It is a widely held belief among Californians that everybody deserves medical care and health insurance. Thus residents of the state have benefited from a generous expansion of health insurance coverage over the past 10 years.
- The Affordable Care Act permitted the creation of the Covered California Obamacare exchange.
- Young adults could go on their parents’ insurance.
- The Medicaid expansion covered millions of residents.
- CHIP covered children.
Almost everyone in the state has some access to insurance or a subsidy to make it affordable.
Except one group: mixed documentation status households
That is in the process of changing, incrementally. In certain counties, such as Los Angeles, mixed documentation status persons may receive care; in other counties, such as Orange, they do not. It is a patchwork. In general, rural counties have a harder time paying for indigent groups’ care than richer urban counties.
In 2016 the state widened the eligibility criteria to cover “uninsured low-income, indigent adults that are not otherwise eligible for other publicly funded health care programs” using the County Medical Services Program (CMSP). This pilot project provides basic medical and dental care for immigrants whose status may be uncertain in 47 mostly rural counties in the northern part of the state, the Central Valley, and the Imperial Valley.
In Humboldt and Del Norte counties, in the redwood forests of the northern coast, small numbers of mixed documentation status people live quietly, often apart from the mainstream, linguistically isolated, and deliberately unnoticed.
Open Door Community Health Centers, an FQHC based in Arcata with 12 locations along the north coast, is making it a mission to find them and get them enrolled in this new state program. It is the only provider organization in the region participating in CMSP.
“It’s an especially important population and gap in service, that needs as much attention as can be given,” said Brea Olmstead, Open Door member services director.
By late November 2020, just a couple months into the program, Alfredo Lopez had enrolled four people. How did he find them?
“I am the Latino health coordinator,” he explained. “We use the promotore de salud model” of lay workers who go out into the Spanish-speaking community to connect people with health and wellness resources.
When patients come in for appointments, “I always ask the question whether they have insurance or not.” Lopez had a list of 10 mixed documentation status patients who did not have any insurance. “I started calling them. I told them there is a CMSP program, they can get help with medications. These were patients I already knew.”
One of the patients he enrolled is a woman in her 70s. She has been “in and out of the ER probably five to six times in the last six months, with multiple chronic conditions, including diabetes and high blood pressure, among others,” Lopez reported.
She takes a lot of medications. Sometimes it is really hard for her to get all the medications she needs and to manage her conditions. She relies on family members for food and prescription pickups.
“Most of the time she doesn’t get the service because she doesn’t have money to pay,” Lopez said. “I offered to enroll her in the program. That way she will get help with medical visits and medications, especially for diabetes. Insulin is one of the biggest barriers for her. She stopped using the insulin, then her blood sugar goes really high, and she goes to the hospital. With this program she will be constant to get the insulin she needs to treat her diabetes.”
Nobody really knows how many undocumented people live in far northern California. Humboldt and Del Norte counties have a combined population of 160,000. Of that perhaps 1% to 6% of residents are of mixed documentation status, Olmstead said, but “it is very hard to know.”
More often than not those with mixed documentation status work in agriculture, in dairies or flower farms. Near the Oregon border is the largest day lily bulb farm outside northern Europe. Then, of course, there is the Emerald Triangle’s marijuana industry. These are not even incorporated businesses, but rather black market operations employing mixed documentation status people, very under the radar.
“But still they get sick,” Olmstead said.
Open Door’s participation with CMSP is a natural outgrowth of its existing robust program on social determinants of health. “We are definitely tuned in to other community partners in the area that offer resources,” said Jarrett Nicholson, Humboldt member services office manager. As certified enrollment counselors for Covered California, he said, “We assist folks with navigating through insurance, but we also do navigation to CalFresh, and other county programs.”
CMSP works on a variant of the HMO model. There are approved providers and approved pharmacies. Once a person is enrolled for coverage, they are attached to a specific clinic site and pharmacy for preventative care and follow-up. Open Door can then bill for any preventative service, labs, and pharmacy prescriptions. CMSP does not cover hospitalizations.
In theory, at least, preventable hospitalizations among those of mixed documentation status should decline under CMSP. For the member services staffers, it was not uncommon to run into situations where a person had some serious medical issues and didn’t have insurance to cover it. In some of these cases, Nicholson said, “the medical issue has been amplified because … they have ignored it and ignored it until they couldn’t ignore it any more. Now it’s a serious issue.”
Open Door was founded in 1971, modeled after a free clinic in San Francisco’s Haight-Ashbury district. Over time it evolved from serving the low-income community in Humboldt County to effectively become the default clinic system for the wider population as mainstream private physician practices in the area closed. It established a replicable template for rural health clinics elsewhere.
Open Door can embrace the CMSP because it is financially sound and takes an expansive approach to its mission. For many years it was led by a healthcare visionary, the late Herrmann Spetzler, who instilled a sense of risk-taking and ambition in his staff and acolytes. He built a relationship between the clinics and the local hospitals, the county, and between physical health and mental health care. Open Door also boosted its telemedicine capabilities well ahead of the COVID-19 pandemic.
“I think they’ve had extraordinary leadership up there,” said Lucien Wulsin, a health policy consultant in Los Angeles who founded the Insure the Uninsured Project. “They are really the dominant provider in an area which has a real dearth of providers.
“They see huge volumes of people who are over the income levels that other clinics take,” Wulsin said. “Typically, you see clinics taking care of people at under 200% of poverty. Open Door takes care of people regardless of income” – but on the up side -- which gives it license to collect private insurance. In rural zones where provider networks are thin and insurance competition is scarce, that is a huge strategic opportunity for an ambitious FQHC.