TO THE PRINTER: We estimated a 3/8-inch spine. We need to hold off on producing film for cover until we have a comp of the book with exact page count to judge thickness of spine. Please provide both UCLA and Ikkanda Design with a paper dummy — UCLA will need one to sign off on and Ikkanda Design will need in order to accurately set up this cover with an exact spine measure if it dif- fers at all from the 3/8-inch in this file. A T H E S TA T E O F rt cover HEALTH INSURANCE IN CALIFORNIA: Disk FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY UCLA CENTER FOR HEALTH POLICY RESEARCH 10911 WEYBURN AVENUE, SUITE 300 LOS ANGELES, CALIFORNIA 90024 PHONE: (310) 794-0909 FAX: (310) 794-2686 chpr@ucla.edu www.healthpolicy.ucla.edu E. RICHARD BROWN, PhD NINEZ PONCE, PhD THOMAS RICE, PhD SHANA ALEX LAVARREDA, MPP JUNE 2002 FUNDED BY A GRANT FROM UCLA CENTER FOR HEALTH POLICY RESEARCH THE CALIFORNIA WELLNESS FOUNDATION version 2 T H E S TA T E O F HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY E. RICHARD BROWN, PhD NINEZ PONCE, PhD THOMAS RICE, PhD SHANA ALEX LAVARREDA, MPP JUNE 2002 UCLA CENTER FOR HEALTH POLICY RESEARCH 10911 WEYBURN AVENUE, SUITE 300, LOS ANGELES, CA 90024 www.healthpolicy.ucla.edu The views expressed in this report are those of the authors and do not necessarily represent the UCLA Center for Health Policy Research, the Regents of the University of California, The California Wellness Foundation, or other funders. Suggested citation: ER Brown, N Ponce, T Rice, SA Lavarreda. The State of Health Insurance in California: Findings from the 2001 California Health Interview Survey. Los Angeles, CA: UCLA Center for Health Policy Research, 2002. Copyright © 2002 by the Regents of the University of California The UCLA Center for Health Policy Research is affiliated with the UCLA School of Public Health and the School of Public Policy and Social Research. VISIT THE CENTER’S WEB SITE AT: www.healthpolicy.ucla.edu www.chis.ucla.edu This study and report were funded by a grant from The California Wellness Foundation. The report is based on data from the 2001 California Health Interview Survey, which was supported by funds received from the State of California Department of Health Services, The California Endowment, the National Cancer Institute, the California Children and Families Commission, the Centers for Disease Control and Prevention (CDC), and the Indian Health Service. The California Health Interview Survey (CHIS) is a collaboration of the UCLA Center for Health Policy Research, the California Department of Health Services, and the Public Health Institute. TABLE OF CONTENTS Exhibits iii Executive Summary 1 Acknowledgements 7 1. The Lack of Health Insurance Coverage in California: An Overview 9 How Many Californians Lack Health Insurance Coverage? Different Time Frames Convey Policy-Relevant Perspectives 10 The California Health Interview Survey 11 2. Wide Differences in Coverage across Population Groups 13 Coverage Differences across the Lifespan 13 Universal Coverage of the Elderly — But Critical Gaps in Services Covered 16 High Uninsured Rates among Low-income Californians 17 Disparities in Coverage among Ethnic Groups 20 Even Larger Disparities in Coverage by Citizenship and Immigration Status 22 Uninsured Rates Differ Dramatically by County 28 Why Are So Many Californians Uninsured? 29 3. The State of Employment-based Health Insurance 31 Who Has Job-based Coverage? 31 Who Works and Is Still Uninsured? 33 Uninsured Workers: Who’s Not Offered, Who’s Not Eligible, and Who Doesn’t Take Up Job-based Coverage? 39 Why Don’t Employees Take Up Their Employer’s Health Plan? 40 Conclusion 41 UCLA CENTER FOR HEALTH POLICY RESEARCH i TABLE OF CONTENTS 4. Medi-Cal and the Healthy Families Program 43 The Patchwork Quilt 43 The Importance of Medi-Cal and Healthy Families to Children 44 Uninsured Children and Adults Who Are Eligible for Medi-Cal or Healthy Families 45 Characteristics of Uninsured Children and Adults Who Are Eligible for Medi-Cal or Healthy Families 47 Where Do Eligible Families Live? 49 Why Aren’t Eligible Children Enrolled? 51 5. The Consequences of Not Having Health Insurance 53 California’s Population as a Whole 53 Californians with Particular Health Problems 58 6. Public Policies that Expand Coverage for Children and Adults 61 Is There Cause for Optimism? 61 Public Policy Tools to Expand Coverage 61 Conclusion 66 Appendix. Survey Methods and Effects on Results 67 ii THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBITS Exhibit 1. Percent and Number of Persons Uninsured by Age Group, All Ages, California, 2001 9 Exhibit 2. Health Insurance Coverage of the Nonelderly Population, Ages 0–64, California, 2001 13 Exhibit 3. Health Insurance Coverage by Age Group, Ages 0–64, California, 2001 14 Exhibit 4. Health Insurance Coverage by Detailed Age Group, Ages 0–64, California, 2001 15 Exhibit 5. Health Insurance Coverage and Percent with Prescription Drug and Dental Coverage, Ages 65 and Over, California, 2001 16 Exhibit 6. Health Insurance Coverage by Family Income Relative to Federal Poverty Level, Ages 0–64, California, 2001 18 Exhibit 7. Percent with Health Care Coverage All Year Round by Family Income, Children and Adults, Ages 0–64, California, 2001 19 Exhibit 8. Health Insurance Coverage by Race and Ethnic Group, Ages 0–64, California, 2001 20 Exhibit 9. Health Insurance Coverage by Race/Ethnic Group and Family Income Relative to Federal Poverty Level, Ages 0–64, California, 2001 21 Exhibit 10. Percent with Health Care Coverage All Year Round by Race/Ethnic Group, Children and Adults, Ages 0–64, California, 2001 22 Exhibit 11. Health Insurance Coverage of Nonelderly Adults by Own Citizenship and Immigration Status, Ages 18–64, California, 2001 23 Exhibit 12. Health Insurance Coverage of Children by Family Citizenship and Immigration Status, Ages 0–17, California, 2001 24 Exhibit 13. Health Insurance Coverage by English Proficiency, Ages 0–64, California, 2001 25 Exhibit 14. Percent of Children and Adults Uninsured at Time of Interview by County, Ages 0–64, California, 2001 26-27 Exhibit 15. Reasons Persons Do Not Have Coverage Among Uninsured at Time of Interview and Uninsured at Some Time during the Year, Ages 0–64, California, 2001 29 Exhibit 16. Percent of Adults with Job-based Health Insurance, Ages 18–64, California, 2001 32 Exhibit 17. Offer, Eligibility, and Take-up Rates among Employees for Own Job-based Health Insurance by Demographic Characteristics, Ages 18–64, California, 2001 34-35 UCLA CENTER FOR HEALTH POLICY RESEARCH iii EXHIBITS Exhibit 18. Distribution of Uninsured Employees by Access to Own Job-based Insurance and by Selected Demographic and Labor Market Characteristics, Ages 18–64, California, 2001 38-39 Exhibit 19. Reasons Eligible Employees Do Not Participate in Employer Health Plans, Employees, Ages 18–64, California, 2001 41 Exhibit 20. Medi-Cal and Healthy Families Income Eligibility as a Percent of Federal Poverty Guidelines for Families with Children and for Pregnant Women, California, 2001 43 Exhibit 21. Health Insurance Coverage by Race and Ethnic Group, Ages 0–18, California, 2001 45 Exhibit 22. Eligibility for Medi-Cal and the Healthy Families Program, Uninsured Nonelderly Persons by Age Group, Ages 0–64, California, 2001 46 Exhibit 23. Nonelderly Persons by Eligibility for and Enrollment in Medi-Cal and the Healthy Families Program and by Race/Ethnic Group, Ages 0–18, California, 2001 47 Exhibit 24. Language Spoken at Home and English Proficiency among Uninsured Children and Adults Who Are Eligible for Medi-Cal and the Healthy Families Program, Ages 0–64, California, 2001 48 Exhibit 25. Approximate Number of Uninsured Children and Parents Who Are Eligible for Medi-Cal or the Healthy Families Program by County, Ages 0–64, California, 2001 50 Exhibit 26. Reasons Uninsured Eligible Children Are Not Enrolled in Medi-Cal or the Healthy Families Program, Ages 0–18, California, 2001 52 Exhibit 27. Self-reported Health Status by Insurance Type, Ages 18–64, California, 2001 53 Exhibit 28. Self-reported Health Status by Insurance Type, Ages 0–17, California, 2001 54 Exhibit 29. Usual Source of Care by Insurance Type, Ages 18–64, California, 2001 55 Exhibit 30. Reasons for No Usual Source of Care by Insurance Type, Ages 18–64, California, 2001 55 Exhibit 31. Usual Source of Care by Insurance Type, Ages 0–17, California, 2001 56 Exhibit 32. Visits to a Doctor in the Past 12 Months among People in Fair/Poor Health by Insurance Type, Ages 18–64, California, 2001 57 Exhibit 33. Delays of Health Care by Insurance Type, Ages 18–64, California, 2001 57 Exhibit 34. Respondents with Selected Chronic Diseases by Access Indicator and Insurance Type, Ages 18–64, California, 2001 58 iv THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY Exhibit A-1. Uninsured Persons by Age Group Based on 2001 California Health Interview Survey and March 2001 Current Population Survey, All Ages, California 69 Exhibit A-2. Percent of 2001 California Health Interview Survey Completed, California Unemployment Rate, and Medi-Cal and Healthy Families Enrollees by Month 71 Exhibit A-3. Percent Comparisons of the Unweighted CHIS Sample to the 2000 Census for Seven Race Categories 74 Exhibit A-4. Health Insurance Coverage Estimates for Children and Nonelderly Adults for 2001 California Health Interview Survey, March 2000 and 2001 Current Population Surveys, and 1999 National Survey of America’s Families, California 75 Exhibit A-5. State Survey’s Point-in-Time and the CPS’s Annual Estimates of Uninsurance 76 UCLA CENTER FOR HEALTH POLICY RESEARCH v vi THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXECUTIVE SUMMARY summary An estimated 4,519,000 Californians lacked health insurance access to health care services. To make CHIS more inclusive at the time they were interviewed in 2001 based on data and to capture the rich diversity of the California population, from the new California Health Interview Survey (CHIS the questionnaires were translated and interviews were 2001). An additional 1,753,000 persons were insured when conducted in six languages: English, Spanish, and four Asian interviewed, but were uninsured during at least some of the languages. The data provide a level of detail and precision preceding 12 months. Thus, a total of 6.3 million never before available to describe and understand health Californians experienced lack of coverage during at least insurance and uninsurance within California. some part of a year. The determination of how many Californians are uninsured depends on the time frame used to make the s Employment-based health insurance remains critically estimate. CHIS asks respondents questions about their health important, covering nearly two-thirds of all nonelderly insurance coverage or lack of coverage at the time of the adults and children in California (18.7 million). interview, and an additional set of questions that focuses on s Medi-Cal and Healthy Families combined cover 16% of health insurance coverage and uninsurance during the Californian children and adults under 65 — a total of preceding 12 months. These extensive questions enable 4.65 million nonelderly persons. researchers to examine coverage from several time frames. Each time frame reflects a different policy-relevant s Despite the important role these sources of coverage play, perspective. We focus primarily on three time frames: the together with privately purchased insurance and some 4.5 million persons who were uninsured at the time they additional public programs, 15.2% of nonelderly were interviewed (the “average monthly caseload” of Californians remain uninsured. uninsured persons who at a given time may need to be served by safety-net health care providers or health DIFFERENT TIME FRAMES CONVEY insurance programs); the 6.3 million persons who were POLICY-RELEVANT PERSPECTIVES uninsured at any time in the last 12 months (the “annual This report examines health insurance coverage in California caseload” of uninsured persons over the course of a year based on CHIS 2001 data. CHIS 2001 provides new time whom the safety net may need to serve); and the 3.6 million frames and a rich source of data with which to better persons who were uninsured throughout the last 12 months understand health insurance coverage and the lack of (the core group with persistent lack of coverage). coverage for California’s diverse population, both statewide and at the local level. CHIS covers a broad range of public health concerns, including health status and conditions, health-related behaviors, health insurance coverage, and UCLA CENTER FOR HEALTH POLICY RESEARCH 1 WIDE DIFFERENCES IN COVERAGE ACROSS s American Indians and Alaska Natives’ relatively low rate POPULATION GROUPS of job-based insurance (54.4%) results in a high Uninsured rates decline as income rises, falling from 30.0% uninsured rate (17.8%) despite a relatively high rate of of nonelderly persons below the federal poverty level to 5.8% Medi-Cal and Healthy Families coverage. for persons with incomes 300% or more above that level. Health insurance disparities are even greater among persons s More than 3 million Californians who are uninsured have of different citizenship and immigration statuses. annual incomes that do not exceed 200% of the poverty level — that is, up to $23,118 for a family of two and s Half of all nonelderly adults who are noncitizens without $28,258 for a family of three. “green cards” are completely uninsured (51.2%), one- and-a-half times the rate for noncitizens who have Differences in access to employment-based health insurance, obtained their green cards (32.3%) and nearly five times as well as to Medi-Cal and Healthy Families, result in the rate for U.S.-born citizens (11.3%). Children’s disparities in health insurance coverage among California’s coverage also differs based on their own and their diverse racial and ethnic groups. parents’ citizenship and immigration status. s Among the nonelderly population, whites have the Finally, uninsured rates vary dramatically by county of highest rate of job-based insurance (75.4%) and the residence, reflecting distinct differences among the regions lowest rate of uninsurance (8.6%). within California. s At the other extreme, Latinos have the lowest rate of s Driven by a strong economy and tight labor market, the job-based insurance (42.3%) and the highest uninsured nine-county Greater Bay Area has the lowest uninsured rate (28.3%). rate (8.9% of the nonelderly population). Exceptions to s Six in 10 African Americans (60.2%) have health this profile are San Francisco County (13.1%) and insurance obtained through their own or a family Sonoma County (11.8%). member’s job, and another one in four (27.6%) is s The four-county Sacramento Area also has a low rate of enrolled in Medi-Cal or Healthy Families, leaving a uninsurance (9.1%). The northern and Sierra counties relatively low rate of uninsurance (9.5%). nearly all share moderately high rates of uninsurance, s Two-thirds of Asian Americans have job-based insurance averaging 15.0%. (66.3%), but they are less likely than African Americans s The San Joaquin Valley has an uninsured rate (16.4%) to be covered by Medi-Cal or Healthy Families, resulting that is nearly twice that of the Bay Area, led by Tulare in an uninsured rate of 13.0% of nonelderly Asians. County (20.4%). The Central Coast is also high (15.7%), Native Hawaiians and other Pacific Islanders have led by Santa Barbara (20.1%). coverage rates similar to those of Asians. 2 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY s Los Angeles County remains the epicenter of uninsurance s U.S.-born workers enjoy the highest level of offer (88.6%) in California and the nation. One in five nonelderly and take-up (84.9%) rates. Naturalized citizens residents of the county is uninsured — more than experience offer, eligibility, and take-up rates very similar 300,000 children and nearly 1.4 million adults. The rest to those of U.S.-born citizens, with even higher eligibility of Southern California (15.6%) also has high uninsured rates (93.9% for naturalized citizens vs. 90.3% for U.S.- rates in all the counties that comprise that region. born citizens). s Noncitizens without “green cards” have the lowest offer THE STATE OF EMPLOYMENT-BASED HEALTH rate (50.4%) for all sociodemographic and labor market INSURANCE groups. However, if they do work for a firm that offers We identified three main reasons some employees have coverage, these immigrants experience no significant coverage through their employment while others do not. disadvantage in eligibility, and they accept coverage at Do they work in firms that offer health insurance to their rates comparable to U.S.-born workers. employees (offer rate)? For employees that do work in establishments that offer health insurance, do their employers s A wide spread exists between the highest and the lowest deem them eligible for benefits (eligibility rate)? Even if they offer rates by income (43 percentage points), education level are eligible, do employees accept the health benefits offered (36 percentage points), and wages (22 percentage points). and pay the required contributions, if any (take-up rate)? While there are variations in offer, eligibility, and take-up More than 1.85 million workers (14.5%) are still uninsured, rates, the likelihood of working in a firm that offers health comprising over half (51.1%) of all uninsured adults. insurance is clearly the key contributor to disparate Among uninsured employees, 61.6% were employed in coverage rates. firms that did not offer health insurance, and 24.3% worked for firms that offered health benefits but were not eligible s California’s African Americans and whites have the for them. Among those who worked for firms that offered highest offer rates, 90.7% and 88.8%, respectively. benefits for which they were eligible, 14.1% did not take up s Latino employees have the lowest job-based coverage health insurance coverage from their employers. compared to all other race and ethnic groups, largely a s Among uninsured workers, the economically vulnerable result of a low offer rate (70.4%). American Indians and groups are most likely to work in firms that do not offer Alaska Natives (81.8%) and Asian Americans and Pacific health benefits — Latinos (70.3%), noncitizens without Islanders (84.1%) also experience low offer rates. green cards (82.5%), workers earning the lowest wages (65.2%), agricultural industry workers (81.8%), and employees of very small firms (83.5%). UCLA CENTER FOR HEALTH POLICY RESEARCH 3 MEDI-CAL AND THE HEALTHY FAMILIES PROGRAM Parents of nearly one in four uninsured children eligible for The Medi-Cal and Healthy Families programs, along with Healthy Families did not know of the program’s existence, numerous related health insurance safety-net programs, suggesting a continuing need to give this program visibility have been stitched together like a patchwork quilt. This quilt among target populations. consists of an important, but fragmented and confusing, Among the nearly 3.5 million uninsured adults ages array of programs that together cover more than one in four 19-64, approximately 413,000 parents and 52,000 other children, more than one in 10 nonelderly adults, and nearly adults are eligible for Medi-Cal under existing policies. one in five elderly Californians. Altogether, more than 1.1 million uninsured children and adults are currently eligible for coverage through either s Latino children are more than three times as likely as Medi-Cal or Healthy Families. whites to depend on Medi-Cal (34.4%) and Healthy Families (7.6%) for their coverage, with an uninsured rate THE CONSEQUENCES OF NOT HAVING of 18.7%. Coverage for American Indian and Alaska Native HEALTH INSURANCE children follows a pattern similar to that of Latinos: fairly A significant relationship exists between insurance status high coverage through Medi-Cal (30.3%) and Healthy and self-reported health status for adults and children (ages Families (4.8%) and a high uninsured rate (15.0%). 0-17). In general, those with Medi-Cal rate their health as s A small proportion of African-American children are poorest – which is not surprising given that poorer uninsured (3.2%), a result of a high total enrollment in individuals tend to be less healthy and that the disabled Medi-Cal and Healthy Families (42.7%). population is over-represented in Medi-Cal. The uninsured also report lower health status compared to the other s Asian-American and Pacific Islander children have lower groups, and among children are the least healthy group. rates of enrollment in Medi-Cal (18.8%) and greater enrollment in Healthy Families (6.0%), but they are s Just over one-third of uninsured adults (35.6%) report protected by relatively strong employment-based their health to be excellent or very good, a much smaller coverage, resulting in an uninsured rate of 6.29% that is proportion than those with job-based insurance (61.2%). statistically the same as that for white children (4.8%). One-fourth of adults without insurance report fair or poor health (25.9%), which is much higher than for adults Of the nearly 1 million uninsured children under age 19 in with job-based coverage (10.5%). California, an estimated 355,000 are eligible for Medi-Cal s Over three-fourths of children with job-based coverage and another 301,000 are eligible for the Healthy Families report their health as excellent or very good (75.5%); this Program. Approximately one-third are not eligible for these is true of less than half of uninsured children (45.8%). programs either because their incomes exceed the eligibility Uninsured children are also more than three times as level for Healthy Families (161,000 children) or because they likely (17.8%) to report fair or poor health status as those are not citizens and have no “green card” (180,000 children). with job-based coverage (4.8%). 4 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY In spite of their poorer health status, the uninsured are s More fully engage community-based organizations, much less likely than the insured to report a usual source of churches, and schools in culturally appropriate outreach, medical care, and among those that do that source is and expand funding for these efforts. Local jurisdictions considerably less likely to be a doctor’s office. can generate local resources and innovation to expand coverage of their residents. s Nearly half (45.0%) of uninsured adults list no usual source of care, which is three times as high as any of the s Continue the policy dialogue of the State Health Care other four insurance categories. Options Project established by SB 480 by examining alternative ways to insure all Californians. s Among all nonelderly, the uninsured and those with Medi-Cal coverage are at least three times as likely to list California is squeezed by a fiscal dilemma: it has a persistent a clinic or community-based hospital as their major and large problem of uninsurance, and it faces an extraordi- source of coverage as those with job-based or individually narily large shortfall in tax revenues. The budget problems purchased coverage. This shows the continuing may discourage the State from expanding its efforts to importance of safety-net clinics and hospitals for the provide coverage, and this may lead to rescission of already uninsured and those with Medi-Cal and Healthy Families adopted expansions and reform. However, in the longer run coverage. California and the nation must commit to extending to all residents affordable coverage that provides good access to PUBLIC POLICIES TO EXPAND COVERAGE FOR high-quality, health-enhancing care. Although there are CHILDREN AND ADULTS costs to ensuring that all residents have coverage, there are Our recommendations focus on the State’s process to greater costs associated with a large portion of our stimulate public dialogue on ways to improve and expand population remaining uninsured — lost earnings, lost our public health insurance coverage programs and to move school days, lost potential, and lost life. toward universal coverage. We believe that California will achieve its best results if it uses existing and emerging opportunities to expand its public coverage programs. s Cover entire families, including children and parents, by implementing the Healthy Families expansion to parents and eliminating the assets test for parents applying for Medi-Cal. s Reduce fragmentation for families by integrating Medi- Cal and Healthy Families. UCLA CENTER FOR HEALTH POLICY RESEARCH 5 6 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY acknowledgements ACKNOWLEDGEMENTS The authors are grateful for the assistance of a number of people who contributed to the report’s analyses or preparation. Wei Yen, PhD, coordinated the statistical programming with the assistance of Elizabeth Loughren; Jenny Chia, PhD, conducted the majority of analyses for the report; and Lida Becerra, MS, Lu-May Chiang, and Stanley Yuen all assisted with data analysis. Jeff Luck, PhD, Jennifer Kincheloe, MPH, Wei Yen, PhD, and Rong Huang, MS, developed the variable to estimate eligibility for Medi-Cal and Healthy Families. Hongjian Yu, PhD, provided statistical consultation. Marianne Cantwell, MPP, and Karen Markus assisted with project management. Paula Y. Bagasao, PhD, provided oversight for communications and production and Clodagh Harvey, PhD, provided the editorial review. Many thanks also go to Ikkanda Design Group for designing the report and to Dan Page for media services. Special thanks are due to Richard Kronick, PhD, Roberta Wyn, PhD, and Sandra Shewry for their thorough and enormously helpful critical review of a draft of the report. We are deeply grateful for the generous support of the project provided by The California Wellness Foundation and especially our program officer, Ruth Holton. Despite the important contributions of all these colleagues, which made this report possible, any errors or omissions are the responsibility of the authors. UCLA CENTER FOR HEALTH POLICY RESEARCH 7 8 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY 1. THE LACK OF HEALTH INSURANCE COVERAGE IN CALIFORNIA: AN OVERVIEW HELEN H. SCHAUFFLER, PH.D., AND SARA 1 MCMENAMIN, MPH E. Richard Brown An estimated 4,519,000 Californians were uninsured in 2001, CHIS 2001 provides new time frames and a rich source based on data from the 2001 California Health Interview of data with which to better understand health insurance Survey (CHIS 2001) — none of whom had either private coverage and the lack of coverage for California’s diverse health insurance or coverage through a public program at the population, both statewide and at the local level. The data time they were interviewed (Exhibit 1, column A). In addition provide a level of detail and precision never before available to those who were uninsured at the time they were interviewed, to describe and understand rates of health insurance and an additional 1,753,000 persons experienced uninsurance at uninsurance within California. least sometime during the preceding 12 months (Exhibit 1, This report examines health insurance coverage in column B). Thus, a total of 6.3 million Californians California based on CHIS 2001 data. We pay particular experienced lack of coverage for all or some of a year attention to the lack of insurance, sources of coverage, and (Exhibit 1, column C). 