Paperwork woes keep some moms and kids from enrolling in Medi-Cal. Is an ‘express lane’ the fix?

Sarah Shirley often deliberates over what to put on the dinner table. At times, she’s had to ration milk and other staples for her sons, ages 2 and 3. She supplements with squash and greens from a backyard garden that’s become a lifeline. 

For months, she made regular trips from her Northern California home in rural Winters to various county agencies to sort out food stamp and health insurance enrollment, as well as nutritional assistance through the federal Women, Infants and Children (WIC) program. On days when she brought the boys along, they ran circles around the office as she tried to fill out forms. 

Shirley, 31, says the stress of applying for benefits — not to mention the gas expenditures — add a whole other headache to living in poverty.

“It makes it hard for me to be patient, to be kind, to be present and connected with them,” she said. “Because my mind is always somewhere else, my mind is always worrying.”

For many months, those worries stemmed from paperwork struggles while trying to get herself and the kids into Medi-Cal, California’s version of the state-federal Medicaid program for low-income residents. They’re all on a health plan now, but she says her youngest son went more than a year without coverage because of enrollment hold-ups.

“I tried to pursue it as aggressively as I could,” she said. “And I’m sure if I had gone in there and advocated for myself and for his Medi-Cal case and fought, I could have had it taken care of more quickly. But with everything else going on, it wasn’t a priority. Maintaining our food supply was a priority. 

Low-income mothers and their young children have distinct health care needs, but advocates say red tape and busy schedules can prevent them from signing up for insurance. A bill moving through California’s Legislature could better sync Medi-Cal enrollment with other public benefits, with the goal of connecting more vulnerable families to care. 

Supporters of the proposal say coverage is key to keeping down rates of maternal and infant mortality, which are both on the decline in California.

“It’s really the linchpin of healthy early childhood development,” said Kristen Golden Testa, director of the California nonprofit The Children’s Partnership, which is sponsoring the bill.

AB 526, from Assembly member Cottie Petrie-Norris, D-Laguna Beach, would streamline Medi-Cal enrollment for WIC participants, and vice versa. As it stands, uninsured women who sign up for the nutrition program are given a phone number or directed to another counter or office to enroll in Medi-Cal. It’s a separate pile of paperwork, even though the income-eligibility guidelines are similar. The bill would allow the two systems to communicate.

Golden Testa says WIC enrollees should be low-hanging fruit in the state’s effort to cover the remaining uninsured. 

“There can’t be any easier outreach than that,” she said “It’s one thing when you’re going to try to find eligible folks and enroll them, but we know who they are. We know their phone numbers, we know their names, and we know all their eligibility information.”

Still, 87,000 kids and 11,000 pregnant women — roughly 9% of California’s 1.1 million WIC participants — are not enrolled in Medi-Cal, according to the California WIC Association, a nonprofit that promotes WIC and related services.

“Our state has made a commitment to covering all kids,” Golden Testa said. “So, this is part of fulfilling that, and certainly making sure that we don’t lose traction.”

The California Department of Public Health, which oversees WIC in the state, and the Department of Health Care Services, which houses Medi-Cal, declined to comment on whether streamlining enrollment for the two programs would be helpful. 

Some low-income moms struggle with documentation — enrollees must provide income information, proof of residence and other forms. Periodic eligibility assessments can bump families off Medicaid and force them to reapply. Too many steps can lead potential enrollees to give up, and research shows it may be contributing to a rise in uninsured kids. 

There were 114,000 uninsured kids who were eligible for Medi-Cal in 2016-2017, according to the California Health Interview Survey. That’s 21% of the 543,000 Californians who are eligible for the program but not enrolled.  

Sarah Shirley says her problems with Medi-Cal were tied to a clerical error. She says enrollment workers had two cases on file for her younger son Winston, and they weren’t able to complete either one. 

She was constantly being referred to other caseworkers, she said. Without a policy number or a Medi-Cal card, she avoided the doctor’s office. She also was suffering from postpartum depression at the time. 

“I didn’t want to deal with the headache of finding another physician,” she said. “I didn’t want to deal with trying to access care and getting rejected, or getting another medical bill that we can’t pay. I just said, ‘OK, he’ll be OK.’”

Nolan Sullivan, who oversees Medi-cal enrollment for Yolo County, said application duplications can happen when someone moves between counties or applies through a local agency or Covered California, which “mucks things up a little bit.” 

“Part of the problem with having all these players in the pot is this does happen periodically,” he said. “It’s very infrequent, though.”

Shirley says that while Winston wasn’t seeing a doctor, she kept a close eye on his sniffles and fevers, and hoped immunity benefits from breastfeeding would protect him from anything serious. 

But Dr. Rita Hamad, a family medicine physician at UC San Francisco who studies the impact of policy on health, says kids need vaccines, asthma screenings and other care, and that skipping visits and taking shortcuts early in life can have long-term consequences.

“Living in poverty and not having access to healthy food, and the chronic stress of poverty, is really bad for people’s health,” she said. “All those things get under the skin to cause health problems, and really are the root of these huge disparities we see.”

The new Assembly bill would create an online “express lane” to allow WIC eligibility information to be used for Medi-Cal enrollment. It would also make it easier for Medi-Cal enrollees to sign up for WIC, by allowing the two programs to share enrollee data in a way that isn’t currently possible.

A legislative analysis says the changes would carry unspecified information technology costs, and Medi-Cal benefit costs “likely in the tens of millions of dollars” if large numbers of children and pregnant women enroll in health insurance. The state may be eligible for federal funding to cover the IT costs. The bill has no registered opposition. 

A similar bill last year did not make it to former Gov. Jerry Brown’s desk. Advocates are hopeful the new measure will pass, given Gov. Gavin Newsom’s stated intentions to give women and children a boost. 

California previously had an expedited Medi-Cal enrollment process for people in CalFresh, the state’s version of food stamps. It was a temporary program made possible by a federal waiver, and resulted in more than 400,000 people signing up for Medi-Cal between October 2013 and January 2015, according to the Centers for Medicare and Medicaid Services. 

Golden Testa with The Children’s Partnership says the federal government changed the rules for acquiring the waiver and California decided to opt out. But advocates consider the experiment a success.

Sarah Shirley says a system that could jointly manage her family’s CalFresh enrollment, WIC benefits and Medicaid insurance would be a dream come true. She also wishes there were more employees designated to help people navigate the system.

She imagines there are many other busy, low-income single moms feeling similarly overwhelmed by paperwork. 

“I cannot be the only person who has fallen through the cracks this way,” she said. “If they can just find a way to condense the enrollment … that would help.” 

She plans to apply for a county committee on health care access for rural residents. If she gets the spot, she says her top goal will be speaking up for moms and kids. 

INFOBOX 

ENROLLING IN MEDI-CAL

Residents can apply for Medi-Cal in multiple ways, including:

• Visiting the website www.CoveredCA.com or calling 1-800-300-1506
• Calling or visiting your local county human services office (give # appropriate to local area)
• Visiting www.benefitscal.com, a portal for several low-income state benefit programs 
• Filling out a 36-page form and mailing it in  
• Visiting a local county human services office in person. (sites can localize with one or two addresses relevant to their audience)

Applicants need to provide:

• their Social Security number if they are a U.S. citizen
• documentation information for immigrants with eligible status
• employer and income information for everyone in the family
• federal tax information
• information about health insurance others in the household receive
• proof of identification
• proof of finances

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