Opinion ID: 1401176
Heading Depth: 2
Heading Rank: 4

Heading: The Validity of the County's Contingent Eligibility Standard

Text: As explained previously, in the trial court the County moved to dissolve the preliminary injunction to permit implementation of either the revised or contingent CMISP eligibility standard. Under the contingent standard, an individual living alone would be ineligible for health care if his or her income exceeded $439 per month. The trial court refused to dissolve the injunction to permit the County to implement the contingent standard, because the court deemed this standard to be unrelated to individual residents' financial ability to obtain subsistence medical services. In assessing the legality of the County's contingent standard, the trial court observed that no provision similar to section 17000.5 sets forth a formula that counties may utilize in determining the scope of medical care services required by section 17000. The County's contingent standard is based upon a formula using the general assistance standard of aid and the average per capita cost of providing all indigent medical care in the County, and excludes from the County's medical care obligation any resident whose income equals or exceeds $439  regardless whether the resident financially will be able to obtain subsistence medical care. According to the trial court, this standard therefore lacks a factual basis and is unreasonable. Although the court declined to preclude any standard based upon a flat amount of income, it stated that the County's eligibility standard must be predicated factually upon individual residents' financial ability to pay the actual costs of obtaining subsistence medical care, which the trial court defined as medical services necessary for the treatment of acute life and limb threatening conditions and emergency medical services within the meaning of Health and Safety Code section 1317. [13] The County asserts that the trial court's conclusion divests the County of its legislative discretion to establish financial eligibility standards for section 17000 assistance. The County relies upon Health and Safety Code section 1445, which states in relevant part: Under such limitations and restrictions as are prescribed by law, ... the boards of supervisors in each county ... may provide medical and dental care and health services and supplies to persons in need thereof who are unable to provide the same for themselves.... Each county may, insofar as it is able to do so, provide the means to meet promptly and adequately the health needs of the indigent sick.... (See also § 17107 [counties may establish their own policies regarding the amount of property an individual shall be permitted to have while receiving assistance].) According to the County, Health and Safety Code section 1445 is permissive and provides that a county, in the exercise of its discretion, may provide for unmet medical need, but only if it chooses to do so. The County's position finds some support in Bay General Community Hospital v. County of San Diego (1984) 156 Cal.App.3d 944, 953, 959-960, 203 Cal. Rptr. 184 ( Bay General ), which relied in part upon Health and Safety Code section 1445 in concluding that counties have broad discretion in setting standards for the provision of medical care under section 17000. In County of San Diego, supra, 15 Cal.4th 68, 61 Cal.Rptr.2d 134, 931 P.2d 312, however, we expressly disapproved of Bay General insofar as it (1) states that a county's responsibility under section 17000 extends only to indigents as defined by the county's board of supervisors, and (2) suggests that a county may refuse to provide medical care to persons who are `indigent' within the meaning of section 17000 but do not qualify for Medi-Cal. (15 Cal.4th at p. 101, fn. 23, 61 Cal.Rptr.2d 134, 931 P.2d 312.) Our decision states unequivocally: [C]ounties have no discretion to refuse to provide medical care to `indigent persons' within the meaning of section 17000 who do not receive it from other sources. [Citations.] ( Id. at p. 101, 61 Cal.Rptr.2d 134, 931 P.2d 312, fn. omitted, italics added.) In any event, Health and Safety Code section 1445 confers discretion upon counties to provide medical care [ u ] nder such limitations and restrictions as are prescribed by law .... (Italics added.) Although we had no occasion in County of San Diego to determine the precise contours of the obligation of counties to provide medical care pursuant to section 17000, we held that this obligation extends at least as far as the class of all adult medically indigent persons  those individuals who are not aged, blind, disabled, or eligible for AFDC, and who before 1982 would have qualified for Medi-Cal. ( County of San Diego, supra, 15 Cal.4th at p. 104, 61 Cal.Rptr.2d 134, 931 P.2d 312.) The County's contingent standard would render a significant portion of this class of individuals ineligible for health care. The standard therefore fails to satisfy the County's obligations under section 17000. Moreover, we agree with the trial court that the contingent standard is invalid because it fails to take into account the financial ability of residents to obtain subsistence medical care. Although section 17000.5 relieved counties of the obligation of calculating general assistance grants based upon actual need, no similar provision allows counties to adopt an eligibility standard for the receipt of medical care that is not based upon actual subsistence needs. A number of decisions support the conclusion that a county may not condition the receipt of health care upon a financial eligibility standard that fails to consider individual residents' ability to obtain necessary care. In County of San Diego, we observed that the fate of amendments to section 17000 proposed in 1971 suggests that the category of individuals entitled to medical care under that statute extends beyond medically indigent persons who previously were eligible for Medi-Cal. One proposal would have added the following italicized language to section 17000: Every county ... shall relieve and support all incompetent, poor, indigent persons, and those incapacitated by age, disease, or accident, lawfully resident therein, when such persons are not supported and relieved by [other means], however, the health needs of such persons shall be met