Alma earned her reputation as a trusted source of information through her internship as a junior community health worker. She was among 35 Fresno County students recently trained to discuss how covid vaccines help , and to encourage relatives, peers, and community members to stay up to date on their shots, including boosters.

When Alma’s internship drew to a close in October, she and seven teammates assessed their work in a capstone project. The students took pride in being able to share facts about covid vaccines. Separately, Alma persuaded her family to get vaccinated. She said her relatives, who primarily had received covid information from Spanish-language news, didn’t believe the risks until a close family friend died.

“It makes you want to learn more about it,” Alma said. “My family is all vaccinated now, but we learned the hard way.”

Community health groups in California and across the country are training teens, many of them Hispanic or Latino, and deputizing them to serve as health educators at school, on social media, and in communities where covid vaccine fears persist. According to a 2021 survey commissioned by Voto Latino and conducted by Change Research, said they didn’t trust the safety of the vaccines. The number jumped to 67% for those whose primary language at home is Spanish. The most common reasons for declining the shot included not trusting that the vaccine will be effective and not trusting the vaccine manufacturers.

And vaccine hesitancy is not prevalent only among the unvaccinated. Although of Hispanics and Latinos have received at least one dose of a covid vaccine, few report staying up to date on their shots, according to the Centers for Disease Control and Prevention. The CDC estimated of Hispanics and Latinos have received a bivalent booster, an updated shot that public health officials recommend to protect against newer variants of the virus.

Health providers and advocates believe that young people like Alma are well positioned to help get those vaccination numbers up, particularly when they help navigate the health system for their Spanish-speaking relatives.

“It makes sense we should look to our youth as covid educators for their peers and families,” said Dr. Tomás Magaña, an assistant clinical professor in the pediatrics department at the University of California-San Francisco. “And when we’re talking about the Latino community, we have to think deeply and creatively about how to reach them.”

Some training programs use peer-to-peer models on campuses, while others teach teens to fan out into their communities. , a public youth corps based in Oakland, is leveraging programs in California, New Mexico, Colorado, and Michigan to turn students into covid vaccine educators. And the in Florida, which trains high school juniors and seniors to teach freshmen about physical and emotional health, integrates covid vaccine safety into its curriculum.

In Fresno, the junior community health worker program, called , adopted the promotora model. Promotoras are non-licensed health workers in Latino communities tasked with guiding people to medical resources and promoting better lifestyle choices. that promotoras are trusted members of the community, making them uniquely positioned to provide vaccine education and outreach.

“Teenagers communicate differently, and they get a great response,” said Sandra Celedon, CEO of , one of the organizations that helped design the internship program for students 16 and older. “During outreach events, people naturally want to talk to the young person.”

The teens participating in Promotoritos are mainly Latino, immigrants without legal status, refugee students, or children of immigrants. They undergo 20 hours of training, including social media campaign strategies. For that, they earn school credit and were paid $15 an hour last year.

“Nobody ever thinks about these kids as interns,” said Celedon. “So we wanted to create an opportunity for them because we know these are the students who stand to benefit the most from a paid internship.”

Last fall, Alma, who is Latina, and three other junior community health workers distributed covid testing kits to local businesses in their neighborhood. Their first stop was Tiger Bite Bowls, an Asian fusion restaurant. The teens huddled around the restaurant’s owner, Chris Vang, and asked him if he had any questions about covid. Toward the end of their conversation, they handed him a handful of covid test kits.

“I think it’s good that they’re aware and not afraid to share their knowledge about covid,” Vang said. “I’m going to give these tests to whoever needs them — customers and employees.”

There’s another benefit of the program: exposure to careers in health care.

California faces a in the health care industry, and health professionals don’t always reflect the increasing diversity of the state’s population. Hispanics and Latinos represent 39% of California’s population, but only 6% of the state’s physician population and 8% of the state’s medical school graduates, according to a .

Alma said she joined the program in June after she saw a flyer at the school counselor’s office. She said it was her way to help prevent other families from losing a loved one.

Now, she is interested in becoming a radiologist.

“At my age,” Alma said, “this is easily the perfect way to get involved.”

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In 2015, one of those warehouses was built right in front of her old house, blocking her view of her suburban neighborhood. Soon thereafter, her son battled bronchitis and pneumonia. “It got so bad that I ended up taking him to the ER about three to four times a year,” she said. Her son, now 16, like so many others in the region developed asthma due to air pollution. She grew concerned that state policies were overlooking predominantly Hispanic and low-income residents in her community.

Gonzalez, 35, has evolved from a concerned parent into an environmental advocate. Her years as an educator specializing in bilingual and special education, along with a bout of homelessness, fuel her passion for advocating for marginalized communities. Today, she serves as executive director of the Center for Community Action and Environmental Justice, which works on air quality and environmental justice issues on behalf of the region.

Gonzalez and the organization have endorsed on the November ballot. Funded primarily by the ride-hailing company Lyft, it would impose an additional 1.75% tax on what Californians earn above $2 million per year to fund zero-emission vehicle purchases, electric charging stations, and wildfire prevention programs.

While the initiative would provide subsidies for low-income consumers, it would also subsidize businesses, such as Lyft and other ride-hailing companies, by helping them add clean cars to their fleet. Lyft and other ride-hailing companies are under to make at least 90% of their vehicle fleets electric by 2030.

The once-popular measure has slipped into toss-up territory. A by the Public Policy Institute of California found 55% of likely voters back the measure, down from 63% in April. And it has divided environmentalists and Democrats.

The measure would generate an estimated $3.5 billion to $5 billion a year, growing over time, according to the nonpartisan . Of that, 45% would primarily subsidize zero-emission vehicles and 35% would boost construction of residential and public charging stations, with at least half of each category directed to low-income households and communities. The remaining 20% would fund wildfire suppression and prevention.

The state Democratic Party and the American Lung Association endorsed Proposition 30, calling it an innovative measure that will expand access to electric vehicle chargers for every Californian, regardless of where they live or work.

But opponents include the California Teachers Association and Democratic Gov. Gavin Newsom, who the measure “a Trojan horse that puts corporate welfare above the fiscal welfare of our entire state.”

California is a leader in pushing — and paying for — clean energy, but the state has been criticized for failing to distribute California’s equitably. For example, a found wealthier communities in Los Angeles County had more electric and plug-in hybrid vehicles than its disadvantaged communities. And state Assembly member Jim Cooper, a Black Democrat from Elk Grove who will become Sacramento County sheriff next year, has said the state’s push for electric vehicles fuels “.”

Gonzalez points to studies, such as by Earthjustice, showing how people who live close to warehouses are more likely to be low-income and at higher risk of asthma due to the air pollution generated by diesel trucks.

KHN reporter Heidi de Marco met with Gonzalez at her new home, where a development is proposed behind her property, to discuss why she and her organization endorsed Proposition 30. Gonzalez said she has not been paid by Lyft. The interview has been edited for length and clarity.

Q: Why is Proposition 30 important for your community?

Our families are dying, and nobody is doing anything about it. We’re seeing all the illnesses that are connected to pollution, such as asthma, pneumonia, lung cancer, COPD [chronic obstructive pulmonary disease], and even diabetes.

We just decided to support it because we felt, as a team, that it was the right thing to do given how impacted we are by car and truck pollution. There are layers upon layers of pollution.

Along with the influx of warehouses bringing tons of trucks and their diesel exhaust emissions, the Inland Empire is unique when it comes to pollution. We have all the polluting industries that you can think of, from rail yards bringing more diesel emissions, from the trains to gas plants, which are emitting a lot of pollution. We have toxic landfills, airports, and all the car traffic from the intersections of the 10, 60, 215, and the 15 freeways.

Q: Proposition 30 is funded by Lyft, and Newsom opposes it, calling it a “cynical scheme” by the company to get more clean cars for its fleet. Lyft has been criticized by labor groups for lowering compensation through gig work instead of paying fair wages and benefits. Why are you siding with Lyft?

I see it two ways. One, yes, we need to hold Lyft accountable for the way they treat their drivers and making sure they’re paying them fair wages. I do believe Lyft should do better. But the way that I see it, the fact that they’re transitioning into clean-energy vehicles is where I have to give them props.

Even the developers in our communities have the money to transition their diesel trucks to clean energy, but they’re not investing in that. We have a climate change crisis, and I don’t necessarily see them as the enemy. I see them as folks trying to be part of the solution and transitioning to clean energy.

Q: Will the initiative make a difference when so much of the Inland Empire’s pollution is from Los Angeles and the warehouse industry?

It will make electric vehicles and clean energy vehicles more affordable. And it would create those incentives that our low-income community needs, especially our small-business owners like our self-employed truck drivers that cannot afford to transition to a clean-energy vehicle or a truck. This program would give them those subsidies that they need so they can afford to transition.

This proposition will also give money to expand the clean-vehicle infrastructure that we need. Because here we are telling everybody to change to clean-energy vehicles, but we don’t have the infrastructure. Where are they going to charge their cars when they go to work? Or when they go to school? Or even in their own homes?

So, this campaign would put us in the right direction because I don’t see any other efforts being done, including with the state. I feel like sometimes the governor is a little hypocritical because here he is trying to be a champion for climate change, but he’s not showing a real plan to transition compared to this proposition, where they at least have a plan in place to tackle that transition.

Q: The state and federal governments have already invested billions in clean-car programs. Why is Proposition 30 needed?

It’s going to take a while before the money gets to the appropriate agencies. Another thing that I see that the government fails at is that they always leave out the most affected, marginalized, disenfranchised communities such as the Inland Empire. We have been overseen for so long, and every time the government creates these programs, all this investment and infrastructure, local agencies sometimes don’t know about it — or they don’t do the work to ask for the money.

And what this program does through Prop. 30 is that it’s taxing the rich, the people that make over $2 million. We always give the tax breaks to the rich and it’s about time that the rich pay their fair share.

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What you see is a beautiful little boy with smooth, lustrous skin, an abundance of glossy brown hair, and a disarming smile. What you hear are coos and cries that don’t immediately signal anything is horribly awry.

But his parents, Adriana Pinedo and Hector Martinez, know the truth painfully well.

Although Adriana’s doctors and midwife had described the pregnancy as “perfect” for all nine months, Aaron was born with most of his brain cells dead, the result of two strokes and a massive bleed he sustained while in utero.

Doctors aren’t sure what caused the anomalies that left Aaron with virtually no cognitive function or physical mobility. His voluminous hair hides a head whose circumference is too small for his age. He has epilepsy that triggers multiple seizures each day, and his smile is not always what it seems. “It could be a smile; it could be a seizure,” his mother said.

Shortly after Aaron was born, doctors told Adriana, 34, and Hector, 35, there was no hope and they should “let nature take its course.” They would learn months later that the doctors had not expected the boy to live more than five days. It was on Day 5 that his parents put him in home hospice care, an arrangement that has continued into his second year of life.

The family gets weekly visits from hospice nurses, therapists, social workers, and a chaplain in the cramped one-bedroom apartment they rent from the people who live in the main house on the same lot on a quiet residential street in this Inland Empire city.

One of the main criteria for hospice care, largely for seniors but also applied to children, is a diagnosis of six months or less to live. Yet over the course of 17 months, Aaron’s medical team has repeatedly recertified his hospice eligibility.

Under of the 2010 Affordable Care Act, children enrolled in Medicaid or the Children’s Health Insurance Program are allowed, unlike adults, to be in hospice while continuing to receive curative or life-extending care. Commercial insurers are not required to cover this “concurrent care,” but many now do.

More than a decade since its inception, concurrent care is widely credited with improving the quality of life for many terminally ill children, easing stress on the family and, in some cases, sustaining hope for a cure. But the arrangement can contribute to a painful dilemma for parents like Adriana and Hector, who are torn between their fierce commitment to their son and the futility of knowing that his condition leaves him with no future worth hoping for.

“We could lose a life, but if he continues to live this way, we’ll lose three,” said Adriana. “There’s no quality of life for him or for us.”

Aaron’s doctors now say he could conceivably live for years. His body hasn’t stopped growing since he was born. He’s in the 96th percentile for height for his age, and his weight is about average.

His parents have talked about “graduating” him from hospice. But he is never stable for long, and they welcome the visits from their hospice team. The seizures, sometimes 30 a day, are a persistent assault on his brain and, as he grows, the medications intended to control them must be changed or the doses recalibrated. He is at continual risk of gastrointestinal problems and potentially deadly fluid buildup in his lungs.

Adriana, who works from home for a nonprofit public health organization, spends much of her time with Aaron, while Hector works as a landscaper. She has chosen to live in the moment, she said, because otherwise her mind wanders to a future in which either “he could die — or he won’t, and I’ll end up changing the diapers of a 40-year-old man.” Either of those, she said, “are going to suck.”

While cancer is one of the major illnesses afflicting children in hospice, many others, like Aaron, have rare congenital defects, severe neurological impairments, or uncommon metabolic deficiencies. 

“We have diseases that families tell us are one of 10 cases in the world,” said Dr. Glen Komatsu, medical director of Torrance-based TrinityKids Care, which provides home hospice services to Aaron and more than 70 other kids in Los Angeles and Orange counties.

In the years leading up to the ACA’s implementation, pediatric health advocates lobbied hard for the concurrent care provision. Without the possibility of life-extending care or hope for a cure, many parents refused to put their terminally ill kids in hospice, thinking it was tantamount to giving up on them. That meant the whole family missed out on the support hospice can provide, not just pain relief and comfort for the dying child, but emotional and spiritual care for parents and siblings under extreme duress.

TrinityKids Care, run by the large national Catholic health system Providence, doesn’t just send nurses, social workers, and chaplains into homes. For patients able to participate, and their siblings, it also offers art and science projects, exercise classes, movies, and music. During the pandemic, these activities have been conducted via Zoom, and volunteers deliver needed supplies to the children’s homes.

The ability to get treatments that prolong their lives is a major reason children in concurrent care are more likely than adults to outlive the six-months-to-live diagnosis required for hospice.

“Concurrent care, by its very intention, very clearly is going to extend their lives, and by extending their lives they’re no longer going to be hospice-eligible if you use the six-month life expectancy criteria,” said Dr. David Steinhorn, a pediatric intensive care physician in Virginia, who has helped develop numerous children’s hospice programs across the U.S.

