A red bandana holds back Judit Garcia’s hair as sweat stains become visible on her pink shirt.
Her face and arms are sweaty, and she looks tired.
But she’s not giving up.
Almost an hour after beginning her workout, the 42-year-old Raisin City resident is still keeping up with all the steps in her Zumba class in the neighboring rural town of Caruthers. It doesn’t help that it’s a very hot evening in the Central Valley, and the air conditioning isn’t keeping the small bright green room cool.
“It feels good,” she says in Spanish after class ended. “I had never done Zumba before.”
About two years ago, Garcia was diagnosed with prediabetes and also had high cholesterol. Since then, she lost her Medi-Cal coverage and hadn’t been able to see a doctor until recently – in Mexico. But she had taken matters into her own hands to prevent or delay developing Type 2 diabetes by exercising and making significant changes in her diet.
In 2017, an estimated 2.8 million Californians like Garcia lacked medical coverage, according to the UCLA California Health Interview Survey. And despite her efforts to keep herself healthy through lifestyle changes, health professionals warn that is not a substitute for ongoing medical care and a doctor’s guidance on how to best manage chronic or potentially life-threatening conditions.
An estimated 13 million residents, or nearly half of California adults, suffer from prediabetes, like Garcia, or undiagnosed diabetes, according to a 2016 study by the UCLA Center for Health Policy Research.
People suffering from prediabetes are at greater risk of developing Type 2 diabetes, heart disease and stroke, according to the U.S. Centers for Disease Control and Prevention.
Stroke costs alone are estimated at $34 billion each year nationwide, according to the CDC.
“It’s very difficult, and it worries me a lot,” Garcia said of her family’s lack of health insurance. She especially worries about her husband because he also has health problems.
Ineligible for Medi-Cal
There are no other homes around the Garcia family’s home, except the house behind hers, where Garcia’s grown son lives with his family.
The area is surrounded by fields, and little else.
Inside their old, small home, luxuries are limited to a flat-screen TV in the living room. It feels hot in the small dining room, despite the hum of an overextended air conditioning system.
Garcia’s family has mixed-immigration status. She recently received her green card, but her husband, whom she married four years ago, is undocumented, making him ineligible for Medi-Cal or other government-sponsored coverage.
Garcia and her husband’s combined adjusted gross income in 2018 was $47,239, the couple’s income tax records show. A 17-year-old niece who is a U.S. citizen lives with them.
The couple’s combined income puts her above the eligibility limit to qualify for Medi-Cal, the state’s version of the federal Medicaid health insurance program for low-income individuals. In fact, the last time she applied for Medi-Cal, the couple’s combined adjusted gross income was a bit higher – $53,882, records show.
In a scenario such as Garcia’s, “the husband’s income would be included in the Medi-Cal eligibility determination regardless of the individual’s immigration status due to the couple’s relationship status,” said Anthony Cava, spokesman for the California Department of Health Care Services.
“We always keep working, and even if they say it’s a lot of money, it’s not enough,” she says.
Garcia says she can’t afford to buy insurance for herself and her niece. Garcia mostly works cleaning houses during the day, and her husband works in the fields. Their employers don’t offer them medical insurance.
She looked into getting insurance through Kaiser Permanente, and based on a quote she got by phone, the estimate for herself and her niece was anywhere between $500 and $600 a month. Garcia said she also called Covered California, the state’s health insurance marketplace created under the Affordable Care Act, but was told that it wasn’t taking applications at the time because it was outside the open enrollment period. She plans to shop around for insurance on Covered California again, now that open enrollment has begun.
But Garcia doesn’t know what kind of plan she would like to get. She only knows that she’s willing to pay no more than $200 a month for coverage for herself and her niece. That means that even with government subsidies, health insurance may still be out of her reach.
Based on a Covered California estimate online, her niece could qualify for Medi-Cal. The Covered California plan with the most affordable monthly premium for Garcia in 2020 would be a Blue Shield bronze plan, in which she would pay $149 in monthly premiums, with subsidies, with an annual deductible of $13,800. The estimated yearly out-of-pocket cost is $3,966, for a medium-use level of doctor’s visits.
Health care plans without an annual deductible tend to charge higher monthly premiums, and include other costs.
“It’s almost like paying rent,” she says. “The insurances right now are so expensive. There’s no insurance that you can get for an affordable price.”
Although the Affordable Care Act has helped reduce the number of uninsured in the state, many continue to cite costs as the primary reason for foregoing insurance, according to data from the annual California Health Interview Survey.
“I don’t believe that has changed,” said Nadereh Pourat, a professor-in-residence at the UCLA Fielding School of Public Health whose expertise includes access to care.
Before passage of the ACA, 50.6%, or about 2.7 million of the estimated 5.4 million uninsured Californians at that time, cited cost as the main reason for not having health insurance in 2009, according to the UCLA survey.
Nearly 36% of uninsured Californians surveyed in 2017 said cost was still the main reason for not having health insurance. That represented a little over 1 million of the estimated 2.8 million who lack coverage.
Families ineligible for Medi-Cal may not be fully aware of subsidies available through Covered California, or their subsidies may not be adequate, so they choose between buying basic necessities or health insurance, Pourat said.
Also, insurance prices increase, “but the wages don’t catch up with them,” she said. “There are a lot of people who are not able to keep up.”
People are less likely to get preventive care when they don’t have insurance, Pourat said. As a result, conditions that could have been easily treated early on might be missed.
