October 2018 ACA Reduces Racial/Ethnic Disparities in Health Coverage Differences in the uninsured rate between white, African American, and Asian/Pacific Islander Californians have been eliminated; however, the coverage rate for Latinos still lags behind. U nder the Patient Protection and Affordable In 2017 multiple unsuccessful attempts by the Trump Care Act (ACA), millions of Californians have administration and Congress to repeal the ACA and gained health coverage. These gains have enact policies that would have reduced the number come either through the expansion of Medicaid of Californians with coverage created uncertainty (called Medi-Cal in California) to low-income adults for consumers about coverage options and require- earning up to 138% of the federal poverty guide- ments. California also took steps to mitigate the line (FPG), or through Covered California, the state’s effects of certain federal actions. Federal actions and ACA health insurance marketplace, where people the uncertain environment may not have had a heavy earning up to 400% FPG can purchase subsidized influence on Californians’ decisions regarding cover- insurance coverage. The major coverage expansions age for 2017, due in large part to timing. For example, of the ACA were implemented starting in 2014, 2017 open enrollment for Covered California ended and by 2016 the uninsured rate among nonelderly on January 31, 2017, before ACA repeal attempts Californians had fallen from 15.5% to a historic low began in earnest and before many of the federal of 8.5%. actions were announced. Covered California’s 2018 open enrollment began in November 2017, near This brief examines health care coverage rates and the end of CHIS data collection for 2017. 2018 CHIS sources of coverage among nonelderly (under age data may better capture the effects of 2017 federal 65) Californians based on the 2017 California Health actions and uncertainties. Interview Survey (CHIS). The authors focus on non- elderly Californians because those over 65 are nearly This brief focuses on changes from 2013 to 2017 universally covered by Medicare. For ease of pre- to compare pre- and post-ACA implementation. sentation, the nonelderly uninsured rate is referred It also flags important changes from 2016 to to in the text as the “uninsured rate.” 2017. Only changes that are statistically significant Issue Brief (see definition below) are highlighted. (The term “changed significantly” is used throughout the brief Key Findings to mean a statistically significant change.) Uninsured rate remained stable and nearly 2016’s historic narrowing of disparities in 50% lower than before ACA implementation. coverage between most racial/ethnic groups In 2017 the uninsured rate among nonelderly was maintained, although Latinos continued to Undocumented Adults: What Counts Californians was 8.5%, just over half the 15.5% experience a higher uninsured rate than others. as Insurance? uninsured rate in 2013, before full implementation The ACA has significantly reduced the uninsured In this brief, in keeping with previous CHIS of ACA coverage provisions. Since 2016, with the rate among all racial/ethnic groups in California and analyses, all Californians reporting Medi-Cal ACA’s main coverage provisions in place since 2014, has produced historic declines in racial disparities in coverage are considered covered by Medi- California’s nonelderly uninsured rate has been health coverage rates. Cal. This includes undocumented adults who stable. are not eligible for full-scope Medi-Cal but Between 2013 and 2017, the uninsured rate may have used restricted-scope Medi-Cal. declined by more than 40% for each group, with Restricted-scope Medi-Cal is not comprehen- Figure 1. Uninsured Rate Among Californians slightly larger declines among African Americans sive coverage, covering only emergency and Age 0 – 64, 2013 – 2017 and Asians/Pacific Islanders (see Figure 2, page 3). pregnancy-related services. When asked by survey researchers about health coverage, By 2016, there was no statistically significant differ- some undocumented immigrants who have ence between the uninsured rates for non-Latino 15.5% used restricted-scope Medi-Cal may respond whites (5.8%), African Americans (5.8%), and Asians/ that they have Medi-Cal coverage. If undocu- 13.6%*† Pacific Islanders (5.6%) — the first time such equity in mented immigrants reporting Medi-Cal were health coverage rates had been achieved between considered uninsured, the number of Califor- these racial/ethnic groups since CHIS began collect- nians who are uninsured would be higher, as ing data in 2001. 9.5%*† would the number of uninsured among some 8.5%* 8.5%* demographic groups, such as Latinos. Although Latinos experienced a significant decline in their uninsured rate, dropping from 21.4% in 2013 to 12.4% in 2017, the coverage rate for Latinos contin- ued to lag behind other racial/ethnic groups. 