Speaker 1: The broken backbone of America's health care system. Community health
Speaker 1: workers fill the gaps in places without enough doctors and nurses.
Speaker 1: Trump's budget cuts are costing them their jobs, putting untold
Speaker 1: clients at risk. By Megan Greenwell read aloud by Mark Gledorf.
Speaker 1: The crops begin even before the Fresno city limits end
Speaker 1: rows of neatly pruned trees and bushes and vines, incubating almonds, pistachios, cotton, tomatoes, plums, peaches, nectarines, oranges, lemons, grapefruits, mandarins,
Speaker 1: and grapes for eating, for drinking, for drying into raisins.
Speaker 1: This bounty is trucked hundreds or thousands of miles across
Speaker 1: California and the country away from Fresno. The irony of
Speaker 1: life in the San Joaquin Valley is that locals rarely
Speaker 1: benefit from their regions abundance. Almost one in five residents
Speaker 1: don't reliably have enough to eat. Among them is seventy
Speaker 1: six year old Signora Flores, who, on this march more
Speaker 1: is dressed in an elaborately applicated turquoise cardigan and matching
Speaker 1: tank top, her long gray hair secured with a satin
Speaker 1: scrunchy at the top of her head. She limps into
Speaker 1: the waiting room for a nine a m. Appointment, already
Speaker 1: weeping from some combination of exhaustion, hunger, thirst, pain, and heartache.
Speaker 1: It's not quite clear when she last ate, but it
Speaker 1: wasn't today. She drops heavily onto a small couch in
Speaker 1: the waiting room and tries to catch her breath. The
Speaker 1: woman she's meeting, a community health worker at a small
Speaker 1: nonprofit called cultivala Salute, had offered to come to her home,
Speaker 1: Knowing that Flores doesn't have a car and Fresno's bus
Speaker 1: system is body at best.
Speaker 2: Staffers refer to their.
Speaker 1: Clients using courtesy titles. Flores's name has been changed to
Speaker 1: protect her medical privacy. Yet Flores preferred to walk one
Speaker 1: point six miles south on Fresno Avenue, lugging a large
Speaker 1: Cheetah print tote bag stuffed with documents that have bedeviled
Speaker 1: her for weeks. The trip took her an hour. In
Speaker 1: forty five minutes, when the receptionist hands her a pint
Speaker 1: sized bottle of water, she holds it to the sky,
Speaker 1: whispers Gracias padre, and SIPs. A woman in false eyelashes,
Speaker 1: and Doc Martin's arrives to escort Flores to a center
Speaker 1: block meeting room, then runs to grab a second water,
Speaker 1: an apple, and a two pack of granola bars out
Speaker 1: of a staff kitchen. As Flores pulls her papers out
Speaker 1: of the tote. The pair settle in for what will
Speaker 1: become a two hour session, covering almost every aspect of
Speaker 1: a troubled life. The very fact that this meeting is
Speaker 1: necessary incriminates the US healthcare system, whose labyrinth of unaffordable
Speaker 1: bills and unavailable appointments can seem designed to prevent people
Speaker 1: from getting the treatment they need. Livia Alejo thirty seven,
Speaker 1: the woman now whispering dios Mio as Flores explains her.
Speaker 2: Situation through tears.
Speaker 1: Isn't a doctor, a nurse, a therapist, a government employee,
Speaker 1: or an insurance representative. As a community health worker, She's
Speaker 1: simply trying to make up for this systemic failures of
Speaker 1: all five. Alejo, who moved from Mexicali, Mexico, to Fresno
Speaker 1: in middle school, sometimes struggles to describe what she does
Speaker 1: in this office and in living rooms around the city
Speaker 1: and the surrounding farmland. Even the official definition of community
Speaker 1: health worker from the American Public Health Association equivocates to
Speaker 1: the point of meaninglessness. A trusted member of and or
Speaker 1: has an unusually close understanding of the community served, who
Speaker 1: serves as a liaison, link intermediarrea between health, social services
Speaker 1: and the community to facilitate access to services and improve
Speaker 1: the quality and cultural competence of service delivery. The job
Speaker 1: is just so many things at once. Translator, advocate, case manager,
Speaker 1: paperwork wrangler, digital guide, health coach. Detective Alejo works with
Speaker 1: seventeen patients at a time. As the supervisor of Cultiva's team,
Speaker 1: she's indirectly in charge of more than one hundred. After
Speaker 1: five years, She's fluent in every element of the social
Speaker 1: stils net for Fresno residents. She knows who to call
Speaker 1: when the state's public insurance system hasn't sent someone their
Speaker 1: ID card, where to find doctors accepting new patients, which
Speaker 1: nonprofits still have money for rental assistance this month, where
Speaker 1: to get food after benefits run out, and which programs
Speaker 1: will rule out undocumented immigrants. Solving one problem often means
Speaker 1: uncovering several more basic ones, as if she's trying to
Speaker 1: sow address but first has to spin raw fiber into thread.
