UCLA CENTER FOR ~ HEALTH POLICY RESEARCH Se -___ The California Endowment Funded by a grant from The California Endowment The State of Health Insurance in California Findings From the 2019 and 2020 California Health Interview Surveys Shana Alex Charles, PhD, MPP Susan H. Babey, PhD Joelle Wolstein, PhD, MPP January 2022 '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, or The California Endowment. Suggested Citation: Charles SA, Babey SH, Wolstein J. 2022. The State of Health Insurance in California: Findings From the 2019 and 2020 California Health Interview Surveys. Los Angeles, CA: UCLA Center for Health Policy Research. california =| | health interview survey chis.ucla.edu 'This study and report were funded by a grant from The California Endowment. The report is based on data from the 2019 and 2020 California Health Interview Surveys, which were supported by funds received from the California Department of Health Care Services; California Department of Public Health; The California Endowment; California Health Benefit Exchange; California Tobacco Control Program; First 5 California; California Department of Mental Health; Kaiser Permanente; San Diego County Health and. Human Services Agency; and California Wellness Foundation. Copyright 2022 by the Regents of the University of California The UCLA Center for Health Policy Research is based in the UCLA Fielding School of Public Health and affiliated with the UCLA Luskin School of Public Affairs. UCLA CENTER FOR HEALTH POLICY RESEARCH it healthpolicy.ucla.edu Read this publication online The publication represents the 20th anniversary of the State of Health Insurance in California (SHIC) report series. It is the 10th installment of the UCLA Center for Health Policy Research's ongoing, in-depth study of the overall outlook for health insurance coverage in our state, which has the population size of a country but operates within the federalist framework of the U.S. system. Longtime readers of this report series will find similar chapters as in the past-a demographic overview, private coverage, public coverage, and access to care impacts-and will recognize the focus on adults under age 65 and children, since seniors are almost universally covered through Medicare. However, we are now providing the data in a more streamlined and broadly accessible chartpack, allowing readers to draw their own conclusions based on the comprehensive data provided. Our data are from the 2019 and 2020 California Health Interview Surveys (CHIS), representing the decade following the enactment of the Patient Protection and Affordable Care Act of 2010, also known as the ACA or "Obamacare." Most of the health insurance expansions took full effect in 2014. Since then, ACA expansion has continued in California, including the growth of subsidies and coverage, notwithstanding rollbacks and roadblocks posed by the federal government from 2017 to 2020. Despite these advances, this chartpack shows that significant coverage gaps remain in California. Racial and ethnic disparities persist (Chapter 1); many small businesses struggle to even offer health insurance to employees (Chapter 2); more than half a million low-income people who could be eligible for Medi-Cal remain uninsured (Chapter 3); and being UCLA CENTER FOR HEALTH POLICY RESEARCH 3 Foreword uninsured remains a significant barrier to accessing health care (Chapter 4). Since the CHIS data are self-reported by respondents, numbers in this chartpack may not match with administrative data totals, particularly for Medi-Cal coverage. Our estimates of Medi-Cal coverage are lower overall than the state administrative enrollment data for 2020, due to known factors: 1) CHIS includes only the noninstitutionalized population and excludes people residing in nursing homes, dormitories, and prisons; 2) there is some respondent confusion between having Medi-Cal and Medicare coverage; and 3) some Medi-Cal beneficiaries who were signed up for the program by other entities (including hospitals, to recoup costs, or through continuing enrollment due to pandemic-era relaxation of cancellation regulations) may be unaware of their current enrollment. In addition, CHIS self-reported data for public coverage in California overall, which combines Medi-Cal and Medicare for all ages (14.7 million), closely matches the self-reported data for public coverage in California reported by the American Community Survey that was administered by the U.S. Census Bureau in 2020 (14.9 million).! Additionally, CHIS instituted a change in its survey administration method beginning in 2019. Prior to 2019, households were mostly required to take CHIS over the phone, with some small component of online surveys. 1 Source: U.S. Census Bureau, 2020 American Community Survey 1-Year Experimental Estimates, Table ID: XK202703; title: Public Health Insurance Status Starting in 2019, CHIS changed to being a survey that is mainly administered online, with phone surveys given only as a follow-up if a randomly chosen household has failed to complete the online survey.' In its evaluation of the methodology change, the CHIS research team cautioned against comparing health insurance data over time. Therefore, we have included only 2019 and 2020 data in this report, and we note that any comparisons with previous State of Health Insurance in California reports should be interpreted cautiously, keeping this methodology change in mind. We hope that providing the 2019-2020 CHIS data will highlight the continued challenges in need of solutions on which policymakers, advocates, government agencies, and other stakeholders can focus their future efforts. There is still much work to be done. 2 For mote information on the methodology change and its impact on CHIS estimates, see CHIS 2019-2020 Redesign: Rationale, Empirical Evaluation, and Trends, at https:/thealthpolicy.ucla.edulchis/design!Documents/CHIS2019-2020- Redesign- WorkingPaper-09142021 pdf. Acknowledgments The authors would like to thank the programming team at the UCLA Center for Health Policy Research, led by Zebry Jiang, who cleaned the CHIS datasets, created the variables, and performed the data runs without which this chartpack would not have been possible. We also appreciate the work of Ethan Nguyen, who assisted in creating the charts for Chapters 2 and 3 as part of his graduate work at California State University, Fullerton. Thank you to Nadereh Pourat, Anthony Wright, and Lucien Wulsin for their thoughtful and thorough reviews. Finally, thank you to Tiffany Lopes and the entire CHPR Communications team for the final publication work on the chartpack. vt UCLA CENTER FOR HEALTH POLICY RESEARCH Foreword 3 Ta b | eC of Chapter 1: A Demographic Look at Health Insurance in California Contents Exhibit 1.1 Health Insurance Coverage for Adults and Children Ages 0-64, California, 2019-2020 Exhibit 1.2 Health Insurance Coverage for Adults Ages 65 and Older, California, 2019-2020 10 Exhibit 1.3 Health Insurance Coverage by Household Income as a Percentage of the Federal Poverty Level (FPL), Ages 0-18, California, 2019-2020 11 Exhibit 1.4 Health Insurance Coverage by Household Income as a Percentage of the Federal Poverty Level (FPL), Ages 