1 eligibility for public programs. The report begins with an EXHIBIT 1. PERCENT AND NUMBER OF PERSONS UNINSURED BY AGE GROUP, ALL AGES, CALIFORNIA, 2001 UNINSURED AT INSURED AT TIME TOTAL UNINSURED UNINSURED DURING TIME OF OF INTERVIEW BUT AT TIME OF INTERVIEW ALL OF LAST INTERVIEW UNINSURED AT OR AT SOME TIME 12 MONTHS** SOME TIME DURING DURING LAST LAST 12 MONTHS 12 MONTHS* (A) (B) (C) (D) AGES 0–64 15.2% 5.8% 21.1% 12.2% 4,501,000 1,719,000 6,220,000 3,623,000 AGES 0–17 9.6% 4.7% 14.3% 7.3% 880,000 428,000 1,308,000 675,000 AGES 18–64 17.7% 6.3% 24.1% 14.4% 3,620,000 1,290,000 4,911,000 2,947,000 AGES 65 AND OVER 0.5% 1.0% 1.5% 0.5% 18,000 35,000 53,000 17,000 ALL AGES 13.7% 5.3% 19.0% 11.0% 4,519,000 1,753,000 6,272,000 3,640,000 Populations are weighted estimates based on the 2000 Census. Note: Numbers may not add to total due to rounding. * Includes persons who were uninsured at the time of the interview and Source: 2001 California Health Interview Survey persons who had coverage at the time of the interview but were uninsured during all or some of the preceding 12 months (C = A+B) ** Includes persons who were uninsured at the time of the interview and those who were uninsured during all of the preceding 12 months 1 Estimates of the number of persons who are uninsured at any point in time are based on persons who were uninsured at the time of the interview, while estimates of persons who are uninsured for all or part of the year include those were uninsured at the time of the interview or during the preceding 12 months. UCLA CENTER FOR HEALTH POLICY RESEARCH 9 overview of health insurance coverage in California. The Each time frame reflects a different policy-relevant overview in Section 2 includes a detailed examination of perspective. We will focus primarily on three of these time uninsurance and sources of current coverage for children and frames. The 4.5 million persons who were uninsured at the adults, including who is uninsured, why they are uninsured, time they were interviewed (Exhibit 1, column A) may be and how long their uninsurance lasts. Section 3 examines regarded as the “average monthly caseload” — the number of employment-based health insurance closely, including who uninsured persons at a given time who may need to be served has it and who does not. Section 4 focuses on Medi-Cal by safety-net health care providers or health insurance (California’s Medicaid program) and Healthy Families programs. The 6.3 million persons who were uninsured at (California’s State Children’s Health Insurance Program, also any time in the last 12 months (Exhibit 1, column C) may be called SCHIP); in this section we examine who is enrolled in thought of as the “annual caseload” — the number of these public coverage programs and estimate who is uninsured persons over the course of a year whom the safety uninsured but eligible to enroll. Section 5 assesses the net may need to serve. The 3.6 million persons who were consequences of lack of insurance on the access to health care uninsured throughout the last 12 months (Exhibit 1, column for uninsured children and adults. Finally, Section 6 offers D) represent the core group with persistent lack of coverage. recommendations to expand coverage to uninsured About one in 10 (9.6%) children under the age of 18 was Californians. Throughout the report we focus on estimates of uninsured at time of interview: a total of 880,000 children uninsurance and health insurance coverage at the time of the (average monthly caseload). Including those who were interview unless otherwise noted. insured at the time of the interview but who were uninsured for at least some of the preceding 12 months (annual HOW MANY CALIFORNIANS LACK HEALTH caseload), a total of 1,308,000 (14.3% of the state’s children) INSURANCE COVERAGE? DIFFERENT TIME FRAMES experienced lack of coverage at some time during the year CONVEY POLICY-RELEVANT PERSPECTIVES (Exhibit 1). About half that number of children — a total of The determination of how many Californians are uninsured 675,000 — were uninsured throughout the year. depends on the time frame used to make the estimate. CHIS Nonelderly adults are more likely than children to be asks respondents questions about their health insurance uninsured: 3.6 million (17.7% of all nonelderly adults ages coverage or lack of coverage at the time of the interview, and 18–64) were uninsured at the time they were interviewed an additional set of questions that focuses on health (average monthly caseload), and a total of 4.9 million insurance coverage and uninsurance during the preceding 12 (24.1%) were uninsured at some time during the year months. This extensive set of questions enables researchers to (annual caseload). More than 2.9 million were uninsured examine coverage from several time frames. during the entire 12 months leading up to the interview. 10 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY The elderly are the least likely to be uninsured at any CHIS covers a broad range of public health concerns, time — thanks to Medicare, the federal social security health including health status and conditions, health-related insurance program for the elderly and permanently disabled behaviors, health insurance coverage, and access to health nonelderly adults. Less than 1% of the elderly were uninsured care services. To make CHIS more inclusive and to capture when they were interviewed, and an additional 1.5% were the rich diversity of the California population, the question- uninsured during some portion of the previous 12 months. naires were translated and interviews were conducted in six languages: English, Spanish, Chinese (both Mandarin and THE CALIFORNIA HEALTH INTERVIEW SURVEY Cantonese dialects), Vietnamese, Korean, and Khmer The estimates of uninsurance based on CHIS 2001 data (Cambodian). Questionnaires were also reviewed by expert differ from estimates of uninsurance based on the Current teams to ensure that question wording was culturally Population Survey (CPS). The CPS is the data source appropriate for a variety of population groups. In addition, previously used by the UCLA Center for Health Policy special community outreach campaigns were conducted in Research for its annual reports on health insurance coverage, appropriate languages targeting communities of color to and the lack of it, in California. The CPS differs from CHIS encourage the participation of populations that often have in a number of important ways, which are described and low participation rates in surveys. discussed in the Appendix to this report. Below we describe CHIS is a collaboration of the UCLA Center for Health CHIS itself. Policy Research, the California Department of Health This report is based on analyses of data from the CHIS Services, and the Public Health Institute. Funding for CHIS 2001 telephone survey. The findings are based on the CHIS 2001 has been provided by the California Department of 2001 random-digit dial (RDD) sample which included Health Services, the National Cancer Institute, The California interviews in more than 55,000 randomly selected Endowment, the California Children and Families households drawn from every county in California. CHIS is Commission, the Centers for Disease Control and Prevention the largest health survey ever conducted in any state and one (CDC), and the Indian Health Service. (For more of the largest in the nation. In each household, one adult was information on CHIS, please see the Appendix or visit randomly selected for interview (the “sample adult”). In www.chis.ucla.edu.) households with children, CHIS also interviewed one adolescent age 12–17 (the “sample adolescent”) and obtained information for one child under age 12 (the “sample child”) by interviewing the adult who is most knowledgeable about the child. The RDD survey began at the end of November 2000 and was completed in October 2001. UCLA CENTER FOR HEALTH POLICY RESEARCH 11 12 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY 2. WIDE DIFFERENCES IN COVERAGE ACROSS POPULATION GROUPS 2 E. Richard Brown and Shana Alex Lavarreda Employment-based health insurance remains a critically Californians remain uncovered for medical expenses. The important source of coverage for the nonelderly absence of such coverage is a serious obstacle to people population. Nearly two-thirds of all nonelderly adults and receiving the health services they need, as demonstrated by children in California — 18.7 million in all — obtain health a large and consistent body of research as well as by insurance through their own or a family member’s evidence from the 2001 California Health Interview Survey employment (Exhibit 2). But public programs, mainly presented in Section 5. Medi-Cal and Healthy Families, are also important sources of coverage for the nonelderly, as Medicare is for the elderly. COVERAGE DIFFERENCES ACROSS THE LIFESPAN Together, Medi-Cal and Healthy Families cover 16% of Job-based health insurance covers a somewhat larger California’s nonelderly adults and children — a total of 4.65 proportion of nonelderly adults than children: 58.9% for million people. children vs. 65.1% for adults at the time of the interview. Despite the important role these sources of coverage But Medi-Cal and Healthy Families protect two-and-a-half play, together with privately purchased insurance and some times the proportion of children as nonelderly adults: additional public programs, 4.5 million nonelderly 27.6% of children are covered by Medi-Cal and another EXHIBIT 2. HEALTH INSURANCE COVERAGE OF THE NONELDERLY POPULATION, AGES 0-64, CALIFORNIA, 2001 Other Public Coverage Uninsured 1% 15% 348,000 4,501,000 Privately Purchased Medi-Cal Insurance 14% 5% 4,193,000 1,408,000 Healthy Families 2% Job-based Insurance 458,000 63% 18,718,000 Populations are weighted estimates based on the 2000 Census. Note: Numbers may not add to total due to rounding. Source: 2001 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH 13 EXHIBIT 3. HEALTH INSURANCE COVERAGE BY AGE GROUP AGES 0–64, CALIFORNIA, 2001 , AGE GROUP (IN YEARS) 0–17 18–64 0–64 UNINSURED 9.6 17.7 15.2 MEDI-CAL 22.8 10.3 14.2 HEALTHY FAMILIES 4.8 <1.0 1.6 JOB-BASED INSURANCE 58.9 65.1 63.2 PRIVATELY PURCHASED INSURANCE 2.9 5.6 4.8 OTHER PUBLIC COVERAGE 1.2 1.2 1.2 TOTAL 100% 100% 100% POPULATION IN 2000 9,203,000 20,422,000 29,625,000 Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey 4.8% by Healthy Families compared to just over 10% for Uninsurance is low among young children, rises into nonelderly adults. The net result is that a much smaller young adulthood, and then declines with increasing age. In proportion of California’s children are uninsured than are California, approximately 536,000 children up to age 11 nonelderly adults — due largely to differences in eligibility (8.6% of all children in this age group) are uninsured for these two federally supported, state-administered public (Exhibit 4). Children in this age group who do not receive programs. Children are also more likely than nonelderly employment-based health insurance through a parent are adults to be insured all year round: 85.3% of children vs. better protected than any other group by Medi-Cal and the 76.0% of adults. Healthy Families Program. Nearly six in 10 (57.9%) have Uninsured rates vary considerably across age groups job-based insurance, but another 24.6% are covered by as well as across ethnic groups and by income and other Medi-Cal and 5.0% by Healthy Families. social characteristics. Differences in uninsured rates are Adolescents ages 12-17 also benefit from their driven primarily by differences in employment-based parents’ job-based insurance, which covers 60.8%, but they insurance and, to a lesser extent, by eligibility rules for are not as well protected by Medi-Cal or Healthy Families as public coverage programs like Medi-Cal and Healthy are younger children. As a result, adolescents have a higher Families. These differences are related to social characteristics, uninsured rate, 11.7%, leaving about 334,000 with no economic factors, and public policies — to a large extent private or public coverage. irrespective of individuals’ need for health services. 14 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 4. HEALTH INSURANCE COVERAGE BY DETAILED AGE GROUP AGES 0–64, CALIFORNIA, 2001 , AGE GROUP (IN YEARS) 0–11 12–17 18–24 25–34 35–44 45–54 55–64 UNINSURED 8.6 11.7 27.4 21.9 15.5 12.2 10.9 MEDI-CAL 24.6 18.9 14.8 10.4 8.9 8.1 10.8 HEALTHY FAMILIES 5.0 4.3 0.6 N/A N/A N/A N/A JOB-BASED INSURANCE 57.9 60.8 50.8 62.3 69.7 72.0 68.2 PRIVATELY PURCHASED INSURANCE 2.9 2.8 4.5 4.5 5.2 6.6 8.2 OTHER PUBLIC COVERAGE 1.0 1.5 1.8 0.9 0.8 1.2 2.0 TOTAL 100% 100% 100% 100% 100% 100% 100% POPULATION IN 2000 6,252,000 2,952,000 3,262,000 5,106,000 5,305,000 4,250,000 2,498,000 Note: Numbers may not add to 100% due to rounding. N/A = not applicable (age group not eligible for Healthy Families Program at this time) Source: 2001 California Health Interview Survey Among young adults ages 18-24, only one in two Coverage of adults improves with increasing age. (50.8%) receives health insurance through their own or a Employment-based health insurance coverage rises to 62.3% family member’s employment, the lowest rate among all age for those ages 25-34, to 69.7% for those 35-44 years of age, groups. Many young adults are covered by a parent or spouse, and then to 72.0% for those ages 45-54. Eligibility for Medi- but a small proportion of those who enter the workforce Cal declines across this age span, and the private purchase obtain their own job-based coverage. Half of young adults of health insurance increases slightly among those without with employment-based coverage obtain it as primary access to employer health benefits. Among adults ages 55-64, enrollees, compared to about three-fourths of adults above job-based insurance coverage declines to 68.2%, the result of age 24. Those who do not receive health benefits from their a combination of retirement, disability, and changes in employer may be covered by privately purchased health family circumstances, such as divorce or the death of a insurance, but this is financially out of reach for many spouse, that result in loss of employment-based coverage. young adults who are just entering the labor market or are As these life changes occur, individuals respond by buying in college. Medi-Cal and Healthy Families eligibility private health insurance if they can afford it, enrolling in provisions exclude those in the upper part of this age span, Medi-Cal if they are disabled and have very low incomes, or leaving approximately 895,000 uninsured — one in four going without coverage at a time of increasing need for young adults (27.4%), the highest rate among all age groups. health care. UCLA CENTER FOR HEALTH POLICY RESEARCH 15 Younger men are somewhat more likely than younger not have Medicare coverage, including just 0.5% who are women to be covered by employment-based health insurance, completely uninsured. The fact that Medicare is a social but younger women are twice as likely as young men to have insurance program open to virtually all persons who reach Medi-Cal coverage and thus are considerably less likely than age 65 accounts for its universality. young men to be uninsured. The gender difference in Despite Medicare’s near-universal coverage, many uninsured rates disappears with increasing age as job-based elderly Californians are inadequately covered for essential coverage increases for both men and women, and as Medi- health services, particularly given the growing health-care Cal coverage declines for women. needs that come with advancing age. Approximately 6.5% of Californians age 65 and over — more than 200,000 seniors UNIVERSAL COVERAGE OF THE ELDERLY — BUT in all — have only Medicare coverage, leaving a large gap in CRITICAL GAPS IN SERVICES COVERED their coverage due to Medicare’s deductibles and Nearly everyone age 65 and over receives Medicare. Seven in copayments and the lack of prescription drug benefits. 10 (70.0%) of the elderly report that they have Medicare About nine in 10 elderly Medicare beneficiaries report and some type of private coverage, including Medicare that they have prescription drug coverage, including about HMOs, and another 18.5% have both Medicare and Medi- half of seniors who have only Medicare coverage (Exhibit 5). Cal (Exhibit 5). Only 4.4% of the elderly report that they do Unfortunately, people's knowledge of their health insurance EXHIBIT 5. HEALTH INSURANCE COVERAGE AND PERCENT WITH PRESCRIPTION DRUG AND DENTAL COVERAGE, AGES 65 AND OVER, CALIFORNIA, 2001 HEALTH INSURANCE COVERAGE % OF GROUP WHO REPORT % OF GROUP WHO REPORT PRESCRIPTION DRUG COVERAGE DENTAL CARE COVERAGE MEDICARE AND PRIVATE INSURANCE 70.0 83.0% 47.7% MEDICARE AND MEDI-CAL 18.5 84.8% 49.2% MEDICARE ONLY 6.5 49.7% 24.8% OTHER COVERAGE ONLY 4.4 91.0% 61.1% UNINSURED 0.5 N/A 8.9% TOTAL 100% 81.6% 46.8% POPULATION IN 2000 3,426,000 Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey 16 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY benefits is limited. This is true of the working-age population, The absence of coverage for prescription drugs is a most of whom do not understand key aspects of their particularly serious problem for persons with chronic managed care plans. It is even more true of Medicare illnesses —cancer, diabetes, asthma, hypertension, or AIDS, beneficiaries, who, due to their unfamiliarity with managed for example — for which the cost of drugs can run up to care and higher likelihood of cognitive difficulties, have thousands of dollars per year. This problem is exacerbated shown particularly low levels of understanding about their by rapidly rising prices and expenditures for prescription coverage.2 Many seniors with Medicare supplemental coverage, drugs, a trend that increases the financial burdens on those as well as those who have only Medicare, may confuse with no drug coverage, and that is leading Medicare HMOs discount programs with having prescription drug coverage. to limit drug coverage for the elderly and greatly increase A relatively recent trend has been the marketing of copayments for those who have coverage.4 so-called “medical savings programs” such as “WellCard,” A small proportion of the elderly report that they “Affordable Benefit Options,” “Chamber Health,” and other have coverage for dental care — a critical need for many companies’ products that offer PPO-like discounts with elderly persons. Only one in two elderly persons with pharmacies, physicians, and other providers for a monthly Medicare and private insurance or with Medicare and premium, but they do not pay or reimburse for health care Medicaid and just one in four seniors who have only expenses. In California, state law enables anyone covered by Medicare report that they have dental coverage (Exhibit 5). Medicare to receive the same discount on their prescriptions As with prescription drug coverage, many respondents to that the State gets when it buys drugs under the Medi-Cal surveys are unable to report accurately on their dental or program, but most elderly residents do not know about this medical benefits.5 discount program.3 Although this discount program is helpful, it also does not reimburse seniors for prescription HIGH UNINSURED RATES AMONG drug expenditures. For these reasons, we believe that the LOW-INCOME CALIFORNIANS reported proportions of Medicare beneficiaries who say Uninsured rates decline as income rises, falling from 30.0% they have prescription drug coverage greatly overstate the of nonelderly persons below the federal poverty level to actual numbers. 26.2% among the near poor (those with incomes between 101% and 200% of the poverty level), to 15.1% for those 2 Cunningham PJ, Denk D, Sinclair M, “Do Consumers Know How Their Health Plans 4 Toner R, “Maine at Front Line in Fight Over the High Cost of Drugs, New York ” Work?” Health Affairs 2001; 20(2): 159-66; Goldstein E, Fyock J, “Reporting of Times, May 11, 2002. CAHPS Quality Information to Medicare Beneficiaries, Health Services Research ” 5 Cunningham PJ, Denk D, Sinclair M, “Do Consumers Know How Their Health Plans 2001; 36(3): 477-88. Work?” Health Affairs 2001; 20(2): 159-66. 