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The forgotten middle: Why Californians aren’t getting the care they need
Jeffrey R. Lewis


Special to the Journal

While Sacramento continues to increase the number of people eligible for Medi-Cal, the California version of Medicaid, there’s a large, yet overlooked group that continues to miss out on healthcare. That would be California’s middle-income families (often called “the forgotten middle”). These families don’t qualify for Medi-Cal and are often forced to enroll in high-deductible health insurance plans (HDHPs). While these plans promise to offer a short-term lower cost through reduced monthly premiums, in practice, families still shoulder the burden of rising care costs through either financial or personal means.

Many families reduce their healthcare costs by delaying or skipping care and medication while enrolled in an HDHP. For those with a chronic health condition or who experience a medical emergency, that high deductible can be a financially crushing amount. Families in the forgotten middle who have HDHPs often face a difficult choice: putting the health of a child or partner first at the cost of delaying or avoiding care for another family member. In fact, a poll commissioned by Legacy Health Endowment across Merced and Stanislaus counties in April 2024 found the following distressing facts:


●       Nearly one-half (48%) of the people surveyed said that the cost of their annual deductible has had a large effect on their decisions about accessing healthcare;

●       Eight out of 10 (81%) of people with high deductibles are skipping or delaying seeking medical care or filling a prescription for themselves so they can make sure that a child or spouse /partner can have access to healthcare services;

●       One-third (33.0%) say their high insurance deductible has led them to put their own healthcare needs in jeopardy to ensure their spouse/partner or children can have full access to healthcare and

●       For those postponing their healthcare, 65% said it had had a significant effect on their overall physical health, while 68% said it had had a significant impact on their overall physical, mental, and emotional health.

Supporters of HDHPs often highlight that these plans are ideal for generally healthy individuals and encourage them to compare pricing to find the lowest-cost healthcare provider. Yet many in the forgotten middle don’t have the time or resources to negotiate their healthcare costs. There’s an enormous lack of transparent pricing in healthcare costs, and few provider groups make their costs easily accessible for the average patient.

To better serve our communities, we had to look outside of this opaque system. When we examined what our communities needed most, it was clear that they needed flexible, accessible, and affordable healthcare. That’s why Legacy Health Endowment partnered with Hello Alpha, a virtual primary care clinic, to launch Sonja Cares (  

Sonja Cares will be available to 1,500 local residents (18 and older) starting June 3rd this year. Each eligible resident will receive virtual care for over 100 medical conditions completely free of cost.

The program is uniquely designed to meet the needs of the Central Valley’s forgotten middle: all medical visits occur online, and the platform delivers care through a secure, message-based system. Instead of relying on real-time communications that involve appointments, access to private space, and limited business hours, patients submit their health information online and receive a secure message from their healthcare provider. This significantly lowers the cost of healthcare, while eliminating the most common barriers to care: time, administrative burden, unpredictable costs, and even stigma.

For many communities in Stanislaus and Merced counties, the Sonja Cares program means that individuals and families will not have to choose between their care or a loved one’s. It means that a working mom can submit her health information before her workday begins, have a treatment plan ready by the end of her shift, and still have time to take her daughter to the pediatrician. A first-generation college student working part-time can get a medication refill between classes without relying on her parent’s health insurance plan.

We need healthcare solutions that reflect the diversity of our communities and work to narrow health inequities. Around 17 million Californians fall into the forgotten middle–and they deserve healthcare, too.

The hope with Sonja Cares is to offer the forgotten middle in Stanislaus and Merced healthcare assistance that truly fits into their lives and create a program that we can continue to build on.

The need is great. The time for Sonja Cares is now.

— Jeffrey Lewis is the President and CEO of Legacy Health Endowment. The words expressed are his own. Gloria Lau, PhD is the founder of Hello Alpha.