Pricey LA Imposes Financial Barriers to Care

The high cost of living in Los Angeles County poses great challenges for undocumented immigrants and low-income families. According to the California Poverty Measure, which accounts for geographical differences in housing costs, LA has the highest poverty rate (13.7%) among the state’s counties, 2 percentage points higher than the state average (11.7%) (Danielson, Malagon, and Bohn 2022).

High costs force individuals to prioritize their basic needs, forgoing health services that do not fit into their constrained budgets. In the words of one interviewee, “A lot of undocumented immigrants are low-wage workers. They don’t have extra fungible income. So, any income that they have often gets spent on housing, food, basic supplies, and their kids, so health care sometimes drops to the bottom of the list.”  

Undocumented immigrants also worry about what will happen if they cannot afford to pay for health care after receiving it. Interviewees noted patients’ concerns about medical debt, Medi-Cal liens, and immigration sponsor deeming (in which immigrants must include their sponsor’s income in program applications—see National Immigration Law Center 2019), all of which pose barriers to signing up for safety net programs or getting health care. Low incomes can be a double-edged sword with respect to helping individuals access health care.

Health care safety net programs are targeted to low-income individuals—both Medi-Cal and My Health LA have an income eligibility threshold of $20,120 for a single person—but low-wage jobs themselves can stand in the way of getting health care. Undocumented immigrants with low-wage jobs tend to lack stable work schedules and paid time off, resulting in missing or delaying care. One interviewee noted that CHC visits outside normal work hours are coveted since they reduce conflict with patients’ jobs.

Transportation and Language Needs Pose Barriers in Multiple Ways

Undocumented immigrants may lack transportation to travel to health care providers. Transportation needs can also be the result of language needs, with patients having to travel long distances to see providers who speak their preferred language. Barriers can also stem from the lack of a cultural bridge, or an understanding and integration of cultural needs in health care.

Transportation barriers to care are present especially for older adults who are less mobile and may have greater health needs. One expert differentiated transportation access by residency tenure: long-settled immigrants are familiar with bus routes and know how to key in on specific phrases even if they do not necessarily speak English. More recent arrivals have a harder time navigating the sprawling county and its public transit system.

Complicating the picture further is LA’s high level of linguistic diversity. Most health care services and resources are provided in English or Spanish, while resources in Asian and Pacific Islander languages are not provided as often.

The Medi-Cal program provides a concrete example of the difficulties in serving expansive linguistic needs. The program establishes threshold languages by geography, and plans must provide materials in these languages to individuals who are not English-proficient. However, there are about 50 languages represented among our LA County study members and only a few, including English and Spanish, are threshold languages in LA. Technical Appendix E contains a complete list of LA County study patients’ preferred languages.

Furthermore, experts shared that patients may be unaware of their right to an interpreter and to receive materials in their preferred language as a result of the low health literacy among this group. Instead, older children and application assisters often serve as informal interpreters.

On a positive note, these barriers could be effectively addressed through staffing and other resources. We heard from several experts about the importance of hiring bi- and multilingual providers at CHCs, improving the availability of translation services, and providing document translation into a range of languages that go beyond LA’s 11 Medi-Cal threshold languages. Hiring staff with needed language skills may be harder for some roles. For example, it takes a very high level of fluency to conduct therapy in a second language, which poses a challenge for hiring behavioral health providers who speak multiple languages.

Addressing These Challenges Can Help with Medi-Cal Enrollment in 2024

We learned that community outreach is integral in LA County. CHC-based experts described their efforts to host informational workshops, and highlighted other groups doing similar work, such as the BAILA Network (Benefits Access for Immigrants Los Angeles 2023). CHCs go into the community and attend school events to engage with people who may be eligible for resources but need more information.

While LA County provides support to access these resources, some experts we spoke with expressed concerns about county staffing shortages and weaknesses in the county health system in addressing the needs of all patients. Some CHCs have difficulty enrolling their patients in Medi-Cal through county welfare agencies, with assisters waiting on hold for long periods. The county has no back-channel access for clinic assisters, so they get in line with everyone else who calls. Patients may be long gone by the time a phone connection is made, and the assister may not be successful in getting them on the phone to speak directly with the county, derailing the enrollment effort. Additionally, we heard that relationships between counties and community-based organizations (CBOs) could be improved and that the county could incorporate more on-the-ground feedback from CBOs to improve programs and outreach.

Even after the expansion, however, insurance challenges may continue for undocumented immigrants. Medi-Cal eligibility is not the same as enrollment. The application process is complex and enrollment assistance is instrumental for CHC patients. We heard that immigrants do not always understand the questions asked, and consequently, share incomplete information when applying for Medi-Cal. They may also experience instability in employment or county residency, complicating their ability to collect the required supporting documents. Here, too, language support will be needed. According to an interviewee, “[p]atients are willing to trust you and come to you to get [Medi-Cal] enrollment done when this kind of service or workshop is provided in their language by someone who knows where they are coming from.”

Confusion can persist, even among those who have managed to enroll in Medi-Cal. One expert shared that patients lack a solid understanding of their Medi-Cal coverage in terms of scope, provider networks, and medical group geographic limits. As a result, some patients do not understand why their preferred provider is out of their network.