The promoters have emerged as an essential piece in the ambitious plan to provide health care in California to all residents.
Listen to this note:
It's late February and the road to Hamilton City, a farming community about 10 miles west of Chico, is lined with blooming almond trees, their pink blossoms covering fields for miles around. In the center of the city there is only one clinic.
Inside we meet MarÃa Soto, whose work as promotion girl is an essential piece in California's ambitious plan to offer assistance in accessing health services to all residents, regardless of their immigration status.
"I identify a lot with the community," Soto, 57, tells us. ?I have worked in the fields, harvesting and sorting nuts here. So I love it. It gives me great satisfaction when someone says to me: "Thank you for helping me." This is of incalculable value to me.
Soto is one of the three promoters of the nonprofit Ampla Health, which operates more than a dozen clinics in six counties—Glenn, Butte, Colusa, Sutter, Tehama and Yuba—in largely rural Northern California. As a federally qualified health center, Ampla is charged with expanding access to Medi-Cal (California's version of Medicaid) throughout its jurisdiction.
This work took on greater importance starting January 1, when undocumented immigrants between 26 and 49 years old were able to benefit from the program.
Previous expansions were aimed at both older adults and children. This latest phase makes California one of the first states in the country to offer access to federally subsidized health services to all eligible residents.
With 16 million members, or one in three Californians, Medi-Cal is the largest Medicaid provider in the country. With the current expansion, the state hopes to add between 500,000 and 700,000 more beneficiaries to its list, at a cost of about $2.6 billion a year. Medi-Cal's total annual operating budget exceeds $37 billion.
Eligibility is based on income, with the upper limit for an individual set at $21,680 per year, with approximately another $7,100 for each additional household member. Medi-Cal covers medical, dental and vision services. Through CalAIM, the state has also expanded the range of services offered.
The challenge now is making sure the communities that will benefit are informed about the opportunities available, which in far northern California is easier said than done.
Access health care ?without fear?
We are in an open field of almond trees, on a farm about 30 minutes from Hamilton. Around us is a group of a dozen farm workers, all originating from the same community in the state of Puebla, Mexico.
"Once he came and interrupted our work," Elfego Palestino Vidal jokes, pointing to Soto. "I've never signed up," he says, adding that in recent years he's seen more of his classmates fall ill due to increasingly extreme weather. ?Sometimes it is very cold, it rains a lot and then it is very hot.? Having access to Medi-Cal "will help a lot," he says.
Famous for its sprawling forests, towering peaks and rugged coastline, the North State, as it is known - stretching from the Oregon state line in the north to just above Sacramento in the south - is also beset by some of the state's most glaring health disparities, from higher rates of poverty and premature death from drug addiction and mental and behavioral health challenges.
Much of the region is also designated as a Healthcare Provider Shortage Area (HPSA), meaning there are fewer healthcare resources per capita. For marginalized communities, including many of the farmworkers interviewed for this article, that creates additional barriers to accessing health care.
Another farmworker, Leonardo Hernández Mesa, a husband and father of two, describes how he put off visiting the doctor in the past when he fell ill and pointing to his throat and ear when remembering a recent bout of infections. "Emergency visits are too expensive," he says, adding that his brother - also a farm worker - has Type 1 Diabetes.
"This is a great opportunity to get health insurance without fear," says Leonardo, adding that it will allow people to detect health problems earlier and not later. He says he has often heard others talk about postponing hospital visits.
A study from the University of California, UC Merced, last year found that nearly half of California farmworkers lacked health insurance at some point in the previous 12 months. The study also revealed that only 43% of farmworkers had visited a doctor's office, while only 35% had gone to the dentist. Other studies have found a large disparity in access to mental health and other behavioral services for agricultural workers in particular.
