WEBVTT - The Broken Backbone of America’s Healthcare System 0:00:00.720 --> 0:00:05.280 The broken backbone of America's health care system. Community health 0:00:05.320 --> 0:00:08.680 workers fill the gaps in places without enough doctors and nurses. 0:00:09.160 --> 0:00:12.800 Trump's budget cuts are costing them their jobs, putting untold 0:00:12.840 --> 0:00:17.720 clients at risk. By Megan Greenwell read aloud by Mark Gledorf. 0:00:18.920 --> 0:00:22.120 The crops begin even before the Fresno city limits end 0:00:22.800 --> 0:00:34.400 rows of neatly pruned trees and bushes and vines, incubating almonds, pistachios, cotton, tomatoes, plums, peaches, nectarines, oranges, lemons, grapefruits, mandarins, 0:00:34.720 --> 0:00:38.480 and grapes for eating, for drinking, for drying into raisins. 0:00:39.200 --> 0:00:42.519 This bounty is trucked hundreds or thousands of miles across 0:00:42.560 --> 0:00:46.320 California and the country away from Fresno. The irony of 0:00:46.360 --> 0:00:49.320 life in the San Joaquin Valley is that locals rarely 0:00:49.360 --> 0:00:53.440 benefit from their regions abundance. Almost one in five residents 0:00:53.479 --> 0:00:56.920 don't reliably have enough to eat. Among them is seventy 0:00:56.960 --> 0:00:59.880 six year old Signora Flores, who, on this march more 0:01:00.240 --> 0:01:04.200 is dressed in an elaborately applicated turquoise cardigan and matching 0:01:04.240 --> 0:01:07.399 tank top, her long gray hair secured with a satin 0:01:07.480 --> 0:01:10.399 scrunchy at the top of her head. She limps into 0:01:10.400 --> 0:01:13.399 the waiting room for a nine a m. Appointment, already 0:01:13.400 --> 0:01:18.480 weeping from some combination of exhaustion, hunger, thirst, pain, and heartache. 0:01:18.920 --> 0:01:21.920 It's not quite clear when she last ate, but it 0:01:22.000 --> 0:01:25.679 wasn't today. She drops heavily onto a small couch in 0:01:25.680 --> 0:01:28.640 the waiting room and tries to catch her breath. The 0:01:28.680 --> 0:01:31.480 woman she's meeting, a community health worker at a small 0:01:31.520 --> 0:01:35.360 nonprofit called cultivala Salute, had offered to come to her home, 0:01:35.640 --> 0:01:38.560 Knowing that Flores doesn't have a car and Fresno's bus 0:01:38.600 --> 0:01:40.119 system is body at best. 0:01:40.720 --> 0:01:41.959 Staffers refer to their. 0:01:41.880 --> 0:01:46.080 Clients using courtesy titles. Flores's name has been changed to 0:01:46.120 --> 0:01:50.000 protect her medical privacy. Yet Flores preferred to walk one 0:01:50.040 --> 0:01:53.760 point six miles south on Fresno Avenue, lugging a large 0:01:53.880 --> 0:01:57.280 Cheetah print tote bag stuffed with documents that have bedeviled 0:01:57.320 --> 0:02:00.160 her for weeks. The trip took her an hour. In 0:02:00.240 --> 0:02:03.560 forty five minutes, when the receptionist hands her a pint 0:02:03.640 --> 0:02:05.920 sized bottle of water, she holds it to the sky, 0:02:06.400 --> 0:02:11.560 whispers Gracias padre, and SIPs. A woman in false eyelashes, 0:02:11.600 --> 0:02:14.440 and Doc Martin's arrives to escort Flores to a center 0:02:14.440 --> 0:02:17.119 block meeting room, then runs to grab a second water, 0:02:17.440 --> 0:02:19.799 an apple, and a two pack of granola bars out 0:02:19.840 --> 0:02:22.799 of a staff kitchen. As Flores pulls her papers out 0:02:22.840 --> 0:02:25.480 of the tote. The pair settle in for what will 0:02:25.520 --> 0:02:28.880 become a two hour session, covering almost every aspect of 0:02:28.919 --> 0:02:32.400 a troubled life. The very fact that this meeting is 0:02:32.480 --> 0:02:37.440 necessary incriminates the US healthcare system, whose labyrinth of unaffordable 0:02:37.480 --> 0:02:41.160 bills and unavailable appointments can seem designed to prevent people 0:02:41.200 --> 0:02:45.200 from getting the treatment they need. Livia Alejo thirty seven, 0:02:45.560 --> 0:02:49.400 the woman now whispering dios Mio as Flores explains her. 0:02:49.320 --> 0:02:50.600 Situation through tears. 