under [ Medi-Cal ]. (Assem. Bill No. 949 (1971 Reg. Sess.) § 53.3, as amended June 17, 1971.) The proposed amendment ultimately was deleted, however, and the Assembly Committee on Health explained: The proposed amendment to Section 17000, ... which would have removed the counties' responsibilities as health care provider of last resort, ... is deleted since it cannot remove the fact that counties are, by definition, a `last resort' for any person, with or without the means to pay, who does not qualify for federal or state aid. (Assem. Com. on Health, Analysis of Assem. Bill No. 949 (1971 Reg. Sess.) as amended July 20, 1971, p. 4.) Consistent with this explanation, the Attorney General subsequently concluded: The definition of medically indigent in [the chapter establishing Medi-Cal] is applicable only to that chapter and does not include all those enumerated in section 17000. If the former medical care program, by providing care only for a specific group, public assistance recipients, did not affect the responsibility of the counties to provide such service under section 17000, we believe the most recent expansion of the medical assistance program does not affect, absent an express legislative intent to the contrary, the duty of the counties under section 17000 to continue to provide services to those eligible under section 17000 but not under [Medi-Cal]. (56 Ops.Cal.Atty.Gen. 568, 570 (1973).) As we explained in County of San Diego, supra, 15 Cal.4th at page 104, 61 Cal.Rptr.2d 134, 931 P.2d 312, [a]bsent controlling authority, [the Attorney General's opinion] is persuasive because we presume that the Legislature was cognizant of the Attorney General's construction of section 17000 and would have taken corrective action if it disagreed with that construction. [Citation.] Historically, individuals eligible for medical care under section 17000, but not under other specialized aid programs, have been persons with insufficient means to pay for subsistence medical care. ( County of San Diego, supra, 15 Cal.4th at pp. 102-103, 61 Cal.Rptr.2d 134, 931 P.2d 312 [For purposes of a county's duty to provide residents with hospitalization, prior judicial decisions have defined the term indigent person as an individual `who has insufficient means to pay for his maintenance in a private hospital after providing for those who legally claim his support.' [Citation.]]; Tailfeather v. Board of Supervisors, supra, 48 Cal.App.4th at p. 1240, 56 Cal.Rptr.2d 255 [[A] long line of precedent hold[s] that section 17000 requires provision of medical services to the poor at a level which does not lead to unnecessary suffering or endanger life and health....]; Cooke v. Superior Court (1989) 213 Cal.App.3d 401, 413-415, 261 Cal.Rptr. 706, disapproved on another point in County of San Diego, supra, 15 Cal.4th at p. 106, 61 Cal.Rptr.2d 134, 931 P.2d 312, fn. 30 [Sections 10000 and 17000 require counties to provide humane health care, including care sufficient to avoid substantial pain and infection.]; County of San Diego v. Viloria (1969) 276 Cal.App.2d 350, 352-353, 80 Cal.Rptr. 869 [Section 17000 requires counties to furnish hospitalization to indigent persons, who are liable for a share of the cost only to the extent of their ability to pay.].) Indeed, in County of San Diego, we disapproved Bay General, supra, 156 Cal.App.3d at pages 958-960, 203 Cal.Rptr. 184, because the Court of Appeal had determined that a county could meet its section 17000 obligation by implementing a financial eligibility standard excluding individuals whose income rendered them ineligible for Medi-Cal, but who nevertheless were unable to pay for medical care. No subsequent legal developments have altered this established standard of eligibility for medical care under section 17000. Every county, as the provider of last resort, shall relieve and support all ... those incapacitated by age, disease, or accident, lawfully resident therein, when such persons are not supported and relieved by [other means]. (§ 17000.) Accordingly, in determining a financial eligibility standard for county health services pursuant to section 17000, the County must consider whether implementation of the standard would leave some residents who are incapacitated by age, disease, or accident, and whose condition is not relieved through other means, without subsistence medical care. Although we have no occasion in the present case to determine the specific medical services a county must offer to provide residents with subsistence medical care pursuant to section 17000, that obligation extends at least as far as the trial court determined in granting the preliminary relief sought by plaintiffs  medical services necessary for the treatment of acute life-and-limb-threatening conditions and emergency medical services within the meaning of Health and Safety Code section 1317. Contrary to the County's assertion, recognizing such an obligation neither requires the County to satisfy all unmet needs, nor mandates universal health care. Indeed, the County states that the standard set forth in the preliminary injunction has permitted a 20 percent reduction in the County's primary health care caseload. The Legislature has eliminated any requirement that counties provide the same quality of health care to residents who cannot afford to pay as that available to nonindigent individuals receiving health care services in private facilities. ( Tailfeather v. Board of Supervisors, supra, 48 Cal.App.4th at pp. 1238-1239, 56 Cal. Rptr.2d 255.) Section 10000 imposes a minimum standard of care  one requiring that subsistence medical services be provided promptly and humanely. (48 Cal. App.4th at pp. 1243, 1245, 56 Cal.Rptr.2d 255.) Counties retain discretion to determine how to meet this standard, but they may not deny subsistence medical care to residents based upon criteria unrelated to individual residents' financial ability to pay all or part of the actual cost of such care. We agree with the trial court that the County's contingent eligibility standard does not satisfy its section 17000 obligation, and conclude that the trial court did not abuse its discretion in precluding the County, during the pendency of the action, from implementing any eligibility standard that fails to consider the financial ability of residents to pay actual medical subsistence costs.