Another factor is that kids, even sick ones, are simply more robust than many older people.

“Sick kids are often otherwise healthy, except for one organ,” said Dr. Debra Lotstein, chief of the division of comfort and palliative care at Children’s Hospital Los Angeles. “They may have cancer in their body, but their hearts are good and their lungs are good, compared to a 90-year-old who at baseline is just not as resilient.”

All of Aaron Martinez’s vital organs, except for his brain, seem to be working. “There have been times when we’ve brought him in, and the nurse looks at the chart and looks at him, and she can’t believe it’s that child,” said his father, Hector.

When kids live past the six-month life expectancy, they must be recertified to stay in hospice. In many cases, Steinhorn said, he is willing to recertify his pediatric patients indefinitely.

Even with doctors advocating for them, it’s not always easy for children to get into hospice care. Most hospices care primarily for adults and are reluctant to take kids.

“The hospice will say, ‘We don’t have the capacity to treat children. Our nurses aren’t trained. It’s different. We just can’t do it,’” said Lori Butterworth, co-founder of the Children’s Hospice and Palliative Care Coalition of California in Watsonville. “The other reason is not wanting to, because it’s existentially devastating and sad and hard.”

Finances also play a role. Home hospice care is paid at a set by Medicare — slightly over $200 a day for the first two months, about $161 a day after that — and it is typically the same for kids and adults. Children, particularly those with rare conditions, often require more intensive and innovative care, so the per diem doesn’t stretch as far.

The concurrent care provision has made taking pediatric patients more viable for hospice organizations, Steinhorn and others said. Under the ACA, many of the expenses for certain medications and medical services can be shifted to the patient’s primary insurance, leaving hospices responsible for pain relief and comfort care.

Even so, the relatively small number of kids who die each year from protracted ailments hardly makes pediatric hospice an appealing line of business in an industry craving growth, especially one in which private equity investors are active and seeking a big payday.

In California, only 21 of 1,336 hospices reported having a specialized pediatric hospice program, and 59 said they served at least one patient under age 21, according to of 2020 state data by Cordt Kassner, CEO of Hospice Analytics in Colorado Springs, Colorado.

Hospice providers that do cater to children often face a more basic challenge: Even with the possibility of concurrent care, many parents still equate hospice with acceptance of death. That was the case initially for Matt and Reese Sonnen, Los Angeles residents whose daughter, Layla, was born with a seizure disorder that had no name: Her brain had simply failed to develop in the womb, and an MRI showed “fluid taking up space where the brain wasn’t,” her mother said.

When Layla’s team first mentioned hospice, “I was in the car on my phone, and I almost crashed the car,” Reese recalled. “The first thought that came to mind was, ‘It is just the end,’ but we felt she was nowhere near it, because she was strong, she was mighty. She was my little girl. She was going to get through this.”

About three months later, as Layla’s nervous system deteriorated, causing her to writhe in pain, her parents agreed to enroll her in hospice with TrinityKids Care. She died weeks later, not long after her 2nd birthday. She was in her mother’s arms, with Matt close by.

“All of a sudden, Layla breathed out a big rush of air. The nurse looked at me and said, ‘That was her last breath.’ I was literally breathing in her last breath,” Reese recounted. “I never wanted to breathe again, because now I felt I had her in my lungs. Don’t make me laugh, don’t make me exhale.”

Layla’s parents have no regrets about their decision to put her in hospice. “It was the absolute right decision, and in hindsight we should have done it sooner,” Matt said. “She was suffering, and we had blinders on.”

Adriana Pinedo said she is “infinitely grateful” for hospice, despite the heartache of Aaron’s condition. Sometimes the social worker will stop by, she said, just to say hello and drop off a latte, a small gesture that can feel very uplifting. “They’ve been our lifeline,” she said.

Adriana talks about a friend of hers with a healthy baby, also named Aaron, who is pregnant with her second child. “All the stuff that was on our list, they’re living. And I love them dearly,” Adriana said. “But it’s almost hard to look, because it’s like looking at the stuff that you didn’t get. It’s like Christmas Day, staring through the window at the neighbor’s house, and you’re sitting there in the cold.”

Yet she seems palpably torn between that bleak remorse and the unconditional love parents feel toward their children. At one point, Adriana interrupted herself midsentence and turned to her son, who was in Hector’s arms: “Yes, Papi, you are so stinking cute, and you are still my dream come true.”

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A hint of smoke from burning wood wafted through their dirt-and-grass yard anchored by native trees. Maia, 17, searched for the source as Mia, 14, reached for the garden hose, then turned on the spigot and doused the perimeter of the property with water.

The smoky smell sent the sisters back to one gusty October evening in 2017 when wildfire came for their previous home. From the back of the family’s minivan that night, the girls watched flames surround their trailer in Glen Ellen, a village in Northern California’s wine country. They abandoned their belongings, including Mia’s favorite doll, and left without their cat, Misi, who was spooked by the fire. The only thing the family saved was the 3-month-old’s baby blanket.

The family drove away, weaving through dark roads illuminated by burning trees and flaming tumbleweeds. Mia was quiet. Maia vomited.

As California wildfires grow more , many children who live through them are experiencing lasting psychological trauma such as anxiety, depression, and post-traumatic stress disorder. Children may also develop sleep or attention problems, or struggle in school. If not managed, their emotional trauma can affect their physical health, potentially leading to chronic health problems, mental illness, and substance use.

Since 2020, the state has asked doctors who participate in the state’s Medicaid program for low-income people to screen children — and adults — for potentially traumatic events related to , which are linked to chronic health problems, mental illness, and substance use. In the state’s that took place from January 2020 through September 2021, children and adults were found to be at higher risk for toxic stress or trauma if they live in the state’s northern counties, a primarily rural region that has been struck by in recent years.

While the screenings can help detect neglect, abuse, or household dysfunction, doctors and health officials have suggested wildfires contributed to the high ACEs scores in rural Northern California. In an annual report, in Shasta County, where the Carr Fire burned in 2018, were found to be at high risk of trauma. In Napa County, where the Tubbs Fire ripped through wine country in 2017, were deemed to be at high risk of trauma.

In a supplemental analysis, researchers found that in some counties in Northern California have experienced one or more traumatic event, compared with 60% for the state as a whole. That includes Butte County, where the took the lives of 85 people.

“When the population has a high range of trauma to begin with and you throw in environmental trauma, it just makes it that much worse,” said , a pediatrician at Shasta Community Health Center who has conducted some of the screenings, known as .

Wildfires disrupt routines, force people to move, and create instability for children who need to be . In recent years, California demographers have attributed some to wildfires that destroy homes and displace families.

“There’s nothing more stressful for a child than to see their parents freaking out,” said Christopher Godley, director of emergency management for Sonoma County, which since 2015 has been hit by .

Children can also be indirect victims of wildfires. According to a study published by the Centers for Disease Control and Prevention, an estimated in the United States are affected annually by wildfire smoke, which not only affects the respiratory system but may contribute to attention-deficit/hyperactivity disorder, autism, impaired school performance, and memory problems.

In 2017, the Bravo family escaped the Tubbs Fire, which burned parts of Napa and Sonoma counties and the city of Santa Rosa. At the time, it was the in state history, leveling neighborhoods and killing nearly two dozen people.

They slept in their minivan the first night, then took shelter with family in nearby Petaluma.

“I was afraid, in shock,” Maia recalled. “I would stay up all night.”

The sisters were overjoyed to find their cat cowering underneath a neighbor’s trailer 15 days after they evacuated. Misi’s paws had been badly burned.

For the first few years after the fire, Maia had nightmares filled with orange flames, snowing ash, and charred homes. She would jolt awake in a panic to the sound of firetruck sirens.

Children may respond differently to trauma depending on their age. Younger kids may feel anxious and fearful, , or develop separation anxiety from parents or trusted adults. Older kids may feel depressed and lonely, develop eating disorders or self-harming behaviors, or begin to use alcohol or drugs.

“When you have these kids who have had these intense evacuations, experienced losses of life, complete destruction of property, it’s important they have social support,” said Melissa Brymer, director of terrorism and disaster programs at the .

Brymer said children also need coping tools to help them stay calm. These include , playing familiar games, exercising, or seeing a counselor. “Do they need comfort from their parents? Need to distract themselves? Or do some breathing exercises?” she said.

, a clinical psychologist and associate professor at Yale School of Public Health, said that while a little anxiety can motivate adults, it doesn’t do the same for children. She recommends they maintain sleep schedules and eating times.

“For kids, instilling a sense of stability and calm is really important and reestablishing some sense of routine and normalcy,” Lowe said.

Emergency responders have begun to integrate mental wellness, for both adults and kids, into their disaster response plans.

Sonoma County officials now post resources for people alongside tips for assembling emergency kits, known as “,” and developing an escape plan.

And the county will deploy mental health workers during disasters as part of its new emergency operations plan, Godley said. For example, the county will send behavioral health specialists to emergency shelters and work with community groups to track the needs of wildfire survivors.

“Many of the more vulnerable populations are going to need specialized behavioral health and that’s going to be especially true for children,” Godley said. “You just can’t pop them in front of a family and marriage therapist and expect that the kids are going to immediately be able to be really supported in that environment.”

Maia and Mia moved three times after their trailer burned down. Maia started seeing the school counselor a few weeks after returning to school. Mia was more reluctant to accept help and didn’t start counseling until January 2018.

“Talking about it with the counselor made me calm,” Maia said. “Now, I can sleep. But when I hear about fires, I get nervous that it’s going to happen again.”

Their mother, Erandy Bravo, encouraged her daughters to manage their anxiety by journaling, but the sisters opted for a more practical approach to cope with their trauma. They focused on preparation and, over summer break, kept a go bag with their schoolbooks, laptops, and personal belongings they would want in case of another fire.

The girls attend workshops on how to handle anxiety at a local teen center and have become leaders in a support group. Maia, who graduated from high school in June, will study psychology when she starts at Santa Rosa Junior College in the fall. Mia, who is in the 10th grade, wants to be an emergency dispatcher.

Still, the Bravo sisters remain vigilant.

At their new home, when the sisters smelled smoke in their yard earlier this year, they soon realized it came from the neighbor’s chimney. Mia turned off the water and coiled up the hose. The sisters, feeling safe, let down their guard and headed back inside.

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Lewis prayed she would earn $75, just enough to fill the tank of her Kia sedan so she could drive her 8-year-old daughter, Annabelle, 80 miles south to Los Angeles to receive her weekly chemotherapy treatment for acute lymphoblastic leukemia. Just a year ago, the same tank of gas would have cost $30 less.

After a full shift as a gig worker, the mother had earned close to what she needed. “It took a lot longer than I thought,” she said.

High inflation is hitting families across the nation. According to the U.S. Bureau of Labor Statistics, consumer from a year earlier, one of the biggest increases in recent decades. The Bureau of Economic Analysis found that consumers are spending the most on .

Overall wages continue to climb, but after adjusting for the rising price of goods and services, workers’ over the past year. A recent found that 74% of registered voters put inflation, including rising gas prices, at the top of their concerns.

For millions of families living with — such as heart disease, diabetes, and cancer — or other debilitating conditions, inflation is proving a punishing scourge that could be harmful to their health. Unlike dining out less or buying fewer clothes, many patients don’t have a choice when it comes to paying for medicine, medical supplies, and other ancillary costs. Some must drive long distances to see a specialist, and others must adhere to a strict diet.

“Chronic disease patients are usually on the front lines of seeing a lack of supplies or an increase in out-of-pocket costs,” said Paul Conway, chair of policy and global affairs for the American Association of Kidney Patients.

Health care has grown increasingly unaffordable. Half of adults report having , according to Â鶹ŮÓÅ polling. One-third say they or a family member has skipped recommended medical treatment in the past year because of the cost, and one-quarter of adults report rationing pills or leaving prescriptions unfilled.

Inflation has squeezed families further by driving up the price of gas and food, as well as medical products such as needles and bed-wetting pads. Health care costs since July 2021, and medical commodities — which include prescription and over-the-counter drugs, medical equipment and supplies — are .

Inflation is particularly detrimental to the health of low-income patients; studies have found a . According to the California Budget & Policy Center, making $50,000 or less struggle to pay for food, housing, and medical costs.

For Deborah Lewis and her husband, Spencer, their concerns about the rising cost of gas have never been about skimping on summer travel or weekend getaways. It’s about making sure they have enough gas to drive Annabelle to Children’s Hospital Los Angeles for chemotherapy and other medications delivered through a port in her chest.

The family relies on Spencer’s disability check, which he receives because he has Ehlers-Danlos syndrome, a hereditary disorder that causes him severe joint pain. He also copes with broken discs in his spine and a cyst pushing against his spinal nerves. In January, he stopped working as a pest control technician, shifting more financial responsibilities to his wife.

The disability check covers rent and utilities, leaving Deborah’s freelance work to cover gas. They also get $500 a month from , which helps families with critically ill children.

On a June morning, Deborah packed snacks for the drive ahead as Annabelle, wrapped in her favorite blanket, waited on the couch. Most of her long blond hair has fallen out because of her treatments. The night before, Deborah spent $73.24 to fill up at Costco.

Before they left, Deborah learned the couple carried a negative balance in their checking account. “I have so much on my plate,” she said.

The family has already delayed health care for one family member: Their dog, a Doberman pinscher named Chief, skipped a vet visit for a mass pushing up his intestines.

Politicians are keenly aware of inflation’s leaching effects. In October, most California households will receive to help offset the high cost of gas and other goods under a budget Gov. Gavin Newsom signed in June. The average price of a gallon of gas in California , while the national average is about $4.

But health experts worry that even with the one-time aid, affordability could become a life-or-death issue for some Californians. For example, the price of insulin can range from .

“We’ve seen a number of patients living with diabetes and on a fixed income greatly impacted by rising inflation,” said Matthew Freeby, an endocrinologist and director of the UCLA Gonda Diabetes Center. “Both Type 1 and Type 2 diabetes typically require multiple prescription medications that may already be costly. Patients have had to choose between day-to-day finances and their lifesaving medications, such as insulin or other treatments.”

Inflation is also a challenge for people who depend on certain foods as part of their health care regimen, especially with in the past year.

