Effectiveness of state mandates to maintain local government health services for the poor

State governments have used several types of mandates to assure that local governments fulfill state-defined responsibilities, including public health care for the poor. This article reports the findings of a study of procedural public-participation mandates and financial sanctions imposed by California to hold counties to their obligations to provide indigent health care. An inventory of the laws' implementation in all California counties found noncompliance by some counties, although all counties complied after a state Health Services Department unit was established to monitor the counties and provide them with state aid. Case studies in eight counties identified factors that influenced the effectiveness of the laws in modifying or reversing county proposals to close county hospitals or reduce other health services. Policy guidelines are suggested for states that want to develop mandates to enforce indigent-care responsibilities of local governments.