Care for the un­doc­u­mented varies widely across Cal­i­for­nia coun­ties

The Fresno Bee (Sunday) - - Insight - BY SAMMY CAIOLA

In the out­pa­tient wait­ing room at Zucker­berg San Fran­cisco Gen­eral Hospi­tal, Span­ish and Chi­nese chat­ter spills from phar­macy win­dows as other pa­tients doze on chairs or play on their phones.

When the over­head speaker beck­ons, they step for­ward with stacks of pa­per­work and walk out with brown pa­per pre­scrip­tion bags.

The room is bustling with pa­tients us­ing Healthy San Fran­cisco, one of Cal­i­for­nia’s most com­pre­hen­sive county health pro­grams for peo­ple who don’t qual­ify for state or fed­eral in­sur­ance be­cause of their im­mi­gra­tion sta­tus.

Other coun­ties cover fewer peo­ple, of­fer only ba­sic ser­vices, or ex­clude the un­doc­u­mented en­tirely. Where a per­son lives can make all the dif­fer­ence in whether health care is avail­able at all out­side of emer­gency rooms.

Alice Kur­niadi, a pro­gram man­ager with the San Fran­cisco Depart­ment of Pub­lic Health, says get­ting peo­ple both pre­ven­tive and fol­low-up care is key to bring­ing down costs and help­ing peo­ple live longer.

“Healthy San Fran­cisco is kind of serv­ing as a model,” she said. “It still is a pro­gram that’s needed, be­cause we don’t have true uni­ver­sal cov­er­age and there are peo­ple who are still left out.”

A new re­port re­leased Thurs­day by the In­sure the Unin­sured Project, a non­profit group push­ing for uni­ver­sal health care, shows that county pro­grams for the med­i­cally in­di­gent are gen­er­ally serv­ing fewer peo­ple now than they did be­fore the Af­ford­able Care Act.

At the same time, more coun­ties are of­fer­ing some level of care to their un­doc­u­mented pop­u­la­tion than ever be­fore. Be­cause health providers sel­dom ask pa­tients about im­mi­gra­tion sta­tus, there’s no way to cal­cu­late how many un­doc­u­mented peo­ple are served through county-run clin­ics and hospi­tals.

But ad­vo­cates say it’s a small frac­tion of the state’s 1.5 mil­lion un­doc­u­mented and unin­sured peo­ple in Cal­i­for­nia, many of whom seek treat­ment only in emer­gency sit­u­a­tions. Un­der state law, hospi­tals must treat all emer­gency pa­tients. Most coun­ties pro­vide pri­mary care, but get­ting care for chronic con­di­tions that re­quire spe­cial­ists can be dif­fi­cult.

Coun­ties with the lean­est ben­e­fits leave peo­ple with un­treated di­a­betes, hy­per­ten­sion or can­cer – con­di­tions that can lead to much more se­vere ill­ness or even pre­ventable death, ac­cord­ing to Lau­rel Lu­cia, di­rec­tor of the Health Care Pro­gram at the UC Berke­ley La­bor Cen­ter.

Un­doc­u­mented chil­dren are cur­rently cov­ered by Medi-Cal and the full cost of their non-emer­gency care is paid by the state. But when it comes to un­doc­u­mented adults, some coun­ties are re­luc­tant to cover non-emer­gency care be­cause they would have to foot the en­tire bill. Oth­ers sim­ply feel it isn’t their re­spon­si­bil­ity.

An­thony Wright, pres­i­dent of the con­sumer group Health Ac­cess, says coun­ties vary “widely and wildly” in what they of­fer this pop­u­la­tion. “The county is a last-re­sort safety net that is there in


some ar­eas and less so in oth­ers,” he said. “Peo­ple have dif­fer­ent ac­cess to health care based on the county they’re in. And at the end of the day that’s not a great pol­icy.”


Be­fore the Af­ford­able Care Act took ef­fect in 2014, county health de­part­ments treated all sorts of peo­ple with­out in­sur­ance, in­clud­ing sin­gle adults, home­less in­di­vid­u­als and peo­ple who made too much money to qual­ify for state pro­grams.

At that time, the state had more than 3 mil­lion unin­sured. But when Cal­i­for­nia broad­ened Med­i­Cal el­i­gi­bil­ity and cre­ated the Cov­ered Cal­i­for­nia health ex­change, many of those peo­ple gained in­sur­ance cov­er­age and stopped re­ly­ing on their coun­ties for free or sub­si­dized care.

The state also shifted the amount of fund­ing go­ing to coun­ties to cover the med­i­cally in­di­gent. That opened a door for coun­ties to ei­ther run smaller pro­grams or start cov­er­ing peo­ple they’d pre­vi­ously ex­cluded. The num­ber of county pro­grams serv­ing med­i­cally in­di­gent adults re­gard­less of im­mi­gra­tion sta­tus jumped from 11 to 47 be­tween Oc­to­ber 2017 and July 2018, ac­cord­ing to the re­port from the In­sure the Unin­sured Project.

Still, stan­dards of care vary. Some coun­ties pro­vide peo­ple with a card, but it’s not the same as hav­ing health in­sur­ance. It’s just a way to show el­i­gi­bil­ity for sub­si­dized care in a county clinic, a pub­lic hospi­tal, or a provider the county is con­tract­ing with.

