Abstract
COVID-19 has completely refashioned our healthcare landscape and day-to-day lives. During the pandemic, we have all transitioned to a new normal which includes remote work, navigating health insurance options after losing employment or becoming underemployed, and partaking in cautious outings outside of our homes equipped with face masks, gloves, and antibacterial gel or wipes. The pandemic has also shifted our perspectives on accessing healthcare and the utilization of healthcare delivery systems. The Health Consumer Center at Neighborhood Legal Services of Los Angeles is a free legal resource to all Los Angeles County residents who have questions about their health insurance. In the past, people reached out to the Health Consumer Center at Neighborhood Legal Services of Los Angeles County for issues related to Medi-Cal or Covered California eligibility, access to healthcare barriers such as authorization for services, and navigating their appeal rights with regards to health plan or governmental agency decisions that they disagreed with. Now, with the rise of COVID-19 in California, the pandemic has intensified the existing barriers to accessing healthcare for California’s most vulnerable populations including people with disabilities, people with limited English proficiency, people of color, and seniors. The context of calls to our hotline has also shifted to emergency questions related to healthcare coverage, medical coverage for COVID-19, eligibility for Medi-Cal because of a new layer of unemployment benefits, and assistance from the CARES Act. The rapidly changing landscape results in greater confusion about what is available, how does one qualify, and who can help consumers navigate these questions. This Article explores what occurs based on real stories from the consumers who have contacted HCC for assistance during the pandemic.
Introduction
The COVID-19 crisis has laid bare the huge disparities already present in this country’s healthcare system. In “normal times”—those not marked by a global pandemic—low-income Americans face enormous barriers to healthcare, which disproportionately impact people of color.[1] The COVID-19 crisis has further jeopardized the health and safety of many individuals by enhancing these barriers.
Throughout California, one-third of all Californians rely on Medi-Cal, California’s Medicaid program, to access healthcare.[2] The pandemic has created tension in the need to sustain Medi-Cal programs and services without interruption while still taking critical steps to protect the health of both the state employees who administer these benefits and the Californians who receive them. Beyond the scope of Medi-Cal, California’s marginalized populations are endangered by other risks created by COVID-19 as well. Latinx people make up over half of all COVID-19 patients, and communities of color generally bear a disproportionate number of COVID-19-related deaths.[3] Low-income individuals and those experiencing homelessness have decreased access to basic essential items, food, and sanitation supplies, and they are disproportionately impacted by the limited availability and accessibility of COVID-19 testing services.
This Article will explore these issues based on cases that come to the Health Consumer Center (HCC) of Neighborhood Legal Services of Los Angeles County (NLSLA).[4] Specifically, it will examine issues surrounding Medi-Cal eligibility, the process of transitioning between Covered California and Medi-Cal, and barriers to healthcare caused by the COVID-19 crisis. Given the glaring intersectionality between California’s low-income populations and its communities of color, and in light of ongoing national unrest as a result of widespread violence against Black people, it will also examine ways in which the pandemic has emphasized longstanding racial divides in the accessibility of adequate healthcare. Overall, this Article will show how the pandemic has seriously jeopardized the health and wellbeing of marginalized Californians, regardless of whether they had COVID-19.
I. Medi-Cal Eligibility and Coverage
Medicaid is a cooperative federal and state program designed to furnish healthcare to the poor.[5] California’s Medicaid program is known as “Medi-Cal.”[6] All Medi-Cal beneficiaries are entitled to receive certain mandatory services, including physician visits and treatment, prescription drugs, and more.[7] The federal Medicaid statute protects a beneficiary’s right to a fair hearing.[8] In addition, state law allows a beneficiary to appeal any action relating to their receipt of public social services.[9]
In 2019, approximately 13 million Californians were enrolled in Medi-Cal.[10] Fifty percent of Medi-Cal beneficiaries identified as Latinx.[11] Black people make up just over 6 percent of California’s overall population, but 8 percent of its Medi-Cal recipients.[12] During the COVID-19 crisis, the number of Californians qualifying for Medi-Cal increased dramatically because of loss of income or reduction in available employment. While we do not have an exact number of Californians newly eligible for Medi-Cal, we can look to unemployment as an indicator.[13] California’s unemployment rate was reported as 16.3 percent in June 2020, up from 4.1 percent in May 2019.[14] Thus, there are likely far more Californians now eligible for Medi-Cal. Alarmingly, however, statewide data also show a significant decrease in enrollment for Medi-Cal, despite the increase in the number of people who are potentially eligible.[15] An important component of our advocacy is to identify why the stories we hear within the HCC and the enrollment data do not match.
