More than 700,000 eligible for free or low-cost health insurance in California may not sign up

The doctor and nurses at the Coachella Valley Volunteers in Medicine clinic in Indio know many of their patients qualify for free medical insurance – and they tell them that. But many of the patients simply don’t sign up.   

The free clinic – which is funded through gifts, grants and donations and receives no government reimbursements – serves about 1,000 individuals a year. It could lessen its caseload or serve new clients if many of its patients who are eligible for Medi-Cal, the state’s health program for low-income people, would actually sign up. Once enrolled, those patients could be seen at a variety of health facilities, not just CVVIM.  

So what’s holding them back? The staff at the Coachella Valley Volunteers in Medicine say there are many factors, including fear of signing up and lack of knowledge how to. 

“First, sometimes it’s as simple as they don’t understand their eligibility or how or where to apply,” said Doug Morin, CVVIM’s director. “Second, many documented individuals fear retribution for family members who may not be documented from (Immigration and Customs Enforcement) officials and even general law enforcement.” 

Hundreds of millions of dollars have been spent in California to inform people about their eligibility for Medi-Cal. But experts are now wondering: Once people are informed, what carrots and sticks can be used to actually get them signed up?

More than 700,000 projected to qualify for insurance but won’t sign up

Approximately 543,000 Californians were eligible for Medi-Cal coverage in 2016-17 but not enrolled, according to data from the California Health Insurance Survey. But researchers from UC Berkeley and UCLA expect that figure could approach 730,000 in 2020.

The state is working on multiple fronts to bring down the number of uninsured:

• California recently expanded Medi-Cal to undocumented young adults ages 19 to 25. This expansion, starting Jan. 1, will cover an estimated 90,000 additional young adults and cost the state $98 million annually.  
• Researchers say new subsidies that take effect in January may also reduce the number of Californians who are uninsured. The subsidies are for individual Californians who earn between $50,000 and $75,000 and families of four earning $103,000 to $155,000. But the new subsidies won’t impact the poorest populations, because those people already qualify for free coverage. 
• The state is also adopting penalties for those who refuse to sign up for insurance. A new California mandate means currently uninsured residents will need to sign up for insurance during open enrollment (between October and January) or pay a $695 fine during the next tax season.

Bradley Gilbert, executive officer of the Inland Empire’s Medi-Cal and Medicare health plan, predicts the mandate will lower the number of uninsured. But he doubts it will result in 100% of eligible people enrolling.

Gilbert said the positive note is that many of the uninsured qualify for free or low-cost state-subsidized insurance, but “the frustrating part” is identifying why they are uninsured and finding new ways to educate them.

In 2018, Covered California — the state’s healthcare marketplace established under the Affordable Care Act — spent more than $111 million on outreach and marketing efforts. That’s far more than the entire federal government: In 2017, President Donald Trump cut federal spending on advertising for public health exchanges from $100 million to $10 million. 

The people most likely to be uninsured despite qualifying for Medi-Cal are the poorest and most isolated, Gilbert said. 

Gilbert’s organization, IEHP (Inland Empire Health Plan), plans to expand outreach efforts with more targeted flier campaigns and social media ads on YouTube and Facebook, trying to reach those who remain misinformed or fearful. 

Gilbert said he’s able to target ads to sub-zones of ZIP codes that have high numbers of uninsured individuals. He said Coachella Valley is a big focus area for the program’s outreach efforts.

Studies have shown that people living in regions with targeted advertising efforts and sign-up assistance are more likely to enroll in a health care plan, according to a report by The Commonwealth Fund, a private foundation aimed at supporting health care research and policy advocacy. The studies showed the outreach particularly helped increase enrollment in lower-income black and Latino communities in California. 

Overall, California saw a 25% higher rate of health insurance marketplace sign-ups in 2018 compared with federally facilitated health care marketplaces in other states, according to the Commonwealth report. Experts attribute this to California’s decision to invest more in education and outreach at a time when federal outreach funds have been diminishing.

