Riverside/San Bernardino: Vast Region, Market Fragmentation Add to Access Woes

Riverside/San Bernardino: Vast Region, Market Fragmentation Add to Access Woes

Community Report | By the Center for Studying Health System Change

The Riverside and San Bernardino counties in California's Inland Empire presented a distinctive set of health care challenges. Covering an enormous geographic area that stretched from the outskirts of Los Angeles deep into the desert, the region's health care market was fragmented along geographic, economic and institutional lines. This fragmentation, combined with rapid population growth, physician shortages and high rates of uninsured residents, created access problems that were among the most severe in the communities HSC studied.

Geographic and Demographic Pressures

The Inland Empire's rapid population growth -- driven largely by families moving inland from coastal California in search of affordable housing -- outpaced the development of health care infrastructure. Many new residents commuted long distances to jobs in Los Angeles or Orange County, but the region lacked the concentration of medical providers typical of older urban centers. The ratio of physicians to population was among the lowest of any major metropolitan area in California, and many areas within the two counties qualified as federally designated health professional shortage areas.

A Fragmented Market

The sheer size of the region meant that health care providers and health plans operated in loosely connected submarkets rather than a single integrated market. Hospitals in the western portions of the two counties competed in a different competitive environment than those in the desert communities to the east. Health plans that dominated in one submarket might have minimal presence in another. This fragmentation made it difficult for any single organization to coordinate care across the region and left patients in some areas with few provider options.

High Uninsurance Rates Strain the Safety Net

The Inland Empire had above-average rates of uninsured residents, driven by a workforce concentrated in lower-wage service, construction and agricultural jobs that frequently did not offer employer-sponsored health insurance. The region's safety net providers -- community health centers, county hospitals and emergency departments -- bore a heavy burden of uncompensated care. Limited Medi-Cal reimbursement rates made it difficult for providers to sustain operations while serving large numbers of publicly insured and uninsured patients.

Hospital Capacity Constraints

Hospital bed capacity had not kept pace with population growth. Emergency department overcrowding and ambulance diversions were common, particularly in the western portions of the counties closest to Los Angeles. Several hospitals struggled financially, and the closure of facilities in neighboring communities funneled additional patients to remaining hospitals. California's seismic retrofit requirements added another layer of financial pressure, requiring major capital investments that some facilities found difficult to finance.

Physician Recruitment Difficulties

Recruiting and retaining physicians remained a persistent challenge. The region lacked a medical school, and graduates of schools in nearby Los Angeles and Orange County tended to remain in those more established markets. Low Medi-Cal payment rates and a high proportion of uninsured patients reduced the financial attractiveness of practicing in the Inland Empire, particularly for specialists. The resulting physician shortage compounded the access problems created by the region's geography and market fragmentation.

Sources and Further Reading

This report was published by the Center for Studying Health System Change as part of the Community Tracking Study, funded by the Robert Wood Johnson Foundation.