Toyan Miller, 60, an integrative nutritional health practitioner from San Dimas, California, has been diagnosed with vasculitis and Hashimoto’s thyroiditis, two autoimmune diseases that cause inflammation. Miller’s medically tailored diet requires gluten-free, organic food. Miller said she’s dipping into her savings to afford the average of $300 she spends each week on groceries. Last year, she spent about $100 less.

“The avocado mayonnaise price freaked me out,” she said. “It used to be $8. Now, it’s $16.99.”

Even those who are healthy may find themselves helping family or friends in need.

In the mountainous Los Angeles neighborhood of Laurel Canyon, Shelley Goldstein, 60, helps her parents, both in their 90s, pay for items, such as incontinence products, not covered by health insurance. Goldstein’s father was recently diagnosed with Alzheimer’s disease and lives in a retirement community with his wife, Doris.

“Those are basic things, but that’s like $70 a month between the two of them,” said Goldstein, who works as a speaking coach. “That’s a lot.”

Goldstein worries about how much more of her parents’ health costs she’ll have to shoulder since they are pensioners on fixed incomes.

“What keeps me up at night right now is what’s to come,” she said. “There’s two of them. My parents’ increased need for pads, meds, and other medical support increases as their health declines.”

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As a child growing up in San Jose, California, Marta Segura heard horrific stories from her parents about women fainting on the factory lines and men overheating in the farm fields. They didn’t know those jobs exposed them to life-threatening conditions.

Then, it hit home.

“My dad, himself, got really sick one time and almost died,” said Segura, 58, the daughter of and a cannery worker. “That resonated with me as a kid.”

Segura, who serves as director of Los Angeles’ in the Department of Public Works, was given a second title this month: chief heat officer, the city’s first. She joins a number of heat officers around the world as cities from , Greece, to , begin to coordinate a better response to extreme heat and develop sustainable cooling strategies. Phoenix and Miami are the only other U.S. cities with heat officers.

As Los Angeles continues to experience more frequent , Segura will work across city departments to help create an early-warning system for heat waves and develop long-term strategies to reduce heat exposure, such as planting trees and updating building codes. Her office will also launch a in July in English and Spanish.

Extreme weather can cause cramps, stroke, and heat exhaustion. Extreme heat contributed to the deaths of around 12,000 people in the U.S. each year from 2010 to 2020, according to a study by the University of Washington. Those figures are likely to rise.

Low-income, majority-minority neighborhoods experience significantly more heat than wealthier, whiter neighborhoods, from the University of California-San Diego’s School of Global Policy and Strategy. The research shows that surface temperatures in communities with higher rates of poverty can be up to 7 degrees Fahrenheit warmer, compared with the richest neighborhoods, during summer.

“Neighborhoods in South Los Angeles send an additional 20 to 30 people to the emergency room on heat days compared to 2 additional people from wealthier neighborhoods,” said Dr. David Eisenman, director of the Center for Public Health and Disasters at UCLA. Eisenman will work with Segura to identify climate-vulnerable communities.

Segura, 58, takes her new job as state lawmakers consider expanding heat warnings. would establish California’s first chief heat officer position and create a statewide extreme-heat and community resilience program. would create the nation’s first warning system for heat waves, just as existing systems warn of other natural disasters such as wildfires, tornadoes, and hurricanes.

KHN reporter Heidi de Marco met with Segura in her City Hall office to discuss her new role and how she plans to tackle the city’s climate risk. The interview has been edited for length and clarity.

Q: Why was this position created?

We’ve noticed a fivefold increase in extreme heat events and heat waves. There are more heat-related illnesses and more hospitalizations and deaths.

There are two goals. The first is changes to the system — the services and the infrastructure of the city. The other is education and awareness — that people know that extreme heat is more serious so they can take steps to protect themselves.

We’re tackling education with an extreme-heat campaign that will launch July 1. In terms of changing the system and services, the city is painting the roofs and roads with white, cool[ing] paint, planting more trees for maximum shade in vulnerable communities.

Q: You will be working to reduce heat-related hospitalizations and deaths, as well as working with different city agencies to implement a heat action plan. How will that work?

We’re already discussing updating our building codes for decarbonization and climate adaptation.

The other approach is through public works. For example, installing more shade structures, more kiosks, especially for metro and bus transportation furniture. They’re also installing more hydration stations.

So when you add that to our public facilities — parks, libraries, youth centers, which are all accessible during the day — you have a lot of opportunities to tell people where to go in the event of a heat storm or heat wave.

Q: How do you plan to address inequality?

It keeps me up at night. Addressing the most vulnerable community isn’t out of charity. And it isn’t because of moral reasons. It’s because if we don’t help the most vulnerable communities of Los Angeles, which are over 50% of the population, we’re not going to get to our climate solutions.

Landlords are less likely to invest in heat pumps or other air conditioning systems because that would only raise the rent and the rent would displace individuals. So we need a policy in the city of L.A. that prevents displacement and helps in some ways to subsidize those low-income housing units or find financing structures that allow landlords to be able to invest and keep our families healthy and safe.

Q: Is there a particular challenge in messaging to immigrant communities?

I think what I learned in my family is we tend to have the radio on as we go about our work. So it’s going to be important to use radio. It’s also going to be important to use text messaging services, like WhatsApp.

We want to make sure to get this information out to employers, so we probably need to come up with culturally relevant communications. It’s an evolving campaign.

Q: What kind of budget are you working with?

We will be allocating approximately 30% of our budget to heat-risk prevention work, and although our budget is not large, our impact on other partner departments, such as public works and the emergency management department, is significant.

We can’t look at my budget in a silo since the council has directed us to work collaboratively to combine the respective parts of our budgets for heat-risk prevention. However, I can say that my office will be doubling in size, from four to eight [employees], and this will give us the leverage and resources we need to make the kind of impact the city of L.A. seeks to make in the long run.

Q: How do you plan to address the homeless community?

What we actually would like to have are more pop-up units, where we have canopies and hydration.

So that’s a conversation I’m having with our deputy mayor of homelessness and housing so that we can coordinate together. And that’s a good example of something that my office can’t do alone because I need their expertise and their allocated resources to ensure that we’re providing the best available comprehensive resources for the city.

Q: You are the first Latina to hold such a position in the United States. How does that feel?

It’s significant because [Latinos] have been suffering disproportionately from climate hazards for a very long time, and we haven’t had positions like this in the past. If they see someone from their community, or that looks like they’re from their community, that speaks their language, that culturally relates to them, that has had similar experiences, I think it makes a big difference, right?

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The 73-year-old retired orthopedic surgeon in Fresno, California, knew it was time for cataract surgery. “It’s like car tires wearing out because you drive on them so much,” he said.

In December 2021, he went to the outpatient department of the local hospital to undergo the common procedure that usually replaces the natural eye lens with an artificial one and is designed to restore vision. The outpatient procedure went smoothly, and Manimtim healed over the next few weeks.

Manimtim, who since retiring took a job evaluating disability claims for the state of California, knows the health care system and keeps tabs on his health benefits. He knew he already had met his health insurance deductible for the year, so he expected a manageable out-of-pocket expense for the surgery. He calculated his coinsurance would be about $750.

Then the bills came.

Patient: Danilo Manimtim, 73, of Fresno, California. He is insured through his employer by Anthem Blue Cross of California for outpatient care and is covered by .

Total Bill: Overall, the charges were $9,084 for surgery, anesthesia, medical supplies, pharmacy, and clinical laboratory services. Anthem paid $5,027 and initially billed Manimtim $4,057.

Service Providers: . It is part of Trinity Health, with 88 hospitals and 125 urgent care centers . The hospital system brought in nearly in revenue for the most .

Medical Service: Cataract surgery as an outpatient, involving anesthesia.

What Gives: Manimtim’s big bill stems from a simple decision that turned out to be a pitfall in the nation’s complicated health care system: He scheduled his surgery at a nearby hospital — a hospital that happened to charge about $7,000 more for the procedure than his insurer would pay.

Manimtim has proof that it could have been different right under his own roof: Four months later, his wife, Marilou Manimtim, 66, got the exact same procedure at an outpatient eye care surgical center in Fresno called . It is a half-mile from Saint Agnes Medical Center but is not affiliated with the hospital.

Both patients have the same insurance coverage through Anthem Blue Cross of California; they had identical cataract surgeries; and both providers were in Anthem’s coverage network. Marilou owed $204, while Danilo was on the hook for a staggering $4,057.

“This is ridiculous, and it feels very unfair,” Danilo Manimtim said. “How can it be so much more expensive than the surgical center? It’s walking distance away, and if I would have gone there, I would have saved myself a lot of money.”

Manimtim’s insurance plan, via his employer, the California Public Employees’ Retirement System, caps payment for outpatient cataract surgery at $2,000, according to Anthem. CalPERS instituted a , in which it determines a reasonable price for a high-quality procedure of that type in California. It then reimburses only up to that amount, encouraging patients to shop for treatment priced under the bar. For the cataract surgery itself, patients in Manimtim’s plan are on the hook for any charges above $2,000.

Even for hospital-based care, Saint Agnes’ overall charges are high for cataract surgery, said Dr. , chief medical officer for , which analyzes health care prices for employers. “The hospital charged three to four times the amount of what this surgery typically costs, which is around $3,000.”

“Nobody gets $9,000 for cataract surgery,” he added.

If Manimtim had opted for Medicare Part B, the part of the Medicare program that covers outpatient care, he likely would have been on the hook for only , a Medicare cost comparison tool shows. Medicare pays a set amount for procedures regardless of where they are performed.

But like many older Americans who are still working, Manimtim chose not to sign up for that coverage, instead opting for his employer’s plan because his monthly premium would be significantly cheaper.

Health care prices often have very little to do with the actual costs of providing the care and its quality — and patients often face the “double whammy” of high prices and complex benefits, said Anthony Wright, executive director of Health Access California, a nonprofit advocacy group. Too often, patients are on their own to figure out high prices and complex benefits, he said.

“You wonder what is the rationale for any of the prices in our health care system,” Wright said.

Resolution: After inquiries by KHN, Anthem contacted the hospital, Saint Agnes, seeking help for Manimtim. Although the doctor is responsible for requesting an exemption from CalPERS’ $2,000 limit on payments for cataract surgery under Manimtim’s plan, that didn’t happen before his surgery. Anthem asked the hospital and doctor to consider the request post-surgery, said Anthem spokesperson Michael Bowman.

Saint Agnes spokesperson Kelley Sanchez told KHN that the hospital and provider later requested the exemption that would allow the insurer to pay more than the $2,000 limit and that it was ultimately approved by Anthem. That is expected to leave Manimtim with a much smaller coinsurance bill, around $750 — and get him off the hook for being taken to collections by the hospital. The hospital will receive a higher payment from Anthem, which will cover a large portion of the remaining $4,057 bill.

And that high payment, like all high payments, contributes to rising health insurance payments for all.

Sanchez said the hospital isn’t in the price-gouging business but noted that hospitals generally have higher costs and tend to charge more than outpatient facilities.

“We never want to cause harm or create hardship for our patients, and that extends to our billing practices,” Sanchez said in a prepared statement.

She noted that Saint Agnes has financial assistance programs available and encourages patients to ask questions and understand potential costs before seeking care. “Every patient’s insurance plan is unique so it is their responsibility to understand their plan benefits,” she wrote. “It’s still complicated and we recognize that, and will continue to work toward greater price transparency.”

The Takeaway: The bottom line for patients, experts say, is to be sure to read the fine print of insurance coverage plans to understand all out-of-pocket responsibilities, including premiums, deductibles, copays, and coinsurance. Also, a small number of large employers that self-insure are , putting caps on what they’ll pay for common procedures. Shop around, and ask about prices on the front end if possible.

“People often focus on premiums because they are easy to compare, but premiums don’t tell the full story, and this example illustrates the trade-offs,” said Tricia Neuman, .

Anthem spokesperson Bowman urged patients to use the online Anthem “” to compare patient costs and find a cheaper option if one is available. Had Manimtim done that, he might have seen that getting his cataract surgery at an outpatient surgical center would have been much cheaper. But the details of provider cost and insurance coverage can be idiosyncratic and are often not displayed in a patient-friendly manner. Manimtim did try to explore his benefits before the procedure, he said, but did not get a clear answer from the insurer or hospital.

Manimtim also had advice for consumers: If you receive a medical bill and don’t understand the charges, don’t pay right away. Instead, call your provider and insurer to ask about the charges and whether there are ways to lower your bill.

“People need to be more informed by the insurance companies and hospitals about what options they have, to prevent overbilling,” Manimtim said. “A lot of people don’t know this could happen to them.”

Stephanie O’Neill contributed the audio portrait with this story.

Bill of the Month is a crowdsourced investigation by KHN and that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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In the three months since she began eating the customized meals, De Los Santos has learned to manage her diabetes by maintaining a healthy blood sugar level.

Two hours to the south, in Indio, Vidal Fonseca gets ready for his third dialysis appointment of the week. He, too, battles kidney disease and diabetes. The 54-year-old former farmworker was released from the hospital in November with an order to follow a strict diet, but he makes a mess in the kitchen and struggles to get his glucose under control. He doesn’t receive the prepared meals.

Here in California’s vast Inland Empire, where more than half of adults have diabetes or are at risk of developing diabetes, one health plan is delivering medically tailored meals to select patients. In bringing food straight to their door for a few months, state officials hope patients will develop healthier eating habits long after the shipments stop. It’s all part of a grand state experiment to improve the health of some of its sickest and costliest patients.

California’s five-year initiative, known as , will test whether Democratic Gov. Gavin Newsom can slow public spending on Medi-Cal, the state’s Medicaid program for people with low incomes, which skyrocketed to $124 billion this fiscal year, up nearly threefold from a decade ago. Medi-Cal managed-care insurers will try to keep people out of expensive health care institutions by delivering social services, such as helping patients find housing, removing toxic mold from their homes, and delivering medically tailored food.

CalAIM, which is expected to cost $8.7 billion, is unconventional because it is being carried out primarily by health plans, not county social service departments. It will serve only a sliver of the 14.5 million Californians enrolled in Medi-Cal. And the state is still developing a way to track health outcomes, meaning nobody knows yet whether it will save money.

“This is a new program, and often with new programs, you’re building the plane as you’re flying it,” said Shelly LaMaster, director of integrated care at Inland Empire Health Plan.