19-64, California, 2019-2020 12 Exhibit 1.5 Health Insurance Coverage by Education, Ages 19-64, California, 2019-2020 13 Exhibit 1.6 Health Insurance Coverage by Racial/Ethnic Group and Gender, Ages 0-64, California, 2019-2020 14 Exhibit 1.7 Health Insurance Coverage by Asian Ethnicity, Ages 0-64, California, 2019-2020 15 Exhibit 1.8 Health Insurance Coverage by Hispanic/Latinx Ethnicity, Ages 0-64, California, 2019-2020 16 Exhibit 1.9 Health Insurance Coverage by Citizenship Status, Ages 0-64, California, 2019-2020 17 Exhibit 1.10 Health Insurance Coverage by Region, Ages 0-64, California, 2019-2020 18 Chapter 2: Private Health Insurance Markets in California 19 Exhibit 2.1 Employer-Based Insurance by County, Ages 0-64, California, 2020 20 Exhibit 2.2 Health Insurance Coverage by Work Status, Ages 19-64, California, 2020 21 Exhibit 2.3 Rates of Employer-Based Insurance and Privately Purchased Coverage by Age Group, Adults Ages 19-64, California, 2020 22 Exhibit 2.4 Rates of Employer-Based Insurance and Privately Purchased Coverage by Racial and Ethnic Group, Adults Ages 19-64, California, 2020 23 Exhibit 2.5 Offer, Eligibility, and Take-Up Rates of Employer-Based Insurance by Firm Size, Employed Adults Ages 19-64, California, 2020 24 Exhibit 2.6 Private Health Insurance Coverage by Main Industry of Employment, Employed Adults Ages 19-64, California, 2019 25 UCLA CENTER FOR HEALTH POLICY RESEARCH Ss) Ta b e of Exhibit 2.7 Rates of Mental Health Insurance Coverage Among Enrollees in Employer-Based Insurance and Privately Purchased Insurance, Adults Ages 19-64, California, 2019 and 2020 26 C ontents Exhibit 2.8 Rates of Dental Health Insurance Coverage Among Enrollees in Employer-Based Insurance and Privately Purchased Insurance, Adults Ages 19-64, California, 2019 and 2020 27 Exhibit 2.9 Distribution of Family Type Among Privately Purchased Coverage Enrollees Compared to Total Population, Ages 19-64, California, 2020 28 Exhibit 2.10 Distribution of Racial/Ethnic Groups Among Privately Purchased Coverage Enrollees Compared to Total Population, Ages 19-64, California, 2020 29 Exhibit 2.11 Distribution of Self-Reported Health Status Among Privately Purchased Coverage Enrollees Compared to Total Population, Ages 19-64, California, 2020 30 Chapter 3: Medi-Cal Coverage for Children and for Adults Under Age 65 in California 31 Exhibit 3.1 Rates of Public Coverage Among Adults and Children by County, Ages 0-64, California, 2020 32 Exhibit 3.2 Rates of Public Coverage by Age Group, Ages 0-64, California, 2019 and 2020 33 Exhibit 3.3 Rates of Public Coverage by Age and Racial/Ethnic Group, Ages 0-64, California, 2019-2020 34 Exhibit 3.4 Rates of Medi-Cal Enrollment by Citizenship, Language Spoken at Home, and Family Type, Ages 19-64, California, 2020 35 Exhibit 3.5 Rates of Medi-Cal Enrollment by Industry of Main Employment, Employed Adults Ages 19-64, California, 2019 36 Exhibit 3.6 Household Income as a Percentage of the Federal Poverty Level (FPL) Among Uninsured Adults and Children, Ages 0-64, California, 2020 37 Exhibit 3.7 Distribution of Racial and Ethnic Groups Among Uninsured With Household Income of 0%-138% FPL Compared to All With Income of 0%-138% FPL and Total Population, Ages 19-64, California, 2019-2020 38 Exhibit 3.8 Distribution of Language Spoken at Home Among Uninsured With Household Income of 0%-138% FPL Compared to All With Income of 0%-138% FPL and Total Population, Ages 19-64, California, 2020 39 Exhibit 3.9 Distribution of Region of Residence Among Uninsured With Household Income of 0%-138% FPL Compared to All With Income of 0%-138% FPL and Total Population, Ages 19-64, California, 2019-2020 40 6) UCLA CENTER FOR HEALTH POLICY RESEARCH Chapter 4: Access to Care and Health Insurance in California 41 Ta b | eC of Exhibit 4.1 Prevalence of Self-Reported Diagnosed Chronic Conditions by Health Insurance Type, Adults Ages 19-64, California, 2019-2020 42 Contents Exhibit 4.2 Receipt of Condition-Specific Care by Insurance Type, California, 2019-2020 43 Exhibit 4.3 Rate of Having No Usual Source of Care by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 44 Exhibit 4.4 Rate of Having No Doctor Visit in Past Year by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 45 Exhibit 4.5 Rate of Having No Preventive Care Visit in Past Year by Insurance Type, Ages 19-64, California, 2019-2020 4G Exhibit 4.6 Rate of Delaying Needed Medical Care in Past Year by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 47 Exhibit 4.7 Rate of Delaying Prescription Medication in Past Year by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 48 Exhibit 4.8 Rate of Forgoing Necessary Care in Past Year by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 49 Exhibit 4.9 Rate of Having an Unmet Need for Mental Health Care in Past Year by Insurance Type, Ages 19-64, California, 2019-2020 50 Exhibit 4.10 Main Reason for Delaying Care Among Those Who Experienced Delays in Needed Care, by Insurance Type, Ages 0-64, California, 2019-2020 51 Exhibit 4.11 Rate of Reported Barriers to Accessing Primary and Specialty Care by Insurance Type, Ages 19-64, California, 2019-2020 52 Conclusion 53 UCLA CENTER FOR HEALTH POLICY RESEARCH 7 4 alain inn a apy Chapter 1 kg 'ee A Demographic Look at Health Insurance in California } A * t . i l. California, as in the rest of the United States, people new publicly funded option for people who were previously obtain health insurance coverage through either privately uninsured. Medi-Cal acts as an invaluable safety net when or publicly funded means. The largest proportions of adults combined with the state's Children's Health Insurance under 65 and children (defined as ages 18 and younger Program (CHIP)/Healthy Families, forming a seamless due to the extension of Medi-Cal coverage until age 19) public insurance program. For older Californians, the are insured through employer-based insurance. While publicly funded Medicare program serves as the backbone of the privately purchased market remains robust, it has not health insurance coverage. If someone is not able to access expanded significantly, even with the subsidies offered any of these pathways to obtain health insurance, then they through Covered California that make this form of private are uninsured. In this section, health insurance coverage coverage more affordable. Instead, the expansion of the rates among Californians in these categories are examined Medicaid program (known as Medi-Cal in California) within subgroups defined by age, gender, racial/ethnic under the Patient Protection and Affordable Care Act of group, education, household income, citizenship status, and 2010 (ACA, also known as "Obamacare") has offered a region of residence. UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 1.1 Health Insurance Coverage for Adults and Children Ages 0-64, California, 2019-2020 Six in 10 of California's adults under age 65 and children Privately Other were covered by employer- Public . . coverage Coverage based insurance (59.5%), while 5.6% 2.5% 7.7% (2.5 million) remained 1,828,000 808,000 uninsured. Uninsured 7.7% 2,523,000 Medi-Cal Employer-Based Insurance 24.8% 59.5% 8,115,000 19,470,000 Notes: "Medi-Cal" includes Medi-Cal or CHIP/Healthy