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San Bernardino County

Introduction and Purpose
Everyone has a specific preference when it comes to where they would like to live. Some enjoy a rural area that’s quiet and away from all of the commotion while others, like myself, enjoy an urban area that’s filled with people and everything is convenient. San Bernardino County is an urban area even though looking at a topography map, you would imagine it’s a rural area due to the large mountain and desert regions of the county. The county is the largest of the 58 counties in California and is approximately 20,052 sq. miles (City-Data, 2012). About 80% of the land is vacant, with 15% used by the military and the rest makes up the urban area where the vast population lives (San Bernardino County Community Indicators Report, 2014). The largest industries in the county are Trade, Transportation and Utilities, Government, Educational and Health Services, Manufacturing, and Construction. The unique thing about San Bernardino County is that it contains both a mountainous region and a desert region with quite a few regional and national parks. Residents are able to choose from a large amount of outdoor and recreational activities. There are many things to do in the county that ranges from camping and visiting historical sites to checking out different museums in the area. The purpose of this paper is to provide some background information on the county of San Bernardino including its general demographics, socioeconomic status, and the health and wellness of the county. The top 3 health issues in the county are identified and explained. At the end of the paper, solutions and recommendations are given to help with the health issues.
County Background
General Demographics
Population by Age and Gender
San Bernardino consists of 2,081,313 people with 95% of the population in urban areas and 5% in rural areas. Males make up 41.9% of the population and females make up 48.9% (City-data, 201). This is only roughly 5.4% of the entire population of California which consists of 38,332,521 people. Below is a chart that breaks down this population by age and is compared to the state of California.

(US Census Bureau, 2013)

Population by Race

(US Census Bureau, 2013)
Socioeconomic Status The percentage of the population in poverty in San Bernardino County is 20.4% with 28.2% being children 0-17 years old (US Department of Agriculture, 2013). This percentage is quite high with 24 other counties in California who also have 17.9% or more of the population who are in poverty. The median household income from 2008 to 2012 was $54,750. This is a bit lower when compared to the state of California with a median income of $61,400 (US Census Bureau, 2012). According to the Cost of Living Index in 2013, the Riverside-San Bernardino metropolitan area measured 113.0 with the average being 100.0. When compared to the median income, the cost of living is higher (San Bernardino County Community Indicators Report, 2014).

Health and Wellness
Medi-Cal Managed Care In California, the Department of Managed Health Care (DMHC) manages all HMO plans and certain plans for people with Medi-Cal benefits which includes Medi-Cal Managed Care Plans (Department of Managed Health Care, 2014). About 6.6 million people with Medi-Cal benefits receive their health care through 6 different managed care plans. These plans are: Two-Plan, County Organized Health Systems (COHS), Geographic Managed Care (GMC), Regional Model (RM), Imperial, and San Benito. Out of these 6 plans, San Bernardino consists of a Two-Plan model (California Department of Health Services, 2014).
Two-Plan Model Medi-Cal beneficiaries in San Bernardino are able to choose from two different plans, hence the name “two-plan”. One is a commercial HMO plan that is chosen by the state and the other is a local initiative plan which includes existing county hospitals and health care facilities. The two plans available in the county are Inland Empire Health Plan (IEHP) and Molina Healthcare of California Partner Plan (California Department of Health Services, 2014).
Inland Empire Health Plan vs Molina Healthcare The table below will highlight some differences between the two plans.

| Inland Empire Health Plan (IEHP) | Molina Healthcare | Plan Network Hospitals | 12 hospitals in network plan | 8 hospitals in network plan | Doctors available | Over 700 primary care doctors, 200 OB/GYNs and 1,300 specialists | Over 2,600 primary care physicians and specialists | Urgent Care Centers | 49 urgent care centers | 24 hour statewide emergency services at over 70 locations | Pharmacies | Over 580 local pharmacies and chain pharmacies | 6,000 pharmacies state-wide | Languages | Member services representatives speak both Spanish and English. Interpretation services available in more than 140 languages. Many IEPH providers speak multiple languages. Refer to IEPH Doctor Directory for more information. | Member services are multi-lingual and trained to use relay services. Interpreter services available at no cost which includes arranging for interpreters to meet you at doctor visits in over 160 languages. Sign language interpreters also available. |
(California Department of Health Services, 2014)

Choosing which plan is the best will depend on the individual’s preferences. If access is an important issue, an IEHP plan is recommended since there are more hospitals in the network allowing for more health care access. For culturally diverse beneficiaries, language is most likely an important issue. In this case, a Molina Healthcare plan seems to be better choice. They offer interpreters who will meet at doctor visits so patients don’t have to rely on the staff at the doctor’s office.
Health Insurance In San Bernardino County, about 79% of the total population have health insurance, compared to California with 81% of the population insured. Residents who are 65 years and older had the highest coverage at 97%, children under 6 years old at 93%, children between 6-17 years old at 88%, and adults 18-62 years old at 72%. This might appear to be a great amount of people insured in the county, but it is well below the target amount of 100% of the population with health insurance set by California and Healthy People 2020 (Community Vital Signs, 2013).
Hospitals
There are 26 hospitals located throughout San Bernardino County. Below is a map that shows their location.