The health plan is one of two Medi-Cal managed-care insurers serving San Bernardino and Riverside counties and has about 1.5 million enrollees. Inland Empire Health Plan says about 11,000 of its enrollees will be eligible for deliveries of meals and food boxes. The average meal benefit has a value of $1,596 and lasts three months, though health insurers can choose to extend food deliveries.

Because plans decide which enrollees receive services, many worthy patients — even those enrolled in the same plan or who live in the same county — are being left out. In the Inland Empire, some patients have started receiving food while others are still getting enrolled. So far, 40% of the recipients are Hispanic, 35% are white, and 18% are Black, which tracks with the region’s demographics. (Hispanics can be of any race or combination of races.)

Initial deliveries for most participants will be frozen meals, varying from taco bowls to chicken curry. Later, they may receive boxes filled with fresh fruits, vegetables, whole-grain bread, pasta, and rice so they can prepare their own meals.

De Los Santos is among the lucky 720 enrollees who have been approved for the benefit since January. Participants must be referred to the program, but referrals can come from doctors, community groups, and family members — Medi-Cal enrollees can even refer themselves.

De Los Santos’ case manager identified her need after conducting an assessment. Then a dietitian screened her for her food preferences and health concerns to develop a nutrition plan.

Her first box of nutritionally tailored meals arrived in February from , one of two prepared-meal companies contracted by the Inland Empire Health Plan. Each week she receives convenient, microwave-ready meals and an information sheet with the macronutrient breakdown of each dish.

“I’m on an eating schedule now,” she said. “I’m eating lots of meats and salads and vegetables, like broccoli and cauliflower, that are good for me.”

Meanwhile, Fonseca, also an Inland Empire Health Plan enrollee, relies on his wife and daughter to figure out how to get his diabetes under control. After he was diagnosed in November, they scrambled to learn how to cook for him by looking up recipes online.

“Before he was diagnosed with renal disease, he was eating a diet high in iron-rich foods that are typical for us to eat, like lentils and beans, but not good for kidney disease,” said his 29-year-old daughter, Maria Cruz. “We were giving him poison.”

Fonseca said he had heard about food banks but not home-delivered meals. “The menu for someone in my condition with both renal failure and diabetes is very limited and specific,” he said in Spanish. “Talking to a nutritionist and receiving meals specifically made for me for free would be a huge help.”

But even though his conditions would qualify him for meal delivery, it’s up to the insurer to enroll him.

Participating in the program would alleviate the guesswork for his wife and daughter. Fonseca’s wife, Eufracia Constantino, still works in the fields. She wakes up at 4:30 a.m. to cook his breakfast every morning before she leaves for work. His daughter prepares lunch for him, which typically consists of chicken or fish, stir-fried vegetables, and hard-boiled eggs.

“I would usually be driving trucks with a burrito in one hand and the steering wheel in the other,” said Fonseca, who was an agricultural truck driver.

De Los Santos, who up until recently was the family breadwinner, has had to adjust to becoming a patient. Two months ago, her husband, Fermin Silva, became her state-funded paid caregiver and the couple struggles to pay rent and utilities. To save money, they will move into a two-bedroom mobile home next month.

“Now I don’t have to worry about buying my meals,” she said. “I would say I’ve saved about $150 a month.”

While she saves money, Fonseca spends an extra $100 a week to buy the healthy food his wife and daughter prepare for him.

“We’ve had to stretch my wife’s paycheck,” Fonseca said. “We don’t fill the grocery cart up like before.”

The California Department of Health Care Services, which runs Medi-Cal, hopes the patients who receive medically tailored meals will tap the health system less often. The goal is to make people healthier by empowering them to adopt better eating habits and learn to sustain a good diet. Although some recipients may have irreversible conditions, such as congestive heart failure or severe diabetes, officials still see opportunities to reduce hospital admissions and emergency room visits.

that providing meal delivery services helps reduce health care costs. State officials note that food benefits will be expanded over time and that there’s no price cap on the initiative.

But the health agency could not provide data on how many Medi-Cal patients are eligible for food delivery and won’t report the number of people receiving the service until later this year. The state plans to gauge the cost-effectiveness of these social services as the program expands, according to agency spokesperson Anthony Cava.

Inland Empire Health Plan officials say it could be challenging to identify the impact of an individual benefit since many members receive multiple services. And it takes time to realize health consequences.

De Los Santos’ meals will end soon. She declined an extension, saying she has learned enough about portioning and self-control. She feels confident about continuing her healthy diet with the help of her husband, who will cook for her.

“My husband tells me to slow down,” she said, “but I have so much more energy.”

Fonseca fears a lifetime of poor eating combined with a physically demanding job has taken a toll on his body. He used to work two fields in one day and traveled depending on the crop season. He never took time off. “Now all I have is time,” he said, “but the dialysis makes me feel exhausted.”

He asked his nurse about getting medically tailored meals.

“He has to be healthy to qualify to get on a kidney transplant waiting list,” said his daughter. “That’s our hope.”

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Unauthorized immigrants who fall below certain income thresholds are now eligible for full coverage by Medi-Cal, California’s version of Medicaid, the federal-state partnership that provides health insurance to low-income people.

Unauthorized immigrants of all ages account for 40% of the state’s uninsured residents. Official estimates put the number of newly eligible people . Those who sign up will join unauthorized immigrants ages 25 and under already enrolled in Medi-Cal.

And if Gov. Gavin Newsom gets his way, which seems entirely plausible considering the state’s , California could allow all remaining low-income unauthorized immigrants — people — to join Medi-Cal by 2024, or sooner.

As I have , Medi-Cal has some well-known problems. But it is still far better than no insurance at all. Read on to learn about the new benefits and how you can enroll if you are eligible.

Under current law, all unauthorized immigrants who meet the financial criteria can get limited Medi-Cal coverage, including emergency and pregnancy services and, in some cases, long-term care. But when they sign up for full Medi-Cal, they get that includes primary care, prescription drugs, mental health care, dental and eye care, eyeglasses, and much more. That’s no small thing for people who are getting gray.

“This is a key moment when you want to incorporate all these aging undocumented immigrants into the health care system,” says Arturo Vargas Bustamante, a professor of health policy and management at UCLA’s Fielding School of Public Health. If you let their chronic conditions go unattended, he says, they’ll just end up in the emergency room and be more expensive to treat.

He calls it “a responsible way of investing.”

As Bustamante points out, it’s no longer the case that immigrants come to work temporarily in the United States and then return to their home countries. They are staying, raising families, and growing old in this country. And unauthorized immigrants play an important role in the labor force, paying an estimated in state and local taxes a year in California and $11.7 billion nationally. Nobody benefits if they’re too sick to work.

While it will take time to roll out the new benefits, the task will be made easier by the fact that the of unauthorized immigrants who will become eligible for full coverage are already signed up for limited Medi-Cal benefits — so the state has contact information for them.

Those already in limited Medi-Cal will be automatically upgraded to full-scope Medi-Cal. Assuming their contact details are current, they will receive packets in the mail explaining their expanded benefits and prompting them to choose a health plan and a primary care provider.

“We expect to see people who are already enrolled in restricted-scope Medi-Cal go into full-scope Medi-Cal right away,” says Ronald Coleman, managing director of policy at the California Pan-Ethnic Health Network, a nonprofit that promotes health access for communities of color. “The question is: Will they understand their benefits and know how to navigate the system?”

Those who are not signed up for restricted Medi-Cal may not be easily identified and, given cultural and language barriers, could be difficult to convince.

The Department of Health Care Services, which administers Medi-Cal, is working with county officials, consumer advocates, and the state health insurance exchange, , to reach eligible immigrants. It has published notices with in multiple languages. And the agency has an “older adult expansion” page on its website, available in and .

Advocates have also been gearing up. The California Pan-Ethnic Health Network, for example, is sponsoring legislation, , which would direct $30 million to community groups to conduct outreach and enrollment for people in underserved communities who are eligible for Medi-Cal. A similar program expires in June. Separately, the network is seeking an additional $15 million specifically for unauthorized adult immigrants, says Monika Lee, a spokesperson for the organization.

Even as advocates and health officials spread the word about the new eligibility rules, they expect to encounter deep distrust from immigrants who vividly remember the Trump administration’s public charge rule, which stoked fear that applying for public benefits might harm their immigration status or even lead to deportation. With elections looming, many fear those days are not entirely in the past.

“What advocates are trying to do on the ground is explain what county offices do with their information. It’s not shared with immigration,” says Tiffany Huyenh-Cho, a senior attorney at . “We’re really trying to allay some of those concerns people still have.”

Modesto resident Alina Arzola, a 64-year-old unauthorized immigrant who came from Guanajuato, Mexico, says she is not afraid of the immigration police. She is hesitant to sign up for Medi-Cal for a different reason: She fears the quality of the care is not very good.

“Economically, perhaps it would help me,” she says. But she says she has not heard good things from her 87-year-old mother, who is a U.S. citizen and a Medi-Cal enrollee. In December 2020, her mom had surgery scheduled to remove her cataracts. It was all confirmed, Arzola recalls, but when her mom arrived, the doctor wasn’t there. He never showed up.

Arzola, who has diabetes, gets primary care at , a clinic in Modesto that treats uninsured people at no charge. But the clinic is not allowed to provide free care to people who are able to obtain affordable insurance — and that means that Arzola will soon no longer be able to go to the clinic, which she deeply regrets.

So she will likely bite the bullet and sign up for Medi-Cal.

“I’m sure it wouldn’t be convenient for me to be without medical care,” Arzola says, “so I don’t have any alternative.”

The Department of Health Care Services and other resources are available to help you or a loved one learn about the new Medi-Cal benefits for older immigrants, including how to sign up and how to choose a health plan and provider.

The Health Consumer Alliance (888‑804‑3536 or ) provides free consultations and has offices across the state. It also has a — available in English, Spanish, Vietnamese, and multiple other languages — that explains the Medi-Cal expansion to older adults. It provides contact information for enrollment, whether through your county welfare office, Covered California, or your local community clinic.

The Latino Coalition for a Healthy California (916-448-3234 or ) offers a and fact sheets in English and Spanish. The advocacy groups Health Access and the California Immigrant Policy Center have put out a joint FAQ in and .

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In three hours on a recent Saturday, Ho-king and Brenda Rodriguez, a medical assistant, vaccinated 16 people — far fewer than they had anticipated. Nearly everyone who showed up at the fair, organized by Saban Community Clinic, was an adult seeking a booster shot or a young child getting a first dose (children ages 5 to 11 for a vaccine late last year).

As covid infections have declined so too has interest in covid vaccines — even though the shots are at preventing serious illness and death from the virus.

In California’s most-populous county, where have not received even one dose, vaccination events have turned desolate. county residents got their first dose in March, a 79% decline from January, according to the Los Angeles County Department of Public Health.

Those who remain unvaccinated are harder to convince, telling health care workers and vaccination coordinators that they don’t feel a sense of urgency.

According to a January survey by the , about 1 in 10 California adults said they definitely won’t get vaccinated, , and 86% of unvaccinated adults said the omicron variant wasn’t enough to persuade them. Employers and businesses are . And although proof of vaccination once offered perks like allowing people to go maskless indoors, face coverings are generally in California.

At a recent vaccination drive coordinated by an immigrant advocacy group in Palmdale, near Lancaster in northern L.A. County, only two people showed up over four hours, both for second doses. As of April 1, ages 5 and up were unvaccinated, compared with 17% of county residents, according to county data.

Jorge Perez, ’s vaccine coordinator, spent a week promoting the event with his team, going door to door, visiting local businesses, and publicizing it on social media. At previous vaccine drives, “we got 42 people, then 20, then four,” said a disappointed Perez. “Now two.”

Perez reduced the number of staffers at vaccination events from five to two in February as the numbers started to dwindle.

Much work remains to be done to combat vaccine misinformation, especially given the spread of BA.2, an omicron subvariant that is , said , chief medical officer for , a public Medicaid insurance plan that serves county residents. The number of covid cases and hospitalizations since February, but the county is again seeing a bump in cases, according to this week.

People have various reasons for remaining unvaccinated, Seidman said. “For some, it’s distrust of the government or health care providers in general,” he said. “Some are more cautious and want to take a wait-and-see approach. Others simply don’t believe the science.”

A by JAMA Internal Medicine shows just how entrenched views are. Many people who refused to get vaccinated early on said they were waiting for the shots to get full approval from the FDA. But when the agency’s came in August 2021, the study concluded, it did little to change people’s minds and “had little immediate impact on vaccination intentions.”

In California, unvaccinated people were as likely to die from covid as people who had been fully vaccinated and received a booster dose, according to state data from March 7-13.

Perez said people getting their first shots now are doing so mainly because they feel obligated — to meet a work requirement, for example, or enter places such as restaurants, bars, and gyms that require proof of vaccination.

That was the case for Modesto Araizas, one of the two people who showed up at the Palmdale vaccine event. Despite contracting covid twice, missing work, and having a hard time breathing, he didn’t get vaccinated until he needed proof of vaccination to eat at his favorite seafood restaurant.

“I haven’t been scared,” said Araizas, 46. “I take vitamins, eat healthy food, and I work out.” 

Until recently, the federal government for tests, treatments, and vaccines for uninsured people. But the stopped accepting reimbursement claims for tests and treatments March 22, and for vaccinations April 5.

Many uninsured people now will likely need to pay out-of-pocket for tests and other services.

Perez is hoping people might become more open to vaccines if covid tests become too expensive for them. No one will want to keep paying for tests when they can just get a shot, he reasoned.

Nurse Roxanna Segovia works at a pop-up vaccine and testing clinic in front of South LA Cafe in South Central L.A. She recently spent 45 minutes trying to persuade a man who had visited the clinic regularly for free tests to get vaccinated.

“He gave me all the reasons he has not been vaccinated, like his civil rights were being violated and Bible verses,” Segovia said. “His job requires it now, and he said he was losing money by missing work waiting for test results. If he continued this way, he wouldn’t be able to feed his family, but even so, he still wasn’t sure if he was making the right choice.”

At the end of their conversation, he got the shot.

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Alma earned her reputation as a trusted source of information through her internship as a junior community health worker. She was among 35 Fresno County students recently trained to discuss how covid vaccines help , and to encourage relatives, peers, and community members to stay up to date on their shots, including boosters.