3 Rosenblatt, B, “Dwindling Drug Benefits, Los Angeles Times, March 25, 2002. For ” information about California’s policy, see http://www.dhs.ca.gov/mcs/mcpd/mbb/ contracting/sb393/index.htm. UCLA CENTER FOR HEALTH POLICY RESEARCH 17 EXHIBIT 6. HEALTH INSURANCE COVERAGE BY FAMILY INCOME RELATIVE TO FEDERAL POVERTY LEVEL, AGES 0–64, CALIFORNIA, 2001 5.8 15.1 30.0 26.2 6.5 4.6 2.0 3.2 9.9 1.6 24.9 49.8 85.0 69.1 44.0 16.8 Up to 100% 101%-200% 201%-300% More than of FPL of FPL of FPL 300% of FPL Uninsured Job-based Insurance Privately Purchased Insurance Medi-Cal Healthy Families Other Public Coverage FPL = federal poverty level Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey with incomes 201% to 300% of the poverty level, and to private purchase of health insurance out of financial reach, 5.8% for nonelderly persons with incomes above that level and even an income up to 300% of poverty would make (Exhibit 6).6 More than 3 million Californians who are privately purchased coverage a stretch.7 uninsured have incomes that do not exceed 200% of the The gradient for employment-based insurance is the poverty level — that is, up to $23,118 for a family of two opposite, rising from 16.8% of nonelderly persons below and $28,258 for a family of three. This income level puts the poverty to 85.0% for those with incomes above 300% of 6 In 2001, the federal poverty threshold was $9,044 for one person, $11,559 for a family physical therapy — a questionable value for a generally health young man or woman. of two, and $14,129 for a family of three. The least expensive HMO, one that would provide more comprehensive benefits and much less cost sharing, would cost this person $1,456 annually. For a family of three, 7 For a twenty-six-year-old male or female, the least expensive plan available in the Los including a mother and father age 30 and a two-year-old child, the least expensive Angeles area through eHealthInsurance.com is $408 annually, but that requires a HMO, providing comprehensive benefits and standard HMO cost sharing, would be $1,000 deductible and 20% coinsurance for covered benefits, and it does not cover $5,486 annually. These estimates were obtained May 13, 2002 from prenatal/postnatal care or delivery, dental care, outpatient prescription drugs, or https://www.ehealthinsurance.com/ehi/IFPCompareChoose.fs. 18 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 7. PERCENT WITH HEALTH CARE COVERAGE ALL YEAR ROUND BY FAMILY INCOME, CHILDREN AND ADULTS, AGES 0–64, CALIFORNIA, 2001 PERCENT WITH COVERAGE DURING ALL OF LAST 12 MONTHS FAMILY INCOME CHILDREN ADULTS AGES 0-17 AGES 18–64 UP TO 100% OF FPL 75.2% 51.7% 101% - 200% OF FPL 78.2% 59.7% 201% - 300% OF FPL 86.8% 74.7% MORE THAN 300% OF FPL 95.6% 88.4% FPL = federal poverty level Source: 2001 California Health Interview Survey poverty (Exhibit 6). Medi-Cal and the Healthy Families This pattern has important policy implications. Program partially compensate for the lack of job-based Employment-based health insurance coverage at the time of coverage for low-income families and disabled adults, but the interview is very low for poor children and adults alike: substantial income-related disparities remain in rates 11.7% and 20.5%, respectively. However, Medi-Cal and of uninsurance. Healthy Families cover nearly seven in 10 poor children but less than 4 in 10 poor adults, a difference that is due largely Stability of Coverage to children’s broad eligibility for public coverage programs The probability of having health care coverage throughout vs. the very restrictive options available to adults. Children the year (through either private health insurance or a public are eligible based on income alone (if they are citizens or program) rises with family income, as shown in Exhibit 7. legal immigrants), but poor adults must meet strict income However, it is noteworthy that the disparity in year-round and asset limits and, in addition, fit into “categorical” coverage between poor persons and those with family requirements of being members of a family with dependent income exceeding 300% of poverty is smaller for children (a children, being disabled or blind, or being age 65 or over. gap of 20.4 percentage points) than for adults (a difference Thus, low-income children have more stable coverage than of 36.7 percentage points). Put slightly differently, poor adults as a result of public policies designed to enroll and children are 78% as likely as those with incomes more than retain children in Medi-Cal and Healthy Families. three times the poverty level to be insured all year round, while poor adults are only 58% as likely. UCLA CENTER FOR HEALTH POLICY RESEARCH 19 EXHIBIT 8. HEALTH INSURANCE COVERAGE BY RACE AND ETHNIC GROUP AGES 0–64, CALIFORNIA, 2001 , WHITE LATINO ASIAN NATIVE AFRICAN AMERICAN OTHER & AMERICAN HAWAIIAN AMERICAN INDIAN & MULTIPLE & OTHER ALASKA RACE PACIFIC NATIVE ISLANDER UNINSURED 8.6 28.3 13.0 12.9 9.5 17.8 16.3 MEDI-CAL/HEALTHY FAMILIES 8.1 26.5 13.9 13.4 27.6 24.3 16.0 JOB-BASED INSURANCE 75.4 42.3 66.3 67.2 60.2 54.4 62.0 PRIVATELY PURCHASED INSURANCE 6.9 1.6 5.7 5.9 1.4 2.5 4.8 OTHER PUBLIC COVERAGE 1.1 1.2 1.2 --- 1.6 0.9 1.7 TOTAL 100% 100% 100% 100% 100% 100% 100% POPULATION IN 2000 14,664,000 8,837,000 3,208,000 91,000 1,797,000 117,000 913,000 Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey --- Indicates inadequate sample size with which to make estimate DISPARITIES IN COVERAGE AMONG another one in four (27.6%) is enrolled in Medi-Cal or ETHNIC GROUPS Healthy Families, giving them a relatively low rate of Differences in access to employment-based health insurance, uninsurance (9.5%) compared to whites. as well as to Medi-Cal and Healthy Families, result in Two-thirds of Asian Americans have job-based disparities in health insurance coverage among California’s insurance (66.3%), but they are less likely than African diverse ethnic groups. Among the nonelderly population, Americans to be covered by Medi-Cal or Healthy Families, whites have the highest rate of job-based insurance (75.4%) resulting in an uninsured rate of 13.0% for nonelderly and the lowest rate of uninsurance (8.6%; Exhibit 8). Asians, about one-and-a-half times the rate for whites. At the other extreme, Latinos have the lowest rate of Native Hawaiians and other Pacific Islanders’ coverage job-based insurance (42.3%) and the highest uninsured rate resembles that of Asians, although the sample size is small (28.3%). The uninsured rates for Salvadorans and (as is the population), yielding estimates that are imprecise. Guatemalans are considerably higher (35.0% and 38.0%, The uninsured rate for Japanese-origin Asians as well as for respectively) than those for Mexican-origin Latinos (28.1%), South Asians is lower than for other Asian ethnic groups, a pattern seen for children as well as for adults. but the uninsured rate for Vietnamese, Cambodians, and African Americans, Asian Americans, and Native other Southeast Asians is considerably higher. The Hawaiians and other Pacific Islanders have job-based uninsured rate for Koreans, however, is far higher than for insurance rates intermediate between Latinos and whites. other groups — 21.7% of children and 33.6% of nonelderly Six in 10 African Americans (60.2%) have health insurance adults — equaling or exceeding the rates for Latinos. obtained through their own or a family member’s job, and 20 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 9. HEALTH INSURANCE COVERAGE BY RACE/ETHNIC GROUP AND FAMILY INCOME RELATIVE TO FEDERAL POVERTY LEVEL, AGES 0–64, CALIFORNIA, 2001 WHITE LATINO ASIAN AFRICAN AMERICAN AMERICAN AMERICAN INDIAN & & PACIFIC ALASKA ISLANDER NATIVE UNINSURED FAMILY INCOME UP TO 100% OF FPL 22.4% 36.7% 17.9% 9.1% 29.7% FAMILY INCOME 101%–200% OF FPL 18.6% 32.4% 26.8% 13.6% 19.5% MEDI-CAL/ HEALTHY FAMILIES FAMILY INCOME UP TO 100% OF FPL 48.8% 47.0% 54.8% 69.6% 52.3% FAMILY INCOME 101%–200% OF FPL 23.1% 24.4% 25.1% 36.0% 37.3% JOB-BASED INSURANCE FAMILY INCOME UP TO 100% OF FPL 24.2% 13.9% 20.8% 19.3% 14.0% FAMILY INCOME 101%–200% OF FPL 50.1% 40.5% 41.7% 46.4% 40.5% FPL = federal poverty level Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey American Indians’ and Alaska Natives’ relatively low These racial and ethnic disparities in health insurance rate of job-based insurance (54.4%) also results in a high coverage reflect differences in income, education, and uninsured rate (17.8%) despite a relatively high rate of citizenship across these groups. The important role that Medi-Cal and Healthy Families coverage. Among American income plays in determining coverage across ethnic groups Indians and Alaska Natives uninsured rates do not seem to is illustrated by the effects of both Latinos’ and whites’ rates differ whether they live in urban or rural areas or whether of job-based insurance, coverage by Medi-Cal and Healthy they are enrolled in a tribe recognized by either federal or Families, and uninsurance. Among nonelderly persons state governments (data not shown). Only about one in 10 below the poverty level, there is little difference in rates of American Indian and Alaska Native adults in California coverage by Medi-Cal and Healthy Families: 48.8% for reports that they obtain any medical care through the whites and 47.0% for Latinos (Exhibit 9). However, there is Indian Health Service, which is not a substitute for health a substantial difference in their job-based coverage: 13.9% insurance coverage in any case.8 of Latinos compared to 24.2% of whites. The result of that 8 The United States government has a trust responsibility to provide health care to the majority of American Indians and Alaska Natives, who do not live near the facilities all federally recognized American Indians and Alaska Natives. Being eligible for the they are entitled to use. Thus, American Indians and Alaska Natives who do not have Indian Health Service is not equivalent to being insured, in part because of this legal any other coverage are considered by the U.S. Census Bureau to be uninsured. responsibility to provide care and because most IHS facilities are not accessible to UCLA CENTER FOR HEALTH POLICY RESEARCH 21 EXHIBIT 10. PERCENT WITH HEALTH CARE COVERAGE ALL YEAR ROUND BY RACE/ETHNIC GROUP CHILDREN AND ADULTS, AGES 0–64, CALIFORNIA, 2001 , PERCENT WITH COVERAGE DURING ALL OF LAST 12 MONTHS RACE/ETHNIC GROUP CHILDREN ADULTS AGES 0-17 AGES 18–64 WHITE 91.9% 84.5% LATINO 76.1% 56.7% ASIAN AMERICAN & PACIFIC ISLANDER 90.9% 79.0% AFRICAN AMERICAN 93.9% 81.7% AMERICAN INDIAN & ALASKA NATIVE 83.2% 72.0% Source: 2001 California Health Interview Survey difference is a wide disparity in uninsurance: 36.7% of The proportion of each group reporting coverage Latinos vs. 22.4% of whites. Within each income group, throughout the year reflects a pattern similar to the pattern other ethnic groups have rates of employment-based for current coverage. Latino children and especially Latino coverage and uninsurance that are intermediate between adults are considerably less likely than their counterparts in Latinos and whites. other ethnic groups to be covered throughout the 12-month Latinos suffer a double blow in this relationship. Not period preceding the interview, although American Indians only is their uninsured rate higher than any other group at and Alaska Natives have rates that are not much higher than each income level, but a larger proportion of Latinos are those of Latinos (Exhibit 10). poor and near poor: 67% of Latinos have family incomes below 200% of the federal poverty level compared to 19% EVEN LARGER DISPARITIES IN COVERAGE BY for whites (data not shown). Again, other ethnic groups CITIZENSHIP AND IMMIGRATION STATUS have poverty rates between those of Latinos and whites. Half of all nonelderly adults who are noncitizens without “green cards” are completely uninsured (51.2%), a rate nearly one-and-a-half times that for noncitizens who have 22 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 11. HEALTH INSURANCE COVERAGE OF NONELDERLY ADULTS BY OWN CITIZENSHIP AND IMMIGRATION STATUS, AGES 18–64, CALIFORNIA, 2001 U.S.-BORN NATURALIZED NONCITIZEN WITH NONCITIZEN WITHOUT CITIZEN CITIZEN GREEN CARD GREEN CARD UNINSURED 11.3 16.6 32.3 51.2 MEDI-CAL/HEALTHY FAMILIES 8.8 11.0 14.9 16.0 JOB-BASED INSURANCE 72.1 66.1 48.6 29.8 PRIVATELY PURCHASED INSURANCE 6.4 5.2 3.7 2.3 OTHER PUBLIC COVERAGE 1.4 1.1 0.5 0.7 TOTAL 100% 100% 100% 100% POPULATION IN 2000 13,610,000 2,894,000 2,156,000 1,765,000 Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey obtained their green cards (32.3%) and nearly five times the Compared to whites or African Americans, a much rate for U.S.-born citizens (11.3%, Exhibit 11).9 As with larger proportion of Latinos and Asian Americans and differences by income and by ethnicity, these disparities are Pacific Islanders are noncitizens. Nearly one-third (30.1%) the result of wide differences in employment-based of Asian adults are not citizens, compared to less than 4% coverage, including a more than two-fold difference of whites and African Americans, and about one in 10 Asian between noncitizens without green cards at the low end adults does not yet have a green card (data not shown). (29.8%) and naturalized and U.S.-born citizens at the high Fully half (51.6%) of Latino adults are noncitizens, and end (66.1% and 72.1%, respectively). The Latino-white approximately one-fourth lack a green card. difference is also due to higher rates of noncitizenship The disadvantages related to citizenship and among Latinos, a point to which we will return shortly. immigration status are also apparent in children’s coverage. 9 This refers to immigrants who are neither permanent residents nor in the process of receiving their “green cards. These two groups are combined since having a “green ” card” makes a significant difference in access to health care for immigrants. UCLA CENTER FOR HEALTH POLICY RESEARCH 23 EXHIBIT 12. HEALTH INSURANCE COVERAGE OF CHILDREN BY FAMILY CITIZENSHIP AND IMMIGRATION STATUS, AGES 0–17, CALIFORNIA, 2001 CHILD AND BOTH CHILD CITIZEN, CHILD CITIZEN, CHILD CITIZEN, CHILD IS PARENTS PARENT PARENT PARENT NONCITIZEN U.S.-BORN NATURALIZED NONCITIZEN NONCITIZEN CITIZENS CITIZEN WITH WITHOUT GREEN CARD GREEN CARD UNINSURED 4.5 13.8 16.3 15.1 39.9 MEDI-CAL/HEALTHY FAMILIES 18.0 42.0 44.1 65.6 30.4 JOB-BASED INSURANCE 73.2 41.3 36.5 16.0 23.3 PRIVATELY PURCHASED INSURANCE 3.6 1.3 1.8 1.2 1.4 OTHER PUBLIC COVERAGE 0.6 1.6 1.3 2.1 5.1 TOTAL 100% 100% 100% 100% 100% POPULATION IN 2000 5,978,000 799,000 1,196,000 604,000 501,000 Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey Children whose parents were both born in the United States And among the half-million noncitizen children in have the most advantaged coverage: nearly three-fourths California, only one in four receives employment-based (73.2%) have employment-based insurance and only 4.5% insurance, and only 30.4% are covered by Medi-Cal or are uninsured (Exhibit 12). However, rates of employment- Healthy Families, leaving 39.9% completely uninsured. based coverage are far lower, and uninsured rates are at least These low rates of coverage among noncitizen three times higher, for children with other family citizenship children and citizen children with noncitizen parents are due and immigration statuses. Among the more than 1.1 million to multiple factors. Their parents’ restricted access to job- U.S.-citizen children in California who have at least one based insurance, which will be examined in Section 3, may parent who is a noncitizen with a green card, only 36.5% be compounded by restricted eligibility for public programs have employment-based insurance, 44.1% rely on Medi-Cal if the child is undocumented, or by lingering concerns or Healthy Families, and 16.3% are uninsured. Job-based among noncitizens generally that they may be classified as a insurance is even lower for U.S.-citizen children who have at “public charge” if they enroll their children in Medi-Cal or least one parent who is a noncitizen without a green card. Healthy Families.10 10 The federal welfare reform and immigration reform legislation in 1996 restricted fear among noncitizens that enrolling themselves or their children in Medicaid might Medicaid to citizens and to legal immigrants who were in the United States when jeopardize their re-entry into the United States. A modification of the policy, issued by welfare reform was signed (August 22, 1996). It imposed waiting periods for Medicaid the Immigration and Naturalization Service (INS) in May 1999 and widely disseminated entitlement on immigrants and financial liability on their sponsors. It also led to more by community-based organizations, has eased these concerns, but such fears may widespread potential application of “public charge” classification (someone who is, or linger within the immigrant community. is likely to become, dependent on public benefits). This policy generated widespread 24 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 13. HEALTH INSURANCE COVERAGE BY ENGLISH PROFICIENCY, AGES 0–64, CALIFORNIA, 2001* SPEAK ENGLISH VERY WELL SPEAK ENGLISH FAIRLY WELL SPEAK ENGLISH NOT WELL OR NOT AT ALL UNINSURED 13.2 19.8 37.2 MEDI-CAL/HEALTHY FAMILIES 14.9 22.4 36.8 JOB-BASED INSURANCE 66.1 52.8 23.8 PRIVATELY PURCHASED INSURANCE 4.6 3.7 0.9 OTHER PUBLIC COVERAGE 1.2 1.3 1.3 TOTAL 100% 100% 100% POPULATION IN 2000 4,930,000 3,320,000 3,222,000 * Asked of all respondents who speak languages other than English at Note: Numbers may not add to 100% due to rounding. home. For adults and for children ages 12-17 English proficiency is for , Source: 2001 California Health Interview Survey themselves; for children under age 12, English proficiency is for responding adult. Noncitizens without a green card include immigrants Among those who speak a language other than English at in a variety of immigrant categories; among them are home, two-thirds (66.1%) receive job-based insurance and undocumented immigrants, whose uncertain immigration 13.2% are uninsured (Exhibit 13). However, among the 3.2 status makes them vulnerable in the labor market. This status million Californians with limited English proficiency, only is often combined with other characteristics, such as low 23.3% have employment-based coverage, more than one- educational attainment or limited English proficiency, that third (36.8%) are covered by Medi-Cal or Healthy Families, put them at a disadvantage in the labor market. Among and 37.2% are completely uninsured. adults, 40% of noncitizens with a green card and 52% of Because employers are not required to offer health those without a green card have less than a high school benefits to their workers, vulnerability in the labor market education compared to 19% for naturalized citizens and due to immigration status among a large group of workers just 6% for U.S.-born citizens (data not shown). Many may encourage employers in particular labor markets to immigrant adults and some adolescents are limited in their avoid the added costs of health benefits if they can recruit English-language proficiency, further impairing their ability and retain the workers they need without them. As we will to obtain employment that includes health benefits. see in a later section, immigrant workers without a green The effects of these factors are evident in their card are more likely to work for employers who do not offer relationship to English language proficiency, which is, of health insurance to any workers. course, also related to other factors such as education. UCLA CENTER FOR HEALTH POLICY RESEARCH 25 EXHIBIT 14. PERCENT OF CHILDREN AND ADULTS UNINSURED AT TIME OF INTERVIEW BY COUNTY, AGES 0–64, CALIFORNIA, 2001 CHILDREN ADULTS ALL NONELDERLY TOTAL (AGES 0-17) (AGES 18-64) (AGES 0-64) NONELDERLY POPULATION (AGES 0-64) % (95% RANGE) % (95% RANGE) % ( 95% RANGE) CENSUS 2000 NORTHERN AND SIERRA COUNTIES 9.4 (7.8-10.9) 17.4 (16.1-18.7) 15.0 (13.9-16.0) 1,065,000 BUTTE 10.2 (5.2-15.3) 16.7 (13.0-20.4) 14.8 (11.8-17.8) 169,000 SHASTA 9.3 (5.0-13.5) 17.6 (13.7-21.5) 15.0 (12.0-18.0) 136,000 HUMBOLDT, DEL NORTE 7.2 (3.7-10.7) 16.4 (12.8-20.0) 13.8 (11.0-16.6) 128,000 SISKIYOU, LASSEN, TRINITY, 13.3 (7.3-19.4) 18.7 (15.0-22.4) 17.1 (13.9-20.2) 76,000 MODOC MENDOCINO, LAKE 10.0 (5.1-14.9) 20.1 (16.7-24.6) 17.5 (14.3-20.6) 119,000 TEHAMA, GLENN, COLUSA 11.5 (7.4-15.7) 20.7 (16.6-24.8) 17.6 (14.5-20.6) 85,000 SUTTER, YUBA 8.9 (4.0-13.7) 14.9 (11.5-18.3) 12.8 (10.0-15.6) 121,000 NEVADA, PLUMAS, SIERRA 11.2 (6.5-15.9) 15.4 (11.5-19.4) 14.2 (11.1-17.4) 95,000 TUOLUMNE, CALAVERAS, ** ** 16.9 (13.0-20.8) 13.6 (10.6-16.7) 137,000 AMADOR, INYO, MARIPOSA, MONO, ALPINE GREATER BAY AREA 4.1 (3.1-5.2) 10.6 (9.6-11.7) 8.9 (8.1-9.7) 5,920,000 SANTA CLARA ** ** 12.4 (9.6-15.1) 9.7 (7.7-11.9) 1,500,000 ALAMEDA 4.9 (2.1-7.6) 9.7 (7.5-12.0) 8.4 (6.6-10.2) 1,276,000 CONTRA COSTA ** ** 7.1 (5.1-9.2) 6.2 (4.6-7.9) 835,000 SAN FRANCISCO ** ** 15.0 (12.7-17.4) 13.1 (11.1-15.2) 655,000 SAN MATEO ** ** 8.0 (5.6-10.4) 7.0 (5.0-9.0) 612,000 SONOMA 7.3 (3.4-11.1) 13.5 (9.9-17.1) 11.8 (8.9-14.6) 392,000 SOLANO ** ** 7.9 (6.0-9.8) 6.2 (4.8-7.6) 343,000 MARIN ** ** 8.1 (5.3-11.0) 7.2 (4.8-9.5) 204,000 NAPA ** ** 11.1 (8.1-15.3) 8.9 (6.3-11.6) 102,000 SACRAMENTO AREA 3.5 (2.0-5.5) 11.6 (9.7-13.4) 9.1 (7.7-10.5) 1,566,000 SACRAMENTO 3.4 (1.4-5.4) 12.4 (9.7-15.0) 9.5 (7.6-11.5) 1,069,000 PLACER ** ** 5.1 (3.1-7.1) 3.9 (2.5-5.4) 215,000 YOLO ** ** 13.3 (9.5-17.1) 10.7 (7.8-13.6) 146,000 EL DORADO ** ** 13.7 (10.1-17.3) 11.8 (9.0-14.6) 136,000 continued on next page 26 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 14. PERCENT OF CHILDREN AND ADULTS UNINSURED AT TIME OF INTERVIEW BY COUNTY, AGES 0–64, CALIFORNIA, 2001 (CONTINUED) CHILDREN ADULTS ALL NONELDERLY TOTAL (AGES 0-17) (AGES 18-64) (AGES 0-64) NONELDERLY POPULATION (AGES 0-64) % (95% RANGE) % (95% RANGE) % ( 95% RANGE) CENSUS 2000 SAN JOAQUIN VALLEY 10.3 (8.6-12.0) 19.9 (18.3-21.4) 16.4 (15.2-17.6) 2,881,000 FRESNO 10.2 (6.0-14.5) 20.5 (16.5-24.4) 16.8 (13.8-19.8) 706,000 KERN 12.8 (8.8-16.7) 20.6 (17.3-23.8) 17.7 (15.2-20.2) 572,000 SAN JOAQUIN 8.1 (4.6-11.5) 18.6 (15.1-22.2) 14.9 (12.2-17.5) 489,000 STANISLAUS 11.6 (6.5-16.7) 14.4 (10.9-17.9) 13.4 (10.5-16.3) 396,000 TULARE 9.8 (5.9-13.7) 26.8 (22.2-31.5) 20.4 (17.0-23.8) 328,000 MERCED 6.2 (3.1-9.4) 20.9 (16.9-24.8) 15.3 (12.5-18.1) 188,000 KINGS 11.4 (7.6-15.2) 16.7 (13.0-20.3) 14.7 (12.0-17.4) 100,000 MADERA 11.3 (5.8-16.8) 19.4 (15.2-23.5) 16.5 (13.2-19.8) 102,000 CENTRAL COAST 12.4 (9.8-15.0) 17.2 (15.5-19.0) 15.7 (14.3-17.2) 1,811,000 VENTURA 13.5 (8.3-18.6) 14.3 (11.1-17.5) 14.1 (11.3-16.8) 667,000 SANTA BARBARA 16.0 (10.5-21.5) 21.9 (17.8-26.0) 20.1 (16.8-23.5) 335,000 SANTA CRUZ 7.0 (3.5-10.5) 14.8 (11.2-18.4) 12.7 (9.8-15.5) 223,000 SAN LUIS OBISPO 5.6 (2.5-8.6) 17.6 (13.7-21.5) 14.4 (11.4-17.4) 197,000 MONTEREY, SAN BENITO 13.0 (7.5-18.4) 19.4 (15.2-23.6) 17.2 (13.9-20.6) 390,000 LOS ANGELES 12.3 (10.9-13.71) 23.2 (22.2-24.3) 19.8 (19.0-20.7) 8,464,000 LOS ANGELES 12.3 (10.9-13.71) 23.2 (22.2-24.3) 19.8 (19.0-20.7) 8,464,000 OTHER SOUTHERN CALIFORNIA 10.4 (8.9-11.8) 18.1 (16.9-19.3) 15.6 (14.7-16.6) 7,918,000 ORANGE 9.8 (7.3-12.3) 17.7 (15.5-19.9) 15.3 (13.6-17.1) 2,537,000 SAN DIEGO 11.5 (8.6-14.4) 16.6 (14.6-18.7) 15.1 (13.4-16.8) 2,417,000 SAN BERNARDINO 9.4 (6.4-12.4) 19.8 (16.9-22.6) 16.0 (13.9-18.2) 1,524,000 RIVERSIDE 10.3 (6.7-13.9) 19.9 (16.9-22.9) 16.5 (14.2-18.9) 1,322,000 IMPERIAL 14.1 (9.8-18.5) 21.9 (17.7-26.0) 19.0 (15.9-22.0) 118,000 ** The estimate is not statistically stable because coefficient of variation Source: 2001 California Health Interview Survey is over 30%. Note: The “95% range” (more commonly called a “confidence interval”) provides a more reliable estimate of the uninsured rate for persons in the population group than does the “point estimate. Point estimates ” with narrower 95% ranges are more precise or reliable than those with wider ranges. UCLA CENTER FOR HEALTH POLICY RESEARCH 27 UNINSURED RATES DIFFER DRAMATICALLY residents have low family incomes (43.6% vs. 36.6% have BY COUNTY incomes below 200% of poverty), and a larger proportion of Counties vary widely in the proportions of children and poor residents are uninsured (35.2% vs. 30.0% among those adults who are uninsured. Driven by a strong economy and with incomes below poverty). Los Angeles County has tight labor market through much of 2001, the nine-county moderate per capita income (about 95% of the state average Greater Bay Area has the lowest uninsured rates (8.9% of in 1999) with moderate average earnings per job as well as a the nonelderly population; Exhibit 14). The two Bay Area fairly high cost of living. exceptions to this profile are San Francisco County (13.1%) San Francisco’s uninsured rate is high among Bay Area and Sonoma County (11.8%). The four-county counties. It is low relative to Los Angeles (13.1% vs. 19.8%), Sacramento Area also has a low rate of uninsurance (9.1%), but a total of 86,000 uninsured residents must depend on for similar reasons. San Francisco’s safety net for much of their care. Like Los Other parts of the state have much higher uninsured Angeles, San Francisco has a relatively large immigrant rates. The San Joaquin Valley has an uninsured rate (16.4%) population. However, San Francisco’s low-income population that is nearly twice that of the Bay Area, led by Tulare County is about half the proportion of Los Angeles County’s (23.4% (20.4%). The northern and Sierra counties nearly all share have incomes below 200% of poverty vs. 43.6% in Los moderately high rates of uninsurance. The Central Coast is Angeles), and a lower proportion of San Francisco’s poor also high (15.7%), led by Santa Barbara County (20.1%). residents are uninsured (25.1% vs. 35.2% in Los Angeles). The rest of Southern California (15.6%) also has high San Francisco has high average earnings per job and high uninsured rates in all the counties that comprise that region per capita income (about 166% of the state average in 1999), (Exhibit 14). both of which are associated with high rates of job-based Los Angeles County remains the epicenter of insurance and low uninsured rates, despite the city’s high uninsurance in California and, indeed, the nation. One in cost of living. five nonelderly residents of the county is uninsured — This brief comparison suggests the important influence more than 300,000 children and nearly 1.4 million adults. of low average income on a county’s health insurance A number of factors contribute to Los Angeles County’s profile although other factors also help to account for these high uninsured rate. Three in 10 Latino residents of the variations. These economic indicators (the most recent county are uninsured, a much higher rate than for other available from the California Department of Finance) are groups; more than six in 10 of Los Angeles’s nonelderly for 1999, prior to the economic downturn that hit San residents are Latino, whose low average incomes tend to put Francisco hard and Los Angeles more moderately, and thus health insurance coverage out of financial reach. Los may not accurately reflect the conditions that influenced Angeles has a very large immigrant population, many of health insurance coverage in 2001.11 The particular set of whom are noncitizens with low incomes. Compared to factors that generate a high uninsured rate in one county California as a whole, a larger proportion of the county’s compared to another cannot be discerned from a descriptive 11 California County Profiles, Sacramento: Department of Finance, February 2002. 