0:02:51.120 --> 0:02:54.480 Isn't a doctor, a nurse, a therapist, a government employee, 0:02:54.680 --> 0:02:58.560 or an insurance representative. As a community health worker, She's 0:02:58.600 --> 0:03:01.200 simply trying to make up for this systemic failures of 0:03:01.240 --> 0:03:05.880 all five. Alejo, who moved from Mexicali, Mexico, to Fresno 0:03:05.960 --> 0:03:09.200 in middle school, sometimes struggles to describe what she does 0:03:09.240 --> 0:03:11.760 in this office and in living rooms around the city 0:03:11.800 --> 0:03:15.560 and the surrounding farmland. Even the official definition of community 0:03:15.600 --> 0:03:19.240 health worker from the American Public Health Association equivocates to 0:03:19.280 --> 0:03:22.880 the point of meaninglessness. A trusted member of and or 0:03:23.000 --> 0:03:26.959 has an unusually close understanding of the community served, who 0:03:27.040 --> 0:03:31.560 serves as a liaison, link intermediarrea between health, social services 0:03:31.760 --> 0:03:35.120 and the community to facilitate access to services and improve 0:03:35.200 --> 0:03:39.200 the quality and cultural competence of service delivery. The job 0:03:39.280 --> 0:03:43.760 is just so many things at once. Translator, advocate, case manager, 0:03:43.920 --> 0:03:49.200 paperwork wrangler, digital guide, health coach. Detective Alejo works with 0:03:49.360 --> 0:03:53.520 seventeen patients at a time. As the supervisor of Cultiva's team, 0:03:53.720 --> 0:03:57.160 she's indirectly in charge of more than one hundred. After 0:03:57.200 --> 0:03:59.760 five years, She's fluent in every element of the social 0:03:59.760 --> 0:04:03.240 stils net for Fresno residents. She knows who to call 0:04:03.280 --> 0:04:06.000 when the state's public insurance system hasn't sent someone their 0:04:06.040 --> 0:04:09.840 ID card, where to find doctors accepting new patients, which 0:04:09.880 --> 0:04:13.240 nonprofits still have money for rental assistance this month, where 0:04:13.280 --> 0:04:16.320 to get food after benefits run out, and which programs 0:04:16.360 --> 0:04:20.640 will rule out undocumented immigrants. Solving one problem often means 0:04:20.720 --> 0:04:23.800 uncovering several more basic ones, as if she's trying to 0:04:23.800 --> 0:04:27.000 sow address but first has to spin raw fiber into thread. 0:04:27.839 --> 0:04:31.320 We're the source of the resources, Alejo says. We have 0:04:31.400 --> 0:04:34.800 to find what is missing. The payoff from programs such 0:04:34.839 --> 0:04:37.760 as Cultive La Salute can be something close to magic. 0:04:38.279 --> 0:04:41.120 Peer reviewed research has found that community health workers can 0:04:41.200 --> 0:04:44.640 lower blood sugar in diabetic patients, lower blood pressure in 0:04:44.720 --> 0:04:49.280 hypertensive ones, and lower cholesterol in hyper lipidemic ones. Patients 0:04:49.279 --> 0:04:52.480 who get support from community health workers smoke fewer cigarettes, 0:04:52.640 --> 0:04:57.520 get more exercise, and rate their mental health more positively better. Yet, 0:04:57.760 --> 0:05:00.520 these advocates know how to deliver care in a cost 0:05:00.520 --> 0:05:03.680 effective way, not just for clients, but also for health 0:05:03.720 --> 0:05:07.600 insurers and governments. By keeping people fed, housed, and out 0:05:07.640 --> 0:05:11.279 of the hospital, community health workers, earning an average salary 0:05:11.279 --> 0:05:14.400 of fifty one thousand dollars a year, are arguably the 0:05:14.400 --> 0:05:18.159 most cost effective part of America's health care system. One 0:05:18.200 --> 0:05:21.400 study found that every dollar invested in community health worker 0:05:21.440 --> 0:05:24.360 programs results in a two dollars and forty seven cent 0:05:24.440 --> 0:05:28.400 return for Medicaid. As a result, they've long been popular 0:05:28.440 --> 0:05:33.279 with Republicans as well as Democrats. GOP senators including Tom Tillis, 0:05:33.360 --> 0:05:36.880 Lisa Murkowski, and Bill Cassidy have sponsored bills designed to 0:05:37.000 --> 0:05:40.400 increase the number of community health workers serving rural areas. 