.2d 134, 931 P.2d 312, makes clear that a county's duty to provide medical care pursuant to section 17000 is independent of other obligations imposed by that section, including the obligation to pay general assistance. In County of San Diego, because the state had relieved counties of their obligation under section 17000 to provide health care to medically indigent persons, but subsequently had transferred that responsibility back to the counties, we held that the state had mandated a new program or higher level of service (Cal. Const., art. XIII B, § 6), and that the state accordingly was required to reimburse the counties for the costs of that program. (15 Cal.4th at pp. 75-76, 92-99, 61 Cal.Rptr.2d 134, 931 P.2d 312.) General assistance, on the other hand, always has been the responsibility of the counties. ( Mooney v. Pickett, supra, 4 Cal.3d at pp. 677-680, 94 Cal.Rptr. 279, 483 P.2d 1231.) Our conclusion in County of San Diego that the counties' obligation to provide health care to medically indigent persons pursuant to section 17000 was an unfunded state mandate directly conflicts with the County's unsupported assertion that general assistance is the only type of aid required by section 17000. (See also Tailfeather v. Board of Supervisors (1996) 48 Cal.App.4th 1223, 1234, 56 Cal.Rptr.2d 255 [The courts have uniformly concluded that section 17000's reference to the counties' duty to `relieve and support' indigents includes a requirement for provision of medical care. [Citations.]].) [9] The County maintains that the County of San Diego decision offers no support for plaintiffs' position in the present case, because our opinion did not consider the effect of section 17000.5. As we have explained, however, section 17000.5, by its terms, is limited to general assistance. Our conclusion in County of San Diego that counties have an obligation to provide medical care to all medically indigent persons specifically was limited to this aspect of a county's duty under section 17000. We expressed] no opinion regarding the scope of a county's duty to provide other forms of relief and support under section 17000. ( County of San Diego, supra, 15 Cal.4th at p. 101, fn. 24, 61 Cal.Rptr.2d 134, 931 P.2d 312.) Thus, our failure to consider section 17000.5 was not an oversight, but rather an implicit recognition that this statute has no bearing upon a county's duty to provide health care to its residents. [10] The decision in County of San Diego and the cases cited therein establish that section 17000 gives counties no discretion to refuse to provide medical care to adult medically indigent persons  defined, for purposes of that decision, as most individuals who meet financial eligibility requirements for Medi-Cal but are not at least 65 years of age, blind, disabled, or eligible for AFDC. ( County of San Diego, supra, 15 Cal.4th at pp. 77-80, 100-104, 61 Cal.Rptr.2d 134, 931 P.2d 312.) Because such medically indigent persons are not necessarily eligible for general assistance, there is no merit in the County's contention that section 17000.5 permits the County to limit the provision of medical care only to those individuals eligible for general assistance. Recognizing that County of San Diego undermines its position, the County simply respectfully disagrees with our unanimous conclusion in that case that counties must provide medical care to medically indigent adults pursuant to section 17000, independent of the statutory scheme that transferred responsibility for such individuals from the state to the counties in 1982. The County's disagreement is based upon the circumstance that the Legislature deemed the class of medically indigent adults to be distinct from the historical section 17000 population. This circumstance does not support the County's position, however, but rather clarifies that section 17000 always has required counties to provide health care to those individuals who are not relieved or supported by other means. As our decision in County of San Diego repeatedly emphasizes after exhaustive analysis, the Legislature's various definitions of medically indigent under state welfare programs never were intended to include all individuals to whom counties must provide health care pursuant to section 17000. ( Comity of San Diego, supra, 15 Cal.4th at pp. 100-104, 61 Cal.Rptr.2d 134, 931 P.2d 312.) [T]he 1982 legislation can be viewed as having mandated an increase in the services that counties were providing through existing section 17000 programs, by adding adult [medically indigent persons] to the indigent population that counties already had to serve under that section. [Citation.] ( Id. at p. 98, fn. 19, 61 Cal.Rptr.2d 134, 931 P.2d 312, italics added; see also id. at pp. 114-115, 61 Cal.Rptr.2d 134, 931 P.2d 312 (dis. opn. of Kennard, J.) [The counties' legal obligation to provide medical care arises from section 17000, not from the subsequently enacted 1982 legislation.].) [O]ur discussion demonstrates the Legislature excluded adult [medically indigent persons] from Medi-Cal knowing and intending that the 1982 legislation would trigger the counties' responsibility to provide medical care as providers of last resort under section 17000. ( Id. at p. 98, 61 Cal.Rptr.2d 134, 931 P.2d 312, original italics.) [T]he Legislature