Since the pandemic began in early 2020, the rate of unemployment in the United States and in California has skyrocketed.[16] According to the state’s Employment Development Department, “The number of unemployed Californians rose to almost 2.9 million over just two months, surpassing the previous 2.2 million peak during the recession that took more than two years to reach.”[17] California Governor Gavin Newsom warned that the state’s unemployment rate could rise to levels not seen since the Great Depression.[18] As a result of unemployment, many Californians are finding themselves without employment benefits like health insurance. Furthermore, unemployment benefits do not come close to matching regular wages, and this makes it difficult for those who are newly unemployed to afford private insurance policies comparable to employer-sponsored insurance plans.[19]
Throughout the crisis, California’s Department of Health Care Services (DHCS), which funds and administers Medi-Cal services,[20] has issued various guidance for changes to Medi-Cal programs during the COVID-19 pandemic, increasing flexibility so that Californians could obtain or maintain healthcare coverage for the duration of the emergency period.[21] These changes include suspending negative actions that would terminate coverage, impose a deductible (“share of cost”), or otherwise limit people’s healthcare coverage; waiving premiums for those affected by COVID-19; and extending deadlines for beneficiaries to appeal negative actions.[22] Additionally, income received from stimulus checks is not counted toward income eligibility for Medi-Cal.[23]
The state of California also created a new program that provides individuals seeking COVID-19 treatments with presumptive eligibility for Medi-Cal.[24] It “provide[s] access to coverage for COVID-19 diagnostic testing, testing-related services, and treatment services . . . including all medically necessary care [related to COVID-19], such as the associated office, clinic, or emergency room visit . . . without regard to immigration status, income, or resources and will have date specific eligibility.”[25] Taken together, these efforts show that the state has attempted to make it easier for Californians to access Medi-Cal, and, in turn, to receive COVID-19 treatment.
Despite Medi-Cal’s increased flexibility during the emergency period, many of HCC’s clients are nevertheless experiencing problems with Medi-Cal coverage, jeopardizing their healthcare at a time when access to healthcare is particularly important. Clients have reported having their Medi-Cal coverage terminated during the emergency period, despite the guidelines prohibiting termination. In one instance, the mother of a young boy with a preexisting respiratory condition reported receiving notice that her son’s Medi-Cal benefits would terminate at the end of the month for failure to turn in his redetermination packet, which she had never received. In another case, a client contacted HCC after losing his Medi-Cal coverage, causing him to cancel medical appointments related to his diabetes, a condition linked to more serious complications resulting from COVID-19.[26]
Some Medi-Cal beneficiaries have also been assigned a share of cost for their coverage during the crisis, likewise contrary to DHCS guidance. A Medi-Cal share of cost is a monthly deductible amount that must be met before Medi-Cal will cover healthcare services. For many beneficiaries living on low income, having a share of cost essentially means not being able to access Medi-Cal services at all.
