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[whitespace] Arcadio Viveros
Photograph by George Sakkestad

Man of the People: Executive Director Arcadio Viveros stands in front of Salud Para La Gente, one of the few nonprofit clinics that serve the Pajaro Valley.

The Price of Health

There's a health-care crisis in Santa Cruz. But not to worry. It's mostly the poor, after all.

By Andrea Perkins

FIFTY-YEAR-OLD Micaella Reyes removes her long maroon stockings, revealing blue, knotted varicose veins and ulcers that spread like crimson flowers to her swollen ankles and feet. A cannery worker in Watsonville, Reyes was afraid to apply for MediCal, California's version of the federal Medicaid program, because somebody told her it would affect her immigration status. She has been in the process of applying for U.S. citizenship for the last few years.

For a while, a friend drove her twice a month to Los Gatos, the closest town that had a specialist for her condition. The treatments were $175 a pop (a sacrifice that wasn't easy to make, especially with three kids at home), but they stopped the pain and made standing for eight hours a day at the cannery a little more bearable.

But after a year, Reyes' friend was no longer able to take her to the specialist, and having no other way to get there, she had to stop the treatments. That was when the ulcers developed.

Her freckled face falls into an easy smile. Recently, Reyes, a diabetic, learned that new legislation prevents a recipient of MediCal from being considered a public charge. That meant she could apply for the program without endangering her chances of becoming a citizen. Happily, she signed up--only to find that it didn't cover the treatments she needed.

According to the United Way Community Assessment Project released in July, there are more than 35,000 stories like Reyes' in Santa Cruz County alone, where 14 percent of the population does not have health insurance--which means not having access to primary care and, a lot of the time, not being able to see a doctor unless it's in an emergency room. Preventive medicine becomes a luxury item, standard for the insured but only partially available for MediCal patients.

Since 1987, even during the recent strong economy, the number of uninsured people nationwide has increased at the turbo-charged rate of 1 million a year, according to U.S. Census data. Today there are 44 million people living without any health insurance, making health care a hot issue this election year.

But while the talking heads focus mainly on prescription drug coverage for the elderly and more health insurance for children, nothing is said about that other big group in the middle. Many of these invisible everyday workers are still waiting for the swelling economy to sweep them up. Until then, they will continue to face the challenge of staying healthy in a system where health care, like everything else, is treated like a commodity.

"At some point, the health care system has got to seriously address this issue," says Rhama Khalsa, director of the Santa Cruz County Health Agency. "What has been done is not working. We need a different approach."

According to the U.S. Census, poor workers were less likely to be insured than poor nonworkers, who can qualify for government programs. In 1998, half of all poor full-time workers were uninsured, making up 80 percent of all uninsured people. Sometimes, even when an employer offers coverage, employees still can't afford it.

According to a Sept. 18 New York Times story, health premiums across the country have risen by 10 percent (in some cases even more) in just the last few months. The Center for Studying Health System Change, in Washington, D.C., found that one in five uninsured people opt out of employer-sponsored coverage because it's too expensive.

In California, fewer than half of private businesses offer health insurance to their employees. According to Carol Griffith, health center manager for the Santa Cruz County clinics, "Out of the 5,700 visits paid every year to the clinics, most are by poor working adults with no children younger than 18."

"There's nowhere for them to go," Griffith says. "It's the people who keep working and aren't disabled that are the worst off. Government programs address the disabled, kids and seniors, but not the others."

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Between the Cracks

VIRGINIA CARIDAD carries a broken cell phone in the outer pocket of her handbag, just for looks. "I'm finally making 12 dollars an hour and it's like, 'Wow!'" she says. "It's been so hard finding a job with benefits."

Her new job at a local nonprofit organization offers them. However, Caridad will have to wait three months to qualify for her employer's coverage plan because she has a chronic and incurable pre-existing condition: Hepatitis C. Like others without access to modern-day health care, Caridad has turned to alternative medicine in the meantime.

"I'm trying this milk thistle tonic, but I'm really deteriorating," she says. "I owe Dominican Hospital thousands for MRIs and spinal taps. There have been times when I've lied about being insured in order to get tests done. I was desperate. I had to take a chance. I committed a crime just so I could get a blood test to see how my enzymes were doing." (See sidebar, left, on Dominican's record on indigent care.)