When Alma’s internship drew to a close in October, she and seven teammates assessed their work in a capstone project. The students took pride in being able to share facts about covid vaccines. Separately, Alma persuaded her family to get vaccinated. She said her relatives, who primarily had received covid information from Spanish-language news, didn’t believe the risks until a close family friend died.

“It makes you want to learn more about it,” Alma said. “My family is all vaccinated now, but we learned the hard way.”

Community health groups in California and across the country are training teens, many of them Hispanic or Latino, and deputizing them to serve as health educators at school, on social media, and in communities where covid vaccine fears persist. According to a 2021 survey commissioned by Voto Latino and conducted by Change Research, said they didn’t trust the safety of the vaccines. The number jumped to 67% for those whose primary language at home is Spanish. The most common reasons for declining the shot included not trusting that the vaccine will be effective and not trusting the vaccine manufacturers.

And vaccine hesitancy is not prevalent only among the unvaccinated. Although of Hispanics and Latinos have received at least one dose of a covid vaccine, few report staying up to date on their shots, according to the Centers for Disease Control and Prevention. The CDC estimated of Hispanics and Latinos have received a bivalent booster, an updated shot that public health officials recommend to protect against newer variants of the virus.

Health providers and advocates believe that young people like Alma are well positioned to help get those vaccination numbers up, particularly when they help navigate the health system for their Spanish-speaking relatives.

“It makes sense we should look to our youth as covid educators for their peers and families,” said Dr. Tomás Magaña, an assistant clinical professor in the pediatrics department at the University of California-San Francisco. “And when we’re talking about the Latino community, we have to think deeply and creatively about how to reach them.”

Some training programs use peer-to-peer models on campuses, while others teach teens to fan out into their communities. , a public youth corps based in Oakland, is leveraging programs in California, New Mexico, Colorado, and Michigan to turn students into covid vaccine educators. And the in Florida, which trains high school juniors and seniors to teach freshmen about physical and emotional health, integrates covid vaccine safety into its curriculum.

In Fresno, the junior community health worker program, called , adopted the promotora model. Promotoras are non-licensed health workers in Latino communities tasked with guiding people to medical resources and promoting better lifestyle choices. that promotoras are trusted members of the community, making them uniquely positioned to provide vaccine education and outreach.

“Teenagers communicate differently, and they get a great response,” said Sandra Celedon, CEO of , one of the organizations that helped design the internship program for students 16 and older. “During outreach events, people naturally want to talk to the young person.”

The teens participating in Promotoritos are mainly Latino, immigrants without legal status, refugee students, or children of immigrants. They undergo 20 hours of training, including social media campaign strategies. For that, they earn school credit and were paid $15 an hour last year.

“Nobody ever thinks about these kids as interns,” said Celedon. “So we wanted to create an opportunity for them because we know these are the students who stand to benefit the most from a paid internship.”

Last fall, Alma, who is Latina, and three other junior community health workers distributed covid testing kits to local businesses in their neighborhood. Their first stop was Tiger Bite Bowls, an Asian fusion restaurant. The teens huddled around the restaurant’s owner, Chris Vang, and asked him if he had any questions about covid. Toward the end of their conversation, they handed him a handful of covid test kits.

“I think it’s good that they’re aware and not afraid to share their knowledge about covid,” Vang said. “I’m going to give these tests to whoever needs them — customers and employees.”

There’s another benefit of the program: exposure to careers in health care.

California faces a in the health care industry, and health professionals don’t always reflect the increasing diversity of the state’s population. Hispanics and Latinos represent 39% of California’s population, but only 6% of the state’s physician population and 8% of the state’s medical school graduates, according to a .

Alma said she joined the program in June after she saw a flyer at the school counselor’s office. She said it was her way to help prevent other families from losing a loved one.

Now, she is interested in becoming a radiologist.

“At my age,” Alma said, “this is easily the perfect way to get involved.”

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In 2015, one of those warehouses was built right in front of her old house, blocking her view of her suburban neighborhood. Soon thereafter, her son battled bronchitis and pneumonia. “It got so bad that I ended up taking him to the ER about three to four times a year,” she said. Her son, now 16, like so many others in the region developed asthma due to air pollution. She grew concerned that state policies were overlooking predominantly Hispanic and low-income residents in her community.

Gonzalez, 35, has evolved from a concerned parent into an environmental advocate. Her years as an educator specializing in bilingual and special education, along with a bout of homelessness, fuel her passion for advocating for marginalized communities. Today, she serves as executive director of the Center for Community Action and Environmental Justice, which works on air quality and environmental justice issues on behalf of the region.

Gonzalez and the organization have endorsed on the November ballot. Funded primarily by the ride-hailing company Lyft, it would impose an additional 1.75% tax on what Californians earn above $2 million per year to fund zero-emission vehicle purchases, electric charging stations, and wildfire prevention programs.

While the initiative would provide subsidies for low-income consumers, it would also subsidize businesses, such as Lyft and other ride-hailing companies, by helping them add clean cars to their fleet. Lyft and other ride-hailing companies are under to make at least 90% of their vehicle fleets electric by 2030.

The once-popular measure has slipped into toss-up territory. A by the Public Policy Institute of California found 55% of likely voters back the measure, down from 63% in April. And it has divided environmentalists and Democrats.

The measure would generate an estimated $3.5 billion to $5 billion a year, growing over time, according to the nonpartisan . Of that, 45% would primarily subsidize zero-emission vehicles and 35% would boost construction of residential and public charging stations, with at least half of each category directed to low-income households and communities. The remaining 20% would fund wildfire suppression and prevention.

The state Democratic Party and the American Lung Association endorsed Proposition 30, calling it an innovative measure that will expand access to electric vehicle chargers for every Californian, regardless of where they live or work.

But opponents include the California Teachers Association and Democratic Gov. Gavin Newsom, who the measure “a Trojan horse that puts corporate welfare above the fiscal welfare of our entire state.”

California is a leader in pushing — and paying for — clean energy, but the state has been criticized for failing to distribute California’s equitably. For example, a found wealthier communities in Los Angeles County had more electric and plug-in hybrid vehicles than its disadvantaged communities. And state Assembly member Jim Cooper, a Black Democrat from Elk Grove who will become Sacramento County sheriff next year, has said the state’s push for electric vehicles fuels “.”

Gonzalez points to studies, such as by Earthjustice, showing how people who live close to warehouses are more likely to be low-income and at higher risk of asthma due to the air pollution generated by diesel trucks.

KHN reporter Heidi de Marco met with Gonzalez at her new home, where a development is proposed behind her property, to discuss why she and her organization endorsed Proposition 30. Gonzalez said she has not been paid by Lyft. The interview has been edited for length and clarity.

Q: Why is Proposition 30 important for your community?

Our families are dying, and nobody is doing anything about it. We’re seeing all the illnesses that are connected to pollution, such as asthma, pneumonia, lung cancer, COPD [chronic obstructive pulmonary disease], and even diabetes.

We just decided to support it because we felt, as a team, that it was the right thing to do given how impacted we are by car and truck pollution. There are layers upon layers of pollution.

Along with the influx of warehouses bringing tons of trucks and their diesel exhaust emissions, the Inland Empire is unique when it comes to pollution. We have all the polluting industries that you can think of, from rail yards bringing more diesel emissions, from the trains to gas plants, which are emitting a lot of pollution. We have toxic landfills, airports, and all the car traffic from the intersections of the 10, 60, 215, and the 15 freeways.

Q: Proposition 30 is funded by Lyft, and Newsom opposes it, calling it a “cynical scheme” by the company to get more clean cars for its fleet. Lyft has been criticized by labor groups for lowering compensation through gig work instead of paying fair wages and benefits. Why are you siding with Lyft?

I see it two ways. One, yes, we need to hold Lyft accountable for the way they treat their drivers and making sure they’re paying them fair wages. I do believe Lyft should do better. But the way that I see it, the fact that they’re transitioning into clean-energy vehicles is where I have to give them props.

Even the developers in our communities have the money to transition their diesel trucks to clean energy, but they’re not investing in that. We have a climate change crisis, and I don’t necessarily see them as the enemy. I see them as folks trying to be part of the solution and transitioning to clean energy.

Q: Will the initiative make a difference when so much of the Inland Empire’s pollution is from Los Angeles and the warehouse industry?

It will make electric vehicles and clean energy vehicles more affordable. And it would create those incentives that our low-income community needs, especially our small-business owners like our self-employed truck drivers that cannot afford to transition to a clean-energy vehicle or a truck. This program would give them those subsidies that they need so they can afford to transition.

This proposition will also give money to expand the clean-vehicle infrastructure that we need. Because here we are telling everybody to change to clean-energy vehicles, but we don’t have the infrastructure. Where are they going to charge their cars when they go to work? Or when they go to school? Or even in their own homes?

So, this campaign would put us in the right direction because I don’t see any other efforts being done, including with the state. I feel like sometimes the governor is a little hypocritical because here he is trying to be a champion for climate change, but he’s not showing a real plan to transition compared to this proposition, where they at least have a plan in place to tackle that transition.

Q: The state and federal governments have already invested billions in clean-car programs. Why is Proposition 30 needed?

It’s going to take a while before the money gets to the appropriate agencies. Another thing that I see that the government fails at is that they always leave out the most affected, marginalized, disenfranchised communities such as the Inland Empire. We have been overseen for so long, and every time the government creates these programs, all this investment and infrastructure, local agencies sometimes don’t know about it — or they don’t do the work to ask for the money.

And what this program does through Prop. 30 is that it’s taxing the rich, the people that make over $2 million. We always give the tax breaks to the rich and it’s about time that the rich pay their fair share.

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What you see is a beautiful little boy with smooth, lustrous skin, an abundance of glossy brown hair, and a disarming smile. What you hear are coos and cries that don’t immediately signal anything is horribly awry.

But his parents, Adriana Pinedo and Hector Martinez, know the truth painfully well.

Although Adriana’s doctors and midwife had described the pregnancy as “perfect” for all nine months, Aaron was born with most of his brain cells dead, the result of two strokes and a massive bleed he sustained while in utero.

Doctors aren’t sure what caused the anomalies that left Aaron with virtually no cognitive function or physical mobility. His voluminous hair hides a head whose circumference is too small for his age. He has epilepsy that triggers multiple seizures each day, and his smile is not always what it seems. “It could be a smile; it could be a seizure,” his mother said.

Shortly after Aaron was born, doctors told Adriana, 34, and Hector, 35, there was no hope and they should “let nature take its course.” They would learn months later that the doctors had not expected the boy to live more than five days. It was on Day 5 that his parents put him in home hospice care, an arrangement that has continued into his second year of life.

The family gets weekly visits from hospice nurses, therapists, social workers, and a chaplain in the cramped one-bedroom apartment they rent from the people who live in the main house on the same lot on a quiet residential street in this Inland Empire city.

One of the main criteria for hospice care, largely for seniors but also applied to children, is a diagnosis of six months or less to live. Yet over the course of 17 months, Aaron’s medical team has repeatedly recertified his hospice eligibility.

Under of the 2010 Affordable Care Act, children enrolled in Medicaid or the Children’s Health Insurance Program are allowed, unlike adults, to be in hospice while continuing to receive curative or life-extending care. Commercial insurers are not required to cover this “concurrent care,” but many now do.

More than a decade since its inception, concurrent care is widely credited with improving the quality of life for many terminally ill children, easing stress on the family and, in some cases, sustaining hope for a cure. But the arrangement can contribute to a painful dilemma for parents like Adriana and Hector, who are torn between their fierce commitment to their son and the futility of knowing that his condition leaves him with no future worth hoping for.

“We could lose a life, but if he continues to live this way, we’ll lose three,” said Adriana. “There’s no quality of life for him or for us.”

Aaron’s doctors now say he could conceivably live for years. His body hasn’t stopped growing since he was born. He’s in the 96th percentile for height for his age, and his weight is about average.

His parents have talked about “graduating” him from hospice. But he is never stable for long, and they welcome the visits from their hospice team. The seizures, sometimes 30 a day, are a persistent assault on his brain and, as he grows, the medications intended to control them must be changed or the doses recalibrated. He is at continual risk of gastrointestinal problems and potentially deadly fluid buildup in his lungs.

Adriana, who works from home for a nonprofit public health organization, spends much of her time with Aaron, while Hector works as a landscaper. She has chosen to live in the moment, she said, because otherwise her mind wanders to a future in which either “he could die — or he won’t, and I’ll end up changing the diapers of a 40-year-old man.” Either of those, she said, “are going to suck.”

While cancer is one of the major illnesses afflicting children in hospice, many others, like Aaron, have rare congenital defects, severe neurological impairments, or uncommon metabolic deficiencies. 

“We have diseases that families tell us are one of 10 cases in the world,” said Dr. Glen Komatsu, medical director of Torrance-based TrinityKids Care, which provides home hospice services to Aaron and more than 70 other kids in Los Angeles and Orange counties.

In the years leading up to the ACA’s implementation, pediatric health advocates lobbied hard for the concurrent care provision. Without the possibility of life-extending care or hope for a cure, many parents refused to put their terminally ill kids in hospice, thinking it was tantamount to giving up on them. That meant the whole family missed out on the support hospice can provide, not just pain relief and comfort for the dying child, but emotional and spiritual care for parents and siblings under extreme duress.

TrinityKids Care, run by the large national Catholic health system Providence, doesn’t just send nurses, social workers, and chaplains into homes. For patients able to participate, and their siblings, it also offers art and science projects, exercise classes, movies, and music. During the pandemic, these activities have been conducted via Zoom, and volunteers deliver needed supplies to the children’s homes.

The ability to get treatments that prolong their lives is a major reason children in concurrent care are more likely than adults to outlive the six-months-to-live diagnosis required for hospice.

“Concurrent care, by its very intention, very clearly is going to extend their lives, and by extending their lives they’re no longer going to be hospice-eligible if you use the six-month life expectancy criteria,” said Dr. David Steinhorn, a pediatric intensive care physician in Virginia, who has helped develop numerous children’s hospice programs across the U.S.

Another factor is that kids, even sick ones, are simply more robust than many older people.

