Medi-Cal changes aim to expand coverage for low-income Californians

 By Tim Clark

In the last several years, California has proposed or implemented three major changes to Medi-Cal that could add half a million Californians to its safety net health coverage program. Those changes—in one case updating financial rules that had been unchanged since 1989—resulted after steady advocacy from various advocacy programs including the Health Consumer Center of the Legal Aid Society of San Mateo County.

“These very welcome changes will make free or low-cost health care available through Medi-Cal to many deserving individuals, including seniors, persons with disabilities, and undocumented immigrants,” said Amira Elbeshbeshy, directing attorney and director of Legal Aid’s Health Consumer Center.

One change, which went into effect July 1, increased the amount of assets a Medi-Cal recipient may have and remain eligible from $2,000 to $130,000 per person or family member. Under the legislation, the asset limitation will be removed entirely in January 2024. Eligibility limits based on income, as opposed to assets, were increased in 2020.

The second reform, “share of cost” reform, is “the most exciting for us,” Elbeshbeshy said.

Here is how it worked before this reform: Medi-Cal recipients were required to pay their “share of cost” if their income exceeded $1,564 per month or $18,768 annually. If their income was even $1 over that level, their “share of cost” or monthly deductible was approximately $940, about two-thirds of their income. Those limits had not been adjusted since 1989.

After years of lobbying, Medi-Cal advocates won $31 million in California’s 2022-23 state budget to address the problematic share of cost. The change is scheduled to go into effect in January 2025. Under the current Covid public health emergency, still in effect, the state is not taking any taking any actions that would downgrade coverage for current Medi-Cal recipients.

To illustrate the “share of cost” issue, staff attorney Camille Nguyen cited a recent client whose income is only $71 over the current limit. This woman was recently diagnosed with cancer and is about to start chemotherapy. Under the proposed Medi-Cal reform she would have a share cost of $71 rather than the $1,015 cost that she is currently responsible for.

Finally, as of May 1, Medi-Cal has added coverage for undocumented immigrants aged 50 and older. Previous changes covered children and young adults through age 25. The latest action leaves a coverage gap for undocumented individuals between ages 26 to 49. That last gap for undocumented immigrants is slated to be closed in 2024, but other coverage gaps remain in the complex Medi-Cal program.

To inform San Mateo County residents of these changes, the Health Consumer Center collaborates with other health law programs through the statewide Health Consumer Alliance as well as the Health Plan of San Mateo, the managed care plan for Medi-Cal recipients in the county, to outreach to the community.

Ironically, California’s worst public health emergency in decades indirectly boosted Legal Aid’s ability to work on legislative changes: Because of the pause on Medi-Cal negative actions for current recipients, the Health Consumer Center was seeing fewer Medi-Cal clients, freeing more of the staff’s time for legislative work and for other practice areas. The practice is now focusing more on medical debt, improper billing, and charity care under the federal Hospital Fair Pricing Act, working with San Mateo Medical Center, the county’s public hospital.

If the unit’s work sounds like a cross between legal work and social policy, it reflects the background of director Elbeshbeshy. After earning her law degree from Fordham and working for several years in New York City, she got a master's degree in Social Work from University of Southern California (USC).

“This is the perfect job to apply my education as a lawyer and a social worker,” she says. In her social work internship, Elbeshbeshy was told not to address certain legal issues—just leave that to the lawyers. Nowadays, she doesn’t hear that anymore.

Legal Aid Leads Deportation Defense Campaign

Tim Clark

When San Mateo County decided, under pressure from community advocates, to earmark $764,000 to defend low income San Mateo County residents threatened with deportation, the Legal Aid Society of San Mateo County found itself in the middle of the negotiations. Legal Aid had earned that position.

After faith-based activists at Faith in Action and its community allies—San Mateo County clergy, congregations and communities—brought the energy, the County Board of Supervisors came up with the cash while M. Stacey Hawver, executive director of Legal Aid Society of San Mateo County, rounded up the legal talent.