Even though she lived in a shelter for a few months when she lost her mobile home in a traffic accident, Caridad has always worked: as a temporary employee for the county during elections, as a banquet waitress at the Holiday Inn, as a part-time aid to a paralegal secretary. She describes the stress of using group showers and trying to iron clothes in the shelter while managing to show up to work on time with a smile on her face.

Just a few months ago she was on MediCruz, the county health care program designed for those who can't get on MediCal. But because she made $100 more than the $600 a month cutoff, she paid a $90 premium. "When you're making $700 a month and paying $200 on a rented room and they still tell you that you make too much to be subsidized, that's kind of weird to me," Caridad says.

Since its implementation in 1983, MediCruz has had a fixed budget of $5 million. While its budget hasn't increased, the number of people (mostly single people or couples without children) who apply for the program has. Eligibility requirements haven't changed since 1990. A single person can't make more than $600 a month, while a family of four is limited to $1,100.

"The maintenance need level [the income level at which recipients don't have to pay a monthly premium for coverage] of MediCruz parallels that of MediCal," explains Bob Varti, medical care program administrator for MediCruz. "It has been 10 years since MediCal raised the income level and they really need to raise it."

Unlike the rest of the state and the nation, the number of uninsured people in Santa Cruz County has actually decreased in recent years, perhaps as a result of this unique program. Santa Cruz is one of five counties in California that have a county equivalent to MediCal. The MediCruz program recently expanded into Monterey County in what is called the Central Coast Alliance for Health, the idea being that with a wider patient base, more funding will become available.

According to David McNutt, the county health officer, federal funding for MediCruz has dropped half a million dollars during the last two years. "We have to make it up on the county level," McNutt says. "MediCruz is able to meet immediate needs but it can't provide full coverage." The program doesn't cover preventive medicine or prescriptions.

Wayfarer Care

'BY NOT PROVIDING preventive care, we are shooting ourselves in the foot," says Paul Gendreau, who has worked at the Homeless Persons Healthcare Project for 10 years as a public health nurse, social worker and part-time case manager. Nestled amid other homeless resource facilities on River Street, the HPHP occupies a small, renovated cottage near Costco. The project was born 22 years ago, thanks to one of 130 nationwide grants from the Stuart B. McKinley Foundation. Most of the grants went to counties with large cities, but persistent homeless advocates in Santa Cruz saw a need for a health care facility for the homeless and made themselves heard.

Gendreau's chiseled face looks tired. "We're always on overwhelm here," he says. "We're the last place some people can go. By the time they show up here they don't just have one problem, they have four, five or six problems. Traditionally, homeless people were really only seen in emergency rooms when they were in the really late stages."

Besides treating and educating people from Pajaro Valley to the county's north coast, the small staff of nine refers over 3,000 homeless people a year to clinics and government programs and provides services during the six months it can often take to receive benefits from those programs.

According to the United Way, 57 percent of the homeless in Santa Cruz County are on MediCal and 19 percent are on MediCruz. The UW report also shows that the number of homeless people in the county has increased to 3,300, up from 1,190 in 1990. A third of them are working, and more than a third do not receive any type of government assistance.

"Because of the high coast of living, many people are just a paycheck away from being homeless," Gendreau says, his long, tapered fingers tapping the table where a book of all the patients who have died sits under a candle. "It really burns my ass, to tell you the truth, when someone sees somebody who looks able-bodied and thinks that just by getting work everything will be solved. But when you hear their stories, it's really amazing that they're still walking around. Under the obnoxious behavior there is a real human being who is sometimes exquisitely ashamed of what they're doing and can't stop.

"Some conservatives will say, 'If you build it then they will come.' But most of the homeless people here are our own; they've been in the county for years. It's not like they say, 'Homeless services are great in Santa Cruz! Let's go!'" The United Way survey backs this up, revealing that 77 percent of the homeless have lived here five years or more.

This year, the Homeless Persons Healthcare Project received $900,000 in grants from the county, state and federal governments. The program uses those resources to cover health care costs for the homeless at county clinics and at Salud Para La Gente, a nonprofit primary care clinic in Watsonville. The project offers what preventive care it can, routinely treating skin and respiratory infections and diabetes. It also offers 28-day detox programs for people with drug or alcohol dependency.

