by Leslie Layton
Kenyatta Aarif knew her high blood-pressure reading had startled two student nurses from Chico State. The nursing students were conducting a public-health outreach project in Oroville’s depressed Southside neighborhood, checking the blood pressure of the willing every Thursday during their fall semester.
She assured the students, stationed across the street from her small soul-food restaurant, that she’d refill her prescription for medication right away. “I scared those kids to death,” Aarif said of her first screening.
Aarif told herself something different — that she’d watch her diet more carefully. Then, a few weeks later, Aarif — who says she’s in her 40s — had two heart attacks and a stint inserted into a clogged artery at Enloe Medical Center in Chico.
Aarif had no health insurance, nor the money for the exam she needed to get her prescription renewed. She hadn’t been able to access routine health care — a problem that’s common amongst California’s uninsured, but more acute in rural counties where there are fewer low-cost clinics, public-health services and non-profit health initiatives. Aarif has no car, and public transportation out of Southside is limited.
The lack of care probably led to an emergency that was far more expensive than the cost of an exam and a bottle of pills would have been. “It doesn’t make sense that in the richest country in the world, I can’t get health care,” Aarif said.
The federal health-care reform law is designed to address Aarif’s complaint by making millions of low-income adults who have no dependent children, eligible, for the first time, for Medicaid — government health insurance that has traditionally been provided poor families and disabled individuals.
But Second District Congressman Wally Herger, who represents rural Northern California, pledged Jan. 6 to “help lead the effort to repeal ObamaCare” in his new position as chairman of the Ways & Means Subcommittee on Health, according to his website.
The funds for the Medicaid expansion — the largest since the program’s creation 40 years ago — have already been earmarked. But the Patient Protection and Affordable Care Act of 2010 also has a public-health component that would support the kind of healthy-lifestyle program that might have helped Aarif avert heart problems in the first place.
Funding for the public-health component still has to be appropriated by Congress and is very much at risk in the upcoming battles over the new law, said Anthony Wright, executive director of the consumer-advocacy organization Health Access. Yet, especially in rural counties, better preventive care could help reduce spiraling health-care costs.
Aarif said she was stunned that she was released from Enloe with only the most general of instructions. Lose 100 pounds, lower your cholesterol, don’t smoke, doctors told her. Until she begins cardiac rehabilitation this spring, she’s on her own.
In a late-December interview, Aarif said she hadn’t smoked since the day of her heart attacks, but wasn’t sure how to go about such a huge weight-loss task. She said she made some notations from a nutrition chart on the wall of her cardiologist’s office, but no one could find an extra copy of the chart for her.
“Nobody has told me how to take care of myself,” she said. “Not a lot of care has gone into this; I’m kind of flying blind. I guess keeping poor people alive is not good business. If you’re poor and alive, you’re using up too dang much money.”
Aarif exemplifies America’s working poor — a group growing in numbers that includes many self-employed and small business owners — who are among the uninsured or under-insured. She has a small income that precludes her from getting full coverage under Butte County’s health plan for indigent adults, County Medical Services Program.
The eligibility criteria for California’s CMSP hasn’t been adjusted in more than 25 years; for a single person, anything over $600 a month is likely to be considered disposable income that can go into health care. That means that many CMSP recipients must pay such a high monthly deductible they can’t afford routine care.
The lack of routine care for the poor shows up in the chronic illnesses that plague Butte County and in hospitalization rates for preventable disease. More than half of Butte County residents diagnosed with heart disease in 2007 earned $30,000 a year or less, UCLA research shows.
In most parts of the Northern Sacramento Valley, obesity and smoking — factors that complicate disease management — are more common than in other parts of the state. And the counties pay a high price in hospitalization rates for several illnesses that can usually be managed by seeing a doctor, a new state study says.
High hospitalization rates for the illnesses that were studied suggests that “people aren’t getting the primary care they need,” said state Research Analyst Mike Kassis. (See sidebar: “Sickness in the 2nd District.”)
The federal law, set to take full effect in 2014, will extend Medi-Cal programs to thousands of low-income adults by removing most asset and resource limitations and raising the income roof for eligibility. That expansion could begin this year in California counties that have large public-health systems and have moved to take advantage of the state’s early implementation program. But implementation will take longer in small counties like Butte that have no public hospitals.
The earliest that Medicaid expansion could begin in Butte and 33 other small counties is July 1, 2012, said the state’s CMSP executive director Lee Kemper. Counties must put up matching funds for early implementation and meet dozens of federal requirements, he noted.
Cristi Roach, a Butte County eligibility program manager for food stamps and Medi-Cal, said social service agencies as well as the medical community will have to jump infrastructure hurdles. Roach said she already has 40 new caseworkers in training to handle the growth in caseloads over the last two years. With social workers sometimes managing up to 500 cases each, a Medi-Cal expansion would force her to “staff up” further, and she’d need funding for that, she said.
Meanwhile, the federally-funded Del Norte Clinics are expanding to meet what could be a dramatic increase in demand for doctors who accept Medi-Cal insurance. CEO Benjamin Flores said the Chico, Lindhurst and Hamilton City clinics are expanding with funds provided in connection with the new law.
Specialists in rural Northern California who accept Medi-Cal will continue to be difficult to find, health-care providers say.
That’s one reason the public-health components in the new law are crucial. “Preventing disease is very important to lowering costs and bettering outcomes,” said Ken Logan, a doctor who works at Chico Family Health Center. “This cannot be done without strong preventive medicine components.”
Logan said that too often in the United States, instead of providing preventive care, “we wait and do the fancy bypass when they come in.”
The new federal law’s public-health components would include tobacco cessation and nutrition programs, and an expansion of breast cancer education and screening.
That could be welcome news in Butte County, which struggled to meet demand for breast cancer screenings for uninsured women this past year.
In October, when Chico organizations and businesses partnered with the California Health Collaborative to run a free, one-day mammogram screening for uninsured women, they were overwhelmed by demand. Women began lining up at the local radiology clinic at 4:45 a.m. in the rain. One man asked permission to spend the night before the screening in the parking lot to ensure that his wife would get her first mammogram.
Laverna Hubbard, who helped run the screening as both a member of Soroptimist Bidwell Rancho and as executive director of North State Radiology, assured the couple they could return early the next morning.
While Northern Californians form pre-dawn lines for cancer screenings, Congress is poised for a fight over funding the new law and the law itself.
Health Access’s Anthony Wright says this next battle will be fought at both the state and federal levels. “There will be awful proposals to cut the budget for health and human services infrastructure,” Wright said. “To cut these programs harms the ability to care for patients now… and [under] the new federal law.”
This series was funded by a New America Media health reporting fellowship. Part III will look at health care reform and women’s health.