Families; "Other public" Sources: Pooled 2019 and 2020 California Health Interview Surveys insurance includes Medicare, military coverage, coverage through Veterans Affairs and other military coverage, and coverage through county programs. Figures may not total 100% because of rounding. UCLA CENTER FOR HEALTH POLICY RESEARCH Seven in 10 (70%) Californians ages 65 and older were covered under Medicare and a supplemental plan, as a "wraparound" plan to cover gaps in Medicare; an additional 16.9% had Medi-Cal as their wraparound coverage. Exhibit 1.2 Health Insurance Coverage for Adults Ages 65 and Older, California, 2019-2020 Privately Uninsured Purchased 0.5% Coverage 31,000 5.2% 319,000 Medicare Only 7.4% 452,000 Medicare & Medi-Cal Medicare & Supplement 16.9% 70.0% 1,031,000 4,278,000 Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 1.3 Health Insurance Coverage by Household Income as a Percentage of the Federal Poverty Level (FPL), There were more health Ages 0-18, California, 2019-2020 insurance coverage options for 100% - low-income children. Medi- Other Public Cal covered more than 85% !) Privately Purchased 90% - Coverage of the lowest-income children i Employer-Based and more than half (53%) 80% - Insurance of children in families with i Medi-Cal incomes of 139%-249% FPL. 70% - Wi Uninsured 60% - Total Population 2019-2020 50% - (Ages 0-18) 0%-138% FPL: 2,310,000 40% - 139%-249% FPL: 1,530,000 250%-399% FPL: 1,570,000 30% - 400%-599% FPL: 1,340,000 20% - 600%+ FPL: 3,105,000 10% - 0% - 0%-138% FPL 139%-249% FPL | 250%-399% FPL | 400%-599% FPL 600+% FPL "Estimate is unstable because coefficient of variation is above 30%. incomes <138% FPL are eligible for no-cost Medi-Cal. In 2020, those in income ranges up to 600% became eligible for progressive subsidies to purchase their own insurance. Households with incomes of 601% FPL and above are not eligible for assistance of any kind. Note: The Federal Poverty Level (FPL), updated annually by the Department of Health and Human Services, is used to calculate eligibility for Medi-Cal and the Children's Health Insurance Program (CHIP), as well as for subsidies to purchase private coverage through Covered California. Households with Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH There were fewer health Exhibit 1.4 | Health Insurance Coverage by Household Income as a Percentage of the Federal Poverty Level (FPL), Ages 19-64, California, 2019-2020 insurance coverage options for low-income adults than 100% - Other Public for low-income children. WW Privately Purchased Medi-Cal covered fewer than 90% Coverage 60% of the lowest-income il Employer-Based 80% - Insurance adults, compared to more WI Medi-Cal % =| - than 85% of the lowest-income 70% WE Uninsured children (see Exhibit 1.3 for children's data). 60% - Total Population 2019-2020 50% - (Ages 19-64) 0%-138% FPL: 4,668,000 40% 139%-249% FPL: 3,791,000 250%-399% FPL: 4,045,000 30% - 400%-599% FPL: 3,937,000 10% - 0% - 0%-138% FPL 139%-249% FPL | 250%-399% FPL | 400%-599% FPL 600+% FPL Note: The Federal Poverty Level (FPL), updated annually by the Department of incomes $138% FPL are eligible for no-cost Medi-Cal. In 2020, those Health and Human Services, is used to calculate eligibility for Medi-Cal and in income ranges up to 600% became eligible for progressive subsidies to the Children's Health Insurance Program (CHIP), as well as for subsidies purchase their own insurance. Households with incomes of 601% FPL and to purchase private coverage through Covered California. Households with above are not eligible for assistance of any kind. Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 1.5 Health Insurance Coverage by Education, Ages 19-64, California, 2019-2020 100% 7 5.0% 4.0% 90% 80% | 70% 7 60% | 50% - 40% - 30% 20% - 10% 4.2% Other Public !) Privately Purchased Coverage i) Employer-Based Insurance Hi Medi-Cal Hi Uninsured 0% < High School High School Diploma Sources: Pooled 2019 and 2020 California Health Interview Surveys Some College College Degree or Higher UCLA CENTER FOR HEALTH POLICY RESEARCH As education levels increase, the rate of employer-based insurance increases, and the rate of Medi-Cal coverage decreases. Individuals with higher levels of education were more likely to have jobs that offered employer-based health benefits. Of note is the lack of variation in privately purchased insurance coverage across education levels; Covered California is reaching populations regardless of education level. Among women, those who are Black or African American and Hispanic/Latinx had the lowest rates of employer-based insurance across all groups. Exhibit 1.6 Health Insurance Coverage by Racial/Ethnic Group and Gender, Ages 0-64, California, 2019-2020 100%- 93% 23% 20% 2.4% 1.0% 1.1% 4.8% 6 4.3% 3.9% 5 8 6.9% 6.2% 6.4% 7.4% 75% 3.4% 3.2% 90%- 80%- 70%- 60%- 50%- 40%- 30%- 20%- 10%- 0% - Black/African American Note: Nonbinary and other genders had sample populations too small to present. Sources: Pooled 2019 and 2020 California Health Interview Surveys 2.2% 3.9% 6.0% 6.1% Other Single or Multiple Racial/Ethnic Group Other Public Privately Purchased Coverage Employer-Based Insurance Hi Medi-Cal Wi Uninsured Exhibit 1.7 Health Insurance Coverage by Asian Ethnicity, Ages 0-64, California, 2019-2020 Variation was found in health 100% - 1.5% eek seek eee Other Public insurance coverage across Asian ethnic groups. Medi- !) Privately Purchased 90% - Coverage Cal filled in the gaps where MM Employer-Based employer-based insurance was 80% - Insurance lacking for all groups except Wi Medi-Cal people of Korean ethnicity, 70% - Wi Uninsured who had the highest rates of 60% - uninsurance (15%). Total Population 2019-2020 50% - (Ages 0-64) Chinese: 1,485,000 40% - Japanese: 370,000 Korean: 414,000 30% - Filipino: 1,142,000 20% - South Asian: 870,000 Vietnamese: 577,000 10% Other Asian/2+ Asian Ethnicities: 545,000 0% - Japanese | South Asian Filipino Chinese | Vietnamese Korean Other Single or Multiple Asian Groups Estimate is unstable because coefficient of variation is above 30%. Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH There was variation in health insurance coverage across Hispanic/Latinx ethnic groups. Compared to other Latinx ethnic groups, Mexicans and Central Americans were more likely to be enrolled in Medi- Cal and less likely to have employer-based insurance. Central Americans had the highest rate of uninsurance (17.1%). Exhibit 1.8 Health Insurance Coverage by Hispanic/Latinx Ethnicity, Ages 0-64, California, 2019-2020 100% Other Public kkk 1) Privately Purchased 90% - Coverage ® Employer-Based 80% - Insurance Hi Medi-Cal 70% - Wi Uninsured 60% - Total Population 2019-2020 50% - (Ages 0-64) Mexican: 10,517,000 40% Central American: 1,196,000 Puerto Rican: 159,000 30% - South American: 457,000 20% - Other Latinx: 525,000 2+ Latinx Ethnicities: 1,167,000 10% - 0% ; . : Puerto Rican South Other Latinx 2 or More Central Mexican American Latinx American Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 1.9 Health Insurance Coverage by Citizenship Status, Ages 0-64, California, 2019-2020 Noncitizens, with or without a green card, had significantly 100% 2.4% 9 2.0% 2.8% i 2.8% Other Public lower rates of employer-based Privately Purchased . 