“We end up having a population that is not as healthy as it could (be), and we pay more for it,” Pourat said.
Garcia’s husband, who suffers from high blood pressure, pays out of pocket if he wants to see a doctor. So, their only choice is to try to manage their health on their own, said Garcia, who has also encouraged her husband and niece to make lifestyle changes.
“When I see people who don’t qualify for Medi-Cal, they are sick and they don’t make changes in their lives, it makes me very sad,” she says. “I wish I could tell them to make changes – it’s possible. They can help themselves.”
Minutes later, as Garcia’s two small grandchildren played, her daughter’s husband placed a plate on the table full of fresh fruit sliced in bite-sized pieces.
Changes to manage her health
Among the changes Garcia has made to manage her prediabetes is becoming more physically active, and it’s been one of the hardest adjustments.
“Exercising was the most difficult change because it’s very tiring,” she said, adding that making it a habit wasn’t easy.
Now, Garcia tries to go to Zumba class three to four times a week. Her niece joins her.
If she doesn’t go to Zumba, she takes long walks, unless she goes to work in the fields or at the vineyards for a few hours in the evening.
On a summer evening, Garcia, her husband, her niece and a friend headed to a vineyard on the outskirts of Raisin City to make a few extra dollars — and get some physical activity.
Wearing a long-sleeve shirt and a baseball cap, Garcia went down a long row, cutting the vines, so the soon-to-be raisins could dry while hanging on the trellises.
“It’s like exercising,” she said in Spanish. “I don’t have to go to Zumba (today), but I like Zumba better than this.”
She used to be overweight, she says, noting that her weight dropped from 190 to 154 pounds over three months this summer.
In the dark about prediabetic condition
Through much of the summer, Garcia was uncertain whether she had been successful in preventing or delaying Type 2 diabetes.
She missed a free clinic June 22 focused on diabetes that was organized by organizations in the community, such as Centro La Familia, the Fresno County Department of Public Health and Community Medical Centers at the Community Regional Medical Center.
“I was going to go get a glucose and diabetes exam, but I forgot and didn’t go,” she said, despite the flier she kept to remind herself.
Registered nurse Susan Hopper, a diabetes educator at Saint Agnes Medical Center in Fresno, said people in Garcia’s situation really need a physician to help manage their condition. A doctor would be able to determine whether the patient is doing better, worse or staying the same.
“Patients can’t do that for themselves,” she said.
But Garcia insists she’s been eating much healthier as well, and began drinking a lot more water to prevent becoming diabetic. By mid-August, she said she had gone five months without drinking a soda.
It’s been hard to let go of greasy hamburgers, fast food from McDonalds and the sugary coffee from Starbucks with multiple shots of caffeine, she said.
Before going to Zumba class one evening in July, she showed off her skill at making oatmeal tortillas.
She boiled the water in a small pan, poured oatmeal flour into a bowl, then two spoonfuls of boiling water. She added a bit of cool water before mixing the flour.
Next, she wiped a plate with a drop of oil and softened the ball of oatmeal flour on it.
She used a Mexican iron tortilladora, or tortilla press, to make the tortillas, before cooking them on a flat pan.
Garcia says she started making the oatmeal tortillas in July. She was having a hard time cutting down on real corn tortillas and eating healthy food because it wouldn’t fill her stomach.
“I was struggling a lot with hunger,” she says. “I wasn’t used to it. I used to eat eight tortillas” a day.
Weeks earlier, Garcia’s fridge was filled with mostly vegetables and fruits, and a pack of tortillas that she has now replaced with her healthy oatmeal version.
“I’m 80% sure that I was able to prevent (diabetes),” she said in August.
But she won’t know for sure until she sees a doctor.
While it’s good for patients to make lifestyle changes, Hopper said, it’s not always as simple as it may seem.
People may think letting go of sugary desserts, and having more fruit instead, is the way to go. But there’s limits on carbohydrates and portion size.
For example, someone may be eating large apples when they should be eating smaller ones, Hopper said.
“They need a physician to guide them along and changing the diet is always good, but you also need to know what you need to change and how to change it,” she said.
Those who test their blood sugar at home also need to know what the numbers mean, she said. A doctor would be able to help interpret what the numbers show.
“If we don’t have numbers, then we are kind of lost,” Hopper said.
Sometimes, prediabetic patients are prescribed medication to delay the onset of Type 2 diabetes.
A patient such as Garcia could be having kidney failure, or her vision could be changing, or she might be experiencing numbness in her feet and hands, but she wouldn’t know what is happening without having a doctor to analyze her numbers, Hopper said.
“She could be on her way to a stroke, and it all goes back to the numbers,” Hopper said.
Garica said she used to have numbness in her arms that would sometimes keep her up at night, but she hasn’t experienced that following her diet changes.
Saint Agnes Medical Center offers a free year-long prediabetes class, which Hopper recommends for people in Garcia’s situation.
“In prediabetes and diabetes, there’s a lot of learning that needs to happen,” she said.
Garcia went to Mexico for the first time in 20 years in September. She had a physical exam, and also saw a dentist, as health care is much more affordable there.
Her cholesterol was good, and she has been able to prevent diabetes, she said in October, after returning from Mexico.
“The changes that I made at home is what helped me,” she said. “I’m no longer in doubt.”
About this series: This project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative — which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capitol Public Radio.