2013 2014 2015 2016 2017 In 2017, there continued to be no statistically sig- Statistical significance is a mathematical test that helps nificant difference in the uninsured rate between researchers assess whether differences are real or the result *Significantly different from 2013 (p < 0.05). of random chance. In these survey findings, if a change is †Significantly different from previous year (p < 0.05). non-Latino whites, African Americans, and Asian/ “statistically significant” the CHIS team is confident the Source: California Health Interview Survey, 2017. Pacific Islanders. Between 2016 and 2017, uninsured change occurred due to a factor other than random chance. rates remained statistically stable within each racial/ ethnic group. California Health Care Foundation 2 Figure 2. Uninsured Rate Among Californians Age 0  64, by Race/Ethnicity, 2013  2017 –  –  Figure 3. Uninsured Rate Among Californians Age 0 – 64, by Region, 2013 – 2017 25% Greater Bay Area 21.4% 10.8% 20.1% Latino 9.1% ■ 2013 20% African American 7.3%* ■ 2014 Asian/Pacific Islander 6.1%* ■ 2015 White 7.4%* ■ 2016 13.8% 15.0%*† Sacramento Area ■ 2017 15% 13.6% 12.1% 12.4% 12.3%* 11.6% 12.4%* In 2017, there continued to 10.3% 7.2%* 10% be no statistically significant 7.7% 7.0%* 5.7%* 6.7%*† 5.8%* difference in the uninsured rate 5.8%* 7.3%* Central Coast between non-Latino whites, 15.8% 5.7%* 8.2%*† 18.2% 5% 7.6%*† 5.6%* 4.4%* African Americans, and Asian/ 4.9%* † 9.3%*† Pacific Islanders. 8.2%* 11.6% 2013 2014 2015 2016 2017 Other Southern CA 16.4% 15.3% 10.2%*† Coverage gains maintained in most California 8.7%* lowest uninsured rate in 2013 (10.8%) and has expe- 9.0%* regions, but variation across regions continued. rienced the smallest decline, reaching a low of 6.1% Northern/Sierra In 2017, every region of California had experienced in 2016. By 2017, the Sacramento area had the low- 16.9% a statistically significant decrease in its uninsured est uninsured rate (5.7%) and the Central Coast had 13.5%*† rate compared to 2013, with the exception of the the highest (11.6%). 8.7%*† 7.3%* Central Coast. (See Figure 3.) The San Joaquin 8.2%* Valley, which had the highest uninsured rate in 2013 Most of the change in the uninsured rates within Los Angeles (18.1%), experienced the largest decline, reaching a each region occurred between 2013 and 2015. Since 17.5% low of 7.6% in 2017. The Greater Bay Area had the then, rates have remained stable. 14.9% 11.6%*† 10.8%* 9.0%* FIGURES 2 AND 3: San Joaquin Valley *Significantly different from 2013 (p < 0.05). 18.1% †Significantly different from previous year (p < 0.05). 12.5%*† Notes: While the uninsured rate among African Americans crept up slightly to 7.3% in 2017, it is not a statistically significant change. 8.3%*† See Appendix for a list of counties within each region. 7.6%* Source: California Health Interview Survey, 2017. 7.6%* ACA Reduces Racial/Ethnic Disparities in Health Coverage 3 Coverage gains maintained for low- and Figure 4. Uninsured Rate Among Californians Medi-Cal enrollment decreased; private Age 0 – 64, by FPG, 2013 – 2017 moderate-income Californians. coverage rebounded. Under the ACA, low- and moderate-income families Under the ACA, the percentage of Californians cov- 400%+ FPG (earning up to 400% FPG) have seen the biggest ered by Medi-Cal rose substantially, from 20.1% decreases in their uninsured rates, reflecting the 5.9% ■ 2013 in 2013 to 33% in 2016 (see Figure 5, page 5). ACA’s Medicaid expansion and subsidized private 4.9% ■ 2014 Although most Californians have continued to get coverage for those earning up to and including 3.8%* ■ 2015 their coverage through their jobs, the percentage 400% FPG. In fact, the biggest decline occurred ■ 2016 with employer-sponsored insurance (ESI) declined 4.1% among those earning 138% FPG or less, the income ■ 2017 between 2013 and 2016. 5.3% eligibility threshold for Medi-Cal, although large and significant declines also occurred among those earn- 201% to 400% FPG However, between 2016 and 2017, these trends ing 139% to 200% FPG and 201% to 400% FPG (see started to shift. The percentage of Californians with 16.0% Figure 4). coverage through Medi-Cal decreased significantly, 14.5% from 33.0% to 29.0% (though it remained significantly 11.3%* higher than 2013). Meanwhile, the percentage of Table 1. Federal Poverty Guidelines, 2017 9.1%* Californians with private insurance coverage (defined   100% 138% 400% 9.3%* as including ESI and insurance purchased on the indi- Single Adult $12,060 $16,643 $48,240 vidual market, both on and off Covered California) 139% to 200% FPG rose significantly from 55.0% to 58.7%. This increase Family of Four $24,600 $33,948 $98,400 23.2% in private coverage offset decreases in Medi-Cal 24.4% enrollment, resulting in a stable uninsured rate, and 15.1%*† may reflect a growing economy and improvements in household income across the state.1 14.6%* 13.6%* The biggest decline in the uninsured 0% to 138% FPG rate has occurred among those 23.2% earning 138% FPG or less, the income 17.8%* † 12.6%* eligibility threshold for Medi-Cal. † 10.7%* 10.5%* *Significantly different from 2013 (p < 0.05). †Significantly different from previous year (p < 0.05). 