90% - | Coverage urenase insurance compared to U.S.- WH Employer-Based born or naturalized citizens. 80% - Insurance Wi Medi-Cal 70% ~ Hi Uninsured 60% - 50% - 40% - 30% 20% 10% 0% - U.S.-Born Citizen Naturalized Citizen Noncitizen With Noncitizen Without a Green Card a Green Card Note: The differences among citizenship groups in Medi-Cal should not be interpreted as being statistically significantly different. Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH There was regional variation Exhibit 1.10 Health Insurance Coverage by Region, Ages 0-64, California, 2019-2020 in health insurance coverage. San Joaquin Valley, Northern/ 100% - 3.3% 2.6% 2.2% 52% 3.0% Other Public Sierra counties, and Los !) Privately Purchased 90% - Coverage Angeles County had the ) Employer-Based highest rates of Medi-Cal 80% - Insurance coverage. Los Angeles had Hi Medi-Cal the highest rate of people who 70% - Hi Uninsured were uninsured (10%). Te) RC 60% - y a 50.3% 50% - 40% - 30% - TORY PAR S1OR sb) 20% - YER) 10% - Cay cay 10.0% Aa 6.5% 0% Greater | Sacramento Central Southern | Los Angeles| Northern/ | San Joaquin Bay Area Area Coast California County Sierra Valley Counties Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH P..... health insurance in California is comprised of two broad markets: 1) employer-based insurance from a person's own or a family member's job or union, and 2) privately purchased coverage that is bought either directly from the insurance company or through the Covered California marketplace, for either an individual or a family. Within the category of employer-based insurance, employees can have either "large group" or "small group" insurance, based on the firm size of the employer (the cutoff is most often 50 employees, but it can sometimes be 100 employees for coverage through the Covered California marketplace). For privately purchased health insurance, the Patient Protection and Affordable Care Act of 2010 (ACA) mandated that the plans have to be comparable both in and out of Covered California. However, if a person or family enrolls through Covered California, they are able to access subsidies based on their household income. In January 2020, California expanded the eligibility for those public subsidies to purchase private insurance to up to 600% of the Federal Poverty Level (FPL), to account for high living expenses for state residents. Private insurance covers the majority of Californians prior to enrollment in publicly funded Medicare at age 65. Even after that, the majority obtain a private supplemental Medicare plan in addition to their public coverage. In sum, the private insurance market continues to thrive in California and to provide the foundation of health insurance for a majority of residents. UCLA CENTER FOR HEALTH POLICY RESEARCH Chapter 2 Private Health Insurance Markets in California Agricultural centers in California (the Central Valley, Northern California, and Imperial County) had the lowest rates of employer-based insurance among all residents under age 65. Exhibit 2.1 Employer-Based Insurance by County, Ages 0-64, California, 2020 Del Norte Siskiyou Shasta Trinity Humboldt ek Mendocino Sierra Nevada Sutter 5 | Placer Nan 7 El Dorado Sonoma Napa § Solano ETT Contra Costa San Francisco Santa Cruz Tulare Percent With Employer-Based Coverage Covered All Year [__] <45% by 45% to <50% Seer) [50% to <55% HS 55%+ San Bernardino Los Angeles Riverside Source: 2020 California Health Interview Survey ®w San Diego Imperial UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 2.2 Health Insurance Coverage by Work Status, Ages 19-64, California, 2020 100% - 90% - 80% - 70% - 60% - 50% - 40% -| 30% - 20% - 10% - 0% Full Time (21+ Hours per Week) Source: 2020 California Health Interview Survey !) Privately Purchased Coverage §) Employer-Based Insurance Bi Medi-Cal Wi Uninsured Total Population 2020 (Ages 19-64) Full Time: 14,937,000 Part Time: 2,648,000 Unemployed/ Looking for Work: 1,557,000 Unemployed/ Not Looking for Work: 3,603,000 Part Time (<20 Hours per Week) Unemployed and Looking for Work Unemployed and Not Looking for Work UCLA CENTER FOR HEALTH POLICY RESEARCH In 2020, nearly three-fourths of full-time employed adults had employer-based insurance (74%); only 7.5% were uninsured, compared to the one out of five adults (20.5%) who were unemployed and looking for work and were uninsured. Young adults ages 19-25 still had the lowest rates of employer-based insurance (51.7%, compared to 61%-66% for other age groups), even after the Affordable Care Act of 2010 allowed them to continue on their parents' coverage as dependents. Exhibit 2.3 Rates of Employer-Based Insurance and Privately Purchased Coverage by Age Group, Adults Ages 19-64, California, 2020 ) Employer-Based Insurance 19-25 !) Privately Purchased Coverage 26-34 35-44 45-54 | | | | | | | | 0% 10% 20% 30% 40% 50% 60% 70% 80% Source: 2020 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 2.4 Rates of Employer-Based Insurance and Privately Purchased Coverage by Racial and Ethnic Group, Adults Ages 19-64, California, 2020 ) Employer-Based Latinx Insurance !) Privately Purchased Coverage Non-Latinx White Non-Latinx Black Non-Latinx 5 : Asian VAR Val Other hab th 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Source: 2020 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH In 2020, Latinx adults continued to have the lowest rate of employer-based insurance (50.8%) compared to other racial/ethnic groups. Only two-thirds of employees at small firms (68%) reported that their employers were able to offer health insurance to any employees, compared to nearly 95% at larger firms (more than 50 employees), resulting in fewer than half of employees at small firms (48.3%) obtaining coverage through their employers. Exhibit 2.5 100% -_ 90% -_| 80% - 70% -_ 60%-| 50% -| 40% -_ 30% -_| 20% - 10%- 0%-_ Note: % Offered EBI % Eligible if Offered "% Offered EBI" is the percentage of employees who worked for a firm that offered health insurance to any of its employees. "% Eligible if Offered" is the percentage of employees who were eligible for that health insurance if the company offered it to any employee. For example, some companies offer health insurance to management only, or to those in salaried positions but not to hourly workers. "% Accepted EBI" is the percentage of employees UCLA CENTER FOR HEALTH POLICY RESEARCH % Accepted EBI Source: Offer, Eligibility, and Take-Up Rates of Employer-Based Insurance by Firm Size, Employed Adults Ages 19-64, California, 2020 !) <50 Employees Hi >50 Employees Total % Covered who were eligible for the offered health insurance who chose to take up the coverage. Employees may decide to decline coverage if they are covered through a family member's insurance or if they receive a ditect payment instead of coverage. "Total % Covered" is the resulting percentage of all employees who were covered through their own employer's health insurance. 