While California has put an emphasis on outreach at schools and colleges, other states have taken even more innovative approaches. Rhode Island has run ads on pizza boxes. Washington state has advertised on Hulu, Netflix and Spotify. 

‘I tried to sign up on my own but kept having issues’  

Blyphe Sproft’s situation illustrates why attempts to reach the hardest to insure might fall flat.

Sproft, 58, is living at the Coachella Valley Rescue Mission, an emergency shelter in Indio. He doesn’t have a job and doesn’t file taxes, so a tax penalty doesn’t daunt him. And without a permanent address, he’s unlikely to receive mailed fliers or online advertisements targeted by ZIP code. 

Sproft said he has been aware of Medi-Cal for some time and has been trying to sign up because he needs to see a cardiologist. But he’s hit some roadblocks. “I tried to sign up on my own but kept having issues going through the process,” he said. “I need to try again and maybe go to the social services office to get help. I don’t really know what I’m doing.”

Sproft said he didn’t have an identification card the first couple times he attempted to sign up on his own. He needed to show proof of age, citizenship, identity and finances -- documentation that he didn’t have on hand. Typically, identity, age and citizenship requirements are fulfilled when one presents a state-issued identification card, driver’s license or U.S. passport. Bank account statements and recent pay stubs are frequently used to verify an applicant’s financial situation.

Abner Diaz Andrade, 36, another client at the rescue mission, didn’t know Medi-Cal existed until recently. For the past eight months, he was in the Riverside County Jail, where he received health care, but before that he was homeless and uninsured for four years.  He started the process of signing up for Medi-Cal and other public benefits like food stamps in mid-July. 

“I just got my (Electronic Benefit Transfer) card the other day. I’m not sure how to sign up for Medi-Cal, but the caseworkers here are helping me through the process,” Andrade said three days after his release from jail. “Before, I never thought to ask if something like this insurance existed because I didn’t have medical issues, so I didn’t need medical care, but it’s definitely important in case you have a medical emergency.”

Some Californians who qualify for Medi-Cal don’t realize the program is free and don’t sign up because they are wary of cost. (An individual earning less than $17,237 a year would qualify, as would a household of four people with a combined annual income of $35,535 or less.) 

Others may be aware that they qualify for Medi-Cal but are averse to enrolling because a friend or family member told them about an unfavorable or confusing experience they had. 

In another category are Californians who have family members or friends who are undocumented immigrants; they might be wary of connecting with government-provided services for fear it could expose loved ones to punishment or deportation. 

Morin, the director of the free clinic in Indio, said he has patients who applied and were approved for Medi-Cal after their initial appointment with CVVIM but still choose to seek services at the free clinic because they feel safe there and trust that the clinic won’t share their family’s immigration status with others. 

“This fear began several years ago as you know, but recently became an issue again when deportation raids were announced in the media,” said Morin. “We keep information in all of our exam rooms about the legal rights of undocumented immigrants. We have to copy these weekly as our patients take them for themselves, a family member or friend. I would guess we copy upwards of 10 to 15 per week.” 

Despite expanding Medi-Cal eligibility to undocumented young adults, state officials said concerted outreach is necessary to overcome immigrants’ fear of declaring their documentation status. The federal Immigrations and Customs Enforcement agency will not have access to names of those who signed up for health care coverage in California, according to the state.

CVVIM polled about 500 of its patients in 2018 and found that 30% had visited an emergency room in the past six months, with 90% seeking care for a non-emergency reason. Unnecessary, unpaid emergency room visits are absorbed by the hospitals and inflate the cost of care for all. 

“Now that I know it’s an option, I think free insurance would be good,” Andrade said while he waited for the rescue mission’s lunch service to start. “I still don’t know what to do to sign up, but I hope the caseworkers here will be able to walk me through it.” 

Follow the USC Center for Health Journalism Collaborative series "Uncovered California" here.