Speaker 1: We're the source of the resources, Alejo says. We have
Speaker 1: to find what is missing. The payoff from programs such
Speaker 1: as Cultive La Salute can be something close to magic.
Speaker 1: Peer reviewed research has found that community health workers can
Speaker 1: lower blood sugar in diabetic patients, lower blood pressure in
Speaker 1: hypertensive ones, and lower cholesterol in hyper lipidemic ones. Patients
Speaker 1: who get support from community health workers smoke fewer cigarettes,
Speaker 1: get more exercise, and rate their mental health more positively better. Yet,
Speaker 1: these advocates know how to deliver care in a cost
Speaker 1: effective way, not just for clients, but also for health
Speaker 1: insurers and governments. By keeping people fed, housed, and out
Speaker 1: of the hospital, community health workers, earning an average salary
Speaker 1: of fifty one thousand dollars a year, are arguably the
Speaker 1: most cost effective part of America's health care system. One
Speaker 1: study found that every dollar invested in community health worker
Speaker 1: programs results in a two dollars and forty seven cent
Speaker 1: return for Medicaid. As a result, they've long been popular
Speaker 1: with Republicans as well as Democrats. GOP senators including Tom Tillis,
Speaker 1: Lisa Murkowski, and Bill Cassidy have sponsored bills designed to
Speaker 1: increase the number of community health workers serving rural areas.
Speaker 1: But though Cultiva and its peers save both lives and money,
Speaker 1: though they are both effective and well liked, they are
Speaker 1: now also under unprecedented threat. They were among the hardest
Speaker 1: hit programs when the Trump administration canceled twelve billion dollars
Speaker 1: in federal public health grants in the spring of twenty
Speaker 1: twenty five, and subsequent budget cuts the National Institutes of
Speaker 1: Health and the Centers for Disease Control and Prevention delivered
Speaker 1: more blows. Cultiva was forced to lay off half its
Speaker 1: staff of twelve community health workers, and the total number
Speaker 1: serving the Fresno area dropped from sixty to about twenty five,
Speaker 1: says Joe Prato, the county's public health director. As of
Speaker 1: twenty twenty three, fifty eight thousand, five hundred Americans were
Speaker 1: employed as community health workers, sometimes called promo torres, according
Speaker 1: to data from the US Bureau of Labor Statistics. Because
Speaker 1: of the fragmented nature of the workforce, it's not yet
Speaker 1: clear how many of those jobs were lost once the
Speaker 1: funding cuts began in twenty twenty five, but one paper
Speaker 1: found that state and local public health organizations would lose
Speaker 1: about forty five percent of their grant money in twenty
Speaker 1: twenty six. Alejo practically sparkles when she talks about helping
Speaker 1: clients like Flores. She's always felt pulled towards supporting older people.
Speaker 1: Turning that passion into a career, even a stressful and
Speaker 1: underpaid one, felt like a dream, But she says she
Speaker 1: worries about how long she'll get to do it. The
Speaker 1: grant that's funding cultova's remaining community health workers expires at
Speaker 1: the end of this year. Getting Flores to this meeting
Speaker 1: required a series of intentional steps. A neighbor had handed
Speaker 1: her a flyer picked up from a community fair advertising
Speaker 1: Cultova's free monthly grocery box for low income seniors in Fresno.
Speaker 1: Flores called to sign up, so Olejo dropped off the
Speaker 1: food standing on her doorstep. Flores mentioned she was afraid
Speaker 1: she was about to be kicked off Medical, California's healthcare
Speaker 1: system for low income residents. That was the moment Alejo
Speaker 1: had hoped for. It was the reason she'd made the
Speaker 1: delivery herself. She suggested they meet to figure it out together.
Speaker 1: As soon as they sit down, Alejo can tell that
Speaker 1: potential ejection from Medical isn't Flores's most urgent issue. She
Speaker 1: needs mental health treatment, and soon she can stop crying,
Speaker 1: only for a couple of minutes at a time. Her daughter,
Speaker 1: who lives thousands of miles away, is seriously ill with
Speaker 1: kidney disease. Her husband died last year, leaving her bereft
Speaker 1: and with a new level of financial instability. Flores, who
Speaker 1: grew up in El Salvador, is a legal US resident
Speaker 1: with temporary protected status, which shields her from deportation because
Speaker 1: of instability in her home country, but that designation expires
Speaker 1: in September, and the Trump administration is working to end
Speaker 1: TPS for citizens of several other countries.
