Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic OCTOBER 2020 AUTHORS Jen Joynt; Rebecca Ca�erson, MPH and Lucy Rabinowitz, MPH, NORC Contents Introduction……………………………………………………………………………………………………………………………………………………………..2 About the Survey ...........................................................................................................................................................3 Section 1. Health Care Access and Utilization ...............................................................................................................4 Section 2. Substance Use and Mental Health Concerns ................................................................................................7 Section 3. Telehealth Experiences ...............................................................................................................................12 Section 4. COVID-19-Related Stresses and Concerns ..................................................................................................15 Section 5: Experiences with Racial or Ethnic Discrimination .......................................................................................19 Section 6. COVID-19 Impacts on Income and Employment.........................................................................................24 Appendix A: Survey Methodology ...............................................................................................................................26 Appendix B: Demographic Tables ................................................................................................................................28 B.1 Tables by Race and Income...............................................................................................................................28 B.2 Tables by Insurance Coverage .......................................................................................................................... 32 Endnotes ......................................................................................................................................................................36 About the Authors This report was written by Jen Joynt, independent health care consultant. Research was conducted by NORC at the University of Chicago (NORC). NORC is an objective nonpartisan research institution that delivers reliable data and rigorous analysis to guide critical programmatic, business, and policy decisions. The survey and data analysis were led by Rebecca Catterson, MPH, senior research director at NORC and Lucy Rabinowitz, MPH, principal research analyst at NORC. For more information, visit www.norc.org. About the Foundation The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, 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 Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 1 Introduction The year 2020 has been a tumultuous one for all Californians, with the COVID-19 pandemic now dragging into its seventh month and causing significant impacts to the physical, emotional, and financial well-being of all residents, especially those with low incomes. Seven million Californians, or approximately 18% of the state’s residents, are living in poverty.1 To better understand the health care experiences of residents with low incomes, the California Health Care Foundation and NORC at the University of Chicago, a national research organization, conducted a statewide survey of California’s residents age 18 to 64 who had received health care since March 2019, with an oversampling of residents with low incomes.2 The survey, conducted in the summer of 2020, asked respondents about their health care concerns, experiences, and access before and during the COVID-19 pandemic, as well as about their experiences with racial discrimination and the impact of the pandemic on employment and insurance coverage. This initial report highlights a collection of key findings from the survey, focusing on health care access, mental health, telehealth experiences, pandemic-related stresses, and experiences with racial discrimination. Findings in this report are presented for respondents with low incomes (defined as below 200% of the federal poverty level3) compared to respondents with higher incomes (defined as 200% federal poverty level [FPL] or higher) whenever sample sizes are sufficient to allow this comparison. In cases where there is an insufficient sample size, overall findings are presented. The full report, to be released in early 2021, will detail complete findings on respondents’ experiences with health and health care since the pandemic, including analyses of differences by a variety of demographics (including additional analyses by income, race, ethnicity, and insurance coverage and new analyses by region, gender, and language), as well as cross-tabular analysis of the impacts of the COVID-19 pandemic on respondents. Key findings from the survey include:  A large portion of survey respondents who wanted care since the start of the COVID-19 pandemic have not received care. Thirty-one percent of respondents who wanted to see a provider for urgent or emergency care for a health problem unrelated to COVID-19 did not receive care for that problem, and over 40% did not receive care for a nonurgent physical health problem (44%) or a mental health problem (46%).  The COVID-19 pandemic has caused deteriorating mental health for many respondents. Over one-third of respondents (36%) with low incomes reported that their mental health got “worse” or “a lot worse” since the start of the pandemic in March 2020. More than two-thirds of respondents with low incomes (68%) who wanted to see a provider for health care since the start of the pandemic wanted care for a mental health problem.  Telehealth has become an integral source of care for Californians. Among respondents who received care during the pandemic, 62% of respondents overall, 65% of respondents with low incomes, and 76% of respondents of color received a telehealth (phone or video) visit. Most respondents reported positive experiences with telehealth, including large majorities of respondents with low incomes and respondents of color. For example, among respondents with low incomes, 71% reported they would always like the option for phone or video visits, and 63% reported that they would likely choose a phone or video visit over an in- person visit whenever possible.  Ninety-four percent of Latinx respondents reported experiencing at least one stress related to COVID-19. Concern about the health or well-being of a loved one was the most reported COVID-19-related stress for Latinx respondents (56%) followed by children out of school or childcare unavailable (41%) and affording basic needs (35%).  Nationwide racial unrest in 2020 has brought long overdue attention to racial discrimination and highlighted the need to understand the impacts of racism on the health of Californians of color. Nearly 7 in 10 Black respondents (69%) reported having ever personally experienced discrimination or being treated unfairly because of their race or ethnicity. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 2 About the Survey The California Health Care Foundation’s Listening to Californians with Low Incomes Survey was conducted June 24 to August 21, 2020, using a combined probability-based sample and nonprobability sample to achieve an overall sample of 2,249 nonsenior adults (age 18–64) living in California. The foundational probability-based sample comes from the NORC AmeriSpeak Panel (n = 746). The nonprobability sample is comprised of a web sample from Dynata (n = 1,314) to reach more respondents with low incomes and a combined web and telephone sample from Davis Research (n = 189) to reach Vietnamese and Cantonese speakers. A multistage weighting design was applied to ensure accurate representation of the California adult population. Survey respondents were limited to those who saw a doctor or other health care professional about their health since the COVID-19 pandemic or in the year before the pandemic (March 2019 through March 2020). Typically, 75% to 85% of Californians age 18 to 64 have seen a doctor in the last year.4 Survey respondents were asked whether they identified as Hispanic or Latino, and then asked about their racial identity. For the purpose of this report, all Hispanic and Latino respondents will be referred to as Latinx. All respondents who did not identify as Hispanic or Latino are reported on here with concise labels (Asian, Black, multiracial, or White). All non-White respondents are referred to as “respondents of color.” This report provides results for groups with a base sample size of 100 or greater. The margin of sampling error including the design effect for the full sample is plus or minus 3.7 percentage points. For results based on specific subgroups, the margin of sampling error may be higher. The complete survey methodology is available in Appendix A. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 3 Section 1. Health Care Access and Utilization The statewide shelter-in-place order enacted in March to slow the spread of COVID-19 raised many concerns that people might delay obtaining care for important health concerns. Survey questions about health care access and utilization since the start of the pandemic and plans to seek care in the near future reveal significant pent-up demand for health care. Many Californians have had a health problem that they wanted health care for since the start of the pandemic. One in four respondents with low incomes (24%) reported that they wanted to see a health care provider since the start of the pandemic in March 2020, compared to slightly less than one in five survey respondents with higher incomes (19%). Survey respondents with Medi-Cal coverage (28%) were more likely to have wanted to see a health care provider since the pandemic compared to those with employer-sponsored coverage (19%). Figure 1. Respondents with Low Incomes and with Medi-Cal More Likely to Want to See Health Care Provider During Pandemic Q: SINCE THE START OF THE COVID-19 PANDEMIC, HAVE YOU EXPERIENCED ANY HEALTH PROBLEM, INCLUDING MENTAL HEALTH OR SUBSTANCE USE, THAT YOU WANTED TO SEE A HEALTH CARE PROVIDER FOR? BY INCOME <200% FPL 24% ≥200% FPL 19% BY INSURANCE TYPE Employer-sponsored 19% Medi-Cal 28% Privately purchased 24% Other insurance 14% Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. p < .01 for differences by income groups. p < .01 for differences between Medi-Cal and employer-sponsored insurance. Differences between Medi-Cal and privately purchased insurance were not significant. Of all survey respondents who experienced a health problem that they wanted to see a provider for since the start of the pandemic, 62% reported experiencing more than one health problem. The most common health problem for which respondents wanted care was a mental health problem (including stress, depression, and problems with emotions). Over two-thirds of respondents with low incomes (68%) and over half of respondents with higher incomes (53%) who wanted to see a health care provider since the beginning of the pandemic wanted care for a mental health problem. Fifty-nine percent of respondents with higher incomes and 42% of respondents with low income wanted care for a physical health problem (that was not urgent). Survey respondents with low incomes were more likely to want care for a problem with alcohol or drug use (33%) than respondents with higher incomes (18% ). Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 4 Figure 2. Mental Health Problems Top Concern for Respondents with Low Incomes Since the Start of the Pandemic Q: WAS THE PROBLEM YOU WANTED TO SEE A PROVIDER FOR . . . BY INCOME 30% Confirmed or suspected COVID-19 infection 18% Urgent or emergency care for a health problem 33% unrelated to COVID-19 34% 42% Physical health problem that was not urgent 59% Mental health problem (including stress, depression, 68% and problems with emotions) 53% 33% Problem with alcohol or drug use 18% 34% Dental problem 33% <200% FPL ≥200% FPL Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Differences between income groups were not significant, except for respondents who wanted to see a provider for a problem with alcohol or drug use (p < .01). A large portion of all respondents who reported wanting to see a physician or other health care professional since the start of the COVID-19 pandemic did not receive care. Notably, many respondents (31%) did not receive urgent or emergency care for a health problem unrelated to COVID-19. Even larger shares of respondents did not receive care for a nonurgent physical health problem (45%) or mental health problem (44%). Figure 3. Many Respondents Did Not Receive Care for Their Health Problems Since the Start of the Pandemic Q: SINCE THE START OF THE COVID-19 PANDEMIC, DID YOU RECEIVE CARE FOR YOUR . . . Urgent or emergency care for a health problem 69% 31% unrelated to COVID-19 Physical health problem that was not urgent 55% 45% Mental health problem (including stress, depression, 56% 44% and problems with emotions) Yes No Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 5 Among respondents who did not receive care for a health problem, only 64% attempted to contact a provider to make an appointment. Of these, 45% were told that their health problem was not urgent enough to need an appointment during the pandemic. Forty percent were offered a phone or video visit, and 4% an in-person visit. Looking forward, a large majority of survey respondents (64%) plan to seek health care within six months of the survey. Notably, more than three in four respondents with Medi-Cal coverage (78%) plan to seek care in the next six months, with more than half of those with Medi-Cal coverage (54%) planning to seek care in the next month. Smaller but still high percentages of those with privately purchased coverage (68%) and employer-sponsored coverage (62%5) plan to seek care in the next six months. Half of Black respondents planned to seek care in the next month, compared to 37% of White, 30% of Latinx, and 21% of Asian respondents (p < .01 for differences between groups). Figure 4. More Than Half of Respondents with Medi-Cal Coverage Plan to Seek Health Care in Next Month Q: WHEN DO YOU THINK YOU WILL SEEK OUT HEALTH CARE? BY INSURANCE TYPE Employer-sponsored 29% 18% 14% 14% 9% 15% Medi-Cal 54% 13% 11% 5% 6% 11% Privately purchased 30% 27% 11% 11% 12% 8% Other insurance 38% 19% 18% 3% 8% 13% Within the next month Between 1 and 3 months from now Between 3 and 6 months from now More than 6 months from now I do not plan to seek care Don't know or not sure Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. p < .01 for differences by insurance groups. Figures may not sum due to rounding or skipped responses. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 6 Section 2. Substance Use and Mental Health Concerns The COVID-19 pandemic has caused a deterioration in mental health status for many Californians. Respondents with low incomes were more likely to rate their mental or emotional health as “fair” (22%) or “poor” (7%) before the pandemic than those with higher incomes (11% “fair,” 1% “poor”). More than one in five Black respondents (21%) and Latinx respondents (21%) reported their mental or emotional health as “fair” or “poor” before the pandemic compared to less than one in seven White respondents (14%). Figure 5. Rating of Mental Health Before Pandemic Varies by Income, Race, and Ethnicity Q: HOW WOULD YOU RATE YOUR OVERALL MENTAL OR EMOTIONAL HEALTH BEFORE THE COVID-19 PANDEMIC? BY INCOME <200% FPL 20% 23% 28% 22% 7% ≥200% FPL 17% 41% 29% 11% 1% Excellent Very Good Good Fair Poor BY RACE/ETHNICITY Asian 14% 40% 30% 13% 4% Black 20% 28% 32% 20% 1% Latinx 17% 32% 30% 16% 5% White 20% 39% 26% 13% 1% Excellent Very Good Good Fair Poor Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences by income groups. p < .01 for differences between Black and White and between Latinx and White respondents. No significant difference between Black and Latinx respondents. Figures may not sum due to rounding or skipped responses. Survey respondents with low incomes were also more likely to report that their mental or emotional health got “worse” (30%) or “a lot worse” (6%) since the start of the pandemic than did respondents with higher incomes (27% “worse,” 1% “a lot worse”). Survey respondents with higher incomes were more likely to report no change in their mental or emotional health (62%) compared to respondents with low incomes (44%). Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 7 Figure 6. Respondents with Low Incomes More Likely to Report Mental Health Got Worse Since Pandemic Q: SINCE THE START OF THE COVID-19 PANDEMIC, HOW, IF AT ALL, HAS YOUR MENTAL OR EMOTIONAL HEALTH CHANGED? IS IT . . . BY INCOME <200% FPL 9% 11% 44% 30% 6% ≥200% FPL 2% 8% 62% 27% 1% A lot better Better About the same Worse A lot worse Notes: Survey limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. p < .01 for differences between income groups. More than two-thirds of respondents with low incomes (68%) who wanted to see a health care provider since the start of the pandemic wanted care for a mental health problem (including stress, depression, and problems with emotions), compared to just over half of respondents with higher incomes (53%). Latinx respondents (63%) were more likely than White respondents (51%) to want care for a mental health problem. Figure 7. Latinx and Californians with Low-Incomes More Likely to Want Care for Mental Health Problem PERCENTAGE WHO WANT TO SEE PROVIDER FOR MENTAL HEALTH PROBLEM SINCE THE START OF THE COVID-19 PANDEMIC BY INCOME <200% FPL 68% ≥200% FPL 53% BY RACE/ETHNICITY Latinx 63% White 51% Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences between income groups and p < .01 for differences between White and Latinx respondents. More than 4 in 10 respondents with low incomes (42%) and higher incomes (46%) who wanted to see a provider for health care for a mental health problem (including stress, depression, and problems with emotions) since the start of the pandemic did not receive care. Respondents of color (50%) were less likely to have received care for their mental health problem than White respondents (36%). Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 8 Figure 8. Many Californians Did Not Receive Needed Care for Mental Health Problems Q: DID YOU RECEIVE CARE FOR YOUR MENTAL HEALTH PROBLEM SINCE THE START OF THE COVID-19 PANDEMIC? BY INCOME <200% FPL 58% 42% ≥200% FPL 54% 46% Yes No BY RACE/ETHNICITY People of color 50% 50% White 64% 36% Yes No Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. People of color include Asian, Black, Latinx, multiracial, and “other” race respondents. No significant difference for income groups. p < .05 for differences between people of color and White. Differences also emerged in reported problems related to using alcohol, drugs, and other substances both before the pandemic and during the pandemic; in both cases, responents with low incomes and Latinx respondents were more likely to report problems than other groups. Survey respondents with low incomes (16%) were more likely to report having a problem with using alcohol, drugs, or other substances before the pandemic than respondents with higher incomes (9%). More Latinx (18%) and Black respondents (10%) reported having a problem with alcohol or drug use before the pandemic than did White (8%) or Asian respondents (7%). Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 9 Figure 9. Substance Use Problems Before the Pandemic Vary by Income and Race Q: BEFORE THE COVID-19 PANDEMIC, DID YOU HAVE A PROBLEM WITH USING ALCOHOL, DRUGS, OR OTHER SUBSTANCES? BY INCOME <200% FPL 16% ≥200% FPL 9% BY RACE/ETHNICITY Asian 7% Black 10% Latinx 18% White 8% Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences between income and racial groups. More than half of survey respondents overall with preexisting problems using alcohol, drug, or other substances (56%) reported improvement in their problems since the start of the pandemic. Only 16% of respondents overall 6 and those with low incomes reported that their drug or alcohol problem got “worse” or “a lot worse” since the start of the pandemic. Figure 10. Californians with Preexisting Substance Use Problems Report Improvement Since Pandemic Q: SINCE THE START OF THE COVID-19 PANDEMIC, IS YOUR PROBLEM WITH USING ALCOHOL, DRUGS, OR OTHER SUBSTANCES . . . Overall 30% 26% 28% 11% 4% <200% FPL 25% 31% 27% 10% 6% A lot better Better About the same Worse A lot worse Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Figures may not sum due to rounding or skipped responses. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 10 Six percent of respondents with low incomes who did not previously have a problem with using alcohol, drugs, or other substances reported experiencing a problem since the start of the pandemic in March 2020. In comparison, 2% of respondents with higher incomes reported developing an alcohol, drug, or other substance use problem. Differences also emerged by race and ethnicity, with 6% of Latinx respondents reporting a new problem with using alcohol, drugs, or other substances since the start of the pandemic compared to 2% of White and 1% of Asian respondents. Figure 11. Alcohol, Drug, or Substance Use Problems Since Pandemic Vary by Income, Race, and Ethnicity PERCENTAGE REPORTING EXPERIENCING A PROBLEM WITH ALCOHOL, DRUGS, OR OTHER SUBSTANCES SINCE THE START OF THE COVID-19 PANDEMIC BY INCOME <200% FPL 6% ≥200% FPL 2% BY RACE/ETHNICITY Asian 1% Black 3% Latinx 6% White 2% Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences between income groups and racial groups except between Latinx and Black respondents. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 11 Section 3. Telehealth Experiences Telehealth was an important source of care for Californians who received care during the pandemic. Sixty-five percent of survey respondents with low incomes and 62% of respondents overall reported that they had a telehealth (phone or video) visit. Forty-three percent of respondents with low incomes reported having a phone visit, and 34% reporting having a video visit. Three in four respondents of color (76%) who received care during the pandemic received a telehealth visit compared to less than half of White respondents (48%). Nearly equal percentages of respondents of color received care by video (47%) or by phone (46%). Figure 12. Telehealth an Important Source of Care for All Respondents PERCENTAGE WHO REPORTED RECEIVING CARE. . . BY INCOME 34% <200% FPL 43% 65% 36% Overall 38% 62% Video Phone Video or Phone BY RACE/ETHNICITY 47% People of color 46% 76% 27% White 30% 48% Video Phone Video or Phone Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. People of color include Asian, Black, Latinx, multiracial, and “other” race respondents. p < .01 for differences between people of color and White for video or phone. Survey respondents overall and respondents with low incomes reported generally favorable experiences with telehealth visits during the COVID-19 pandemic. Two-thirds of survey respondents with low incomes (67%) and respondents overall (66%) reported that their telehealth (phone or video) visit was a better experience than they thought it would be. Seven in 10 respondents with low incomes (71%) reported they would always like the option to choose a phone or video visit in the future. Sixty-three percent of survey respondents with low incomes and 56% of respondents overall reported that they would likely choose a phone or video visit over an in-person visit whenever possible in the future. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 12 Figure 13. Respondents with Low Incomes Report Positive Experiences with Telehealth Visits PERCENTAGE WHO AGREED WITH FOLLOWING STATEMENTS: A phone or video visit was a better experience than I thought 66% it would be 67% I had an easier time keeping my appointment for a phone or 56% video visit than I did keeping appointments for in-person visits in the past 64% In the future, whenever possible, I would always like the 68% option for phone or video visits 71% I would like my provider to choose whether a phone or video 59% visit is more appropriate for my condition or concern 62% In the future, whenever possible, I would likely choose a 56% phone or video visit over an in-person visit 63% Overall <200% FPL Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Differences between groups were not significant. Respondents of color also reported generally favorable experiences with telehealth during the COVID-19 pandemic. Three-quarters of respondents of color (76%) reported that their phone or video visit was a better experience than they thought it would be, compared to 56% of White respondents. Sixty-four percent of respondents of color would likely choose a phone or video visit over an in-person visit in the future, whenever possible, compared to 45% of White respondents. Figure 14. Respondents of Color Report Positive Experiences with Telehealth PERCENTAGE WHO AGREED WITH FOLLOWING STATEMENTS: A phone or video visit was a better experience than I thought 76% it would be 56% I had an easier time keeping my appointment for a phone or 65% video visit than I did keeping appointments for in-person visits in the past 47% In the future, whenever possible, I would always like the 68% option for phone or video visits 68% I would like my provider to choose whether a phone or video 65% visit is more appropriate for my condition or concern 52% In the future, whenever possible, I would likely choose a 64% phone or video visit over an in-person visit 45% People of Color White Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. People of color include Asian, Black, Latinx, multiracial, and “other” race respondents. p < .01 for differences between groups except for "In the future, whenever possible, I would always like the option for phone or video visits." Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 13 Among survey respondents overall who received a telehealth visit, satisfaction with phone and video visits compared favorably to in-person visits. Among those who received care by phone, 24% of respondents overall reported they were “more satisfied” with their phone visit than with their last in-person visit, and 48% reported they were “just as satisfied.” Twenty-eight percent reported that they were “less satisfied” with their phone visit. Among those who received care by video, one-third of respondents overall (33%) reported they were “more satisfied” with their video visit than with their last in-person visit, and one-third (32%) reported they were “just as satisfied.” Thirty percent of respondents overall reported that they were “less satisfied” with their video visit. Figure 15. High Levels of Satisfaction with Phone and Video Visits Compared to In-Person Visits Q: HOW SATISFIED WERE YOU WITH YOUR PHONE OR VIDEO VISIT COMPARED TO YOUR LAST IN-PERSON VISIT? Phone 24% 48% 28% Video 33% 32% 30% More satisfied Just as satisfied Less satisfied Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Figures may not sum due to rounding or skipped responses. Survey respondents who had a telehealth visit were generally satisfied with how well the technology worked. Survey respondents overall who had a video visit were more likely to report being satisfied with how well the technology worked than respondents overall who had a phone visit. Seven in 10 respondents overall who received care by video reported being “very satisfied” (32%) or “somewhat satisfied” (38%) with how well the technology worked. In comparison, nearly half of respondents who received care by phone were either “very satisfied” (23%) or “somewhat satisfied” (26%) with how well the technology worked. Seven percent of respondents overall were “somewhat dissatisfied” with how well the technology worked for phone visits and video visits. Two percent of respondents overall who had a video visit were “very dissatisfied” with how well the technology worked, and less than 1% of respondents overall who had a phone visit were “very dissatisfied” with how well the technology worked. Figure 16. Respondents More Satisfied with Video Technology Than Phone Technology Q: THINKING ABOUT THE CARE YOU RECEIVED BY PHONE/VIDEO SINCE THE START OF THE COVID-19 PANDEMIC, HOW WOULD YOU RATE YOUR SATISFACTION WITH HOW WELL THE TECHNOLOGY WORKED? 23% Very satisfied 32% 26% Somewhat satisfied 38% 42% Neither satisfied nor dissatisfied 16% 7% Somewhat dissatisfied 7% 0 Very dissatisfied 2% Phone Video Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 14 Section 4. COVID-19-Related Stresses and Concerns The COVID-19 pandemic has been an unprecedented time for many Californians, exposing many to stresses related to their and their family’s health as well as economic and home life impacts of the pandemic. Californians who received care in the last year were asked whether they experienced any of the following stresses as a result of the COVID-19 pandemic:  Concern about the health or well-being of a loved one  Affording basic needs, such as food, rent, and utilities  Children out of school or childcare unavailable  Stress in your relationship or marriage  Death of a loved one  Other stress Survey respondents with low incomes (96%) were more likely to report having experienced at least one of these COVID-19-related stresses than respondents with higher incomes (86%). A similarly high percentage of Latinx respondents (94%) also reported experiencing at least one of these stresses, compared to 91% of Asian, 89% of Black, and 84% of White respondents. Figure 17. Vast Majority of Californians Report Stress Related to COVID-19 PERCENTAGE REPORTING AT LEAST ONE STRESS RELATED TO COVID-19 BY INCOME <200% FPL 96% ≥200% FPL 86% BY RACE/ETHNICITY Asian 91% Black 89% Latinx 94% White 84% Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences between income groups and p < .05 for differences between racial groups. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 15 Concern about the health or well-being of a loved one was the most reported stress for respondents with low incomes and higher incomes, with over half of respondents (53%) experiencing this stress. Respondents with low incomes were more likely to report experiencing stress related to affording basic needs, such as food, rent, and utilities (50%), children out of school or childcare unavailable (38%), and the death of a loved one (10%) than respondents with higher incomes (18% for affording basic needs, 30% for childcare, 4% for death of a loved one). Figure 18. Half of Respondents Report Stress Related to Concern About the Health or Well-Being of a Loved One Q: WHICH OF THE FOLLOWING STRESSES, IF ANY, HAVE YOU EXPERIENCED AS A RESULT OF THE COVID-19 PANDEMIC? 52% Concern about the health or well-being of a loved one 54% 50% Affording basic needs, such as food, rent, and utilities 18% 38% Children out of school or childcare unavailable 30% 25% Stress in your relationship or marriage 26% 10% Death of a loved one 4% <200% FPL ≥200% FPL Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. p < .01 for differences between income groups. Concern about the health or well-being of a loved one was the most reported COVID-19-related stress for Asian (61%), Latinx (56%), White (49%), and Black (38%) survey respondents. The second most common stress for Latinx respondents (41%) was children out of school or childcare unavailable. Affording basic needs was the second most common stress for Black (33%) and Asian (32%) respondents. For White respondents, stress in their relationship or marriage (28%) was the second most common stress. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 16 Figure 19. Experience of Stress Related to COVID-19 Varies by Race/Ethnicity Q: WHICH OF THE FOLLOWING STRESSES, IF ANY, HAVE YOU EXPERIENCED AS A RESULT OF THE COVID-19 PANDEMIC? 61% 38% Concern about the health or well-being of a loved one 56% 49% 32% 33% Affording basic needs, such as food, rent, and utilities 35% 20% 30% 32% Children out of school or childcare unavailable 41% 27% 20% 15% Stress in your relationship or marriage 29% 28% 3% 13% Death of a loved one 8% 4% Asian Black Latinx White Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. To understand how respondents were reacting to the various stresses related to COVID-19 and racial unrest, the survey asked respondents to report which of the following was most concerning to them: “fear of getting COVID-19,” “the economic impact of the COVID-19 pandemic on me and my family,” or “the impact of racism on my and my family’s health and safety.” The top concern for both respondents with low incomes (41%) and those with higher incomes (45%) was fear of getting COVID-19, followed by the economic impact of the pandemic (37% for respondents with low incomes and 41% for those with higher incomes). Nine percent of respondents with low incomes and 6% of those with higher incomes reported “the impact of racism on my and my family’s health and safety” as their top concern. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 17 Figure 20. Respondents Nearly Equally Concerned with Fear of Getting COVID-19 and Economic Impact of Pandemic Q: OF THE FOLLOWING THINGS, WHICH IS THE MOST CONCERNING TO YOU? BY INCOME <200% FPL 41% 37% 9% 13% ≥200% FPL 45% 41% 6% 7% Fear of getting COVID-19 The economic impact of the COVID-19 pandemic on me and my family The impact of racism on my and my family's health and safety Don't know or not sure Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Figures may not sum due to rounding or skipped responses. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 18 Section 5: Experiences with Racial or Ethnic Discrimination The survey included a number of questions to shed light on the experiences of racism among Californians, their concerns about racism, and impacts of racism on their health. When asked to report which of the following was most concerning to them: “fear of getting COVID-19,” “the economic impact of the COVID-19 pandemic on me and my family,” or “the impact of racism on my and my family’s health and safety,” Black respondents were most likely to report that their greatest concern was the impact of racism (21%), compared to Asian (9%), and Latinx respondents (7%). Figure 21. Black Respondents More Likely to Be Most Concerned About Impact of Racism PERCENTAGE REPORTING THAT IMPACT OF RACISM ON RESPONDENT AND THEIR FAMILY’S HEALTH AND SAFETY WAS MOST CONCERNING BY RACE/ETHNICITY Asian 9% Black 21% Latinx 7% Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences between racial groups. The survey asked respondents a number of questions about their personal experiences with racial or ethnic discrimination and the impacts of any racial or ethnic discrimination on their health. Nearly 7 in 10 Black respondents (69%) reported ever personally experiencing discrimination or being treated unfairly because of their race or ethnicity. More than 4 in 10 Asian (43%) and Latinx respondents (43%) reported ever personally experiencing discrimination. Younger respondents, especially those age 18 to 24, were more likely to report experiencing racial or ethnic discrimination (57%) than older age groups (30% to 41%). Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 19 Figure 22. Black and Younger Repondents More Likely to Have Ever Experienced Racial or Ethnic Discrimination Q: THINKING ABOUT YOUR OWN EXPERIENCE, HAVE YOU EVER PERSONALLY EXPERIENCED DISCRIMINATION OR BEEN TREATED UNFAIRLY BECAUSE OF YOUR RACE OR ETHNICITY? BY RACE/ETHNICITY Asian 43% Black 69% Latinx 43% BY AGE 18–24 57% 25–34 41% 35–44 34% 45–54 25% 55–64 30% Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences by racial group and for age group 18–24 compared to all others. When asked about personal experiences with discrimination or being treated unfairly because of their race or ethnicity as a result of the COVID-19 pandemic, Asian respondents (17%) were most likely to report personally experiencing discrimination, followed by Latinx (11%) and Black respondents (11%). Younger age groups reported higher levels of discrimination or being treated unfairly as a result of the COVID-19 pandemic (26% of 18–24 year olds; 18% of 25–34 year olds) compared to older age groups (2% to 7%). Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 20 Figure 23. Asian and Younger Californians More Likely to Have Experienced Discrimination as a Result of the COVID-19 Pandemic Q: HAVE YOU PERSONALLY EXPERIENCED DISCRIMINATION OR BEEN TREATED UNFAIRLY BECAUSE OF YOUR RACE OR ETHNICITY AS A RESULT OF THE COVID-19 PANDEMIC? BY RACE/ETHNICITY Asian 17% Black 11% Latinx 11% BY AGE 18–24 26% 25–34 18% 35–44 7% 45–54 3% 55–64 2% Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences between Asian and Latinx racial groups. No significant differences between Asian and Black respondents. p < .01 for differences between 18–24 compared to all others. Experiencing racial discrimination or being treated unfairly because of one’s race or ethnicity had significant impacts on an individual’s physical and mental health. Respondents with low incomes (43% 7) were more likely to report that their mental health was “worse” or “a lot worse” as a result of racial discrimination than respondents with higher incomes (28%8). (Substantial percentages of both respondents with low incomes (10%) and higher incomes (9%) said “don’t know” or “not sure.”) Thirty-one percent of respondents of color 9 reported that their mental health was “worse” or “a lot worse” as a result of racial discrimination. (Ten percent said “don’t know” or “not sure.”) Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 21 Figure 24. Reported Change in Mental Health Due to Racial Discrimination Q: HOW, IF AT ALL, DID YOUR MENTAL HEALTH CHANGE AS A RESULT OF RACIAL DISCRIMINATION? IS YOUR MENTAL HEALTH . . . BY INCOME <200% FPL 47% 35% 7% 10% ≥200% FPL 62% 27% 2% 9% About the same Worse A lot worse Don't know or not sure BY RACE/ETHNICITY People of color 58% 28% 3% 10% About the same Worse A lot worse Don't know or not sure Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. People of color include Asian, Black, Latinx, multiracial, and “other” race respondents. p < .01 for differences between income groups. Figures may not sum due to rounding or skipped responses. Fewer respondents overall said that their physical health got “worse” or “a lot worse” as a result of racial discrimination compared to their mental health. More respondents with low incomes (23%) reported that their physical health was “worse” or “a lot worse” due to racial discrimination than respondents with higher incomes (12%). (Twenty percent of respondents with low incomes said “don’t know” or “not sure.”) Seventeen percent of respondents of color reported that their physical health was “worse” or “a lot worse” as a result of racial discrimination; 67% said their physical health was “about the same.” Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 22 Figure 25. Reported Change in Physical Health Due to Racial Discrimination Q: HOW, IF AT ALL, DID YOUR PHYSICAL HEALTH CHANGE AS A RESULT OF RACIAL DISCRIMINATION? IS YOUR PHYSICAL HEALTH . . . BY INCOME <200% FPL 57% 20% 3% 20% ≥200% FPL 76% 11% 1% 10% About the same Worse A lot worse Don't know or not sure BY RACE/ETHNICITY People of color 67% 15% 2% 14% About the same Worse A lot worse Don't know or not sure Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. People of color include Asian, Black, Latinx, multiracial, and “other” race respondents. p < .01 for differences by income groups. Figures may not sum due to rounding or skipped responses. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 23 Section 6. COVID-19 Impacts on Income and Employment Not surprisingly, the COVID-19 pandemic has negatively impacted the income and employment of many Californians, especially those with low incomes. Respondents with low incomes were more likely to report a change in family income (53%) as a result of the COVID-19 pandemic than respondents with higher incomes (38%). Latinx respondents (52%) were most likely to report a change in income, followed by Asian (42%), White (39%), and Black (28%) respondents. Figure 26. Latinx and Californians with Low Incomes More Likely to Report Change in Income Due to COVID-19 Q: HAVE YOU EXPERIENCED ANY CHANGE IN FAMILY INCOME AS A RESULT OF THE COVID-19 PANDEMIC? BY INCOME <200% FPL 53% ≥200% FPL 38% Yes BY RACE/ETHNICITY Asian 42% Black 28% Latinx 52% White 39% Yes Notes: Survey conducted by NORC at the University of Chicago between June 24 and August 21, 2020. Respondents limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. p < .01 for differences by income and racial groups. Among respondents with low incomes who reported a change in income, 43% experienced a decrease in income or hours, 18% were laid off, 9% were furloughed, and 7% experienced a reduction in salary. Among Latinx respondents who reported a change in income, 51% reported a decrease in income or hours, 16% were laid off, 11% were furloughed, and 6% reported a reduction in salary. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 24 Figure 27. Type of Change in Income for Respondents with Low Incomes and Latinx Californians Q: WHAT CHANGES DID YOU EXPERIENCE IN YOUR EMPLOYMENT? <200% FPL Other, 9% Increase in income Change in job, or hours worked 2% per week, 11% Reduction in salary or wages, 7% Furlough, 9% Decrease in Layoff, 18% income or hours worked per week, 43% LATINX Change in job, Other, 6% Increase in income 1% or hours worked per week, 10% Reduction in salary or wages, 6% Furlough, 11% Layoff, 16% Decrease in income or hours worked per week, 51% Notes: Survey limited to California residents age 18 to 64 who saw a doctor or other health care professional since March 2019. Survey used the terms Hispanic or Latino. Figures may not sum due to rounding or skipped responses. During the COVID-19 pandemic, many essential workers have needed to work outside the home, often increasing their risk of exposure to the coronavirus as they come into contact with more people while either traveling to and from work and/or through their work activities. Over 4 in 10 (43%) of survey respondents overall reported that they worked in a job that was considered essential during the COVID-19 pandemic. Black (49%) and Latinx (47%) respondents were more likely to work in a job that was considered essential than White (41%) and Asian (36%) respondents. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 25 Appendix A: Survey Methodology The California Health Care Foundation’s Listening to Californians with Low Incomes was conducted June 24 to August 21, 2020, using a combined probability-based sample and nonprobability sample to achieve an overall sample of 2,249 adults age 18–64 living in California. The foundational probability-based sample comes from NORC at the University of Chicago’s AmeriSpeak Panel 10 (n = 746). The nonprobability sample is comprised of a web sample from Dynata11 (n = 1,314) to reach more respondents with low incomes and a telephone sample from Davis Research 12 (n = 189) to reach Vietnamese and Cantonese speakers. Surveys were administered using a web-based questionnaire in English (n = 2,000) and Spanish (n = 60), and both web-based surveys and telephone interviewing for Chinese (n = 99) and Vietnamese (n = 90) speakers. Sampling, data collection, weighting, and tabulation were managed by NORC in close collaboration with California Health Care Foundation (CHCF) researchers. The sample was designed to complete a sufficient number of interviews with respondents of demographic groups (e.g. by race, Hispanic ethnicity, and California region) that would allow accurate representation of the California adult population in the overall sample. AmeriSpeak was selected as the foundational sample for this study for its probability-based survey platform, and its unique in-person recruitment that attains response rates, on average, 5 to 10 times higher than other probability panels13. The AmeriSpeak Panel of California residents was stratified by income level and differentially sampled by strata to reach relatively more respondents with low incomes than respondents with higher incomes. The AmeriSpeak Panel is a nationally representative panel sample recruited using NORC’s National Frame based on both area probability sampling and address-based sampling methods to achieve coverage of approximately 97% of the US population. To achieve sufficient interviews for important and hard-to-reach subgroups for the study, samples from Dynata and Davis Research were utilized. While these opt-in surveys come from a nonprobabilistic source, NORC used its TrueNorth calibration procedure to combine the samples into a unified set of data with the minimum amount of bias possible. The TrueNorth method involves using the AmeriSpeak probability sample to provide benchmarks used to calibrate the surveys from the nonprobability sample. TrueNorth utilizes the advanced techniques of small area estimation.14 To qualify for the study, all respondents needed to confirm through screening that they were adults between the ages of 18 and 64, currently residing in California, and had seen a doctor in the past year. Households at all income levels qualified for the study based on the aforementioned screening criteria; however, respondents who reported their household income was below 200% of the federal poverty level (FPL) were sampled at a higher rate. 15 All selected panelists from AmeriSpeak and Dynata were emailed an invitation that included a link to complete the survey online. Sample selected from Davis Research were also called, and interview data were collected by phone. All qualified respondents were offered incentives for their participation. During the fielding, AmeriSpeak respondents were sent scheduled reminder emails to take the survey. A series of data quality checks were run on the final data, which resulted in 73 completes being removed from the data. A multistage weighting design was applied to ensure accurate representation of the California adult population. The first stage of weighting included corrections to the AmeriSpeak sample for sample design and a demographic adjustment to balance the sample to match known adult population parameters based on the US Census Bureau’s February 2020 Current Population Survey. Parameters included age, gender, educational attainment, race/ethnicity, rural status, poverty threshold, and region in California. AmeriSpeak sample records were combined with Dynata and Davis sample records and True North combined weights constructed. Next, to reduce the possibility that single cases would affect the data too much and to keep variance relatively low, the weights were truncated at the tails of the weight distribution such that no one category of a sociodemographic weighting variable differed more than five percentage points from its benchmark. The margin of sampling error including the design effect for the full sample is plus or minus 3.7 percentage points. For results based on specific subgroups, the margin of sampling error may be higher. See Table 1 for estimated margin of error for a range of estimated percentages by a range of base sample sizes for the survey. Margin of error estimates in this table can be used to inform the general statistical reliability of estimates presented in this report. Calculation of the margin of error for specific survey estimates will differ somewhat from the general margin of errors presented in this table. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 26 Table 1. Estimated Margin of Error by Base Sample Size PROPORTION OF SURVEY RESULTS 10% 20% 30% 40% 50% 60% 70% 80% 90% BASE SAMPLE SIZE MARGIN OF ERROR (+/- PERCENTAGE POINTS) 2,249 2.25 3.00 3.44 3.67 3.75 3.67 3.44 3.00 2.25 1,000 3.40 4.50 5.20 5.50 5.60 5.50 5.20 4.50 3.40 500 4.80 6.40 7.30 7.80 8.00 7.80 7.30 6.40 4.80 250 6.80 9.00 10.40 11.10 11.30 11.10 10.40 9.00 6.80 150 8.80 11.70 13.40 14.30 14.60 14.30 13.40 11.70 8.80 100 14.40 16.50 17.60 18.00 17.60 16.50 14.40 Note: Sampling error is only one of the many potential sources of error in this and any other public opinion poll. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 27 Appendix B: Demographic Tables B.1 Tables by Race and Income Table B.1.1: Need for Health Care Since COVID-19 Q: Since the start of the COVID-19 pandemic, have you experienced any health problem, including mental health or substance use, that you wanted to see a health care provider for? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 722 Yes 20% 12% 22% 22% 22% 24% 19% No 80% 88% 78% 78% 78% 76% 81% Note: Asked to all survey respondents. Table B.1.2: Types of Health Problems Wanted to See Provider For Q: Was the problem you wanted to see a provider for . . . Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 409 46 27 116 197 292 117 Confirmed or suspected COVID-19 infection 22% 33% 11% 36% 10% 30% 18% Urgent or emergency care for a health problem unrelated to COVID- 19 33% 34% 14% 33% 37% 33% 34% Physical health problem that was not urgent 53% 59% 71% 49% 51% 51% 53% Mental health problem (including stress, depression, and problems with emotions) 58% 74% 56% 63% 51% 68% 53% Problem with alcohol or drug use 23% 19% 15% 32% 19% 33% 18% Dental problem 33% 34% 51% 36% 28% 34% 33% Note: Asked to survey respondents who indicated they had a problem they wanted to see a provider for. Table B.1.4: Plans to Seek Health Care Q: When do you plan to seek care? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 242 Within the next month 32% 21% 50% 30% 37% 39% 29% Between 1 and 3 months from now 18% 17% 14% 22% 16% 15% 17% Between 3 and 6 months from now 14% 21% 10% 11% 14% 11% 16% More than 6 months from now 12% 17% 5% 14% 10% 10% 12% I do not plan to seek care 9% 12% 5% 10% 7% 7% 9% Not sure / Don't know 14% 12% 17% 12% 16% 17% 17% Note: Asked to all survey respondents. Table B.1.5: Mental Health Rating Before the COVID-19 Pandemic Q: How would you rate your overall mental or emotional health before the COVID-19 pandemic? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 722 Excellent 18% 14% 20% 17% 20% 20% 17% Very good 36% 40% 28% 32% 39% 23% 41% Good 29% 30% 32% 30% 26% 28% 29% Fair 14% 13% 20% 16% 13% 22% 11% Poor 3% 4% 1% 5% 1% 7% 1% Note: Asked to all survey respondents. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 28 Table B.1.6: Change in Mental Health Since the COVID-19 Pandemic Q: Since the start of the COVID-19 pandemic, how, if at all, has your mental or emotional health changed? Is it . . . Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 722 A lot better 4% 1% 6% 9% 2% 9% 2% Better 9% 14% 3% 10% 6% 11% 8% About the same 57% 53% 73% 50% 61% 44% 62% Worse 28% 27% 17% 29% 28% 30% 27% A lot worse 3% 5% 0% 3% 2% 6% 1% Note: Asked to all survey respondents. Table B.1.9: Substance Use Problem Before the COVID-19 Pandemic Q: Before the COVID-19 pandemic, did you have a problem with using alcohol, drugs, or other substances? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 722 Yes 11% 7% 10% 18% 8% 16% 9% No 89% 93% 90% 82% 92% 84% 91% Note: Asked to all survey respondents. Table B.1.10: Change in Substance Use Problem Since the COVID-19 Pandemic Q: Since the start of the COVID-19 pandemic, is your problem with using alcohol, drugs, or other substances . . . Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 170 23 16 66 57 131 39 A lot better 30% 8% 16% 37% 29% 25% 34% Better 26% 46% 57% 26% 12% 31% 22% About the same 28% 4% 22% 29% 36% 27% 28% Worse 11% 19% . 6% 21% 10% 12% A lot worse 4% 23% 6% 2% 2% 6% 3% Note: Asked to survey respondents who indicated they had a problem with using alcohol, drugs, or other substances. Table B.1.11: Substance Use Problem Since the COVID-19 Pandemic Q: Since the start of the COVID-19 pandemic, have you experienced a problem with using alcohol, drugs, or other substances? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,072 426 102 464 965 1,390 682 Yes 3% 1% 3% 6% 2% 6% 2% No 96% 99% 97% 93% 98% 92% 98% Note: Asked to survey respondents who indicated they did not have a problem with using alcohol, drugs, or other substances before the pandemic. Table B.1.14: Satisfaction with Telehealth Visits Q: Do you agree with the following statement? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 263 28 16 64 140 186 77 A phone or video visit was a better experience than I thought it would be 66% 71% 95% 73% 56% 67% 66% I had an easier time keeping my appointment for a phone or video visit than I did keeping appointments for in-person visits in the past 56% 66% 60% 65% 47% 64% 52% Note: Asked to survey respondents who had a phone or video visit. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 29 Table B.1.14: Satisfaction with Telehealth Visits Q: Do you agree with the following statement? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 442 197 16 67 45 365 77 In the future, whenever possible, I would always like the option for phone or video visits 68% 50% 50% 83% 68% 71% 66% I would like my provider to choose whether a phone or video visit is more appropriate for my condition or concern 59% 59% 60% 70% 52% 62% 57% In the future, whenever possible, I would likely choose a phone or video visit over an in-person visit 56% 52% 44% 75% 45% 63% 50% Note: Asked to survey respondents who received care via phone or video and to 179 respondents with low incomes who did not receive care via phone or video. Table B.1.15: Satisfaction with Telehealth Visits Compared to In-Person Visits Q: How satisfied were you with your phone visit compared to your last in-person visit? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 118 15 9 29 55 89 29 More satisfied 24% 10% 69% 27% 15% 46% 10% Just as satisfied 48% 41% 0% 48% 60% 38% 55% Less satisfied 28% 50% 31% 26% 25% 16% 35% Note: Asked to survey respondents who received care by phone. Q: How satisfied were you with your video visit compared to your last in-person visit? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 112 13 8 25 58 81 31 More satisfied 33% 30% 37% 46% 18% 50% 25% Just as satisfied 32% 18% 15% 31% 40% 36% 30% Less satisfied 30% 52% 49% 11% 41% 14% 38% Note: Asked to survey respondents who received care by video. Table B.1.18: Stresses as Result of the COVID-19 Pandemic Q: Which of the following stresses, if any, have you experienced as a result of the COVID-19 pandemic? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 722 Concern about the health or well- being of a loved one 53% 61% 38% 56% 49% 52% 54% Affording basic needs, such as food, rent, and utilities 28% 32% 33% 35% 20% 50% 18% Children out of school or childcare unavailable 32% 30% 32% 41% 27% 38% 30% Stress in your relationship or marriage 26% 20% 15% 29% 28% 25% 26% Death of a loved one 6% 3% 13% 8% 4% 10% 4% Other stress 15% 13% 11% 8% 21% 10% 17% Note: Asked to all survey respondents. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 30 Table B.1.20: Most Concerning Item Q: Of the following things, which is the most concerning to you? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 722 Fear of getting COVID-19 44% 47% 46% 43% 43% 41% 45% The economic impact of the COVID- 19 pandemic on me and my family 40% 37% 22% 40% 43% 37% 41% The impact of racism on my and my family's health and safety 7% 9% 21% 7% 4% 9% 6% Don't know or not sure 9% 7% 9% 9% 9% 13% 7% Note: Asked to all survey respondents. Table B.1.22: Personal Experiences with Discrimination Q: Thinking about your own experience, have you ever personally experienced discrimination or been treated unfairly because of your race or ethnicity? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 722 Percentage responding Yes 35% 43% 69% 43% 20% 43% 32% Note: Asked to all survey respondents. Table B.1.23: Personal Experiences with Discrimination as a Result of COVID-19 Pandemic Q: Have you personally experienced discrimination or been treated unfairly because of your race or ethnicity as a result of the COVID-19 pandemic? Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 2,249 451 118 532 1,024 1,527 722 Percentage responding Yes 10% 17% 11% 11% 5% 16% 7% Note: Asked to all survey respondents. Table B.1.24: Impact of Discrimination on Mental Health Q: How, if at all, did your mental health change as a result of racial discrimination? Is your mental health . . . Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 659 116 77 225 185 453 206 About the same 56% 61% 44% 61% 50% 47% 62% Worse 30% 27% 42% 24% 36% 35% 27% A lot worse 4% 0% 1% 5% 5% 7% 2% Don't know or not sure 9% 10% 13% 9% 7% 10% 9% Note: Asked only to respondents who experienced racial discrimination. Table B.1.25: Impact of Discrimination on Physical Health Q: How, if at all, did your physical health change as a result of racial discrimination? Is your physical health . . . Race Self-Reported Income Overall Asian Black Latinx White <200% FPL ≥200% FPL Total Unweighted N 700 154 77 226 185 494 206 About the same 69% 75% 54% 66% 76% 57% 76% Worse 14% 17% 22% 13% 9% 20% 11% A lot worse 2% 1% 2% 2% 1% 3% 1% Don't know or not sure 14% 7% 21% 16% 12% 20% 10% Note: Asked only to respondents who experienced racial discrimination. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 31 B.2 Tables by Insurance Coverage Table B.2.1: Need for Health Care Since COVID-19 Q: Since the start of the COVID-19 pandemic, have you experienced any health problem, including mental health or substance use, that you wanted to see a health care provider for? Insurance Coverage Employer- Privately Overall Sponsored Medi-Cal Purchased Other Insurance Total Unweighted N 2,249 760 703 334 317 Yes 20% 19% 28% 24% 15% No 80% 81% 72% 76% 86% Note: Asked to all survey respondents. Table B.2.2: Types of Health Problems Wanted to See Provider For Q: Was the problem you wanted to see a provider for . . . Insurance Coverage Employer- Privately Overall Sponsored Medi-Cal Purchased Other Insurance Total Unweighted N 409 134 142 53 55 Confirmed or suspected COVID-19 infection 22% 22% 18% 18% 6% Urgent or emergency care for a health problem unrelated to COVID-19 33% 32% 38% 33% 23% Physical health problem that was not urgent 53% 51% 43% 74% 55% Mental health problem (including stress, depression, and problems with emotions) 58% 57% 73% 35% 48% Problem with alcohol or drug use 23% 21% 20% 34% 13% Dental problem 33% 31% 39% 35% 37% Note: Asked to survey respondents who indicated they had a problem they wanted to see a provider for. Table B.2.4: Plans to Seek Health Care Q: When do you plan to seek care? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 2,249 760 703 334 317 Within the next month 32% 29% 54% 30% 38% Between 1 and 3 months from now 18% 18% 13% 27% 19% Between 3 and 6 months from now 14% 14% 11% 11% 18% More than 6 months from now 12% 14% 5% 11% 3% I do not plan to seek care 9% 9% 6% 12% 8% Not sure / Don't know 14% 15% 11% 8% 13% Note: Asked to all survey respondents. Table B.2.5: Mental Health Rating Before the COVID-19 Pandemic Q: How would you rate your overall mental or emotional health before the COVID-19 pandemic? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 2,249 760 703 334 317 Excellent 18% 16% 21% 22% 37% Very good 36% 39% 17% 34% 27% Good 29% 28% 35% 33% 26% Fair 14% 14% 23% 10% 8% Poor 3% 3% 4% 2% 2% Note: Asked to all survey respondents. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 32 Table B.2.6: Change in Mental Health Since the COVID-19 Pandemic Q: Since the start of the COVID-19 pandemic, how, if at all, has your mental or emotional health changed? Is it . . . Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 2,249 760 703 334 317 A lot better 4% 3% 6% 10% 7% Better 9% 9% 8% 10% 4% About the same 57% 58% 44% 51% 68% Worse 28% 27% 37% 26% 17% A lot worse 3% 2% 5% 3% 3% Note: Asked to all survey respondents. Table B.2.9: Substance Use Problem Before the COVID-29 Pandemic Q: Before the COVID-19 pandemic, did you have a problem with using alcohol, drugs, or other substances? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 2,249 760 703 334 317 Yes 11% 11% 13% 8% 5% No 89% 89% 86% 92% 94% Note: Asked to all survey respondents. Table B.2.10: Change in Substance Use Problem Since the COVID-19 Pandemic Q: Since the start of the COVID-19 pandemic, is your problem with using alcohol, drugs, or other substances . . . Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 170 72 47 22 17 A lot better 30% 28% 27% 30% 42% Better 26% 29% 22% 23% 14% About the same 28% 27% 35% 45% 39% Worse 11% 12% 5% 2% 5% A lot worse 4% 4% 10% . . Note: Asked to survey respondents who indicated they had a problem with using alcohol, drugs, or other substances. Table B.2.11: Substance Use Problem Since the COVID-19 Pandemic Q: Since the start of the COVID-19 pandemic, have you experienced a problem with using alcohol, drugs, or other substances? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 2,072 687 651 313 298 Yes 3% 2% 5% 10% 0% No 96% 98% 89% 90% 99% Note: Asked to survey respondents who indicated they did not have a problem with using alcohol, drugs, or other substances before the pandemic. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 33 Table B.2.14: Satisfaction with Telehealth Visits Q: Do you agree with the following statement? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 263 85 92 37 42 A phone or video visit was a better experience than I thought it would be 66% 62% 79% 85% 64% I had an easier time keeping my appointment for a phone or video visit than I did keeping appointments for in-person visits in the past 56% 50% 82% 74% 47% Note: Asked to survey respondents who had a phone or video visit. Q: Do you agree with the following statement? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 442 112 179 78 57 In the future, whenever possible, I would always like the option for phone or video visits 68% 67% 78% 73% 37% I would like my provider to choose whether a phone or video visit is more appropriate for my condition or concern 59% 57% 72% 60% 35% In the future, whenever possible, I would likely choose a phone or video visit over an in-person visit . . . 56% 49% 69% 81% 51% Note: Includes respondents who received care via phone or video and 179 respondents with low incomes who did not receive care via phone or video. Table B.2.15: Satisfaction with Telehealth Visits Compared to In-Person Visits Q: How satisfied were you with your phone visit compared to your last in-person visit? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 118 30 52 19 15 More satisfied 24% 5% 63% 36% 35% Just as satisfied 48% 58% 28% 46% 40% Less satisfied 28% 37% 8% 18% 25% Note: Asked to respondents who received care by phone. Q: How satisfied were you with your video visit compared to your last in-person visit? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 112 37 37 18 19 More satisfied 33% 22% 58% 66% 27% Just as satisfied 32% 36% 24% 18% 37% Less satisfied 30% 35% 19% 16% 36% Note: Asked to survey respondents who received care by video. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 34 Table B.2.18: Stresses as Result of the COVID-19 Pandemic Q: Which of the following stresses, if any, have you experienced as a result of the COVID-19 pandemic? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 2,249 760 703 334 317 Concern about the health or well-being of a loved one 53% 54% 54% 53% 33% Affording basic needs, such as food, rent, and utilities 28% 23% 62% 41% 14% Children out of school or childcare unavailable 32% 35% 36% 19% 10% Stress in your relationship or marriage 26% 26% 34% 22% 14% Death of a loved one 6% 5% 10% 8% 1% Other stress 15% 15% 12% 8% 34% Note: Asked to all survey respondents. Table B.2.20: Most Concerning Item Q: Of the following things, which is the most concerning to you? Insurance Coverage Employer- Privately Other Overall Sponsored Medi-Cal Purchased Insurance Total Unweighted N 2,249 760 703 334 317 Fear of getting COVID-19 44% 45% 40% 36% 32% The economic impact of the COVID-19 pandemic on me and my family 40% 40% 46% 42% 32% The impact of racism on my and my family's health and safety 7% 7% 3% 9% 12% Don't know or not sure 9% 7% 11% 13% 24% Note: Asked to all survey respondents. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 35 Endnotes 1 Based on Liana Fox, Supplemental Poverty Measure: 2018 (PDF), US Census Bureau, October 2019. 2 Sixty-eight percent of the sample were residents with low incomes. 3 The FPL was $12,760 for a single person and $26,200 for a family of four in 2020. 4 California Health Interview Survey, UCLA Center for Health Policy Research. 5 Due to rounding, individual percentages may not add up to totals. 6 Due to rounding, individual percentages may not add up to totals. 7 Due to rounding, individual percentages may not add up to totals. 8 Due to rounding, individual percentages may not add up to totals. 9 Due to rounding, individual percentages may not add up to totals. 10 “Panel Design,” AmeriSpeak, n.d. 11 “About Dynata,” Dynata, n.d. 12 Davis Research. 13 “28 Questions to Help Research Buyers of Online Sample (PDF),” AmeriSpeak, n.d. 14 “TrueNorth,” AmeriSpeak, n.d. 15 Respondents confirmed if they had seen a doctor in the year before or since the start of the COVID-19 pandemic. Listening to Californians with Low Incomes: Health Care Access, Experiences, and Concerns Since the COVID-19 Pandemic 36