AUGUST 2021 Measuring Up? Access to Care in Medi-Cal Compared to Other Types of Health Insurance (2018) Overview Medi-Cal is California's Medicaid program, providing health insurance to Californians with low incomes, including about 40% of the state's children, half of Californians with disabilities, over a million seniors, and Contents about one in six working adults. In total, the program covers around 13 million Californians, nearly one- third of the state's population. 1 Overview However, coverage alone does not guarantee access to health care services or affordability. To see how 2 Methodology Californians with Medi-Cal coverage are faring in accessing health care, this report examines data from 5 Findings the 2017–18 California Health Interview Survey (CHIS). This analysis focuses on one main question: Do Medi-Cal enrollees face greater difficulty accessing health care services than Californians with employer- 12 Appendices sponsored insurance (ESI) or coverage purchased through the individual market (IM)? The findings broadly suggest the need for improvement in several areas: ensuring a usual source of care, increasing the supply of providers that will take Medi-Cal patients, and facilitating access to specialists who will see Medi-Cal patients. Addressing these critical areas would help close the gaps in access to care for many California adults and children. CALIFORNIA HEALTH CARE FOUNDATION 1 Methodology: Population and Access Data Indicators This report examines data from the combined 2017–18 California Health Interview The indicators used to measure access gaps were selected based on the following considerations: three domains Survey (CHIS) on adults age (gaps in connections to the health care system, gaps in receipt of care, and gaps in affordability of care) are 19–64, and on children age represented; measures are widely accepted and used for evaluating access to care; measures highlight common 0–18, to examine access barriers to access; and indicators build on measures used in previous work1 (PDF) and are historically used to monitor to care in three domains: access in Medi-Cal.2 individuals' connections For children, the only access measures evaluated are related to connection to the health care system and receipt of to the health system; gaps care (measures on affordability are limited to adults). In addition, the number of children covered by IM plans in the in connections to the CHIS survey sample was too small to allow for meaningful comparisons with children in Medi-Cal. health care system, gaps in The Medi-Cal, ESI, and IM populations were restricted to those who had been continuously insured for the past 12 receipt of care, and gaps in months, though their source of coverage may have changed over that time period. Those who received care through affordability of care. restricted scope Medi-Cal coverage were excluded. Medi-Cal coverage includes the state's Children's Health Insurance Program. All analyses were weighted to reflect the size of the 2018 California population. 1. Tara Becker et al., Medi-Cal Versus Employer-Based Coverage: Comparing Access to Care, California Health Care Foundation, July 2015. 2. Marsha Gold and Genevieve Kenney, Monitoring Access: Measures to Ensure Medi-Cal Enrollees Get the Care They Need, California Health Care Foundation, May 2014. CALIFORNIA HEALTH CARE FOUNDATION 2 Methodology: Data Indicators Three domains were used to examine access to care for adults and children using Table 1: Access to Care Data Indicators, Combined 2017-18 California Health Interview Survey (CHIS) California Health Interview ADULTS (AGE 19-64) CHILDREN (AGE 0-18) Survey (CHIS) 2017-18 data: Domain 1: Gaps in Connections to Health Care System gaps in connections to the No usual source of care (USOC) other than emergency room No usual source of care other than ER* health care system, gaps in (ER) receipt of care, and gaps in Trouble finding general doctor who would see them USOC is the ER* affordability of that care. Told that doctor wouldn't accept health insurance Hard time understanding doctor (among those with a visit in past 2 years) Trouble finding a specialist who would see them Sometimes/never able to get appt. within 2 days (among those who sought an appt.) Hard time understanding doctor (among those with a visit in past 2 