Growing up amid the dusty agricultural fields of the Central Valley, Ruby Marentes-Cabrera cannot recall a time when it was not difficult to breathe.
Diagnosed with asthma as a child, the ninth-grader has come to hate the pistachio trees that surround her home. Garden dust, pesticides, and other allergens often trigger an asthma attack, even infiltrating your home, making simple tasks like vacuuming dangerous.
“We live so close to the fields, I breathe the dust and the chemicals,” said 14-year-old Ruby, describing attacks of controlled coughing and wheezing thanks to her emergency inhaler or breathing treatments with a nebulizer. “It gets so bad that my back hurts, my head hurts, my lungs hurt. I get sick and it takes a lot for me to breathe. “
Ruby is one of nearly two million low-income Californians who have health coverage under Medi-Cal, the state Medicaid program, and have been diagnosed with asthma, a chronic and costly disease that costs California billions. dollars a year in health care expenses, and in lost parenting days and children’s absences from school.
The disease, compounded by air pollution and indoor threats like harsh cleaning products, roach infestations, dust, and mold, hits low-income communities hardest.
Medi-Cal patients accounted for half of the asthma-related ER clinic and emergency room visits in 2016, despite accounting for about a third of the population, according to data cited by state health officials.
Starting in January, California will embark on an ambitious experiment to control asthma in its most vulnerable patients. Medi-Cal will offer recipients like Ruby unconventional “treatments” at home that are not traditionally considered medical care such as removing mold, installing air purifiers, and even replacing carpets, blinds, and mattresses.
These new asthma treatment benefits are just a small part of Governor Gavin Newsom’s broad $ 6 billion initiative to transform the nation’s largest Medicaid program.
The initiative, known as CalAIM, will target the sickest and most expensive patients in the state, and will cover a variety of new social services, including healthy meals delivered to home; help with shopping, laundry, and money management; and security deposits for homeless people looking for housing.
Newsom’s goal is to reduce skyrocketing Medi-Cal spending, which reached a staggering $ 124 billion this fiscal year, by preventing costly care like emergency room visits. But state health officials acknowledge that the new asthma benefits may not save taxpayers money.
Benefits will not be evenly distributed either: Because Medi-Cal managed care insurance plans have immense power in deciding what new services to offer and to whom, the initiative will create a mosaic of eligibility.
Of the 25 participating insurance companies, 11 will offer asthma services at home starting in January in 36 of the state’s 58 counties. Within those counties, some Medi-Cal recipients will qualify; others don’t.
With only two weeks to go until the program debuts, many insurers are struggling to establish networks of nonprofits and private contractors that specialize in providing home asthma services and repairs.
In San Bernardino and Riverside counties, for example, about 400 patients served by the Inland Empire Health Plan, out of nearly 1.4 million Medi-Cal plan members, will have access to asthma services in the first year, in largely because the insurer has identified only one organization equipped to deal with this responsibility.
“If we don’t get this right, this dream can turn into a nightmare,” said Alexander Fajardo, executive director of the El Sol Neighborhood Educational Center in San Bernardino, which is negotiating a contract with the insurer.
Fajardo said that El Sol is preparing intensively. While your organization has experience in providing asthma education, it lacks experience in medical billing, patient privacy regulations, and managed care contracts.
“This is new, so we still have to learn,” Fajardo said.
Jeanna Kendrick, senior director of care integration for the Inland Empire Health Plan, called the experiment to develop new social services “probably the most difficult thing we’ve ever done. ” It takes the plans into uncharted territory, he said, hiring community organizations and teaching them how to handle medical billing, for example.
“We really need to be creative and have some leeway because this is new to all of us, ” Kendrick said.
Jacey Cooper, California’s director of Medicaid, argued earlier this year that health plans will start small, but will add capacity over the five years of the initiative. The state is offering incentives in the form of payments to help plans launch new services and has set aside $ 300 million for the first half of 2022 alone.
The Department of Health Care Services, which administers Medi-Cal, could not say how many low-income Californians will receive new asthma services at home, because they are voluntary and, as a result, cannot predict future costs.
But Anthony Cava, a spokesman for the department, cited data showing that more than 220,000 Medi-Cal recipients have poorly controlled asthma. The state pays $ 200 to $ 350 for a typical asthma-related emergency room visit, and $ 2,000 to $ 4,000 a day for a typical hospital stay, department officials said.
Agency officials could not confirm that asthma benefits will save money, saying the costs will be equal to or less than the costs of traditional medical treatments.
Under the program, health insurers will send contractors to homes and apartments to assess hazards and educate patients about conditions that can trigger asthma attacks. Insurance executives say they will consider approving any services that can help asthma patients, from replacing damaged carpets to purchasing non-toxic cleaning products and pillowcases, within the lifetime limit of 7,500 for each Medi beneficiary. -Lime.
The services will be available to both renters and homeowners.
“It’s not like anyone can just say they just want a new $ 3,000 mattress,” explained Dr. Takashi Wada, medical director of the Inland Empire Health Plan. “But we believe that many of these asthma attacks are preventable, and by avoiding illness, unnecessary visits to the hospital and emergency department are also avoided.”
Fresno and Madera’s counties have some of the worst air quality in the state. They also have the highest rates of childhood asthma-related ER visits in California, along with Imperial County on the border with Mexico, according to 2019 state public health data.
Ruby and her family, who live in Madera, California, appear to be ideal candidates for state-funded asthma benefits, said Joel Ervice, associate director of Regional Asthma Prevention and Management, who pushed for the new services. Both Ruby and her 20-year-old sister Yesenia have asthma and were frequent visitors to the emergency room as children.
But like the Inland Empire, only a small portion of Central Valley asthma patients will initially receive the new services. Ruby and her family hope to be among the lucky ones, but they know they may still have to rely on conventional treatments, such as emergency inhalers, and the hospital, if necessary.
“I’m taking a lot of my medicine right now; it would be nice if my asthma got better,” said Ruby, who wants to be able to play outside the house and excel at outdoor school activities. “I’m having a hard time running a mile in school, so being able to run would be so good for me and my health.”
So far, CalViva Health, a large insurer serving patients in the Central Valley, including the Marentes-Cabrera family, has identified a nonprofit to provide services and is negotiating with others.
That organization, Central California Asthma Collaborative, hopes to serve up to 500 people in seven counties next year. Unlike other nonprofit groups that are still evaluating how to provide services, the collaboration has already identified private contractors to remove mold, install bathroom or kitchen ventilation, and provide other services, said its co-director, Kevin Hamilton.
CalViva Health CEO Jeffrey Nkansah said asthma is a leading cause of hospitalization among the insurer’s members.
“Right now, conversations about identifying partners to provide these services are fluid,” said Nkansah. “We are still working hard to make sure we can implement them by January 1.”
For the Marentes-Cabrera, the incessant clouds of dust and other toxins from the orchards, combined with smoke from seasonal forest fires, are the biggest problem. The particles get into your lungs and into your home, covering surfaces and dirtying the carpet, which, in fact, they would like to replace. But they have no money.
For now, Sandra Cabrera uses non-toxic cleaning products, and her daughters Ruby and Yesenia monitor her lung capacity with oxygen meters.
“I’m trying to control what’s in the house to prevent them from getting sick, cleaning a lot, and using different products,” Cabrera said in Spanish. “We could use help to do more, but it’s really difficult.”