0:05:41.120 --> 0:05:44.640 But though Cultiva and its peers save both lives and money, 0:05:45.000 --> 0:05:47.520 though they are both effective and well liked, they are 0:05:47.560 --> 0:05:51.240 now also under unprecedented threat. They were among the hardest 0:05:51.320 --> 0:05:55.279 hit programs when the Trump administration canceled twelve billion dollars 0:05:55.279 --> 0:05:57.560 in federal public health grants in the spring of twenty 0:05:57.600 --> 0:06:01.200 twenty five, and subsequent budget cuts the National Institutes of 0:06:01.240 --> 0:06:04.440 Health and the Centers for Disease Control and Prevention delivered 0:06:04.440 --> 0:06:07.840 more blows. Cultiva was forced to lay off half its 0:06:07.920 --> 0:06:11.080 staff of twelve community health workers, and the total number 0:06:11.120 --> 0:06:14.799 serving the Fresno area dropped from sixty to about twenty five, 0:06:15.160 --> 0:06:18.880 says Joe Prato, the county's public health director. As of 0:06:18.920 --> 0:06:22.280 twenty twenty three, fifty eight thousand, five hundred Americans were 0:06:22.279 --> 0:06:27.120 employed as community health workers, sometimes called promo torres, according 0:06:27.120 --> 0:06:30.279 to data from the US Bureau of Labor Statistics. Because 0:06:30.279 --> 0:06:33.039 of the fragmented nature of the workforce, it's not yet 0:06:33.080 --> 0:06:35.440 clear how many of those jobs were lost once the 0:06:35.440 --> 0:06:38.960 funding cuts began in twenty twenty five, but one paper 0:06:39.000 --> 0:06:42.240 found that state and local public health organizations would lose 0:06:42.279 --> 0:06:44.799 about forty five percent of their grant money in twenty 0:06:44.880 --> 0:06:48.919 twenty six. Alejo practically sparkles when she talks about helping 0:06:48.960 --> 0:06:53.200 clients like Flores. She's always felt pulled towards supporting older people. 0:06:53.800 --> 0:06:56.719 Turning that passion into a career, even a stressful and 0:06:56.800 --> 0:06:59.800 underpaid one, felt like a dream, But she says she 0:06:59.839 --> 0:07:02.280 worries about how long she'll get to do it. The 0:07:02.279 --> 0:07:06.040 grant that's funding cultova's remaining community health workers expires at 0:07:06.040 --> 0:07:08.839 the end of this year. Getting Flores to this meeting 0:07:08.920 --> 0:07:12.600 required a series of intentional steps. A neighbor had handed 0:07:12.600 --> 0:07:15.920 her a flyer picked up from a community fair advertising 0:07:15.920 --> 0:07:19.760 Cultova's free monthly grocery box for low income seniors in Fresno. 0:07:20.320 --> 0:07:23.240 Flores called to sign up, so Olejo dropped off the 0:07:23.280 --> 0:07:27.080 food standing on her doorstep. Flores mentioned she was afraid 0:07:27.120 --> 0:07:30.280 she was about to be kicked off Medical, California's healthcare 0:07:30.280 --> 0:07:33.440 system for low income residents. That was the moment Alejo 0:07:33.520 --> 0:07:35.840 had hoped for. It was the reason she'd made the 0:07:35.840 --> 0:07:39.640 delivery herself. She suggested they meet to figure it out together. 0:07:40.560 --> 0:07:42.880 As soon as they sit down, Alejo can tell that 0:07:42.960 --> 0:07:47.360 potential ejection from Medical isn't Flores's most urgent issue. She 0:07:47.480 --> 0:07:51.120 needs mental health treatment, and soon she can stop crying, 0:07:51.200 --> 0:07:54.400 only for a couple of minutes at a time. Her daughter, 0:07:54.480 --> 0:07:57.560 who lives thousands of miles away, is seriously ill with 0:07:57.640 --> 0:08:01.840 kidney disease. Her husband died last year, leaving her bereft 0:08:01.880 --> 0:08:05.280 and with a new level of financial instability. Flores, who 0:08:05.320 --> 0:08:08.080 grew up in El Salvador, is a legal US resident 0:08:08.120 --> 0:08:12.040 with temporary protected status, which shields her from deportation because 0:08:12.040 --> 0:08:15.840 of instability in her home country, but that designation expires 0:08:15.880 --> 0:08:18.840 in September, and the Trump administration is working to end 0:08:18.960 --> 0:08:21.600 TPS for citizens of several other countries. 0:08:22.440 --> 0:08:23.400 My heart and my. 0:08:23.480 --> 0:08:28.000 Soul are tired, very tired, she says in Spanish, before 0:08:28.080 --> 0:08:32.560 unspooling an extended, enigmatic analogy about how God causes roses 0:08:32.640 --> 0:08:37.440 to bloom. Alejo listens carefully, occasionally offering a tissue or 0:08:37.520 --> 0:08:41.520 murmuring consolations. She doesn't interrupt or try to fast forward 0:08:41.520 --> 0:08:44.520 to practical steps. Even when Flores is trained of thought 0:08:44.559 --> 0:08:48.200 becomes difficult to follow. For now, she's focused on earning 0:08:48.280 --> 0:08:52.960 trust as a person with an official, unfamiliar title. Alejo 0:08:53.080 --> 0:08:56.120 also knows she is starting at a disadvantage. Tens of 0:08:56.160 --> 0:08:59.400 thousands of people in the Fresno region don't have legal status. 