High stakes for uninsured in Tulare County

Covered California outreach counselor Elida Magaña, 29, set up shop at College of the Sequoias in Visalia in early November in hopes of educating people about their options under health reform. “It’s just starting,” she said. “It’s normal for people to be confused or scared. It’s something new for all of us.” (Lauren M. Whaley, CHCF Center for Health Reporting)


This story originally appeared in the San Francisco Chronicle.

Tulare -- This poor, rural county in the southern Central Valley made its name in agriculture by producing more milk than any other county in the nation.

But for the men and women laboring in the dairies, fields and packing plants here, Tulare County also owns a less auspicious distinction: It is home to the highest percentage of adults in California without health insurance.

As the health care law's rollout bumps along its rocky road, few places, on a per capita basis, have as much at stake as Tulare County. Success or failure here will provide a real measure of the Affordable Care Act's ability to transform the health prospects of hundreds of thousands of Central Valley residents.

About 30 percent of the county's 260,000 adults under the age of 65 have no health coverage, compared with about 23 percent of adults statewide, according to Gallup surveys. This puts the region surrounding Visalia - the county seat - just above Bakersfield, Salinas and Stockton on the list of the nation's top 10 metropolitan areas with the highest percentage of uninsured residents.

Many among the uninsured there work in agriculture, but they are also waiters, hairdressers and construction workers. They tell stories of medications skipped, surgeries postponed and tumors growing unchecked. The county has one of the state's highest obesity rates, according to the University of Wisconsin's Population Health Institute, which also found that more than a quarter of residents describe their health as "fair" or "poor."

The uninsured patient

At a clinic operated by the nonprofit Family HealthCare Network in rural Goshen, outreach worker Josette Guzmán said she is thinking a lot these days about an uninsured patient who came into her clinic last year with stroke-related complications.

The clinic was able to offer the woman sliding fees, but she struggled to pay those, Guzmán said, and couldn't afford her medications. Eventually the woman went to the hospital with a bad headache, Guzmán said. She died in September 2012.

"I remember her always saying, 'I can't wait until that Obamacare starts,' " Guzmán said.

Local public health leaders seem optimistic about the Affordable Care Act. Under newly expanded eligibility measures, the county estimates it may eventually enroll as many as 27,000 people on top of the 138,000 county residents already on Medi-Cal, the state's insurance program for the poor.

That will leave tens of thousands of adults as potential candidates for private insurance under Covered California, the state-run health insurance marketplace that is seeking to dramatically cut the ranks of the uninsured.

A big challenge

Local clinics are working with community volunteers - called promotoras - to get the word out. In addition, state-certified outreach workers and enrollment counselors are turning up at swap meets, health fairs and in the fields during workers' breaks to talk up the law's benefits, which include free checkups, greater protection for families, and subsidies for those who qualify.

But convincing residents to buy insurance presents big challenges.

Much depends on people such as Marisol de la Vega Cardoso, director of business development for the Family HealthCare Network, which has assigned 18 outreach and enrollment workers the task of educating thousands of county residents about the law, many of them in far-flung rural communities.

Cardoso says her organization, which operates 11 clinics in the county, has been preparing for this effort for several years.

Still, she said, "being in every place at the same time, it's going to be difficult."

Donna Ortiz, a deputy director with the county's Health and Human Services Agency, said her agency is committed to making the rollout a success, but added that low educational levels locally, as well as cultural and linguistic barriers, may create issues.

Some residents - particularly the estimated 7 percent of the local population that is undocumented - are reticent to seek out information, even though their children or other family members might be eligible for Medi-Cal or federal subsidies.

Perhaps most important, an additional monthly bill may simply be prohibitive for poor working families.

"Trying to convince this family that's barely keeping their heads above water to spend $100 a month is going to be a hard sell," said Cathy Frey, chief executive officer of the Central Valley Health Network, which advocates for health centers in the valley.

Reaching parents

On a recent Tuesday, Elida Magaña set up shop on the school blacktop in the small farmworker community of Woodville. Four months ago, Magaña, 29, left a cake-decorating job at Save Mart to join the local United Way as a certified outreach counselor for Covered California.

As late afternoon sunlight filtered through the smog, families approached Magaña with questions, mostly in Spanish, mostly about whether they were eligible for insurance and how much it would cost them. Magaña typed their information into her computer to provide estimates and enable follow-ups.

Magaña is optimistic about the rollout.

"It's just starting," she said. "It's normal for people to be confused or scared. It's something new for all of us."

Although insurance is a new expense, being uninsured can be extremely costly. Magaña knows. One of her aunts ignored a tumor until she couldn't stand the pain, Magaña said, then paid for emergency surgery on a credit card.

Her mother, Maria Arellano, has had a thyroid condition since she was a teenager, but has been unable to afford coverage for the past several years.

Arellano, who runs a small day care in Tulare, and is raising two young children who are in her custody, was thrilled when her daughter told her about the new health law. She hopes she and her husband, who make a little more than $30,000 between them, might benefit from subsidies and pay just over $100 a month through Covered California. She's not yet sure if she will qualify.

She starts crying when she talks about being uninsured.

"I'd like to benefit from this program," she said. "I'd like to live many years, because I have two children who need me."

Illness left untreated

At the Samaritan Center, a free clinic near downtown Visalia, many residents arrive experiencing complications after leaving asthma, hypertension or diabetes untreated for years.

"When they come in, their blood sugars will be off the charts," said Jackie Zupp, 77, a retired nurse who volunteers at the clinic every Tuesday. Recently, an uninsured woman came into the office with liver problems, Zupp said. By the time the woman got X-rays, it was too late. She died the next weekend.

Yet despite her patients' obvious health needs, Zupp and some of the clinic's other volunteers have concerns about the Affordable Care Act: that implementation has been too rushed, that there won't be enough doctors to care for the newly insured and that people won't be able to afford the monthly premiums.

Out in the waiting room, several patients expressed confusion when asked about the new law. Others, such as Ed Torres, an uninsured general contractor who had stopped by the clinic to pick up some medication, dismissed it as too expensive.

In some ways, Torres, 55, might seem ideal for health reform: He is considering bankruptcy after a diabetes-related hospitalization landed him with a $25,000 bill. But with an income of about $50,000 a year, he said $300 or $400 a month for health insurance just isn't in his budget. If he can't qualify for veterans benefits, which he's looking into, he said he'd probably opt to be fined by the IRS for not being insured.

"I want to have health insurance, but I don't want it to be forced on me," he said.

Sally Altamirano, the clinic office manager, is hoping that other patients will come to embrace the new law. So many uninsured people have come into her waiting room recently that she sometimes has to turn them away.

"I'm praying, because we do need the help," she said.


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