(Graphic by Wilson Liévano. Original photo by Annika Hom/Mission Local)

California's challenge: overcoming the trust barrier

Annika Hom

Annika Hom

Report for America corps member
Mission Local

April 18, 2023

Yujie Zhou

Yujie Zhou

Report for America corps member
Mission Local

April 18, 2023

SAN FRANCISCO, CA — Jana Beldelcy Valiente spends her Wednesdays volunteering at a community food bank, and has a lot in common with the dollie-towing residents to whom she hands out milk or eggs: She’s undocumented, has no job and no health insurance. 

However, the 58-year-old Guatemalan figured ways to get by. Her daughter, “a bilingual engineer” she says proudly, is the breadwinner. A community clinic near a church provides her free medication to manage high blood pressure and cholesterol. In other words, Beldelcy Valiente knows she’ll be fine — as long as she doesn’t get really sick. 

“I am afraid to have a serious illness,” Beldelcy Valiente said in Spanish. “What if I have an emergency, and need medicine, but it costs too much?” 

Uninsured Californians like Beldelcy Valiente can quickly find themselves in this situation, deciding whether their health or savings should take the blow. And health and social workers offer no shortage of horror stories once the choice is made: An uninsured woman’s face that suddenly became paralyzed, costing  $20,000 in treatment; a young mother who refused prenatal checkups, fearing deportation and having no funds. 

So the latest expansion of Medi-Cal, the state’s version of the federal Medicaid program, could do away with the need to balance fiscal and physical health. Early next year the safety net opens full coverage to some 700,000 undocumented immigrants aged 26 to 49 in California. Now, the question is how to convince all to enroll. Language, it turns out, is one of the easiest barriers to overcome. 

The more daunting challenge is getting residents to trust a government resource, amid misinformation and deportation concerns. Immigration fears “loom like a dark cloud,” one advocate said, and misinformation is rampant, breeding skepticism and dissuading those who need it to accept the safety net. 

“Making sure that people know, ‘Hey, I’m eligible for Medicaid expansion,’ is a key intervention to addressing health disparities in health equity,” said Dr. Carina Marquez, a University of California, San Francisco professor of medicine who tested and vaccinated the city’s Mission District on the ground during the pandemic. 

Yet most state and local agencies focus on the language barrier, and after addressing that — California has already translated Medi-Cal enrollment into some 12 languages — consider the task done. Clearly, at times even that’s not been enough: The state’s pandemic rent relief program, despite hoping to include monolingual immigrants, published subpar and racist translations — early on, a button mistranslated in Chinese told applicants to ‘go back to your country’ — landing a discrimination complaint. Missteps potentially blocked thousands of people from rent assistance that could have prevented poverty. 

And even when the translations were accurate, more hurdles remained — getting the information out, dealing with fears of deportation and making sense of a complicated process. 

Take the case of  Beldelcy Valiente. The foodbank volunteer wants the benefit. She knows what Medi-Cal is, understands what it provides, can access information in her language, and even knows nonprofits that can enroll clients. But did she know she had been eligible for months now? 

Her large, warm eyes turned wide. No, she said, mouth agape. She didn’t know at all. No one told her she qualified. 

Jana Beldelcy Valiente is one of hundreds of thousands of undocumented immigrants who qualify for Medi-Cal, but face barriers in accessing it. (Photo by Annika Hom/Mission Local)

Reading faces, conquering fears

Even if the application is in clients’ preferred language, understanding the jargon and documentation of a government document can be confusing. “There’s a lot of hoops to jump through,” Marquez said. 


Undocumented immigrants who get paid in cash automatically think they can’t participate when they see a proof-of-income document, said Jaime Aragón, the special projects manager for the nonprofit Good Samaritan Family Resource Center, which registers immigrants for public benefits. 


“It’s a huge deterrent,” Aragón said. In actuality, applicants can self-declare income — but they don’t know this, unless someone tells them. 


That’s the flaw of simply translating instructions or program information; so much is left unanswered. Just as essential to the “soft-skills” of building trust are knowing the facts of science and the ins and outs of programs, said Diane Jones, a former HIV nurse who served on the frontlines of the pandemic in the Latinx population. She argued a “case manager”-like approach was essential to getting HIV patients life-saving care, a possible blueprint for Medi-Cal enrollment.  