(Office of Statewide Health Planning Development, 2012)

San Bernardino is a large county, but as mentioned before, about 80% of the land is vacant which explains why the majority of hospitals are located in the south west region where the population is most dense. Of these 26 hospitals, only Colorado River Medical Center and Mountains Community Hospital are critical access hospitals and Arrowhead Regional Medical and Loma Linda University Medical Center are the only ones with a trauma center. According to the Health Resources and Services Administration, a critical access hospital is certified differently from an acute care hospital and there are special requirements that needs to be met. Some of the requirements include having no more than 25 beds, be located in a rural area that’s at least 35 miles away from any other hospital, having 7 day a week emergency care, and maintaining an average length of stay no more than 96 hours for acute inpatient care (Health Resources and Services Administration, 2014).
Hospital Beds per 1,000 people Compared to the other top 10 most populated states, California has the fewest hospital beds per 1,000 at 1.9 (California Health Care Foundation, 2013). However, San Bernardino County has a greater amount at 2.8, which is a little above the US average of 2.7 hospital beds per 1,000 people. Patton State Hospital plays a big role in this because they have the greatest amount of beds available in their facility at 1,287 beds. This is nearly as much as having all beds combined from the next top 3 largest facilities (Office of Statewide Health Planning Development, 2014).
Ratio of population to primary care physician In San Bernardino County, there is 1 physician per every 1,820 people. This is very low considering the average in California is 1 physician per every 1,326 people (countyhealthrankings.org, 2014). There is definitely a shortage of physicians which will be discussed in detail later.
Community Clinics There’s a good amount of clinics throughout the county. There’s 18 primary care clinics, 26 chronic dialysis clinics, 4 surgical clinics, 1 rehabilitation clinic, and 1 alternative birthing clinic. However, there are no psychological clinics in the area (Office of Statewide Planning and Development, 2014).
Public Health In San Bernardino County, all public health services are overseen by the San Bernardino County Department of Public Health. Their mission is to satisfy their customers by providing community and preventative health services that promote and improve the health, safety, well-being, and quality of life of San Bernardino County residents and visitors. Some of their goals are to protect against environmental hazards, assure the quality and accessibility of health services, to inform, educate and empower people about health care, and to monitor health status to identify community health problems. A variety of public health services is available to residents which range from alcohol and drug abuse prevention programs, children services, and environmental health services (County of San Bernardino Public Health Department, 2014).