2020 California Health Interview Survey Exhibit 2.6 § Private Health Insurance Coverage by Main Industry of Employment, Employed Adults Ages 19-64, Employees in the farming, California, 2019 construction, and service industries had the lowest rates Farming, Fishing, of employer-based insurance, and Forestry (193,000) M@ Employer-Based Insurance ranging from 20% to 43.6%. Construction & Mining a vately Purchased (791,000) overage Service (2,838,000) Transportation & Shipping (879,000) Sales (1,292,000) Pee sh/4 aOR Administrative (1,922,000) 66.0% 6.3% Management, Business, & Finance (2,202,000) rr we Health Care o oy (954,000) SIO wy) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Note: Not all industries are included in this chart; only the largest and most illustrative of comparative industries are presented. CHIS 2020 data for industry are not yet available. Source: 2019 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH Despite the inclusion of mental Exhibit 2.7 Rates of Mental Health Insurance Coverage Among Enrollees in Employer-Based Insurance and Privately Purchased Insurance, Adults Ages 19-64, California, 2019 and 2020 health as part of required essential health benefits, more 100% ©) Employer-Based Insurance !) Privately Purchased Coverage than half of adults under age 65 with privately purchased 90% coverage reported not having 80% - mental health insurance i 9 in 2019 and 2020 (55.3% 70% - and 61.3%), compared to nearly nine in 10 adults with 60% - employer-based insurance. 50% - 40% - 30% - 20% 10% - 0% - 2019 2020 Sources: 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 2.8 Rates of Dental Health Insurance Coverage Among Enrollees in Employer-Based Insurance and Privately Purchased Insurance, Adults Ages 19-64, California, 2019 and 2020 100% i) Employer-Based Insurance 90% 80% - 70% - 60% -_| 50% -| 40% -_| 30% - 20% 10% - 0% - !) Privately Purchased Coverage 2019 Sources: 2019 and 2020 California Health Interview Surveys 2020 UCLA CENTER FOR HEALTH POLICY RESEARCH About four in 10 adults under age 65 with privately purchased coverage in 2020 reported also having dental coverage (43.3%), which was less than half the rate among enrollees with employer-based insurance. Compared to the general adult Exhibit 2.9 Distribution of Family Type Among Privately Purchased Coverage Enrollees Compared to Total Population, Ages 19-64, California, 2020 population, adults under age 65 who purchased their own 100% - 6.0% health insurance directly were less likely to need insurance 90% "| Single with children for dependents, and a greater 1) Married with children 80% | proportion had no children 1) Married without children (75.2% VS. 63.8%). 70% I Single without children 60% - Population (Ages 19-64) Privately Purchased 50% -| Coverage: 1,448,000 Total Population: 22,745,000 40% 30% 20% 10% 0% - Privately Purchased Coverage Total Population Sources: 2020 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 2.10 Distribution of Racial/Ethnic Groups Among Privately Purchased Coverage Enrollees Compared to Latinx and non-Latinx Blacks Total Population, Ages 19-64, California, 2020 made up smaller proportions of all adults under age 65 who 100% 4.1% 3.3% purchased their own health 90% "| Other insurance directly compared Non-Latinx Asian or Native to the general adult population, 80% - Hawaiian/Pacific Islander showing the potential for more ®) Non-Latinx Black 70% - outreach to these groups to Wi Non-Latinx White promote health equity. i Latinx 60% | 50% 40% Population (Ages 19-64) 30% Private Insurance: 1,448,000 20% Total Population: 22,745,000 10% - 0% - Privately Purchased Coverage Total Population Sources: 2020 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH There were no statistically significant differences in health status between adults under age 65 who purchased their own health insurance and the general adult population, showing that the privately purchased market is not experiencing adverse selection in California. Exhibit 2.11 Distribution of Self-Reported Health Status Among Privately Purchased Coverage Enrollees Compared to Total Population, Ages 19-64, California, 2020 100% "| 12.2% 90% | 80% | 70% | 60% | 50% | 40% | 30% 20% -| 10% 0% - Privately Purchased Coverage Source: 2020 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH 12.6% Total Population Fair or Poor !) Good fi) Very Good Wi Excellent Population (Ages 19-64) Private Insurance: 1,448,000 Total Population: 22,745,000 C orca public health insurance coverage market is comprised of multiple programs aimed at filling in gaps where private coverage does not reach, but two major programs primarily cover significant portions of the overall population: Medicaid (called Medi-Cal in California) and Medicare. Medi-Cal is a state-federal partnership health insurance program that began as a means to cover low-income parents and children, and that was expanded in 2014 to include low-income childless adults as well. Medicare, in contrast, is a federal universal health insurance program for people ages 65 and older that most workers pay into; there have been some expansions since its inception to include people with permanent disabilities. It is possible to enroll in both programs at the same time, if a person is eligible for both under the different parameters of household income and age. Additionally, the California Chapter 3 Medi-Cal Coverage for Children and for Adults Under Age 65 in California Healthy Families (CHIP) program, California's version of the federal State Children's Health Insurance Program, still exists as an additional program to cover children of working parents who are not quite eligible for Medi-Cal. This chapter explores the populations who report having public coverage, with a focus on the Medi-Cal population. Because we use self-reported California Health Interview Survey (CHIS) data, the population totals may not match California's administrative data (see Foreword for a full discussion of this issue). While Medi-Cal has proven to be a powerful vehicle for expanding coverage among adults under age 65 since its expansion under the Patient Protection and Affordable Care Act of 2010 (ACA), there remains a segment of Californians who could be eligible for enrollment due to their low household incomes who nonetheless remain uninsured. UCLA CENTER FOR HEALTH POLICY RESEARCH In the majority of counties in California, more than one- quarter of the population under age 65 had public health insurance coverage. Exhibit 3.1 Rates of Public Coverage Among Adults and Children by County, Ages 0-64, California, 2020 Del Norte Siskiyou Modoc Trinity Lassen -- eames yt ll Sutter ¢ Placer El Dorado San Francisco C- om \ OO Alameda Q C) '%y Santa Cruz Percent With Medi-Cal Covered All Year [] <15% [15% to <21% HE 21% to <27% a 27%+ Note: "Public coverage" includes Medi-Cal; the small number of adults under age 65 and children with both Medicare and Medi-Cal; and those with Healthy Families/CHIP. Source: 2020 California Health Interview Survey San Diego Exhibit 3.2 Rates of Public Coverage by Age Group, Ages 0-64, California, 2019 and 2020 40% - !) Ages 0-18 35% - 30% - 25% - 20% - 15% - 10% - 5% - 0% - 2019 Note: "Public coverage" includes Medi-Cal; the small number of adults under age 65 and children with both Medicare and Medi-Cal; and those with Healthy Families/CHIP. Sources: 2019 and 2020 California Health Interview Surveys Mi Ages 19-44 [J