Unconventional treatments for asthma

MADERA — Growing up amid the dusty agricultural fields of the Central Valley, Ruby Marentes-cabrera can’t recall a time when it wasn’t difficult to breathe.

Diagnosed with asthma early in childhood, the ninth grader has come to detest the pistachio trees that surround her home because the dust, pesticides and other allergens that blow off the orchards often trigger an asthma attack — even infiltrating her home so that simple chores like vacuuming can be dangerous.

“We live so close to the fields — I breathe the dust and chemicals in,” said Ruby, 14, describing coughing and wheezing fits calmed by puffs from her emergency inhaler or breathing treatments from a nebulizer. “It gets so bad that my back hurts, my head hurts, my lungs hurt. I get sick and it gets really hard to breathe.”

Ruby is among roughly 2 million low-income Californians who have health insurance coverage from Medi-cal, the state’s Medicaid program, and have been diagnosed with asthma, a chronic and expensive disease that costs California billions of dollars per year in health care spending, missed work for parents and lost school days for kids.

The disease — exacerbated by air pollution and indoor threats like harsh cleaning products, cockroach infestations, dust and mold — hits low-income communities the hardest. Medi-cal patients accounted for half the state’s asthmarelated emergency and urgent care visits in 2016, even though they represented about one-third of the population, according to data cited by state health officials.

Starting in January, California will embark on an ambitious experiment to control asthma in its most vulnerable patients. Medi-cal will offer recipients like Ruby unconventional in-home “treatments” not traditionally considered health care: removing mold, installing air purifiers and even replacing carpeting, blinds and mattresses.

These new asthma benefits are just a small part of Gov. Gavin Newsom’s sweeping $6 billion initiative to transform the largest Medicaid program in the country. The initiative, known as CALAIM, will target the state’s sickest and most expensive patients and cover an array of new social services, including home-delivered healthy meals; help with grocery shopping, laundry and money management; and security deposits for homeless people in search of housing.

Newsom’s goal is to lower soaring Medi-cal spending — which hit an astronomical $124 billion this fiscal year — by preventing costly care such as emergency room visits. But state health officials acknowledge the new asthma benefits may not actually save taxpayer money.

Nor will the benefits be distributed equally: Because Medi-cal managed-care insurance plans have immense power to decide which new services to offer and to whom, the initiative will create a patchwork of haves and have-nots. Of the 25 participating insurance companies, 11 will offer in-home asthma services starting in January in 36 of the state’s 58 counties. Within those counties, some Medi-cal recipients will qualify; others will not.

With just two weeks to go before the program debuts, many insurers are scrambling to establish networks of nonprofit organizations and private contractors that specialize in delivering in-home asthma services and home repairs.

Fresno and Madera counties have some of the worst air quality in the state. They also have the highest rates of childhood asthma-related ER visits in California, along with Imperial County on the Mexican border, according to 2019 state public health data.

Ruby and her family, who live in Madera, appear to be ideal candidates for state-funded asthma benefits, said Joel Ervice, associate director of Regional Asthma Management and Prevention, which lobbied for the new services. Both Ruby and her sister Yesenia, 20, have asthma and were frequent visitors to the ER during childhood.

But as in the Inland Empire, only a small share of Central Valley asthma patients will receive the new services initially. Ruby and her family hope they will be among the lucky ones but realize they may still have to rely on conventional treatments such as emergency inhalers — and the hospital if necessary.

“I’m taking my medication a lot right now — it would be good if my asthma got better,” said Ruby, who wants to be able to play outside her home and excel in outdoor school activities. “I’m having a hard time running the mile in school, so being able to run would be so great for me and my health.”

Calviva Health, a major insurer serving patients in the Central Valley, including the Marentes-cabrera family, so far has identified one nonprofit organization to deliver services and is negotiating with others.

That organization, the Central California Asthma Collaborative, expects to be able to serve up to 500 people across seven counties next year. Unlike other nonprofit groups that are still assessing how to deliver services, the collaborative has already identified private contractors to remove mold, install bathroom or kitchen ventilation, and provide other services, co-director Kevin Hamilton said.

Calviva Health CEO Jeffrey Nkansah said asthma is one of the leading causes of hospitalization among the insurer’s enrollees.

“But right now, these conversations around identifying partners to deliver these asthma remediation services are fluid,” Nkansah said. “We’re still working hard to make sure we can get those services in place for Jan. 1.”

For the Marentes-cabreras, the relentless clouds of dust and other toxins from orchards, combined with seasonal wildfire smoke, are the biggest problem.

The particles infiltrate their lungs and their home, covering surfaces and caking the carpet, which they would like to replace. But they don’t have the money.