years) Sometimes/never able to get appt. within 2 days (among those who sought an appt.) Domain 2: Gaps in Receipt of Care No doctor visits in past year No doctor visits in past year More than one emergency room visit in past year One or more emergency room visits in past year † Delayed getting prescription in past year Delayed getting prescription in past year Did not receive needed medical care in past year Did not receive needed medical care in past year Did not visit dentist in past year (among children who have teeth) Domain 3: Gaps in Affordability of Care Delayed medical care due to cost/insurance Did not get help for mental health due to cost * "No USOC other than ER" includes both people who say they have no USOC as well as people who report using the ER as their USOC. "USOC is the ER" includes only those people who reported the ER as their usual source of care. † The emergency room indicator is at a lower threshold for children because children generally have lower rates of emergency room visits than adults (PDF).1 1. Kimberly W. McDermott, Carol Stocks, and William J. Freeman, Overview of Pediatric Emergency Department Visits, 2015 (statistical brief 242), Agency for Health Care Quality and Research, August 2018. CALIFORNIA HEALTH CARE FOUNDATION 3 Methodology: Adjustment and Statistical Significance Medi-Cal enrollees have lower incomes and report poorer health status than those with ESI and IM plans, Adult Medi-Cal enrollees are due in large part to Medi-Cal's eligibility requirements based on income and disability. (See appendix for more likely to have family more information.) Because differences in socioeconomic status and health can contribute to a greater incomes below the poverty need for care and affect access to care, this research took such characteristics into account. First, the level - 40.9% compared to research data were analyzed without adjustment for health and socioeconomic factors, then the data were 5.9% of those with ESI and adjusted to accommodate these characteristics. (See appendix for more information.) 6.9% of those with IM plans. Differences that persist after adjustment suggest that characteristics of the Medi-Cal program - not just characteristics of its enrolled population - may be impeding equity and access to care for Medi-Cal enrollees. This report focuses on differences between groups that are statistically significant. A statistically significant difference of .05 means that researchers are 95% confident the results are not due to random chance. CALIFORNIA HEALTH CARE FOUNDATION 4 Access to Care for Adults with Medi-Cal vs. Employer- Sponsored Insurance (Unadjusted Analysis) Table 2. Access to Care Under Medi-Cal Compared to Employer-Sponsored Insuranc, Adults Age 19–64, The unadjusted analysis California, 2018 found that adults enrolled MEDI-CAL ESI in Medi-Cal fared worse than those with ESI on all 12 Gaps in Connections to Health Care System No usual source of care 22.3% 8.8% * access measures. Trouble finding general doctor who would see them 5.6% 3.2% * Told that doctor wouldn't accept health insurance 8.5% 3.6% * Trouble finding a specialist who would see them 6.8% 3.2% * Hard time understanding doctor: visit in past 2 years 6.4% 2.0% * Sometimes/never able to get appt. within 2 days: sought 42.3% 31.3% * Gaps in Receipt of Care No doctor visits in past year 19.6% 14.2% * More than one emergency room visit in past year 15.6% 7.2% * Delayed getting prescription in past year 12.5% 10.0% * Did not receive needed medical care in past year 16.7% 12.1% * Gaps in Care Due to Affordability Delayed medical care due to cost/insurance 7.4% 4.1% * Did not get help for mental health due to cost 4.2% 2.5% * *Significantly different from Medi-Cal at the .05 level, two-tailed test. A two-tailed test checks for the possibility of a relationship in both directions - that is, the number being compared can be greater than or less than the reference number. Note: Access indicators are not adjusted for differences in health and socioeconomic status. Source: California Health Interview Survey, 2017–18 combined file, weighted to 2018 population. CALIFORNIA HEALTH CARE FOUNDATION 5 Access to Care for Adults with Medi-Cal vs. Employer- Sponsored Insurance (Adjusted Analysis) Table 3. Adjusted Indicators of Access to Care Under Medi-Cal Compared to