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Healthcare in Sonoma County: Uninsured Continues
by Emily Kyle, Irma Saucedo, Yoseline Bean
Sunday May 7th, 2017 8:11 PM
Investigative Research on Healthcare in Sonoma County, specifically the uninsured.
HEALTHCARE IN SONOMA COUNTY:
Uninsured Continues

BY:
Emily Kyle, Irma Saucedo, Yoseline Bean, Tess Von Arx, Keith Serne

ABSTRACT

The purpose of this paper is to understand why 20,000 people in Sonoma County still do not have healthcare insurance and the implementation of the Affordable Healthcare Act, also known as Obama Care, helped lower that amount. According to a study done by the Sonoma County Department of Health Services over 62% of of undocumented immigrants have never had health insurance (Katz 2017). The causes of undocumented immigrants not having health care insurance comes down to two major reasons, which include inability to afford it and not knowing how to access it.

The Affordable Care Act allowed for more than 50 percent of the uninsured people in Sonoma County to gain access to health care but still left over 20,000 without insurance. Most of the 20,000 uninsured in Sonoma County are comprised of undocumented immigrants.

Throughout the years, the changing of a president usually means that some form of health care reform attempted to be enacted by them. With that being said the most recent president has stated he will be removing Obamacare and replacing it with a new and better plan that would likely exclude undocumented people. However, many individuals throughout the United States have stated that the only way a better health care plan could be of service is through a Universal system such as medicare for all.
Introduction

Health care has been an issue all around the United States, in fact it has affected many people close to home. In Sonoma County, there are 20,000 or more individuals that are without health care insurance. Our current Healthcare system involves an individual buying a healthcare plan that meets their needs for certain types of coverages, access, and dependability at a reasonable cost. Many people can receive health insurance through their job, but do not as it can be too expensive to the employee purchase it.

Another downfall of this system is that minimum wage workers may have more than one part-time job so they are not eligible for health insurance. To be eligible for insurance through employer usually the employee must work full-time, which is 40 hours. Most people working two jobs are not given the opportunity to work full-time and this is part of the broken system we are currently in. The system that is supposed to be providing us with the necessary needs ultimately has been failing to provide the most important care of all, health care.

According to Morehouse (2014), millions of undocumented people will remain uninsured even after the Affordable Care Act because many of them are not eligible to apply because they do not have a social security number. Our research focused on why there is 20,000 people in Sonoma county are still uninsured. Based on this research, the discovery as to why they are still uninsured is mainly because people cannot afford it. Uninsured people remain without health coverage because their jobs do not offer it, and they believe that it is cheaper to pay the fine on their taxes every year rather than purchase health insurance.

The reoccurring problem is that uninsured people are risking the potential need of an emergency medical visit. Many residents found other ways to get medical visits. For example, there are free visits at community sites that allow people who are uninsured to visit the site and receive medical attention. Still this is not sufficient coverage for everything a person may need. Medical attention at the sites includes: dentistry, midwifery, medicine, optometry, pharmacy, and other medical professions. Free clinic visits unfortunately do not offer all the different types of health assistance.

Insurance

With the current health care system, insurance companies are able to take advantage of the complexity and uncertainty surrounding care choices. Lack of clear information about prices of medical procedures combined with all the insurance options put consumers in a weak position and sometimes the inability to know which health insurance plan is the correct one for them. There are multiple options when it comes to buying health insurance, health plans (HMOs), and public programs such as Medical and Medicare. Health Insurance gives you coverage if you need medical care or are in a hospital (CDI 2017). According to the California Department of Insurance, there are options such as Group policies that are purchased by your employer or an association. You may be able to add family members to these policies.

Individual/Family policies is insurance you buy outside of an employer or association. Health Maintenance Organizations (HMOs) or managed care plans are different from traditional insurance policies and they are governed by a different set of laws in California (CDI 2017). Through the California Department of Insurance these plans can be purchased as either group or individual/family plans but they are regulated by the California department of Managed Health Care. Self-Insured Health Plans are most common with large employers. A self-insured employer usually has a large pool of money and uses that to pay for the health care of employees (CDI 2017). This usually means your employer contracts with insurance companies to manage the health benefits.