Together they mustered the resources that will, by September 2019, provide deportation defense services (“removal defense” in legal lingo) to 150 San Mateo County residents. That’s about $5,000 per case, a relative bargain for removal defense work. All in all, four FTE attorneys will handle 150 cases, an average caseload of 35-40 cases, a significant expansion of indigent immigration services.

“These cases won’t end in a year,” says Hawver. “We told the county that we would come back for more money this year because many or most of the cases will continue.”

The goal of 150 cases by September appears within reach--through five months ending January 2019, 50 cases had been opened, but the program had to ramp up to hire and then train attorneys for the work. And demand outstrips even the increased supply - an estimated 1,400 county residents currently face deportation proceedings without legal representation.

But this immigration law story really began back in 2017, recounts Lorena Melgarejo, executive director of Faith in Action, which she describes as “building leadership in everyday people, mostly through churches and schools.” Immigrant communities in San Mateo County, like those across the nation, were terrified after the 2016 election of President Donald Trump.

Faith in Action’s 2017 San Mateo County immigration push resulted in $276,000 in county funds for immigration workshops, brief legal consultations, and “affirmative immigration cases”— new legal help for county residents who wanted to apply for citizenship, DACA (Deferred Action for Childhood Arrivals), U Visas for victims of crime, Violence Against Women Act (VAWA), Special Immigrants Juvenile Status for child victims of parental abuse, neglect, or abandonment, or other forms of immigration relief. The county then declined to fund deportation defense.

“That was a good win in 2017, and Legal Aid managed the funds and built a network of attorneys to do the work,” says Melgarejo. “Working with Stacey has been great.”

So when Faith in Action and clergy in the Peninsula Solidarity Network and hundreds of advocates asked San Mateo County for $764,000 to defend immigrants in deportation proceedings—not just “affirmative cases”— both the county and advocates naturally turned again to Legal Aid as a procurer of legal talent. Spread out to match lawyer language abilities to clients and ensure access in all regions of the county, seven agencies share revenue in the current contract:

• International Institute of the Bay Area added one full-time attorney.

• Asian Pacific Islander Legal Outreach added one full-time attorney to serve North San Mateo County, particularly the Filipino community and speakers of Asian languages.

• Catholic Charities hired two half-time immigration attorneys.

• University of San Francisco Immigration & Deportation Defense Clinic added a half-time attorney to spend at least two days per week in Pescadero and Half Moon Bay because the Coastside area was recognized as underserved with immigration legal resources.

• Legal Aid of San Mateo County hired a half-time attorney, who splits time with its LIBRE program for immigrants.

“It was important that county government put in money to say to immigrants ‘You belong here,’” Hawver says. “We want them to feel secure in raising their children and in going to their jobs, to reduce fears that at any moment someone could be snatched and disappear with no recourse, with no one to help.”

The contract also includes funding for the Immigrant Legal Resource Center, which helps train lawyers, and Faith in Action’s Rapid Response Hotline for verification of ICE enforcement activity, attorney activation, information and referrals, and accompaniment services to support immigrants attending immigration court hearings. In addition, other legal agencies that did not participate in the contract also provide immigration legal services in the county: Community Legal Services of East Palo Alto (CLSEPA), Pangea Legal Services and Tahirih Justice Center.

Of the program’s first 50 clients through January 2019, 29 were younger than 18 years, with 20% under age 6. The preponderance of young undocumented immigrants surprised County Supervisor David Pine; it in part reflects Legal Aid’s active practice with special immigrant juvenile status cases.

The largest number of cases were from Guatemala and El Salvador, followed by Honduras and Mexico. Initial clients live in Daly City, East Palo Alto, Half Moon Bay, Pescadero, Redwood City, San Bruno, San Mateo and elsewhere in the county.

The San Mateo County contract serves low-income county residents in deportation proceedings and prioritizes:

• Residents at imminent risk of removal

• Unaccompanied minors

• Elderly immigrants and those with special needs

• Immigrants with strong claims for relief from removal

• Immigrants with longstanding ties to San Mateo County

• Immigrants who do not have serious criminal records.