“That’s what we need for undocumented. They need to be shepherded, navigated, all the way until they get into the clinic,” Jones said. “And the clinic needs to see if the patient stays in care.”


Enter the on-the-ground health and social workers, who have trained to be quasi-mind readers of the immigrant experience. Promotoras, Spanish-speaking outreach workers, fan the community and knock on doors, engaging residents in elevator pitches and keeping ears to the ground for frequently asked questions or rumors. 


Promotoras ask clients first what they know about a program. Aragón said, “It’s starting the dialogue…and getting deeper in those fears.” 


My friend said this affects my ex-husband’s alimony, is common hearsay in San Francisco’s Latinx community, Aragón and city social workers said. I heard my kids will be enlisted into the U.S. Armed Services if I accept. Don’t I have to pay the government back if I take this? Mixed-status families, where undocumented parents have U.S.-born children, mistakenly believe taking benefits harms their children. 


Similar problems abound in the Chinese community. Following a decade of working with freshly arrived immigrants in San Francisco’s Chinatown, Candy Lin has become fluent in reading faces. As a family service worker at the nonprofit Wu Yee Children’s Services, she’s assisted hundreds of Mandarin and Cantonese immigrants to enroll in public programs and knows the key to successful communication requires anticipating what’s left unsaid. 


“They have that look … you kind of know that they are puzzled about something,” Lin said. “I kind of answer the questions in their head or in their heart.”


About 70 percent of immigrants Lin works with, for example, heard a rumor that enrolling for Medi-Cal or CalFresh, state food stamps, could hurt their green card applications or their relative’s immigration status, the social worker said. Another Chinese immigrant group, Self-Help for the Elderly, found “100 percent” of clients heard those rumors, an advocate said. (This might have started from the fact that immigrants who only receive cash benefits or require long-term Medicaid could be denied a green card; but again, receiving benefits does not affect green card status.)  Yet, Lin said, the Medi-Cal translations have no portion in Chinese to “tackle all these rumors.”  


In 2019, some of those fears came true. President Donald Trump’s administration changed the definition of the so-called “public charge” rule, which prevents immigrants who access certain public services from gaining legal status. He added Medicaid, food stamps and housing vouchers to that list of services. 


That change caused an almost immediate effect on Medi-Cal disenrollments in San Francisco. Up until the public charge law was altered in 2019, the number of undocumented Latinx signing for Medi-Cal had since 2017 been increasing, and reached a high of 2,650 enrollments, according to the city’s Human Services Agency data. A year after the public charge was announced, that number fell by almost half. Late last year, Biden reversed the 2019 public charge amendment. Immigrants will not be punished for enrolling in Medi-Cal, food stamp or housing voucher programs. 


Neighbors pass on this information until it morphs into rumors, resembling a childhood game of telephone. That confuses others. Though immigrants with visas are exempt from public charge, Aragón encounters many who feel they’re ineligible or are too scared to take the risk. 


But that change in 2019, as well as Trump’s threats that undocumented immigrants should be excluded from the 2020 U.S. Census — that never happened — is still fixed in the memory of many who are “unpackaging” fear years later. “A lot of fear was perpetuated,” Aragón said. “But it was founded, right?”

The payout of trust

Equally important to building trust is having the right information. While many of the nonprofit partners are equipped with Medi-Cal knowledge, sudden program changes from the top aren’t always communicated on the ground. 


For example, two social workers who enroll immigrants in Medi-Cal in early 2023 did not know about Gov. Gavin Newsom’s new expansion change for those aged 26 to 49 next year, despite it unlocking health insurance for hundreds of thousands of Californians. Staff from organizations purportedly involved in enrollment said they knew nothing about it. 


When Mission Local phoned a public affairs representative at the state about expansion of Medi-Cal for undocumented immigrants, they responded: “Do you mean, for CalFresh?” 


Nailing facts is especially essential for precise topics like science or health. 


“I can be the nicest navigator, but if I have incorrect information I am giving my client, I shouldn’t be trusted,” Jones said. “I don’t deserve to be there. It’s totally harmful.”