Medical is California’s version of the federal Medicaid program. This program generally covers lower-income families and single adults (CDI 2017). It is mostly provided by Managed Care Organizations and covers an array of medical procedures, office visits, and other health related expenses. Assistant for Infants and Mothers (AIM) is for low income pregnant women and their infants who do not have health coverage and do not qualify for Medical or Medicaid (CDI 2017).

Medical Supplement Insurance is designed to supplement original Medicare and can be purchased by anyone enrolled in Medicare. Covered California, as part of the Affordable care act is a health insurance where individuals, families, and small businesses can purchase insurance products sold by private insurers (CDI 2017).

There are different types of healthcare programs such as PPOs, EPOs, HMOs. Preferred Provider Organizations has a network (or group) of preferred providers (CDI 2017). You pay less if you go to these providers and they are also called in-network providers (CDI 2017). With a PPO, you can go to a doctor or hospital that is not on the preferred provider list (CDI 2017). This is called going out-of-network. However, you pay more to go out-of-network. The PPO pays less or nothing at all.

In Exclusive Provider Organizations you usually do not use a primary care doctor (CDI 2017). Most of the time you do not need referrals to see specialist who are in-network. There can be a limit on the doctors or hospitals you can use. You cannot go outside the network or you will have to pay for the fees yourself.

Health Maintenance Organization is when you usually have a primary care doctor. If you see a provider outside of your HMO's network, they will not pay for those services (except in the case of emergency and urgent care). The doctors and other providers may be employees of the HMO or they may have contracts with the HMO (CDI 2017). To join an HMO, you must live in the area the HMO services. Outside this area you can only get emergency or urgent care.

If you can afford health insurance but choose not to buy it, you must pay a fee called the individual shared responsibility payment (HealthCare.Gov 2017). The fee is sometimes called the "penalty," "fine," or "individual mandate." You owe the fee for any month you, your spouse, or your tax dependents don’t have qualifying health coverage (sometimes called "minimum essential coverage"). You pay the fee when you file your federal tax return for the year you don’t have coverage. In some cases, you may qualify for a health coverage exemption from the requirement to have insurance. If you qualify, you won’t have to pay the fee. The fee for not having health insurance in 2016 & 2017: The fee is calculated 2 different ways – as a percentage of your household income or per person. You’ll pay whichever is higher. The Percentage of income is 2.5 percent of household income or paying per person: 695$ per adult and 347.50$ per child (HealthCare.Gov). Both of these calculating tools cannot exceed 2,085 dollars per year.

Our interviewees were upset they had to pay but they would rather pay the 695$ from their tax return then pay out of pocket for private insurance because it is much more expensive than that. Specifically, in Sonoma County, if Obamacare is repealed more than 35,000 residents will lose coverage in Sonoma county, costing the county more than 2,000 jobs and an economic loss of nearly $200 million (Kovner 2017). Santa Rosa community Health Centers covered about 14,000 residents through the Medical expansion when Obamacare was enacted. In Sonoma County alone, 35,240 adults (which is approximately the population of Windsor and Sebastopol) obtained Medical after Obamacare covered adults without children under 18 and with an income less than 138% of the federal poverty level (Kovner 2017). Overall the county had 112,732 men, women, and children enroll in Medi-Cal (Kovner 2017). The uninsured rate dropped from 13.1 percent, which is 64,000 residents in 2013 to 6.3 percent which is 31,000 residents in 2015 (Kovner 2017). Repeal of the Affordable care act would impose a statewide loss of 209,000 jobs and $20.3 billion goods and services (Kovner 2017).

Single Payer

Single Payer healthcare is a system in which residents pay the state- via taxes in amounts determined by the state- that will cover everyone's healthcare costs, rather than individuals buying from private insurers competing for their business. Overall single payer healthcare has the ability to be more cost effective than other programs we currently have and would allow for all residents to receive care at a cost effective price. The average American would be paying no more than they currently do but they would receive more health care than they currently have (Klinefelter).