It is not clear why these well-intentioned pieces of DHCS guidance are not uniformly implemented to protect vulnerable Medi-Cal beneficiaries from negative action, but one could venture a few guesses. One reason may be that the COVID-19 emergency measures are not well publicized and beneficiaries may not be aware of their options. The new pieces of guidance may also not be well communicated to the county-level welfare agencies administering Medi-Cal enrollment and eligibility determinations, causing eligibility workers to erroneously terminate or otherwise limit beneficiaries’ coverage. Inconsistencies and errors in Medi-Cal coverage disproportionately affect low-income Californians at a time when the number of low-income Californians is much higher than usual, and these barriers to coverage prevent people from accessing healthcare at a time when human health is unusually endangered. Those who find themselves with reduced incomes may feel the need to sacrifice other necessities, like forgoing certain grocery items or skipping a utility payment, if they are worried that their healthcare is in jeopardy. Sadly, sacrificing nutritional needs or housing security also leads to adverse health effects, further threatening the wellbeing of low-income households.
II. Transition to Covered CA
The COVID-19 crisis has created issues in health insurance coverage because of its impacts on the economies of California and the country as a whole. Covered California is the state’s health insurance marketplace that was created under the Affordable Care Act. Californians whose incomes are above the Medi-Cal limit but who may not have access to employer-provided insurance are able to purchase health insurance through Covered California. As the COVID-19 emergency continues to increase unemployment, more Californians are forced to seek independent health insurance. Many Californians who have been on an insurance plan through Covered California and lost income as a result of COVID-19 are becoming eligible for Medi-Cal and must navigate the transition between the two programs.
Transitions from employer insurance to Covered California or from Covered California to Medi-Cal can be confusing, especially during an emergency when changes to income and employment happen suddenly and without warning. Clients reported confusion when they were laid off in a month for which they were still being charged the full premium for their Covered California plans and were thus faced with payments that did not match their income level and that they could not afford. Clients have also expressed concern about potential gaps in coverage when transitioning between insurance options, which is a particularly worrisome prospect during a global pandemic. Additionally, some faced enrollment issues because there was a gap in time between the issuance of special new unemployment benefits and Covered California developing a way for their information system to count those benefits as income.[27]
When a client has been laid off or has lost income because of the COVID-19 crisis, they may suddenly find themselves without the resources to pay Covered California premiums. In April, Covered California announced new state subsidies to help enrollees with their premiums,[28] later reporting that the new subsidies allowed for additional financial assistance that, on average, reduced household premiums by 70 percent.[29] As of late May, Covered California reported over 123,000 new enrollees since creating a special-enrollment period in March.[30]
Clients have expressed concern based on a perception that, because it is aimed at people with lower incomes, Medi-Cal is an inadequate insurance program. HCC has advised clients that Medi-Cal does, indeed, offer full medical coverage. As noted on the DHCS website, “Medi-Cal currently provides a core set of health benefits, including doctor visits, hospital care, immunization, pregnancy-related services and nursing home care. The Affordable Care Act ensures all Medi-Cal health plans offer what are known as Essential Health Benefits (EHB).”[31]
While people need not worry that Medi-Cal won’t provide adequate coverage, there are legitimate concerns inherent in a transition to Medi-Cal that people may wish to avoid. For instance, Medi-Cal is not accepted by all doctors because of its lower reimbursement rate.[32] Someone who is pregnant or on a longterm care plan may wish to continue seeing their current doctor, and that doctor may not accept Medi-Cal. Thus, someone newly unemployed may wish to continue their employer-based insurance through Consolidated Omnibus Budget Reconciliation Act (COBRA).[33] COBRA premiums, however, can be cost prohibitive for someone who is out of work. Someone newly unemployed may also prefer to obtain a plan through Covered California over Medi-Cal, but if they are eligible for Medi-Cal they become ineligible for the Advance Premium Tax Credits that would normally make a Covered California plan affordable.[34] These transitional issues force Californians to make difficult choices. Choosing COBRA coverage or Covered California without tax credits may severely impact someone’s financial position and leave them without resources to pay for essentials other than healthcare. Thus, even middle-income individuals and families who have historically been financially stable may suddenly find themselves living paycheck to paycheck when faced with lost income and potentially higher healthcare costs because of the pandemic.