Speaker 2: My heart and my.
Speaker 1: Soul are tired, very tired, she says in Spanish, before
Speaker 1: unspooling an extended, enigmatic analogy about how God causes roses
Speaker 1: to bloom. Alejo listens carefully, occasionally offering a tissue or
Speaker 1: murmuring consolations. She doesn't interrupt or try to fast forward
Speaker 1: to practical steps. Even when Flores is trained of thought
Speaker 1: becomes difficult to follow. For now, she's focused on earning
Speaker 1: trust as a person with an official, unfamiliar title. Alejo
Speaker 1: also knows she is starting at a disadvantage. Tens of
Speaker 1: thousands of people in the Fresno region don't have legal status.
Speaker 1: Utal US emigration and Customs enforcement sweeps in other cities
Speaker 1: during the second Trump administration have shrouded California's Central Valley
Speaker 1: in fear. People here don't open the door to strangers,
Speaker 1: literally or emotionally, like many emigrant children. Alijo served as
Speaker 1: her parents translator for years. When she was in college
Speaker 1: at Fresno State, she escorted her father to the hospital
Speaker 1: after an accident on the job. He'd asked a doctor
Speaker 1: about his periodic fainting spells, but the clinic never even tested.
Speaker 2: His blood sugar. Olijo says.
Speaker 1: By the time they diagnosed him with diabetes, the disease
Speaker 1: had advanced so far that he died within a month.
Speaker 1: The hospital never offered a Spanish speaking doctor or translator,
Speaker 1: or anyone to tell Alejo's mom in her native language
Speaker 1: that her husband had died.
Speaker 2: Alijo had to do it.
Speaker 1: My family needed someone to advocate for them and to
Speaker 1: be able to explain their needs to other people, she says,
Speaker 1: and I didn't know where to look. I didn't have
Speaker 1: a person who could guide me and help me find
Speaker 1: resources to help my dad. After that, becoming that guide
Speaker 1: was all she ever wanted to do. Alejo has blocked
Speaker 1: off two and a half hours for this appointment standard
Speaker 1: for a Cultiva intake meeting. She and the community health
Speaker 1: workers who report to her know most of their clients
Speaker 1: are used to being ushered through an overburdened public clinic
Speaker 1: in ten minutes, may be getting handed a scribbled prescription
Speaker 1: on their way out.
Speaker 2: They evaluate every new.
Speaker 1: Client along twenty one pathways, including food security, health, insurance,
Speaker 1: transportation needs, medical screenings, education, and employment. Any pathway they
Speaker 1: identify as an area of concern is added to the
Speaker 1: case file with specific follow up steps. Just getting through
Speaker 1: the screening questions can take more than an hour, even
Speaker 1: with a client who provides straightforward answers, which Flores doesn't.
Speaker 2: As Flores pulls.
Speaker 1: Documents from her bag re enrollment letters, bills, explanations of benefits,
Speaker 1: appointment reminders, prescriptions, Alejo notices that almost all of them
Speaker 1: are exclusively in English, like the ones her dad received
Speaker 1: about two decades ago. They're also studded with terms two
Speaker 1: technical for most people to grasp in any language, even
Speaker 1: after five years in the job. Alejo occasionally blinks in
Speaker 1: confusion at a line and turns to her laptop to
Speaker 1: google what these government and corporate bureaucracies are trying to say.
Speaker 1: Within a half hour, she pieces together what's happened. A
Speaker 1: phone representative had told Floraes she couldn't book any medical
Speaker 1: appointments for April or May because her medical was set
Speaker 1: to expire at the end of March. That was a technicality.
Speaker 1: She met all the qualifications to re enroll and just
Speaker 1: needed to fill out the correct form. But the person
Speaker 1: on the phone hadn't told Flores that, or hadn't told
Speaker 1: her in a way she understood. And she hadn't understood
Speaker 1: the letter that arrived at her home saying she needed
Speaker 1: to apply again. She panicked, Sure she was about to
Speaker 1: stop getting her medication, Sure the clinic wouldn't let her
Speaker 1: in the door for the appointments she scheduled months ago.
Speaker 1: Her shoulders shake as she explains all this, her sniffles
Speaker 1: turn into sobs. Step one, Alejo sees now is to
Speaker 1: fill out the the re enrollment paperwork. She'll return to
Speaker 1: the mental health question later. For reasons relating to language, literacy,
Speaker 1: red tape, and corporate dysfunction. Millions of poor Americans either
Speaker 1: aren't insured despite being eligible, or don't see a doctor regularly.
