Monterey County launched a scaled-back health insurance program for low-income residents in March, nearly a year after most other California counties set up similar plans to help transition to Affordable Care Act programs.

About half of the total number of patients planned for the pilot insurance program, 154, already enrolled, said Mary Hiebner, management analyst for the county’s Department of Social and Employment Services.

Initially county officials hoped to insure as many as 1,500 people. That number was reduced to 300 as the county sought to limit liability and the cost of the insurance program.

Monterey County, which operates a safety-net hospital and has a constrained budget, wasn’t sure it could afford to back the insurance plan and lose federal cash it receives for treating low-income, uninsured adults at Natividad Medical Center, the county hospital.

“It is unlikely we would receive any new revenue from taking on a health plan,” Natividad CEO Harry Weis warned county officials. “Uninsured patients already go to Natividad without the hospital being fully on the hook for the cost.”

It hasn’t been that long since funding Natividad nearly sunk the county’s budget.

In 2006, it had a $22 million deficit, most of which the county had to pay from the cash it uses to fix roads, plan developments and provide other services. Many feared the hospital, the only safety net hospital in the region, would have to close.

The community rallied and two hospitals, Salinas Valley Memorial and Community Hospital of the Monterey Peninsula, chipped in $8 million over two years to keep Natividad afloat.

Today, Natividad generates revenue. But it is precarious and the specter of deficits is fresh.

“We have to be very careful today about what we can afford to keep Natividad revenue positive,” Weis said.

It is a juggling act.

In 2006, the hospital lost $25 million in caring for uninsured patients. Today that number is down to about $15 million. The hospital works carefully to be reimbursed for its care, dipping into a federal fund to cover the expense of emergency health care for uninsured adults to make up some of the difference.

If those patients were to become insured at the county’s expense those reimbursements would disappear.

Only eight other counties in California have a public hospital like Natividad. And, in most of those cases, county officials grant large subsidies to cover the care they provide. In one case, Weis told county officials, the subsidies average $66 million.

It’s something Monterey County can’t afford.

“It’s a very large and deep commitment those counties have made to those hospitals,” he said. “Monterey County is the smallest population-wise and [its hospital] has not received any [county] subsides.”

The debate to trim or drop the planned insurance plan was heated. Ultimately, the county cut its share of funding for the insurance by $10 million to $3.3 million, but the program is in place.

“Immediately what we see is adults who have historically not had access to health care have a medical exam and access to lab to work,” said Sam Trevino, spokesperson for the county’s department of Social and Employment Services. “Going from avoidance of health care to getting care and information about taking charge of your own health is really empowering.”

The low-income health care insurance plan, known as ViaCare, is a holding program for Medi-Cal, which will expand in 2014 under the Affordable Care Act.

California encouraged counties to set up bridge insurance programs like ViaCare to prepare for the expansion. This way, counties develop a list of who qualifies for Medi-Cal under the ACA and can quickly transition them. Also, officials can help patients establish medical homes and figure out how many new patients may come into the health care system once the expansion is complete.

While supporters of the low income health care program are excited to have something in place, the compromise plan isn’t the broad insurance plan they hoped would be put in place.

“Each of those (without health insurance) are needy and hurting,” said Kathy Goldenkranz, a member of the advocacy group Communities Organized for Power in Action. “But if we can just get a few on the books with health insurance, I think we will be proud.”

Still, those entering the waiting list for coverage won’t be left without care. They will be able to go to Natividad and other county medical centers.

And once the ViaCare rolls are full, those who put their name on the waiting list, like those who received ViaCare, will automatically transition to the state’s expanded Medi-Cal program in 2014.

ViaCare covers Monterey County residents who earn less than $11,172 a year and couples who make less than $15,132 annually.

According to Trevino, the department turned down only 15 applicants who earned too much money, qualified for Medi-Cal already, had children or didn’t meet the program’s residency requirement.

Others left out of the program and potentially out of the Affordable Care Act changes will likely include immigrants without documentation and those who don’t make enough money to buy health insurance and those who don’t qualify for Medi-Cal but don’t by private insurance from the state-run insurance board.

To help them, a new plan, called AccessPoint, sprung from the ViaCare debate.

County officials agreed to work with other regional health care providers to create a card that links together approval for care for uninsured low-income adults and sets a system of copays.

The program will also help establish a medical home base for the poor, uninsured adults in hopes of treating chronic conditions and keeping them out of hospitals. It will be funded in ways similar to current care for the uninsured.

“We would have to beg, borrow and steal and the same way we do now,” said Public Health Administrator Ray Bullick when the plan was first proposed. “We believe if we coordinate we can provide savings or at least better care to the client.”

The Board of Supervisors will take a look at the AccessPoint plan in May.