BY MARIJKE ROWLAND AND VIVIENNE AGUILAR

CV Journalism Collaborative

When Isabel Almendarez moved from the Bay Area to the San Joaquin Valley last year, she figured her Medi-Cal health coverage would come with her.

An enrollee for almost three decades, the 45-year-old had her four children – now ages five to 20 – while on the program that pays for health care services for California’s poorest, elderly and disabled. Her four kids are all also enrolled in Medi-Cal, which insures 15 million people across the state.  

But the move, and a change in the way Medi-Cal re-enrolls patients, made it hard for Almedarez to get health care for herself and her kids. 

First there was a 30-day wait because of the change of address. Then, once they were approved, she and her kids were all placed on separate plans with separate coverage areas. 

At one point, Almendarez was told she’d need to take her daughter back to the Bay Area for care, nearly an eight-hour round trip from Fresno, where they live now. Last summer, to get her 5-year-old son necessary dental care, she had to travel two hours each direction to Lodi.

Almendarez, who spent most of last year trying to re-enroll and get her whole family on the same plan, said the situation caused her to feel stressed, frustrated and tired all at once. 

“They assigned me to clinics (and)  I didn’t know where they were, (there were) doctors I didn’t know,” she explained.” 

When the COVID-19 pandemic began in 2020, Medi-Cal started automatically re-enrolling patients as a public health measure to ensure that they did not lose their health care during the crisis. Now, Almendarez is among thousands of Valley residents who have struggled to stay covered since May 2023, when the pandemic emergency ended and county agencies restarted the application review process.

The period since, called the COVID-19 public health emergency unwinding by government health agencies, has seen a sharp drop in enrollment as people must again navigate the application process to renew coverage. 

Systemic problems plague Medi-Cal enrollment process

While the state and counties had anticipated a significant drop-off of Medi-Cal enrollees during the unwinding, the process of re-enrolling patients has highlighted systemic challenges faced by the program, from administrative backlogs and clogged phone lines to paperwork errors and language barriers. The decline of patients on the Medi-Cal rolls also comes at a time when more Californians should be eligible for Medi-Cal coverage, with the expansion of services to undocumented residents at the start of this year. 

“It is absolutely not OK when a child who remains eligible for the program loses coverage because of administrative barriers, because their mother waited on the phone too long, or because they mailed an application and they didn’t make it, said Mayra Alvarez, president of the nonprofit The Children’s Partnership, a statewide advocacy group for children which has been tracking the unwinding period on California families. “Or because they moved apartments and didn’t get the right letter in the mail. Those are not reasons that a child, a family, should lose the security that comes with health insurance coverage.” 

The impact on the Valley counties of San Joaquin, Stanislaus and Merced has been felt across the region’s network of health care providers. In the same one-year-snapshot period since the COVID emergency rules ended, San Joaquin County lost about 18,000 patients from the rolls,  according to the state Department of Health Care Services. Stanislaus County lost about 17,000 patients during the same period, and Merced County saw a decline of about 10,000 former enrollees.

The large losses aren’t just problematic for the people now living without health coverage. The drop in Valley residents with access to their doctors, specialists and mental health experts means more individuals could miss out on preventive services, suffer serious health problems, and require more expensive and complex care in the future. 

Marc Smith, membership services director for Community Medical Centers, one of the largest safety-net providers in San Joaquin County, said losing Medi-Cal coverage – even for just a month or two – can result in major disruptions to care and people losing access to their primary care doctors and specialists. 

That loss of access can mean longer waits and larger out-of-pocket bills until their coverage is restored. 

“If they don’t have access to regular health care, their health status is going to deteriorate,” Smith said. “So what ends up happening? Sadly, if they have a significant health problem, they end up in the hospital, and if they end up in the hospital, obviously more damage is done to their health.”

A look at CMC’s Medi-Cal membership numbers also shows a steep decline in coverage. In May 2023, Health Plan of San Joaquin, a major Medi-Cal insurance plan provider in the Valley, estimated they’d see about 18% losses in membership during the unwinding period. 

But CMC recently did their own deep dive into its enrollment data and found it had lost a staggering 34,000 patients, mostly across San Joaquin County and some in Solano County – a 24.6% drop. 

Although it’s not uncommon for people to drop on and off Medi-Cal, a loss of that size – equivalent to about half the population of the city of Lodi, where CMC opened a new clinic this year – took CMC by surprise. 

Paperwork problems responsible for majority of disenrollments

Smith acknowledged other possible contributors to the decline in enrollments. For example, some people might have started new, higher-paying jobs and no longer need Medi-Cal because they qualify for Covered California or private insurance. Others may have moved out of the area. But, he said, the vast majority are likely still living in the Valley, now uninsured. 

CMC’s findings echo larger regional and statewide trends that show large numbers of people likely still eligible for Medi-Cal, including children, who have lost coverage. 

And most of those disenrollments – almost nine out of 10 – are for procedural paperwork issues, according to data from the Sacramento-based nonprofit California Budget and Policy Center.

“There’s some research showing that a lot of people who have been losing their coverage are still eligible, which underscores the need to simplify the renewal process and reduce administrative burdens in order to keep Californians covered,” said Adriana Ramos-Yamamoto, senior policy analyst with the California Budget and Policy Center. “We saw that the percentage of people who are disenrolled due to procedural reasons was about 85%… this is maybe a result of Medi-Cal enrollee not receiving or returning the requested forms or not returning their forms on time or other issues with the application system.”

