While the vast majority of homeless people meet the requirements to receive Medi-Cal, many do not enroll in the program or receive the medical care they need.
Six months ago, Vivián Ramírez had no health coverage, although it was not something that mattered to him. This 48-year-old woman, a resident of Indio, had other priorities at hand: she had no home to live in and she had to find a place to sleep every night. In addition, he had addiction problems and tried to deal with his depression.
Enrolling in Medi-Cal – the state health insurance program for low-income people – was not a priority. I didn't know how to do it, nor was I thinking about getting health care.
Approximately 130,000 people are homeless in California, according to the latest state survey conducted in 2018. Virtually all of them would qualify for Medi-Cal services, although it is not clear how many people who are enrolled actually receive health care.
Based on the limited amount of data available and anecdotal evidence, enrollment rates vary from region to region, depending on the practices of local agencies and county priorities.
In the Riverside County Coachella Valley, for example, 86% of the 200 homeless people who participated in the survey conducted in person by The desert sun At the beginning of 2019, he said he had no insurance, an index slightly lower than that of the general population. These 200 people represent approximately 46% of the indigent population of the valley. Overall, almost 90% of Californians had coverage in 2016, according to a study by UC Berkeley and UCLA. There are no data available that indicate the number of people without coverage and who live on the street in other parts of the state.
Brett Feldman, director of street medicine at the Keck School of Medicine at the University of Southern California (USC), points out that most of the people he serves in Los Angeles County – of 60,000 who live without a stable home – have coverage.
In Northern California, the Homeless Health Care Program estimates that only 38% of those it serves were covered in 2018. This mobile health care program serves about 20,000 patients a year (and Not all users live on the street.) San Francisco has a little more than 8,000 homeless people.
However, even in the case of those who technically have coverage, it can be difficult to receive services since, generally, providers have difficulty coordinating appointments with patients without a permanent address and, in many cases, they do not have a identification document.
Undoubtedly, a long-term solution that responds to the health difficulties associated with living on the street should include housing for the homeless. However, even if housing is offered, this population would need to have educational campaigns that inform them about how to enroll in Medi-Cal and how to travel through the health care system. San Francisco and Los Angeles counties have invested millions of dollars in these measures, combining housing services with more comprehensive ones, including health care, job counseling and alcoholism rehabilitation centers.
But because the problem of homelessness increases every year, it is difficult for these programs to continue to meet the needs of this population. Dissemination campaigns and changes to facilitate the process of registering Medi-Cal for the homeless could be a very valuable step, say the defenders of these measures.
The Accessible Health Act (ACA), which allocated funds to implement informational measures on the enrollment process, gave states the authority to extend the qualification requirements to the Medicaid program beginning in 2014, although California benefited from a Earlier expansion program launched in 2011. Since then, county employees in California have worked to improve and increase dissemination campaigns among the most vulnerable populations in the state, especially through educational instances to learn how to use the Medi-Cal program. Some counties have managed to be more effective than others in the dissemination measures carried out.
How to transit through the system
One of the people at the forefront of issues related to educational measures is Verónica García, a specialist in the registration process for health coverage at Borrego Health. This health center in Southern California is federally certified and was created to provide health care to underserved populations.
Every Wednesday and Thursday, Garcia arrives with his laptop, forms and pens at his impromptu workplace in Coachella Valley Rescue Mission, a shelter for the homeless located in the city of Indio. When he is not working on the mission, Garcia organizes dissemination campaigns in camps or places where homeless people can protect themselves from the extreme summer temperatures in the desert of southern California.
Garcia is a person especially known in the annex of the mission, where he begins the process of registration in Medi-Cal immediately after receiving people.
“I see that people find it overwhelming to do all this alone,” says Garcia. “Many think they are not able to do it. They say there are too many questions or they don't understand them. Even if they are informed about Medi-Cal, if they live on the street, they are probably not enrolled in the program since they do not have a computer, Internet, telephone or transportation to do so. Therefore, it is very difficult for them. ”
Vivián Ramírez appeared six months ago in the mission without any membership or health coverage.
"I lived on the street and used drugs," Ramírez recalls. “But when I arrived here, I was enrolled in Medi-Cal as part of the initial evaluation. Here they help you sign up for everything. ”
The aid does not end with the initial procedures, says García.
Between the Borrego Health Center and the rescue mission, officials ensure that its users complete the registration process and, once enrolled, find a doctor. The mission allows applicants to use the center's address as their permanent address, and thus they can ensure they receive correspondence with information on the next steps and the available physician options. Garcia helps residents complete the necessary paperwork and send them.
Since he was able to enroll in Medi-Cal, Ramírez has been able to see a basic care doctor for a general exam, in addition to receiving mental health services. Thanks to the vouchers you receive from the local Medi-Cal program, you have access to transportation to and from medical consultations. His medications are delivered directly to the mission, where he continues to live.
In Sacramento County, initiatives such as Sacramento Covered (a nonprofit organization that contacts residents with coverage options) and the Health Care Program for People Living on the Street (an initiative of the County Department of Health Services) work to enroll in Medi-Cal to people in street situations and also connect them with doctors.
The officials of the Sacramento dissemination campaigns enrolled about a thousand people in Medi-Cal in recent months, after increasing the measures, said Peter Beilenson, director of Health Services for Sacramento County. In this county, it is estimated that there are 5,570 homeless, according to a count made sometime in 2019.
