Bridging the Rural Divide in California's Medi-Cal Services
The story was originally published by Ethnic Media Services with support from our 2024 California Health Equity Impact Fund.
Four years after its founding in 1941, Tulelake became the site of a vast internment camp for 18,000 Japanese Americans during World War II. Activists today say this small, majority-Latino farming community is one of the most underserved in Siskiyou County.
(Credit: Manuel Ortiz.)
TULELAKE, Ca. – In March voters in Siskiyou County’s District 1 headed to the polls to elect their representative on the county’s Board of Supervisors. Among the three candidates, two listed as their top priorities law enforcement and support for farmers.
Angelina Cook, the third candidate, made public health access her lead issue.
“My motivation to run was to address the litany of unmet needs in the county and public health is ground zero,” explains Cook, managing director for the McCloud Watershed Council in the town of McCloud, on the south end of Siskiyou County. “Without physical health, there is no economic health,” said Cook.
She lost by a wide margin.
Once the “timber basket” of California, Siskiyou today ranks among the poorest counties in the state and is consistently at or near the bottom in terms of health outcomes, according to a 2023 report by the California Center for Rural Policy at Cal Poly Humboldt.
Cook calls District 1 – which spans much of the county’s eastern half – “the most under-served and unrepresented off all the disadvantaged communities” in Siskiyou and blames the county’s elected officials for “focusing on recruiting big industry, rather than addressing local needs.”
Laura Perez runs the Early Head Start program in Tulelake, where she has lived for more than 30 years. “We don’t have any support for the families here,” she says of the area’s lack of health care infrastructure.
(Credit: Peter Schurmann)
For residents of Tulelake, a small, majority-Latino farm worker community on the eastern edge of District 1, that disconnect has heavy consequences.
“We only have one clinic, and they are scheduling out months ahead. We don’t have a pharmacy. We don’t have transportation. There are no providers,” says Laura Perez, who runs the Early Head Start program in Tulelake. Those who need immediate care must travel 30 miles across the state border to Klamath Falls in Oregon, where doctors may or may not accept Medi-Cal depending on who is on staff any given day.
Perez talks of waits of up to a year for new Medi-Cal applications to be processed by the county (according to the California Department of Health Care Services the process should take no longer than 45 days) with patients paying out of pocket in the interim. For those who do get coverage, available services are limited and often far away.
A grassroots effort to meet health care needs
Yet in Tulelake, a grassroots movement is slowly gaining momentum to promote health care education, help residents navigate available resources, and overcome the distrust that prevents many from seeking care.
The timing couldn’t be more important.
On Jan. 1, California made Medi-Cal (the state’s version of Medicaid) available to all eligible residents regardless of immigration status. At the same time, the state is also undertaking a dramatic expansion in services covered under Medi-Cal to address the social drivers of health. Things like poverty, nutrition, housing – issues once seen as outside the purview of the traditional healthcare setting, and highly salient for residents here – are now considered legitimate targets for Medi-Cal services.
The challenge for activists in Tulelake is learning how to leverage the resources Medi-Cal wants to implement. At the fore of that effort is the non-profit TEACH (Training, Employment, and Community Help) Inc.
Just south of the Oregon border, Tulelake is both stunning in its natural beauty and striking in its isolation.
(Credit: Peter Schurmann)
“I help clients with different applications,” says TEACH Family Peer Support Worker Leticia Reyes. “Medi-Cal, Cal Fresh, Cal Works, low-income energy assistance and pretty much whatever they need. We’re the only place in town that does this.”
Reyes’ colleague and fellow Tulelake native, Kelly Harris says the agency – with a staff of just three – logged some 1600 hours since June of last year helping residents apply for Medi-Cal, work for which the agency is currently not funded to do. Barring this, residents would have to make the two-hour drive to the county seat in Yreka.
Asked why the county doesn’t have more of a presence in the community, Reyes shrugged. “I’m not sure. They’ve never come even to give us a training.”
Multiple attempts to reach officials with the county for this story went unanswered.
Harris says part of the issue is that most of the county’s attention – and funding – centers along cities and communities that parallel the I5 corridor which runs north-south through the center of Siskiyou. Places like Tulelake, far to the east and a stone’s throw from the border with neighboring Modoc County, tend to get left out.
Lost in translation
Then there is the language divide. Many of Tulelake’s residents are monolingual Spanish speakers and require language assistance when applying for benefits. (The county’s Medi-Cal website is only available in English, with a phone number to call for those who need support in Spanish.)
