Democrats deployed simple arithmetic to maneuver healthcare reform through Washington: More preventive care up front equals lower total healthcare costs down the road. 


But as Monterey County officials crunch the numbers, they’re looking at big implementation costs up front – and they’ve been relatively slow to get one major, federally authorized program up and running. 


In California, 50 of 58 counties have already launched optional “bridge” programs to cover more than 400,000 of the state’s previously uninsured, with temporary insurance plans that will roll over into more lasting programs on January 1, 2014, when the Affordable Care Act takes effect. 


Monterey County’s anticipated Sept. 1 launch date is getting pushed back even after waiting out the U.S. Supreme Court decision and the proposed merger of county hospital Natividad Medical Center with Salinas Valley Memorial Hospital. 


At least half a dozen county departments have to sign off on the county’s low-income health program, ViaCare, before it goes to the Board of Supervisors for approval. 


“Even if everything was a yes internally, it’s still a few months away,” Natividad CEO Harry Weis says.


Weis, along with the county Health Department, is leading the charge in launching ViaCare, an insurance plan that will cover 1,000 county residents who earn up to 100 percent of the federal poverty line, or $23,050 for a family of four. Enrollment will be first-come, first-serve, and if ViaCare goes well, it could expand to 1,500 people. 


It’s a temporary fix until 2014, when Obamacare kicks in and an estimated 25,000 Monterey County residents will get health coverage under an expanded Medi-Cal pool. 


Until then, the feds are reimbursing counties for just 50 percent of their bridge programs, leaving Natividad on the hook for an estimated $6.5 million a year. 


Weis worries fronting an additional $6.5 million could create a cash-flow problem. “We have to make sure this program doesn’t mortally injure Natividad as a safety-net organization,” he says. 


As a safety-net hospital, Natividad already provides care to the uninsured – but ViaCare would resemble commercial health plans, and it’s difficult to project how much an enrollee will end up costing the county. 


Weis is particularly worried about a provision that requires ViaCare members to be covered even while traveling. “It’s not like a Kaiser health plan where you’re supposed to only go to a Kaiser facility,” he says. “They have a lot of choice where they go, and the risk lands back with us.”


That risk, in theory, is cheaper in the long run than sporadic emergency room trips. 


Consider Mario Torres, who cares for his 83-year-old mother in their Salinas home, where he cleans, does laundry and shuttles her to doctor appointments. Torres is compensated 46 hours a month for his work through the state’s In-Home Supportive Services program – not enough to qualify for an IHSS health plan. 


Torres quit construction work to become his parents’ caretaker, and until his father died a year and a half ago, he worked 155 hours a month – enough to qualify for coverage, which Torres, who’s a Type II diabetic, used for regular doctor visits. 


“I need to get looked at every six months to make sure [the diabetes] is controlled, and to have the medicine I need to stay healthy,” he says. 


Since his insurance lapsed, Torres hasn’t had a check-up, but he’s been to the E.R. twice (for a rash and food poisoning, which he worried was liver failure related to diabetes).


“We believe there’s great savings to be achieved by keeping people out of these acute situations,” Monterey County Health Director Ray Bullick says. 


But Bullick – who’s a proponent of expanded coverage under federal healthcare reform – still sees the county’s hesitation for launching ViaCare as justified. “If all of a sudden, Lord forbid, we got a bunch of clients who blew out the bank, you cannot dis-enroll based on cost,” he says. “It’s incumbent on us to have some system in place to minimize that risk.” 


That system: A 1,500-person cap, even though about 15,000 residents would qualify. 


Bullick’s long-term vision is an improved bridge to outpatient services. “My goal is that everyone would leave the hospital not with a name and number, but with an appointment,” he says. 


He’s already reassigned some public health nurses to be more hands-on in securing outpatient follow-up care, but with an estimated 55,000 county residents soon to be insured under expanded Medi-Cal and insurance exchanges, ViaCare will be something of a pilot. The program will test the county’s preparedness to provide routine care to people who now just skip it. 


If Torres enrolls in ViaCare, he says, he’ll resume regular check-ups. “I would have some lab work done just to make sure everything’s fine,” he adds. 


But if he doesn’t make the ViaCare rolls, Torres will likely have to wait until 2014 for coverage. 


Anthony Wright, executive director of Sacramento-based consumer advocacy group Health Access, says that’s too long. “For every day people go unenrolled, it’s a day that we’re leaving millions of dollars in Washington, D.C.,” he says. 


Assemblyman Bill Monning, D-Carmel, jockeyed on the Assembly floor for SB 208, which authorized California’s low-income health plans. “I’m in 100 percent agreement, wanting to see [ViaCare] sooner rather than later,” Monning says. “But I think there’s a convergence of issues that have delayed Monterey [County] that shouldn’t be interpreted as a lack of will.” 


Most early adopters of bridge programs were larger counties. To Wright, that’s just more reason for Monterey County to pick up the pace: “If anything, it’s even more important for those counties with a less robust safety net to build the infrastructure they’ll need in 2014 and beyond,” he says.