By Nicole Hayden and Deepa Bharath, USC Center for Health Journalism
Vivian Ramirez didn’t have health insurance six months ago, but she didn’t really care. The 48-year-old from Indio had other priorities. She was homeless. She needed to find a place to sleep each night. She was struggling with an addiction. And she was grappling with her depression.
Medi-Cal, the state’s health insurance program for low-income individuals, could wait. She didn’t know how to sign up and wasn’t planning on seeking health care anyway.
An estimated 130,000 people are homeless in California, according to the last statewide count in 2018. Virtually all would qualify for Medi-Cal, but it’s unclear how many have actually enrolled and are receiving care. The limited data available, coupled with anecdotal evidence, show that enrollment rates vary from region to region, depending on local agency practices and county priorities.
In Riverside County’s Coachella Valley, for example, 86% of 200 homeless individuals who participated in an in-person survey by The Desert Sun in early 2019 reported being insured – a rate only slightly lower than the general population. The 200 individuals made up about 46% of the valley’s homeless population. Overall, nearly 90% of Californians were insured as of 2016, according to a study by UC Berkeley and UCLA. There are no data detailing the number of uninsured individuals who are homeless in other parts of the state.
Brett Feldman, director of street medicine at the University of Southern California’s Keck School of Medicine, said the majority of those he serves in Los Angeles County — which is home to nearly 60,000 homeless — have insurance.
In Northern California, the San Francisco Health Care for the Homeless Program estimated that just 38% of those it served in 2018 were insured. The mobile health care program sees about 20,000 patients per year (not all of its clients are homeless). San Francisco has just over 8,000 homeless individuals.
Yet even for those who are technically insured, receiving care can be a challenge because providers may have trouble coordinating with patients who lack a permanent address, and they usually expect them to provide identification, which many experiencing homelessness also lack.
To be sure, a long-term solution to the health challenges that come with living on the street would be to provide housing for unsheltered individuals, but even with housing this vulnerable population would still need education efforts to inform individuals how to sign up for Medi-Cal and how to navigate the health care system once they are signed up. San Francisco and Los Angeles Counties have invested millions in such efforts -- coupling housing with wrap-around services that include health care as well as case management, job counseling, sobering centers and more.
But with the number of homeless growing every year, it’s difficult for such comprehensive programs to keep up with the need. Outreach and changes to ease Medi-Cal sign-ups for the homeless could serve as a valuable step, advocates say.
The federal Affordable Care Act, which earmarked money for enrollment education, provided states with the authority to expand Medicaid eligibility starting in 2014, although California benefited from an early expansion program that launched in 2011. Since then, county workers in California have worked to improve and increase their outreach to the state’s most vulnerable populations, especially by educating people on how to use Medi-Cal. Some counties have been more effective in that outreach than others.
Navigating the system
One of the people on the front lines of education is Veronica Garcia, a health insurance enrollment specialist for Borrego Health, a federally qualified health center in Southern California established to provide health care in underserved areas. Every Wednesday and Thursday, she totes her laptop, forms and pens into her makeshift workspace at the Coachella Valley Rescue Mission, a homeless shelter in the city of Indio. When she’s not at the mission, she does outreach at homeless encampments or cooling centers — places where those on the streets can escape the triple-digit summer temperatures of Southern California’s desert.
But she’s most recognized in the annex of the mission, where she starts the Medi-Cal enrollment process as soon as people walk in off the street.
“I find it’s too much for people to do it on their own,” Garcia said. “Many clients think they’re not able to do it. They say there are too many questions, or they don’t understand it. If they are aware of Medi-Cal and were homeless, it’s likely they didn’t sign up because they didn’t have a laptop or internet or a phone or transportation. So, it’s really hard.”
Vivian Ramirez showed up to the mission with no possessions and no health insurance six months ago.
“I was homeless and doing drugs on the street,” Ramirez recalled. “But when I first got here, signing up for Medi-Cal was part of the initial assessment. They sign you up for everything. Everyone who walks through that door gets signed up for Medi-Cal.”
The assistance doesn’t stop with that initial paperwork, Garcia said.
Between Borrego Health and the rescue mission, caseworkers make sure clients finish the sign-up process and, once enrolled, find a doctor. The mission allows clients to use its address as their permanent mailing address, ensuring they can receive mail detailing next steps and physician options. Garcia helps residents finish any necessary paperwork and submit it.
Since signing up for Medi-Cal, Ramirez has been able to see a primary care doctor for a physical and receive mental health services. Thanks to vouchers from the local Medi-Cal program, she gets rides to and from doctor’s appointments. Her prescriptions are delivered directly to the mission, where she is still staying.
In Sacramento County, efforts like Sacramento Covered (a nonprofit that connects residents to coverage) and the Health Care for the Homeless Program (an initiative from the county’s Department of Health Services) work to simultaneously sign up individuals who are experiencing homelessness for Medi-Cal and connect them to physicians.
Sacramento outreach workers have signed up about 1,000 people for Medi-Cal in the past few months, after increasing efforts, said Peter Beilenson, Sacramento County Health Services director. There are an estimated 5,570 individuals experiencing homelessness in Sacramento County, according to the 2019 point-in-time count.