Speaker 1: When people don't receive preventive care, they're more likely to
Speaker 1: rely on the emergency room, which in turn costs local, state,
Speaker 1: and federal governments.
Speaker 2: More.
Speaker 1: Hospitals are required to treat patients regardless of their ability
Speaker 1: to pay, and hospital care is more expensive to provide.
Speaker 1: Prevention is cheaper than a cure, and Fresno's economy is
Speaker 1: dependent on immigrants, many of whom have a temporary visa
Speaker 1: like Flores or no legal status, so kicking them all
Speaker 1: out or refusing to treat them would cost money too.
Speaker 1: A sea of peer reviewed research supports what Alejo is
Speaker 1: doing as she sits with Flores. Trust blooms from understanding
Speaker 1: from not needing to explain the basic facts of one's life.
Speaker 1: Studies have shown that shared lived experience allows community health
Speaker 1: workers to boost screening rates for breast cancer, cervical cancer,
Speaker 1: and coorectal cancer, and to increase access to primary care
Speaker 1: and followup appointments after hypertension diagnoses. As a result, patients
Speaker 1: with multiple chronic conditions spent sixty nine percent less time
Speaker 1: in the hospital when they received support from a community
Speaker 1: health worker, according to research published in twenty eighteen, Once
Speaker 1: such workers have gained patients trust, they must then figure
Speaker 1: out what to do with it, says Shrea Cangovi, a
Speaker 1: physician in Philadelphia who's written many of the most cited
Speaker 1: papers on community health worker effectiveness. She now runs a
Speaker 1: company that builds infrastructure and training for community health worker programs.
Speaker 1: The worst programs her research has found focus on what
Speaker 1: she calls screen and refer work. You know, missus Jones,
Speaker 1: Do you have enough food to eat? Here's the number
Speaker 1: to the food pantry. People know where the food pantry is.
Speaker 1: Deeper problems are keeping them hungry. In India, where Kangovi
Speaker 1: grew up, we would never dream of having clinicians play
Speaker 1: both offense and defense. Community health workers, who've been a
Speaker 1: core part of the country's healthcare system for hundreds of years,
Speaker 1: take a proactive approach helping people address the social determinants
Speaker 1: of health, food, housing, and social support, all of which
Speaker 1: can make people either healthier or sicker. Doctors get involved
Speaker 1: when treatment is required, which happens less frequently when there's
Speaker 1: a team playing offense. The US has always underperformed on
Speaker 1: the offense side of healthcare. Even before the Trump budget cuts,
Speaker 1: few experts thought community health programs were being funded to
Speaker 1: their full potential. A sustainable, cost effective system wouldn't rely
Speaker 1: on the whims of the executive branch at all. Community
Speaker 1: health workers would be thought of like doctors and nurses,
Speaker 1: so integral a part of the healthcare economy that they'd
Speaker 1: never again need to apply for one year grants. There's
Speaker 1: always a timeline for grants, a beginning date and an
Speaker 1: end date, says Timothy Callahan, a health policy scholar at
Speaker 1: Boston University who studied community.
Speaker 2: Health worker programs.
Speaker 1: You might do everything right as a community health worker,
Speaker 1: but you lose your role anyway because the grant ends
Speaker 1: and there's no new grant. Cultiva la Salute is applying
Speaker 1: to become an authorized medical provider, which would allow it
Speaker 1: to bill its community health workers salaries directly to the state,
Speaker 1: but no one knows how long that process will take.
Speaker 1: Aleijo understands that she can't solve everything for Flores. At
Speaker 1: the root of her client's diverse problems is a unifying one.
Speaker 1: They're poor in a country where life often punishes people
Speaker 1: for being poor. Flores didn't work enough years to qualify
Speaker 1: for Social Security. She retired in twenty ten after complications
Speaker 1: from a long illness that almost cost her a kidney.
Speaker 1: She's still grieving her husband and suffering from the knowledge
Speaker 1: that her daughter is sick thousands of miles away. What
Speaker 1: Aleijo can do is blunt the effect of all these
Speaker 1: indignities and do the heavy lifting to make someone's life
Speaker 1: a little easier. Before last year's layoffs, her team was
Speaker 1: doing it for twice as many people. After this meeting,
Speaker 1: Alijo will leave the work at work, trying to be
Speaker 1: satisfied with doing her best for the day and move on.
Speaker 1: She's practiced this skill ever since her social work internships
Speaker 1: in college. Blasting music on her way to the job helps,
Speaker 1: but here pouring over documents in this small cinder block office,
Speaker 1: there's only Flores. Alejo's phone vibrates and flashes constantly. While
Speaker 1: on silent.