has always viewed all adult [medically indigent persons] as `indigent persons' within the meaning of section 17000 for medical care purposes. ( Id. at p. 102, 61 Cal.Rptr.2d 134, 931 P.2d 312.) `Section 17000, as authoritatively interpreted, mandates that medical care be provided ... promptly and humanely. The duty is mandated by statute. There is no discretion concerning whether to provide such care....' [Citation.] ( Id. at p. 104, 61 Cal.Rptr.2d 134, 931 P.2d 312.) Contrary to the County's urging, we do not believe it would be appropriate to disregard authoritative, settled statutory interpretation that was central to the analysis and holding of one of our decisions. (See People v. Latimer (1993) 5 Cal.4th 1203, 1213, 23 Cal.Rptr.2d 144, 858 P.2d 611 [`Considerations of stare decisis have special force in the area of statutory interpretation, for ... [the Legislature] remains free to alter what we have done.' [Citations.]].) The County has advanced no persuasive contention that our conclusion in County of San Diego is erroneous. Accordingly, consistent with established authority, the scope of the County's obligation to provide health care to indigent residents is defined by section 17000  not section 17000.5. Even if there were some ambiguity in the language of section 17000.5 that would permit us to examine extrinsic aids to ascertain its meaning, nothing in the legislative history of the statute suggests that it was intended to affect a county's health care obligations under section 17000. The Legislative Counsel's Digest of the Senate bill amending section 17000.5 in 1996, to refer to medical care, states: Existing law authorizes the board of supervisors in any county to adopt a general assistance standard of aid, including the value of in-kind aid. [¶] This bill would provide that the value of in-kind aid includes, but is not limited to, the value of specified amounts of medical aid and care. (Legis. Counsel's Dig., Sen. Bill No. 681 (1995-1996 Reg. Sess.), italics added.) Similarly, the Senate Floor Analysis states: This bill allows counties various options to reduce their General Assistance Cash Grant costs. [¶] A. Provides that the value of in-kind assistance aid, which a board of supervisors may adopt within its general assistance standard of aid includes, but is not limited to, the value of up to $40 per month of medical care.... (Sen. Rules Com., Analysis of Sen. Bill No. 681 (1995-1996 Reg. Sess.) Jan. 30, 1996, p. 5, italics added.) These descriptions of the bill are consistent with our determination that section 17000.5 concerns only the calculation of general assistance grants, not the scope of the obligation to provide health care. Contrary to the County's position, the circumstance that the Legislature has changed the mechanism for providing funds to counties and has afforded counties some measure of financial relief by reducing their welfare obligations in other areas does not establish that it intended to limit public health care services in the manner suggested by the County. The provisions of law regarding a public assistance program must be fairly and equitably construed to effect the stated objects and purposes of the program. (§ 11000.) Our construction of section 17000.5 furthers the objectives of the statutory scheme governing indigent relief  to provide for the protection, care, and assistance of all the needy and distressed people of the state, and to administer appropriate aid and services promptly and humanely. (§ 10000.) If a county had discretion to refuse to provide medical care to any individual who is not financially eligible for general assistance, or who is receiving general assistance payments without a $40 reduction for in-kind medical care, a significant number of its residents who do not qualify to receive health services from other sources would lack medically necessary care. Under the County's amended CMISP eligibility standard that was enjoined by the trial court, approximately 65 percent of the residents previously eligible for primary health care services offered by the County through CMISP would receive no medical care from the County. Under the County's revised standard, the County could choose to discontinue providing medical services to all of the residents previously eligible for CMISP. In our view, the Legislature would not have made such a sweeping change in the scope of counties' obligations pursuant to section 17000 without a clear expression of an intention to do so. No such expression of purpose is reflected in section 17000.5 or its legislative history. [11] Accordingly, we conclude that the Court of Appeal erred in determining that the County may satisfy its duty to provide health care by limiting eligibility for CMISP to those individuals eligible for general assistance (the November 1992 amended standard), or by declining to reduce its general assistance standard of aid by $40 and providing no health care to any of its indigent residents (the January 1993 revised standard). Therefore, the appellate court also erred in concluding that plaintiffs have no likelihood of success on the merits of their claims. The trial court acted within its discretion in issuing a preliminary injunction prohibiting the County from implementing either the amended or the revised standard.