In 2015, immigrant advocates applauded a bold decision by Fresno County leaders to set aside $5.6 million to pay for specialty medical care for thousands of poor and undocumented residents without health insurance, expecting that the money would be spent within three years.
But four years later, the controversial program that was dubbed a “social experiment” by one opponent has spent less than $1 million of the earmarked money, with far fewer residents than anticipated completing the application process. Those who have, meanwhile, face long waits for care because of a lack of providers.
Health care officials and activists have cited a number of factors for why the effort has not gone as planned: a complex application process, insufficient outreach to the immigrant community, and growing fears of government programs stemming from the Trump administration’s crackdown on undocumented residents.
Under the current political climate, Clinica Sierra Vista in Fresno is “struggling with getting (patients) into our clinics,” said Cassandra Martinez, who works at the health clinic, which refers patients to the county specialty care program.
“The fear is definitely there, and the desire of helping is also there, it’s just a matter of how do you do it,” she said.
Fresno County supervisors voted to free up the money for specialty care services such as cancer care, gallstone surgery and broken bones in April 2015 by deferring repayment of road funds to the state. But the rollout was slow, and program spending has plunged in recent years.
The county spent nearly $440,000 on services in the 2016-17 fiscal year, but the number dropped to $273,227 in 2017-18. As of April 29, $110,495 had been spent in the fiscal year that started in July. All told, the county has spent $847,738 of the $5.6 million over four years, according to an analysis by the USC Center for Health Journalism News Collaborative.
David Pomaville, director of the Fresno County Department of Public Health, said he couldn’t draw conclusions from the spending data but added that he believes “people are more concerned about disclosing information as a result of tighter immigration controls.”
Immigrant advocates say fear is not the only reason residents haven’t sought services. A complicated application process has limited sign-ups from the start, they say.
To be referred for specialty care under this pot of money, patients must have had at least one visit with a primary care provider within the past year at a federally qualified center.
Additionally, patients are required to apply for Medi-Cal, the federal-state health insurance program for low-income residents. The application is several pages long, and has to be signed by medical staff, the patient and the provider, said Miguel Rodriguez, chief operations officer at United Health Centers, one of three main partners with the county.
“The process itself requires you to fully vet the patients, so they don’t have any other health insurance. ... That creates a little bit of a bottleneck,” he said. “That’s a lot of steps to have to jump through to get them on to the program.”
In 2016, the county estimated that 4,000 to 5,000 undocumented residents could seek specialty care services annually. At the time, advocates argued that the county deliberately created a cumbersome application process to limit their participation.
But Pomaville said the county’s application process was designed “to make sure that any payer source was identified and exhausted before the county’s dollars were used.”
He did acknowledge doubts raised by advocates about whether the county would have enough money to pay for all the eligible residents who might apply. “Certainly, that was a concern,” he said. “Any time you deal with a health care program ... you have to know and understand what your costs are going to be.”
Specialty providers receive the same pay under this program as under Medi-Cal. These low reimbursement rates “really slimmed down the number of providers that would accept (patients),” said Rodriguez of United Health Centers.
And there are long delays to see those specialty providers who do participate.
“We can get patients into the program, but they are still having to wait,” Rodriguez said.
In a recent case, a patient had a heart attack while waiting for an appointment with a cardiologist, said Reyna Villalobos, director of programs and population health at Clinica Sierra Vista. The patient survived.
“If it’s taking a year to get in to see a specialist, that doesn’t do the patient any good.”
Patients referred and approved for specialty services receive care at Community Regional Medical Center in Fresno.
The wait for procedures is often months, but the average time depends on the type of specialty care they need, those involved in the program say.
As of April 29, a total 1,344 referrals had been approved and another 184 were denied, according to data analyzed by the Center for Health Journalism Collaborative. The largest chunk of referrals — 32% — was for radiology, followed by 14% for gastroenterology, 13% for cardiology and 10% for outpatient surgery.
Other specialty requests were for services in oncology, neurology, pulmonology, gynecology and urology.
Fresno County would like to see a permanent fix to cover these kinds of health services for the undocumented, but that would have to come from the state, Pomaville said. “This was a stop-gap measure to try to get individuals connected to care,” he said.
The county could lessen wait times by recruiting other hospitals and even private providers, said Villalobos. Pomaville said that is unlikely -- he doesn’t think the county will modify the program because there needs to be a statewide solution.
It’s critical to let people know that these services are available now, Villalobos added. The county could better promote the program by working with churches, she said, as well as conducting outreach at health fairs, swap meets and other community events.
“Health changes in a second, and if people are prolonging their (wait for care), things can get worse for them.”
WHAT: Specialty care services for uninsured residents who do not qualify for full-scope Medi-Cal coverage
WHO QUALIFIES: Fresno County residents, regardless of immigration status
WHERE TO GO: Visit any federally qualified center, such as Clinic Sierra Vista, United Health Centers and Valley Health Team