III. Barriers to Care
The pandemic has also created barriers to medical care in more direct ways than through these insurance-related issues. Doctors have reported declining numbers of heart attack and stroke patients, possibly because people are afraid to go to a hospital or medical office and face the risk of contracting COVID-19 from staff or other patients.[35] The pandemic has also affected the care of patients who require dialysis. Dialysis centers have had to limit the amount of treatment space available, which in turn limits the number of patients who can receive dialysis at any given time. This creates huge health risks for patients who require regularly scheduled dialysis treatments to stay healthy.[36]
It also remains unclear whether low-income populations have adequate access to sanitation and hygiene supplies. It has proven difficult for everyone to access these supplies, like soap or hand sanitizer, at any given store at any time of day. For those with limited resources, it is likely much harder to obtain these necessities. This is particularly problematic because many workers whose jobs have been deemed essential, and therefore must work during the pandemic, live in poverty. They may be left without the supplies that would allow them to stay safe outside their homes. Further, Californians experiencing homelessness are unlikely to have access to hygiene and sanitation supplies, and likewise may have no means of receiving information (such as internet access or a cell phone) about where or how they can be tested for COVID-19.
IV. COVID-19’s Disproportionate Impact on Ethnic Minorities
Unfortunately, COVID-19 has not affected all ethnic communities equally. As of July 26, there were 452,288 confirmed cases of COVID-19 in the state of California.[37] Latinx individuals make up 38.9 percent of California’s population but have consistently constituted over half of all COVID-19 patients. Meanwhile, white individuals make up 36.6 percent of the population and only 18.4 percent of patients (as of July 26, 2020).[38] Deaths among Black and Latinx adults between eighteen and sixty-four are also disproportionately high in relation to their share of the population, while white and Asian deaths in the same age group are much more proportionate.[39]
The actual number of COVID-19 cases may be higher because of issues with testing.[40] These include high cost, difficulty of physical access, and inability to take time off work. Initially, only wealthier populations were getting COVID-19 tests because only they could afford it, causing a misleading spike in cases in wealthy neighborhoods and inaccurately reflecting which communities COVID-19 was hitting most severely.[41] Gradually, that has changed. Additionally, many testing centers are drive-in only, which excludes everyone who does not have a car—predominantly low-income communities made up of ethnic minorities.[42] Lastly, there are many people who do not want to get tested despite having symptoms, because they do not get paid sick leave and cannot afford time off work.
But even if tested, access to care varies between different ethnic communities.[43] For instance, chronic diseases like diabetes, asthma, heart disease, and COPD can make a COVID-19 case much more severe than for people without those chronic diseases. Young Black people experience a higher rate of these diseases compared to the rest of the population, which translates directly into increased severity of COVID-19’s impact on these communities.[44] One underlying reason for this could be that Black people do not experience the same healthcare system that white people do.[45] Additionally, counties with a majority minority population appear to be more heavily impacted. For instance, we can look to Imperial County, which has an 85 percent Latinx population.[46] Imperial County houses 0.46 percent of the California population[47] but has the highest proportion of cases in California, with well over 5,000 cases per 100,000 people.[48]
California must take immediate action to combat the racial disparities inherent in its economic and healthcare systems. The huge overlap between the state’s communities of color and its low-income population is inseparable from the enormous barriers standing between people of color and appropriate and adequate healthcare. As a global pandemic, the COVID-19 crisis appears to be impacting communities of color much more harshly than it is white people, and the statistics of how COVID-19 has impacted the state have illuminated the unequal distribution of healthcare resources in California. The state must work to eliminate these longstanding systemic barriers that have been built not just through direct healthcare policy, but generally through all economic or social policy that results in racial inequity.
Going Forward
This Article has explored barriers to health insurance coverage and access to healthcare services based on the experiences of HCC’s clients. It has identified key issues California’s marginalized populations face in securing healthcare access during a pandemic. Going forward, there need to be stronger protections to ensure that these Californians have uninterrupted access to healthcare. This will reduce the likelihood of disparate impacts on the health and income of such a huge portion of the population.