28 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 15. REASONS PERSONS DO NOT HAVE COVERAGE AMONG UNINSURED AT TIME OF INTERVIEW AND UNINSURED AT SOME TIME DURING THE YEAR, AGES 0–64, CALIFORNIA, 2001 REASONS FOR NOT HAVING INSURANCE UNINSURED AT TIME UNINSURED AT SOME TIME OF INTERVIEW DURING LAST 12 MONTHS* CAN’T AFFORD/TOO EXPENSIVE 42.6 24.6 EMPLOYMENT-RELATED FACTORS CHANGED EMPLOYER/LOST JOB 8.2 25.4 EMPLOYER DOES NOT OFFER 6.4 7.9 NOT ELIGIBLE DUE TO WORKING STATUS 6.2 8.1 OTHER BARRIERS NOT ELIGIBLE DUE TO CITIZENSHIP OR IMMIGRATION STATUS 7.4 2.3 NOT ELIGIBLE DUE TO HEALTH OR OTHER PROBLEMS 2.4 4.3 FAMILY/PERSONAL SITUATION CHANGED 1.9 5.6 LOST/CAN’T QUALIFY FOR PUBLIC PROGRAM COVERAGE 1.7 2.1 IN PROCESS OF/PROBLEMS WITH GETTING INSURANCE 1.8 5.0 LACK OF INFORMATION ON INSURANCE/FORMS TOO DIFFICULT 1.8 1.4 OWN ACTION OR INACTION PAYS FOR OWN HEALTH CARE/GETS HEALTH CARE FOR FREE 2.7 1.8 HEALTHY (NO NEED)/DON’T BELIEVE IN HEALTH INSURANCE 10.5 5.8 PERSONAL REFUSAL OR INACTION 3.7 4.1 OTHER 2.7 1.7 TOTAL 100% 100% * These individuals had health insurance coverage at the time of the Note: Numbers may not add to 100% due to rounding. interview, but experienced uninsurance at some time during the Source: 2001 California Health Interview Survey past year. analysis such as this; teasing out the factors that account for the reader to rely on the range because the “true” estimate intercounty variations in health insurance coverage requires has a 95% chance of falling within that range. The estimated further research. numbers of uninsured are rounded to the nearest “000” The reader should pay close attention to the “95% because they are not precise numbers. range” in Exhibit 14. These are called “confidence intervals,” which are a measure of the precision of the estimate shown, WHY ARE SO MANY CALIFORNIANS UNINSURED? based on its sample size and the extent of variation among Among the 4.5 million Californians who lacked coverage at the respondents who comprise that population group. A the time they were interviewed, four in 10 (42.6%) said that wider range, or confidence interval, indicates a less precise the main reason they were uninsured was that health estimate. In cases where the range is fairly wide, we encourage insurance premiums were unaffordable (Exhibit 15). Some UCLA CENTER FOR HEALTH POLICY RESEARCH 29 were employees who could not afford the contribution The reasons for uninsurance vary among people required by their employer, as we will see in the next section with differing social characteristics (data not shown). of this report, but most were people who did not have access For example, compared to most other ethnic groups, Latinos to employment-based coverage. Lack of affordability was are more likely to cite citizenship or immigration issues cited as the main reason for being uninsured by one in four and to report that their employer does not offer coverage, of those who were insured when interviewed but who but less likely to cite losing or changing employment or experienced lack of coverage in the last year (currently insured, unaffordability. Although the reasons cited by noncitizens but uninsured at some time during the last 12 months). with green cards do not differ very much from the reasons Another two in 10 (21%) of the currently uninsured given by citizens, noncitizens without green cards are more reported that the main reason for their lack of insurance likely to report barriers related to immigration status (one was employment-related — changing or losing a job, being in four) and less likely to cite losing or changing employment ineligible for their employer’s plan, or an employer failing to or the unaffordability of coverage. Low-income persons offer any health benefits (although some individuals whose (up to 200% of the federal poverty level) are more likely to employer did not offer health benefits said that coverage was report citizenship or immigration issues or health problems unaffordable). Employment-related factors were the main as the main reason for not being insured, while more reason for lack of coverage during the previous 12 months affluent persons (those with family incomes above that for four in 10 of those who were insured at the time of the level) report unaffordability or losing or changing interview, including one in four (25.4%) who said it was employment as the main reason. due to changing or losing a job. Finally, some reasons appeared to relate to the A substantial proportion of respondents reported respondent’s own action or inaction. About one in 10 (10.5%) other barriers to getting or retaining coverage. Among the of the currently uninsured and 5.8% of those who were currently uninsured, 7.4% reported that their citizenship or uninsured at some time during the last 12 months reported immigration status prevented them being covered, a either that they were healthy and did not need medical perspective that probably relates more accurately to insurance or that they do not believe in health insurance. It eligibility for public programs than to job-based insurance. is noteworthy that the proportion who reported not needing This barrier was reported by only 2.3% of those who were or not believing in health insurance as the main reason for uninsured at some time during the last 12 months. Other being uninsured varied relatively little by social characteristics. reported barriers to coverage included health or other The proportion of uninsured persons who gave such reasons problems that led to being denied coverage, changes in did not differ by income; the proportion of Latinos who personal situations (such as a divorce or death of a family gave this reason was just 4 percentage points higher than for member who provided the coverage), being ineligible for whites, and it was about 3 percentage points lower for U.S.- coverage through a public program (e.g., respondents who born citizens than for all immigrants. were told or believed that they are ineligible or who lost such coverage that they previously had), and problems with getting insurance or lack of information about it. 30 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY 3. THE STATE OF EMPLOYMENT-BASED HEALTH INSURANCE Ninez Ponce, Thomas Rice, 3 and Shana Alex Lavarreda The majority of Americans under the age of 65 receive their Latinos are far less likely than other racial and ethnic health insurance coverage through employment, either groups to have job-based coverage. Less than half of through their own job or that of a family member. In this California Latino adults have job-based health insurance section we examine employment-based coverage among compared to three-quarters of whites, about two-thirds of California adults ages 18-64, first focusing on overall job- African Americans and Asian American and Pacific based coverage rates and then on three components of Islanders, and three-fifths of American Indian and Alaska coverage (defined below): employer offer rates, worker Natives and those in other racial and ethnic groups. The eligibility rates, and worker take-up rates. We then focus on rates are particularly low for Latinos because, as a group, California’s uninsured employees to identify where the they share characteristics that result in low job-based breakdowns in coverage occur. Specifically, we examine who coverage rates: Latinos are less likely to be citizens, they have is most at risk of working in a firm that does not offer lower average incomes and education levels, and they work health insurance, who tends to not be eligible, and who is disproportionately in industries and occupations where job- most likely to not take up job-based health insurance. We based coverage is low. conclude this section by exploring the reasons why workers Job-based coverage varies considerably by age, with do not take up their employer’s health insurance plan. only about half of those between ages 18 and 24 having job-based coverage — a rate far lower than the rates for WHO HAS JOB-BASED COVERAGE? older individuals. Younger individuals are less likely to Over two-thirds (65.1%) of California adults obtain health have such coverage because many are still in school, and a insurance through their own or a family member’s disproportionate share tend to be in the types of jobs that employer. Exhibit 16 shows the percentage of California lack coverage. adults with employment-based health insurance coverage Although there is little difference in rates by gender, according to several demographic and labor force character- family composition does have a major impact. Less than istics. In this table, a person is defined as having job-based half of single individuals with children, and somewhat coverage whether or not he or she obtained it directly from more than half without children, have job-based coverage. their own employer or received it as a dependent from a This compares to two-thirds of married individuals working family member. In subsequent tables when with children, and over three-quarters of those married examining offer, eligibility, and take-up rates, we will focus without children. only on job-based coverage that a person receives from his Citizenship status is one of the most important or her own job. correlates of job-based coverage. Only three in 10 noncitizens without a green card report coverage, and half of permanent residents — rates far below the about 70% levels for naturalized citizens and U.S. born citizens. UCLA CENTER FOR HEALTH POLICY RESEARCH 31 EXHIBIT 16. PERCENT OF ADULTS WITH JOB-BASED HEALTH INSURANCE, AGES 18-64, CALIFORNIA, 2001 TOTAL POPULATION (n = 13,300,000) SELECTED INDUSTRIES (SMALLEST TO LARGEST) ALL ADULTS, AGES 18-64 65.1% AGRICULTURE 40.3% RACE/ETHNICITY CONSTRUCTION 56.6% WHITE 75.4% MANUFACTURING OF DURABLE GOODS 80.9% LATINO 46.8% EDUCATIONAL SERVICES 86.4% ASIAN AMERICAN & PACIFIC ISLANDER 66.4% BUSINESS AND REPAIR SERVICES 67.4% AFRICAN AMERICAN 63.9% RETAIL TRADE 57.3% AMERICAN INDIAN & ALASKA NATIVE 57.4% SELECTED OCCUPATIONS (SMALLEST TO LARGEST) OTHER & MULTIPLE RACE 62.7% FARMING, FORESTRY, AND FISHING 39.5% AGE GROUP PRECISION, CRAFT, REPAIR 63.7% 18 – 24 YEARS 50.8% SALES 67.9% 25 – 34 YEARS 62.3% ADMINISTRATIVE SUPPORT 77.9% 35 – 44 YEARS 69.7% PROFESSIONAL SPECIALTY 84.3% 45 – 54 YEARS 72.0% FAMILY COMPOSITION 55 – 64 YEARS 68.2% SINGLE, NO CHILDREN 57.7% CITIZENSHIP STATUS SINGLE, WITH CHILDREN 47.4% U.S.-BORN CITIZEN 72.1% MARRIED, NO CHILDREN 77.5% NATURALIZED CITIZEN 66.1% MARRIED, WITH CHILDREN 68.6% NONCITIZEN WITH GREEN CARD 48.6% FAMILY INCOME AS PERCENT OF FPL* NONCITIZEN WITHOUT GREEN CARD 29.8% UP TO 100% 20.5% EDUCATION LEVEL 101% – 200% 44.4% LESS THAN HIGH SCHOOL 34.1% 201% – 300% 67.5% HIGH SCHOOL DIPLOMA 59.9% 301% + 83.7% SOME COLLEGE 69.9% EMPLOYMENT STATUS COLLEGE GRADUATE OR HIGHER 80.7% FULL-TIME EMPLOYED 74.3% GENDER PART-TIME EMPLOYED 56.9% MALE 66.6% UNEMPLOYED, LOOKING FOR WORK 33.7% FEMALE 63.7% UNEMPLOYED, NOT LOOKING FOR WORK 45.7% Source: 2001 California Health Interview Survey * FPL = Federal Poverty Level 32 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY One of the greatest disparities occurs in the area of citizenship status, education level, or other sociodemographic education. Only about one-third of those with less than a factors. Exhibit 17 shows the connection between the high school education have job-based coverage compared to employee’s “own,” or primary, job-based health insurance at least six in 10 for all other groups and over eight in 10 for coverage and key labor market and sociodemographic college graduates. Income follows a similar pattern, with characteristics. (Unlike the previous exhibit, we do not only one-fifth of those below the poverty level having job- consider here dependent coverage from a family member’s job.) based coverage. The proportion rises gradually with income We also probe more deeply into the reasons why some up to over the 80% level for those above 300% of the employees have coverage through their employment while poverty level. It should be kept in mind, however, that others do not. Do they work in firms that offer health many of those below poverty have Medi-Cal or Healthy insurance to their employees (offer rate)? For employees Families coverage. who work where health insurance is offered, do their Employment characteristics also have a major impact employers deem them eligible for job-based health benefits on job-based coverage. Those in certain industries, such as (eligibility rate)? Even if they are eligible, do employees agriculture, construction, and service, are considerably less accept the health benefits offered and pay the required likely to have employment coverage than those in the contributions, if any, that the benefit may entail (take-up manufacturing of durable goods and education. Similarly, rate)? certain occupations tend to lack job-based coverage: only two-thirds of those in sales compared to nearly 85% in Widest Disparities Are in Offer Rates professional specialties have such coverage. Finally, the While there are variations in offer, eligibility, and take-up percentage of time employed also matters a great deal. rates by race and ethnicity, the likelihood of working for a Three-quarters of full-time workers have job-based coverage firm that offers health insurance is clearly the key compared to just over half of part-time workers and one- contributor to disparate coverage rates (see Exhibit 17). third of the unemployed looking for work. Offer rates span a considerable range: from 70.4% to 90.7%, while the range is smaller for take-up rates (81.9% to WHO WORKS AND IS STILL UNINSURED? 88.1%), and smaller still for eligibility rates (88.7% to 92.2%). In this section, we begin by examining sociodemographic characteristics and labor market factors of California’s nearly 13 million employees to identify groups that are most at-risk for being uninsured.12 Some workers may face greater barriers in getting job-based coverage not only because of the nature and type of job they hold but also because of age, 12 “Employees” are respondents who reported that they are “currently working for an employer for wages, and therefore the category, implicitly, excludes the self-employed. ” UCLA CENTER FOR HEALTH POLICY RESEARCH 33 EXHIBIT 17. OFFER, ELIGIBILITY, AND TAKE-UP RATES AMONG EMPLOYEES FOR OWN JOB-BASED HEALTH INSURANCE BY DEMOGRAPHIC CHARACTERISTICS, AGES 18-64, CALIFORNIA, 2001 TOTAL POPULATION OFFER1 ELIGIBILITY2 TAKE-UP3 GENDER OFFER1 ELIGIBILITY2 TAKE-UP3 (n = 12,984,000) EMPLOYEES, 83.4% 90.8% 84.4% MALE 84.3% 93.1% 87.7% AGES 18-64 FEMALE 82.3% 87.8% 80.0% RACE/ETHNIC GROUP SELECTED INDUSTRIES WHITE 88.8% 91.1% 83.3% AGRICULTURE 54.3% 84.5% 81.1% LATINO 70.4% 88.7% 81.9% CONSTRUCTION 69.5% 91.2% 83.9% ASIAN AMERICAN & 84.1% 92.0% 84.8% MANUFACTURING OF 90.4% 94.8% 89.7% PACIFIC ISLANDER DURABLE GOODS AFRICAN AMERICAN 90.7% 91.8% 88.1% EDUCATIONAL 93.3% 87.1% 84.1% SERVICES AMERICAN INDIAN & 81.8% 89.5% 82.1% ALASKA NATIVE BUSINESS AND 80.6% 93.4% 85.5% REPAIR SERVICES OTHER & 85.8% 92.2% 83.3% MULTIPLE RACE RETAIL TRADE 71.8% 81.7% 74.8% AGE GROUP SELECTED OCCUPATIONS 18–24 YEARS 70.8% 72.3% 70.5% FARMING, FORESTRY, 52.8% 86.6% 86.2% FISHING 25–34 YEARS 82.9% 91.7% 86.1% PRECISION, CRAFT, 76.3% 93.6% 85.0% 35–44 YEARS 85.3% 93.7% 84.8% REPAIR 45–54 YEARS 87.6% 94.6% 86.0% SALES 81.5% 88.3% 79.7% 55–64 YEARS 88.8% 93.9% 88.5% ADMINISTRATIVE 89.0% 86.3% 82.1% SUPPORT FAMILY COMPOSITION PROFESSIONAL 94.3% 93.6% 87.4% SINGLE, 80.7% 86.8% 88.8% SPECIALTY NO CHILDREN HOURS WORKED PER WEEK SINGLE, 81.0% 89.8% 89.4% WITH CHILDREN 0-20 HOURS 64.1% 54.8% 58.2% MARRIED, 88.8% 93.9% 83.4% 21-34 HOURS 69.3% 73.0% 68.4% NO CHILDREN 35-39 HOURS 79.4% 89.4% 74.3% MARRIED, 83.3% 92.8% 80.1% WITH CHILDREN 40+ HOURS 87.3% 95.1% 87.3% continued on next page 34 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 17. OFFER, ELIGIBILITY, AND TAKE-UP RATES AMONG EMPLOYEES FOR OWN JOB-BASED HEALTH INSURANCE BY DEMOGRAPHIC CHARACTERISTICS, AGES 18-64, CALIFORNIA, 2001 (CONTINUED) INCOME AS PERCENT OFFER1 ELIGIBILITY2 TAKE-UP3 WAGES PER HOUR OFFER1 ELIGIBILITY2 TAKE-UP3 OF FPL* LAST MONTH UP TO 100% 48.9% 71.6% 67.6% < $9.51 63.3% 76.0% 71.9% 101% – 200% 70.7% 85.1% 79.9% $9.51–$14.25 85.6% 89.3% 83.1% 201% – 300% 84.4% 88.3% 85.3% $14.26–$19.00 91.8% 95.1% 87.2% 301% + 92.3% 94.2% 86.2% $19.01+ 95.2% 96.9% 89.0% CITIZENSHIP STATUS FIRM SIZE U.S.-BORN 88.6% 90.3% 84.9% FEWER THAN 42.5% 83.9% 73.7% CITIZEN 10 EMPLOYEES NATURALIZED 84.2% 93.9% 84.5% 10 – 50 72.3% 88.7% 79.3% CITIZEN EMPLOYEES NONCITIZEN WITH 71.8% 89.5% 81.4% 51 – 99 84.7% 91.0% 81.6% GREEN CARD EMPLOYEES NONCITIZEN WITHOUT 50.4% 90.1% 81.1% 100 – 999 91.7% 91.4% 86.2% GREEN CARD EMPLOYEES EDUCATION LEVEL 1000+ EMPLOYEES 97.8% 93.4% 87.0% LESS THAN 57.6% 86.3% 79.1% HIGH SCHOOL HIGH SCHOOL 79.5% 88.6% 81.8% DIPLOMA SOME COLLEGE 86.0% 89.3% 83.1% COLLEGE GRADUATE 93.6% 94.2% 87.9% OR HIGHER Source: 2001 California Health Interview Survey 2 Eligibility rate = Total number of eligible employees divided by total * FPL = Federal Poverty Level number of employees offered health insurance. 1 Offer rate = Total number of employees offered health insurance divided 3 Take-up rate = Total number of people who took up insurance divided by total number of employees. by total number of eligible employees. Sociodemographic Characteristics different from the next lowest group, American Indians and Latino employees have the lowest job-based coverage Alaska Natives, and their low rate of coverage is largely a compared to all other race and ethnic groups. Although result of a low offer rate (70.4%). Latino employees’ eligibility (88.7%) and take-up (81.9%) American Indians and Alaska Natives (81.8%) and rates are low compared to other race/ethnic groups, their Asian Americans and Pacific Islanders (84.1%) also eligibility and take-up rates are not statistically significantly experience low offer rates. California’s African Americans UCLA CENTER FOR HEALTH POLICY RESEARCH 35 have the highest offer rates (90.7%), one of the highest We also see a correlation between gaining job-based eligibility rates (91.8%), and the highest take-up rate health insurance and citizenship/nativity status. As expected, (88.1%), due in part to education levels and incomes that U.S.-born workers enjoy the highest level of offer (88.6%) are higher, on the average, than their national counterparts, and take-up (84.9%) rates. For offer, eligibility, and take-up, and to a high rate of employment in larger firms and in the naturalized citizens experience rates very similar to those of public sector.13 U.S.-born citizens, with even higher eligibility rates (93.9% Younger workers, ages 18 to 24, experience lower for naturalized citizens vs. 90.3% for U.S.-born citizens). offer, eligibility, and take-up rates than older workers. Offer This is probably because for the select group of employees and eligibility rates rise substantially for the 25-34 age who work in firms that offer insurance coverage, naturalized group and continue to increase for older workers. Greater citizens are more likely to work full time than their U.S.- opportunities for dependent coverage through spouses may born counterparts. Illustrating the variability within the explain the much lower take-up rates for female workers immigrant group, we find that immigrants who are not (80.0%). Eligibility rates for female workers are also lower permanent residents take the hardest hit in terms of offer than for males, perhaps because more females work part time rates (50.4%), having the lowest offer rate for all socio- and therefore do not qualify for health benefits. But employers demographic and labor market groups shown in Exhibit 17. may also be tacitly encouraging their female employees to However, if they do work for a firm that offers, these take up their spouse’s dependent coverage. A study by immigrants face no significant disadvantage in eligibility Dranove, Spier, and Baker (2000) found that employers and take-up rates compared to U.S.-born workers. with more female employees required higher contribution rates from their workers than employers with more male Labor Market Characteristics employees.14 This study’s finding seems to apply to Job-based coverage also increases with education level, California workers: the gender gap in coverage does not income, and wages. But the gulf between the least and most stem mainly from an offer gap (only 2.0% difference) but advantaged is most pronounced in the offer rate. Exhibit 17 from an eligibility gap (5.3% difference) and, even more so, shows the wide spread between the highest and the lowest from a take-up gap (7.7% difference). offer rates by income (43%), education level (36%), and The take-up gap is also evident when examining the wages (22%). Low-income, low educational attainment, and worker’s type of family. Compared to single workers whose low-wage workers are left further behind by low rates in take-up rates are near 90%, take-up rates are lower for eligibility and in take-up. We note that low job-based married workers, especially for those with children (80.1%). coverage for low-income workers who are parents may be This suggests both access to dependent coverage through offset by Medi-Cal coverage. But coverage is still also low for spouses and, for qualified low-income parents, access to workers whose incomes are between 101 to 200% FPL. Medi-Cal. Thus, parents who are in this income category are wedged 13 February 1999 Current Population Survey. 14 Dranove D, Spier KE, Baker L, “Competition Among Employers Offering Health Insurance, Journal of Health Economics 2000; 19, 121-40. ” 36 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY between being too poor to afford job-based coverage but We find no unusual patterns in offer, eligibility, and having income levels that are too high to be eligible for take-up rates in terms of hours worked per week. For all Medi-Cal. The anticipated parent expansion of Healthy components of coverage, the outlook in securing health Families, California’s Children’s Health Insurance Program, benefits gets better with increasing hours worked. This is would provide a coverage alternative for this group. also true for firm size, where there is more than a two-fold Certain industries and occupations typically have low gain in the offer rate when a worker who works in a small coverage rates, such as agriculture and farming. In Exhibit firm with fewer than 10 employees (42.5%) is compared 17, we highlight selected industries and occupations in with a worker in a large firm with more than 1000 employees California. Combined, these industries employ nearly half of (97.8%).15 Costs may prohibit employers in small firms California’s workers. The agriculture industry has the lowest from offering health benefits so that offer rates are low. offer rate (54.3%) because of its reliance on a seasonal and And even for those small firms that can and do offer, their migrant labor force that may discourage employers from eligibility rules appear to be slightly more stringent than offering health benefits. Retail trade, which includes small those of larger employers. Finally, take-up rates for establishments such as restaurants and grocery stores, establishments of under 100 employees range from 73.7% to constitutes a large share of California’s economy (13%). 81.6%, and they are significantly lower than take-up rates This sector has both the lowest eligibility rate (81.7%) and for the larger establishments (86.2% to 87.0%). This may take-up rate (74.8%), in part because many retail trade reflect a double penalty for low-income workers who work employees work part time and thus are ineligible for health in small firms who have less income to pay for premiums, benefits. For California’s construction industry workers (6% but have to pay higher contributions. Typically, both average of workers), low coverage rates are largely a result of low premiums and average employee contributions are higher offer rates (69.5%). However, their eligibility (91.2%) and for small firms.16 take-up (83.9%) rates are relatively higher compared to To summarize, disparities in job-based coverage in other industries. California are significant across a range of socio- Consistent with what we found in offer rates for the demographic and labor market characteristics. The widest agriculture industry, the lowest offer rates are for the disparities are in offer rates, particularly for workers who farming, forestry, and fishing occupations (52.8%). have less education, lower incomes, lower wages, and who Administrative support, which draws on the part-time and are noncitizens. Differences in eligibility are much less female labor supply, has the lowest eligibility rate (86.3%). significant across all groups, though workers who work part Californians employed in sales jobs have the lowest take-up time, who are under twenty-five years old, and who earn rates (79.7%), largely because they are frequently covered in low wages have considerably low eligibility rates. Lastly, we their family member’s job-based health plan. find that disparate rates in accepting employer-sponsored 15 Firm size refers to the number of workers in all establishment sites as reported by 16 William M. Mercer, Inc. Employer-Sponsored Health Insurance: A Survey of Small the employee. Employers in California, Oakland, CA: California Healthcare Foundation, 1999. UCLA CENTER FOR HEALTH POLICY RESEARCH 37 EXHIBIT 18. DISTRIBUTION OF UNINSURED EMPLOYEES BY ACCESS TO OWN JOB-BASED INSURANCE AND BY SELECTED DEMOGRAPHIC AND LABOR MARKET CHARACTERISTICS, AGES 18-64, CALIFORNIA, 2001 TOTAL POPULATION (n = 1,850,000) NOT OFFERED NOT ELIGIBLE DIDN’T TAKE UP TOTAL UNINSURED EMPLOYEES, AGES 18-64 61.6 24.3 14.1 100% RACE WHITE 47.1 37.9 15.0 100% LATINO 70.3 15.7 14.0 100% ASIAN AMERICAN & PACIFIC ISLANDER 60.9 23.9 15.2 100% AFRICAN AMERICAN 49.0 38.3 12.7 100% AMERICAN INDIAN & ALASKA NATIVE 54.6 35.2 10.2 100% OTHER & MULTIPLE RACE 64.8 28.1 7.1 100% CITIZENSHIP STATUS U.S.