The current problem with the healthcare system now is that insurance companies have the ability to take advantage of the complexity and uncertainty surrounding health care choices to make comparison shopping extremely difficult (Folbre). Relying on a single source of revenue for the health care system may encourage rational, deliberate trade-offs between cost and quality/quantity (Glied 2009:556).

There are three principle ways that Single Payer systems can achieve a lower cost containment. First, this system makes it possible to reduce the administrative costs of organizing and delivering health care services (Glied 2009:600). Second is that single payer systems may be able to exert power over providers; if they have no alternative that forces them to accept lower payment rate (Glied 2009:601). Lastly, single payer systems can centrally control the overall level of health care resources by constraining their availability so that they will be better able to determine the size of the health care system (Glied 2009:601). Overall, a single payer system would allow for administrative costs to be lowered and be a more cost effective way for residents to receive care when necessary.

Sonoma County Resources

Sonoma County provides many resources for those who lack health insurance. The first is the Disease Control unit is responsible for the investigation of outbreaks of communicable diseases, surveillance of reportable diseases, and provision of educational materials and services to assist communities in reducing the incidence of communicable diseases. Any uninsured residents rely on these services, so these are extremely important and helpful.The Disease Control unit provides the following services: Infectious communicable disease investigation, tracking, and reporting. Tuberculosis case management, AIDS surveillance and HIV reporting, Perinatal Hepatitis B case management, Flu program coordination, Immunization assistance, Health information and recommendations (Sonoma County Department of Health 2016).

Children can be the biggest victims due to lack of health care. Many children go years without seeing any medical attention. The California Children’s services states that if your child has a catastrophic or serious medical condition that meets program eligibility criteria, this program may be able to provide financial assistance for medical services and coordinate health care services. Services include physical and occupational therapy, financial assistance, case management and access to specialized medical care. Your child must be under 21 years of age, family income must meet certain eligibility guidelines and only certain conditions are covered.

We don’t completely understand why they put an age limit on these services. With normal health care plans The eligibility of these services include that your child must be under 21 years of age which is the age limit to be covered under your parent’s plan. The child must be a permanent resident of the California county where you apply. Your family income must be less than $40,000 per year, according to the adjusted gross income on your California income taxes. A child whose family has a higher income may receive services if the estimated cost of medical care in one year is expected to exceed 20 percent of the family income. If your child has full scope Medi-Cal with no Share of Cost, the family income can exceed $40,000 (Sonoma County Department of Health 2016). State regulations require families to apply for Medi-Cal when they are requesting medical coverage to pay for hospitalizations, medical provider appointments, medications and/or durable medical equipment or supplies from the CCS program. There is no income or Medi-Cal requirement for children eligible to receive Medical Therapy Unit therapy services only, diagnostic services only or for those families who adopted a child with a known CCS eligible medical condition (Sonoma County Department of Health 2016). Overall, all of these services are super beneficial. And all of those who apply to the eligibility rules should definitely take advantage. The one thing we would like to change with one of the eligibility guidelines is that maybe not put the age limit at 21 years of age. Regardless, uninsured residents should be thankful these resources are available to them, and use them when needed.

Methods

For this research the method of choice was qualitative interviews. Interviewing people who do not have health insurance to find out why they do not and what plans they have for the future. Also, interviewing healthcare professionals to find out their views on our system and why people do not have insurance. These interviews can help to create ideas on how to make the system better for average Americans in Sonoma County.

Trying to understand on a personal level why the 20,000 people in Sonoma County who are still uninsured, a total of 12 people were interviewed. The first 6 people who were interviewed were among Latino families and 2 of them were single. Another two were food service industry workers and they had similar thoughts about health care. Three more people were interviewed who are both self-employed and in their early thirties. Our interview questions focused on their age, occupation, why they do not have health insurance, and what is their plan for the future regarding health insurance. Ages ranged from 23-48 years old, six were female and four were male.