In particular, the state should develop a protocol to quickly and efficiently communicate whatever safeguards it puts in place to prevent loss of health benefits because of sudden economic changes. During the COVID-19 crisis, policies were enacted to suspend negative actions for Medi-Cal beneficiaries and to provide more subsidies for those on Covered California plans. Even so, many eligible recipients did not learn about these protections until well into the emergency period, and many of these policies consequently failed to protect people. Beneficiaries of these programs are generally low-income and therefore are less likely to have reliable access to internet service, computers, and cell phones. If notices are not sent out via mail or posted at social service offices, many beneficiaries are unlikely to find out about program changes. Even with safeguards in place, beneficiaries experienced negative actions like Medi-Cal terminations at a time when negative actions were suspended. Clearly, there were communication issues on both ends—to the agencies administering benefits and to Californians receiving benefits. The state should improve its communications protocol to avoid these errors moving forward.
The COVID-19 crisis has greatly impacted the health of low- and middle-income Californians, often without them even coming into contact with the virus. It has illuminated how the health of low-income Californians and communities of color is most at risk during a health crisis. As the pandemic rages on, the state must take immediate action to prepare for future crises and to resolve longstanding inequities in the way it administers healthcare.
[1]. Khiara M. Bridges, Implicit Bias and Racial Disparities in Health Care, Am. Bar Ass’n, https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/racial-disparities-in-health-care [https://perma.cc/M28M-NCVP].
[2]. See Cal. Health Care Found., Medi-Cal Facts and Figures: Crucial Coverage for Low-Income Californians (2019), https://www.chcf.org/wp-content/uploads/2019/02/MediCalFactsFiguresAlmanac2019.pdf [https://perma.cc/3PMN-DZHR].
[3]. As of August 11, 2020, Latinx people made up 57.4 percent of California's cases. L.A. Times Staff, Tracking the Coronavirus in California, L.A. Times (last updated Aug. 11, 2020), https://www.latimes.com/projects/california-coronavirus-cases-tracking-outbreak [https://perma.cc/5Z37-QTLU] [hereinafter Coronavirus in California]. People of color made up over 69 percent of deaths in California. Id.
[4]. The Health Consumer Center (HCC) of Los Angeles provides telephone advice and assistance to help empower consumers to resolve health access and service problems independently. When self-help does not resolve the problem, we use a range of legal advocacy tools to assist clients and bring about quick, positive results. Our advocates work to identify widespread issues coming through the Center that may need to be addressed on a policy or systemic level, and then lead efforts to make changes in local and state agencies. See Health, Neighborhood Legal Servs. L.A. Cnty., https://www.nlsla.org/services/health [https://perma.cc/P2SL-96Q4] (last visited July 1, 2020).
[5]. See 42 U.S.C. §§ 1396(a)–(f).
[6]. Cal. Welf. & Inst. Code § 14000.4 (West 2019).
[7]. See 42 U.S.C. § 1396(a); Cal. Welf. & Inst. Code §§ 14131–14138 (West 2019).
[8]. 42 U.S.C. § 1396(a)(3).
[9]. See Cal. Welf. & Inst. Code § 10950.
[10]. Cal. Health Care Found., supra note 2, at 2.
[11]. Id. at 23.
[12]. Id.; QuickFacts: California, U.S. Census Bureau, https://www.census.gov/quickfacts/CA [https://perma.cc/TE7J-AWHW] (last visited July 1, 2020).
[13]. Adults between the ages of 19–64 are eligible for Medi-Cal if their income is within 138 percent of the Federal Poverty Limit (FPL) based on their household size. See Cal. HealthCare Found., What Is MAGI? (2014), https://www.chcf.org/wp-content/uploads/2017/12/PDF-HealthReformTranslationMAGI.pdf [https://perma.cc/UG2P-M4JA]. This income limit is 1468 dollars per month for a household of one, 1983 dollars per month for a household of two, and so on. This eligibility is based on income only, regardless of assets. With the rise in unemployment, it is likely that many Californians became income-eligible for Medi-Cal.