Speaker 2: She never even glances at it.
Speaker 1: We'll be right back with the broken backbone of America's
Speaker 1: healthcare system. Welcome back to the broken backbone of America's
Speaker 1: healthcare system. The simple task of filling out Flores's re
Speaker 1: enrollment paperwork introduces another challenge. She doesn't have an email
Speaker 1: address and doesn't know how to set one up, and
Speaker 1: without email, enrolling any any government benefit can take weeks.
Speaker 1: Alejo signs her up for Gmail, narrating the process allowed
Speaker 1: in Spanish to keep her client involved, then creates an
Speaker 1: account on benefitscal dot com, California, Nia's portal for safety
Speaker 1: net services. Within a few minutes, the two have filled
Speaker 1: out the necessary form to renew Flores's health insurance. Now
Speaker 1: they can investigate the status of her upcoming appointments. Flores
Speaker 1: has already booked an annual primary care exam and a mammogram,
Speaker 1: meaning she's more on top of things than many Americans,
Speaker 1: but she doesn't know if the appointments are still valid.
Speaker 1: Alejo suggests they call together to find out. Although Medical
Speaker 1: is Flor's insurance provider, in this case, she needs to
Speaker 1: call Calviva Health, its Central Valley subsidiary. That Flores has
Speaker 1: insurance at all gives her advantages over many of her neighbors.
Speaker 1: At the same time that budget cuts have annihilated community
Speaker 1: health worker programs, changes to other programs have made it
Speaker 1: more difficult for many poor people in Fresno to get insured.
Speaker 1: The Trump administration's one Big Beautiful Bill Act rolled back
Speaker 1: rules that streamlined medicate enrollment and renewal processes, and implemented
Speaker 1: work requirements that will start in twenty twenty seven. California, meanwhile,
Speaker 1: pauw non citizens eligibility for full coverage medical starting on
Speaker 1: the first of this year. Flores is grandfathered in, but
Speaker 1: three million fewer Californians are expected to be enrolled in
Speaker 1: medical by twenty twenty eight. Right now, the dominant narratives
Speaker 1: are about how there are people in our country who
Speaker 1: don't belong here. Says Genoviva e Isless, Cultiva's founder and
Speaker 1: executive director. We're in a very different situation than I've
Speaker 1: ever seen before in terms of the antagonism, even when
Speaker 1: it actually costs money. Calviva, which serves a region where
Speaker 1: more than half the population is Latino, makes it easy
Speaker 1: to talk to someone in Spanish, But our continua on
Speaker 1: espanol oprima eldos is the second sentence the recorded voice offers.
Speaker 1: Within thirty seconds, Alejo is connected to a woman who
Speaker 1: introduces herself as Elizabeth. Alejo speaks first, saying she's with
Speaker 1: a client who has questions about her coverage.
Speaker 2: This throws Elizabeth off.
Speaker 1: Excuse me, who are you a community health worker helping Flores?
Speaker 1: Alejo says, okay, can I speak with her? Please take
Speaker 1: me off speakerphone. Alijo follows the directions, instructing Flores to
Speaker 1: speak into the phone's mouthpiece. This plan lasts a matter
Speaker 1: of seconds. Elizabeth needs Flores's membership number, and Flores doesn't
Speaker 1: know where to find it. Alejo switches back to speakerphone
Speaker 1: and stays silent, copying the numbers Elizabeth is asking for
Speaker 1: from Flora's enrollment paperwork in big block letters so Flores
Speaker 1: can read them aloud. It's an inefficient system, but it works.
Speaker 1: Elizabeth soon confirms that Flores still has a mammogram scheduled
Speaker 1: during the last week of April and a primary care
Speaker 1: appointment in mid May, both of which medical will cover any.
Speaker 2: Distrust Flores felt for Aleho earlier.
Speaker 1: This morning is long gone. Her list of illnesses and
Speaker 1: fears pours out of her like water from a toppled glass.
Speaker 1: Alejo tells her client she's very grateful she's sharing her worries,
Speaker 1: but Flores cuts her off. I'm not even telling you
Speaker 1: everything because people say this old woman is crazy.
Speaker 2: I'm not crazy.
Speaker 1: Sometimes Flores has to stop talking long enough to catch
Speaker 1: her breath, but then she's right back to it. She
Speaker 1: explains her daily medication schedule. One pill at eight thirty
Speaker 1: a m. And again at eight thirty p m, a
Speaker 1: different one at ten thirty a m. Two more at noon,
Speaker 1: and one at two p m. She's religious about taking
Speaker 1: them on time, in part because she's religious in the
Speaker 1: traditional sense. There are so many things only God knows.