Uninsured Residents

From the interviews conducted with uninsured residents (Group C), the common theme with all these interviewees was that youth was their biggest factor why they didn’t have health insurance. Their jobs don’t provide health coverage, but even if it did they wouldn’t put their money towards that. Also, keeping in mind that most minimum wage jobs are only part time so the company will not have to pay for health care insurance. Their mindset is that they’re young (early 30s) and feel that they will worry about that when the get older. It can seem a little absurd that they aren’t worrying about their health at a young age, but that’s how they look at it and are comfortable with that. There seems to be a correlation with many more younger adults who feel that health care isn’t as important than other necessities in life. This is something we may continue to see more.

Uninsured Latino families

In our study of the 20,000 people who are still uninsured, a total of about 12 people were interviewed. The first six people who were interviewed were among Latino families and two of them were single. The interview questions focused on their age, occupation, why they do not have health insurance, and what is their plan for the future regarding health insurance. Ages ranged from 23-48 years old, five were female and one was male. Results that were found within the six people interviewed shows that people are still uninsured for three main reasons. Lack of information about health insurance, they do not believe they need it, and/or unable to afford it.

Methods

For this research the method of choice was qualitative interviews. Interviewing people who do not have health insurance to find out why they do not and what plans they have for the future. Also, interviewing healthcare professionals to find out their views on our system and why people do not have insurance. Our population consisted of 4 different groups that will be defined as the following: Group A: six Latino people, Group B: two food service workers, Group C: two local resources, and Group D: one administrative medical professionals that was personally interviewed. These interviews can help to create ideas on how to make the system better for average

Americans in Sonoma County.

A total of 12 people were interviewed to find out why they personally do not have insurance and why. The first 6 people who were interviewed were among Latino families and 2 of them were single. Another two were food service industry workers and they had similar thoughts about health care. Three more people were interviewed who are both self-employed and in their early thirties. Our interview questions focused on their age, occupation, why they do not have health insurance, and what is their plan for the future regarding health insurance. Ages ranged from 23-48 years old, six were female and four were male.

Findings

Health care is an important subject for everyone. People tend to ignore the fact that at any time one could be in a serious health condition. Due to the lack of information, fear, and income expense many people are still uninsured. Among the six Latino people we interviewed in Sonoma County, they have stated that they were not aware of being able to qualify for Medicaid. The studies that were conducted through the interviews correlated with Cooper (2016) that indicates that 4.7 million people in the uninsured group are in the U.S. illegally for Medicaid or subsidies to help them purchase their own plan. What these undocumented people do not know is that now people can purchase their own health insurance and or apply for Medicaid.

Mandelbaum (2014) has made a prediction that by 2025, “fewer than 20 percent of workers in the private sector will receive traditional employer-sponsored health insurance.” The source of this claim? Dr. Ezekiel J. Emanuel, in his just-published book, “Reinventing American Health Care.” about half of the people that were interviewed also stated that they do not have health insurance because their employers do not offer health insurance plans. The predictions stated by Dr. Emanuel has many effects that within the next few years most employers will announce their decision of cancelling health coverage. This will force employees to purchase their own plans if ACA is still in place.

Uninsured people believe they can cope by paying out of pocket if necessary or avoid assistance to health attention. Others stated that they have used the ER at least once, and their bill is outrageously expensive and are unable to pay for it at the moment. Pietrangelo (2015) says that ER costs shift for those who do have insurance.

Many of the interviews conducted had similar information to what research shows. The two food service industry workers, Group B, had similar thoughts about health insurance. They both did not have insurance because the costs were too high and they could not afford it. They both work two part time jobs, which do not allow them to get insurance through their work. Interviewee number one seemed to be frustrated with the idea that he could potentially get insurance if the company would help him pay. “I wish I could just pay a little out of my checks to our work like my friends do because they work full time and get insurance, I really just want vision”. This statement from the interviewee shows what matters to him, which is vision coverage because that is a problem he is having now and not in the future.