-BORN CITIZEN 46.5 39.0 14.5 100% NATURALIZED CITIZEN 63.5 18.7 17.8 100% NONCITIZEN WITH GREEN CARD 66.2 17.3 16.5 100% NONCITIZEN WITHOUT GREEN CARD 82.5 7.4 10.0 100% EDUCATION LEVEL LESS THAN HIGH SCHOOL 76.0 11.5 12.5 100% HIGH SCHOOL DIPLOMA 56.5 28.3 15.1 100% SOME COLLEGE 54.7 30.0 15.2 100% COLLEGE GRADUATE OR HIGHER 48.3 37.7 14.0 100% WAGES PER HOUR LAST MONTH < $9.51 65.2 22.0 12.8 100% $9.51 - $14.25 54.1 29.1 16.7 100% $14.26 - 19.00 56.1 27.8 16.1 100% $19.01+ 45.1 36.6 18.2 100% continued on next page 38 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 18. DISTRIBUTION OF UNINSURED EMPLOYEES BY ACCESS TO OWN JOB-BASED INSURANCE AND BY SELECTED DEMOGRAPHIC AND LABOR MARKET CHARACTERISTICS, AGES 18-64, CALIFORNIA, 2001 (CONTINUED) SELECTED INDUSTRIES (SMALLEST TO LARGEST) AGRICULTURE 81.8 12.3 5.9 100% CONSTRUCTION 75.2 11.4 13.4 100% MANUFACTURING OF DURABLE GOODS 56.6 29.3 14.1 100% EDUCATIONAL SERVICES 38.1 53.1 8.8 100% BUSINESS AND REPAIR SERVICES 67.6 18.9 13.5 100% RETAIL TRADE 55.9 27.1 17.0 100% FIRM SIZE FEWER THAN 10 EMPLOYEES 83.5 9.3 7.2 100% 10 – 50 EMPLOYEES 70.1 16.7 13.2 100% 51 – 99 EMPLOYEES 54.9 23.5 21.6 100% 100 – 999 EMPLOYEES 45.4 36.8 17.8 100% 1000+ EMPLOYEES 14.7 56.7 28.6 100% Source: 2001 California Health Interview Survey health benefits are most marked by the variables of age, benefits, or if they choose not to participate in job-based income, wages, and hours worked per week, suggesting both health plans. Among California’s uninsured employees, affordability issues and dependent coverage from parents and 61.6% were employed in firms that do not offer health spouses. We explore the reasons why employees do not take insurance to their employees, 24.3% worked for firms that up their job-based health benefits in a subsequent section. offer but did not consider them eligible for job-based health benefits, and finally, among those who worked for firms UNINSURED WORKERS: WHO’S NOT OFFERED, where they were eligible for company health insurance, 14.1% WHO’S NOT ELIGIBLE, AND WHO DOESN’T TAKE did not take up health insurance coverage from their jobs. UP JOB-BASED COVERAGE? Exhibit 18 shows a general and not surprising pattern More than 1.85 million workers (14.5%) are still uninsured. among California’s uninsured workers, namely, that the These workers account for over half (51.1%) of uninsured economically vulnerable groups are the least likely to work adults in California. We focus on uninsured workers to try in firms that offer health benefits — Latinos (70.3%), to understand if their lack of coverage is a result of working noncitizens without green cards (82.5%), workers earning for firms that do not offer health insurance, if it is due to the lowest wages (65.2%), agricultural industry workers their employers’ eligibility rules for extending health (81.8%), and employees of very small firms (83.5%). UCLA CENTER FOR HEALTH POLICY RESEARCH 39 On the other hand, in terms of eligibility, the uninsured WHY DON’T EMPLOYEES TAKE UP THEIR workers who are least likely to be eligible for health benefits EMPLOYER’S HEALTH PLAN? offered by their firms tend to be more advantaged groups — In this section, we report the main reasons why California’s U.S.-born citizens, college graduates, workers with incomes employees do not participate in employers’ health plans, even greater than 300% FPL, and employees of larger firms. There though they are eligible, to understand better if the reasons is no clear pattern among those who do not take up employer- for not taking up insurance coverage are due to affordability, based health insurance. They are not overwhelmingly the values, or alternatives in coverage. least disadvantaged group, as they were for offer rates, for Exhibit 19 shows the reasons behind the employees’ example. There is, however, a pattern of higher wage earners decisions to not take up health insurance from their employer. not taking up job-based coverage, suggesting that these We explore the reasons for not doing so for all eligible workers may benefit from dependent coverage from their employees and for uninsured eligible employees. spouses. Moreover, unlike the patterns in offer and eligibility, For all eligible employees, nearly three-quarters (72%) we find no startling disparities among those who did not did not participate in their employer’s health plan because take up among the uninsured. they were covered by another plan; 19% reported that their Our findings suggest that the uninsured worker faces job-based coverage was too expensive; 6% traded insurance the greatest setback in the prospects for job-based coverage for a higher wage or did not want their company’s health by working for a firm that does not offer coverage. Clearly, insurance; and only 3% declared that they do not believe or the breakdown in coverage occurs predominantly at the value health insurance. Thus, for California’s eligible employer’s decision whether or not to offer such coverage. employees, the main reason for not taking up coverage is This means that strategies such as employee tax credits, that coverage from another source is available to them. which only address financing support for employees who Affordability does remain an issue, though, for cannot afford their job-based benefit contributions, leave out approximately 282,000 eligible workers in California. the majority of uninsured workers. Individual financing Affordability is an even larger issue for California’s relief strategies also do little to reduce disparities by uninsured eligible workers. About half of uninsured workers socioeconomic characteristics because economically who are eligible to participate in their employer’s health plan vulnerable groups are the most likely not to work for a firm reported that the plan was “too expensive.” Six percent that offers health insurance coverage at all. reported that they traded insurance for higher pay or did not like their employer’s plan; 9% reported that they do not 40 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 19. REASONS ELIGIBLE EMPLOYEES DO NOT PARTICIPATE IN EMPLOYER HEALTH PLANS, EMPLOYEES, AGES 18-64, CALIFORNIA, 2001 SELF-REPORTED REASONS FOR NOT TAKING UP OWN EMPLOYER’S OFFERED PLAN ALL ELIGIBLE UNINSURED EMPLOYEES ELIGIBLE EMPLOYEES COVERED BY ANOTHER PLAN/COVERED BY SAME PLAN AS SPOUSE 72% – TOO EXPENSIVE 19% 50% TRADED INSURANCE FOR HIGHER PAY/DOESN’T LIKE OR WANT COMPANY INSURANCE 6% 6% DON’T NEED/BELIEVE IN HEALTH INSURANCE 3% 9% OTHER – 35% TOTAL 100% 100% Source: 2001 California Health Interview Survey value health insurance. Thirty-five percent reported reasons insurance coverage (14.1%). About half of uninsured similar to those discussed at the end of Section 2. Thus, our workers who had “passed” the offer and eligibility phases of findings do not support the notion that a considerable coverage reported that they were priced out in taking up number of workers may be uninsured “voluntarily”" coverage, a group that constitutes only about seven percent because they do not value or need health insurance. Clearly, of uninsured workers. affordability tops and dominates the list of reasons for lack Policies, such as employee tax credits, that target of coverage among eligible uninsured workers. financing support for employees could provide relief for some uninsured employees, but such policies would still CONCLUSION leave out most uninsured workers. And because economically We began this section by noting that a majority (65.1%) of vulnerable groups are shut out early in the offer phase of California’s nonelderly adults secure health insurance coverage, policies that only address incentives to take up through their employer or through their family member’s job-based insurance are unlikely to reduce disparities by employer. We then focused our analysis on California’s labor market and socioeconomic characteristics in job- nearly 13 million employees and discussed the components based coverage. While eligibility issues still have a bearing of coverage to identify which groups of workers may be on coverage, clearly efforts must focus on improving offer more at risk in the offer, eligibility, or take-up phases. Then, and take-up rates. Policies aimed at increasing the number focusing on 1.85 million uninsured workers, we found that of employers who offer health insurance, in combination a substantial proportion (61.6%) work in firms that do not with strategies to help low-income workers afford health offer insurance, with relatively smaller shares of workers insurance, would have a modest impact on California’s who are not eligible (24.3%) and who do not take up health most economically vulnerable workers. UCLA CENTER FOR HEALTH POLICY RESEARCH 41 42 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY 4. MEDI-CAL AND THE HEALTHY FAMILIES PROGRAM E. Richard Brown, Jeff Luck, Jennifer Kincheloe, Wei Yen, and Shana Alex Lavarreda 4 During the last four years, California has expanded its patchwork quilt. This quilt consists of an important, but safety-net health insurance programs and taken steps fragmented and confusing, array of programs that together toward making them more user-friendly and more seamless. cover more than one in four children, more than one in 10 In 1997, California created the Healthy Families Program as nonelderly adults, and nearly one in five elderly Californians. part of its implementation of the federal State Children’s Health Insurance Program (SCHIP); at the same time, the THE PATCHWORK QUILT State increased income eligibility in Medi-Cal for children Under current eligibility rules, children who are citizens, or up to 18 years of age. The Medi-Cal and Healthy Families noncitizens legally residing in the United States, are eligible programs, along with numerous related health insurance for either Medi-Cal or Healthy Families up to 250% of the safety-net programs, have been stitched together like a federal poverty guidelines (FPG).17 The specific program for EXHIBIT 20. MEDI-CAL AND HEALTHY FAMILIES INCOME ELIGIBILITY AS A PERCENT OF FEDERAL POVERTY GUIDELINES FOR FAMILIES WITH CHILDREN AND FOR PREGNANT WOMEN, CALIFORNIA, 2001 201% - 250% FPG Not Not Eligible Eligible Healthy Families Eligible Healthy 134% - 200% FPG Families eligibility authorized, 101% - 133% FPG not yet Medi-Cal Eligible implemented LESS THAN 100% FPG 19 - 64 Years Up to 1 Year 1 - 5 Years 6 - 18 Years with Children Pregnant Children Parents Women FPG = Federal Poverty Guidelines Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey 17 The federal poverty guidelines, published by the U.S. Department of Health and Human Services (DHHS), are used for administrative purposes to determine financial eligibility for federal programs, including Medicaid and California’s Healthy Families Program. The income levels are nearly the same as those for the poverty threshold used by the U.S. Census Bureau, but the poverty guidelines count incomes of the immediate (“nuclear”) family members, excluding incomes of other household members. In 2001, the poverty guidelines were $8,590 for one person, $11,610 for a family of two, $14,630 for a family of three, and $17 ,650 for a family of four. Federal Register, 2001; 66(33): 10695-10697 . UCLA CENTER FOR HEALTH POLICY RESEARCH 43 which they are eligible depends on their age, family income, Other adults are eligible for Medi-Cal only if they are allowed deductions from income, and family size (see disabled or blind adults under age 65 or elderly persons Exhibit 20 for age and income provisions for families with above that age and if they meet severe income and asset children). For example, children ages 6-18 are eligible for limits.18 Medi-Cal up to 100% of FPG, and they are eligible for Healthy Families from 101% to 250% of FPG, but children THE IMPORTANCE OF MEDI-CAL AND HEALTHY between ages 1 and 5 are eligible for Medi-Cal up to 133% FAMILIES TO CHILDREN of FPG and for Healthy Families from 134% to 250% of In this section, we focus on the extent of Medi-Cal and FPG. Thus, children within the same family may be eligible Healthy Families coverage. We begin by examining health for different programs, adding confusion and fragmentation insurance coverage for children up to age 18, a slightly to what otherwise might be a seamless system of coverage. different age group than we considered earlier because Pregnant women and their infants are eligible for children in this age group are the target group for Medi-Cal to 200% of FPG, and for the Access for Infants expansions of coverage since 1997. and Mothers (AIM) program between 200% and 300% of One in 10 white children up to age 18 was covered FPG. Parents with children are eligible for Medi-Cal up to by Medi-Cal in 2001 and another 2.2% were enrolled in 100% of FPG; however, in addition to the income provisions Healthy Families; their low enrollment rates in these that children must meet, parents must list their assets and programs reflect their high rates of employment-based not exceed a low asset limit established by Medi-Cal (called coverage (Exhibit 21). Just 4.8% of white children were an “assets test”). California has received approval to uninsured. implement a new expansion for parents to enable them to In contrast, Latino children are more than three times enroll in Healthy Families if their incomes do not exceed as likely to depend on Medi-Cal (34.4%) and Healthy 200% of the FPG (applicants to the Healthy Families Families (7.6%) for their coverage. Despite the higher Program will not need to pass an assets test) and if they pay proportion enrolled in these public programs, Latino the monthly premiums required of parents. Thus, parents’ children are four times as likely to be uninsured (18.7%) coverage may differ from that of their children, and many because they are less than half as likely to be covered by job- parents may not be eligible at all for the programs that based insurance. There is little difference in Medi-Cal and could cover their children — adding to confusion and Healthy Families coverage rates across Latino ethnic fragmentation and thereby discouraging enrollment and, subgroups although fewer Salvadoran children may be potentially, use of services. Moreover, Governor Davis, protected by Medi-Cal than other Central American or responding to the State’s grim fiscal condition in May 2002, Mexican-origin children. has proposed putting the expansion of Healthy Families to parents on hold and rolling back their eligibility for Medi- Cal from 100% of poverty to 67%. 18 For more information about Medi-Cal, see Understanding Medi-Cal: The Basics (2nd ed.), Oakland, CA: Medi-Cal Policy Institute, September 2001. 44 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 21. HEALTH INSURANCE COVERAGE BY RACE AND ETHNIC GROUP AGES 0–18, CALIFORNIA, 2001 , WHITE LATINO ASIAN AFRICAN AMERICAN OTHER & AMERICAN AMERICAN INDIAN & MULTIPLE & PACIFIC ALASKA RACE ISLANDER NATIVE UNINSURED 4.8 18.7 6.2 3.2 15.0 11.7 MEDI-CAL 10.5 34.4 18.8 40.3 30.3 23.1 HEALTHY FAMILIES 2.2 7.6 6.0 2.4 4.8 4.9 JOB-BASED INSURANCE 76.9 36.4 64.5 52.5 47.0 57.4 PRIVATELY PURCHASED INSURANCE 5.0 1.1 3.1 0.8 1.8 2.5 OTHER PUBLIC COVERAGE 0.6 1.7 1.4 0.8 1.0 0.4 TOTAL 100% 100% 100% 100% 100% 100% POPULATION IN 2000 4,214,000 3,619,000 965,000 646,000 46,000 265,000 Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey Coverage for American-Indian and Alaska Native children in other Asian ethnic groups; they are disadvantaged children follows a similar pattern to that of Latinos: fairly by a low rate of job-based insurance that is not offset by low employment-based coverage, fairly high coverage higher enrollment in Medi-Cal or Healthy Families. through Medi-Cal (30.3%) and Healthy Families (4.8%), and a high uninsured rate (15.0%). UNINSURED CHILDREN AND ADULTS WHO ARE A small proportion of African-American children are ELIGIBLE FOR MEDI-CAL OR HEALTHY FAMILIES uninsured (3.2%), a result of a high total enrollment in Of the nearly 1 million uninsured children under age 19 in Medi-Cal and Healthy Families (42.7%), and despite a California, two-thirds are eligible for one of California’s public relatively low proportion covered by employment-based health care coverage programs: an estimated 355,000 for health insurance. Medi-Cal and another 301,000 for the Healthy Families Compared to African Americans, Asian-American Program (Exhibit 22). Approximately one-third are not and Pacific Islander children have lower rates of enrollment eligible for either program, either because their incomes in Medi-Cal (18.8%) and greater enrollment in Healthy exceed the eligibility level for Healthy Families (161,000 Families (6.0%), but they are protected by relatively strong children) or because they are not citizens and have no employment-based coverage, resulting in an uninsured rate “green card” (180,000 children). The latter group are eligible that is statistically the same as that for white children. for emergency services paid for by Medi-Cal and may receive, Korean children are far more likely to be uninsured than through the Children’s Health and Disability Prevention UCLA CENTER FOR HEALTH POLICY RESEARCH 45 (CHDP) program, immunizations, health screenings, and Despite the opportunities for coverage that are treatment for conditions identified during screening. available, nearly 2.2 million uninsured children and adults Among the nearly 3.5 million uninsured adults ages are citizens, or noncitizens with green cards, who are not 19-64, approximately 413,000 parents and 52,000 other (and will not be) eligible for any public coverage program. adults who are not custodial parents are eligible for Medi- The 538,000 children and parents in this group are ineligible Cal under existing policies. Altogether, more than 1.1 due to incomes that exceed the Healthy Families limit, or in million uninsured children and adults are currently eligible the case of parents, because they may have assets that exceed for coverage through either Medi-Cal or Healthy Families. the Medi-Cal allowance. California has received federal approval to extend In addition, nearly 900,000 uninsured California enrollment in Healthy Families to parents of eligible adults and children are noncitizens without the legal status children in families with incomes up to 200% of the federal that a green card conveys. Neither the federal government poverty level. Although the Governor has proposed delaying nor the State provides adequate options for them. They may this expansion due to the State’s severe decline in tax receive emergency services paid for by Medi-Cal and, if revenues, if it were implemented an estimated 281,000 pregnant, they may qualify for prenatal care as well as parents (about one in five uninsured parents) would be delivery paid for by Medi-Cal, but they have few other eligible for Healthy Families (see the shaded portion of options for affordable care. Exhibit 22). With this important expansion, more than 1.4 million uninsured Californians — three in 10 of the state’s uninsured residents — would be eligible for Medi-Cal or Healthy Families. EXHIBIT 22. ELIGIBILITY FOR MEDI-CAL AND THE HEALTHY FAMILIES PROGRAM, UNINSURED NONELDERLY PERSONS BY AGE GROUP AGES 0–64, CALIFORNIA, 2001 , MEDI-CAL HEALTHY CITIZEN OR NONCITIZEN TOTAL ELIGIBLE FAMILIES NONCITIZEN WITHOUT ELIGIBLE WITH GREEN CARD, GREEN CARD, NOT ELIGIBLE NOT ELIGIBLE CHILDREN, 355,000 301,000 161,000 180,000 997,000 AGES 0-18 35.6 30.2 16.2 18.0 100% PARENTS WITH CHILDREN 413,000 281,000 378,000 340,000 1,412,000 IN THEIR HOME, 29.3 19.9* 26.7 24.1 100% AGES 19-64 OTHER ADULTS, 52,000 N/A 1,643,000 376,000 2,080,000 AGES 19-64 2.5 78.9 18.0 100% * Expansion of Healthy Families to include parents of eligible children up Source: 2001 California Health Interview Survey to 200% FPG has been approved, but not yet implemented. Note: Numbers may not add to 100% due to rounding. Numbers may not add to total uninsured counts due to some respondents not answering some questions. 46 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY CHARACTERISTICS OF UNINSURED CHILDREN AND Of the 2.6 million children who are eligible for Medi- ADULTS WHO ARE ELIGIBLE FOR MEDI-CAL OR Cal, more than eight in 10 are enrolled, based on estimates HEALTHY FAMILIES from the 2001 California Health Interview Survey.19 About Many efforts are underway to enroll eligible families in six in 10 of those who are enrolled are Latino, but three- coverage programs, but more can be done. Many community- fourths of uninsured children who are eligible for Medi-Cal based outreach efforts are likely to disappear if such outreach are Latino (Exhibit 23), underscoring the need for substantial funds are eliminated from the State budget, as proposed in efforts targeted to Latino communities to reach this the Governor’s “May revise.” Nevertheless, information that unenrolled and uninsured group. Latinos represent a large we present below can help to inform and guide these efforts share of the uninsured population because they have a high by establishing clearer profiles of the eligible-but-uninsured uninsured rate, low incomes, and account for a large share population. The analysis below focuses especially on of the population. One in five Medi-Cal enrollees is white, children and their eligibility for Medi-Cal or Healthy Families. about one in nine is African American, and one in 12 is EXHIBIT 23. NONELDERLY PERSONS BY ELIGIBILITY FOR AND ENROLLMENT IN MEDI-CAL AND THE HEALTHY FAMILIES PROGRAM AND BY RACE/ETHNIC GROUP AGES 0–18, CALIFORNIA, 2001 , MEDI-CAL ELIGIBLE HEALTHY FAMILIES ELIGIBLE COVERED BY UNINSURED BUT COVERED BY UNINSURED BUT MEDI-CAL MEDI-CAL HEALTHY HEALTHY ELIGIBLE FAMILIES FAMILIES ELIGIBLE WHITE 20.1 16.5 20.2 21.1 LATINO 56.5 73.1 60.4 66.5 ASIAN AMERICAN & PACIFIC ISLANDER 8.2 3.9 12.7 6.6 AFRICAN AMERICAN 11.8 1.5 3.4 2.5 AMERICAN INDIAN & ALASKA NATIVE 0.6 0.9 0.5 0.6 OTHER & MULTIPLE RACE 2.8 4.2 2.8 2.7 TOTAL 100% 100% 100% 100% NUMBER OF PERSONS 2,206,000 355,000 458,000 301,000 Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey 19 The CHIS estimate of Medi-Cal enrollment for ages 0-18 is 2,206,000, compared to administrative data count of 2,700,000 enrollees (based on data from the California Department of Health Services reports for the midpoint during the period in which CHIS was conducted). Therefore, although CHIS captures a greater number of enrollees than previous surveys (see Appendix for further discussion on this point), CHIS still undercounts Medi-Cal enrollment relative to administrative data, an ongoing concern with population-based surveys. UCLA CENTER FOR HEALTH POLICY RESEARCH 47 EXHIBIT 24. LANGUAGE SPOKEN AT HOME AND ENGLISH PROFICIENCY AMONG UNINSURED CHILDREN AND ADULTS WHO ARE ELIGIBLE FOR MEDI-CAL AND THE HEALTHY FAMILIES PROGRAM, AGES 0–64, CALIFORNIA, 2001 MEDI-CAL ELIGIBLE HEALTHY FAMILIES ELIGIBLE CHILDREN AGES 0-18 355,000 301,000 SPEAK ONLY ENGLISH AT HOME 69,000 71,000 ENGLISH AND SPANISH AT HOME 179,000 171,000 SPANISH ONLY AT HOME 87,000 32,000 ASIAN OR OTHER LANGUAGES AT HOME 20,000 27,000 SPEAK ENGLISH VERY WELL* 61,000 94,000 SPEAK ENGLISH FAIRLY WELL* 69,000 56,000 SPEAK ENGLISH NOT WELL/NOT AT ALL* 149,000 78,000 PARENTS AGES 19-64 413,000 281,000** SPEAK ONLY ENGLISH AT HOME 51,000 64,000 ENGLISH AND SPANISH AT HOME 152,000 125,000 SPANISH ONLY AT HOME 177,000 67,000 ASIAN OR OTHER LANGUAGES AT HOME 33,000 25,000 SPEAK ENGLISH VERY WELL* 28,000 39,000 SPEAK ENGLISH FAIRLY WELL* 63,000 42,000 SPEAK ENGLISH NOT WELL/NOT AT ALL* 163,000 64,000 ADULTS AGES 19-64, WITHOUT CHILDREN 52,000 NOT ELIGIBLE SPEAK ONLY ENGLISH AT HOME 19,000 ENGLISH AND SPANISH OR SPANISH ONLY AT HOME 21,000 ASIAN OR OTHER LANGUAGES AT HOME *** * Asked of respondents who speak languages other than English at Note: The sample sizes on which these estimates are based are small; home. For children ages 12-18, English proficiency is for themselves; the estimated numbers should be taken as approximations rather than for children under age 12, English proficiency is for responding adult. as precise numbers. ** Expansion of Healthy Families to include parents of eligible children Source: 2001 California Health Interview Survey up to 200% FPG has been approved, but not yet implemented. *** The estimate is not statistically stable because coefficient of variation is over 30%. 