After the Russian invasion, Katie Nelha and her husband couldn't safely return to their home in Mykolaiv, Ukraine, so they took their chances as refugees. Flying from Poland, where they were working, to Mexico in early April, they crossed into the U.S. at Tijuana, where they were granted a temporary visa for humanitarian reasons.
Once in Sacramento, Nelha, 24, relied on a county translator to help her enroll in Medi-Cal, California's Medicaid program, to cover the cost of visiting an optometrist. "I need glasses to pass my eye test and get a driver's license so we can start looking for work," Nelha said through an interpreter. She plans to find a job in one of the city's dozens of Ukrainian and Russian restaurants.
The thriving Slavic communities in the California cities of Los Angeles, Sacramento, San Diego, and San Francisco have become magnets for Ukrainians fleeing war less than a year after the state experienced an influx of Afghans in response to the U.S. withdrawal from Afghanistan. Many refugees need health care immediately, for conditions such as pregnancy, high blood pressure, and diabetes or because of trauma they've recently experienced.
Earlier this year, the state Department of Health Care Services issued an advisory reminding local governments to enroll refugees in health programs because those who may not be eligible for federal services often qualify for state-administered programs, including full-coverage Medi-Cal, which covers doctor visits, vaccinations, screenings, and medications.
But the social service agencies tasked with delivering much of that care are straining to keep up with demand. Understaffed after years of dwindling funding, they're now desperate for skilled interpreters who can walk newly arrived refugees through the application process and attend clinic appointments with them.
"We have four staff who speak Russian or Ukrainian, and we really need three more to meet all the demand," said Dr. Sumi Mishra, medical director for Sacramento County's Department of Health Services. "We can't find them."
Mishra said the county's refugee health clinic is recruiting for six open positions. But because the jobs require language skills, the candidate pool is limited. And a county salary — a recent posting put the range for a Ukrainian language specialist at $37,000 to $45,000 — often can't compete with private-sector offerings. The median household income in Sacramento County is more than $70,000, according to 2020 data from the U.S. Census Bureau.
The shortage extends to other languages as well. "We can't find enough Pashto and Dari speakers [for Afghan enrollees] who will take those positions," Mishra said.
Rich Desmond, a Sacramento County supervisor whose district includes some of the unincorporated areas in which many Ukrainian immigrants have settled, said the pandemic exposed long-standing funding and staff shortages in public health. Between 2010 and 2019, public health workforce funding in the state fell 14%, according to the UC Berkeley Labor Center. And several Sacramento County health officials told KHN that they're chronically understaffed.
"It really laid bare where the gaps were," Desmond said.
The problem appears to be more severe in Sacramento County because of the influx of refugees to the region. The Los Angeles County Department of Health Services, for example, said it has enough interpreters to meet demand.
Sacramento has the highest concentration of Ukrainian immigrants in the country, according to the Migration Policy Institute, which says that about 18,000 Ukrainians reside permanently in the Sacramento area. Federal counts of the current surge say about 200 Ukrainian refugees arrived in California between October and June. But Florin Ciuriuc, executive director of the Slavic Community Center of Sacramento, said that as many as 10,000 refugees have come to the Sacramento area since the war began in late February and that the vast majority were Ukrainian.
The undercount extends statewide. County health officials and immigrant support networks put the total number of newly arrived Ukrainians in California at 20,000 or more — a 33% increase to the 60,000 Ukrainian immigrants already living in the state.
It's a continuation of a long-standing pattern. Between 2002 and 2019, California resettled more refugees than any other state, about 108,000, according to the Pew Research Center. Many of them arrived from Iran, Iraq, Laos, and Ukraine. California is home to a Southeast Asian refugee community that numbers in the hundreds of thousands and dates to the end of the Vietnam War.
More recently, the state has welcomed an influx of Afghan refugees.
Because of U.S. involvement in Afghanistan, many Afghan refugees could apply for special immigrant visas, which took time to process and gave states and counties advance notice of how many people might be coming their way and when, Desmond said.
Not so with Ukrainian refugees initially. Like Katie Nelha, many arrived in California via the U.S.-Mexico border before the Biden administration stopped allowing Ukrainians to enter there in April.
Some Ukrainians resettling in California have come through under humanitarian parole or temporary protected status — both of which qualify them for Medi-Cal. But most can claim a Medi-Cal status known as Permanently Residing Under Color of Law, or PRUCOL, to qualify for benefits. Because PRUCOL covers immigrants who have applied for a legal status but are still awaiting a response, there may be vast numbers of Ukrainians who are eligible for care — and therefore known to local health officials and immigrant networks — even though they're not officially designated as refugees.
Desmond said Sacramento County supervisors are pushing the state to free up discretionary funding to address the refugee surge. The county recently set aside $3 million to provide support services to recently arrived Afghans and may take similar action for Ukrainians.
When Afghans began settling in Sacramento last fall, the county used state funding to hire shift interpreters, part-time workers to bridge language gaps. It contracts with a half-dozen translation services to fill those spots, but Mishra, the county medical director, said hiring full-time staff would be preferable.
Refugees often have pressing health needs.
New immigrants must take a tuberculosis test within 14 days of arriving in the U.S. And common health problems include elevated lead levels in children, high blood pressure, and diabetes. Health workers also screen people for region-specific issues — such as a bacteria found in Afghanistan that leads to gastritis, and thyroid disease, a potential consequence of the Chernobyl nuclear disaster, among Ukrainians.
Mishra worries about invisible scars, too.
"Many of these people were experiencing PTSD," she said. "They were coming out of very, very traumatic situations — in some cases seeing family members die. But it's something that is not really discussed openly within their community. We often have to ask a lot of questions for that to reveal itself."
Noel Sanchez, a spokesperson for the San Francisco Department of Public Health, said doctors screen carefully for signs of depression, anxiety, and post-traumatic stress disorder.
Some of the county translators' duties include guiding newcomers through the layered U.S. health care system. When Russian refugees Andrew Dozhdev, 25, and Kivil Spassky, 21, were asked in Sacramento in June whether they had seen a doctor since fleeing their country because of their opposition to the war, both shook their heads and hesitated.
"I hope I don't need one," Dozhdev finally replied.
With county agencies understaffed and overwhelmed, the task often falls to nonprofit and community or religious groups. Dmitriy Pridyuk, senior pastor at Revival Christian Center in Sacramento's Foothill Farms area, said his church is housing about 35 immigrants on a short-term basis, providing them with a place to sleep and shower, food, and other assistance.
As for the care itself, county health officials said they are committed to serving refugees, although their staffing shortages are unlikely to be resolved soon.
"More and more families are just showing up at our doorstep," Mishra said. "We made the decision that we were not going to turn them away even if we don't have a clear read on their legal status."
This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.