Speaker 1: But God is here that guides me and gives me
Speaker 1: the strength to accept my illnesses, she says, then turns
Speaker 1: her eyes to the heavens. You have the power and
Speaker 1: the strength to cure me, amen, Aleo adds, or to
Speaker 1: keep you healthy for the moment. The reality is that
Speaker 1: a cure is not the goal for a seventy six
Speaker 1: year old with multiple overlapping chronic conditions. Flores is most
Speaker 1: concerned about her diabetes. Her blood sugar has been skyrocketing recently,
Speaker 1: which keeps her in bed much of the time. Sometimes
Speaker 1: her heart raises so fast she feels as if it's
Speaker 1: going to escape her chest. She worries her medicines arm
Speaker 1: working anymore. Type two diabetes is the single most common
Speaker 1: condition among Aleiho's patients. Latinos are eighty percent more likely
Speaker 1: than white Americans to have diabetes, which research is a
Speaker 1: tribute to a mix of genetic factors such as higher
Speaker 1: insulin resistance and sociocultural ones like lower average income. These
Speaker 1: demographic factors have made diabetes an area of particular interest
Speaker 1: for community health worker programs and the researchers who study
Speaker 1: their effectiveness. Multiple peer reviewed studies have shown that community
Speaker 1: health workers can successfully treat diabetes by coaching patients to
Speaker 1: monitor their blood sugar, take their medications, get more physical activity,
Speaker 1: and eat more healthily. A twenty twenty five literature review
Speaker 1: found that patients under the care of a community health
Speaker 1: worker for at least twelve months saw a clinically significant
Speaker 1: zero point five point reduction in their blood sugar. Alijo
Speaker 1: has no interest in broaching the subject of lifestyle changes
Speaker 1: at this meeting. Flores seems to be hanging on by
Speaker 1: a thread. Prescribing more exercise feels beside the point. Community
Speaker 1: health work is so often a matter of triage, and
Speaker 1: Aleijo is an expert at judging in the moment what
Speaker 1: actually demands her attention. What this moment requires, she sees,
Speaker 1: is ensuring Flores is under regular medical care. Flora has
Speaker 1: recently switched to a new primary care doctor, whom she
Speaker 1: likes much better than the last. She didn't feel he
Speaker 1: took her concerns very seriously. Hearing about the new doctor
Speaker 1: makes Alejo beam. She can still picture the moment almost
Speaker 1: twenty years ago when a nurse whispered to her that
Speaker 1: she had the right to ask for a different provider
Speaker 1: for her dad, who was being disrespected. Aleijo asks every
Speaker 1: client whether their doctor treats them well. If the answer
Speaker 1: is no, she'll call to coordinate a switch herself. The
Speaker 1: optometrist is another story. Diabetes is starting to claim Flores's eyesight.
Speaker 1: When Aleijo asks for her signature on a form allowing
Speaker 1: a Cultiva employee to make calls on her behalf, Flores
Speaker 1: struggles to find the line for her name. She had
Speaker 1: cataract surgery recently, which insurance cover, and she pulls a
Speaker 1: prescription for glasses from the stack of papers she's gotten
Speaker 1: her Cheetah print bag. The doctor told her that medical
Speaker 1: wouldn't cover the glasses, and the cheapest ones she saw
Speaker 1: for sale at his office were twelve hundred dollars, which
Speaker 1: she doesn't have. She's planning to go to Walmart tomorrow
Speaker 1: to check the prices. She thinks glasses cost more like
Speaker 1: seven hundred dollars there, which is still too much, but
Speaker 1: the store offers payment plans. Alejo looks stricken by the
Speaker 1: idea of Flores taking out a high interest loan just
Speaker 1: to afford the glasses. She needs you qualify for free
Speaker 1: glasses through medical she says, firmly. I will make a call.
Speaker 1: She jots down a note to follow up on the glasses,
Speaker 1: then turns to figuring out how to get Flora's regular
Speaker 1: access to food. This, too, will benefit taxpayers as well
Speaker 1: as her client. Food in security and additional spending on
Speaker 1: healthcare are deeply intertwined problems. One paper showed that in
Speaker 1: California alone, not having enough to eat resulted in seven
Speaker 1: point two billion dollars in additional healthcare costs in twenty sixteen.