During the pandemic in San Francisco, a close and early alliance formed between community leaders in the Latino Task Force and researchers and doctors at UCSF. By the time the global health crisis commenced, more immigrants than ever were without health care, and it was the immigrant population that became ground zero for covid infections. 


Jones, along with Marquez, works with the alliance known as Unidos en Salud that treats mostly Latinx immigrants. Jones said 50 percent of their clients don’t have health insurance, and about 60 percent don’t have access to a primary care doctor, suggesting similar fears or barriers to access. For some reason, 10 percent have insurance, but don’t have a doctor. 


But during the last three years, doctors at UCSF have worked to build and maintain trust by working hand in hand with the community. Even today, any research results that come from the low-barrier testing and vaccination site in a vacant lot next door to a McDonald’s get reported first to the community, in a closed meeting. 


Doctors explain the latest public health news during “cafecito” chats on the corner, held for residents in Spanish. Slowly over time, the doctors in lab coats have become familiar faces; they started consulting some local nonprofits, and showed up at community-led press conferences. 


Maintaining that trust requires careful moves. Jones said it was understood from the start that some questions would be a surefire tactic to scare clients away, despite their health problems. “We wanted low-barrier, the lowest of the low,” Jones said. “We don’t ask about the immigration issue.” 


But that is a mistake even well-meaning government officials or large health systems make. “The way HSA throws the questions at the clients may actually already scare the client away,” Lin said.  


HSA interactions are “not always positive,” Aragón said. He’s heard of staff “barking back,” conversing with clients in a “monotone, not really caring,” or sending them on a wild goose chase for documents. 


Beatriz Flórez Huertas, a Colombian immigrant and a city-trained translator who is at the Human Services Agency and previously assigned to the Emergency Operations Center in the pandemic, understands this well; she sometimes felt “untrusting or fearful” of contacting the government in times of need. She remarked: “Approaching the police for help or if I have questions, for instance, could sometimes make me feel scared even though I work for the government.”


Hoping for optimal success, San Francisco’s HSA is tapping community partners to increase Medi-Cal enrollment and outreach. The agency also launched an immigrant engagement and outreach pilot, where Latinx and Chinese nonprofits teach eligible immigrants about Medi-Cal, CalFresh and other benefits. 


Nonprofits Mission Economic Development Agency, Self-Help for the Elderly, Good Samaritan Family Resource Center and Wu Yee Children’s Services will lead the charge, through a $500,000 a year city contract that lasts from 2022 to 2025. The groups hold focus groups to better inform outreach materials and deploy promotoras.


Workers wait patiently. Crystal Huang, a program coordinator at Chinese Newcomers Service Center, said some of her clients ask her to talk on the phone for hours with their bilingual children to ease communication, or to call HSA to show she’s not tricking them. When a client pretends a “friend” needs help registering for Medi-Cal, she humors them. 


Lin anticipates, and starts her conversation on the defensive. “I have to tell them that I have no connection with the government agency. Like, I’m not FBI.” 

The uphill battle

Even with the right strategies, converting new applicants has no shortcuts. Building trust takes time, and those best positioned to earn that in San Francisco had already begun years ago.

Thanks to these expansions, since January, 2023, the state and partners have signed up some 124,623 undocumented adults 26 and younger for Medi-Cal, as well as some 333,028 who are 50 and older, according to a statement from the California Department of Health Care Services.

Taking a page from the community groups’ playbooks, Medi-Cal outreach started months early. Buses are tagged with multilingual ads for Medi-Cal enrollment, outreach is at places immigrants gather already, in appropriate languages.

On a recent Thursday morning, Flórez Huertas walked around a resource symposium at a federal building in the Tenderloin neighborhood. Nearby, Aragón was wearing a crisp suit and representing Good Samaritan, and a Self-Help for the Elderly staff, smiling and ready to talk. The battle to overcome them happens one immigrant at a time.

This story is part of “More than Words,” a Report for America initiative that brought together newsrooms covering Latino communities in eight states to examine the impact of language barriers on the social, economic, and educational advancement of Latinos and the local efforts to close this gap.

This project is made possible by