Officials conduct surveys in camps under bridges, in the center of the city and in places near the bank of the American and Sacramento rivers. People can use the address of the organization Sacramento Covered as your postal address and keep it as a reference throughout the registration process.
"We noticed that many were already enrolled in Medi-Cal, but had dropped out due to the application renewal process," says Beilenson.
Medi-Cal requires that people re-enroll in the program every year to verify that they continue to meet the requirements.
“Perhaps they did not receive information where they were told that they should re-register, since they do not have a permanent address. By being able to use the address of Sacramento Covered, people arrive and withdraw their Medi-Cal card, get information about the assigned provider and other information they receive by mail, ”says Beilenson.
Due to legal requirements, one of the main ways in which health plans communicate with registered people is through the mail. This becomes a major impediment for those in street situations, says Alison Klurfeld, director of programs and alliances between safety nets of THE. Care, one of the Los Angeles County Medi-Cal health management plans.
Feldman, whose team offers basic health care and behavioral health services on the streets of Los Angeles, notes that the lack of an identification document is a serious impediment to accessing Medi-Cal. Although a person successfully enrolls in Medi-Cal, many clinics refuse to treat the patient if they do not have a photo ID. These documents are highly sought after by thieves, as they can sell for up to $ 150 on the street, Feldman adds.
"They can't get an identification document unless they have the Social Security card or birth certificate, and most people don't carry these things with them," says Feldman. "That's why we spend a lot of time getting those documents for them."
When asked if the state was considering facilitating access to Medi-Cal for those without a fixed address, Scott Murray, spokesman for California Health and Human Services, said in a statement that people should have a address to receive the Medi-Cal card.
The California Department's Health Care Services policy allows individuals to use the state's social services organization to receive correspondence, or the county can assign a mail box for the same service, he says. However, officials working in this field, noted that the postal box option is used very infrequently.
The solution is to allow greater access to Medi-Cal through the Internet, said California State Sen. Jeff Stone, a La Quinta Republican. Stone suggested installing booths with computers in public buildings throughout the state, although he has not yet introduced a law.
Feldman agreed that this measure could be useful: "making the system as agile as possible for these people whose lives are chaotic would be the best strategy," he says.
How to help people navigate the Medi-Cal program
Beilenson, director of Sacramento County Health Services, frequently visits the camps of people in street situations to see for himself the difficulties they face. During a recent visit, many people told him that they had Medi-Cal, but that they had never gone to the doctor because they did not know who the basic care doctor assigned to him was. These notifications are sent by mail.
He said that the officials of the dissemination campaigns ensure that people know who their assigned doctor is, even if that means that the official receives the correspondence in the office of Sacramento Covered and then deliver it in person in the camps.
“Allowing us to receive correspondence from people helps us avoid being left out of the system. It is not a perfect system, but it is better than in many places, ”said Beilenson. While people in street situations theoretically have health coverage, it is often difficult to have access to care.
C.J. Tobe, director of community health at Desert AIDS Project, a federally certified health clinic in Palm Springs, notes that the clinic recently changed its way of disseminating information, after observing that many of the people who live on the street they serve have Medi-Cal.
In mid-July, the team responsible for dissemination of Desert AIDS Project it was installed in Sunrise Park, the main park located in downtown Palm Springs, with the aim of helping people know what their assigned basic care doctor was, how to find a doctor who accepts Medi-Cal and is within walking distance distance from the place where they sleep at night, and how to change doctors, if they wish.
“Now we are concentrating on providing a list of doctors who can go and learn to communicate with their offices,” says Tobe. “We show you how to take the next step. We also show them what kind of health coverage it serves and why it is important that they see a doctor or a behavioral health specialist. ”
Other organizations also try to close the gaps in health care, since just having a coverage card does not solve the problem.
More than 60% of the population in the street situation in southern California suffers from medical or behavioral health problems for those who have not received care, said Pooja Bhalla, director of operations at Illumination Foundation, a nonprofit organization that provides services to homeless people in the region, including recovery care once patients are discharged from the hospital or emergency room.
"Basic care is offered in physical places," he says. “We don't have a good public transportation system in southern California. Therefore, how can a person reach the clinic? Essentially, in the case of these people, care must be taken to the places where they are located. ”
Feldman's team working on the streets of Los Angeles focuses on this task. For someone who lives on the street or works during the day, taking a bus to go to a medical appointment is not always logical. Feldman says that providers must think differently about how to offer care and, therefore, their program brings attention to places where homeless people live.
Medi-Cal could focus more on the patient if he only slightly modified his billing process, says Feldman. When providers send their invoices to Medi-Cal, they must indicate the code corresponding to the “place where the attention was provided”. There is a code for the care offered in a shelter for people in a street situation, but there is no code for “street” or “field visit”, therefore, it is difficult to bill for services provided in those places.
The California Department of Health Care has models of care designed to provide Medi-Cal-funded services for people living on the street, said Anthony Cava, a department spokesman. The state is implementing pilot projects of new models that will help coordinate the care provided to high-risk populations, including people in street situations, although this does not necessarily mean that they will be able to receive street care.
“If a small change were made, this would facilitate the way we provide care and give our programs greater economic stability,” says Feldman. "We are on the street providing exactly the same level of care that doctors specializing in basic care offer."
Nicole Hayden and Deepa Bharath are reporters are part of the project USC Center for Health Journalism. Read the full article on Laopinión.com