[14]. Margot Roosevelt, Despite Gradual Reopening, California’s Unemployment Rate Remains Stagnant, L.A. Times (June 19, 2020), https://www.latimes.com/business/story/2020-06-19/coronavirus-unemployment-california-jobs-may [https://perma.cc/82XM-47JS].
[15]. See CMS PI SOCRATA by Month, Cal. Dep’t Health Care Servs., https://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/SOCRATAbyMonth.aspx [https://perma.cc/84BP-3CW7] (last visited July 3, 2020); Cal. Dept. of Health Care Servs., Medi-Cal Certified Eligibles Data Table by County and Aid Code Group May 2020 (Dates Represented: February 2020) (2020), https://www.dhcs.ca.gov/dataandstats/statistics/Documents/County-and-4-Group-Table-Feb2020.pdf [https://perma.cc/ 7AWS-FG8Y].
[16]. See Heather Long & Andrew Van Dam, U.S. Unemployment Rate Soars to 14.7 Percent, the Worst Since the Depression Era, Wash. Post (May 8, 2020), https://www.washingtonpost.com/business/2020/05/08/april-2020-jobs-report [https://perma.cc/E6XF-JSV4]; George Avalos, Coronavirus Unemployment: One-Fourth of California Workers Could Lose Jobs, Governor Says, Mercury News (May 11, 2020), https://www.mercurynews.com/2020/05/11/coronavirus-unemployment-layoff-job-california-great-depression-newsom-tech-retail-restaurant-hotel-construction [https://perma.cc/R88E-FWJ7].
[17]. California Unemployment Rate Rose to Record 15.5 Percent in April, Emp. Dev. Dep’t, https://www.edd.ca.gov/Newsroom/unemployment-may-2020.htm [https://perma.cc/KQM5-XNLD] (last visited July 1, 2020).
[18]. Id.
[19]. Sarah Bohn, Marisol Cuellar Mejia & Julien Lafortune, Unemployment Benefits in the COVID-19 Pandemic, Pub. Pol’y Inst. Cal. (Apr. 9, 2020), https://www.ppic.org/blog/unemployment-benefits-in-the-covid-19-pandemic/#:~:text=(Notably%2C%20benefits%20in%20California%20are,expanded%20both%20eligibility%20and%20benefits [https://perma.cc/4QAK-S4G2].
[20]. About the Department of Health Care Services, CAL. DEP’T HEALTH CARE SERVS., https://www.dhcs.ca.gov/Pages/AboutUs.aspx [https://perma.cc/HVT5-BN7Y] (last visited July 1, 2020).
[21]. See, e.g., Letter from Sandra Williams, Chief, Medi-Cal Eligibility Div., to all county welfare directors et al., Access to Care During Public Health Crisis or Disaster for Medi-Cal (Mar. 16, 2020), https://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/MEDIL/2020/I20-07.pdf [https://perma.cc/Q8VD-N7LX] (delaying the processing of annual Medi-Cal redeterminations and suspending negative actions affecting Medi-Cal benefits); Letter from Sandra Williams, Chief, Medi-Cal Eligibility Div., to all county welfare directors et al., Follow-Up Guidance to MEDIL I 20-07 (Apr. 10, 2020), https://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/MEDIL/2020/I20-08.pdf [https://perma.cc/3MJS-JDAN] (directing counties to prioritize eligibility determinations for new Medi-Cal applicants and immediate need requests to restore eligibility above other actions).
[22]. See supra note 21.
[23]. How Coronavirus Stimulus Payments Affect Your Household Income, Covered Cal., https://www.coveredca.com/CARES-Act [https://perma.cc/VW79-N643] (last visited July 3, 2020).