0:09:00.040 --> 0:09:03.320 Utal US emigration and Customs enforcement sweeps in other cities 0:09:03.360 --> 0:09:07.480 during the second Trump administration have shrouded California's Central Valley 0:09:07.520 --> 0:09:10.920 in fear. People here don't open the door to strangers, 0:09:11.160 --> 0:09:16.280 literally or emotionally, like many emigrant children. Alijo served as 0:09:16.280 --> 0:09:19.440 her parents translator for years. When she was in college 0:09:19.440 --> 0:09:22.560 at Fresno State, she escorted her father to the hospital 0:09:22.600 --> 0:09:25.560 after an accident on the job. He'd asked a doctor 0:09:25.600 --> 0:09:29.599 about his periodic fainting spells, but the clinic never even tested. 0:09:29.200 --> 0:09:31.080 His blood sugar. Olijo says. 0:09:31.600 --> 0:09:34.560 By the time they diagnosed him with diabetes, the disease 0:09:34.600 --> 0:09:37.280 had advanced so far that he died within a month. 0:09:37.920 --> 0:09:40.920 The hospital never offered a Spanish speaking doctor or translator, 0:09:41.280 --> 0:09:44.000 or anyone to tell Alejo's mom in her native language 0:09:44.080 --> 0:09:45.360 that her husband had died. 0:09:46.000 --> 0:09:47.400 Alijo had to do it. 0:09:48.320 --> 0:09:50.680 My family needed someone to advocate for them and to 0:09:50.720 --> 0:09:53.480 be able to explain their needs to other people, she says, 0:09:53.960 --> 0:09:56.160 and I didn't know where to look. I didn't have 0:09:56.200 --> 0:09:58.160 a person who could guide me and help me find 0:09:58.200 --> 0:10:02.040 resources to help my dad. After that, becoming that guide 0:10:02.200 --> 0:10:05.680 was all she ever wanted to do. Alejo has blocked 0:10:05.679 --> 0:10:08.480 off two and a half hours for this appointment standard 0:10:08.520 --> 0:10:11.440 for a Cultiva intake meeting. She and the community health 0:10:11.440 --> 0:10:13.920 workers who report to her know most of their clients 0:10:13.960 --> 0:10:16.720 are used to being ushered through an overburdened public clinic 0:10:16.800 --> 0:10:19.960 in ten minutes, may be getting handed a scribbled prescription 0:10:20.080 --> 0:10:20.760 on their way out. 0:10:21.440 --> 0:10:22.760 They evaluate every new. 0:10:22.640 --> 0:10:27.160 Client along twenty one pathways, including food security, health, insurance, 0:10:27.280 --> 0:10:32.640 transportation needs, medical screenings, education, and employment. Any pathway they 0:10:32.679 --> 0:10:35.120 identify as an area of concern is added to the 0:10:35.160 --> 0:10:38.959 case file with specific follow up steps. Just getting through 0:10:38.960 --> 0:10:41.720 the screening questions can take more than an hour, even 0:10:41.760 --> 0:10:45.439 with a client who provides straightforward answers, which Flores doesn't. 0:10:46.120 --> 0:10:47.439 As Flores pulls. 0:10:47.160 --> 0:10:51.760 Documents from her bag re enrollment letters, bills, explanations of benefits, 0:10:51.880 --> 0:10:55.840 appointment reminders, prescriptions, Alejo notices that almost all of them 0:10:55.880 --> 0:10:59.040 are exclusively in English, like the ones her dad received 0:10:59.040 --> 0:11:02.720 about two decades ago. They're also studded with terms two 0:11:02.840 --> 0:11:06.120 technical for most people to grasp in any language, even 0:11:06.120 --> 0:11:09.520 after five years in the job. Alejo occasionally blinks in 0:11:09.600 --> 0:11:12.440 confusion at a line and turns to her laptop to 0:11:12.520 --> 0:11:15.760 google what these government and corporate bureaucracies are trying to say. 0:11:16.640 --> 0:11:19.680 Within a half hour, she pieces together what's happened. A 0:11:19.720 --> 0:11:22.840 phone representative had told Floraes she couldn't book any medical 0:11:22.840 --> 0:11:26.000 appointments for April or May because her medical was set 0:11:26.000 --> 0:11:29.200 to expire at the end of March. That was a technicality. 