‘A persistent puzzle’: Californians embrace Medicaid — but food stamps? Not so much.

May 2 2018

Just three states — all much more conservative than the Golden State — have lower rates of participation, according to the latest available federal data. The poor performance stands in sharp contrast to California’s leadership on enrollment in Medi-Cal, the state's version of Medicaid, which also serves people living in low-income households.

The reasons for California's low rate of participation in the food assistance program, known as CalFresh, remain a "persistent puzzle," said Kim McCoy Wade, chief of the CalFresh branch of the state's Department of Social Services. But she and others suggest it may be due to the less-than-optimal quality of customer service and a bulky bureaucracy.

About 4.1 million Californians, or 70 percent of those eligible, are enrolled in CalFresh. That leaves about 2 million who could be getting the benefit but aren't, according to a January report citing the 2015 federal data.

The national average is 83 percent. Several states — including Illinois, New Mexico and Oregon — report 100 percent enrollment of those who qualify for the food stamp program, known at the federal level as the Supplemental Nutrition Assistance Program, or SNAP.

Medi-Cal now serves more than 13.5 million people, or about one-third of California’s population, a number significantly boosted by Medicaid’s expansion under the Affordable Care Act. Only about 322,000 people who qualify for Medi-Cal aren't signed up, according to a 2016 report by University of California-Berkeley researchers. They estimate that more than 90 percent of those eligible for Medi-Cal who don't have another source of insurance are enrolled.

But California has begun leveraging its vast pool of new Medi-Cal beneficiaries to boost enrollment in CalFresh. Officials are building upon relationships between county welfare departments and new Medi-Cal enrollees, using electronic records on Medicaid recipients to identify food stamp candidates and then guiding them through the enrollment process.

"We are taking the successes from the Affordable Care Act and are turning to our next-biggest program and trying to apply those lessons," said McCoy Wade. "The Medi-Cal-CalFresh connection is something where we think there is a lot of room to grow."

The push comes as both programs are under threat from Washington, D.C. Just last month, Republicans in Congress unveiled a farm bill that would mandate stricter work requirements for SNAP beneficiaries. Several times over the past few years, President Donald Trump and congressional Republicans have proposed overhauling the Medicaid program to rein in costs.

The food stamp program is administered at the county level — and there are 58 counties. Only 10 states run their programs that way. "Because we are decentralized … it takes us longer to move the whole ship," McCoy Wade said.

However, that explanation does not fully address the issue in California, since Medicaid, too, is run by counties.

About 74 million Americans are on Medicaid and about 42 million people are in the food program.

"Doing things to help integrate the programs can be mutually beneficial, both for saving on administrative costs and being able to enroll more families," said Michael Katz, a research associate at the Urban Institute. SNAP and Medicaid have different eligibility rules, but they serve similar populations.

"It's not a perfect overlap, but it is a pretty close Venn diagram," said Jared Call, managing nutrition policy advocate at California Food Policy Advocates.

Several California counties have tried to be proactive in enrolling food stamp candidates. San Francisco County placed a CalFresh eligibility worker at a public hospital and a community clinic. Los Angeles County mailed over 1 million flyers to Medi-Cal recipients who potentially qualified for food stamps.

San Bernardino County has self-service kiosks and staff members at the entrances of county offices, who help people enroll in CalFresh if they are interested. "It's a one-stop shop," said Nancy Hillsdale, who manages an office in Colton, Calif.

But residents can be reluctant to apply. Some immigrants living in the country legally fear that if they receive food stamps it may affect their chances of becoming citizens later. (Undocumented immigrants don't qualify, but any family members who are citizens do.) Others feel the "stigma around food stamps," said Gladys Deloney, Sacramento County's deputy director of human services. That sentiment is not as prevalent in seeking help with medical expenses, she said.

The percentage of Medi-Cal beneficiaries enrolled in CalFresh varies widely by county. In 2016, for example, San Francisco County enrolled 31 percent of its Medi-Cal recipients in the food stamp program compared with nearly double that rate in Fresno County. A coalition of food advocates recommended last year that the state set a target for counties, and that the counties launch campaigns to raise awareness about food assistance.

In San Diego County, officials printed CalFresh materials for health fairs and sent texts to everyone who applied for Medi-Cal with a link to apply for the food benefits, said Rick Wanne, director of eligibility operations for the county. But Wanne said enrolling people in CalFresh is a lot more difficult than in Medicaid. "There is a laundry list of long-standing … rules and regulations that make it difficult to get on the program," he said.

For example, applicants for CalFresh must be re-interviewed every year and update their information every six months. Medicaid, by contrast, does annual renewals without requiring interviews.

McCoy Wade said CalFresh eliminated some of the most burdensome requirements, including providing fingerprints, and it's starting to make a difference. The state increased its participation rate from 66 percent to 70 percent in the most recent report. That occurred as the economy improved and fewer needed the help. "We are closing the gap," though there is still work to be done, McCoy Wade said.

Lack of transportation, long lines at county offices and lack of flexibility in setting appointment times may also contribute to low participation, county officials said. And paperwork often gets mailed to residences, making it harder for homeless people or those who move frequently to stay enrolled. That's what happened to 25-year-old Crystle Conant, who lives only part time at her father's house in San Bernardino County.

"When I swipe my card at the store and it gets declined, then I know," she said. "I haven't renewed in time."

KHN's coverage of these topics is supported by Blue Shield of California Foundation and California Health Care Foundation

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.