The issue of immigrants with criminal records almost derailed negotiations last summer and ultimately delayed the contract by a month. Immigrant advocates sought to avoid an absolute bar on representing clients with criminal records. In the end, the contract requires legal services agencies to screen applicants for criminal convictions and get the County Manager’s approval to represent a client who has committed a serious or violent felony in the last decade. The issue hasn’t arisen so far under the contract.

When the first contract ends in September, Hawver says it will have produced “a well-trained cadre of removal defense attorneys” hired and trained under the contract. The community, she hopes, will have “a sense that there’s a bigger safety net for deportation proceedings.” As for the County, “We will meet our goals and have good stories--but they’ll still wish we could take 150 new cases in a second year. Which we can’t.”

Melgarejo effuses more. “We don’t celebrate our victories enough. Rejoice a little bit. Sometimes we can win. It’s not going to be perfect, but it’s 100% better than it was last year.”

A Family Keeps Their Housing Thanks to Legal Aid

Tim Clark

Welcoming our newest blogger: Tim Clark is a partner at The FactPoint Group, a Silicon Valley-based research and consulting firm that is dedicated to the business improvement of its clients. A concerned citizen who wanted to learn more about the issues facing low-income persons in our community, Tim got in touch with the Legal Aid Society of San Mateo County shortly after the election, and has remained a dedicated volunteer. 

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For Fiona C. and her three children, their Redwood City apartment in a Latino neighborhood was more than a place to sleep. It was the center of lives-work, school, home and friends--that they had built for seven years, three kids and their single mom, supporting the family on Fiona's two cleaning jobs. 

The two younger children were doing well in elementary school, and at Woodside High School, the eldest daughter performed not only academically but on the swim team and cheer squad. 

So the 60-day eviction notice that came to Fiona (not her real name) in November 2016, on the same day that the apartment complex's new owners closed escrow on the 10-unit apartment building, was a major disruption. 

Oddly, other residents in the apartment complex received rent hikes (these are market rate apartments, not subsidized) of $300 a month-to $2,300-but no eviction notice. Fiona asked the new landlord for an extension so her two younger children could finish the academic year at their familiar schools, walking distance from their home. 

The landlord offered Fiona "a deal": An extra 30 days (not enough for her children to finish the year at their schools) if she paid the $300 rent increase-plus another $500 for unspecified reasons. Fiona paid the extortionary price. 

Fiona's options were limited in San Mateo County's pricey rental market, where the county says the median price of a two-bedroom apartment runs $2,980 as of September 2016. That median figure exceeds Fiona's annual income. In August 2017 listings for Redwood City, one-bedroom rentals ranged from $1,120 to $2,995 per month. A rare two-bedroom rental ranged from $3,495 to $3,695. 

Fiona found her way to a Housing Rights Legal Clinic in Fair Oaks Community Center, Redwood City, that is run by the Legal Aid Society of San Mateo County. There Fiona spoke, in Spanish, with Legal Aid housing coordinator Lacei Amodei. 

Soon after, Legal Aid attorney David Carducci contacted the landlord to protest the illegal collection of the extra $800 and to ask why Fiona alone among the tenants was being evicted. Fiona's unit was messy, the landlord said. 

What made the extra $800 illegal? Collecting increased rent without any notice or 60-day time period,  Carducci said, and the landlord had no legal basis to make her pay the extra $500 other than extortion because Fiona was desperate to hold off the eviction.

Meanwhile, Carducci and the housing coordinator visited the unit themselves and found it in good condition-no worse than expected for three kids and their toys living there. 

Despite Legal Aid's efforts, the landlord hired an attorney and filed an eviction lawsuit against Fiona. Legal Aid defended her aggressively, taking the deposition of the landlord. 