Group B both had recent medical emergencies and they had to pay some out of pocket. They both still have medical bills being sent to them and they do not pay them because they do not have the money. They hope to pay them off or just let them go to collections because they cannot afford to pay rent and pay medical bills. One stated, “I worry about not paying them but I need to eat and pay for my place so I don’t really know what to do to, I just want it to go away completely… I do not feel that I should have to pay hundreds of dollars because I was sick one time.” Paying close to a thousand dollars because of strep throat and an emergency visit is one more reason why single payer is the best option for our country. They both want to have insurance in the future because they want vision coverage because glasses are so expensive. They hope to have better jobs in the future with a benefit package, but not sure what they want to do to make that happen.

The health care system has changed throughout the years and the Sonoma County health care system has struggled to maintain care for all individuals in the area. A person we interviewed in the medical profession was asked several questions to give us knowledge about the field and issues that many people go through. We managed to speak to a professional from the medical field. For their own privacy, we have changed their name. The medical professional we interviewed works in a non profit hospital. The doctor, David, has been working in the medical field for fifteen years, and one of the main reasons he chose this career is because he wants to help others that are in need. During the interview an important question that we asked him was if he was satisfied with his profession and if he thought it was going to be the way that it is. David stated, “there are situations that dissatisfy me….not being able to help my patients as much as I wish too.” As we could see that he did seemed disappointed about some of the issues that occurs in the hospital we started to notice that many patients go see one doctor and then are being transfer for better care to another doctor. When the patients have to attend another physician their insurance does not cover it or if it does cover it they still have to pay a copay again. These are the issues that David spoke about that sometimes his patients cannot get the full care that they need because of the health care insurances not being able to cover their full care. The partnership between the health insurance and the hospitals do not seem to coordinate on what is better for the patient rather they focus on the profit of insurance company (Karlamangla.)

Many individuals all over the United States have stated what a sufficient health care can be, a universal insurance for all. In addition, David contributed to the conversation when asked what a good insurance provider would be for his patients. He stated, “Universal care for all, and or so at least give forgiveness to those that cannot afford to pay for their hospital bills.”

As a result, we came to conclude through this interview that doctors, such as David, struggle to maintain a stable health for their patients because of the lack of health insurances. As health care expanded to Obamacare we still have a inadequate dysfunctional system for individuals that are low income. Meanwhile, those that have private insurance receive the high functional system for their health.
In Sonoma County there are still individuals without health care, some because they do not bother to enter into the system that will not protect them fully when their health is bad, and others because they simply do not wish to pay for a insufficient health care. In contrast, doctors such as David explain the inadequate and insufficient attention that health care provider give to their clients.

Limitations

Through this research we came across few limitations. The main issue we had was trying to interview medical professionals and this was difficult since they would not schedule interview times or pursuing phone interviews. Trying different hospitals around Sonoma County and still we were unable to get more information directly from them. We had one person reply and send us information that is easily accessible online.

Results

The people who were interviewed for this research shared one common thing they believe health insurance is important and that they have either tried to get it and or are planning to get it in the future. Many of the uninsured in Sonoma County can not afford to purchase insurance according to the interviews that were conducted. A lot of them are financially struggling and trying to make ends meet and unfortunately health insurance is being pushed down their priorities. They felt that housing and food is the most important to spend their money on. They also feel that it is cheaper to pay the fine at the end of the year when filing for taxes than purchasing a plan today, and it is cheaper from research conducted.

In group A two of the interviewees declared that there are other alternatives to getting health care attention. For example, some stated that they use free clinics that are offered in their community, however they are aware that emergencies could happen and that is the risk they are taking.

From talking to the medical professional, it is clear that the current health care system has not been working. This need to be changed because access to health care should be be a priority for everyone. The problem within the interviews conducted among the Latino people is the lack of information. For instance the different resources that are available for them. The Latino communities fear to even try at this point to get help to apply for health care insurance due to President Donald Trump. The fear is far more of a concern to the Latino families than their health care. Unfortunately this is the sad reality of many undocumented people. Struggles are arising as the years go by for those who are uninsured, because low-income families are usually the ones affected.

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