1. “Local Area Unemployment Statistics, 2008 – 2018,” Bureau Note: See Table 1 for 2017 federal poverty guidelines (FPG) income of Labor Statistics, data.bls.gov; “Real Median Household values for single adults and families of four. Income in California,” Federal Reserve Bank of St. Louis, Source: California Health Interview Survey, 2017. fred.stlouisfed.org. California Health Care Foundation 4 Figure 5. Source of Health Insurance Coverage, Californians Age 0  64, 2013  2017 –  –  Summing It All Up — and Looking Ahead The story of health insurance coverage in 2017 is one 100% of overall stability. The tremendous gains under the ACA largely persisted, including historic progress Private (ESI + Private Purchase) 90% Employer-Sponsored Insurance (ESI) in narrowing racial/ethnic disparities in coverage. Medi-Cal However, lagging progress among Latinos, persis- 80% Private Purchase tent variation across regions, and many Californians Other Public still being uninsured point to the need for further Uninsured 70% work to ensure all Californians can get the coverage 60.0% they need. 58.2% 60% 55.8%*† 55.0%* 58.7%† 53.9% Continued monitoring of the uninsured rate will 50.9%* † 48.9%* 48.2%* 51.2% 50% be particularly important going forward given the uncertainty created at the federal level around the 40% ACA in 2017. In addition to the multiple ACA repeal 31.1%*† 33.0%* attempts, many other federal policies in 2017, such 30% 25.7%*† as the elimination of cost-sharing reduction pay- 29.0%*† 20.1% ments to insurers on the ACA health insurance 13.6%*† 20% 15.5% 7.3%*† 9.5%*† 8.5%* marketplaces, were potentially destabilizing. The 2.4%*† 6.9% 6.9% 2018 CHIS data may help show if the 2017 federal 6.1% 3.6%† 3.5%* 8.5%* 10% 4.4% policy environment affected Californians’ decisions 7.5%* 3.9% around enrolling in, or purchasing, coverage. 2013 2014 2015 2016 2017 Visit www.chcf.org for additional analyses focused on access metrics as well as future examinations *Significantly different from 2013 (p < 0.05). †Significantly different from previous year (p < 0.05). of affordability drawing on CHIS and other data Source: California Health Interview Survey, 2017. sources. ACA Reduces Racial/Ethnic Disparities in Health Coverage 5 Methodology In this fact sheet, health insurance coverage has Data for this fact sheet were drawn from the newly About the Author been measured as coverage at a point in time (at released 2017 California Health Interview Survey Tara Becker, PhD, is a senior public administra- time of survey response), rather than as coverage (CHIS), in conjunction with data from the previously tion analyst at the UCLA Center for Health Policy over the past year. Each respondent was coded into released 2011–16 CHIS annual data files. C H IS Research. a single health insurance coverage type based on covers a wide array of health-related topics, includ- the following hierarchy: uninsured, Medicare, Medi- ing health insurance coverage, health status and About the UCLA Center for Health Cal, ESI, private direct purchase (which includes behaviors, and access to health care. CHIS is based Policy Research purchase on the individual market including on and on interviews conducted continuously through- The UCLA Center for Health Policy Research is one off Covered California), and other public coverage. out the year, with respondents in approximately of the nation’s leading health policy research Those with Medicare were then reclassified into 20,000 California households annually. For more centers. “other public coverage.” For these reasons, the esti- information about CHIS, please visit CHIS online at The Center is the home of the California Health mates included in this brief may not be comparable www.chis.ucla.edu. Interview Survey (CHIS) and is affiliated with to estimates from other sources that report coverage the UCLA Fielding School of Public Health. over the past year or use a different health insurance hierarchy. See also “Undocumented Adults: What PB2018-10. Counts as Insurance?” on page 2. The measure of income included in this fact sheet is About the Foundation based on family income earned in the past month as The California Health Care Foundation is dedicated a percentage of the FPG issued by the Department to advancing meaningful, measurable of Health and Human Services. The data also contain improvements in the way the health care delivery measures of income based on household income in system provides care to the people of California, the past calendar year as a percentage of the federal particularly those with low incomes and those poverty thresholds issued by the Census Bureau. The whose needs are not well served by the status family income as a percentage of the FPG measure quo. We work to ensure that people have access was included because this measure is more con- to the care they need, when they need it, at a price sistent with the income and poverty line measures they can afford. used to determine eligibility for federal programs, including Medicaid and health insurance exchange CHCF informs policymakers and industry leaders, premium subsidies. invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. California Health Care Foundation 6 Appendix. California Counties within the CHIS Regions CENTRAL COAST Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, Ventura GREATER BAY AREA Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma LOS ANGELES Los Angeles NORTHERN/SIERRA Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yuba SACRAMENTO AREA El Dorado, Placer, Sacramento, Yolo SAN JOAQUIN VALLEY Fresno, Kern, Kings, Madera, Merced, San Joaquin, Stanislaus, Tulare OTHER SOUTHERN CALIFORNIA Imperial, Orange, San Bernardino, San Diego, Riverside ACA Reduces Racial/Ethnic Disparities in Health Coverage 7