"Our mission at Legal Aid's Housing Unit is to prevent homelessness, and that means keeping people in safe affordable housing," said Carducci, who is also Director of Litigation for Legal Aid. "Our highest priority through the Housing Clinics is to identify the people who are at high risk of homelessness-that's the 10% of clients who come to the Housing Clinic that we devote the most resources to. We can advise 90% of the Housing Clinic clients on the spot, but the ones at real risk we prioritize."  

San Mateo County's biennial census of homeless in the county on Jan. 25, 2017, found 1,253 homeless people in San Mateo County, roughly half or 637 unsheltered (living on streets, in cars, in RVs, in tents/encampments) and 616 sheltered homeless people (in emergency shelters and transitional housing programs). That marked a 16% decline from the 1,483 homeless counted in 2015. A major factor in the decline was a change in how certain facilities were counted. 

Unlike housing discrimination, no government entity regulates rents-so private attorneys and agencies such as Legal Aid become "law enforcement." Carducci's legal strategy in cases with an eviction notice is to try to keep the family in their home so they do not have to move-whenever possible. Many who are priced out of San Mateo County move to the East Bay, Central Valley or out of state. 

In Fiona's case, Legal Aid's defense-specifically taking the landlord's deposition-against the landlord's litigation led the landlord to dismiss the case, and Fiona's family stayed, albeit at the higher rent. "Obviously Fiona's landlord did not have a compelling legal reason to evict her and her kids.  By standing up for her rights, we prevented a total displacement of this family that is established in their community," Carducci said. 

Legal Aid Restores Safety to a 20-Year Survivor of Domestic Violence

"Natalie" had been married to "Paul" for 20 years. They have three young children. Ever since the start of their marriage, Paul abused Natalie.

Paul had a drug addiction, and had been in and out of jail many times. His children were afraid of him, and suffered from panic attacks when he was around. He exhibited violent behavior in the house: breaking glass in the children's bedrooms, punching through the television, shattering the car windows, and ruining the carpets. Paul even purposefully sabotaged the sump pump in the basement, causing the house to flood.

Paul frequently yelled at Natalie in front of their children.  He spit in her face, and even threatened to kill her. Paul would not refer to Natalie by her name, only by "bitch." After an episode in which Paul poured hot beans on Natalie's body and threw lard in her hair, Natalie filed a police report, leading to a temporary restraining order against Paul. But even after the temporary order was filed, Paul continued to violate it, leaving Natalie and her children no less afraid than before.

Natalie needed a permanent restraining order. She was referred to Legal Aid's Director of Pro Bono Janet Seldon by partner Bay Area Legal Aid, who, along with Community Overcoming Relationship Abuse (CORA), comprise our Domestic Violence Collaborative. Janet turned to her pro bono network and placed the case with Jonathan Joannides-- an attorney with Wilson Sonsini-who agreed to represent Natalie in court. With Jonathan's pro bono help, Natalie was granted a permanent restraining order, including full protection for her children and no visitation rights for Paul. Paul cannot violate this order without facing criminal charges.

Domestic violence is a problem in every community-one in three women will experience physical abuse in their lifetime.  Access to legal services is critical in enabling survivors to establish independent and permanent functional family units. A recent study concluded that the "availability of legal services has a significant, negative effect on the incidence of abuse" and that offering "long-term, realistic alternatives to their relationships" is a key component for women leaving abusive relationships.

Legal Aid and its cadre of pro bono attorneys are able to provide legal representation to survivors of domestic violence, and help them navigate the complex and intimidating criminal and family court systems. Between April 2015 and March 2017, Legal Aid closed 204 domestic violence and elder abuse cases. In over half of those cases, the attorneys provided extensive legal services to clients; helping 63% of clients secure permanent restraining orders against their abusers.

Although no form of legal action can undo the suffering that Natalie and her children endured, a permanent restraining order can enable them to finally move forward with their lives, and to begin to recover, knowing that the law protects them.