0:11:29.559 --> 0:11:32.280 She met all the qualifications to re enroll and just 0:11:32.320 --> 0:11:35.000 needed to fill out the correct form. But the person 0:11:35.040 --> 0:11:37.920 on the phone hadn't told Flores that, or hadn't told 0:11:37.920 --> 0:11:40.600 her in a way she understood. And she hadn't understood 0:11:40.640 --> 0:11:42.920 the letter that arrived at her home saying she needed 0:11:42.960 --> 0:11:46.280 to apply again. She panicked, Sure she was about to 0:11:46.320 --> 0:11:49.280 stop getting her medication, Sure the clinic wouldn't let her 0:11:49.320 --> 0:11:52.199 in the door for the appointments she scheduled months ago. 0:11:52.400 --> 0:11:55.800 Her shoulders shake as she explains all this, her sniffles 0:11:55.920 --> 0:11:59.520 turn into sobs. Step one, Alejo sees now is to 0:11:59.559 --> 0:12:02.360 fill out the the re enrollment paperwork. She'll return to 0:12:02.400 --> 0:12:07.079 the mental health question later. For reasons relating to language, literacy, 0:12:07.240 --> 0:12:11.040 red tape, and corporate dysfunction. Millions of poor Americans either 0:12:11.080 --> 0:12:14.760 aren't insured despite being eligible, or don't see a doctor regularly. 0:12:15.400 --> 0:12:18.200 When people don't receive preventive care, they're more likely to 0:12:18.240 --> 0:12:21.839 rely on the emergency room, which in turn costs local, state, 0:12:21.880 --> 0:12:22.880 and federal governments. 0:12:22.920 --> 0:12:23.160 More. 0:12:23.760 --> 0:12:26.840 Hospitals are required to treat patients regardless of their ability 0:12:26.840 --> 0:12:30.400 to pay, and hospital care is more expensive to provide. 0:12:30.720 --> 0:12:34.400 Prevention is cheaper than a cure, and Fresno's economy is 0:12:34.440 --> 0:12:37.600 dependent on immigrants, many of whom have a temporary visa 0:12:37.679 --> 0:12:41.040 like Flores or no legal status, so kicking them all 0:12:41.080 --> 0:12:43.520 out or refusing to treat them would cost money too. 0:12:44.440 --> 0:12:47.480 A sea of peer reviewed research supports what Alejo is 0:12:47.520 --> 0:12:51.280 doing as she sits with Flores. Trust blooms from understanding 0:12:51.559 --> 0:12:54.559 from not needing to explain the basic facts of one's life. 0:12:55.080 --> 0:12:58.840 Studies have shown that shared lived experience allows community health 0:12:58.840 --> 0:13:02.120 workers to boost screening rates for breast cancer, cervical cancer, 0:13:02.160 --> 0:13:05.920 and coorectal cancer, and to increase access to primary care 0:13:06.000 --> 0:13:10.680 and followup appointments after hypertension diagnoses. As a result, patients 0:13:10.679 --> 0:13:14.200 with multiple chronic conditions spent sixty nine percent less time 0:13:14.200 --> 0:13:17.000 in the hospital when they received support from a community 0:13:17.000 --> 0:13:21.160 health worker, according to research published in twenty eighteen, Once 0:13:21.240 --> 0:13:24.400 such workers have gained patients trust, they must then figure 0:13:24.440 --> 0:13:27.440 out what to do with it, says Shrea Cangovi, a 0:13:27.440 --> 0:13:30.480 physician in Philadelphia who's written many of the most cited 0:13:30.520 --> 0:13:34.120 papers on community health worker effectiveness. She now runs a 0:13:34.120 --> 0:13:37.920 company that builds infrastructure and training for community health worker programs. 0:13:38.320 --> 0:13:41.400 The worst programs her research has found focus on what 0:13:41.480 --> 0:13:45.120 she calls screen and refer work. You know, missus Jones, 0:13:45.160 --> 0:13:47.319 Do you have enough food to eat? Here's the number 0:13:47.360 --> 0:13:50.720 to the food pantry. People know where the food pantry is. 0:13:51.480 --> 0:13:55.760 Deeper problems are keeping them hungry. In India, where Kangovi 0:13:55.880 --> 0:13:59.000 grew up, we would never dream of having clinicians play 0:13:59.040 --> 0:14:02.560 both offense and defense. Community health workers, who've been a 0:14:02.559 --> 0:14:05.560 core part of the country's healthcare system for hundreds of years, 0:14:05.960 --> 0:14:09.960 take a proactive approach helping people address the social determinants 0:14:09.960 --> 0:14:13.920 of health, food, housing, and social support, all of which 0:14:14.000 --> 0:14:17.800 can make people either healthier or sicker. Doctors get involved 0:14:17.840 --> 0:14:20.840 when treatment is required, which happens less frequently when there's 0:14:20.840 --> 0:14:25.080 a team playing offense. The US has always underperformed on 0:14:25.160 --> 0:14:29.000 the offense side of healthcare. Even before the