Outreach workers canvass encampments under bridges, downtown and near the banks of the American and Sacramento rivers. Individuals can use the address for Sacramento Covered as their mailing address to move along the sign-up process.
“Many we find were previously signed up for Medi-Cal but dropped off because of the re-application process,” Beilenson said.
Medi-Cal requires people to re-enroll each year to verify that they still qualify for coverage.
“Perhaps they didn’t receive mail informing them to re-sign up because they don’t have a permanent address. By using the Sacramento Covered address, people can come in and pick up their Medi-Cal card, get their provider assignment and any other updates that just come by mail,” Beilenson said.
Because of legal requirements, one of the main ways health plans communicate with enrollees is via mail. That becomes a major impediment for those experiencing homelessness, said Alison Klurfeld, director of safety net programs and partnerships at L.A. Care, one of Los Angeles County's Medi-Cal managed care plans.
Feldman, whose team provides full primary care and behavioral health care on the streets of Los Angeles, said a lack of identification is a serious impediment to Medi-Cal access. Even if an individual successfully enrolls in Medi-Cal, many clinics won’t see the patient if he or she does not have a photo ID. Identification cards are a much-sought item for thieves, as a card can be sold for up to $150 on the street, Feldman said.
“They can’t get an ID unless they have a Social Security card or birth certificate, and most people don’t carry those things around,” Feldman said. “So, we spend a lot of time actually trying to get those things for them.”
When asked whether the state was considering making Medi-Cal more accessible to those without a fixed address, Scott Murray, California Health and Human Services spokesman, said in a statement that people still need an address to receive their Medi-Cal card.
California Department of Health Care Services policy allows individuals to use county social services agency addresses to receive mail, or the county can designate a P.O. Box for that individual to receive mail, he said. Workers in the field, however, say this latter option is uncommon.
The solution is making access to Medi-Cal more available via the internet, said California state Sen. Jeff Stone, R-La Quinta. He has suggested installing computer kiosks at public buildings across the state, although he has not introduced legislation.
Feldman agreed this could help. “Making the system as nimble as possible for people whose lives are chaotic is the best approach,” he said.
Helping people navigate Medi-Cal
Beilenson, the Sacramento County Health Services director, often visits homeless encampments to see for himself what challenges people face. During one visit recently, he heard from several individuals that they did have Medi-Cal but never went to the doctor because they didn’t know who their assigned primary care physician was. Such notifications are sent through the mail.
He said his outreach workers make sure individuals find out their assigned physician, even if that means having caseworkers receive the mail at the Sacramento Covered office and then deliver it themselves to encampments.
“Letting us receive people’s mail helps keep people from falling through the cracks. It’s not perfect, but it’s better than many places,” Beilenson said. While individuals experiencing homelessness might have health insurance on paper, it’s often difficult for them to access care.
C.J. Tobe, community health director for the Desert AIDS Project, a federally qualified health clinic in Palm Springs, said the clinic recently changed how it does outreach after learning that many of the homeless individuals they serve have Medi-Cal.
In mid-July, Desert AIDS Project’s outreach team fanned out in Sunrise Park, the central park in downtown Palm Springs, with the goal of teaching people how to find out who their primary care physician was, how to identify a doctor who accepts Medi-Cal within walking distance of where they sleep at night, and how to change who their doctor is, if they wish.
“We are now focused on being able to provide a list of physicians they can go to and how to contact those physicians,” Tobe said. “We show them how to take the next step. We show them what health insurance is for and tell them why it’s important to see a doctor or a behavioral health specialist.”
Other organizations are also trying to fill in health care gaps that having an insurance card alone doesn’t address.
More than 60% of the homeless population in Southern California has unaddressed medical or behavioral health needs, said Pooja Bhalla, chief operating officer of the Illumination Foundation, a nonprofit that provides services for individuals experiencing homelessness in the region, including recuperative care after patients are released from hospitals and emergency rooms.
"Primary care is offered in brick-and-mortar buildings," she said. "We don't have good public transportation in Southern California. How do you get to a safety net clinic? What do you expect when you get there? For homeless people, essentially, the care needs to be brought to them."
Feldman’s street team in Los Angeles focuses on doing just that. For someone living on the street or working a daily job, taking a bus to a doctor’s appointment doesn’t always make sense. He said providers need to think differently about how care is delivered, which is why he brings care to where people are living on the street.
“What is Medi-Cal itself doing? Once you get Medi-Cal, you’re assigned a provider and that provider is charged with taking care of you,” Feldman said. “What are those providers doing to encourage their enrollees to use their services? Are these services really patient-centered or are they billing-centered? Billing-centered care isn’t the reality of the street.”
Medi-Cal could become more patient-centered if it modified its billing process even slightly, Feldman said. When providers bill Medi-Cal, they must note a “location of care” code. There is a care code that’s a homeless shelter, but no code for “street” or “field visit,” making it hard to bill for services provided in those locales.
The California Department of Health Care has care models aimed at providing Medi-Cal funded services to homeless individuals, said Anthony Cava, a spokesman. The state is piloting new models that will help coordinate care for high-risk populations, including individuals experiencing homelessness, though that doesn’t necessarily mean patients are able to receive care on the street.
“It would be easier to provide care and would create a financial stability for our programs if just that small change was made,” Feldman said. “We are on the street providing the exact same level of care that primary care physicians are providing.”