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By George White and Adriana Godoy Leiss

With more health coverage opportunities on the horizon, The California Wellness Foundation grantees are canvassing neighborhoods, staging health fairs and helping their communities navigate the uncharted territory of the Affordable Care Act.

For several weeks before and after the Oct. 1,  2013, open enrollment launch date for Covered California, concerned Californians have been searching for answers to questions related to major impending changes to medical coverage laws, including new regulations that could make insurance more affordable for some and provide a safety net for others who can pay little or nothing for the health care they need.

 Do I have to acquire private insurance? How much will it cost? How can I find a plan that’s affordable? Am I now eligible for Medi-Cal? If so, how do I qualify for that program? When do all of the changes take effect?

 These are some of the questions many state residents are asking. Health centers across the state are preparing Californians for change. That change is the Patient Protection and Affordable Care Act, the landmark federal law passed in 2010 that will provide affordable health insurance to more Americans. Enrollment was launched on Oct. 1, 2013, and coverage under the law is scheduled to commence January 2014. The reforms, commonly called Obamacare, include provisions that:

• prohibit health insurers from refusing coverage based on medical histories;

• require health providers to establish minimum care standards and electronic medical records for patients;

• require the uninsured to obtain health insurance or pay a financial penalty;

• call on states to establish private health insurance marketplaces where policies and rates can be compared; and

• expand Medicaid — and affiliated state-based programs such as Medi-Cal — to include more low-income Americans by extending coverage to adults without dependents.

Covered California, the health insurance marketplace in the Golden State, has been set up to help individuals compare health insurance plans and choose according to their health needs and budgets. For several months leading up to the launch, the state has been actively hiring and training certified health educators, enrollment counselors and licensed insurance agents. And through its Community Outreach Network, the state is making grants to health providers, nonprofit organizations, business and academic groups, and others to raise public awareness and understanding of Covered California.

While the state of California’s campaign efforts are underway, TCWF grantees that serve low-income and uninsured Californians are also answering many questions and working diligently to increase awareness among their own patients and networks about the expanded coverage.

“Outreach is urgent because many Californians — those with and without access to the Internet among them — need more information on the impending changes,” said Sandra J. Martínez, director of public policy at TCWF. “We need people who can explain the options and help residents get the message,” she said. Health centers from across the state, including many funded by TCWF, are involved in outreach.

Spreading the Word in the South Bay of Los Angeles County

The outreach team at South Bay Family Health Care (SBFHC) is staging health fair events and working with churches and neighborhood groups to inform the uninsured and low-income residents in the South Bay and Harbor Gateway regions of Los Angeles County. SBFHC, a federally qualified health center with medical centers in Gardena, Inglewood, Redondo Beach and Carson, serves nearly 20,000 patients annually. About 84% of them live below poverty leel and 36% have no medical insurance.

SBFHC’s medical centers are certified as patient-centered medical homes (PCMH), a team-based model of care in which patients are engaged in direct relationships with providers who coordinate all aspects of health care to increase wellness and quality of life. There are several provisions in the ACA directed at the establishment of PCMHs.

SBFHC is making progress despite challenges, notes John Merryman, senior director of marketing and public relations for SBFHC, which received a core operating support grant from TCWF in June 2013 to provide primary medical care to underserved residents. “Many of the people we’re trying to connect with change residences or telephone numbers regularly,” Merryman said. “It makes it difficult to reach them by mail or by phone.” In terms of mobile technology, Merryman said SBFHC is looking into developing mobile applications that will enable smart phone users — of which he says there are many in the service area — to access information. “While some may not have home computers, many have smart phones with Internet connections,” he said.

SBFHC has also been working with the Los Angeles Department of Health Services to enroll thousands of qualified, uninsured residents into Healthy Way L.A., a no-cost county health insurance program. Under the ACA, these patients will automatically transition to Medi-Cal on January 1, 2014.

Enrolling Urban American Indians in San Diego

With more than 52,000 people identifying as American  Indian or Alaska Native, San Diego County has the second highest Native American population in California’s 58 counties. One in five earns income below the federal poverty level, and nearly 30 percent of adults are likely to be uninsured all or part of the year.