"We can't do any in-patient care, though. That would suck up our budget in two months," Gendreau explains. Instead, the project makes sure that people who need post-hospital convalescence receive motel vouchers, allowing them a few days to recover off the street. "We sometimes think that people who don't have insurance get discharged too quickly from the hospital," Gendreau adds.

One of the few private primary-care doctors in Santa Cruz willing to treat homeless people without insurance is Dr. Stephen Halpern. For the last 20 years, he has treated those in need of medical care regardless of situation, enforcing a minimal charge and giving out free samples of medication. According to Halpern, and everyone else interviewed for this article, what is needed is universal health care. "In a country like this we can certainly afford it," Halpern says. "Congress keeps talking about tax vouchers, but tax vouchers don't mean anything to a person living in a cardboard box."

Matt Nathan, Paul Borg
Photograph by George Sakkestad

Say 'Ahhhh ...' Public health nurse Matt Nathan, left, counsels homeless client Paul Borg at the Homeless Persons Healthcare Project.

Shredding the Net

THE HEALTH CARE SITUATION in South County is even less rosy. The regional office of the Federal Bureau of Health Care Delivery and Assistance has designated the Pajaro Valley population as "medically underserved." Watsonville's Salud Para La Gente is one of the few primary care clinics in the area.

"There are significant disparities in health outcomes and access to services for a significant percentage of our Latino population," says McNutt, pointing to the Santa Cruz County Community Assessment Project, published every year by the United Way. The 1999 report reveals that only 67 percent of the Latino population have health insurance, compared with 88.9 percent of the white population.

Salud Para La Gente doesn't turn anyone away. There is a sliding fee scale based on the patient's ability to pay. They also have a variety of payment plans and in many cases forgive up to 75 percent of a visit's cost, if not all of it.

Like many other health care professionals working with the less advantaged, Salud Para La Gente Executive Director Arcadio Viveros looks worn out. Seated under a placard that reads, "Our job is to comfort the disturbed and disturb the comfortable," Viveros stifles a yawn. Diego Rivera prints and a photo taken with Caesar Chavez clutter the walls of his office. Tape peels off threadbare spots on the carpet. The clinic is full of people waiting to be seen.

"In cases where a patient has zero resources and doesn't qualify for any existing programs, we pay for their visit, plus the referral to the hospital, if need be, and the pharmacy bill."

According to Viveros, half of Salud's patients need that kind of assistance. "A lot of our patients used to be on MediCal and Medicare, but since the Managed Care Act of 1997, some private doctors have gone into the business of accepting those patients." This takes government-paid-for patients away from Salud. At the same time, doctors continue to send their patients without money or insurance to nonprofit clinics.

"The safety net is about to break," Viveros says.

To meet rising demands, Salud is raising funds to set up a clinic in north Monterey County to serve the Pajaro Valley. To consolidate administrative costs and bring services to more people, Salud plans to merge with Clinica Del Valle Del Pajaro this fall. Salud is also adding a dental clinic--something sorely needed in a county where last year only 12 local dentists accepted patients on MediCal or MediCruz. Viveros would also like to get an in-house pharmacy, putting his case before pharmaceutical companies hoping they will donate trained staff and medication to the cause.

"What good is a doctor's appointment if you can't afford the medicine he prescribes?" asks Viveros. "I saw this lady the other day paying for her prescriptions--$268! From what I could tell, she was on a fixed income and shelling out cash for probably what was a monthly supply of medicine for a chronic condition. Some people have to ask themselves, shall I have an adequate diet or take my pills this month?"

"This county is really taking an advocacy role when it comes to health care," Rhama Khalsa says. "We are trying to get the state and federal governments to raise the income limit on MediCal, start sliding scale options for people who might be over the eligibility limit and encourage local employers to provide more coverage."

There isn't too much the county can do without state and federal assistance. But change may be afoot. Since the state did not enroll as many children as planned in the Healthy Families Program (an insurance program for low-income kids that includes preventive care), the state now faces the prospect of returning leftover funds to the federal government. Governor Davis has until September 30 to sign a package of insurance bills that would use these funds to provide health insurance to over 600,000 people, mostly working adults.

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From the September 20-27, 2000 issue of Metro Santa Cruz.

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