“When we say they’re ‘cov­er­ing the un­doc­u­mented,’ what do we re­ally mean by that?” said Deb­o­rah Kelch, ex­ec­u­tive di­rec­tor of the In­sure the Unin­sured Project. “That’s a piece we all need to put into the mix.”

For in­stance, Sacramento County’s Healthy Part­ners pro­gram launched in 2016 to of­fer ser­vices to the unin­sured, re­gard­less of im­mi­gra­tion sta­tus. It was open to adults who are al­ready en­rolled in re­stricted scope Medi-Cal, younger than 64 and be­low a cer­tain in­come bracket – roughly $16,548 a year for an in­di­vid­ual or $34,638 a year for a fam­ily of four.

The pro­gram orig­i­nally had a 3,000-pa­tient cap, though there are an es­ti­mated 65,000 un­doc­u­mented adults in the county. Im­mi­grant ad­vo­cacy groups suc­cess­fully fought to raise the cap to 4,000 pa­tients and re­move the up­per age limit in 2018, but it still falls far short of the re­quests for med­i­cal care.

Holan­desa Lopez left Nicaragua 17 years ago. She sought a bet­ter life in Cal­i­for­nia, but found her­self long­ing for the fam­ily and ca­reer she had left back home. Though the shock of her new life of­ten sent her into bouts of de­pres­sion, her im­mi­gra­tion sta­tus kept her from seek­ing help. Five years ago, she de­vel­oped a prob­lem she couldn’t ig­nore – an ab­dom­i­nal pain so in­tense she would lie on the floor un­til it went away.

When it be­came un­bear­able, she went to the hospi­tal for help in hopes of us­ing her emer­gency Medi-Cal to re­ceive care. An exam and MRI showed she had a mass in her pan­creas, but the hospi­tal wouldn’t take it out.

“My di­ges­tive sys­tem was get­ting worse, and I could tell,” she said through a trans­la­tor. “I couldn’t work. I couldn’t take care of my son. I be­gan to knock on peo­ple’s doors ev­ery­where … Everybody told me the same thing, that I needed to have money in or­der to get my op­er­a­tion.”

Back at the hospi­tal a year later, doc­tors told Lopez the be­nign mass had dou­bled in size, but they couldn’t op­er­ate be­cause it wasn’t an emer­gency. She even­tu­ally got pro bono surgery at an­other hospi­tal through a char­ity pro­gram.

Now, she gets her care – in­clud­ing ther­apy – at Wel­lS­pace Health, a net­work of com­mu­nity clin­ics. But she wor­ries that won’t suf­fice if she ever needs surgery again.

Sacramento County’s Healthy Part­ners pro­gram cov­ers spe­cialty ser­vices and in­pa­tient hospi­tal care, but Lopez said she’d never heard of it. If ei­ther of two bills mov­ing through the leg­is­la­ture be­come law, Medi-Cal could ex­pand to all in­come-qual­i­fy­ing adults

Lopez said she would sign up with­out a se­cond thought.

“Com­ing to this coun­try, the only thing they care about is the child,” she said. “They don’t treat the mother. They only treat the child be­cause he’s the one who has a So­cial Se­cu­rity num­ber. But they never take into con­sid­er­a­tion the mother, her health prob­lems, her men­tal health prob­lems.”

Some coun­ties have been adamant that treat­ing the un­doc­u­mented is not their re­spon­si­bil­ity.

Fresno County won a 2014 law­suit con­clud­ing that it didn’t have to cover the un­doc­u­mented pop­u­la­tion.

David Po­mav­ille, di­rec­tor of pub­lic health ad­min­is­tra­tion for the county, said they sim­ply couldn’t pay for it.

“We would have had to make re­ally dra­co­nian cuts to the rest of pub­lic health in fa­vor of the un­doc­u­mented pro­gram the way it ex­isted,” he said.

The county even­tu­ally cre­ated a new re­fer­ral sys­tem, which di­rects pa­tients to com­mu­nity clin­ics. It cur­rently serves about 400 peo­ple.

Po­mav­ille said it isn’t a sus­tain­able so­lu­tion.

“Leav­ing coun­ties to solve this prob­lem, I think is un­re­al­is­tic,” he said. “This is a band-aid on a big­ger prob­lem that needs to be ad­dressed statewide.”

This ar­ti­cle is part of the USC Cen­ter for Health Jour­nal­ism News Col­lab­o­ra­tive, which in­volves print and broad­cast jour­nal­ists across Cal­i­for­nia. The Bee's Michael Finch II, the Orange County Reg­is­ter's Deepa Bharath, The (Palm Spring) Desert Sun's Ni­cole Hay­den and Univi­sion 21 Fresno's Jose Gon­za­lez con­trib­uted to this re­port.

AN­DREW NIXON Cap­i­tal Pub­lic Ra­dio

Holan­desa Lopez in­ven­to­ries jew­elry at her job. Peo­ple like Lopez who don’t qual­ify for state or fed­eral in­sur­ance be­cause of their im­mi­gra­tion sta­tus have widely dif­fer­ent health care op­tions in Cal­i­for­nia coun­ties. Some ex­clude the un­doc­u­mented en­tirely.

AN­DREW NIXON Cap­i­tal Pub­lic Ra­dio

When Holan­desa Lopez had an ab­dom­i­nal pain that be­came un­bear­able, she went to the hospi­tal for help in hopes of us­ing her emer­gency Medi-Cal to re­ceive care. An MRI showed she had a mass in her pan­creas, but the hospi­tal wouldn’t take it out.

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