48 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY Asian American and Pacific Islander. Only 16.5% of Medi- As might be expected, uninsured parents who are Cal-eligible children are white and small fractions are Asian eligible for Medi-Cal follow a similar pattern of English American and Pacific Islander, African American, American proficiency as that reported for eligible children. (For Indian and Alaska Native, and other ethnic groups. children up to 11 years of age, it is the parent who reports We estimate that of approximately three quarters of a on language use and English proficiency, as with other million children who were eligible for Healthy Families in indicators.) Eligible adults ages 19-64, without children 2001, about 458,000 were enrolled when interviewed.20 The living in their home, are more evenly distributed across ethnic group distribution of enrollees in Healthy Families is language groups (the small size of this population makes the very similar to the distribution of the eligible-but-uninsured estimated numbers even less precise and precludes the population. Two-thirds of uninsured children who are analysis by English proficiency). eligible for Healthy Families are Latino, one-fifth are white, and the remainder are other ethnic groups. WHERE DO ELIGIBLE FAMILIES LIVE? Advocates have emphasized the importance of Where do the children and their parents who are eligible for conducting outreach efforts in languages appropriate to the either Medi-Cal or Healthy Families live? Because resources eligible population. Data from CHIS 2001 suggest that this for outreach efforts need to be used cost-effectively, it is emphasis has been appropriate. Among the 355,000 helpful to understand the geographic distribution of uninsured children who are eligible for Medi-Cal, about uninsured children and parents who are eligible for one of 69,000 speak only English at home (Exhibit 24). The great these public programs. Exhibit 25 provides approximations majority either speak only Spanish or speak both English of the eligible-but-uninsured population by region and, where and Spanish at home: approximately 266,000 children. The sample size permits, by county. These estimates are based on remainder speak some combination of Asian and other relatively small sample sizes, and we provide only those languages. (Note that the sample sizes on which these estimates that are sufficiently reliable to guide public policy. estimates are based are relatively small; the estimated (Note the wide range estimates, or confidence intervals, that numbers should be taken as approximations rather than as indicate the degree of precision of an estimate.) precise numbers.) Corresponding to the distribution of uninsured For uninsured children who are eligible for Healthy residents, the great majority of uninsured eligible children Families, the number who speak only Spanish at home is live in Southern California — one-third in Los Angeles and smaller than for Medi-Cal eligible children. The number nearly another third in the rest of Southern California. who have limited English proficiency is also smaller: 149,000 About one in eight lives in the San Joaquin Valley and one for Medi-Cal vs. 78,000 for Healthy Families. in 12 in Central Coast counties. With their low rates of 20 This estimate matches closely with the administrative data from the Managed Risk Medical Insurance Board (MRMIB), which runs the Healthy Families Program. UCLA CENTER FOR HEALTH POLICY RESEARCH 49 EXHIBIT 25. APPROXIMATE NUMBER OF UNINSURED CHILDREN AND PARENTS WHO ARE ELIGIBLE FOR MEDI-CAL OR THE HEALTHY FAMILIES PROGRAM BY COUNTY, AGES 0–64, CALIFORNIA, 2001 CHILDREN ADULTS WITH CHILDREN (AGES 0-18)* (AGES 19-64)* (95% RANGE) (95% RANGE) NORTHERN AND SIERRA COUNTIES 23,000 (19,000-27,000) 11,000 (8,000-13,000) BUTTE, SHASTA, HUMBOLDT, DEL NORTE, SISKIYOU, LASSEN, TRINITY, MODOC, MENDOCINO, LAKE, TEHAMA, GLENN, COLUSA, SUTTER, YUBA, NEVADA, PLUMAS, SIERRA, TUOLUMNE, CALAVERAS, AMADOR, INYO, MARIPOSA, MONO, ALPINE GREATER BAY AREA 42,000 (31,000-53,000) 32,000 (18,000-46,000) SANTA CLARA, ALAMEDA, CONTRA COSTA, SAN FRANCISCO, SAN MATEO, SONOMA, SOLANO, MARIN, NAPA SACRAMENTO AREA 12,000 (8,000-17,000) ** ** SACRAMENTO, PLACER, YOLO, EL DORADO SAN JOAQUIN VALLEY 80,000 (68,000-93,000) 46,000 (37,000-55,000) FRESNO 18,000 (10,000-26,000) 11,000 (6,000-16,000) KERN 23,000 (17,000-29,000) 12,000 (8,000-17,000) SAN JOAQUIN 11,000 (6,000-15,000) 6,000 (2,000-10,000) STANISLAUS 10,000 (6,000-15,000) ** ** TULARE 10,000 (7,000-14,000) 7,000 (4,000-10,000) MERCED 3,000 (1,000-5,000) 3,000 (1,000-4,000) KINGS 3,000 (2,000-4,000) 2,000 (1,000-3,000) MADERA 2,000 (1,000-4,000) 2,000 (1,000-3,000) CENTRAL COAST 56,000 (43,000-68,000) 20,000 (14,000-26,000) VENTURA 28,000 (18,000-39,000) ** ** SANTA BARBARA 10,000 (6,000-14,000) 4,000 (2,000-7,000) SANTA CRUZ 3,000 (1,000-5,000) ** ** SAN LUIS OBISPO 2,000 (1,000-3,000) 4,000 (1,000-6,000) MONTEREY, SAN BENITO 12,000 (6,000-18,000) ** ** LOS ANGELES 242,000 (215,000-268,000) 175,000 (153,000-198,000) LOS ANGELES 242,000 (215,000-268,000) 175,000 (153,000-198,000) OTHER SOUTHERN CALIFORNIA 201,000 (172,000-231,000) 123,000 (101,000-146,000) ORANGE 51,000 (37,000-65,000) 42,000 (28,000-56,000) SAN DIEGO 63,000 (46,000-81,000) 31,000 (19,000-43,000) SAN BERNARDINO 42,000 (29,000-55,000) 24,000 (14,000-34,000) RIVERSIDE 38,000 (24,000-53,000) 23,000 (14,000-33,000) IMPERIAL 6,000 (5,000-8,000) 3,000 (1,000-5,000) (See Exhibit 25 notes on page 51) 50 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY uninsurance, the Bay Area and Sacramento Area account for Of the 355,000 uninsured children eligible for Medi- less than one in 10 uninsured eligible children. Although the Cal, parents of one in three thought that their children were northern and Sierra counties have somewhat higher not eligible (Exhibit 26). Another 7.8% reported being uninsured rates than the Bay Area or Sacramento Area, their unsure about their children’s eligibility as the reason for not low population density is reflected in their relatively small applying, and less than 1 percent did not know the program share of the state’s uninsured eligible children. existed. These parents reflect opportunities for educational Uninsured parents who are eligible for Medi-Cal are, outreach programs. Parents of about one in eight uninsured as might be expected, distributed in approximately the same eligible children objected to some characteristics of the proportions across the regions. The smaller number of program, particularly the onerous paperwork that has been uninsured eligible parents results in an even smaller sample a hallmark of Medicaid nationally and Medi-Cal in size, permitting even fewer reliable estimates for counties California. It is noteworthy that parents of just 3.3% of and regions. uninsured children eligible for Medi-Cal made comments reflecting the perception that Medi-Cal is associated with WHY AREN’T ELIGIBLE CHILDREN ENROLLED? welfare, suggesting that the program is less stigmatized than In addition to understanding some of the characteristics of many believed. And the parents of very few eligible children uninsured eligible children and where they live, it is — less than 4% — do not perceive a need for coverage for important to understand what their parents perceive as their children. (Responses from parents of about four in 10 barriers to enrolling in Medi-Cal or Healthy Families. In Medi-Cal-eligible children could not be classified into CHIS 2001, parents of uninsured children who were meaningful categories.) estimated to be potentially eligible for Medi-Cal were asked why their children were not enrolled, and we followed the same procedure for parents of children potentially eligible for Healthy Families. * Children ages 0-18 are considered “eligible” if they are eligible for either Note: These estimates are approximations, based on relatively small sample Medi-Cal or Healthy Families. Adults ages 19-64 are considered “eligible” sizes; all estimates are rounded to the nearest “000. The “95% range” ” ONLY if they are eligible for Medi-Cal. (also called a “confidence interval”) provides a more reliable estimate of ** The estimate is not statistically stable because the coefficient of variation the number of eligible persons in the population group than does the equals or exceeds 30%. “point estimate. Point estimates with narrower 95% ranges are more ” precise, or reliable, than those with wider ranges. Source: 2001 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH 51 EXHIBIT 26. REASONS UNINSURED ELIGIBLE CHILDREN ARE NOT ENROLLED IN MEDI-CAL OR THE HEALTHY FAMILIES PROGRAM, AGES 0-18, CALIFORNIA, 2001 UNINSURED CHILDREN REASONS FOR NOT ENROLLING MEDI-CAL HEALTHY FAMILIES ELIGIBLE ELIGIBLE (AGES 0-18) (AGES 0-17) BELIEVE NOT ELIGIBLE 31.9 19.6 INCOME TOO HIGH, NOT ELIGIBLE 17.3 10.5 NOT ELIGIBLE DUE TO CITIZENSHIP/IMMIGRATION STATUS 7.3 3.5 OTHER REASON NOT ELIGIBLE 7.3 5.6 DIDN’T KNOW IF ELIGIBLE 7.8 14.2 DIDN’T KNOW IT EXISTED 0.3 23.3 PROGRAM CHARACTERISTICS 13.3 2.4 PAPERWORK TOO DIFFICULT 10.0 1.6 DON’T LIKE/WANT WELFARE 3.3 0.8 DON’T BELIEVE IN/DON’T NEED HEALTH INSURANCE 3.8 3.7 OTHER 42.8 36.8 TOTAL 100% 100% Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey * Reasons why potentially Medi-Cal eligible uninsured persons were not enrolled were asked of all children and adults, but the comparable question for Healthy Families was asked only for children. Of the approximately 300,000 uninsured children 14.2% said they did not know if their children were eligible. who are eligible for Healthy Families, parents of nearly one Among parents of eligible children, only 2.4% objected to in four did not know of the program’s existence, suggesting program characteristics, including only 1.6% who perceived a continuing need to give this program visibility among the paperwork to be overwhelming (in contrast to 10.0% for target populations. Another one in five knew of it but Medi-Cal-eligible children). thought that their children were not eligible, while another 52 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY 5. THE CONSEQUENCES OF NOT HAVING HEALTH INSURANCE 5 Thomas Rice and Shana Alex Lavarreda In this section of the report, we examine the relationship CALIFORNIA’S POPULATION AS A WHOLE between insurance status and several measures of access to Exhibit 27 shows the relationship between insurance status health care. Although previous research has shown that the and self-reported health status for adults (ages 18-64). In uninsured have less access to care, the magnitude of this general, those with Medi-Cal rate their health as poorest – disadvantage is not fully known, particularly in California.21 not surprising given that poorer individuals, on average, Uninsured individuals and families typically can use safety- tend to be less healthy, and because the disabled population net facilities, but research is scant regarding the extent to is over-represented in Medi-Cal. The uninsured, however, which this allows them to obtain necessary care. also report lower health status compared to the other groups. This section is divided into two parts. We first examine Just over one-third of the uninsured report their health to several indicators of access for the California population as a be excellent or very good compared to over three-fifths of whole: self-reported health status, usual source of care, and adults with job-based insurance. Similarly, over one-fourth utilization and delays in care. However, this information is of the insured report fair or poor health, in contrast to only necessarily incomplete because it does not adjust for the fact about one-tenth of adults with job-based coverage. that those with different insurance status may, on average, have different levels of illness. In the second section, we examine the access consequences for those Californians with particular illnesses or health problems. EXHIBIT 27. SELF-REPORTED HEALTH STATUS BY INSURANCE TYPE, AGES 18-64, CALIFORNIA, 2001 SELF-REPORTED HEALTH STATUS EXCELLENT VERY GOOD GOOD FAIR OR POOR TOTAL UNINSURED 14.5 21.1 38.5 25.9 100% MEDI-CAL/HEALTHY FAMILIES 10.3 16.9 34.5 38.3 100% JOB-BASED INSURANCE 23.0 38.2 28.3 10.5 100% PRIVATELY PURCHASED INSURANCE 30.8 38.0 23.5 7.7 100% OTHER PUBLIC COVERAGE 18.0 38.5 23.0 20.5 100% Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey 21 Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: Institute of Medicine, 2001; and Institute of Medicine. Care Without Coverage: Too Little, Too Late. Washington, DC: Institute of Medicine, 2002. UCLA CENTER FOR HEALTH POLICY RESEARCH 53 EXHIBIT 28. SELF-REPORTED HEALTH STATUS BY INSURANCE TYPE, AGES 0-17, CALIFORNIA, 2001 EXCELLENT VERY GOOD GOOD FAIR OR POOR TOTAL UNINSURED 23.5 22.3 36.4 17.8 100% MEDI-CAL/HEALTHY FAMILIES 30.0 23.8 32.0 14.2 100% JOB-BASED INSURANCE 43.9 31.6 19.7 4.8 100% PRIVATELY PURCHASED INSURANCE 48.7 31.1 16.8 3.4 100% OTHER PUBLIC COVERAGE 18.1 23.7 37.2 21.0 100% Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey Exhibit 28 provides similar information for children as high as any of the other four insurance categories. The (ages 0-17). The patterns are similar here, with the exception uninsured are only half as likely as those with Medi-Cal to that uninsured children report slightly lower health status list a doctor’s office or HMO as their usual source of care than those on Medi-Cal or Healthy Families. Note that and only one-third as likely as those with job-based coverage responses for children ages 12-17 were given by the adolescents or individually purchased private insurance. Both the themselves, while responses for children ages 0-11 were given uninsured and those with Medi-Cal coverage are about by the “most knowledgeable adult” (MKA). Again, there are three times as likely to list a clinic or community-based large differences between the uninsured and those with job- hospital as their major sources of coverage than those with based coverage. Whereas over three-fourths of the latter job-based or individually purchased coverage. report their health as excellent or very good, this is true of The CHIS survey queried adults about their major less than half of uninsured children. Uninsured children are reason for lacking a usual source of care. The main pattern, also more than three times as likely to report fair or poor shown in Exhibit 30, is that over half of the uninsured cite health status than those with job-based coverage. lack of insurance or costs, compared to about one-third of In spite of their poorer health status, the uninsured those with Medi-Cal or other public coverage and less than are much less likely than the insured to report a usual one-tenth of those with job-based or individually purchased source of medical care, and among those who do, that coverage. Probably because of their poorer health status, the source is considerably less likely to be a doctor’s office. uninsured are less likely than those with Medi-Cal or job- Exhibit 29 shows the relationship between insurance status based or individually purchased coverage to say that it is and usual source of care for adults. Nearly half of the because they never get sick. uninsured list no usual source of care, which is three times 54 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 29. USUAL SOURCE OF CARE BY INSURANCE TYPE, AGES 18-64, CALIFORNIA, 2001 USUAL SOURCE OF CARE DOCTOR’S CLINIC/ EMERGENCY SOME OTHER NO USUAL TOTAL OFFICE/HMO COMMUNITY- ROOM PLACE SOURCE OF BASED CARE HOSPITAL UNINSURED 26.5 25.3 2.6 <0.1 45.6 100% MEDI-CAL/ 53.5 28.5 2.7 <0.1 15.4 100% HEALTHY FAMILIES JOB-BASED INSURANCE 82.2 8.1 1.1 <0.1 8.7 100% PRIVATELY PURCHASED 76.7 8.6 0.9 <0.1 13.9 100% INSURANCE OTHER PUBLIC COVERAGE 28.9 58.2 3.4 <0.1 9.6 100% Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey EXHIBIT 30. REASONS FOR NO USUAL SOURCE OF CARE BY INSURANCE TYPE, AGES 18-64, CALIFORNIA, 2001 REASONS FOR NO USUAL SOURCE OF CARE NEVER GET SICK NO INSURANCE COST OF CARE OTHER TOTAL UNINSURED 24.3 34.1 21.1 20.5 100% MEDI-CAL/HEALTHY FAMILIES 32.0 18.9 15.3 33.8 100% JOB-BASED INSURANCE 47.0 3.4 2.4 47.2 100% PRIVATELY PURCHASED 49.9 3.0 5.5 41.6 100% INSURANCE OTHER PUBLIC COVERAGE 25.1 23.3 8.7 42.9 100% Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH 55 EXHIBIT 31. USUAL SOURCE OF CARE BY INSURANCE TYPE, AGES 0-17*, CALIFORNIA, 2001 USUAL SOURCE OF CARE DOCTOR’S CLINIC/ EMERGENCY SOME OTHER NO USUAL TOTAL OFFICE/HMO COMMUNITY- ROOM PLACE SOURCE OF BASED CARE HOSPITAL UNINSURED 31.2 40.3 1.1 1.2 26.2 100% MEDI-CAL/ 54.6 37.9 1.3 0.3 5.9 100% HEALTHY FAMILIES JOB-BASED INSURANCE 85.3 10.2 0.5 0.4 3.6 100% PRIVATELY PURCHASED 80.9 10.9 0.5 0.7 7.0 100% INSURANCE OTHER PUBLIC COVERAGE 32.8 47.6 0.2 2.3 17.1 100% * Ages 0-11 received a follow-up question regarding type of clinic. Note: Numbers may not add to 100% due to rounding. However, since both ages 0-11 and ages 12-17 were asked the same Source: 2001 California Health Interview Survey initial question about type of usual source of care, the two have been combined into a single dataset. Exhibit 31 shows the relationship between insurance the continuing importance of community health and status and usual source of care for children. Although the county clinics among families with Medi-Cal and Healthy differences between children and adults in reporting a usual Families coverage. source of care are not statistically significant, uninsured The next two tables provide measures of usage or children are significantly more likely than others to have no lack of usage of services among California adults. Exhibit 32 usual source. Like adults, uninsured children are also much shows the relationship between insurance status and number less likely to have the doctor’s office or HMO as their usual of physician visits for those who report their health as being source of care than are members of these other groups. The only fair or poor. The uninsured in fair or poor health are other interesting pattern in the table is that only about 10% more than twice as likely to forego physician visits. Thirty- of children with either job-based or privately purchased five percent did not see a doctor in the past 12 months, individual coverage list a clinic or community-based hospital more than twice that of any other group. The figures are as their usual source of care, whereas one-third with Medi- equally dramatic if one groups the first two columns and Cal or Healthy Families, and nearly half of those with other looks at respondents with between zero and two visits. Over public coverage, cite this source. Thus, even among the two-thirds of the uninsured in fair or poor health visited the insured, those with public insurance are far more likely to doctor twice or less during the year, compared to less than seek their care from clinics or community-based hospitals. half of members of the other insurance groups. This shows the roles of the safety net for the uninsured and 56 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT 32. VISITS TO A DOCTOR IN THE PAST 12 MONTHS AMONG PEOPLE IN FAIR/POOR HEALTH BY INSURANCE TYPE, AGES 18-64, CALIFORNIA, 2001 NUMBER OF DOCTOR VISITS IN PAST 12 MONTHS NO DOCTOR VISIT 1-2 3-4 5+ TOTAL UNINSURED 35.2 33.2 13.9 17.8 100% MEDI-CAL/HEALTHY FAMILIES 9.8 18.2 17.4 54.6 100% JOB-BASED INSURANCE 10.5 29.0 19.7 40.7 100% PRIVATELY PURCHASED INSURANCE 14.0 33.0 16.0 37.1 100% OTHER PUBLIC COVERAGE 10.3 8.8 21.3 59.7 100% Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey EXHIBIT 33. DELAYS OF HEALTH CARE BY INSURANCE TYPE, AGES 18-64, CALIFORNIA, 2001 DELAY GETTING DELAY HAVING DELAY OF PRESCRIPTION A TEST/TREATMENT ANY OTHER CARE UNINSURED 7.5% 6.4% 19.2% MEDI-CAL/HEALTHY FAMILIES 12.8% 8.4% 13.2% JOB-BASED INSURANCE 9.6% 8.5% 11.2% PRIVATELY PURCHASED INSURANCE 9.9% 10.0% 14.1% OTHER PUBLIC COVERAGE 10.4% 9.5% 14.0% Note: Numbers may not add to 100% due to rounding. Source: 2001 California Health Interview Survey In contrast, the figures in Exhibit 33, which focus on prescriptions or tests than others. The likely explanation is delays in care, do not show much of a pattern. Although the that because they see physicians less frequently, they have uninsured are somewhat more likely to delay getting other fewer opportunities to delay getting prescriptions and tests types of care, they do not show longer delays in getting because physicians are less likely to prescribe/order them. UCLA CENTER FOR HEALTH POLICY RESEARCH 57 EXHIBIT 34. RESPONDENTS WITH SELECTED CHRONIC DISEASES BY ACCESS INDICATOR AND INSURANCE TYPE, AGES 18-64, CALIFORNIA, 2001 SELECTED CHRONIC DISEASES* ACCESS INDICATOR** ASTHMA SYMPTOM PREVALENCE TAKING MEDICATION FOR ASTHMA UNINSURED 6.4% 41.3% MEDI-CAL/HEALTHY FAMILIES 12.2% 67.8% JOB-BASED INSURANCE 8.8% 45.1% DIABETES PREVALENCE TAKING INSULIN OR PILLS FOR DIABETES UNINSURED 3.5% 57.8% MEDI-CAL/HEALTHY FAMILIES 9.5% 75.4% JOB-BASED INSURANCE 4.1% 75.7% HIGH BLOOD PRESSURE PREVALENCE TAKING MEDICATION FOR HIGH BLOOD PRESSURE UNINSURED 12.4% 29.5% MEDI-CAL/HEALTHY FAMILIES 23.9% 61.3% JOB-BASED INSURANCE 16.6% 53.1% HEART DISEASE PREVALENCE TAKING MEDICATION FOR HEART DISEASE UNINSURED 2.7% 27.2% MEDI-CAL/HEALTHY FAMILIES 9.3% 60.1% JOB-BASED INSURANCE 3.6% 42.4% * Rate among whole population. Note: Numbers are individual rates and will not add to 100%. ** Rate among those with the chronic disease. Source: 2001 California Health Interview Survey CALIFORNIANS WITH PARTICULAR Exhibit 34 shows these results for ages 18-64. The HEALTH PROBLEMS uninsured show a somewhat lower symptom prevalence of In addition to querying respondents about their overall asthma than those on Medi-Cal/Healthy Families or with health and use of services, CHIS asked a battery of questions job-based coverage. Among those reporting asthma, among those with particular illnesses or health problems. however, the uninsured have similar rates of taking asthma We report selected findings for asthma, diabetes, high blood medication as individuals with job-based coverage, but are pressure, and heart disease. The survey asked several questions far less likely than those with Medi-Cal. Just 41.3% of the (depending on the type of illness); in this section we show uninsured with asthma take medications, compared to how the results correlate with health insurance. To simplify 45.1% for those with job-based coverage and 67.8% for the presentation, we provide figures for just the three largest those with Medi-Cal or Healthy Families. insurance categories: the uninsured, those with Medi-Cal or Healthy Families, and those with job-based coverage. 