Speaker 1: Delivering groceries to low income people is a logical first step,
Speaker 1: but food alone can only go so far. According to
Speaker 1: a small pilot study published earlier this year, what really
Speaker 1: made a difference in outcomes and thus in costs to
Speaker 1: the government was giving people both food and access to
Speaker 1: a community health worker. The combination resulted in a reduction
Speaker 1: in blood sugar from eight point four percent to six
Speaker 1: point six percent among diabetic patients after six months, which
Speaker 1: can mean the difference between needing insulin or not. California
Speaker 1: residents with temporary protected status don't qualify for cal Fresh,
Speaker 1: the state food assistance program. The box's Cultiva packs for
Speaker 1: low income seniors are delivered only once a month. Alejo
Speaker 1: knows every soup kitchen in the area and which ones
Speaker 1: are closest to Flores's home, but close is a relative
Speaker 1: term in sprawling Fresno. Even if this frail woman was
Speaker 1: able to walk to a site once a week, how
Speaker 1: would she carry the groceries home. There's a delivery service
Speaker 1: called Project Food Box, but they just serve people with
Speaker 1: private insurance, not medical. Alejo has an idea for how
Speaker 1: to fix this problem too. She'll scour Facebook market place
Speaker 1: to see if anyone is giving away some sort of
Speaker 1: dolly or cart that she can bring to Flores. If
Speaker 1: that doesn't work, she'll come up with something else. But
Speaker 1: all of that will have to wait until later. After
Speaker 1: she's typed up her notes called Medical about the glasses
Speaker 1: checked on her staff and seen her other clients before
Speaker 1: she gets to any of that.
Speaker 2: Though Alejo needs to talk to Flores.
Speaker 1: About getting into therapy, she has plenty of experience with
Speaker 1: this delicate conversation. Depression and anxiety are common among her
Speaker 1: older clients, all of whom carry the weight of some
Speaker 1: combination of poverty, hunger, loneliness, immigration, fears, physical disability, and
Speaker 1: chronic health conditions. But that's not to say it always
Speaker 1: goes well. Latino immigrants are less likely than white Americans
Speaker 1: to attend therapy or see a psychiatrist, even when their
Speaker 1: insurance covers it, which Flora's Calviva plan does. Sometimes people
Speaker 1: insist they're doing just fine, even when Alejo can tell
Speaker 1: they're not. Sometimes they tell her they'll call to schedule
Speaker 1: an appointment when they get home, even when she knows
Speaker 1: they won't. Alejo cares about this woman. She wants her
Speaker 1: to see a counselor for the same reason she wants
Speaker 1: her to get her mammogram. She believes people shouldn't die
Speaker 1: from treatable diseases, even if they're poor, even if they're
Speaker 1: not citizens, but even measured in the most mercenary terms.
Speaker 1: Using medical funds to get Flora's mental health care is
Speaker 1: a good investment. People with mental health issues get sicker
Speaker 1: from heart disease and other chronic conditions, which means they
Speaker 1: stop working or need costlier treatment. Mackenzie researchers have found
Speaker 1: that each dollar spent on medical health interventions yields an
Speaker 1: economic return of at least five dollars. After an hour
Speaker 1: in this room, Alijo is ready to push the issue.
Speaker 1: Flores is crying again. Her heart hurts, she says several times.
Speaker 1: I'm so sorry that you've gone through this, Ai says,
Speaker 1: And of course you can talk to a counselor to
Speaker 1: a therapist.
Speaker 2: You have the right.
Speaker 1: We can make an appointment if you like. Flores seems
Speaker 1: surprised by this news. She did ask about seeing a
Speaker 1: therapist once, she says, but her former doctor told her
Speaker 1: she didn't require treatment. I need it more than you do,
Speaker 1: she remembers him, saying. Alejo suggests they call to get
Speaker 1: a referral. Even if she had known she qualified for
Speaker 1: free therapy, Flores wouldn't have been able to handle this
Speaker 1: call alone. A Calviva customer service advocate named Veronica answers
Speaker 1: the phone right away, but she just speaks English with
Speaker 1: a thick Southern drawl. Alejo asks to be connected to
Speaker 1: a Spanish speaker, but there are no customer service advocates
Speaker 1: who speak Spanish. There are interpreters, but Veronica needs to
Speaker 1: talk to Flores first. Good afternoon. My name is Veronica
Speaker 1: and I'm a customer service advocate. Are you needing a
Speaker 1: Spanish interpreter.
Speaker 2: She asks.
Speaker 1: Alejo translates, and Veronica accepts Flores's sea as confirmation. The interpreter,
Speaker 1: who introduces himself as Alejandro, manages to grease the skids
Speaker 1: only slightly. He repeats Flores's full name, but Veronica struggles
Speaker 1: with the spelling, asking him to repeat each letter multiple times.