Protecting Senior Citizens from Abuse: What I Learned from Senior Advocate Attorney Joshua Grossman

Blog author Iliana Arbeed

En espanol aqui

Despite the fact that respect for a society’s elders is a shared value across cultures worldwide, the issue of elder abuse persists. As I learned this week with Senior Advocate Attorney Joshua Grossman, seniors are among the most frequently exploited and neglected members of our community.
 
The California Welfare and Institutions Code defines elder abuse as physical abuse, neglect, financial abuse, abandonment, isolation, abduction or other treatment resulting in physical harm, pain, or mental suffering. This definition also includes the deprivation by a care custodian of any goods or services that the senior needs in order to avoid physical harm or mental suffering. 
 
According to the Bureau of Justice, over 2,150,000 elder abuse cases are opened each year. In a 2017 study by the National Center on Elder Abuse, it was found that 68% of Adult Protective Service cases are responses to instances of elder abuse. What is even more striking is that 66% of those abuse cases are perpetrated by the senior’s own children or spouse.
 
Based on projections from the State of California Department of Finance, our senior population here in San Mateo County is expected to grow by over 70% by 2030. The District Attorney’s Office states that elder abuse—both physical and financial—is one of the fastest growing crimes in our county.
 
Although elder abuse remains a prevalent issue, an alarming amount of cases go unreported. Victims may not report abuse because of their relationship to the abuser, because of their diminished capacity to understand that they are being mistreated, or simply because they are afraid. For every reported case of elder abuse, it is estimated that as many as 24 cases go unreported.
 
As a Seniors Advocate Attorney, Josh describes the initiative taken at Legal Aid to fight elder abuse. He explains, “At Legal Aid, we are constantly educating seniors about their right to live free from all forms of abuse. We explain the options available to them, including how to pursue legal action and how to utilize the community resources available to keep them safe.”
 
In his work at Legal Aid, Josh deals with a variety of tragic elder abuse cases. During our conversations, he shared a story of one of his cases.
 
“Martha,” a 67 year old woman with incapacitating back and hip problems, lives on a fixed income and shares a home with her adult son, a strong man who does not contribute to the household income. He is mentally unstable, and is frequently angry and abusive toward his mother.
 
In a fit of rage one day, Martha’s son forcefully pushed her over in the kitchen, losing his own balance and landing on top of her. He fled, leaving Martha alone on the kitchen floor in severe pain. Martha managed to get herself to a hospital, where nurses alerted the police. Soon after, Martha’s son was arrested for elder abuse and incarcerated. On top of the physical violence toward his mother, Martha’s son had set fire to parts of the home, forcing her to stay in a hotel while the city assessed the property damage. After her release from the hospital, a social worker with San Mateo County Adult Protective Services referred Martha to Legal Aid. 
 
Because Martha was unable to reach Legal Aid’s offices, Josh met with her at the hotel where she was staying. Martha told Josh that she constantly feared for her safety. She was very worried that her son was infuriated by the arrest, and would come after her as soon as he was released from jail. Martha needed help fast.
 
Josh explained to Martha that the law could protect and free her from a life of violence and fear. He explained the legal options available to keep her safe, including the right to a temporary restraining order to protect her after her son was released from jail, and while his elder abuse case was pending.
 
Josh prepared a petition for an elder abuse restraining order, and represented Martha at the hearing two weeks later. The judge issued a three-year protective restraining order for Martha. With her protective order, Martha can now live without the constant fear of being harmed, and is able to recover in the safety of her own home.
 
Extreme situations like Martha’s are not uncommon. However, elder abuse occurs on many levels, which is why Legal Aid does more than just intervene in extreme cases.
 
Beyond achieving justice for severely abused seniors like Martha, Legal Aid reaches out to the senior community—in collaboration with government social workers and other nonprofit partners—in order to inform seniors of their legal rights proactively. In my time spent with Josh in Senior Advocacy, I observed firsthand the depth of Legal Aid’s outreach and community impact. Our community work allows us to respond to the growing problem of elder abuse, restoring both safety and dignity to seniors experiencing any form of mistreatment.