58 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY A similar trend exists among people with diabetes. Overall, then, we see that insurance coverage is Again, prevalence rates are lower for the uninsured, but strongly correlated with taking medication for chronic among those who report having diabetes, far fewer are diseases. In addition, it is noteworthy that for three of the taking insulin or pills: 57.8% of the insured compared to four chronic diseases (asthma, high blood pressure, and 75.4% and 75.7% of those with Medi-Cal/Healthy Families heart disease), far more individuals with Medi-Cal take and those with job-based coverage, respectively. medication than those with private coverage. This indicates Among people with high blood pressure, again the how important Medi-Cal coverage can be for improving pattern is the same. Fewer uninsured report having high health behaviors. Although it is not possible to prove that blood pressure, but there is a dramatic difference by insurance uninsurance causes Californians to refrain from taking status in whether they take medication for this problem. needed medications without controlling for confounding Only 29.5% of the uninsured with high blood pressure take variables, such a sequence of events is highly likely given the medications, about half that for those with Medi-Cal/Healthy high price of medicines and the relatively low incomes of Families (61.3%) or job-based coverage (53.1%). uninsured individuals and families. Combined with our Finally, the data on heart disease exhibits the exact findings from the previous subsection that showed lower same pattern. Although fewer uninsured report having heart health status, utilization, and lack of regular sources of care, disease, those with this condition are much less likely to take it is clear that the uninsured face numerous obstacles in medications. Just 27.2% of the uninsured indicate that they attempting to use California’s health care system. take medication for it, compared to 60.1% of those with Medi-Cal/Healthy Families and 42.4% of those with job- based coverage. UCLA CENTER FOR HEALTH POLICY RESEARCH 59 60 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY 6. PUBLIC POLICIES THAT EXPAND COVERAGE FOR CHILDREN AND ADULTS E. Richard Brown, Thomas Rice, Ninez Ponce, and Shana Alex Lavarreda California’s 4.5 million uninsured residents need the same conducted in March 2001. The increase in coverage was 6 level of access to health care as the rest of the population aided by growing enrollments in Medi-Cal and the Healthy but, as we have shown, their access to care is seriously Families Program — a contrast to the period from 1994 to compromised. The uninsured are overwhelmingly 1998 when Medi-Cal enrollment declined rapidly among moderate- and low-income working men and women and adults and children who were receiving cash assistance.23 their families, playing by society’s rules but without the The combination of growing job-based insurance basic benefit that the majority of employees and others coverage and stable Medi-Cal and Healthy Families receive. As we have seen, these workers are either not offered enrollments reduced the number of uninsured in California health insurance coverage by their employers or they cannot by an estimated 375,000 between 1998 and 2000. The afford the required share of cost for job-based health economic contraction in California and nationally that insurance premiums. occurred since these data were collected, together with substantial increases in the cost of health insurance, are IS THERE CAUSE FOR OPTIMISM? likely to reverse the downward trend in uninsurance.24 Health insurance coverage improved in California over the last several years, but this trend is not likely to be sustained. PUBLIC POLICY TOOLS TO EXPAND COVERAGE The rate of uninsurance declined from 21.0% of the California has many policy tools to help it improve coverage nonelderly population in 1999 to 20.0% in 2000, based on for its uninsured residents through effective public policies. data from the Current Population Survey.22 (Despite its In this final section of the report, we offer several limitations, the CPS provides a useful measure of changes recommendations that could help California improve its over time in health insurance coverage and uninsurance. existing programs and policies and expand them to cover CHIS 2001 provides a more comprehensive understanding uninsured residents. of these issues during 2001, and it will allow California to Our recommendations focus on the State’s process to more accurately and in-depth track changes over time with stimulate public dialogue on ways to improve and expand CHIS 2003 and surveys in subsequent years.) our public health insurance coverage programs and to move This improvement between 1999 and 2000 was driven toward universal coverage. Despite the dominance of by California’s still-strong economy, which resulted in a employment-based health insurance, we believe that efforts substantial increase in employment-based health insurance to expand job-based insurance to low-wage, low-income up to the time the Current Population Survey was employees of small firms are not likely to pay off with 22 For a more detailed look at this change in health insurance in California, see Brown 23 For more on the decline in this period, see Brown ER, Ponce N, Rice T, The State of ER, Alex S, Becerra L, Number of Uninsured Californians Declines to 6.2 Million—2 Health Insurance in California: Recent Trends, Future Prospects. Los Angeles: UCLA Million Are Eligible for Medi-Cal or Healthy Families, Health Policy Fact Sheet. Los Center for Health Policy Research, March 2001; Fix M, Passel J, The Scope and Angeles: UCLA Center for Health Policy Research, March 2002. Impact of Welfare Reform’s Immigrant Provisions. Washington, DC: The Urban Institute, 2002; and Lutzky AW, Zuckerman S, Recent Changes in Health Policy for Low-Income People in California. Washington, DC: The Urban Institute, March 2002. 24 Lee D, “CalPERS to Raise Health Premiums 25%, Los Angeles Times, April 17 2002; ” , and Abelson R, “Hard Decisions for Employers as Costs Soar in Health Care, New ” York Times, April 18, 2002. UCLA CENTER FOR HEALTH POLICY RESEARCH 61 significant expansions. The cost to these employers is great coverage for Medi-Cal-eligible children and adults. The relative to the wages they pay employees, and job-based State receives approximately $2 in federal funds for every health benefits are relatively expensive to low-wage dollar it spends on the Healthy Families Program although workers.25 Some valuable efforts have been made in this the State’s share of SCHIP funds is capped by the total funds direction, but they yield small results and, frankly, show appropriated by the Congress. The availability of a generous little promise of bridging the coverage chasm in California. federal match makes these effective vehicles for expanding We believe that California will achieve its best results if it coverage. uses existing and emerging opportunities to expand its California and other states have moved gradually to public coverage programs. recognize that children and the State itself are best served by policies that embrace the entire family. The federal welfare Public Programs to Cover Uninsured Californians reform legislation of 1996 completed the growing separation of Medicaid from cash public-assistance programs and POLICY RECOMMENDATION liberalized the provisions by which states could expand s Cover entire families, including children and parents, by coverage to children and families. Many states, including implementing the Healthy Families expansion to parents California, have used these options and reformed and and eliminating the assets test for parents applying for expanded their programs to benefit more children and, to a Medi-Cal. lesser extent, their parents. Even opportunities to expand public programs seem distant California could do more to expand coverage options with the very grim loss of tax revenues that struck California and complete the transition of Medi-Cal from its welfare with the collapse of the “dot com” industry and the economic origins to a health insurance program that serves families decline in 2001. The budget process remains to be completed, and individuals on the basis of income alone. Implementing but coverage of families will be severely impacted by current parents’ coverage in Healthy Families is an important part of budget proposals to delay implementation of the Healthy this process, and it would have other benefits beyond Families expansion to parents, cut their Medi-Cal eligibility insuring these adults. There is evidence from other states from 100% of the poverty level to just 67% of poverty, and that children enroll in Medicaid and state programs like reinstate quarterly reporting of changes in income and Healthy Families at a higher rate when both parents and assets for parents in Medi-Cal.26 their children are eligible.27 Moreover, the federal The federal government provides relatively generous government would provide two-thirds of the subsidy costs matching funds for California to support state-level of coverage for these parents, reducing the drain on State expansion of coverage for children and for their parents and and county tax dollars that now subsidize the care of low- some other adults. California receives approximately $1 in and moderate-income uninsured Californians through federal matching funds for every dollar it spends on county-sponsored health services programs, the State’s 25 Marquis S, Long SH, “Trends in the Cost of Employer-Sponsored Coverage, Data ” 27 Ku L, Broaddus M, The Importance of Family-Based Insurance Expansions: New Bulletin No.14, Center for the Study of Health System Change, Fall 1998. Research Findings about State Health Reforms. Washington, D.C.: Center on Budget and Policy Priorities, September 5, 2000. 26 2002-03 Governor’s May Revision, Department of Health Services. Sacramento, CA: May 2002. 62 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY County Medical Services Program, and support to private Enhancing Enrollment of Eligible Persons in Medi-Cal and hospitals and community clinics. Healthy Families More than 400,000 uninsured parents are currently POLICY RECOMMENDATION eligible for Medi-Cal. If California were to implement the s The State should more fully engage community-based expansion of the Healthy Families Program to parents, an organizations, churches, and schools in culturally additional 281,000 uninsured parents would have an sensitive outreach and expand funding for these efforts. opportunity to gain coverage (Exhibit 22). With this expansion, nearly half of the 1.4 million uninsured parents s Fully implement Express Lane Eligibility to expedite with children at home would be eligible for public coverage. enrollment in health programs for children who are Ironically, however, expanding Healthy Families to participating in the Food Stamps and the School Lunch uninsured parents with family incomes up to 200% of the Programs. poverty level would provide a less stigmatizing and The fact that 1.1 million uninsured children and adults are burdensome application process for parents above the eligible for, but not enrolled in, Medi-Cal or Healthy Families poverty level than for those below it. Parents with incomes underscores the importance of expanded efforts to enroll at or below 100% of poverty who apply for Medi-Cal are and retain eligible persons in these programs. Two key steps currently required to answer a long set of intimidating will enhance enrollment without expanding eligibility. questions about assets and provide proof that their First, California has already adopted “Express Lane possessions have little value — while families with incomes Eligibility” to expedite enrollment in Medi-Cal and Healthy above poverty will have no assets test at all when they apply Families for hundreds of thousands of uninsured children for Healthy Families. Since 1996, 16 states have eliminated who are already enrolled in programs with comparable their assets tests for Medicaid eligibility, as California has income-eligibility provisions, such as Food Stamps and the done for children.28 This step is an important one in National School Lunch Program. By using the income enabling all members of a family to be covered, and it would information already provided to these programs, large eliminate an inequity that otherwise disadvantages the numbers of uninsured children can be identified and already disadvantaged. enrolled in health care coverage more quickly, also avoiding unnecessary red tape. However, in response to the growing revenue shortfall, Governor Davis has proposed deferring implementation of Express Lane Eligibility until 2005, saving the State an expected $26 million in General Fund revenues but missing out on valuable opportunities to cover uninsured children.29 28 Maloy KA, Kenney KA, Darnell J, Cyprien S, Can Medicaid Work for Low-Income 29 Express Lane Eligibility: How California Can Enroll Large Numbers of Uninsured Working Families? Washington, DC: Kaiser Commission on Medicaid and the Children in Medi-Cal and Healthy Families, Los Angeles: The 100% Campaign, Uninsured, April 2002. February 2000; and Putting Express Lane Eligibility Into Practice. Santa Monica, CA, and Washington, DC: The Children’s Partnership and Kaiser Commission on Medicaid and the Uninsured, November 2000. See also Rosenblatt RA, “Uninsured Kids Get a Booster Shot, Los Angeles Times, January 7 2001. ” , UCLA CENTER FOR HEALTH POLICY RESEARCH 63 Second, both state and locally funded outreach efforts adults. These programs usually target groups that would not to inform parents and enroll eligible children could more be eligible for Medi-Cal or Healthy Families. San Mateo fully engage community-based organizations, schools, and County seems poised to join this group. Both the City and churches. Community groups and schools have proved very the County of Los Angeles, as well as San Francisco, San Jose, successful in reaching and enrolling eligible children when and some other cities and counties have enacted “living wage” they have the resources to mount sustained efforts.30 In the ordinances to raise the minimum wage for employees of local past, California’s outreach has relied too heavily on government contractors and encourage employers to offer expensive media campaigns and not effectively engaged health benefits.31 These local efforts can make important these other channels of communication. While the state has contributions to addressing the problem of uninsurance. recently involved these groups through outreach contracts, faced with the enormous deficit the Governor has proposed Streamlining the Medi-Cal and Healthy Families Programs eliminating these contracts. Such cuts are likely to reduce POLICY RECOMMENDATION program participation rates of eligible families, particularly s Reduce fragmentation for families by integrating Medi- cutting into culturally appropriate outreach efforts targeted Cal and Healthy Families. to Latino and other immigrant communities — a need that the CHIS data presented in this report confirms. Medi-Cal and Healthy Families benefit millions of Californians, but their patchwork character fragments Mobilize Community Resources and Innovation coverage for families and individuals who must navigate multiple programs. Beneficiaries are divided between two POLICY RECOMMENDATION separate programs, Medi-Cal and Healthy Families, that differ s Local jurisdictions can generate local resources and in eligibility by age and income. Families may weave in and innovation to expand coverage of their residents. out of either program as income fluctuates and as children In the absence of federal and statewide policies that would grow older. Their children may also be divided between the dramatically expand coverage, a number of counties and cities two programs because of different income eligibility levels have committed local resources and mobilized community for different ages. This patchwork system increases adminis- leadership to address the problem. Alameda, Contra Costa, trative costs for multiple bureaucracies needed to administer San Francisco, San Joaquin, Santa Clara, and Solano Counties differing programs, rules, and application and eligibility have all committed local public revenues, usually in determination processes. And it poses a frustrating and collaboration with the the county-sponsored Medi-Cal often discouraging experience for families and individuals managed care plan, to subsidize coverage for children and who must deal with so many bureaucracies. 30 Long P Local Efforts to Increase Health Insurance Coverage among Children in , California, Oakland, CA: Medi-Cal Policy Institute, February 2002. 31 Long P County Efforts to Expand Health Coverage among the Uninsured in Six , California Counties, Oakland, CA: Medi-Cal Policy Institute, February 2002; and de Sá K, “Supervisors Pledge Funds for Coverage, San Jose Mercury News, May 19, 2002. ” 64 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY This fragmentation could be reduced in several ways. The Gap in Coverage Remains Large – The Goal Should Be It could be ameliorated by establishing a “bright line” Universal Coverage between the programs — at, say, 133% of poverty — so that POLICY RECOMMENDATION eligible children up to that level would be enrolled in Medi- s Continue the policy dialogue of the State Health Care Cal and those above that level would be enrolled in Healthy Options Project, mandated by SB 480 and vigorously Families.32 Equally important would be to adopt similar conducted by the Secretary of Health and Human eligibility policies for parents in Medi-Cal as the Governor Services, to examine alternative ways to extend health has agreed to do for parents in Healthy Families, which are insurance coverage to all Californians. the same as current policies for children. Fragmentation could be even more fully remedied by Even if the Healthy Families expansion to parents were integrating Medi-Cal and Healthy Families into a implemented and Medi-Cal and Healthy Families were coordinated or consolidated program. Existing program streamlined, California would continue to have more rules could be coordinated so that gaps and abrupt changes uninsured residents than the populations of nearly half the in eligibility and benefits are smoothed out. Although it states. More than 3 million California residents, including would be best to fully integrate the programs — including more than 2 million who are citizens or legal immigrants, eligibility requirements, application procedures, benefits, would be uninsured and have no public coverage options. and administration — it would also be possible to integrate The United States has the intellectual and financial resources only their interface with beneficiaries and health care to find a way of achieving universal coverage — following providers. This more limited integration could be the examples set long ago by other industrialized countries. accomplished by crafting an administrative overlay that This goal has wide and deep popular support in the United would manage the application and enrollment of the two States although the political means for achieving that goal programs’ beneficiaries, creating a system that appears seem elusive. seamless to beneficiaries and providers and thus avoids the Senate Bill (SB) 480, enacted by the Legislature and fragmentation that currently frustrates families and signed by Governor Davis in 1999, launched a process to advocates.33 develop a study of alternative approaches to reaching Integrating these programs would make them more universal coverage. Secretary Grantland Johnson, who heads streamlined and user-friendly for beneficiaries. Although it the Health and Human Services Agency, has conducted a is unclear whether reducing fragmentation would directly far-reaching process, known as the Health Care Options increase enrollment, there is evidence it would reduce the Project, to generate a wide range of proposals for expanding State’s administrative costs, permitting more funds to be coverage and initiating a public dialogue on them. The redirected to coverage and services.34 process has been informed by nine commissioned reform 32 According to the National Governors Association, 29 states enroll all children up to age 33 Integration of Medi-Cal and Healthy Families has been proposed in a number of 18 with family income up to at least 133% of poverty in their Medicaid programs. This legislative proposals in California, including AB32 by Assemblymember Keith Richman at least avoids fragmenting coverage among children within a family. See and SB 1414 by Senator Jackie Speier. http://www.nga.org/Pubs/IssueBriefs/2000/000120MCHUpdate.asp#1 (Jan. 11, 2001). 34 See Rabovsky D, A Model for Health Coverage of Low-Income Families. Sacramento, CA: Legislative Analyst’s Office, June 1, 1999. UCLA CENTER FOR HEALTH POLICY RESEARCH 65 proposals, quantitative and qualitative comparative analyses California is squeezed by a fiscal dilemma. It has a of the reform proposals, and public symposia held in a persistent and large problem of uninsurance, and it faces an variety of locations throughout the state. The proposals extraordinarily large shortfall in tax revenues. The budget include public program expansions, individual and problems may discourage the State from expanding its employer tax credits, employer and individual mandates, efforts to provide coverage, and it has led to rescission of single-payer models, and combination approaches.35 already adopted expansions and reform. Although it is a long road from generating reform In the longer run, California and the nation must ideas to achieving universal coverage, the Health Care commit to extending to all residents affordable coverage that Options Project can generate a needed political dialogue on provides good access to high-quality, health-enhancing care. the best and most feasible ways to reach that goal. We Although there are costs to ensuring that all residents have recommend that the Governor continue that process, coverage, there are great costs associated with a large engaging the Legislature and a wide range of constituencies. portion of our population remaining uninsured — lost earnings, lost school days, lost potential, and lost life. CONCLUSION California’s 4.5 million uninsured residents face tremendous obstacles to obtaining needed care. California’s uninsured children and adults face barriers to obtaining the care they need to manage their chronic conditions (such as asthma, diabetes, and high blood pressure), care that can help reduce disability and increase productive years of life. They are more likely to delay seeking care for acute conditions (such as infections and injuries), resulting in more lost earnings and increasing the risk of spreading communicable diseases. And they receive fewer preventive services that help reduce the risk of disease and detect diseases at an earlier stage. 35 For more information on the Health Care Options Project and for copies of the papers and analyses, visit the Web site at http://www.healthcareoptions.ca.gov/. 66 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY APPENDIX. SURVEY METHODS AND EFFECTS ON RESULTS appendix This report is based on data from the 2001 California (Mandarin and Cantonese dialects), Vietnamese, Korean, Health Interview Survey (CHIS). In this Appendix, we and Khmer (Cambodian). Questionnaires were also describe the survey, discuss the relationship of its estimates reviewed by expert teams to ensure that question wording to those of other surveys, and compare its method to those was culturally appropriate for a variety of population of other surveys. groups. Community outreach campaigns were conducted in communities of color to encourage the participation of CALIFORNIA HEALTH INTERVIEW SURVEY populations that often have low participation rates in CHIS 2001 randomly selected 55,428 households drawn surveys. These campaigns used media and materials that from every county in California for its random-digit dial were both culturally and linguistically appropriate to (RDD) telephone survey, providing a sample that is particular communities. representative of the state’s noninstitutionalized population CHIS covered a broad range of public health living in households. Data were weighted to the 2000 Census, concerns, including health insurance coverage, eligibility for at both the stratum and statewide levels. CHIS interviewed and participation in public health care programs, access to one sample adult in each household. In households with and use of health care services, health and mental health children, CHIS interviewed one adolescent age 12-17 (a total status, chronic conditions (asthma, cancer, cardiovascular of 5,801), and obtained information for one child under age disease, arthritis, and diabetes), health behavior (including 12 by interviewing the adult who was most knowledgeable diet and physical activity, alcohol and tobacco use, and about the child (a total of 12,592). The interviews were cancer prevention), dental health, women’s health, and conducted between November 2000 and September 2001 by demographic characteristics (including employment, Westat, a highly respected survey research organization. In income, and extensive information on race, Latino, Asian, addition to the RDD sample, CHIS conducted an oversample and Pacific Islander ethnicity; nativity of the respondent of American Indians and Alaska Natives residing in both and his/her parents, citizenship, immigration status, and urban and rural areas and oversamples of Japanese, English proficiency). Vietnamese, South Asians, Koreans, and Cambodians; this For more information on CHIS, please visit report does not include data from these oversamples. www.chis.ucla.edu. All CHIS questionnaires were translated and interviews were conducted in six languages: English, Spanish, Chinese UCLA CENTER FOR HEALTH POLICY RESEARCH 67 CHIS AND THE CURRENT POPULATION SURVEY estimate of persons who were uninsured at the time of the The estimates of uninsurance based on CHIS 2001 data CHIS interview (Exhibit A-1). The estimate of uninsurance differ from estimates of uninsurance based on the Current at the time of the interview or during at least some of the Population Survey (CPS). The CPS is the data source preceding 12 months (6,272,000) is much closer to the CPS previously used by the UCLA Center for Health Policy estimate (6,273,000). Research for its annual reports on health insurance Among children up to age 18, the March 2001 CPS coverage, and the lack of it, in California. estimate (15.4%) is twice the CHIS 2001 estimate of those The CPS is a national cross-sectional survey of who were uninsured throughout the previous 12 months persons living in households, administered in person and by (7.3%) — the period of time that appears to be most similar telephone. The California sample of the March 2001 CPS in the two surveys, based on the wording of the questions. includes 4,338 households, collecting information on The March 2001 CPS estimate is also one-and-a-half times approximately 12,966 persons. The CPS is conducted by the CHIS 2001 estimate (9.6%) of children who were the U.S. Bureau of the Census to obtain information on uninsured at the time of the interview, but it is closest to the employment, unemployment, and demographic status of estimate of those who were uninsured at some time during the noninstitutionalized, U.S. civilian population. The a period of 12 months (14.3%). March CPS also asks about health insurance coverage, For nonelderly adults (ages 18–64), the March 2001 employment, and sources of income during the previous CPS estimated uninsured rate is 22.1%. This rate is one- calendar year as well as ethnicity, immigrant and citizenship and-a-half times the CHIS 2001 estimate that 14.4% were status, and nativity of each household member. The most uninsured throughout the preceding 12 months; well above recent CPS data that are available come from the March the CHIS 2001 estimate of adults who were uninsured at the 2001 CPS, which asks about health insurance coverage in time they were interviewed (17.7%); and slightly lower than 2000. We use the CPS to compare recent estimates with the CHIS 2001 estimate of nonelderly adults who were those from some previous years for which comparable uninsured at some time during a period of 12 months questions were asked.36 (24.1%). Both surveys find very low uninsured rates for Using data from the March 2001 CPS, we would persons age 65 and over: 1.6% based on the March 2001 estimate that 6.27 million Californians were uninsured in CPS compared to CHIS 2001 estimates of less than 1% at 2000 — 2.6 million more than the CHIS 2001 estimate of the time of the interview, less than 1% uninsured the number of Californians who were uninsured throughout throughout 12 months, and 1.5% uninsured at some time the preceding 12 months and 1.8 million more than the during a period of 12 months. 