Indigent Health In California, all 58 counties are responsible for providing health care to low income, uninsured residents who have no other means to pay for care. The 24 largest counties, which of course includes San Bernardino, provide their own county specific, medically indigent service programs, which is often called MISP program services. They each set and determine eligibility, payment methods, services provided, and funding levels. There are three methods that counties generally use to deliver their MISP program services which are provider counties, payer counties, and hybrid counties. San Bernardino County is part of a provider county which means it owns and operates county inpatient hospitals, publicly owned clinics, and other health care facilities that serve both the uninsured and ones with private health coverage (California Health Care Foundation, 2012). The MISP program that serves the county is called Arrow Care which is further explained below.
ArrowCare
ArrowCare is a federally funded program that allows individuals to have access to preventative medicine and care through a primary care provider, emergency coverage, mental health, and a variety of other services. The program took place as of January 1st, 2012 as part of the Medi-Cal expansion project from the Affordable Care Act (arrowcare.org, 2014). To apply, individuals must meet all of the following requirements: 1) Be a San Bernardino County resident 2) Adult between 19-64 years old 3) Not otherwise eligible for Medi-Cal or Health Families 4) Meet income eligibility guidelines which is below the 100% of the Federal Poverty Level 5) Be a United States citizen or have satisfactory immigration status
Children Health Children welfare is measured in the 2014-2015 California County Scorecard of Children’s Well-being. The scorecard ranks all 58 counties by several indicators in education, health, and child welfare and economic well-being. The percentage of newborns who are exclusively breastfed while in the hospital has increased from 54% in 2012, to 57% in 2014 (Children Now, 2014). This increase is in part due to the senate passing SB402, which is an attempt to increase exclusive breastfeeding rates in California in order to improve health outcomes for infants and children. The bill requires that all maternity facilities in California adopt the “Ten Steps to Successful Breastfeeding” or an equivalent process by 2025 (California Breastfeeding Coalition, 2014). With this in place, we should definitely see this rate increase over the next several years. Children with physical handicaps and certain diseases who are eligible receive medical and financial management services by the California Children Services. The program provides a variety of case management, diagnosis and treatment services for children and adults up to 21 years old. However, individuals must be medically, financially, and residentially eligible to receive the benefits of the program (County of San Bernardino Department of Public Health, 2014).
Top 3 Health Problems There’s a variety of health issues throughout San Bernardino County but I have narrowed it down to the top 3 issues I think are the most important. The topics that raise concern are a lack of healthcare professionals, overweight children, and diabetes. There is a shortage of healthcare professionals such as physicians throughout the country let alone in California and San Bernardino County. The Health Resources and Services Administration (HRSA) has created a shortage designation criterion that is used to determine if whether or not a geographic area, population group, or facility is a Health Professional Shortage Area (HPSA) or a Medically Underserved Area or Population (MUA/P). As of June of 2014, there are approximately 6,100 primary care HPSAs throughout the country. In San Bernardino County, nearly all of the hospitals are located in a primary care shortage area and 5 out of the 26 hospitals located in the county are primary care HPSAs. Primary care HPSAs are centered on a physician to population ratio of 1 to 3,500 people (Health Resources and Services Administration, 2014). The second issue deals with the amount of overweight children in the county. In 2013, about 45.8% of San Bernardino County grade school students had an unhealthy body weight, compared to California at 43.9%. This number has increased since 2012, where percentage was at 46.1%. This is a very small decrease so there shouldn’t be any celebrations or victory dances yet. Of this percentage, about 32.4% of students were considered to be far outside of the healthy range while the other 13.4% were considered to be in the “needs improvement” range. Students in the San Bernardino City and Fontana school districts have the most students with unhealthy body compositions at 53% (Community Indicators Report, 2014). The third issue that is a cause for concern deals with diabetes. San Bernardino is ranked the worst out, 58th out of 58 for all of the counties when it comes to diabetes. The county had the highest rate of death due to diabetes. Health data between 2011-2012 indicates that 10.6% of adults in the county were diagnosed with diabetes. Approximately 83% of adults who were diagnosed with diabetes had type II diabetes (Community Indicators Report, 2014).
Consequences
As with any problem, consequences will appear. The lack of physicians in San Bernardino County will affect access to health care in the area. With the population growing and with more demand on health care coverage as set by the Affordable Care Act, more people will need to visit hospitals and clinics, yet there won’t be enough physicians to see everyone. As more individuals are delayed access to care, they will resort to going to the Emergency Rooms since they can’t be denied care there. With more people showing up to the ER and not enough physicians, the quality of health care will decline as well. Patients will have to wait longer and longer and corners will be cut by facilities and physicians as they try to available time (CNN Health, 2013). Overweight children and diabetes go hand in hand since overweight children are more inclined to develop type II diabetes. Besides diabetes, overweight children increase their risk to a different number of diseases such as asthma, heart disease, high blood pressure, and liver complications. Being susceptible to more diseases will mean a greater need for health care which will put a strain on the health care system. With so many people with diabetes in San Bernardino, it’s easy to see why there’s so many dialysis centers throughout the area. As indicated earlier, there are 26 dialysis centers which is the same number of hospitals in the county. The increase of diabetes will sure to increase costs. Those who are diagnosed with diabetes incur medical expenditures of about $13,700 per year in which diabetes contributed $7,000. The medical expenditures of those diagnosed with diabetes is about 2.3 times than what it would be without diabetes. California has the largest population with diabetes so it’s not hard to see why it also has the highest costs at $27.6 billion (American Diabetes Foundation, 2013).
Solutions/Recommendations
Solving these issues overnight is wishful thinking but we can take small steps to alleviate them. Becoming a physician takes a lot of time and requires a lot of dedication as well as money. I would recommend that certain courses be combined together and fast-tracked which will reduce the time it takes to earn a degree. It would be great as well if the government provided some sort of funding or scholarships to individuals who are going to medical school. All of this will make it more appealing to prospective students who are considering on entering the field. Sure it will cost more money now, but it will save the United States tons of money on health care expenditures in the future. More programs should be available for overweight children and their parents to help teach and promote a healthy lifestyle. Knowledge is power so I believe there should be a mandatory class in school that educates children on the harmful effects of being overweight, just like how there are mandatory sex education classes. To reduce the rise of diabetes, there should be more nutritious food available in the area. All you see are fast food places left and right that promote unhealthy foods. The government should provide subsidies to anyone who operates a fast food restaurant that specializes in healthy food. I’ve always thought to myself how rich you would be, if you were the first person to open up an actual healthy fast food restaurant. I believe Americans want to be healthy, but being a society who is always working and is always on the go, convenience trumps any desire to be healthy.