Simón Vázquez, who has worked on the same farm in Hamilton for more than two decades and is the crew leader here, has not seen a doctor since 2018. Simón ?bombs? Soto with questions about where and how to contact her, whether you need to renew each year (which is required), and what you need to bring for a medical or dental visit (only your Medi-Cal ID is required).
?We are here to help you with any questions you have. Do you already have the information to contact me, my phone number? he mentions patiently.
Reaching the "hardly achieved"
"A big part of my day consists of driving around looking for farm workers," explains Soto, who came to the United States as an undocumented immigrant in 1991 and spent time working in the almond fields surrounding Hamilton City. In 2007, she began working with Ampla Health, then known as ClÃnicas Del Norte, after a chance meeting with the organization's promoter coordinator at a local Mexican restaurant. ?She asked me what I knew about being promotion girl. I told you I didn't know anything.
Soto finally applied, received training, and has been committed to the work of promotion girl. "I've fallen more in love with the job as the years have gone by," he says.
The model of the promoters was first developed in Ciudad Juárez, a city in northern Mexico, in the early 1970s, as a way for the municipal government to provide healthcare and related information to underserved communities. The model soon spread throughout Latin America and later reached the United States.
It is not clear how many promoters They currently work in California. Some, like Soto, are employed directly by health care providers or community organizations. Others work more informally. The Vision and Commitment group, which launched the first network of promoters of the state in 2001, has about 4,000 members in 13 regions of California, almost all of them in the south and central part of the state, where the population is greater, as is the demand for services, in general.
According to data from the Center for Reducing Health Disparities at UC Davis, there are an estimated 10,000 agricultural workers in the six counties served by Ampla. If their family members are included, that number increases to almost 30,000 people. Although it is unclear how many of these people are undocumented, data shows that nearly three-quarters of the more than half a million farmworkers in California lack documentation.
Dr. Sergio Aguilar-Gaxiola, who directs the Center for Reducing Health Disparities, says these communities are ?hard to reach,? and says local and state agencies need to be proactive in terms of getting the word out. "I'm not sure if they will take advantage of this Medi-Cal expansion," he said during a recent Ethnic Media Services briefing. ?It depends on how you communicate.?
A "tremendous need"
Aguilar-Gaxiola, who has spent decades researching health inequalities affecting California's farmworker population, points to a variety of barriers - from language and culture to fear of deportation - that prevent many from coming forward to access available resources.
"It is a tremendous need," says Aguilar-Gaxiola. ?Satisfying it requires more than good will and wanting to do the right thing. To reach these populations, generating trust is essential?
During the Trump administration, a law known as the Public Charge Rule, which threatened migrants who accessed public benefits with deportation, cast a shadow over the community. Although essential items like health care and food are not considered part of a public charge determination, many immigrants remain afraid to enroll in public programs like Medi-Cal.
"People will hesitate to enroll in Medi-Cal for fear of public charge," agrees Cynthia Peshek, outreach program director at Ampla Health. ?We need to make sure this is not the situation. They need to move forward and take advantage of these resources. There will still be those who do not want to take risks, so public charge may continue to be a barrier for some?
Ampla Health organizes local health fairs and other community events, in addition to working with promoters as part of a set of strategies aimed at connecting people to health care. But Peshek is concerned that providers in other counties where resources are more limited will not have the resources needed to meet this current expansion. "It's going to be a big company," he says.
Peshek notes that Ampla Health recently added two new clinics to its existing network to meet growing demand. "There are a lot of opportunities right now," he says. ?We need to spread the word in all the areas we serve.?
Back at the farm, another member of the group, Daniel, says he is currently not covered. He is young, in his twenties. She says she visited Ampla Health in the past and now wants to sign up to avoid the high costs of medical services and medications she may need. ?It's a great help?.
As we leave, he nods at Soto. ?Thanks for being here. Thank you for not forgetting about us?
This article was funded by the 2024 California Health Equity Impact Fund from USC Annenberg Center for Health Journalism. With additional information from Manuel Ortiz.
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