Speaker 1: This goes on for two excruciating minutes. Veronica has difficulty
Speaker 1: finding Flores's account using either her name or member number.
Speaker 1: Then she needs an email address, which Flores doesn't know
Speaker 1: because it's existed for less than an hour. Alejo, attempting
Speaker 1: to stay silent because Veronica seems thrown by her presence,
Speaker 1: writes it down, pointing to each letter as Flores reads
Speaker 1: them aloud. Finally, Veronica is ready to begin the questionnaire
Speaker 1: that will allow her to refer Flores to a therapist.
Speaker 1: When she asks about the reason for the call, Flores
Speaker 1: answers without hesitation. Sometimes I feel confused and I get
Speaker 1: panicked from sadness and crying.
Speaker 2: I don't know the reason, she says.
Speaker 1: Sometimes I prefer to isolate myself because I don't feel
Speaker 1: comfortable around other people. Can't come to church anymore because
Speaker 1: I can barely walk and I'm in pretty bad health.
Speaker 1: Asked if she's suicidal, Flores is emphatic. No, I don't
Speaker 1: want to take my own life, she says, but sometimes
Speaker 1: I feel afraid of falling asleep and not waking up.
Speaker 1: Forty minutes after the call began, Alejo and Flores get
Speaker 1: what they came for, the names of three local mental
Speaker 1: health providers who accept Calviva insurance, speak Spanish and are
Speaker 1: at least theoretically accepting new patients. That's not to say
Speaker 1: they're convenient for Flores, though the closest one is a
Speaker 1: few blocks from the Cultiva office, about one and a
Speaker 1: half miles from Flores's home. Alejo immediately starts wondering how
Speaker 1: Flores will make the journey and whether there's some way
Speaker 1: she can take her After they hang up with Veronica
Speaker 1: and Alejandro, Flores's voice is noticeably lighter. Alejo asks whether
Speaker 1: she wants help calling the therapists or an escort to
Speaker 1: her daughter's appointments, but Flores says confidently that she can
Speaker 1: handle it. Looking intently at Alejo, she offers a brief prayer.
Speaker 1: I place into your hands all the people you bring
Speaker 1: into my life. May no harm befall them. May you
Speaker 1: continue to watch over and protect them.
Speaker 2: And I ask God.
Speaker 1: I ask my Father from the bottom of my heart,
Speaker 1: in the name of Christ Jesus, and through the glory
Speaker 1: of His Holy Spirit, to.
Speaker 2: Grant them all the desires of their hearts.
Speaker 1: On the other side of the office easeless, a Laijo's
Speaker 1: boss is fretting about how to keep a Lajo's team employed.
Speaker 1: Across the country, nonprofits and philanthropic leaders are trying to
Speaker 1: find ways to fill the gaps created by federal funding cuts.
Speaker 1: Some local governments have set up emergency funds to keep
Speaker 1: community health programs up and running, and community foundations have
Speaker 1: created new lines of funding. But all of these measures
Speaker 1: put together, still aren't enough to replace the financial might
Speaker 1: of the federal government. Even the most generous grants expire
Speaker 1: in an environment where resources are shrinking, Decisions have to
Speaker 1: be made in health care systems about where to cut,
Speaker 1: and chances are they are not going to want to
Speaker 1: cut doctors or nurses or social workers, says Callahan, the
Speaker 1: health policy scholar. Community health workers are the ones to go.
Speaker 1: As you lose those community health workers, you're losing those
Speaker 1: connections they provide, and the result is less access to care.
Speaker 1: Alijo is trying not to think about any of this.
Speaker 1: She has about an hour to write up her notes
Speaker 1: from the meeting and check in with her team about
Speaker 1: how things are going with their clients. One is on
Speaker 1: her way to an intake appointment at the home of
Speaker 1: another older woman who doesn't have enough food. After she
Speaker 1: eats lunch, Aleijo will set off to meet an undocumented
Speaker 1: couple she's known for months. They need help applying for
Speaker 1: emergency rent assistance so they don't get evicted. She knows
Speaker 1: she's made a measurable difference in Flores's life over these
Speaker 1: two plus hours. She's built a relationship that will allow
Speaker 1: her to work with the woman for years, bringing her food,
Speaker 1: untying the medical knots, connecting her with other services, watching
Speaker 1: the progress she makes in therapy, helping her live a longer.
Speaker 2: And better life.
Speaker 1: She'll get to do all that, that is, the money
Speaker 1: doesn't run out. The two women embrace for several seconds
Speaker 1: before Flores sets.
Speaker 2: Out for the long walk home. Alejo promises to call
Speaker 2: soon to check in.