By Hannah Esqueda
More than two years after the Affordable Care Act theoretically opened the door for universal health care, members of Fresno’s traditionally underserved communities still struggle to find proper access.
In particular community and health advocates warn that undocumented residents and young men of color are being left behind by the ever-growing health care exchange. While an April report from the California Health Care Foundation revealed just under 9 percent of Fresno County residents remain uninsured the bulk of the figure is suspected by advocates to contain their two target populations.
“These groups have traditionally been the hardest to reach,” said Sandra Celedon-Castro, HUB manager at Fresno Building Healthy Communities (BHC). “We’ve really ramped up efforts with enrollment events and are just trying to spread the word and inform these groups.”
Opportunities for access continue to grow, and a major milestone was reached earlier this summer when the state’s Medi-Cal program expanded to provide full-scope coverage to undocumented children for the first time. The move was supported by health groups like Fresno BHC and advocacy organizations throughout the state as part of the California Endowment’s Health 4 All campaign. However, the inclusion of undocumented children is only the first in a long series of hurdles keeping marginalized segments of the population from health care access.
Enrollment agencies are still faced with the task of reaching out and signing people up for coverage and Celedon-Castro said as many as 100,000 Fresno County residents are expected to remain uninsured by 2019.
To help chip away at the remaining figure, Clinica Sierra Vista, one of the region’s top enrollment agencies, has subcontracted with community-based organizations throughout the city to target the undocumented and young men of color.
“The trust is there with these organizations. They’ve worked in the communities they’re in for decades and they have the staff that reflect the audience they are reaching out to,” said Reyna Villalobos, director of community programs at Clinica.
That type of connection is crucial when reaching out to underserved areas where many of the uninsured remain skeptical of the enrollment process. So far, the community-based approach has produced positive results within target populations, she said.
Community organizations like Fresno BHC and Fresno Barrios Unidos are similarly focused on the undocumented and young men of color, zeroing in on the unique hurdles affecting enrollment among these at-risk groups. Both organizations are largely funded through private and public sector grants and operate within South Fresno, covering many of the city’s poorest neighborhoods.
“This is where we primarily do most of our work and it’s based on the fact that these are the census tracts that have the highest instance of concentrated poverty, highest rates of preventable illness, chronic morbidity, obesity, diabetes, asthma and the highest rates of unemployment,” Celedon-Castro said. “All of these are kind of indicators that we know are linked to unhealthy outcomes.”
In 2015 alone, Fresno BHC helped to enroll more than 8,000 residents within its South Fresno target area in Medi-Cal and Covered California health plans. While this figure represents a decline from the initial enrollment spike of 2014, Celedon-Castro said the 2015 numbers included many more from the target demographic of young men of color.
This group in particular has traditionally flown under the radar of health care programs and few are aware of the new medical coverage options available to them, said David Bouttavong, youth program specialist with Fresno Barrios Unidos.
“We saw that young men were being left out of the picture when people were talking about health care enrollment,” he said. “They just weren’t at the front of people’s minds when discussing enrollment or educational efforts.”
To help reverse the trend, Fresno Barrios Unidos created a youth health outreach program with young men of color serving as promotores de salud, or peer health educators. The small but passionate task force consists of Fresno teens Marco Ocana, Efrain Botello and Antonio Jauregui. All three work part-time at the center while juggling college courses and other jobs, and all three share a passion for bettering local health outcomes.
“There’s really no better outreach than peers. These young men can talk to other young men that look like them, face the same problems as them and have the same questions as them,” Bouttavong said.
While not specifically trained to enroll anyone in a health care plan, the mere presence of fellow young men of color serving as promotores at health fairs and other informational events is often enough to get many residents to open up.
“A lot of times we work with the undocumented and a lot of times they’re misinformed [about the enrollment process]. They’ll be scared because they’re undocumented and think that if they give out too much information it may be bad,” Botello said.
“Just that fear that they don’t know what may happen can be very strong. But when they see other young men of color give them that information they feel a little more comfortable so it’s easier for them,” he continued.
Using familiar faces and situations has also proven helpful for Fresno BHC, and Celedon-Castro credited the group’s 2015 enrollment figures with a targeted ad campaign focusing on the importance of preventative health care coverage.
Nicknamed “Mama said…” the ad campaign included radio ads, bus wraps and billboards, all featuring sick or injured young men of color being scolded by their mothers for not having proper medical coverage. By framing the insurance conversation within a family dynamic, advocates said the message has encouraged young men to take a more active stance on their health coverage.
“One of the main things I’ve heard among young men of color is ‘If I don’t feel sick, why do I need this [insurance]’,” Ocana said. “In a sense, they are just beginning to go out in the world. They don’t know what kind of emergencies are out there.”
It’s a hurdle Ocana and his fellow promotores have spent the past two years addressing, working more than 40 community health fairs and helping to provide hundreds of residents with information and guidance on how to enroll in health care coverage. The trio has also helped provide answers for individuals looking for community health resources, even promoting a niche program addressing a previously overlooked health issue for young men of color.
“In addition to chronic health issues, we’re also seeing mental health as a top concern for this community. We have a monthly mental health healing circle to help provide young men with a support network and really show them that there are places like this that are willing to open for them,” Ocana said.
Key to their success has been the group’s ability to couch mental health issues within a culturally specific framework, and Jauregui said the promotores have seen a lot of progress through their fusion of mental health concerns with spiritual traditions.
“Some of our past events have explored community healing through teachings from our culture,” he said. “We’ve really found that it’s important for us to remember our culture and look to our elders for traditions, while also moving forward with mental and spiritual health.”
While the sessions at Barrios offer a safe space for attendees to open up about mental health issues, the program also emphasizes how difficult it can be for individuals in underserved communities to access vital health resources even when covered by health insurance.
From clinics and health offices to park space and grocery stores, many communities in South Fresno face glaring disparities in basic resources affecting health outcomes, Jauregui said. And while the grant funding the promotores program runs out later this summer, he, Ocana and Botello each plan to remain active in promoting healthier lives for their peers.
“We really want to educate the youth in our community in order to build up our future leaders,” Jauregui said. “One day they’ll be the ones in power and the paradigm will shift.”
Botello agreed and said that while the expansion of health care coverage has helped open the door to a better life for many individuals, work still needs to be done before everyone gains entry.
“You see young men of color who are facing a lot of barriers and it’s something that can be solved,” Botello said. “We need more resources and more information to be given to our youth, you know we can’t ignore the situation. This is really showing that we need more access to our health.”
Hannah Esqueda’s reporting on Medi-Cal expansion and enrollment efforts in the Central San Joaquin Valley was undertaken as a USC Center for Health Journalism California Fellow.