Denise Scott shouts angrily over the way America has forgotten her.
"We don't need no more illegals comin' over here!" she screams from a Skid Row sidewalk littered with chicken bones, paper plates and discarded clothes.
"Fix the problems in this country! I need a place to live!"
Christopher Mack, a lead community outreach worker for a health clinic in the heart of Los Angeles' Skid Row, squats next to her. He softly tells her to calm down, to breathe, to remember to see her case worker in the morning about housing.
He also wants to know if she has health insurance.
But Scott, who will turn 61 soon and has lived on Skid Row for 18 months, is in no mood to hear sweet talk. She's bone thin. Her sweater is ripped and riddled with holes. Her clothes and important papers are squashed into various size bags all around her. Tears of frustration drip down her face.
"I'm not a racist," she tells Mack apologetically, "But I can't go to Mexico to get a house and you can't find me a place to live here."
Today is not Scott's day, Mack determines. She is too angry. Despite the fact that she and many others will qualify for health insurance by the end of the year under requirements of the Affordable Care Act, finding a place to live, not health care, is Scott's priority. So Mack will try again another time.
The encounter demonstrates how difficult it can be to provide health coverage to some of the most destitute, even those who qualify for free or subsidized plans. Some of them say that simply trying to survive or find a roof over their heads takes precedence even over caring for their own health.
"Out here, it's about repeated education," said Mack, who has worked the streets of Skid Row 10 years for the JWCH Institute, which runs the Center for Community Health on downtown's 5th Street. "It's about what we in social work call multiple encounters. Where there's a willingness, there are no barriers."
Mack's work is part of what has been an aggressive, three-year outreach campaign by the Los Angeles Department of Health Services to enroll as many of the estimated 390,000 potentially eligible uninsured residents into Healthy Way LA, a no-cost county health insurance that will convert to Medi-Cal in January. Outreach workers from clinics countywide have gone to churches, schools, soup kitchens, homeless shelters and the streets of Skid Row in an effort to find those who qualify.
"The goal is an ambitious one, but we think it is doable given the multitude of incredible partners, internal and external, that we are working with to make it happen," said Amy Luftig Viste, director of community partner programs for the Los Angeles County Department of Health Services.
But the work and the program has had its challenges, she said.
"We have had some difficulties along the way: adequate staff capacity to enroll patients, technological challenges, outreach challenges," Luftig Viste said, but much of that has been remedied by funding that has provided more staff.
"Yes there have been challenges, but we're at 257,000 enrolled -- approximately two-thirds of the state's total -- so despite the challenges we are proud of our success," she said.
One challenge for DHS is the annual renewal of Healthy Way LA. Many of those who have the insurance didn't know they had to renew it, Luftig Viste said.
"Most recently we have created a redetermination mail-in unit, and are now even calling our patients to confirm that they received their renewal paperwork and if necessary to help them fill it out," she said. "This has improved our redetermination rate significantly, but there is still much work to do to ensure that covered members stay covered."
On Skid Row, for example, a complex knot of homelessness, mental illness and drug or alcohol use, along with a deep distrust of government, makes it difficult for Mack and other outreach workers to help people understand how starting in January, Medi-Cal will have expanded to cover all low-income individuals, ages 19 to 64, who are U.S. citizens or national or legal permanent residents for at least 5 years, and are not pregnant. Those who are pregnant qualify for another insurance.
"Most people come to the clinic already in crisis," Mack said.
And there are other issues. Community clinics are working to expand as all the new patients are coming in. But there are not enough primary care physicians.
"The patients in our system now are being seen, but I don't believe there's enough capacity for the new (patients)," said Al Ballesteros, chief executive officer for the JWCH Institute.
"We are seeking to bring in more primary care providers and looking at new sites," he said. "Definitely, all community centers are in expansion mode. Right now, we have several positions for physicians, but we're competing with large health care systems like Kaiser Permanente."
And yet the goal is to make sure all of the newly insured find a medical home within these clinics to help relieve emergency departments. All too often those who suffer from chronic illnesses such as diabetes, asthma and high blood pressure need support to manage their medications.
On a recent morning, Mack and Juan Rivera, a patient enrollment and eligibility manager with JWCH, walk down crowded 5th street, near the Midnight Mission. Their goal is to invite people into the clinic to enroll in Healthy Way LA. About 35 people a week are enrolled, Rivera said.
"One of the biggest comments I get is nothing is free," Rivera said. "We say this is free. It's based on your income and where you live."
But there are many obstacles for the homeless, including proof of citizenship and ID. Others simply don't know about the Affordable Care Act.
When Mack tells Phillip Evans, an older man with a heart condition who uses a walker, that he qualifies for free health care, Evans places his hand to his chest and bends forward. Sharon Dike, a volunteer with AmeriCares who goes out to Skid Row to bring people to the JWCH Institute clinic, steadies him.
"Whoa," Evans said. "I didn't know anything about that."
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