One Step Closer to Universal Healthcare

At the start of the new year, California took a step closer to universal health coverage with the expansion of MediCal. But more important than the more than 700,000 undocumented immigrants in California who will now have free access to healthcare, is the fact that the Golden State will now have an effective weapon against opioid addiction.

MediCal’s expansion will eventually cost the state about $3.1 billion per year and will push California closer to the Democratic goal of providing universal health care to its roughly 39 million residents.

Gov. Gavin Newsom and lawmakers agreed in 2022 to provide healthcare access to all low-income adults regardless of their immigration status through the state’s Medicaid program, known as MediCal.

In an interview shortly after the new year, Harbor Community Health Centers’ director of strategy and compliance, Nathalia Jimenez, explained that the formerly known Harbor Free Clinic hired a therapist and licensed clinical social worker. HarborCHC also hired Chief Medical Officer Dr. Caleb Lusk, a double board-certified doctor in family medicine and addiction medicine.

Jimenez said the opioid crisis has not gone away and noted that Dr. Lusk and the HarborCHC are building a robust program to help those affected by substance use. More on this later.

MediCal Expansion and HarborCHC

In explaining the chronology of the expansion of MediCal, Jimenez explained that the state first expanded coverage for young adults up to age 25, and then the state expanded coverage for adults over 50 a few years ago.

“Originally it was everybody 50 years and older. Now MediCal includes the sort of in-between folks between the ages of 26 and 49 if you meet the income criteria,” Jimenez explained.

Then the state expanded full-scope MediCal to include the undocumented. California is one of the first states to implement this policy. Before this, the undocumented in LA County was part of a program called My Health LA. Jimenez explained that it wasn’t really insurance, but rather a program through which the county helped pay for primary care and certain preventive services so that those folks didn’t end up in the ER.

”Because we know that anybody ending up in the ER for things that aren’t necessarily ER related can cost the system so much more,” Jimenez said.

HarborCHC hired certified enrollers to work with this demographic of patients to make sure that as of Jan. 1, eligible patients were transitioned to full-scope MediCal.

The new enrollees will get placed into a health plan and will be able to pick their primary care doctor and there’s a network of specialists to which patients can be referred.

“They can go to the hospital either at no cost or with a very small copay,” Jimenez explained. “The health plan provides them with transportation if they have transportation needs; with case management if they’re kind of more medically complex.”

Jimenez noted that with the newly enrolled patients getting anchored to primary care providers, those patients will have access to preventive services instead of allowing patients to put off care until things get really bad.

“California has always been more socially liberal than some other states and they realize there’s a lot of working-class folks that are working really hard and contributing to the economy that for one reason or another don’t have access to adequate medical care,” Jimenez explained.

“This demographic of patients doesn’t get mammograms. They don’t get colorectal cancer screenings. If they have diabetes, their illness is completely uncontrolled, resulting in those folks eventually ending up in the emergency room.”

“Once they’re there, you can’t turn anybody away. That would be unethical,” Jimenez said. “So the emergency room treats all of these diseases and illnesses that could have been prevented.”

The result of course is the whole healthcare system spending all this money, without preventing any of the preventable pain and suffering.

It’s all about trying to prevent illnesses and helping people stay healthy and get healthy and that involves doing preventive screenings. For women, HarborCHC performs pap smears and screenings of mammograms and colorectal cancer.

HarborCHC is also able to conduct physicals and blood work.

Legacy and Dentistry

“We started in 1970 as a free clinic focused mainly on women and children and we did just very basic health care. Over the years, we’ve grown and in 2015 we applied for a federal grant and were rewarded. We became what was called, “a federally qualified health center” and that allowed us to really start expanding and providing more care because we got additional funding,” Jimenez explained.

From 2015 to now, HarborCHC has tripled its staff and is treating way more patients.

The health centers have added three dentists and a podiatrist for those diabetic folks to make sure that their feet are okay.

“We’ve expanded our HIV program. We now offer HIV testing and other STI testing to everyone. Jimenez said. “If you’re not HIV-positive, but you’re exposed to it, you can take medication that will prevent you from getting it. If you are HIV- positive then you can take medication to prevent you from transmitting to others.”

“The first step is screening because a lot of people don’t even know that they’re HIV positive. So in 2020, 35% of our patients in the adult populations had received at least one HIV test. So patients 15 to 65 who were tested for HIV at least once is 35% in 2020. Last year, 2023, it was 80%, so we’re really pushing HIV screening because the first step is to know your status. Hepatitis C is going up as well. So screenings for Hepatitis C went from 21% in 2020 to 65% in 2023. “

Jimenez noted that with HarborCHC providing medical, dental, and mental health, patients are accessing all three.