While American Indians and Alaska Natives are exempt from the ACA’s individual mandate — also known as the shared responsibility payment — the federal government is encouraging enrollment because, it says, the law will address inequities, increase access to quality, affordable health care coverage, invest in prevention and wellness, and give individuals and families more control over their care.

However, because of attitudes rooted in historical relationships with the federal government, San Diego American Indian Health Center (SDAIHC) faces outreach and education challenges, according to Douglas Flaker, the organization’s chief administrative officer

Through the Indian Health Service (IHS), a federal agency within the U.S. Department of Health and Human Services, American Indians receive health services from tribal and urban Indian clinics free of charge, or at greatly reduced fees, as part of the U.S. government’s treaty obligations to American Indians. IHS mostly serves American Indians who live on federally recognized reservations and in rural communities. However, over the past five decades, many American Indians have left IHS’ service jurisdiction to move to urban areas, according to Flaker.

“It’s a cultural, historical problem,” he said. “Many have no history of connecting with private medical insurers or federal programs beyond IHS.” As a result of this legacy, the vast majority do not have Medi-Cal or private medical coverage.

SDAIHC is a federally designated Urban Indian Health Program, one of eight in California. It is also certified as a patient-centered medical home. In June 2013, the health center received a two-year, $150,000 core operating support grant from TCWF to provide primary medical care and dental services to underserved residents of San Diego. It provides health services to approximately 12,000 patient visitors per year — 60 percent of whom are Native American and 40 percent of whom include whites, African Americans and Latinos.

SDAIHC recognizes that outreach to San Diego’s American Indians on ACA coverage options warrants a culturally appropriate and unique approach.

“This is a population that suffers from historical trauma, mistrust of non-native health care systems and persistent bias of American Indian health disparities and status,” he said. “In short, there are distinct barriers that surround successful outreach to the American Indian population.”

To address the challenges, Covered California has partnered with the California Consortium for Urban Indian Health (CCUIH), a TCWF grantee, and the California Rural Indian Health Board (CRIHB) to produce outreach materials and training curriculums. In addition to Native American-led outreach at community events, including powwows and South Bay Family Health Center staged four health fairs during 2013 National Health Care Week in August that offered health screenings and information about ACA enrollment. The people most difficult to enroll are those [nonpatients] who are not currently sick.

Outreach in California’s Rural North

Mendocino County, along California’s north coast, is a largely rural region with isolated, small communities spread across wide-ranging terrains. Providing health care to the underserved in the county, as well as parts of neighboring Lake and Sonoma counties, are eight community health centers — all members of the Ukiah-based consortium Alliance for Rural Community Health (ARCH). The collaborative was formed in 1998 to facilitate resource development, concentrate and strengthen advocacy efforts, and share resources.

In June 2011, ARCH received a three-year, $255,000 grant from TCWF to strengthen infrastructure and sustain the provision of primary health care services at its member sites. Each ARCH health center is working toward becoming patient-centered medical homes.

More than 62 percent of the county’s residents obtain health services at ARCH member health centers. ARCH estimates that 9 to 11 percent of its patients have no insurance, and 40 to 45 percent of those it serves are Medi-Cal recipients. There are about 4,000 county residents — those without dependents — who can qualify for Medi-Cal under the expansion that begins in January 2014, according to ARCH.

ARCH member clinics are spread out across a vast, but lightly populated county where many residents are isolated. And with few public billboards and no locally owned television stations, informing people of their eligibility and options has been challenging. ARCH’s certified outreach educators and enrollment counselors are canvassing grocery stores, laundromats, libraries and public events to inform residents, and presenting information in English and Spanish. ARCH is also helping patients enroll via computers at its health centers, by telephone and by mail.

“The people most difficult to enroll are those [nonpatients] who are not currently sick,” said Paula Cohen, chair of ARCH’s board of directors and executive director of Mendocino Coast Clinics, Inc., an ARCH member. “We’re dedicated to getting them interested enough to want to know more.”