Ramos-Yamamoto explained that each paperwork mistake means an applicant has to start the process over, which takes more time and resources. That further delays the activation of their coverage or could discourage people from reapplying for coverage at all, which could cause lasting consequences.

“There are pretty dire consequences to losing health care coverage, even temporarily,” she said. “It’s very disruptive. And so if that’s happening for 85% of the people who have just enrolled in Medi-Cal and they were still eligible…then that could be very disruptive to their individual health outcomes and long term health outcomes.”

Medi-Cal enrollees, applicants face long wait times

Although the state has had a year to work through the paperwork pileup, wait times for patients trying to access help with their applications, and wait times for those applications to be reviewed once they are complete, remain long. 

Some of the longest recorded wait times in the San Joaquin Valley were in Fresno, according to a report by The Children’ Partnership. Fresno had the highest Medi-Cal enrollment in the San Joaquin Valley, and therefore provided the most accurate look at the region’s call-wait times, the group said.

According to the report, researchers placed 742 calls to county Medi-Cal administrative offices and found nearly 70% of those calls were immediately placed on hold. Less than 10% of calls were immediately connected, and about 20% of calls were actually disconnected due to high call volumes.

These procedural problems only get worse for non-English language speakers. 

“Sometimes it takes up to two, three hours to get through a phone call with the county,” said Yoana Perez-Aguilar, a health-coverage team leader at CMC. “I’ll request a call back to the patient, but sometimes it’s hard for them to communicate with the county. Let’s say they only speak Spanish, and they don’t have a translator, and the county calls back, but they don’t speak the language. It’s hard for them to communicate.”

The wait for applications to be reviewed is also longer for Spanish-speaking applicants. Perez-Aguilar said a Spanish-language application takes about three months, while English-language application takes about one month. 

That discrepancy is a trend reflected in statewide data and has significant ramifications for Central Valley counties because of their large Latino populations. Statewide, Ramos-Yamamoto said, about a third of individuals who disappeared from the Medi-Cal rolls after the automatic enrollment program ended were Spanish speakers. 

Even without a language barrier, the paperwork required for Medi-Cal enrollment can be daunting. Almendarez spent last February to September calling county administrators, health plans and local clinics trying to get her family back onto a single Medi-Cal plan together. She said when her application packet and paperwork arrived in the mail, it was about two inches thick. 

“You worry, because you’re like, ‘Oh, what happens if I don’t fill up everything, and what happened if I just do this?,’” she said “You know, it’s confusing, it’s stressing and worrying at the same time, because you don’t want to be without medical (coverage).” 

Need for more culturally-specific support when enrolling

Almendarez was part of a focus group conducted by The Children’s Partnership to study Medi-Cal wait times. The group’s president, Mayra Alvarez, said in addition to shortening wait times, the state and counties need to provide more help to those struggling with the enrollment process.

“We continue to believe that families need support navigating these systems, again either through community health workers or promotoras (Latino leaders who become health care liaisons for their communities),” Alvarez said. “It’s a whole continuum of supports and services to improve Medi-Cal for children and families.”

She said the state Department of Health Care Services has begun reimbursing community health workers for helping people navigate the application process. 

Across the Valley, large migrant communities have faced additional challenges during the unwinding period. According to Perez-Aguilar, although the Medi-Cal expansion to include undocumented residents started in January, some migrants might be keeping their names off the Medi-Cal rolls out of fear. She said she’s heard people express doubts about signing up for services and identifying themselves as undocumented. 

The political rhetoric aimed at immigrants during the current election season – lies about them eating house pets, targeting them for mass deportation – has had a chilling effect on some, Perez-Aguilar said.

“It’s like when the government thinks that you’re a public charge, like a lot of patients or a lot of people in our community think that applying for Medicare will affect, let’s say they’re not legal in the United States, and if they want to apply to get to have a legal status in the U.S., they think Medi-Cal, applying for Medi-Cal will affect them,” she said.

What are some solutions to the disenrollment problem?

Still, for all the obstacles faced by those signing up for Medi-Cal, experts said some solutions, both on the local level and through statewide legislation, are in the works. 

In late September,  Senate Bill 1289 was signed into law by Gov. Gavin Newsom. The new law is meant to hold the Medi-Cal program accountable for long call wait times and disconnecting the line on waiting applicants. It requires the Department of Health Care Services to set new standards for counties to conduct more data collection at call centers. 

County call centers will be expected to begin collecting data on Jan. 1, 2026 and make their first batch of findings available that May. Data will be expected to show a monthly total call volume, average call wait times by language, and average call-abandonment rate.

The bill was championed by the nonprofit Western Center on Law & Poverty, among other groups. Associate Director of Policy Advocacy Linda Nguy said understanding the problems is the first step. 

“We think this information provides the department with an opportunity to better understand some of the barriers to renewals and what the issues are, county by county,” she said. “And so that will ultimately provide greater transparency to help resolve some of the gaps and apply lessons learned.”

For Almendarez, the delay in care she experienced waiting for her family’s Medi-Cal plans to be fixed caused additional anxiety and long drives to visit healthcare providers, sometimes counties away. During her seven-month struggle, she said, one of her daughters needed mental health care, but couldn’t get it without insurance. 

Now that it has finally been resolved, she said everyone in her family’s health has improved.  

“Their health is better,” she said.  “For me it’s less stressing. I am very happy to see this, (my health insurance issues resolved). It is a priority in your life that makes you feel more confident.”

— Translation services provided by Radio Bilingüe Network News Producer Josie Tizcareño.