“We always work to make sure that patients know all the services we offer because sometimes they don’t even know. So we try to do a lot of cross referrals so the doctor sees that a patient, you know, hasn’t been to the dentist in a while.

“They’ll say, ‘Hey, let me know, we have a great dentist here.’ And if you have a medical discovery, like let’s get you to the dentist because we’re really trying to be a one-stop shop.”

The point is to ensure that there is no wrong door when you go HarborCHC for medical help.

“If you’re seeing a dentist and you’re chatting with the dentist and the dentist realizes maybe you have depression and you need to see a therapist, they can refer you over,” Jimenez explained. “We’re really trying to take care of the whole person.”

Jimenez noted that there are studies that show that when pregnant women without good dental care go into preterm labor, bacteria from their mouth travel to their bloodstream and to their intestines. It’s all connected.

The Fight Against the Opioid Crisis From the Hospital Room

Dr. Lusk said San Pedro is just like the rest of LA County in the opioid addiction crisis.

“We’re really struggling with the opioid epidemic. It’s certainly affecting this region,” Dr. Lusk said. “There’s SPA-8, [Service Planning Area] which is San Pedro/ Long Beach and has one of the biggest overdose rates in the county for high potency synthetic opioids or Fentanyl. There’s a lot of methamphetamine use disorder. There are a lot of overdoses among the unhoused patients in the area. We’re seeing it in San Pedro certainly.”

In his capacity as board-certified addiction medicine manager in the opioid and methamphetamine task force for the county, Dr. Lusk regularly gets updated statistics.

“SPA-8 is certainly up there,” the Yale-educated doctor explained. “But it’s stable. I think the past year at least it hasn’t gone up but you know, 2020, 2021. it’s been over 100,000 people with substance-related overdoses.”

According to a report released by the LA County Health Department in November 2023, fentanyl surpassed methamphetamine to become the most common drug type listed as a cause of death in accidental drug overdose deaths in the county in 2022, accounting for 59% of all alcohol and other drug overdose deaths.

Accidental fentanyl overdose deaths increased 1,652% from 109 in 2016 to 1,910 in 2022. From 2016 to 2021, fentanyl overdose emergency D=department visits increased 621% from 133 to 959, and fentanyl overdose hospitalizations increased 225% from 102 to 332 cases.

Adults aged 26-39 years had the highest rates of fentanyl overdose deaths (36.5), emergency department visits (23.8) and hospitalizations (6.5) per 100,000 population in the most recent data year.

Males accounted for more fentanyl overdose deaths and had a rate per 100,000 population that was 4.6 times that of females (32.3 vs. 7.0) in 2022. Males also accounted for more fentanyl overdose emergency department visits and hospitalizations and had rates per 100,000 population that were 3.5 and 4.5 times, respectively, of those for females in 2021.

White residents accounted for the largest numbers of fentanyl overdose deaths, ED visits, and hospitalizations, followed by Latinx, Black and Asian residents. However, after adjusting for differences in population size, Black residents had the highest rates per 100,000 population for fentanyl overdose deaths (49.5) and hospitalizations (4.3), and the second highest rate of ED visits (10.5) as compared to white residents (deaths: 27.2, ED visits: 14.8, hospitalizations: 4.1), and Latinx residents (deaths: 15.0, ED visits: 6.6, hospitalizations: 2.4), and Asian residents (deaths: 2.7, ED visits: 1.2, API hospitalizations: 0.8) in the most recent data year.

Similarly, more affluent areas had higher numbers of fentanyl overdose deaths than less affluent areas, with nearly half (48%) of fentanyl overdose deaths occurring in the most affluent areas and 8% occurring in the least affluent areas in 2016-2022. However, the rate of fentanyl overdose deaths per 100,000 population in the least affluent areas was more than triple that of the most affluent areas (51.4 vs. 15.8) of LA County in 2022.

The report noted that fentanyl overdoses are becoming a public health problem across the country; and across sociodemographic groups and geographic areas. The increases among youth and the widening inequities between under-resourced and more affluent groups underscore the need to target prevention efforts to those of highest risk to decrease fentanyl overdoses and advance health equity in LA County.

Dr. Lusk noted that HarborCHC has behavioral health services that serve all ages, including major depression and anxiety.

“There are some providers who work with substance use disorder and then we have a drug and alcohol counselor that we just hired as well,” Dr. Lusk said.