Article from The California Wellness Foundation’s magazine “Grantee”

SDAIYC Youth – (photo courtesy of SDAIYC)

By Jacie Scott

The San Diego American Indian Youth Center (SDAIYC) is one of the many successful Prevention and Early Intervention (PEI) programs funded by the Mental Health Services Act. Part of San Diego’s American Indian Health Center, the SDAIYC is an urban youth clinic serving primarily American Indian and Alaska Native youth between the ages of 9-22 years old. Unlike some youth “drop-in” centers, the SDAIYC requires youth to maintain a membership with the youth center, to encourage community and commitment to the program, while providing a strong foundation for mental, behavioral and cultural well-being.

The development of a well-rounded cultural self-identity is an important aspect of the SDAIYC. Moreover, the youth center strives to offer members the support, guidance and skills necessary to make important academic decisions and healthy life decisions. A variety of therapeutic, cultural education classes and activities are offered, some of which include drug and alcohol prevention; health and fitness education; current events discussion; healthy cooking classes; exercise groups; Native American art and dance classes; inter-tribal sports; American Indian life skills; spiritual talking circles; and individual, group and family counseling.

In providing these services, the center encourages personal growth and works to prevent substance abuse, domestic violence, bullying, STD’s and teen pregnancy, along with any negative involvement with the legal system. Furthermore, by offering healthy alternatives, youth are better prepared to handle difficult life situations and take care of both their body and mind.

[blockquote]”If it wasn’t for this program I don’t know where I’d be today. All the mentors taught me everything I need to know from this point on.” – Daniella [/blockquote]

In addition to these activities, youth counselors and volunteers also provide tutoring and homework-help for students from elementary school through college. Jesse, a former youth member and current SDAIYC staffer shares, “The youth center helped me plan for my college career. I plan on being a doctor, and the counselors helped me find out what I need to do and what schools I need to go to.” Whether students are interested in college, trade-school, or finding a job, the SDAIYC staff supports youth’s goals for the future.

The SDAIYC is invested in its youth’s cultural understanding and educational success, and the staff does everything they can to ensure students are prepared to take on responsibilities of the working world. Christopher Scott, SDAIYC’s Youth and Family Services Coordinator, states “[We have had our] successes and challenges, but what’s greater is seeing our youth grow.” Several of the youth who start out as members of the youth center eventually become SDAIYC volunteers and employees. Their investment in the youth center shows both their maturity and the importance of the services they received; as they would like nothing more but to mentor their peers in the same way they were once helped by their own mentors.

Among the many youth members who have since become employed at the SDAIYC are Daniella and Gabriel. Daniella, current SDAIYC staffer and youth mentor, shares, “About two years ago I went to my first Pow Wow, and that’s where I met Christopher – and that’s probably one of those moments that’s changed my life.” Daniella had only heard about the youth center before, and went to a Pow Wow with her sister to check it out. It was there she was convinced that the youth center would be a great program for her. Daniella came to the center as a high school student, and after being a youth member for about two months she was offered a job opportunity at SDAIYC.

Daniella says, “Working along side Christopher in the youth center, I was basically taught everything you could possibly do with a first-time job….It’s taught me how to be a better person and how to do everything I need out there in the work-world, socially and mentally, everything.” Daniella is very thankful for the SDAIYC program and mentors and explains that it was the SDAIYC that motivated her to finish high school and get her diploma. Along with working at the youth center, Daniella is also a full time college student, at San Diego City College. “All the mentors taught me everything I need to know from this point on. If it wasn’t for this program I don’t know where I’d be today… It’s been two years…and I’m still working there to this day, I’m still with it,” Daniella states.