Trump budget cuts, 0:14:29.240 --> 0:14:32.040 few experts thought community health programs were being funded to 0:14:32.080 --> 0:14:36.520 their full potential. A sustainable, cost effective system wouldn't rely 0:14:36.640 --> 0:14:39.600 on the whims of the executive branch at all. Community 0:14:39.640 --> 0:14:42.080 health workers would be thought of like doctors and nurses, 0:14:42.400 --> 0:14:45.040 so integral a part of the healthcare economy that they'd 0:14:45.120 --> 0:14:48.520 never again need to apply for one year grants. There's 0:14:48.560 --> 0:14:51.240 always a timeline for grants, a beginning date and an 0:14:51.360 --> 0:14:54.880 end date, says Timothy Callahan, a health policy scholar at 0:14:54.880 --> 0:14:57.600 Boston University who studied community. 0:14:57.160 --> 0:14:58.239 Health worker programs. 0:14:58.800 --> 0:15:01.520 You might do everything right as a community health worker, 0:15:01.800 --> 0:15:04.480 but you lose your role anyway because the grant ends 0:15:04.480 --> 0:15:08.120 and there's no new grant. Cultiva la Salute is applying 0:15:08.160 --> 0:15:11.400 to become an authorized medical provider, which would allow it 0:15:11.440 --> 0:15:14.360 to bill its community health workers salaries directly to the state, 0:15:14.920 --> 0:15:17.640 but no one knows how long that process will take. 0:15:18.520 --> 0:15:22.120 Aleijo understands that she can't solve everything for Flores. At 0:15:22.120 --> 0:15:25.240 the root of her client's diverse problems is a unifying one. 0:15:25.560 --> 0:15:28.760 They're poor in a country where life often punishes people 0:15:28.840 --> 0:15:32.560 for being poor. Flores didn't work enough years to qualify 0:15:32.600 --> 0:15:36.680 for Social Security. She retired in twenty ten after complications 0:15:36.680 --> 0:15:39.400 from a long illness that almost cost her a kidney. 0:15:39.960 --> 0:15:42.840 She's still grieving her husband and suffering from the knowledge 0:15:42.880 --> 0:15:46.520 that her daughter is sick thousands of miles away. What 0:15:46.600 --> 0:15:49.240 Aleijo can do is blunt the effect of all these 0:15:49.240 --> 0:15:52.320 indignities and do the heavy lifting to make someone's life 0:15:52.360 --> 0:15:56.000 a little easier. Before last year's layoffs, her team was 0:15:56.080 --> 0:15:59.760 doing it for twice as many people. After this meeting, 0:16:00.080 --> 0:16:02.840 Alijo will leave the work at work, trying to be 0:16:02.920 --> 0:16:05.360 satisfied with doing her best for the day and move on. 0:16:06.120 --> 0:16:09.200 She's practiced this skill ever since her social work internships 0:16:09.200 --> 0:16:12.680 in college. Blasting music on her way to the job helps, 0:16:13.360 --> 0:16:17.000 but here pouring over documents in this small cinder block office, 0:16:17.160 --> 0:16:21.520 there's only Flores. Alejo's phone vibrates and flashes constantly. While 0:16:21.560 --> 0:16:22.160 on silent. 0:16:22.760 --> 0:16:24.440 She never even glances at it. 0:16:25.440 --> 0:16:28.640 We'll be right back with the broken backbone of America's 0:16:28.640 --> 0:16:35.760 healthcare system. Welcome back to the broken backbone of America's 0:16:35.760 --> 0:16:40.080 healthcare system. The simple task of filling out Flores's re 0:16:40.160 --> 0:16:44.000 enrollment paperwork introduces another challenge. She doesn't have an email 0:16:44.040 --> 0:16:46.280 address and doesn't know how to set one up, and 0:16:46.360 --> 0:16:49.680 without email, enrolling any any government benefit can take weeks. 0:16:50.280 --> 0:16:53.800 Alejo signs her up for Gmail, narrating the process allowed 0:16:53.800 --> 0:16:56.880 in Spanish to keep her client involved, then creates an 0:16:56.880 --> 0:17:01.200 account on benefitscal dot com, California, Nia's portal for safety 0:17:01.240 --> 0:17:04.280 net services. Within a few minutes, the two have filled 0:17:04.280 --> 0:17:07.920 out the necessary form to renew Flores's health insurance. Now 0:17:07.960 --> 0:17:11.920 they can investigate the status of her upcoming appointments. Flores 0:17:11.920 --> 0:17:15.199 has already booked an annual primary care exam and a mammogram, 0:17:15.600 --> 0:17:18.199 meaning she's more on top of things than many Americans, 0:17:18.640 --> 0:17:21.040 but she doesn't know if the appointments are still valid. 