[24]. See COVID-19 Presumptive Eligibility Program, CAL. DEP’T HEALTH CARE SERVS. (July 31, 2020), https://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/COVID-19-Presumptive-Eligibility-Program.aspx#:~:text=Presumptive%20Eligibility%20(PE)%20for%20COVID,associated%20office%2C%20clinic%2C%20or%20emergency [https://perma.cc/G7LF-EW3T]; see also Families First Coronavirus Response Act, Pub. L. No. 116-127, 134 Stat. 178 (2020).
[25]. COVID-19 Presumptive Eligibility Program, CAL. DEP’T HEALTH CARE SERVS., https://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/COVID-19-Presumptive-Eligibility-Program.aspx [https://perma.cc/A5TN-S6SZ] (last visited July 1, 2020).
[26]. How COVID-19 Impacts People With Diabetes, Am. Diabetes Ass’n, https://www.diabetes.org/coronavirus-covid-19/how-coronavirus-impacts-people-with-diabetes [https://perma.cc/4X92-DPF9] (last visited July 3, 2020).
[27]. See Press Release, Covered Cal., Covered California Enrolls Tens of Thousands as Impacts of COVID-19 Pandemic Hits California Households (Apr. 14, 2020), https://www.coveredca.com/newsroom/news-releases/2020/04/14/covered-california-enrolls-tens-of-thousands-as-impacts-of-covid-19-pandemic-hits-california-households [https://perma.cc/H2S8-HST5].
[28]. Id.
[29]. Id.
[30]. Press Release, Covered Cal., Covered California Sees More Than 123,000 Consumers Sign Up for Coverage During the COVID-19 Pandemic (May 20, 2020), https://www.coveredca.com/newsroom/news-releases/2020/05/20/covered-california-sees-more-than-123000-consumers-sign-up-for-coverage-during-the-covid-19-pandemic [https://perma.cc/6ZJT-LRCW].
[31]. What Are the Medi-Cal Benefits?, CAL. DEP’T HEALTH CARE SERVS., https://www.dhcs.ca.gov/services/medi-cal/Pages/Medi-Cal_EHB_Benefits.aspx [https://perma.cc/NX43-GEV3] (last visited July 1, 2020).
[32]. See, e.g., Soumya Karlamangla, Medi-Cal Patients May Not Have Adequate Access to Doctors, Audit Finds, L.A. Times (June 16, 2015), https://www.latimes.com/local/lanow/la-me-ln-medi-cal-audit-20150615-story.html [https://perma.cc/FF25-T5LD] (“Many advocates said the access issues reported in the audit are partly due to low payment rates for Medi-Cal doctors. Those rates, which were lowered by state lawmakers during the recession, discourage doctors from taking on more patients, they say. The rates only apply to the roughly one-quarter of patients who are not enrolled in managed-care plans, and for whom the state is billed for each doctor visit and medical procedure individually.”); Anna Gorman, Medi-Cal Managed Care Patients Frequently Can’t Find Doctors, KQED (June 23, 2015), https://www.kqed.org/stateofhealth/39062/in-medi-cal-many-managed-care-patients-cant-find-doctors [https://perma.cc/QTZ3-DTZD] (“But even if oversight improves, many argue the state still needs to increase Medi-Cal payments to doctors and other providers so that more will participate. A coalition of unions, doctors and hospitals are pushing to raise rates in California.”)
[33]. See generally Continuation of Health Coverage (COBRA), U.S. Dep’t Lab., https://www.dol.gov/general/topic/health-plans/cobra [https://perma.cc/3RB9-WDAM] (last visited July 3, 2020). Coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act) allows people to continue their employer-based health insurance for a set amount of time after losing their job. Id. COBRA coverage requires those who elect to continue coverage to pay the full price of their premiums. See id.
