More of the same: Medi-Cal expansion takes subtle form at the local level
Benigno Garibay, a homeless man in Arvin, holds a stack of papers against a bagged lunch and water bottle. He’s signing up for Medi-Cal, the state’s public health insurance. Underlined by blue marker, Garibay only fills in certain lines. When asked, he said he wouldn’t mind a physical, or for his ears to get checked out.
On Jan. 9, aid workers with the Akido Street Medicine Team set out for Arvin to stalk the side streets and lots far from the public thoroughfares. They’re in the first stages of building their caseload: getting clients.
“Basically we’re trying anyone that isn’t on Medi-Cal to get on it,” said Kirk McGowan, a registered nurse with the team. “Anyone that’s not on Medi-Cal, we want to sign them up.”
Many of their clients are not signed up for Medi-Cal, the state’s health care program for low-income Californians. As of this week, the group has six applications ready to send to Kern County’s Department of Human Services, which handles the filing.
Many of the applications lack the person’s Social Security number, a subtle detail of a major change within the health care world.
Starting this year, California is extending its public health insurance coverage to undocumented adults between 26 and 49 years old, making the state the first to offer a comprehensive plan to those without legal status.
Under the expansion, an estimated 700,000 immigrants without legal status in California can access free or low-cost health care. It’s one of the state’s largest — and most expensive — coverage build-outs in history.
Expanding Medi-Cal has been a goal of health advocates for years. Yet the change is hardly acknowledged by the workers. Nearly all of their clients are homeless, drifting between patches of unincorporated county land. Their legal status, just as their health status, is unknown.
“We’re basically doing the same thing we’ve been doing,” McGowan said.
Itzel Veliz, a social worker with the Akido team, guesses that about half of the team’s clients in Arvin are undocumented, and could benefit tremendously from the expansion. But they don’t ask either way.
The greatest difference, she added, is that in the past, applications submitted without a Social Security or taxpayer identification number were guaranteed to be rejected.
California has seen a sharp decline over the past decade in the number of residents who lack health insurance — with the exception being adults of working age without legal status.
Despite many who work and pay taxes — they make up a tenth of the state’s workforce — they are excluded from most public benefits and account
for nearly two-thirds of the state’s uninsured population.
But the change, however well-intentioned, won’t be cheap. Projections suggest the expansion will cost the state $835 million in the next six months and $2.6 billion every year after, according to the Legislative Analyst’s Office.
This comes as Gov. Gavin Newsom unveiled on Wednesday the first draft of the state’s 2024-25 budget, a $291 billion plan that looks to close a $38 billion deficit. “We’re just a little more optimistic than the naysayers,” Newsom said during his budget presentation.
When prompted by reporters at an event in Los Angeles last week, Newsom said he would not roll back the Medi-Cal expansion.
“I’m committed to it, I believe in universal health care, I believe it’s a human right,” Newsom said. “I’m proud of the fact that the Legislature embraced that vision ... it’s well within our capacity to make that investment. We made that commitment years ago and we’re going to fulfill that commitment.”
While significant, the program represents a tenth of Medi-Cal’s $37 billion budget.
And some researchers believe it will save the state money in the long run.
“It will have a positive impact over time as more people will be able to receive preventive care and establish a primary care home,” said Ana Velasquez, a health insurance assistance program manager with Clinica Sierra Vista. “This, in turn, will result in fewer people ending up in hospital emergency rooms.”
But this all assumes people will sign up, said Nadereh Pourat, who heads the Center for Health Policy Research’s Health Economics and Evaluation Research Program at UCLA.
In fact, there are a lot of people — legal or not — who could sign up but have not, for various reasons. Some simply don’t understand how the system works, or fail to renew their benefits.
Others are skeptical about the process, and think it will be used by authorities to either remove their encampments or deport them.
Concern stems around what Velasquez feels are misconceptions regarding the “public charge rule,” a federal law that requires those seeking to become permanent residents or gain legal status to prove they will not be a burden to the United States, or a “public charge.”
Signing up for Medi-Cal, she added, does not threaten people’s chances in pursuing legal residency, but the fear remains.
On their route, Akido team members ran into several individuals who refused to sign up for Medi-Cal, or at least expressed doubts. One man was certain it’d lead the cops to his doorstep.
“What we’re doing is offering coverage,” Pourat said. “There’s no guarantee that people will take up that coverage. And you still have undocumented people earning just above Medi-Cal levels.”
The result is a deferment of better health, which leads to higher rates of heart disease, asthma and high blood pressure. In some cases, poorer mental health. Symptoms will worsen until they compound and people are forced to visit an emergency room, placing a heavy cost on the state and hospitals.
The expansion of Medi-Cal will also “lower the pressure” on emergency rooms, like those at Adventist Health and Kern Medical, where long wait times in the emergency departments are common.
“They get bombarded every week,” Veliz said.
During their morning route, the Akido team ran into several people who complained of simple issues — back spasms, crooked teeth, clogged ears. The outof-pocket cost for remedying these, workers said, could be astronomical.
Velasquez said that dental and mental health services are commonly sought by Medi-Cal enrollees, due to their high cost and lack of coverage, even with private insurance.
In a 2021 study, Pourat and researchers with the
UCLA Center for Health Policy Research found that the Medi-Cal Health Homes Program, which ran from July 2018 to December 2021, led to fewer trips to the emergency room and fewer hospitalizations among its enrollees.
For those enrolled that the study examined — 90,000 people across 12 California counties — the annual cost of medical bills charged to the state dropped by $1,113 per the average person.
But the program is far from perfect, Pourat said. It leaves out a lot of Californians, legal or not, who make too much to qualify for Medi-Cal, but not enough to afford a private plan. Medi-Cal is also susceptible to economic downturns, she added, saying that dental services and podiatry have been axed from the plan amid past funding shortfalls.
Advocates want to expand the state’s Covered California plan to include more people, but the state’s deficit makes that unlikely.
“I think these days it doesn’t matter where you live. The cost of living in California is quite high,” Pourat said. “If you’re asking people to decide how they spend their limited income and the competition is between rent, food and health insurance — you know what they’re going to do.”
Early projections, Velasquez said, show about 10,000 people across Kern could qualify under the expansion, compared with the 400,000 Kern residents already covered under Medi-Cal, according to 2023 statistics compiled by Kern Human Services.
“This expansion will impact the entire health care sector,” Velasquez wrote, adding that she expects there will be plenty of questions in the days ahead.