The promise of cheaper housing brought Shari Castaneda toPalmdale, Calif., in northern Los Angeles County, about nine yearsago.

The single mom with five kids had been struggling to pay thebills. “I kept hearing that the rent was a lot cheaper out here, soI moved,” she said.

But when she developed health problems — losing her balance andfalling — Castaneda found fewer care options in her new town. Unable tofind local specialty care, she traveled nearly 65 miles to apublic hospital in Los Angeles, where doctorsdiscovered a tumor on her spine.

Then she had to drive nearly 75 miles to the City of Hope cancercenter in Duarte, Calif., for an operation to remove the growth.The procedure left her partially paralyzed. “I walked into thehospital and I never really walked again.”

Castaneda, 58, receives Social Security disability payments andis enrolled in Medi-Cal, the state’s Medicaid program forlow-income people. “There are no doctors available here,” saidCastaneda. “I called every single one of them in the book, andnobody takes Medi-Cal out here.” Instead, Castaneda now seesdoctors nearly 50 miles away in Northridge.

Suburbs in the United States, often perceived as enclaves of theaffluent, are home to nearly 17million Americans who live in poverty — more than in cities orrural areas — and growing demand for care strains the capacity ofsuburban health services to provide for them, according to arecent studyin Health Affairs. Suburban areas have historically received afraction of health funding that cities have, leaving them withinadequate infrastructure and forcing people like Castaneda toscramble for the medical attention they need.

The Health Affairs study found that about a fifth of thesuburban poor are uninsured, and many who do have health insurance— especially people on Medi-Cal — either can’t find providers ormust travel far for appointments.

The Affordable Care Act cut California’s uninsured rate from 17percent in 2013 to about 7 percent last year due largely to the Medicaid expansion,which added more than 3.7 million adults to the state’s Medi-Calrolls. But that has not ensured access to health care for millionsof suburbanites, said Alina Schnake-Mahl, a doctoral candidate atthe Harvard T.H. Chan School of Public Health in Boston, who waslead author of the Health Affairs study.

“That really goes against the idea that everyone in the suburbsis insured because everyone has a white-collar job with coverage,”she said.

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Kaiser Health News is a nonprofit news servicecovering health issues. It is an editorially independent program ofthe Kaiser Family Foundation that is not affiliated with KaiserPermanente.

Coverage doesn’t equate to care even for patients with Medi-Cal,as Castaneda can attest. Before the health law, they had troublefinding doctors who would see them because of Medi-Cal’s lowpayment rates. That problem intensified as millions more signed upfor Medi-Cal, driving many enrollees to seek services at safety-netcare facilities.

Health care services in the suburbs “are not robust enough tofill the needs” of a growing low-income population, said CharlieGillig, supervising attorney at the Health Consumer Center ofNeighborhood Legal Services of Los Angeles County, which hasadvised Castaneda about medical transportation services underMedi-Cal.

One-half of California’s 39 million residents live in suburbs,and rates of poverty among them range from nearly 25 percent aroundBakersfield, in the Central Valley, to about 8 percent in thesuburbs outside San Francisco, according to an analysis by Elizabeth Kneebone, research director atUniversity of California-Berkeley’s Terner Center for HousingInnovation and a senior fellow at the Brookings Institution. Thesame analysis showed that 2.7 million suburban Californians livedbelow the poverty line in 2016, compared with 1.9 million in majorcities.

Castaneda, who uses an oversized power wheelchair, says it’sdifficult — “often impossible” — to arrange for a ride in a van.Getting to the doctor has become a long, painful ordeal.

And that’s if she can even schedule a visit, said Castaneda,noting that she also faces long wait times for her doctor inNorthridge, a suburb that has seen an influx of patients frompoorer areas. “You can’t get an appointment when you’re sick … soI’ve just been waiting and waiting,” she said. “They told me, ‘Ifyou get sick enough, just go to the emergency room.’”

Of course, it can also be tough to get a clinic appointment orsee a specialist in cities, but in the suburbs, Gillig said,“geography exacerbates an already existing problem.”

In hisrecent book on the changing geography of poverty, Scott Allard,a professor of public policy and governance at the University ofWashington, showedthat funding for human services was as much as eight timeshigher in urban areas than in the suburbs.

California’s metropolitan areas have had many decades to buildup massive health care systems to serve the poor, including countyhospitals, federally qualified health centers and communityclinics. But the current scale of suburban poverty is a recentdevelopment.

Policymakers struggle to serve the health needs of cities ineastern Contra Costa County, about 50 miles from San Francisco. InOakley, for example, business and community leaders lobbied hardfor a new health center, which opened in 2011.

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Kaiser Health News is a nonprofit news servicecovering health issues. It is an editorially independent program ofthe Kaiser Family Foundation that is not affiliated with KaiserPermanente.

“There’s a huge need out here, especially for people who areundocumented or uninsured. They don’t have anywhere else to go,”said Leticia Cazares, regional manager for La Clinica, whichoperates the new health center. The clinic has two doctors and anurse practitioner to serve 3,000 patients, most of whom are onMedi-Cal.

Many of the people who visit community clinics like the one inOakley lack insurance, either because they are undocumentedimmigrants or because they make too much money to qualify forMedi-Cal — or subsidized coverage under Obamacare — and can’tafford it on their own.

Alex G.’s family fits both scenarios. Her husband, Edward, and8-year-old son — also named Alex — are U.S. citizens, butshe is an undocumented immigrant. The family lives in Brentwood, atown of about 60,000 in eastern Contra Costa County.

A 32-year-old community college student who declined to give herlast name for fear of deportation, Alex has applied for permanentresidency — a long process with an uncertain outcome.

Her husband has “a good job” as a programmer of industrialmachines. He has employer-based insurance, but it covers only him.For Alex and her son to be covered, the family would have to pay$1,200 a month. Given California’s high cost of living, “we justcan’t afford to pay that,” Alex said. Her husband’s salary of$70,000 is too high for Medi-Cal or Obamacare subsidies.

Alex recently experienced sharp stomach pains and had to waitseveral days for a mobile clinic that parks in front of a nearbycommunity center once a week.

Whenever her son has an ear infection or a fever, Alex takes himto the free mobile clinic. “Not having insurance, I worry all thetime about him getting sick,” she said.

Kaiser Health News is a nonprofit news servicecovering health issues. It is an editorially independent program ofthe Kaiser Family Foundation that is not affiliated with KaiserPermanente.