“Sick kids are often otherwise healthy, except for one organ,” said Dr. Debra Lotstein, chief of the division of comfort and palliative care at Children’s Hospital Los Angeles. “They may have cancer in their body, but their hearts are good and their lungs are good, compared to a 90-year-old who at baseline is just not as resilient.”

All of Aaron Martinez’s vital organs, except for his brain, seem to be working. “There have been times when we’ve brought him in, and the nurse looks at the chart and looks at him, and she can’t believe it’s that child,” said his father, Hector.

When kids live past the six-month life expectancy, they must be recertified to stay in hospice. In many cases, Steinhorn said, he is willing to recertify his pediatric patients indefinitely.

Even with doctors advocating for them, it’s not always easy for children to get into hospice care. Most hospices care primarily for adults and are reluctant to take kids.

“The hospice will say, ‘We don’t have the capacity to treat children. Our nurses aren’t trained. It’s different. We just can’t do it,’” said Lori Butterworth, co-founder of the Children’s Hospice and Palliative Care Coalition of California in Watsonville. “The other reason is not wanting to, because it’s existentially devastating and sad and hard.”

Finances also play a role. Home hospice care is paid at a set by Medicare — slightly over $200 a day for the first two months, about $161 a day after that — and it is typically the same for kids and adults. Children, particularly those with rare conditions, often require more intensive and innovative care, so the per diem doesn’t stretch as far.

The concurrent care provision has made taking pediatric patients more viable for hospice organizations, Steinhorn and others said. Under the ACA, many of the expenses for certain medications and medical services can be shifted to the patient’s primary insurance, leaving hospices responsible for pain relief and comfort care.

Even so, the relatively small number of kids who die each year from protracted ailments hardly makes pediatric hospice an appealing line of business in an industry craving growth, especially one in which private equity investors are active and seeking a big payday.

In California, only 21 of 1,336 hospices reported having a specialized pediatric hospice program, and 59 said they served at least one patient under age 21, according to of 2020 state data by Cordt Kassner, CEO of Hospice Analytics in Colorado Springs, Colorado.

Hospice providers that do cater to children often face a more basic challenge: Even with the possibility of concurrent care, many parents still equate hospice with acceptance of death. That was the case initially for Matt and Reese Sonnen, Los Angeles residents whose daughter, Layla, was born with a seizure disorder that had no name: Her brain had simply failed to develop in the womb, and an MRI showed “fluid taking up space where the brain wasn’t,” her mother said.

When Layla’s team first mentioned hospice, “I was in the car on my phone, and I almost crashed the car,” Reese recalled. “The first thought that came to mind was, ‘It is just the end,’ but we felt she was nowhere near it, because she was strong, she was mighty. She was my little girl. She was going to get through this.”

About three months later, as Layla’s nervous system deteriorated, causing her to writhe in pain, her parents agreed to enroll her in hospice with TrinityKids Care. She died weeks later, not long after her 2nd birthday. She was in her mother’s arms, with Matt close by.

“All of a sudden, Layla breathed out a big rush of air. The nurse looked at me and said, ‘That was her last breath.’ I was literally breathing in her last breath,” Reese recounted. “I never wanted to breathe again, because now I felt I had her in my lungs. Don’t make me laugh, don’t make me exhale.”

Layla’s parents have no regrets about their decision to put her in hospice. “It was the absolute right decision, and in hindsight we should have done it sooner,” Matt said. “She was suffering, and we had blinders on.”

Adriana Pinedo said she is “infinitely grateful” for hospice, despite the heartache of Aaron’s condition. Sometimes the social worker will stop by, she said, just to say hello and drop off a latte, a small gesture that can feel very uplifting. “They’ve been our lifeline,” she said.

Adriana talks about a friend of hers with a healthy baby, also named Aaron, who is pregnant with her second child. “All the stuff that was on our list, they’re living. And I love them dearly,” Adriana said. “But it’s almost hard to look, because it’s like looking at the stuff that you didn’t get. It’s like Christmas Day, staring through the window at the neighbor’s house, and you’re sitting there in the cold.”

Yet she seems palpably torn between that bleak remorse and the unconditional love parents feel toward their children. At one point, Adriana interrupted herself midsentence and turned to her son, who was in Hector’s arms: “Yes, Papi, you are so stinking cute, and you are still my dream come true.”

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A hint of smoke from burning wood wafted through their dirt-and-grass yard anchored by native trees. Maia, 17, searched for the source as Mia, 14, reached for the garden hose, then turned on the spigot and doused the perimeter of the property with water.

The smoky smell sent the sisters back to one gusty October evening in 2017 when wildfire came for their previous home. From the back of the family’s minivan that night, the girls watched flames surround their trailer in Glen Ellen, a village in Northern California’s wine country. They abandoned their belongings, including Mia’s favorite doll, and left without their cat, Misi, who was spooked by the fire. The only thing the family saved was the 3-month-old’s baby blanket.

The family drove away, weaving through dark roads illuminated by burning trees and flaming tumbleweeds. Mia was quiet. Maia vomited.

As California wildfires grow more , many children who live through them are experiencing lasting psychological trauma such as anxiety, depression, and post-traumatic stress disorder. Children may also develop sleep or attention problems, or struggle in school. If not managed, their emotional trauma can affect their physical health, potentially leading to chronic health problems, mental illness, and substance use.

Since 2020, the state has asked doctors who participate in the state’s Medicaid program for low-income people to screen children — and adults — for potentially traumatic events related to , which are linked to chronic health problems, mental illness, and substance use. In the state’s that took place from January 2020 through September 2021, children and adults were found to be at higher risk for toxic stress or trauma if they live in the state’s northern counties, a primarily rural region that has been struck by in recent years.

While the screenings can help detect neglect, abuse, or household dysfunction, doctors and health officials have suggested wildfires contributed to the high ACEs scores in rural Northern California. In an annual report, in Shasta County, where the Carr Fire burned in 2018, were found to be at high risk of trauma. In Napa County, where the Tubbs Fire ripped through wine country in 2017, were deemed to be at high risk of trauma.

In a supplemental analysis, researchers found that in some counties in Northern California have experienced one or more traumatic event, compared with 60% for the state as a whole. That includes Butte County, where the took the lives of 85 people.

“When the population has a high range of trauma to begin with and you throw in environmental trauma, it just makes it that much worse,” said , a pediatrician at Shasta Community Health Center who has conducted some of the screenings, known as .

Wildfires disrupt routines, force people to move, and create instability for children who need to be . In recent years, California demographers have attributed some to wildfires that destroy homes and displace families.

“There’s nothing more stressful for a child than to see their parents freaking out,” said Christopher Godley, director of emergency management for Sonoma County, which since 2015 has been hit by .

Children can also be indirect victims of wildfires. According to a study published by the Centers for Disease Control and Prevention, an estimated in the United States are affected annually by wildfire smoke, which not only affects the respiratory system but may contribute to attention-deficit/hyperactivity disorder, autism, impaired school performance, and memory problems.

In 2017, the Bravo family escaped the Tubbs Fire, which burned parts of Napa and Sonoma counties and the city of Santa Rosa. At the time, it was the in state history, leveling neighborhoods and killing nearly two dozen people.

They slept in their minivan the first night, then took shelter with family in nearby Petaluma.

“I was afraid, in shock,” Maia recalled. “I would stay up all night.”

The sisters were overjoyed to find their cat cowering underneath a neighbor’s trailer 15 days after they evacuated. Misi’s paws had been badly burned.

For the first few years after the fire, Maia had nightmares filled with orange flames, snowing ash, and charred homes. She would jolt awake in a panic to the sound of firetruck sirens.

Children may respond differently to trauma depending on their age. Younger kids may feel anxious and fearful, , or develop separation anxiety from parents or trusted adults. Older kids may feel depressed and lonely, develop eating disorders or self-harming behaviors, or begin to use alcohol or drugs.

“When you have these kids who have had these intense evacuations, experienced losses of life, complete destruction of property, it’s important they have social support,” said Melissa Brymer, director of terrorism and disaster programs at the .

Brymer said children also need coping tools to help them stay calm. These include , playing familiar games, exercising, or seeing a counselor. “Do they need comfort from their parents? Need to distract themselves? Or do some breathing exercises?” she said.

, a clinical psychologist and associate professor at Yale School of Public Health, said that while a little anxiety can motivate adults, it doesn’t do the same for children. She recommends they maintain sleep schedules and eating times.

“For kids, instilling a sense of stability and calm is really important and reestablishing some sense of routine and normalcy,” Lowe said.

Emergency responders have begun to integrate mental wellness, for both adults and kids, into their disaster response plans.

Sonoma County officials now post resources for people alongside tips for assembling emergency kits, known as “,” and developing an escape plan.

And the county will deploy mental health workers during disasters as part of its new emergency operations plan, Godley said. For example, the county will send behavioral health specialists to emergency shelters and work with community groups to track the needs of wildfire survivors.

“Many of the more vulnerable populations are going to need specialized behavioral health and that’s going to be especially true for children,” Godley said. “You just can’t pop them in front of a family and marriage therapist and expect that the kids are going to immediately be able to be really supported in that environment.”

Maia and Mia moved three times after their trailer burned down. Maia started seeing the school counselor a few weeks after returning to school. Mia was more reluctant to accept help and didn’t start counseling until January 2018.

“Talking about it with the counselor made me calm,” Maia said. “Now, I can sleep. But when I hear about fires, I get nervous that it’s going to happen again.”

Their mother, Erandy Bravo, encouraged her daughters to manage their anxiety by journaling, but the sisters opted for a more practical approach to cope with their trauma. They focused on preparation and, over summer break, kept a go bag with their schoolbooks, laptops, and personal belongings they would want in case of another fire.

The girls attend workshops on how to handle anxiety at a local teen center and have become leaders in a support group. Maia, who graduated from high school in June, will study psychology when she starts at Santa Rosa Junior College in the fall. Mia, who is in the 10th grade, wants to be an emergency dispatcher.

Still, the Bravo sisters remain vigilant.

At their new home, when the sisters smelled smoke in their yard earlier this year, they soon realized it came from the neighbor’s chimney. Mia turned off the water and coiled up the hose. The sisters, feeling safe, let down their guard and headed back inside.

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Lewis prayed she would earn $75, just enough to fill the tank of her Kia sedan so she could drive her 8-year-old daughter, Annabelle, 80 miles south to Los Angeles to receive her weekly chemotherapy treatment for acute lymphoblastic leukemia. Just a year ago, the same tank of gas would have cost $30 less.

After a full shift as a gig worker, the mother had earned close to what she needed. “It took a lot longer than I thought,” she said.

High inflation is hitting families across the nation. According to the U.S. Bureau of Labor Statistics, consumer from a year earlier, one of the biggest increases in recent decades. The Bureau of Economic Analysis found that consumers are spending the most on .

Overall wages continue to climb, but after adjusting for the rising price of goods and services, workers’ over the past year. A recent found that 74% of registered voters put inflation, including rising gas prices, at the top of their concerns.

For millions of families living with — such as heart disease, diabetes, and cancer — or other debilitating conditions, inflation is proving a punishing scourge that could be harmful to their health. Unlike dining out less or buying fewer clothes, many patients don’t have a choice when it comes to paying for medicine, medical supplies, and other ancillary costs. Some must drive long distances to see a specialist, and others must adhere to a strict diet.

“Chronic disease patients are usually on the front lines of seeing a lack of supplies or an increase in out-of-pocket costs,” said Paul Conway, chair of policy and global affairs for the American Association of Kidney Patients.

Health care has grown increasingly unaffordable. Half of adults report having , according to Â鶹ŮÓÅ polling. One-third say they or a family member has skipped recommended medical treatment in the past year because of the cost, and one-quarter of adults report rationing pills or leaving prescriptions unfilled.

Inflation has squeezed families further by driving up the price of gas and food, as well as medical products such as needles and bed-wetting pads. Health care costs since July 2021, and medical commodities — which include prescription and over-the-counter drugs, medical equipment and supplies — are .

Inflation is particularly detrimental to the health of low-income patients; studies have found a . According to the California Budget & Policy Center, making $50,000 or less struggle to pay for food, housing, and medical costs.

For Deborah Lewis and her husband, Spencer, their concerns about the rising cost of gas have never been about skimping on summer travel or weekend getaways. It’s about making sure they have enough gas to drive Annabelle to Children’s Hospital Los Angeles for chemotherapy and other medications delivered through a port in her chest.

The family relies on Spencer’s disability check, which he receives because he has Ehlers-Danlos syndrome, a hereditary disorder that causes him severe joint pain. He also copes with broken discs in his spine and a cyst pushing against his spinal nerves. In January, he stopped working as a pest control technician, shifting more financial responsibilities to his wife.

The disability check covers rent and utilities, leaving Deborah’s freelance work to cover gas. They also get $500 a month from , which helps families with critically ill children.

On a June morning, Deborah packed snacks for the drive ahead as Annabelle, wrapped in her favorite blanket, waited on the couch. Most of her long blond hair has fallen out because of her treatments. The night before, Deborah spent $73.24 to fill up at Costco.

Before they left, Deborah learned the couple carried a negative balance in their checking account. “I have so much on my plate,” she said.

The family has already delayed health care for one family member: Their dog, a Doberman pinscher named Chief, skipped a vet visit for a mass pushing up his intestines.

Politicians are keenly aware of inflation’s leaching effects. In October, most California households will receive to help offset the high cost of gas and other goods under a budget Gov. Gavin Newsom signed in June. The average price of a gallon of gas in California , while the national average is about $4.

But health experts worry that even with the one-time aid, affordability could become a life-or-death issue for some Californians. For example, the price of insulin can range from .

“We’ve seen a number of patients living with diabetes and on a fixed income greatly impacted by rising inflation,” said Matthew Freeby, an endocrinologist and director of the UCLA Gonda Diabetes Center. “Both Type 1 and Type 2 diabetes typically require multiple prescription medications that may already be costly. Patients have had to choose between day-to-day finances and their lifesaving medications, such as insulin or other treatments.”

Inflation is also a challenge for people who depend on certain foods as part of their health care regimen, especially with in the past year.

