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Gavin Newsom Turns To Obamacare Playbook To Reach The Hard To Insure And Hard To Count

Michelle R. Smith / AP Photo

Brochures in clinics serving the uninsured. Home visits from “census promoters.” Ads in Spanish-language media.

With millions of dollars in federal funding at stake, California is trying some unusual strategies to encourage hard-to-count populations to participate in the census and exploring ways to link them with other public outreach efforts, including ones aimed at uninsured Californians.

The Californians the state is targeting for the census tend to be poor. Many lack access to stable housing and transportation. Many are undocumented, and still more come from mixed-status families, where some members have legal status and others don’t.

Those factors also contribute to high uninsured rates in those communities, because immigration status and affordability are the biggest barriers to having health insurance in California.

“There is such an overlap between both populations,” said Maricela Rodriguez, who is working on the census outreach campaign in the governor’s office. “They’re hard to count for a reason.”

The state already is working to coordinate its census-outreach efforts in those communities with other public information campaigns, like its push to encourage Californians to prepare for natural disasters. If the Legislature approves Newsom’s plan to expand health insurance to more undocumented immigrants, efforts to encourage signups for that program could be coordinated with census outreach, too, Rodriguez said.

The state will build on the work it did to enroll people in health insurance during the implementation of the Affordable Care Act, said Daniel Zingale, chief strategist for Gov. Gavin Newsom.

That strategy involves partnering with community groups like health clinics that serve the uninsured and moving away from what Zingale calls a “conventional” approach to public information campaigns.

“Hire a PR firm and buy a lot of television — that’s sort of the old way of thinking,” Zingale said. “We’re really trying to disrupt that way of thinking so the money is spent more effectively, efficiently and actually reaches the folks we need to reach.”

That might mean placing brochures in clinics serving the uninsured, and sending Spanish-speaking “census promoters” for home visits.

The state is spending $90 million on its effort to promote the census, targeting the communities that stand to lose the most in an undercount. Newsom wants to add another $50 million.

California received about $115 billion  from the federal government in 2016 related to programs that allocate money based on census data. The state could lose tens of millions  of dollars in an undercount, with the effects concentrated in the neediest communities that are typically the hardest to count, according to the nonpartisan Legislative Analyst’s Office.

An undercount isn’t expected to reduce funding for Medi-Cal or the Children’s Health Insurance Program going to California. But the state would likely lose millions of dollars for child care, combating substance abuse and other social services, according to the LAO.

Because the census numbers will inform policymaking for a decade, they could have a long-term effect on how much money Congress appropriates for California in the future, Zingale said.

In a serious undercount, California could even lose a congressional seat, although the LAO says that’s unlikely.

Losses from a census undercount would likely be concentrated in disadvantaged communities that are hardest to count, said Sarah Bohn, a researcher at the Public Policy Institute of California.

Nearly 4.5 million Californians reside in areas at high risk of being undercounted by the census, according to a USC Center for Health Journalism Collaborative analysis of the federal agency’s data. Four out of five people reside in communities where Latinos are the majority.

In health clinics that serve those populations, there’s an effort to get people counted. Christian Arana, policy director for the nonprofit Latino Community Foundation, says health settings present a unique opportunity to raise census awareness.

“If community health clinics are already places Latinos are going to, why couldn’t a service site have a kiosk set up?” he said, referring to a station where patients could fill out the census online. “We’re facing challenges with the census. It makes sense to engage these health clinics.”

Advocates say building trust in communities that are traditionally wary of government efforts will be key to getting people to participate, especially if a Trump administration proposed question about citizenship stays in place. The question, which is being challenged in court, would ask respondents their citizenship status, and is expected to deter some immigrants from participating in the census.

As with the Affordable Care Act, a lot of misinformation about the census could scare people from participating, Rodriguez said.

“We discovered that key to breaking through the toxic politics was to have the right messengers,” Zingale said, pointing to neighborhood organizations and multicultural media organizations, such as Spanish language outlets.

Patients say they tend to trust clinics that primarily serve low-income and undocumented patients, because they usually offer care in multiple languages and don’t ask questions about citizenship.

Putting brochures and videos in waiting rooms, or educating patients when they call to make appointments, are just a few ways Arana says clinics statewide can push the census. His group is one of about two dozen nonprofit organizations receiving grants from the state census office to target hard-to-reach populations.

Some health providers have slowly ventured into the political arena as funding for public programs comes under threat. Southern California clinic network AltaMed successfully registered thousands of Latino patients to vote during last June’s primary election.

This year, it’s deploying a team of “census promatores” to do home visits and provide in-clinic support. It’s also setting up census kiosks at clinics in target neighborhoods, and adding census reminders to the wait messages for all incoming phone calls.

Jennie Carreón, AltaMed’s associate vice president of civic engagement, calls it a “Get Out the Census” campaign. 

“The federal government has cut funding for census workers to be out in the field,” she said. “So we want to encourage everyone that as soon as they get their postcard with their code, to go to any trusted messenger location.”

While Latinos make up the largest group that could potentially be undercounted in the census, experts say other minority populations that are distrustful of government surveys are unlikely to answer. And for the 2020 census, the majority of people will be asked for the first time to answer questions online, complicating matters for people living in geographic areas with limited web access.

Lorenda Sanchez is executive director of the California Indian Manpower Consortium, which was recently awarded a state grant to raise census awareness among Native Americans and tribal communities.

“We represent the smallest percentage of the population, and too often are overlooked,” she said at a news conference about census outreach. “Because we are invisible, as other populations, our communities receive scarce to no funding — funding that is critical to health, housing, children’s services, education and infrastructure.”

This project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured.

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