[34]. See Health Care Costs and Getting Help Paying for Coverage, Covered Cal., https://www.coveredca.com/individuals-and-families/getting-covered/health-care-costs/#:~:text=To%20be%20eligible%20for%20premium,Estimate%20your%20FPL%20here [https://perma.cc/9ZD9-UHJ9] (last visited July 3, 2020).
[35]. See Joel Rubin, ‘Where are the Strokes and the Heart Attacks?’ Doctors Worry as Patients Avoid ERs, L.A. Times (Apr. 22, 2020), https://www.latimes.com/california/story/2020-04-22/coronavirus-emergency-rooms-numbers-decline [https://perma.cc/N9QQ-83XX].
[36]. See generally Yvette Brazier, What Is Dialysis, and How Can it Help?, Med. News Today (July 17, 2018), https://www.medicalnewstoday.com/articles/152902 [https://perma.cc/KVE7-6BT4].
[37]. Coronavirus in California, supra note 3.
[38]. Id.
[39]. Ben Poston, Tony Barboza & Alejandra Reyes-Velarde, Younger Blacks and Latinos Are Dying of COVID-19 at Higher Rates in California, L.A. Times (Apr. 25, 2020), https://www.latimes.com/california/story/2020-04-25/coronavirus-takes-a-larger-toll-on-younger-african-americans-and-latinos-in-california [https://perma.cc/4XQG-3A4L].
[40]. See Emily Deruy, Fiona Kelliher & Daniel Wu, As California Tops 300,000 Cases, Delays, Confusion Hamper Efforts to Expand Coronavirus Testing, Mercury News (July 10, 2020), https://www.mercurynews.com/2020/07/09/delays-confusion-hampering-efforts-expand-coronavirus-testing/ [https://perma.cc/4VMD-ENUS].
[41]. See Bulbul Rajagopal & Gabriel Kahn, Why Does ‘Wealthy LA’ Have a Higher Infection Rate?, Crosstown (Apr. 1, 2020), https://xtown.la/2020/04/01/wealthy-los-angeles-high-coronavirus-infection-rate [https://perma.cc/P73A-T2YU].
[42]. See Maria Godoy & Daniel Wood, What Do Coronavirus Racial Disparities Look Like State By State?, NPR (May 30, 2020), https://www.npr.org/sections/health-shots/2020/05/30/865413079/what-do-coronavirus-racial-disparities-look-like-state-by-state [https://perma.cc/MT2B-CENB].
[43]. See APM Research Lab Staff, The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S., APM Res. Lab (June 24, 2020), https://www.apmresearchlab.org/covid/deaths-by-race [https://perma.cc/C5D4-76U7].
[44]. Claudia Boyd-Barrett, Striving for Equity in COVID-19 Testing: A Conversation With the Executive Director of the American Public Health Association, Cal. Heath Care Found. (May 7, 2020), https://www.chcf.org/blog/striving-equity-covid-19-testing [https://perma.cc/Y6ZR-JG3R].
[45]. See Yasmin Anwar, Why Middle-Class Black Women Dread the Doctor’s Office, Berkeley News (Jan. 18, 2019), https://news.berkeley.edu/2019/01/18/invisiblevisits [https://perma.cc/A8UV-S3QY]; Bridges, supra note 1 ("Black people simply are not receiving the same quality of health care that their white counterparts receive, and this second-rate health care is shortening their lives.").
[46]. QuickFacts: California; Imperial County, California, U.S. Census Bureau, https://www.census.gov/quickfacts/fact/table/CA,imperialcountycalifornia/PST045219 [https://perma.cc/ME6X-M4NV].
[47]. Id.
[48]. California Coronavirus Map and Case Count, N.Y. Times (last updated Aug. 19, 2020), https://www.nytimes.com/interactive/2020/us/california-coronavirus-cases.html [https://perma.cc/EWX7-EK32]. We acknowledge that this Article is being written in the midst of the pandemic, a situation that is constantly changing. The figures and trends reflected in this Article are based on the most up-to-date data we can obtain.