Gabriel is another youth member who has since become a counselor at the SDAIYC. Gabriel smiles and says, “My story is actually one of pure luck.” After graduating high school, Gabriel had difficulty finding a job, and after an unsuccessful job hunt decided to volunteer to keep busy during the summer. Fortunately, not long after his decision, he learned that the SDAIYC needed volunteers. Gabriel explains, “Even though it was a volunteer position, I treated it like a job. I showed up with a collared shirt on the first day, and it was awesome…[I became a youth member] and for a few weeks I just got to hang out [with the youth], and next thing you know a volunteer position opened up.” Not long after Gabriel excitedly joined the SDAIYC staff as a youth counselor.

Along with working at the SDAIYC, Gabriel is also going to San Diego City College and plans to transfer to San Diego State University to pursue his Bachelors Degree in Child Development and a Masters in Special Education. Gabriel is very thankful for the way the youth center has helped him and provided him a job with lots of social interaction and workforce training. Even more, Gabriel shares his gratitude for the PEI funding that has allowed for the creation and success of the SDAIYC program. Gabriel states, “Overall, PEI funding has given me the ability to have a job and the opportunity to learn how to work in the real world and many, many youth do not have that. We have trade-schools, but what if a kid wants to strive beyond a plumber, strive to a CEO position? We need PEI programs to help them do that.”

Published in the Mental Health Services Oversight and Accountability Commission (MHSOAC) Newsletter, July 2012

DOWNTOWN SAN DIEGO — A downtown San Diego clinic is struggling after Gov. Arnold Schwarzenegger wiped out a $6.4 million program for community clinics serving American Indians in urban areas.

The San Diego American Indian Health Center has laid off 10 people, a third of its staff, and has been forced to close Wednesdays after it lost more than 20 percent of its budget.

“You just can’t replace $543,000 overnight,” Chief Executive Joe Bulfer said.

A spokesman for the state Department of Finance said the cuts to clinics were part of $489 million in line-item vetoes required when the Assembly refused to go along with a budget deal the Senate approved in August.

“The veto was not the result of the governor having any issue or concerns about the programs,” spokesman H.D. Palmer said. “The governor was compelled to reduce general fund spending as much as he possibly could.”

The cuts are being challenged in a Sacramento appeals court, with a decision expected later this year.

Dr. Chelsea Richardson and dental assistant Franco Gonzalez gave Orlando McCollum a temporary crown yesterday at the San Diego American Indian Health Center. (Nelvin C. Cepeda / Union-Tribune)

When cutting overall state health care funding, Schwarzenegger said many of the 788 clinics affected would continue to get money from other sources and were in line for federal stimulus grants.

Federal stimulus grants have helped community clinics or clinics on reservations, but not the eight clinics that focus on American Indians who live in cities, said Paula Brim, who heads the San Diego clinic’s board.

“We fell through the cracks,” she said.

In the meantime, patients who go to the cramped clinic on First Avenue just north of Maple Avenue on Wednesdays won’t get service and may have to wait longer on the days the clinic is open.

“How are we going to be able to provide the quality care to those in need?” asked Medical Director Edwin Cabrera. “It’s making it much more difficult.”

Such medical providers “do a lot with very little money,” said Jyl Marden, head of the California Consortium of Urban Indian Health.

“;How are we going to be able to provide the quality care to those in need?”; asked Dr. Edwin Cabrera, the downtown clinic’s medical director.

The state committed to funding health care for American Indians in 1954, when it took over many federal responsibilities, including education and policing reservations, said James Crouch, executive director of the California Rural Indian Health Board.It created the Indian Health Program 40 years ago in response to a report on unhealthy conditions on reservations. The program grew slowly, eventually funding clinics in cities.

Tribes fund clinics, Crouch said, but their resources are finite. A fraction of California’s 109 tribes have successful casinos. Plus, many of the people served in urban clinics like San Diego’s come from elsewhere in the country.

The San Diego clinic helps the government fulfill its commitment to health care by making sure it matches the special needs of its clientele, 59 percent of whom are American Indians, many living near the poverty level.

“We have an understanding of the cultural and spiritual needs of Indian people,” Bulfer said.

Mental health services take native traditions into account and clinicians make sure patients understand what’s going on because Indian patients might not ask many questions during exams, said Douglas Flaker, a fundraiser.

Union-Tribune San Diego