Community workers fan out to persuade immigrant seniors to get covered

For three years, Bertha Embriz of San Francisco has gone without health insurance, skipping annual wellness exams and recently tolerating a broken molar by trying not to chew with it. As an immigrant without legal status, the 58-year-old unpaid caregiver knew that California's Medicaid program was closed to her.

That changed in May, when California expanded Medi-Cal — its Medicaid program for residents with low incomes — to adults 50 and older, regardless of immigration status. The problem was that Embriz didn't realize she would be eligible until she attended a community meeting in San Francisco.

"I'd heard that they were giving full Medi-Cal to people over 50, but I didn't know that you didn't have to be" in the country legally, said Embriz, who is waiting for her application to be processed. "Thank God I haven't had any emergencies."

As of October, the most recent month for which data is available, more than 300,000 older immigrant adults who lack legal residency had enrolled in full Medi-Cal benefits, 30% more than the state's original projection. State health officials, who had based their estimate on the number of people enrolled in a limited form of Medi-Cal that covers only emergency medical services, don't know how many additional older Californians are eligible, said Tony Cava, a spokesperson for the state Department of Health Care Services.

Now, some counties have hired a small army of community workers and health educators to enroll as many immigrant seniors as they can find. Workers visit senior centers, churches, English-language classes, immigration offices, markets, and community events, hoping to encounter people like Embriz unaware of their newfound eligibility.

In Alameda County, Medi-Cal program specialist Juan Ventanilla said the social services agency is using existing state outreach grants to partner with eight established community organizations to help get the word out about the expansion and help people sign up.

Workers, he said, specialize in "assisting the most vulnerable in the county in getting access to health care."

Among those fanning out are Ana Hernandez and Bertha Ortega at Casa CHE, a community health education center in the Fruitvale neighborhood of Oakland that is operated by La Clínica de la Raza. Hernandez and Ortega said most people they meet are eager to enroll in Medi-Cal, but they don't know where to start. Many don't speak English, have limited literacy, and struggle to use or access computers. Forms are available in 12 languages, but users may not find their language, such as the Indigenous Mayan language Mam.

"The system looks friendly if you have a lot of experience using a computer," said Ortega, but that's not the case for most of the older adults she helps. "They come in here and we have to fix everything."

Californians without legal status make up the largest portion of the state's uninsured residents, estimated at 3 million by the UC Berkeley Labor Center.

To get many of them covered, state lawmakers have expanded Medi-Cal to immigrants living in California without legal authorization, rolling out the coverage in stages: First, to children in 2016, young adults up to age 26 in 2020, and seniors last year. Next year, full Medi-Cal coverage will become available to all qualified Californians, regardless of age or immigration status. Once that happens, close to 700,000 additional noncitizens ages 26 through 49 are expected to enroll, according to Gov. Gavin Newsom's office.

Yet for all the changes, the program's expansion to older adults may have been the most momentous. Not only do they tend to need the most care, they also cost more to treat because they are likelier to have chronic conditions such as high blood pressure and diabetes. Many don't regularly seek medical care or social services — a tendency exacerbated by the pandemic.

California will be the first state to expand Medicaid coverage to all immigrants. Illinois and Oregon have also expanded state-funded coverage to older adult immigrants, and New York plans to do so in 2024.

Even though Medicaid is a joint state-federal program, the federal government chips in only for emergency and pregnancy-related coverage for people without legal status, which means California taxpayers foot most of the cost of providing coverage, estimated by state budget officials at $878 million for immigrant seniors the first year.

When the expansion to seniors launched in May, people age 50 and older who were already enrolled in the limited form of Medi-Cal were automatically transitioned to the comprehensive version that offers dental, vision, long-term care, and routine medical treatment at no cost to most enrollees. And some Bay Area counties, including Alameda, Contra Costa, and San Francisco, had a leg up in identifying eligible people because they run health care programs for residents without legal status.

In recent months, community health advocates have concentrated on finding eligible seniors who have yet to hear about the expansion. Some have appeared on local television and radio news shows to get the word out.

"We know that there are more out there that are eligible but unenrolled," said Seciah Aquino, acting executive director for the Latino Coalition for a Healthy California. "We are working to make sure that numbers can continue growing and that everyone who now has the privilege to access this benefit is able to sign up."

A focus group study last summer, funded by the California Health Care Foundation, found that about half of Hispanic respondents hadn't heard about the change. An even smaller share of older Asian immigrants knew about it. Asians make up the second-largest group of California immigrants after Hispanics, who account for almost 40% of the state's immigrants. (California Healthline is an editorially independent service of the California Health Care Foundation.)

Some of the people who remain unenrolled are hard to persuade because they fear disclosing their immigration status to a government program, community health workers report. Medi-Cal applicants are required to disclose their immigration status on the application, but state officials say they are required by law to keep the information private and don't share it with immigration authorities.

Those assurances are often met with skepticism.

Many eligible seniors point to the Trump administration's "public charge" policy that made enrollment in Medicaid possible grounds for denying people legal residency in the U.S. Although that policy was overturned in December, fears linger.

Embriz, who had limited Medi-Cal coverage for many years, said she pulled out in 2020 because of the public charge policy. She didn't want her Medi-Cal enrollment to ruin her chances of obtaining a green card. But once she learned that signing up wouldn't affect her green card application, she agreed.

"It would make a big difference," Embriz said about getting routine checkups again. "I have a lot of hope."

For some older immigrants who have signed up, the ability to get full coverage has been a godsend. Maria Rodriguez, 56, of Hayward, learned in September that she was eligible while visiting the local Tiburcio Vasquez Health Center, a clinic that serves uninsured patients. A social worker helped her fill out the application online after a doctor had diagnosed her with diabetes and high blood pressure.

"It's like Medi-Cal fell from heaven," Rodriguez said. "It's very beneficial for my health."

Claudia Boyd-Barrett is a reporter with California Health Report. This article is produced in collaboration with California Healthline, California Health Report, and El Tímpano.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.