Toyan Miller, 60, an integrative nutritional health practitioner from San Dimas, California, has been diagnosed with vasculitis and Hashimoto’s thyroiditis, two autoimmune diseases that cause inflammation. Miller’s medically tailored diet requires gluten-free, organic food. Miller said she’s dipping into her savings to afford the average of $300 she spends each week on groceries. Last year, she spent about $100 less.

“The avocado mayonnaise price freaked me out,” she said. “It used to be $8. Now, it’s $16.99.”

Even those who are healthy may find themselves helping family or friends in need.

In the mountainous Los Angeles neighborhood of Laurel Canyon, Shelley Goldstein, 60, helps her parents, both in their 90s, pay for items, such as incontinence products, not covered by health insurance. Goldstein’s father was recently diagnosed with Alzheimer’s disease and lives in a retirement community with his wife, Doris.

“Those are basic things, but that’s like $70 a month between the two of them,” said Goldstein, who works as a speaking coach. “That’s a lot.”

Goldstein worries about how much more of her parents’ health costs she’ll have to shoulder since they are pensioners on fixed incomes.

“What keeps me up at night right now is what’s to come,” she said. “There’s two of them. My parents’ increased need for pads, meds, and other medical support increases as their health declines.”

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As a child growing up in San Jose, California, Marta Segura heard horrific stories from her parents about women fainting on the factory lines and men overheating in the farm fields. They didn’t know those jobs exposed them to life-threatening conditions.

Then, it hit home.

“My dad, himself, got really sick one time and almost died,” said Segura, 58, the daughter of and a cannery worker. “That resonated with me as a kid.”

Segura, who serves as director of Los Angeles’ in the Department of Public Works, was given a second title this month: chief heat officer, the city’s first. She joins a number of heat officers around the world as cities from , Greece, to , begin to coordinate a better response to extreme heat and develop sustainable cooling strategies. Phoenix and Miami are the only other U.S. cities with heat officers.

As Los Angeles continues to experience more frequent , Segura will work across city departments to help create an early-warning system for heat waves and develop long-term strategies to reduce heat exposure, such as planting trees and updating building codes. Her office will also launch a in July in English and Spanish.

Extreme weather can cause cramps, stroke, and heat exhaustion. Extreme heat contributed to the deaths of around 12,000 people in the U.S. each year from 2010 to 2020, according to a study by the University of Washington. Those figures are likely to rise.

Low-income, majority-minority neighborhoods experience significantly more heat than wealthier, whiter neighborhoods, from the University of California-San Diego’s School of Global Policy and Strategy. The research shows that surface temperatures in communities with higher rates of poverty can be up to 7 degrees Fahrenheit warmer, compared with the richest neighborhoods, during summer.

“Neighborhoods in South Los Angeles send an additional 20 to 30 people to the emergency room on heat days compared to 2 additional people from wealthier neighborhoods,” said Dr. David Eisenman, director of the Center for Public Health and Disasters at UCLA. Eisenman will work with Segura to identify climate-vulnerable communities.

Segura, 58, takes her new job as state lawmakers consider expanding heat warnings. would establish California’s first chief heat officer position and create a statewide extreme-heat and community resilience program. would create the nation’s first warning system for heat waves, just as existing systems warn of other natural disasters such as wildfires, tornadoes, and hurricanes.

KHN reporter Heidi de Marco met with Segura in her City Hall office to discuss her new role and how she plans to tackle the city’s climate risk. The interview has been edited for length and clarity.

Q: Why was this position created?

We’ve noticed a fivefold increase in extreme heat events and heat waves. There are more heat-related illnesses and more hospitalizations and deaths.

There are two goals. The first is changes to the system — the services and the infrastructure of the city. The other is education and awareness — that people know that extreme heat is more serious so they can take steps to protect themselves.

We’re tackling education with an extreme-heat campaign that will launch July 1. In terms of changing the system and services, the city is painting the roofs and roads with white, cool[ing] paint, planting more trees for maximum shade in vulnerable communities.

Q: You will be working to reduce heat-related hospitalizations and deaths, as well as working with different city agencies to implement a heat action plan. How will that work?

We’re already discussing updating our building codes for decarbonization and climate adaptation.

The other approach is through public works. For example, installing more shade structures, more kiosks, especially for metro and bus transportation furniture. They’re also installing more hydration stations.

So when you add that to our public facilities — parks, libraries, youth centers, which are all accessible during the day — you have a lot of opportunities to tell people where to go in the event of a heat storm or heat wave.

Q: How do you plan to address inequality?

It keeps me up at night. Addressing the most vulnerable community isn’t out of charity. And it isn’t because of moral reasons. It’s because if we don’t help the most vulnerable communities of Los Angeles, which are over 50% of the population, we’re not going to get to our climate solutions.

Landlords are less likely to invest in heat pumps or other air conditioning systems because that would only raise the rent and the rent would displace individuals. So we need a policy in the city of L.A. that prevents displacement and helps in some ways to subsidize those low-income housing units or find financing structures that allow landlords to be able to invest and keep our families healthy and safe.

Q: Is there a particular challenge in messaging to immigrant communities?

I think what I learned in my family is we tend to have the radio on as we go about our work. So it’s going to be important to use radio. It’s also going to be important to use text messaging services, like WhatsApp.

We want to make sure to get this information out to employers, so we probably need to come up with culturally relevant communications. It’s an evolving campaign.

Q: What kind of budget are you working with?

We will be allocating approximately 30% of our budget to heat-risk prevention work, and although our budget is not large, our impact on other partner departments, such as public works and the emergency management department, is significant.

We can’t look at my budget in a silo since the council has directed us to work collaboratively to combine the respective parts of our budgets for heat-risk prevention. However, I can say that my office will be doubling in size, from four to eight [employees], and this will give us the leverage and resources we need to make the kind of impact the city of L.A. seeks to make in the long run.

Q: How do you plan to address the homeless community?

What we actually would like to have are more pop-up units, where we have canopies and hydration.

So that’s a conversation I’m having with our deputy mayor of homelessness and housing so that we can coordinate together. And that’s a good example of something that my office can’t do alone because I need their expertise and their allocated resources to ensure that we’re providing the best available comprehensive resources for the city.

Q: You are the first Latina to hold such a position in the United States. How does that feel?

It’s significant because [Latinos] have been suffering disproportionately from climate hazards for a very long time, and we haven’t had positions like this in the past. If they see someone from their community, or that looks like they’re from their community, that speaks their language, that culturally relates to them, that has had similar experiences, I think it makes a big difference, right?

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The 73-year-old retired orthopedic surgeon in Fresno, California, knew it was time for cataract surgery. “It’s like car tires wearing out because you drive on them so much,” he said.

In December 2021, he went to the outpatient department of the local hospital to undergo the common procedure that usually replaces the natural eye lens with an artificial one and is designed to restore vision. The outpatient procedure went smoothly, and Manimtim healed over the next few weeks.

Manimtim, who since retiring took a job evaluating disability claims for the state of California, knows the health care system and keeps tabs on his health benefits. He knew he already had met his health insurance deductible for the year, so he expected a manageable out-of-pocket expense for the surgery. He calculated his coinsurance would be about $750.

Then the bills came.

Patient: Danilo Manimtim, 73, of Fresno, California. He is insured through his employer by Anthem Blue Cross of California for outpatient care and is covered by .

Total Bill: Overall, the charges were $9,084 for surgery, anesthesia, medical supplies, pharmacy, and clinical laboratory services. Anthem paid $5,027 and initially billed Manimtim $4,057.

Service Providers: . It is part of Trinity Health, with 88 hospitals and 125 urgent care centers . The hospital system brought in nearly in revenue for the most .

Medical Service: Cataract surgery as an outpatient, involving anesthesia.

What Gives: Manimtim’s big bill stems from a simple decision that turned out to be a pitfall in the nation’s complicated health care system: He scheduled his surgery at a nearby hospital — a hospital that happened to charge about $7,000 more for the procedure than his insurer would pay.

Manimtim has proof that it could have been different right under his own roof: Four months later, his wife, Marilou Manimtim, 66, got the exact same procedure at an outpatient eye care surgical center in Fresno called . It is a half-mile from Saint Agnes Medical Center but is not affiliated with the hospital.

Both patients have the same insurance coverage through Anthem Blue Cross of California; they had identical cataract surgeries; and both providers were in Anthem’s coverage network. Marilou owed $204, while Danilo was on the hook for a staggering $4,057.

“This is ridiculous, and it feels very unfair,” Danilo Manimtim said. “How can it be so much more expensive than the surgical center? It’s walking distance away, and if I would have gone there, I would have saved myself a lot of money.”

Manimtim’s insurance plan, via his employer, the California Public Employees’ Retirement System, caps payment for outpatient cataract surgery at $2,000, according to Anthem. CalPERS instituted a , in which it determines a reasonable price for a high-quality procedure of that type in California. It then reimburses only up to that amount, encouraging patients to shop for treatment priced under the bar. For the cataract surgery itself, patients in Manimtim’s plan are on the hook for any charges above $2,000.

Even for hospital-based care, Saint Agnes’ overall charges are high for cataract surgery, said Dr. , chief medical officer for , which analyzes health care prices for employers. “The hospital charged three to four times the amount of what this surgery typically costs, which is around $3,000.”

“Nobody gets $9,000 for cataract surgery,” he added.

If Manimtim had opted for Medicare Part B, the part of the Medicare program that covers outpatient care, he likely would have been on the hook for only , a Medicare cost comparison tool shows. Medicare pays a set amount for procedures regardless of where they are performed.

But like many older Americans who are still working, Manimtim chose not to sign up for that coverage, instead opting for his employer’s plan because his monthly premium would be significantly cheaper.

Health care prices often have very little to do with the actual costs of providing the care and its quality — and patients often face the “double whammy” of high prices and complex benefits, said Anthony Wright, executive director of Health Access California, a nonprofit advocacy group. Too often, patients are on their own to figure out high prices and complex benefits, he said.

“You wonder what is the rationale for any of the prices in our health care system,” Wright said.

Resolution: After inquiries by KHN, Anthem contacted the hospital, Saint Agnes, seeking help for Manimtim. Although the doctor is responsible for requesting an exemption from CalPERS’ $2,000 limit on payments for cataract surgery under Manimtim’s plan, that didn’t happen before his surgery. Anthem asked the hospital and doctor to consider the request post-surgery, said Anthem spokesperson Michael Bowman.

Saint Agnes spokesperson Kelley Sanchez told KHN that the hospital and provider later requested the exemption that would allow the insurer to pay more than the $2,000 limit and that it was ultimately approved by Anthem. That is expected to leave Manimtim with a much smaller coinsurance bill, around $750 — and get him off the hook for being taken to collections by the hospital. The hospital will receive a higher payment from Anthem, which will cover a large portion of the remaining $4,057 bill.

And that high payment, like all high payments, contributes to rising health insurance payments for all.

Sanchez said the hospital isn’t in the price-gouging business but noted that hospitals generally have higher costs and tend to charge more than outpatient facilities.

“We never want to cause harm or create hardship for our patients, and that extends to our billing practices,” Sanchez said in a prepared statement.

She noted that Saint Agnes has financial assistance programs available and encourages patients to ask questions and understand potential costs before seeking care. “Every patient’s insurance plan is unique so it is their responsibility to understand their plan benefits,” she wrote. “It’s still complicated and we recognize that, and will continue to work toward greater price transparency.”

The Takeaway: The bottom line for patients, experts say, is to be sure to read the fine print of insurance coverage plans to understand all out-of-pocket responsibilities, including premiums, deductibles, copays, and coinsurance. Also, a small number of large employers that self-insure are , putting caps on what they’ll pay for common procedures. Shop around, and ask about prices on the front end if possible.

“People often focus on premiums because they are easy to compare, but premiums don’t tell the full story, and this example illustrates the trade-offs,” said Tricia Neuman, .

Anthem spokesperson Bowman urged patients to use the online Anthem “” to compare patient costs and find a cheaper option if one is available. Had Manimtim done that, he might have seen that getting his cataract surgery at an outpatient surgical center would have been much cheaper. But the details of provider cost and insurance coverage can be idiosyncratic and are often not displayed in a patient-friendly manner. Manimtim did try to explore his benefits before the procedure, he said, but did not get a clear answer from the insurer or hospital.

Manimtim also had advice for consumers: If you receive a medical bill and don’t understand the charges, don’t pay right away. Instead, call your provider and insurer to ask about the charges and whether there are ways to lower your bill.

“People need to be more informed by the insurance companies and hospitals about what options they have, to prevent overbilling,” Manimtim said. “A lot of people don’t know this could happen to them.”

Stephanie O’Neill contributed the audio portrait with this story.

Bill of the Month is a crowdsourced investigation by KHN and that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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In the three months since she began eating the customized meals, De Los Santos has learned to manage her diabetes by maintaining a healthy blood sugar level.

Two hours to the south, in Indio, Vidal Fonseca gets ready for his third dialysis appointment of the week. He, too, battles kidney disease and diabetes. The 54-year-old former farmworker was released from the hospital in November with an order to follow a strict diet, but he makes a mess in the kitchen and struggles to get his glucose under control. He doesn’t receive the prepared meals.

Here in California’s vast Inland Empire, where more than half of adults have diabetes or are at risk of developing diabetes, one health plan is delivering medically tailored meals to select patients. In bringing food straight to their door for a few months, state officials hope patients will develop healthier eating habits long after the shipments stop. It’s all part of a grand state experiment to improve the health of some of its sickest and costliest patients.

California’s five-year initiative, known as , will test whether Democratic Gov. Gavin Newsom can slow public spending on Medi-Cal, the state’s Medicaid program for people with low incomes, which skyrocketed to $124 billion this fiscal year, up nearly threefold from a decade ago. Medi-Cal managed-care insurers will try to keep people out of expensive health care institutions by delivering social services, such as helping patients find housing, removing toxic mold from their homes, and delivering medically tailored food.

CalAIM, which is expected to cost $8.7 billion, is unconventional because it is being carried out primarily by health plans, not county social service departments. It will serve only a sliver of the 14.5 million Californians enrolled in Medi-Cal. And the state is still developing a way to track health outcomes, meaning nobody knows yet whether it will save money.

“This is a new program, and often with new programs, you’re building the plane as you’re flying it,” said Shelly LaMaster, director of integrated care at Inland Empire Health Plan.