Reyes recounts a disturbing encounter one of her clients had with a county-contracted interpreter.
“Maria is my client. When she first arrived here two and half years ago, she applied for Medi-Cal. Her husband wasn’t working. She wasn’t working.” Two weeks passed and a call came from the interpreter. “Why don’t you work? Why do you always have to depend on the government,” she asked Maria.
According to Reyes, this wasn’t an isolated case. Other residents seeking to enroll in Medi-Cal had had similar encounters with this same interpreter.
Reyes says she put in multiple calls to the county to complain. “Nothing ever happened. I called the front desk and they said they would pass it on to the supervisor. No supervisor ever called. Ever.”
Eventually Maria was able to get herself and her husband enrolled. But as Reyes explains, the pair later lost coverage once her husband began working in the fields and his income put them over the eligibility limit. The problem is that farm work in Tulelake is seasonal. And once the season ended, Maria and her husband tried to get re-enrolled.
“And once again the interpreter called. ‘Why do you guys keep doing this? You guys need to get another job. Stop depending on the government? It’s not ok.’ And once again I complained,” said Reyes.
That was in February. The county has yet to respond.
The ‘community is showing up’
Renee Camila is a practicing doula and the co-founder of SOAR Siskiyou. Here she explains how traditional practices can help build a bridge to improved public health in communities like Tulelake.
Perla Ruiz, who moved to Tulelake from Mexico in 2014, works as a Health and Education Specialist in Modoc County where she helps manage a program connecting families to health services, including things like nutrition and transportation, key challenges for many here.
On her off-hours, she runs local dance classes for residents and last year helped design a float for the local Dia de los Muertos parade. The float, which featured papier mâché doulas, won first prize.
“Every year more families are arriving from Mexico,” Ruiz says in Spanish, “many without documents or seeking asylum. And they don’t know that these services exist, or they’re afraid to ask. In most cases, they are eligible.”
In the absence of support from Siskiyou County, Ruiz says residents are looking out for one another. She gives as one example an older woman who works at a nearby store selling goods from Mexico who, on her down time, offers people rides to appointments, or helps review any pieces of mail from the county or state.
“There aren’t many options other than for us to help one another,” she says.
Renee Camila agrees. Camila was born and raised in San Francisco. The daughter of immigrants from Nicaragua, she moved to Siskiyou nine years earlier. An herbalist and trained doula, she helped launch SOAR Siskiyou in 2021 (the name stands for Seeds of Ancestral Renewal) to support the health needs of low-income communities of color in the county.
“The thing that is so unique about Siskiyou as a whole and the thing we’re seeing here is that despite the lack of resources, despite the distrust, the community is showing up,” she explains.
SOAR draws on art, culture and traditional practices to build a bridge with migrant communities who might otherwise feel alienated by social services like public health. Camila’s team recently paired with promotoras, community health workers and local artists for a community health workshop – the last of four organized by SOAR in Tulelake – focused on maternal and mental health, and community/family relationships.
‘Relationships & trust’
Residents join in a traditional textile workshop as part of a community event organized by the non-profit SOAR Siskiyou focused on maternal and mental health, and community/family relationships.
(Credit: Peter Schurmann)
Cook applauds these efforts, but worries they won’t be enough to bring needed resources.
“Things get so desperate that volunteers do eventually show up,” she says, calling Tulelake a “poster child for underserved communities in Siskiyou.” But, she says, “that won’t bring people who have the resources to do what is necessary.” She adds, “And those who do have the resources are in air conditioned offices in Yreka.”
Still, connections are expanding, if incrementally.
At the entrance to the SOAR event, Partnership Health, the managed care network that covers Siskiyou and some 24 other counties in the north part of the state, set up an information table with a Spanish-speaking representative who had just come from presenting a workshop four hours’ drive west in Del Norte County.
“We’re familiar with access challenges in rural California. Even harder challenges with this adult expansion,” says Partnership Health Chief Strategy & Government Affairs Officer Amy Turnipseed.
According to Turnipseed, Partnership Health has enrolled 70 new patients in Tulelake since Medi-Cal’s adult expansion phase began January 1. It is also working to bring in more providers through an ongoing recruitment program and expand the number of community health workers in the area.
“Workforce and access are issues across all Medi-Cal providers, but in particular in rural communities,” she explains. “We do acknowledge this and try and support that by incentivizing providers to build foundations and roots” in the communities they serve.
“The way you reach this population is through relationships and trust,” notes Turnipseed. “It is being present, and working with the providers who know the communities.”
Additional reporting by Manuel Ortiz.