0:17:21.520 --> 0:17:25.520 Alejo suggests they call together to find out. Although Medical 0:17:25.640 --> 0:17:28.639 is Flor's insurance provider, in this case, she needs to 0:17:28.680 --> 0:17:33.200 call Calviva Health, its Central Valley subsidiary. That Flores has 0:17:33.240 --> 0:17:36.240 insurance at all gives her advantages over many of her neighbors. 0:17:36.720 --> 0:17:39.560 At the same time that budget cuts have annihilated community 0:17:39.560 --> 0:17:42.800 health worker programs, changes to other programs have made it 0:17:42.840 --> 0:17:46.040 more difficult for many poor people in Fresno to get insured. 0:17:46.640 --> 0:17:50.280 The Trump administration's one Big Beautiful Bill Act rolled back 0:17:50.359 --> 0:17:54.679 rules that streamlined medicate enrollment and renewal processes, and implemented 0:17:54.680 --> 0:17:59.400 work requirements that will start in twenty twenty seven. California, meanwhile, 0:17:59.680 --> 0:18:04.000 pauw non citizens eligibility for full coverage medical starting on 0:18:04.040 --> 0:18:07.320 the first of this year. Flores is grandfathered in, but 0:18:07.480 --> 0:18:10.760 three million fewer Californians are expected to be enrolled in 0:18:10.800 --> 0:18:14.720 medical by twenty twenty eight. Right now, the dominant narratives 0:18:14.760 --> 0:18:16.920 are about how there are people in our country who 0:18:16.960 --> 0:18:20.720 don't belong here. Says Genoviva e Isless, Cultiva's founder and 0:18:20.800 --> 0:18:24.400 executive director. We're in a very different situation than I've 0:18:24.400 --> 0:18:27.680 ever seen before in terms of the antagonism, even when 0:18:27.720 --> 0:18:32.080 it actually costs money. Calviva, which serves a region where 0:18:32.119 --> 0:18:35.119 more than half the population is Latino, makes it easy 0:18:35.119 --> 0:18:38.000 to talk to someone in Spanish, But our continua on 0:18:38.200 --> 0:18:42.440 espanol oprima eldos is the second sentence the recorded voice offers. 0:18:42.920 --> 0:18:45.800 Within thirty seconds, Alejo is connected to a woman who 0:18:45.800 --> 0:18:50.480 introduces herself as Elizabeth. Alejo speaks first, saying she's with 0:18:50.560 --> 0:18:52.720 a client who has questions about her coverage. 0:18:53.119 --> 0:18:54.520 This throws Elizabeth off. 0:18:55.680 --> 0:18:59.560 Excuse me, who are you a community health worker helping Flores? 0:18:59.600 --> 0:19:03.640 Alejo says, okay, can I speak with her? Please take 0:19:03.640 --> 0:19:07.840 me off speakerphone. Alijo follows the directions, instructing Flores to 0:19:07.840 --> 0:19:11.160 speak into the phone's mouthpiece. This plan lasts a matter 0:19:11.200 --> 0:19:15.359 of seconds. Elizabeth needs Flores's membership number, and Flores doesn't 0:19:15.359 --> 0:19:18.280 know where to find it. Alejo switches back to speakerphone 0:19:18.320 --> 0:19:21.479 and stays silent, copying the numbers Elizabeth is asking for 0:19:21.560 --> 0:19:25.160 from Flora's enrollment paperwork in big block letters so Flores 0:19:25.160 --> 0:19:28.840 can read them aloud. It's an inefficient system, but it works. 0:19:29.280 --> 0:19:32.520 Elizabeth soon confirms that Flores still has a mammogram scheduled 0:19:32.560 --> 0:19:34.960 during the last week of April and a primary care 0:19:35.000 --> 0:19:39.440 appointment in mid May, both of which medical will cover any. 0:19:39.280 --> 0:19:41.399 Distrust Flores felt for Aleho earlier. 0:19:41.440 --> 0:19:44.639 This morning is long gone. Her list of illnesses and 0:19:44.720 --> 0:19:47.960 fears pours out of her like water from a toppled glass. 0:19:48.480 --> 0:19:51.600 Alejo tells her client she's very grateful she's sharing her worries, 0:19:51.880 --> 0:19:54.639 but Flores cuts her off. I'm not even telling you 0:19:54.720 --> 0:19:57.960 everything because people say this old woman is crazy. 0:19:58.440 --> 0:19:59.600 I'm not crazy. 0:20:00.320 --> 0:20:03.000 Sometimes Flores has to stop talking long enough to catch 0:20:03.040 --> 0:20:05.679 her breath, but then she's right back to it. She 0:20:05.760 --> 0:20:09.120 explains her daily medication schedule. One pill at eight thirty 0:20:09.160 --> 0:20:11.359 a m. And again at eight thirty p m, a 0:20:11.359 --> 0:20:14.240 different one at ten thirty a m. Two more at noon, 0:20:14.359 --> 0:20:17.480 and one at two p m. She's religious about taking 0:20:17.480 --> 0:20:20.119 them on time, in part because she's religious in the 0:20:20.160 --> 0:20:23.800 traditional sense. There are so many things only God knows. 