The health plan is one of two Medi-Cal managed-care insurers serving San Bernardino and Riverside counties and has about 1.5 million enrollees. Inland Empire Health Plan says about 11,000 of its enrollees will be eligible for deliveries of meals and food boxes. The average meal benefit has a value of $1,596 and lasts three months, though health insurers can choose to extend food deliveries.

Because plans decide which enrollees receive services, many worthy patients — even those enrolled in the same plan or who live in the same county — are being left out. In the Inland Empire, some patients have started receiving food while others are still getting enrolled. So far, 40% of the recipients are Hispanic, 35% are white, and 18% are Black, which tracks with the region’s demographics. (Hispanics can be of any race or combination of races.)

Initial deliveries for most participants will be frozen meals, varying from taco bowls to chicken curry. Later, they may receive boxes filled with fresh fruits, vegetables, whole-grain bread, pasta, and rice so they can prepare their own meals.

De Los Santos is among the lucky 720 enrollees who have been approved for the benefit since January. Participants must be referred to the program, but referrals can come from doctors, community groups, and family members — Medi-Cal enrollees can even refer themselves.

De Los Santos’ case manager identified her need after conducting an assessment. Then a dietitian screened her for her food preferences and health concerns to develop a nutrition plan.

Her first box of nutritionally tailored meals arrived in February from , one of two prepared-meal companies contracted by the Inland Empire Health Plan. Each week she receives convenient, microwave-ready meals and an information sheet with the macronutrient breakdown of each dish.

“I’m on an eating schedule now,” she said. “I’m eating lots of meats and salads and vegetables, like broccoli and cauliflower, that are good for me.”

Meanwhile, Fonseca, also an Inland Empire Health Plan enrollee, relies on his wife and daughter to figure out how to get his diabetes under control. After he was diagnosed in November, they scrambled to learn how to cook for him by looking up recipes online.

“Before he was diagnosed with renal disease, he was eating a diet high in iron-rich foods that are typical for us to eat, like lentils and beans, but not good for kidney disease,” said his 29-year-old daughter, Maria Cruz. “We were giving him poison.”

Fonseca said he had heard about food banks but not home-delivered meals. “The menu for someone in my condition with both renal failure and diabetes is very limited and specific,” he said in Spanish. “Talking to a nutritionist and receiving meals specifically made for me for free would be a huge help.”

But even though his conditions would qualify him for meal delivery, it’s up to the insurer to enroll him.

Participating in the program would alleviate the guesswork for his wife and daughter. Fonseca’s wife, Eufracia Constantino, still works in the fields. She wakes up at 4:30 a.m. to cook his breakfast every morning before she leaves for work. His daughter prepares lunch for him, which typically consists of chicken or fish, stir-fried vegetables, and hard-boiled eggs.

“I would usually be driving trucks with a burrito in one hand and the steering wheel in the other,” said Fonseca, who was an agricultural truck driver.

De Los Santos, who up until recently was the family breadwinner, has had to adjust to becoming a patient. Two months ago, her husband, Fermin Silva, became her state-funded paid caregiver and the couple struggles to pay rent and utilities. To save money, they will move into a two-bedroom mobile home next month.

“Now I don’t have to worry about buying my meals,” she said. “I would say I’ve saved about $150 a month.”

While she saves money, Fonseca spends an extra $100 a week to buy the healthy food his wife and daughter prepare for him.

“We’ve had to stretch my wife’s paycheck,” Fonseca said. “We don’t fill the grocery cart up like before.”

The California Department of Health Care Services, which runs Medi-Cal, hopes the patients who receive medically tailored meals will tap the health system less often. The goal is to make people healthier by empowering them to adopt better eating habits and learn to sustain a good diet. Although some recipients may have irreversible conditions, such as congestive heart failure or severe diabetes, officials still see opportunities to reduce hospital admissions and emergency room visits.

that providing meal delivery services helps reduce health care costs. State officials note that food benefits will be expanded over time and that there’s no price cap on the initiative.

But the health agency could not provide data on how many Medi-Cal patients are eligible for food delivery and won’t report the number of people receiving the service until later this year. The state plans to gauge the cost-effectiveness of these social services as the program expands, according to agency spokesperson Anthony Cava.

Inland Empire Health Plan officials say it could be challenging to identify the impact of an individual benefit since many members receive multiple services. And it takes time to realize health consequences.

De Los Santos’ meals will end soon. She declined an extension, saying she has learned enough about portioning and self-control. She feels confident about continuing her healthy diet with the help of her husband, who will cook for her.

“My husband tells me to slow down,” she said, “but I have so much more energy.”

Fonseca fears a lifetime of poor eating combined with a physically demanding job has taken a toll on his body. He used to work two fields in one day and traveled depending on the crop season. He never took time off. “Now all I have is time,” he said, “but the dialysis makes me feel exhausted.”

He asked his nurse about getting medically tailored meals.

“He has to be healthy to qualify to get on a kidney transplant waiting list,” said his daughter. “That’s our hope.”

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Unauthorized immigrants who fall below certain income thresholds are now eligible for full coverage by Medi-Cal, California’s version of Medicaid, the federal-state partnership that provides health insurance to low-income people.

Unauthorized immigrants of all ages account for 40% of the state’s uninsured residents. Official estimates put the number of newly eligible people . Those who sign up will join unauthorized immigrants ages 25 and under already enrolled in Medi-Cal.

And if Gov. Gavin Newsom gets his way, which seems entirely plausible considering the state’s , California could allow all remaining low-income unauthorized immigrants — people — to join Medi-Cal by 2024, or sooner.

As I have , Medi-Cal has some well-known problems. But it is still far better than no insurance at all. Read on to learn about the new benefits and how you can enroll if you are eligible.

Under current law, all unauthorized immigrants who meet the financial criteria can get limited Medi-Cal coverage, including emergency and pregnancy services and, in some cases, long-term care. But when they sign up for full Medi-Cal, they get that includes primary care, prescription drugs, mental health care, dental and eye care, eyeglasses, and much more. That’s no small thing for people who are getting gray.

“This is a key moment when you want to incorporate all these aging undocumented immigrants into the health care system,” says Arturo Vargas Bustamante, a professor of health policy and management at UCLA’s Fielding School of Public Health. If you let their chronic conditions go unattended, he says, they’ll just end up in the emergency room and be more expensive to treat.

He calls it “a responsible way of investing.”

As Bustamante points out, it’s no longer the case that immigrants come to work temporarily in the United States and then return to their home countries. They are staying, raising families, and growing old in this country. And unauthorized immigrants play an important role in the labor force, paying an estimated in state and local taxes a year in California and $11.7 billion nationally. Nobody benefits if they’re too sick to work.

While it will take time to roll out the new benefits, the task will be made easier by the fact that the of unauthorized immigrants who will become eligible for full coverage are already signed up for limited Medi-Cal benefits — so the state has contact information for them.

Those already in limited Medi-Cal will be automatically upgraded to full-scope Medi-Cal. Assuming their contact details are current, they will receive packets in the mail explaining their expanded benefits and prompting them to choose a health plan and a primary care provider.

“We expect to see people who are already enrolled in restricted-scope Medi-Cal go into full-scope Medi-Cal right away,” says Ronald Coleman, managing director of policy at the California Pan-Ethnic Health Network, a nonprofit that promotes health access for communities of color. “The question is: Will they understand their benefits and know how to navigate the system?”

Those who are not signed up for restricted Medi-Cal may not be easily identified and, given cultural and language barriers, could be difficult to convince.

The Department of Health Care Services, which administers Medi-Cal, is working with county officials, consumer advocates, and the state health insurance exchange, , to reach eligible immigrants. It has published notices with in multiple languages. And the agency has an “older adult expansion” page on its website, available in and .

Advocates have also been gearing up. The California Pan-Ethnic Health Network, for example, is sponsoring legislation, , which would direct $30 million to community groups to conduct outreach and enrollment for people in underserved communities who are eligible for Medi-Cal. A similar program expires in June. Separately, the network is seeking an additional $15 million specifically for unauthorized adult immigrants, says Monika Lee, a spokesperson for the organization.

Even as advocates and health officials spread the word about the new eligibility rules, they expect to encounter deep distrust from immigrants who vividly remember the Trump administration’s public charge rule, which stoked fear that applying for public benefits might harm their immigration status or even lead to deportation. With elections looming, many fear those days are not entirely in the past.

“What advocates are trying to do on the ground is explain what county offices do with their information. It’s not shared with immigration,” says Tiffany Huyenh-Cho, a senior attorney at . “We’re really trying to allay some of those concerns people still have.”

Modesto resident Alina Arzola, a 64-year-old unauthorized immigrant who came from Guanajuato, Mexico, says she is not afraid of the immigration police. She is hesitant to sign up for Medi-Cal for a different reason: She fears the quality of the care is not very good.

“Economically, perhaps it would help me,” she says. But she says she has not heard good things from her 87-year-old mother, who is a U.S. citizen and a Medi-Cal enrollee. In December 2020, her mom had surgery scheduled to remove her cataracts. It was all confirmed, Arzola recalls, but when her mom arrived, the doctor wasn’t there. He never showed up.

Arzola, who has diabetes, gets primary care at , a clinic in Modesto that treats uninsured people at no charge. But the clinic is not allowed to provide free care to people who are able to obtain affordable insurance — and that means that Arzola will soon no longer be able to go to the clinic, which she deeply regrets.

So she will likely bite the bullet and sign up for Medi-Cal.

“I’m sure it wouldn’t be convenient for me to be without medical care,” Arzola says, “so I don’t have any alternative.”

The Department of Health Care Services and other resources are available to help you or a loved one learn about the new Medi-Cal benefits for older immigrants, including how to sign up and how to choose a health plan and provider.

The Health Consumer Alliance (888‑804‑3536 or ) provides free consultations and has offices across the state. It also has a — available in English, Spanish, Vietnamese, and multiple other languages — that explains the Medi-Cal expansion to older adults. It provides contact information for enrollment, whether through your county welfare office, Covered California, or your local community clinic.

The Latino Coalition for a Healthy California (916-448-3234 or ) offers a and fact sheets in English and Spanish. The advocacy groups Health Access and the California Immigrant Policy Center have put out a joint FAQ in and .

This story was produced by , which publishes , an editorially independent service of the .

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In three hours on a recent Saturday, Ho-king and Brenda Rodriguez, a medical assistant, vaccinated 16 people — far fewer than they had anticipated. Nearly everyone who showed up at the fair, organized by Saban Community Clinic, was an adult seeking a booster shot or a young child getting a first dose (children ages 5 to 11 for a vaccine late last year).

As covid infections have declined so too has interest in covid vaccines — even though the shots are at preventing serious illness and death from the virus.

In California’s most-populous county, where have not received even one dose, vaccination events have turned desolate. county residents got their first dose in March, a 79% decline from January, according to the Los Angeles County Department of Public Health.

Those who remain unvaccinated are harder to convince, telling health care workers and vaccination coordinators that they don’t feel a sense of urgency.

According to a January survey by the , about 1 in 10 California adults said they definitely won’t get vaccinated, , and 86% of unvaccinated adults said the omicron variant wasn’t enough to persuade them. Employers and businesses are . And although proof of vaccination once offered perks like allowing people to go maskless indoors, face coverings are generally in California.

At a recent vaccination drive coordinated by an immigrant advocacy group in Palmdale, near Lancaster in northern L.A. County, only two people showed up over four hours, both for second doses. As of April 1, ages 5 and up were unvaccinated, compared with 17% of county residents, according to county data.

Jorge Perez, ’s vaccine coordinator, spent a week promoting the event with his team, going door to door, visiting local businesses, and publicizing it on social media. At previous vaccine drives, “we got 42 people, then 20, then four,” said a disappointed Perez. “Now two.”

Perez reduced the number of staffers at vaccination events from five to two in February as the numbers started to dwindle.

Much work remains to be done to combat vaccine misinformation, especially given the spread of BA.2, an omicron subvariant that is , said , chief medical officer for , a public Medicaid insurance plan that serves county residents. The number of covid cases and hospitalizations since February, but the county is again seeing a bump in cases, according to this week.

People have various reasons for remaining unvaccinated, Seidman said. “For some, it’s distrust of the government or health care providers in general,” he said. “Some are more cautious and want to take a wait-and-see approach. Others simply don’t believe the science.”

A by JAMA Internal Medicine shows just how entrenched views are. Many people who refused to get vaccinated early on said they were waiting for the shots to get full approval from the FDA. But when the agency’s came in August 2021, the study concluded, it did little to change people’s minds and “had little immediate impact on vaccination intentions.”

In California, unvaccinated people were as likely to die from covid as people who had been fully vaccinated and received a booster dose, according to state data from March 7-13.

Perez said people getting their first shots now are doing so mainly because they feel obligated — to meet a work requirement, for example, or enter places such as restaurants, bars, and gyms that require proof of vaccination.

That was the case for Modesto Araizas, one of the two people who showed up at the Palmdale vaccine event. Despite contracting covid twice, missing work, and having a hard time breathing, he didn’t get vaccinated until he needed proof of vaccination to eat at his favorite seafood restaurant.

“I haven’t been scared,” said Araizas, 46. “I take vitamins, eat healthy food, and I work out.” 

Until recently, the federal government for tests, treatments, and vaccines for uninsured people. But the stopped accepting reimbursement claims for tests and treatments March 22, and for vaccinations April 5.

Many uninsured people now will likely need to pay out-of-pocket for tests and other services.

Perez is hoping people might become more open to vaccines if covid tests become too expensive for them. No one will want to keep paying for tests when they can just get a shot, he reasoned.

Nurse Roxanna Segovia works at a pop-up vaccine and testing clinic in front of South LA Cafe in South Central L.A. She recently spent 45 minutes trying to persuade a man who had visited the clinic regularly for free tests to get vaccinated.

“He gave me all the reasons he has not been vaccinated, like his civil rights were being violated and Bible verses,” Segovia said. “His job requires it now, and he said he was losing money by missing work waiting for test results. If he continued this way, he wouldn’t be able to feed his family, but even so, he still wasn’t sure if he was making the right choice.”

At the end of their conversation, he got the shot.

This story was produced by , which publishes , an editorially independent service of the .

This <a target="_blank" href="/health-industry/covid-vaccine-los-angeles-interest-drops/">article</a&gt; first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">