Ages 45-64 2020 UCLA CENTER FOR HEALTH POLICY RESEARCH More than one-third of children ages 0-18 had public coverage in 2019 (37.1%) and 2020 (35.9%). Children had the highest rates of public coverage among all racial/ethnic groups, with more than half of Latinx children in California (54.6%) enrolled in Medi-Cal or Healthy Families. Exhibit 3.3 Rates of Public Coverage by Age and Racial/Ethnic Group, Ages 0-64, California, 2019-2020 60% - M™@ Ages0-18 [ Ages 19-44 [ll Ages 45-64 50% - 40% - 30% - 20% 10% - 16.4% 15.0% 0% - Latinx White Black Asian/NHPI Notes: "Public coverage" includes Medi-Cal; the small number of adults under age 65 and children with both Medicare and Medi-Cal; and those with Healthy Families/CHIP. NHPI=Native Hawaiian or Pacific Islander Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 3.4 Rates of Medi-Cal Enrollment by Citizenship, Language Spoken at Home, and Family Type, Ages 19-64, California, 2020 Married with no children ao = Married with children > E Single with no children Le Single with children 5 English only 3 Spanish only no @§ Chinese only ot 5 ° English & Spanish < 5 English & Chinese © U.S.-born citizen = & Naturalized citizen a 3 Noncitizen with green card oa = Noncitizen without green card 0% Source: 2020 California Health Interview Survey 10% 20% 30% 40% 50% UCLA CENTER FOR HEALTH POLICY RESEARCH Among adults under age 65, those who were single with children (46.9%), spoke only Spanish at home (42.7%), or were noncitizens with a green card (34.6%) had the highest rates of Medi-Cal coverage, indicating the importance of inclusive outreach. One-third of farm workers Exhibit 3.5 Rates of Medi-Cal Enrollment by Industry of Main Employment, Employed Adults Ages 19-64, California, 2019 (32.5%) and one-fourth (25.9%) of service industry workers in California had Farming, Fishing, and Forestry (193,000) Medi-Cal coverage. Service (2,838,000) Transportation & Shipping (879,000) Sales (1,292,000) Administrative (1,922,000) Construction & Mining (791,000) Health Care (954,000) Management, Business, and Finance (2,202,000) 0% 5% 10% 15% 20% 25% 30% 35% Note: Not all industries are included in this chart; only the largest and most illustrative of comparative industries are presented. CHIS 2020 data for industry are not yet available. Source: 2019 California Health Interview Survey UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 3.6 Household Income as a Percentage of the Federal Poverty Level (FPL) Among Uninsured Adults and Children, Ages 0-64, California, 2020 601%+ FPL 9.9% 227,000 401%-600% FPL 0%-138% FPL 13.0% 28.0% 300,000 643,000 251%--400% FPL 19.6% 29.5% 679,000 Note: The Federal Poverty Level (FPL), updated annually, reflects the household Source: 2020 California Health Interview Survey incomes that are included in the eligibility cutoffs for public coverage or subsidies for purchasing private coverage through Covered California. Households with <138% FPL are eligible for no-cost Medi-Cal, while those in the ranges up to 600% are eligible for progressive subsidies to purchase their own insurance. Households with incomes at 601% FPL or above are not eligible for assistance of any kind. UCLA CENTER FOR HEALTH POLICY RESEARCH The Medi-Cal expansion over the past decade aimed to reduce the rates of uninsurance by covering low- income childless adults as well. Still, low-income families that could have qualified for Medi- Cal (that is, those with incomes less than or equal to 138% FPL) made up more than one- fourth of the population under age 65 without insurance. More than three-fourths of the Exhibit 3.7 Distribution of Racial and Ethnic Groups Among Uninsured With Household Income of 0%-138% FPL Compared to All With Income of 0%-138% FPL and Total Population, Ages 19-64, California, 2019-2020 remaining uninsured adults who may have been eligible for 100% 7] wick 1.9% 3.3% Medi-Cal because of household income were of Latinx descent 90% ~ | Other single or multiple race 9 (77.5%). Non-Latinx Asian and 80% Other Pacific Islander §®) Non-Latinx Black 70% Wi Non-Latinx White Hi Latinx 60% | 50% Population (Ages 19-64) Uninsured, 40% 0%-138% FPL: 643,000 0%-138% FPL: 8,055,000 30% Total Population: 22,745,000 20% -| 10% 0% - Uninsured 0%-138% FPL Total Population 0%-138% FPL Note: The Federal Poverty Level (FPL), updated annually, reflects the household * Estimate is unstable because the coefficient of variation is above 30%. Data incomes that are included in the eligibility cutoffs for public coverage or for "Uninsured, 0%-138% FPL" are pooled for 2019 and 2020 to provide subsidies for purchasing private coverage through Covered California. stable percentages. Households with income <138% FPL are eligible for no-cost Medi-Cal, while oo, ; those in income ranges up to 600% FPLare eligible for progressive subsidies Sources: Pooled 2019 and 2020 California Health Interview Surveys to purchase their own insurance. Households with incomes of 601% FPL or above are not eligible for assistance of any kind. UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 3.8 Distribution of Language Spoken at Home Among Uninsured With Household Income of 0%-138% FPL Nearly half of all uninsured Compared to All With Income of 0%-138% FPL and Total Population, Ages 19-64, California, 2020 adults who may have been 100% 7] eligible for Medi-Cal due to 12.8% 12.5% ; household income (45.4%) ("0 "ee 15.7% 90% | Other language(s) spoke both English and © Spanish only Spanish at home, and an 80% ~ | wy: . @ English & Spanish additional one in five (20.9%) i spoke only Spanish. 70% - Wi English p yop 60% Population (Ages 19-64) Uninsured, 0%-138% FPL: 643,000 50% -| 0%-138% FPL: 8,055,000 40% Total Population: 22,745,000 30% 20% | 10% 0% - Uninsured 0%-138% FPL Total Population 0%-138% FPL Note: The Federal Poverty Level (FPL), updated annually, reflects the household Source: 2020 California Health Interview Survey incomes that are included in the eligibility cutoffs for public coverage or subsidies for purchasing private coverage through Covered California. Households with <138% FPL are eligible for no-cost Medi-Cal, while those in the ranges up to 600% FPL are eligible for progressive subsidies to purchase their own insurance. Households with incomes of 601% FPL or above are not eligible for assistance of any kind. UCLA CENTER FOR HEALTH POLICY RESEARCH More than seven in 10 Exhibit 3.9 Distribution of Region of Residence Among Uninsured With Household Income of 0%-138% FPL Compared to All With Income of 0%-138% FPL and Total Population, Ages 19-64, California, 2019-2020 uninsured adults who may have been eligible for Medi-Cal 100% J 9 9 . . 3.5% 4.1% 3.2% due to household income lived Northern/Sierra Counties in a Southern California county 90% - Bay Area (72.3%), including 41.4% in Los I Sacramento Area Angeles County alone. 