0:20:23.880 --> 0:20:26.720 But God is here that guides me and gives me 0:20:26.760 --> 0:20:30.280 the strength to accept my illnesses, she says, then turns 0:20:30.280 --> 0:20:33.119 her eyes to the heavens. You have the power and 0:20:33.160 --> 0:20:37.320 the strength to cure me, amen, Aleo adds, or to 0:20:37.400 --> 0:20:40.600 keep you healthy for the moment. The reality is that 0:20:40.680 --> 0:20:42.919 a cure is not the goal for a seventy six 0:20:43.040 --> 0:20:47.120 year old with multiple overlapping chronic conditions. Flores is most 0:20:47.160 --> 0:20:51.080 concerned about her diabetes. Her blood sugar has been skyrocketing recently, 0:20:51.359 --> 0:20:54.360 which keeps her in bed much of the time. Sometimes 0:20:54.359 --> 0:20:56.760 her heart raises so fast she feels as if it's 0:20:56.800 --> 0:20:59.919 going to escape her chest. She worries her medicines arm 0:21:00.080 --> 0:21:04.000 working anymore. Type two diabetes is the single most common 0:21:04.040 --> 0:21:08.040 condition among Aleiho's patients. Latinos are eighty percent more likely 0:21:08.080 --> 0:21:10.960 than white Americans to have diabetes, which research is a 0:21:11.080 --> 0:21:13.520 tribute to a mix of genetic factors such as higher 0:21:13.520 --> 0:21:18.800 insulin resistance and sociocultural ones like lower average income. These 0:21:18.840 --> 0:21:22.600 demographic factors have made diabetes an area of particular interest 0:21:22.720 --> 0:21:25.800 for community health worker programs and the researchers who study 0:21:25.840 --> 0:21:29.920 their effectiveness. Multiple peer reviewed studies have shown that community 0:21:29.920 --> 0:21:34.040 health workers can successfully treat diabetes by coaching patients to 0:21:34.119 --> 0:21:38.080 monitor their blood sugar, take their medications, get more physical activity, 0:21:38.320 --> 0:21:41.760 and eat more healthily. A twenty twenty five literature review 0:21:41.800 --> 0:21:44.160 found that patients under the care of a community health 0:21:44.200 --> 0:21:47.400 worker for at least twelve months saw a clinically significant 0:21:47.520 --> 0:21:51.320 zero point five point reduction in their blood sugar. Alijo 0:21:51.480 --> 0:21:54.359 has no interest in broaching the subject of lifestyle changes 0:21:54.400 --> 0:21:57.159 at this meeting. Flores seems to be hanging on by 0:21:57.200 --> 0:22:01.720 a thread. Prescribing more exercise feels beside the point. Community 0:22:01.760 --> 0:22:04.479 health work is so often a matter of triage, and 0:22:04.520 --> 0:22:06.960 Aleijo is an expert at judging in the moment what 0:22:07.080 --> 0:22:11.000 actually demands her attention. What this moment requires, she sees, 0:22:11.440 --> 0:22:15.119 is ensuring Flores is under regular medical care. Flora has 0:22:15.160 --> 0:22:18.119 recently switched to a new primary care doctor, whom she 0:22:18.240 --> 0:22:20.800 likes much better than the last. She didn't feel he 0:22:20.840 --> 0:22:24.399 took her concerns very seriously. Hearing about the new doctor 0:22:24.440 --> 0:22:27.639 makes Alejo beam. She can still picture the moment almost 0:22:27.640 --> 0:22:29.920 twenty years ago when a nurse whispered to her that 0:22:30.000 --> 0:22:32.040 she had the right to ask for a different provider 0:22:32.040 --> 0:22:35.879 for her dad, who was being disrespected. Aleijo asks every 0:22:35.920 --> 0:22:38.919 client whether their doctor treats them well. If the answer 0:22:39.000 --> 0:22:42.639 is no, she'll call to coordinate a switch herself. The 0:22:42.720 --> 0:22:47.800 optometrist is another story. Diabetes is starting to claim Flores's eyesight. 0:22:48.320 --> 0:22:51.120 When Aleijo asks for her signature on a form allowing 0:22:51.119 --> 0:22:54.440 a Cultiva employee to make calls on her behalf, Flores 0:22:54.480 --> 0:22:57.360 struggles to find the line for her name. She had 0:22:57.400 --> 0:23:01.080 cataract surgery recently, which insurance cover, and she pulls a 0:23:01.119 --> 0:23:03.760 prescription for glasses from the stack of papers she's gotten 0:23:03.800 --> 0:23:07.160