36 CPS added a “verification” question in 2000 which identified more respondents who have coverage. This change limits much of our trend analysis to 1999 (March 2000 CPS) and 2000 (March 2001 CPS). We have extrapolated a slightly longer time trend to measure the magnitude of change. 68 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT A-1. UNINSURED PERSONS BY AGE GROUP BASED ON 2001 CALIFORNIA HEALTH INTERVIEW SURVEY AND MARCH 2001 CURRENT POPULATION SURVEY, ALL AGES, CALIFORNIA 2001 CALIFORNIA HEALTH INTERVIEW SURVEY MARCH 2001 CURRENT POPULATION SURVEY PERCENT UNINSURED UNINSURED AT UNINSURED AT UNINSURED DURING UNINSURED TIME OF INTERVIEW SOME TIME DURING ALL OF LAST IN 2000*** LAST 12 MONTHS* 12 MONTHS** AGES 0–17 9.6% 14.3% 7.3% 15.4% AGES 18–64 17.7% 24.1% 14.4% 22.1% AGES 65 AND OVER 0.5% 1.5% 0.5% 1.6% ALL AGES 13.7% 19.0% 11.0% 18.1% NUMBER UNINSURED IN 2000 4,519,000 6,272,000 3,640,000 6,273,000 * Includes persons who were uninsured at the time of the interview and Source: 2001 California Health Interview Survey and March 2001 those who were insured at the time of the interview but uninsured at Current Population Survey some time during the preceding 12 months ** Includes persons who were uninsured at the time of the interview and those who were uninsured during all of the preceding 12 months *** Persons who reported no coverage at any time during 2000 There are important differences between CHIS and Point in time vs. duration of time. CHIS asks about the CPS that are likely to affect estimates of uninsurance as health insurance coverage at the time of the interview (a well as estimates of different sources of coverage. CHIS and “point-in-time” estimate) and about changes in coverage CPS differ in the time period for which they measure health and lack of insurance during the previous 12 months insurance coverage, the breadth of their questions about (duration of coverage or uninsurance). The March CPS asks health insurance coverage, and differences in their samples respondents about coverage at any time during the and their inclusiveness of California’s population. preceding calendar year so that uninsurance ostensibly reflects lack of insurance throughout that calendar year. DIFFERENCES BETWEEN CHIS AND Although health services researchers disagree about whether THE CPS: TIME CPS is actually measuring the absence of coverage CHIS and the CPS ask about coverage for different time throughout the year, it is clear that CHIS and CPS differ in frames, they differ in the time period the respondent must the time period for which they are measuring coverage, and recall, and they differ in the time periods they cover. this difference by itself could produce differences in estimates of coverage.37 As noted in a U.S. Department of 37 See Lewis K, Ellwood M, Czajaka J, Counting the Uninsured: A Review of the Literature, Occasional Paper Number 8. Washington, DC: The Urban Institute, July 1998; and State Health Access Data Assistance Center (University of Minnesota School of Public Health), “State Health Insurance Coverage Estimates: Why State- Survey Estimates Differ from CPS, Issue Brief 3, July 2001. ” UCLA CENTER FOR HEALTH POLICY RESEARCH 69 Health and Human Services analysis of survey differences of Recall period. The CHIS questions’ focus on the uninsurance estimates, “As more time passes, more people current point in time requires a shorter recall period than will experience a lapse in health coverage. Thus, the total the CPS questions’ focus on coverage at any time during the number of people who experience a period of uninsurance previous calendar year. Shorter recall is generally considered over the course of an entire year will be greater than the to produce a more accurate measure of coverage. number of uninsured at a given point in time (such as the Changing economic conditions and public programs. time of the survey interview).”38 CHIS 2001 asked about coverage and uninsurance at the CHIS provides opportunities not previously available time of the interview; interviews were conducted between in California to assess and track not only how many people November 2000 and October 2001. The March 2001 CPS are uninsured in California, but how many are uninsured at asked about coverage during 2000 and its measure of a given point in time and how many are uninsured over any uninsurance ostensibly reflected lack of coverage throughout specified time period. There is no inherently superior 2000. Changes in economic conditions and public policy reference time for measuring lack of health insurance. The between 2000 (the period asked about by CPS) and any number of people who are uninsured at some time during a point in time in 2001 (at the time of the CHIS interview) period of 12 months is a good measure of the population would likely contribute to differences between the surveys in that is at risk of needing some assistance with coverage or their estimates of health insurance coverage. To the extent with getting care during the course of a year. The estimate that economic conditions continued to improve for the first of persons who are uninsured throughout a 12-month half or two-thirds of 2001, and to the extent that Medi-Cal period is a useful measure of the population that and the Healthy Families Program were improving their experiences longer-term uninsurance, for whom special enrollment and retention during this period, we would efforts will need to be made to create opportunities to expect to see higher estimates of coverage and lower estimates obtain affordable coverage. However, the number who were of uninsurance for CHIS than for CPS. uninsured at the time they were interviewed may be a better It is evident in Exhibit A-2 that two-thirds of CHIS indicator of the magnitude of the need for assistance that interviews were conducted before the economy began to State health insurance programs or safety-net providers sink rapidly in the summer of 2001. The unemployment should have the capacity to serve at any point in time. For rate during the period of CHIS data collection averaged most of this report, we use estimates of health insurance 4.5% compared to 4.9% for the period that the CPS asked coverage and uninsurance at the time of interview as our about. Throughout this period, both Medi-Cal and Healthy primary time frame. Families enrollment rose steadily — with Medi-Cal rising 38 U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, “Understanding Estimates of the Uninsured: Putting the Differences in Context, http://aspe.hhs.gov/search/progsys/homeless/HIestimates.htm ” (n.d.). 70 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT A-2. PERCENT OF 2001 CALIFORNIA HEALTH INTERVIEW SURVEY COMPLETED, CALIFORNIA UNEMPLOYMENT RATE, AND MEDI-CAL AND HEALTHY FAMILIES ENROLLEES BY MONTH NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT 2000 2000 2001 2001 2001 2001 2001 2001 2001 2001 2001 2001 CHIS INTERVIEWS 0.2% 4.5% 8.1% 9.3% 10.8% 16.9% 16.4% 13.1% 11.6% 6.9% 1.9% 0.3% COMPLETED CALIFORNIA 4.7% 4.4% 5.2% 5.1% 5.0% 4.8% 4.7% 5.3% 5.7% 5.4% 5.4% 5.7% UNEMPLOYMENT RATE MEDI-CAL 4,319.6 4,336.1 4,398.8 4,447.9 4,508.8 4,559.8 4,614.4 4,655.9 4,698.8 4,745.5 4,787.1 4,838.0 ENROLLEES* HEALTHY FAMILIES 354.9 362.9 375.4 386.5 400.9 415.0 432.5 444.6 456.2 466.4 474.5 489.1 ENROLLEES* * in thousands Source: 2001 California Health Interview Survey and Employment Development Department, Labor Market Information Division from 4,320,000 children and nonelderly adults in November health-care use is likely to generate better recall about 2000 to 4,838,000 in October 2001, and Healthy Families insurance coverage that may be relevant to the respondent’s rising from 354,902 in November 2000 to 489,145 in health condition or use of services, thus resulting in higher October 2001. This rapid growth in both programs may not estimates of health insurance coverage. have been measured by the other, older surveys. Form of the Survey Questions. CHIS asks an extensive set of questions about health insurance, whereas DIFFERENCES BETWEEN CHIS AND THE CPS: CPS asks a relatively brief set of questions that may not FOCUS AND CONTENT elicit as much information about coverage as does CHIS. CHIS and the CPS differ in the overall focus of their Starting in 2000, CPS added a “verification” question respective surveys and the form and content of questions on designed to measure coverage not previously reported by health insurance coverage. respondents to the basic set of health insurance questions — Focus of Survey. CHIS asks about health insurance in and it did identify more people with coverage, particularly the context of an interview on an extensive range of health among more affluent respondents. CPS significantly topics and after a series of questions on use of health care underestimates coverage by Medicaid relative to enrollment services. CPS focuses primarily on labor force issues and numbers from administrative data; this undercount is due asks some health insurance questions toward the end of the in part to the limited questions asked about Medicaid.39 interview. The CHIS interview’s focus on health status and CHIS questions achieve a higher estimate for Medi-Cal 39 For the difference between administrative data and CPS estimates of Medi-Cal enrollment, see Brown ER, Yu H, Fong K, Wyn R, Cumberland W, Levan R, Adjusted Population-Based Estimates of Medi-Cal Coverage. Los Angeles: UCLA Center for Health Policy Research, August 1997. UCLA CENTER FOR HEALTH POLICY RESEARCH 71 coverage and a separate estimate for Healthy Families; when federal poverty level, based on data from the March 2001 used separately or combined, these CHIS questions yield a CPS).40 Persons who live in households without telephones higher estimate of public coverage than do the CPS are less likely to be insured than persons who live in questions (although the estimate is still somewhat lower households with telephones (32.5% vs. 17.6%, respectively, than numbers found in administrative data). also based on data from the March 2001 CPS). Despite this CHIS also yields a higher estimate of employment- difference, because the proportion of the population that based health insurance than does the CPS conducted in lives in households without telephones is so small, the CPS essentially the same time period. One reason for this may be estimate of uninsurance would be less than one percentage that CHIS asks working respondents who do not report job- point lower if households without telephones were excluded. based insurance whether their employer offers health Nevertheless, CHIS compensates for lack of telephone benefits and whether they are eligible for offered benefits. coverage by asking if the household was without a telephone These questions may also stimulate recall to a greater degree in the previous 12 months and, if so, for how long. The than the more limited questions asked in the CPS. CHIS results are then statistically adjusted, using special weighting procedures, to compensate for households DIFFERENCES BETWEEN CHIS AND THE CPS: without telephones. SURVEY ADMINISTRATION AND INCLUSION OF Inclusion of Non-English Speaking Groups in THE POPULATION Sample. CHIS and CPS samples differ in their inclusion of CHIS and the CPS are administered differently. Several persons who do not speak English. All CHIS questionnaires aspects of survey administration affect the inclusiveness of are translated and administered in six languages whereas population groups in each survey. Some of these differences CPS is only translated into Spanish, but very few interviews would tend to make CPS more inclusive and others would are conducted in Spanish. CHIS’s linguistic adaptation tend to make CHIS more inclusive. enables it to include more fully immigrant population Inclusion of Households without Telephones in groups that tend to have low incomes and poor access to Sample. CHIS and CPS samples differ in their mode of private health insurance and public programs. In CHIS administration, which influences the inclusion of 2001, 10.7% of all adult interviews and 20.1% of all households without telephones. As a survey conducted only interviews with the sample child’s “most knowledgeable by telephone, the CHIS sample includes only residential parent” were conducted in a language other than English. households with telephones, whereas the CPS is conducted The great majority of these were in Spanish, thus including by telephone and in-person and thus includes residences many Latino immigrants who, as a group, have high without telephones. In California, 3.5% of residents live in uninsured rates. Thus, offering the CHIS interview in households without a telephone, although the proportion of multiple languages would be likely to include more households without a telephone is higher in very low- uninsured persons, lowering CHIS’s estimates of health income households (11.3% of persons below 50% of the insurance coverage relative to the CPS. 40 Estimates of telephone coverage are from the UCLA Center for Health Policy Research’s analyses of the March 2001 Current Population Survey. 72 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY Response Rate and Adjustment for Nonresponse. requires more time to complete than most other telephone Telephone survey response rates are defined as the ratio of surveys. CHIS is unique in that it requires multiple completed interviews to eligible (residential) telephone interviews per household when adolescents and/or children numbers. Telephone numbers in the sample that end up are also present. with an unknown eligibility are classified as either eligible California is one of the more difficult states in which or ineligible based on a method of assigning a statistical to obtain “high” response rates. The 2000 California likelihood that they are residential or not. In CHIS 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey there are two levels of response rates which, when multiplied reported a response rate of 43.4% (average 20 minutes, only together, produces the overall survey response rate. The first English and Spanish language households are eligible). The level, the “screener” response rate, is the response to an 1999 National Survey of America's Families (NSAF), which interviewer contacting a telephone number, determining included a monetary incentive, had a response rate of 51.7% eligibility (is it a residence and thus eligible, or is it a nonres- for adults in the California RDD sample. Although NSAF idential or nonworking number?), explaining the study, and had the same computational approach as CHIS, the selecting a respondent. The overall screener response rate monetary incentive — something CHIS did not offer — is for CHIS 2001 was 59.2%. The second level, the “completed largely responsible for this higher response rate. Accounting interview” response rate, is the rate of success in having the for the differences between CHIS and BRFSS, the response selected respondents actually complete the CHIS interview. rates for these two surveys are similar and thus usual for a The completed interview response rate was 63.7%. California survey. Therefore, the overall survey response rate for CHIS 2001 is As an additional effort to reduce nonresponse bias in 37.7%, the product of 59.2% multiplied by 63.7%. CHIS 2001, several nonresponse adjustments were made to Comparing the CHIS 2001 response rate of 37.7% the CHIS sample in the CHIS weighting scheme. The with other telephone surveys is not a straightforward process. weighting adjusts for such factors as the age and gender of Not all surveys handle the incorporation of eligibility status respondents who did not complete the interview, refused to of nonresponding telephone numbers in exactly the same do the interview, or were just not available to start the way nor do they all collect and record the information on interview, and several other adjustments based on information telephone numbers in their sample with the same level of in the sample were designed to reduce nonresponse bias. detail that CHIS did. The CHIS computational approach is Imputation of Missing Values. The item nonresponse one that professional survey organizations set as the preferred rate (a result of the respondent refusing to answer or replying method. Also, response rates differ based on differences in with “Don’t know” to a question) in CHIS 2001 is relatively the type of organization that is sponsoring them; CHIS low: with a few exceptions, less than 0.5 percent for the informs respondents that UCLA is sponsoring the survey. majority of questions. The household income item has the Response rates also differ depending on the amount of time highest nonresponse rate at about 15 percent, a rate respondents must spend completing an interview; CHIS comparable to many national surveys for their questions on UCLA CENTER FOR HEALTH POLICY RESEARCH 73 household income. The second highest item nonresponse Weighting of the Sample. In order for the CHIS rate in CHIS 2001 is for the race question, at about 3 percent. sample to accurately represent the California population, For the CHIS 2001 insurance questions, the item nonresponse the sample is weighted using data from the 2000 Census. A rate ranges from a low of less than 0.1 percent to a high of number of sample adjustments are made for such effects as 0.9 percent. selection probability, nonresponse, and nontelephone Missing values (nonresponses) were imputed for coverage. Correcting for the sample design, the data are selected variables used in this report. Three different statistically weighted to reflect the correct proportions of methods were used in the imputation: logical, relational, gender, age, race, and ethnicity as reported in the 2000 and statistical imputations. Logical imputation was used to Census. When the weights are applied, the CHIS population deduce the information for a variable from other estimates made will have been correctly adjusted to make information provided by a particular respondent. In the CHIS data identical to the 2000 Census proportion relational imputation, an imputed value of a variable was across all these dimensions. obtained or deduced from a related respondent (e.g., using a The closer the unweighted sample is to the Census parent’s information to impute that of a child). The method proportions, the smaller are the required adjustments. As an of “hot-decking” was used in statistical imputation in which example, on the dimensions of race and ethnicity, the CHIS respondents were grouped through modeling and then in sample is remarkably similar to the race and ethnic each group separating donors (nonmissing) and receivers distribution of the 2000 Census. In CHIS, the proportion of (missing). Values were then randomly drawn from donors respondents reporting Hispanic or Latino origin was 21.4%, of the same group (with replacement) and were assigned virtually identical to the expected 21.2% in the 2000 Census to receivers. data (adjusted for the CHIS stratified sample design). EXHIBIT A-3. PERCENT COMPARISONS OF THE UNWEIGHTED CHIS SAMPLE TO THE 2000 CENSUS* FOR SEVEN RACE CATEGORIES GROUP CHIS RDD SAMPLE 2000 CENSUS WHITE 69.9 70.4 OTHER 11.6 10.7 ASIAN 7.1 8.1 AFRICAN AMERICAN 4.7 5.9 TWO OR MORE RACES REPORTED 4.5 3.5 AMERICAN INDIAN & ALASKA NATIVE 1.7 1.1 NATIVE HAWAIIAN & OTHER PACIFIC ISLANDER 0.4 0.2 TOTAL 100% 100% * Census distributions adjusted for the CHIS stratified sample design. Source: 2001 California Health Interview Survey and Employment Development Department, Labor Market Information Division 74 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY EXHIBIT A-4. HEALTH INSURANCE COVERAGE ESTIMATES FOR CHILDREN AND NONELDERLY ADULTS FOR 2001 CALIFORNIA HEALTH INTERVIEW SURVEY, MARCH 2000 AND 2001 CURRENT POPULATION SURVEYS, AND 1999 NATIONAL SURVEY OF AMERICA’S FAMILIES, CALIFORNIA UNINSURED MEDI-CAL/ JOB-BASED PRIVATELY OTHER TOTAL HEALTHY INSURANCE PURCHASED FAMILIES AGES 0-17 CHIS 2001 9.6 27.6 58.9 2.9 1.2 100% CPS 2001 15.4 24.7 55.4 3.0 1.5 100% CPS 2000 16.8 23.8 52.5 4.5 2.4 100% NSAF 1999 13.2 20.7 60.1 * 6.0 100% AGES 18-64 CHIS 2001 17.7 10.4 65.1 5.6 1.2 100% CPS 2001 22.1 7.7 63.2 4.7 2.3 100% CPS 2000 22.9 8.0 61.8 4.9 2.5 100% NSAF 1999 18.8 11.1 63.4 * 6.8 100% * Included in “Other” estimate Source: 2001 California Health Interview Survey; March 2000 and 2001 Current Population Survey (analyses by UCLA Center for Health Policy Research) and The Urban Institute (Haley JM, Fragale M. “Health Insurance, Access, and Use: California, Assessing the New Fedaralism Program, ” December 2001) Exhibit A-3 shows how well CHIS approximated the SUMMING UP: COMPARING ESTIMATES FROM reported single race distribution plus the “two or more” race CHIS, CPS, AND NSAF category when compared to the 2000 Census proportions. Health insurance coverage estimates from CHIS 2001 differ These unweighted results show an excellent response to from those of the March 2000 and 2001 Current Population CHIS across all groups. Because these distributions are so Surveys and the 1999 National Survey of America’s Families, similar, only small race and ethnicity weighting adjustments which is conducted by Westat for The Urban Institute. In are required for the CHIS sample to reflect California’s Exhibit A-4, we compare estimates from these surveys for diverse population. It should be noted that the large “other” uninsurance and coverage through Medi-Cal, the Healthy and “two or more races” categories include some persons Families Program, employment-based health insurance, who, on the basis of additional information provided by privately purchased health insurance, and other public respondents, were classified into more descriptive categories programs for children and adults. This exhibit demonstrates such as Latino, Asian, and African American. that different estimates are related, at least in part, to differences in survey methods, questions, and year of UCLA CENTER FOR HEALTH POLICY RESEARCH 75 EXHIBIT A-5. STATE SURVEY’S POINT-IN-TIME AND THE CPS’S ANNUAL ESTIMATES OF UNINSURANCE STATE STATE SURVEY YEAR STATE SURVEY POINT- CPS ESTIMATE FROM IN-TIME ESTIMATE STATE SURVEY YEAR MASSACHUSETTS 1998 8.1% 10.3% MINNESOTA 1998 5.3% 8.0% WISCONSIN 1998 6.0% 11.8% Source: State Health Access Data Assistance Center (University of Minnesota School of Public Health), “State Health Insurance Coverage Estimates: Why State-Survey Estimates Differ from CPS, Issue Brief 3, July 2001 ” administration. The 1999 NSAF was administered by Thus, the differences between CHIS’s estimates of telephone at a time when employment was not as strong as uninsurance and those drawn from the CPS reflect a variety it was when most of the CHIS interviews were conducted; of methodological differences between the surveys. The the NSAF was conducted earlier in the period of rapid reader can have confidence in the CHIS estimates because of growth in enrollment in Medi-Cal and the Healthy Families the detail and precision of the questions, the inclusiveness of Program. Despite these temporal differences, the 1999 NSAF the sample, and the care with which the estimates have been estimates and those of CHIS 2001 are closer to each other produced. than either is to those of the 2000 or 2001 CPS — most likely a result of the greater similarity in NSAF and CHIS questions on health insurance coverage. A FINAL COMPARISON: CPS AND OTHER STATE SURVEYS A final comparison is worth noting: most state surveys find lower uninsured rates than are generated from the CPS samples for that state. This pattern is demonstrated in Exhibit A-5, which compares three state surveys from 1998, all asking about coverage at a point in time, with estimates from the March 1999 CPS for the year of the state survey. 76 THE STATE OF HEALTH INSURANCE IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY TO THE PRINTER: We estimated a 3/8-inch spine. We need to hold off on page count to judge thickness of spine. Please provide one to sign off on and Ikkanda Design will need in ord fers at all from the 3/8-inch in this file. 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