80% HI San Joaquin Valley Hi Ceniral Coast 70% | Wi Other Southern California 60% - Hl Los Angeles County 50% Population (Ages 19-64) Uninsured, 40% 0%-138% FPL: 643,000 0%-138% FPL: 8,055,000 30% Total Population: 22,745,000 20% 10% 0% - Uninsured 0%-138% FPL Total Population 0%-138% FPL Note: The Federal Poverty Level (FPL), updated annually, reflects the household * Estimate is unstable because the coefficient of variation is above 30%. Data incomes that are included in the eligibility cutoffs for public coverage or for "Uninsured, 0%-138% FPL" were pooled for 2019 and 2020 to provide subsidies for purchasing private coverage through Covered California. stable percentages. Households with <138% FPL are eligible for no-cost Medi-Cal, while those in the ranges up to 600% are eligible for progressive subsidies to purchase their own insurance. Households with incomes of 601% FPL or above are not eligible for assistance of any kind. Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Chapter 4 Access to Care and Health Insurance in California M.. Californians do not get the health care they of factors, including eligibility requirements for certain need. Insurance coverage is an important determinant of types of coverage, along with the out-of-pocket costs that access to health care because it makes health care more are included in the insurance plan or policy - e.g., co- affordable. Access to timely and appropriate health care can payments, deductibles, and caps on the amount of coverage. help individuals prevent illness as well as manage chronic Additionally, although the mandated essential health benefits conditions, thus avoiding potential complications. Having have increased comparability across insurance products, insurance improves access to care, but access can also there is still some variation in the breadth of benefits vary by type of insurance. This may be due to a number packages. UCLA CENTER FOR HEALTH POLICY RESEARCH Adults insured with Medi-Cal had a higher prevalence of hypertension, heart disease, diabetes, and serious or moderate psychological distress than adults covered by employer-based insurance or those with no insurance. Exhibit 4.1 Prevalence of Self-Reported Diagnosed Chronic Conditions by Health Insurance Type, Adults Ages 19-64, California, 2019-2020 Heart disease Diabetes Hypertension Wi Uninsured 8) Employer-Based Coverage Hi Medi-Cal !) Privately Purchased Total Population 2019-2020 (Ages 19-64) Uninsured: 2,278,000 Employer- based: 13,910,000 Current asthma Medi-Cal: 4,519,000 Privately Purchased: 1,472,000 Serious or moderate psychological distress 0% 5% 10% 15% 20% 25% 30% 35% Note: Heart disease, diabetes, hypertension, and asthma are self-reported based on being diagnosed by a medical provider. Psychological distress is assessed with a series of questions assessing number and frequency of symptoms experienced in the past year to determine clinically relevant levels of distress. Adults without insurance do not have a higher prevalence of diagnosed heart disease, diabetes, hypertension, or current asthma. Two factors likely UCLA CENTER FOR HEALTH POLICY RESEARCH contribute to this: (1) People who know they have chronic conditions tend to seek out insurance, and (2) those without insurance may be more likely to have undiagnosed conditions because they have less access to health care. Interestingly, the prevalence of psychological distress was not lower, and this was the only indicator measured by asking about symptoms rather than through a diagnosis given by a provider. Sources: Pooled 2019 and 2020 California Health Interview Surveys Exhibit 4.2 Asthma management plan Ages 0-64 Dilated eye exam in past year among those with diabetes Ages 19-64 Diabetes care plan Receipt of Condition-Specific Care by Insurance Type, California, 2019-2020 Wi Uninsured ©) Employer-Based Coverage Hi Medi-Cal !) Privately Purchased | I | I | | 0% 10% 20% 30% 40% 50% Notes: "Asthma management plan" is among children and adults ages 0-64 with asthma, and "diabetes care plan" and "dilated eye exam" are among adults ages 19-64 with diabetes. Sources: Pooled 2019 and 2020 California Health Interview Surveys 60% 70% 80% 90% 100% UCLA CENTER FOR HEALTH POLICY RESEARCH Fewer than half of those without insurance received an asthma management plan (35%), a diabetes care plan (38%), or a dilated eye exam (45.8%), compared to more than half of those with employer-based insurance or Medi-Cal. More than half of children (58.4%) and adults (53.7%) with no insurance coverage lacked a usual source for health care, figures significantly higher than for those with any type of insurance. However, children and adults with Medi- Cal were still more likely to have no usual source of care than those with employer- based insurance (EBI) (12.4% compared to 9.7% for children, and 22.2% compared to 11.2% for adults). Exhibit 4.3 Rate of Having No Usual Source of Care by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 Wi Uninsured MN) Employer-Based Coverage Ages 0-18 Hi Medi-Cal !) Privately Purchased Ages 19-64 0% 10% 20% 30% 40% 50% 60% 70% Notes: "No usual source of care" includes those who reported that urgent care or an emergency department were their usual place to receive care. Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 4.4 Rate of Having No Doctor Visit in Past Year by Insurance Type and Age Group, Ages 0-64, California, More than 40% of children 2019-2020 and adults who lacked insurance coverage had had no doctor visit in the past year, significantly higher than the Mf Uninsured percentage among those with ©) Employer-Based Ages 0-18 Coverage any type of insurance. Higher HI Medi-Cal proportions of people with Privately Purchased Medi-Cal had had no doctor visit in the past year compared to those with EBI. Ages 19-64 0% 10% 20% 30% 40% 50% 60% Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH More than 60% of adults Exhibit 4.5 Rate of Having No Preventive Care Visit in Past Year by Insurance Type, Ages 19-64, California, 2019-2020 without insurance had had no preventive care visit in the past year, a percentage significantly higher than percentages for all Uninsured other categories. Privately purchased ° x 10% 20% 30% 40% 50% 60% 70% Notes: Adult respondents were asked how long it had been since they had seen a provider for a routine check-up. Those who reported a routine check-up in the past 12 months were considered to have had a preventive care visit in the past year. Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 4.6 Rate of Delaying Needed Medical Care in Past Year by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 Hi Uninsured Ages 0-18 ©) Employer-Based Coverage Bi Medi-Cal !) Privately Purchased Ages 19-64 0% 5% 10% 15% 20% 25% 30% Notes: Respondents were asked if they had delayed or not received any medical care * Estimate is unstable because the coefficient of variation is above 30%. they felt they needed in the past year. Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH One in seven (16.6%) children with no insurance experienced a delay in needed medical care. Among adults ages 19-64, one-fourth of those with privately purchased insurance (25%) and more than one-fifth of those with no insurance (22.1%) reported experiencing a delay in receiving needed medical care in the past year. Among children, there was little variation in the percentage who had experienced delays in filling a prescription across the primary insurance types of EBI, Medi-Cal, and privately purchased insurance. Among adults, a higher percentage of those enrolled in Medi-Cal had experienced a delay in getting a prescription compared to those with EBI (12.8% vs. 9.5%). Those with no insurance may have had lower rates of delaying getting prescription medication because they were less likely to have received a prescription for medication. Exhibit 4.7 Rate of Delaying Prescription Medication in Past Year by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 Wi Uninsured Ages 0-18 i) Employer-Based Coverage Hi Medi-Cal !) Privately Purchased Ages 19-64 0% 2% 4% 6% 8% 10% 12% 14% Notes: Respondents were asked if they had delayed getting or did not get any ** Estimate is unstable because the coefficient of variation is above 30%. medicine that was prescribed for them in the past year Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 4.8 Rate of Forgoing Necessary Care in Past Year by Insurance Type and Age Group, Ages 0-64, California, 2019-2020 HH Uninsured Ages 0-18 ) Employer-Based Coverage Wi Medi-Cal !) Privately Purchased Ages 19-64 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% Notes: "Forgoing necessary care" refers to those who experienced delays in needed ** Estimate is unstable because the coefficient of variation is above 30%. medical care and who never received the delayed care. Sources: Pooled 2019 and 2020 California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH One in 10 uninsured children (11.4%) and nearly one in five uninsured adults (18.5%) had to forgo needed care in the past year, figures significantly higher than among those with Medi-Cal (2.5% among children and 10.1% among adults) and those with EBI (2.1% among children and 10.1% among adults). More than three-quarters of adults with no insurance (77%) had an unmet need for mental health care in the past year, along with more than half of those with Medi-Cal, EBI, or private insurance. Exhibit 4.9 Rate of Having an Unmet Need for Mental Health Care in Past Year by Insurance Type, Ages 19-64, California, 2019-2020 Uninsured Employer-based Privately 57.1% purchased 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Notes: "Unmet need for mental health care" refers to adults who had serious or Sources: Pooled 2019 and 2020 California Health Interview Surveys moderate psychological distress or who reported needing care for mental health or substance abuse issues in the past year, and who also reported that they had not seen any health care provider for mental health or substance abuse issues in the past year. UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 4.10 Main Reason for Delaying Care Among Those Who Experienced Delays in Needed Care, by Insurance The vast majority (89.1%) of Type, Ages 0-64, California, 2019-2020 those without insurance who experienced delays in needed 100% 1) Personal and other reasons care reported that cost or lack 90% 4 Mi Health care system of insurance was the main or provider issues reason for delaying care, a Hi Cost or lack of 80% , . insurance figure more than twice that for those with either Medi-Cal or 70% EBI. 60% - 50% 40% 30% 20% | 10% 0% Uninsured Employer- Medi-Cal Privately Based Purchased Notes: Respondents who experienced delays in needed medical care were asked about their main reasons for delaying care. Sources: 2019-2020 pooled California Health Interview Surveys UCLA CENTER FOR HEALTH POLICY RESEARCH Adults with EBI had the lowest reported difficulty in finding primary care (4.9%), difficulty in finding specialty care (8.1%), having insurance not accepted by a primary care provider (4.3%), and having insurance not accepted by a specialty care provider (8.4%). Exhibit 4.11 Difficulty finding primary care Difficulty finding specialty care Insurance not accepted by primary care Insurance not California, 2019-2020 provider Rate of Reported Barriers to Accessing Primary and Specialty Care by Insurance Type, Ages 19-64, Wi Uninsured ff) Employer-Based Coverage Hi Medi-Cal !) Privately Purchased accepted by medical specialist 0% 5% 10% 15% 20% 25% Notes: Respondents who answered yes to either "During the past 12 months, did you have any trouble finding a general doctor who would see you?" or "During the past 12 months, did a doctor's office tell you that they would not take you as a new patient?" were considered to have had. difficulty finding primary care. Respondents responding yes to "In the past 12 months, did you or a doctor think you needed to see a medical specialist?" were asked the following: "During the past 12 months, did you have any trouble finding a medical specialist who would see you?" and "During the past 12 months, UCLA CENTER FOR HEALTH POLICY RESEARCH did a medical specialist's office tell you that they would not take you as a new patient?" Those answering yes to either were considered to have had difficulty obtaining specialty care. Respondents were also asked whether a doctor's office or specialist's office would not accept their insurance. Respondents without insurance were not asked whether they were ever told their insurance would not be accepted. Sources: Pooled 2019 and 2020 California Health Interview Surveys n our previous State of Health Insurance in California report, we noted that for the first time in decades, true universal coverage seemed possible. This seemed feasible in part due to California's efforts to stabilize and expand the ACA marketplace in the face of ongoing political and judicial challenges. But we also noted that health insurance coverage stood at a crossroads, with the next report likely to either (1) document the further successes in and remaining challenges to establishing true universal coverage, or (2) be a postmortem on the ACA that documented the damage done to health coverage. The data in this chartpack indicate that health insurance expansion has continued in California, including the growth of subsidies and coverage, despite rollbacks and roadblocks posed by the federal government from 2017 to 2020. Despite the successes, this chartpack also shows that many challenges to health coverage remain. More than 2.5 million California adults, adolescents, and children have no health insurance coverage; racial and ethnic disparities persist; many Conclusion small businesses struggle to even offer health insurance to employees; more than half a million low-income people who could be eligible for Medi-Cal remain uninsured; and being uninsured remains a significant barrier to accessing health care. While previous expansions in health coverage are good news for residents, California has more work to do to reduce racial and ethnic disparities, reduce or eliminate uninsurance, and remove barriers to accessing health care. Several proposals have been put forward in California as well as at the federal level to further expand coverage. Even incremental expansions to health insurance eligibility would help California meet some of the remaining challenges, although a more comprehensive overhaul of the health care financing system would also address underinsurance among those with current coverage. It remains to be seen whether California will have both the political will and the public financing needed to take these steps forward, as well as how far Californians are willing to go to improve coverage for all residents.