Employer-Sponsored Insurance, After adjusting for Adults Age 19–64, California, 2018 socioeconomic factors and MEDI-CAL ESI health status, the data show that adult Medi-Cal enrollees Gaps in Connections to Health Care System No usual source of care 17.4% 10.7% * experienced worse access to Trouble finding general doctor who would see them 5.0% 3.4% care than those with ESI on Told that doctor wouldn't accept health insurance 8.1% 3.7% * 5 of the 12 measures. Adults Trouble finding a specialist who would see them 5.4% 3.6% * with Medi-Cal were more Hard time understanding doctor: visit in past 2 years 4.0% 2.8% likely to report having no Sometimes/never able to get appt. within 2 days: sought 36.8% 33.0% usual source of care, being Gaps in Receipt of Care told a doctor wouldn't accept No doctor visits in past year 18.8% 14.9% * their health insurance, having More than one emergency room visit in past year 11.0% 8.4% * trouble finding a specialist Delayed getting prescription in past year 9.7% 11.0% that would see them, having Did not receive needed medical care in past year 9.5% 7.7% had no doctor visit in the last Gaps in Affordability of Care year, and having had more Delayed medical care due to cost/insurance 6.0% 4.4% than one ER visit in the last Did not get help for mental health due to cost 3.6% 2.7% year. Differences between the two groups for the other 7 measures were no longer statistically significant. *Significantly different from Medi-Cal at the .05 level, two-tailed test. A two-tailed test checks for the possibility of a relationship in both directions - that is, the number being compared can be greater than or less than the reference number. Note: This table shows regression-adjusted differences controlling for health care needs and socioeconomic status. Source: California Health Interview Survey, 2017–18 combined file, weighted to 2018 population. CALIFORNIA HEALTH CARE FOUNDATION 6 Access to Care for Adults with Medi-Cal vs. Individual Market Insurance (Unadjusted Analysis) Table 4. Access to Care Under Medi-Cal Compared to Individual Market (IM) Insurance, Adults Age 19–64, The unadjusted analysis California, 2018 shows that adults with Medi- MEDI-CAL IM Cal fared worse than those with IM plans on 3 of the 12 Gaps in Connections to Health Care System No usual source of care 22.3% 14.0% * measures: Adults with Medi- Trouble finding general doctor who would see them 5.6% 4.8% Cal were more likely to report Told that doctor wouldn't accept health insurance 8.5% 9.9% no usual source care, having Trouble finding a specialist who would see them 6.8% 4.6% a hard time understanding Hard time understanding doctor: visit in past 2 years 6.4% 2.2% * the doctor, and having more Sometimes/never able to get appt. within 2 days: sought 42.3% 36.8% than one ER visits in the last Gaps in Receipt of Care year. No doctor visits in past year 19.6% 17.9% More than one emergency room visits in past year 15.6% 7.3% * Delayed getting prescription in past year 12.5% 14.4% Did not receive needed medical care in past year 16.7% 16.7% Gaps in Care Due to Affordability Delayed medical care due to cost/insurance 7.4% 9.9% Did not get help for mental health due to cost 4.2% 5.2% *Significantly different from Medi-Cal at the .05 level, two-tailed test. A two-tailed test checks for the possibility of a relationship in both directions - that is, the number being compared can be greater than or less than the reference number. Note: Access indicators are not adjusted for differences in health and socioeconomic status. Source: California Health Interview Survey, 2017–18 combined file, weighted to 2018 population. CALIFORNIA HEALTH CARE FOUNDATION 7 Access to Care for Adults with Medi-Cal vs. Individual Market Insurance (Adjusted Analysis) Table 5. Adjusted Indicators of Access to Care Under Medi-Cal Compared to Individual Market, Adults Age After adjusting for health 19–64, California, 2018 and socioeconomic status, MEDI-CAL IM differences between the Gaps in Connections to Health Care System two groups existed for two No usual source of care 17.4% 15.2% measures. Contrary to results Trouble finding general doctor who would see them 5.0% 4.5% from the unadjusted analysis, Told that doctor wouldn't accept health insurance 8.1% 9.4% adults with Medi-Cal fared Trouble finding a specialist who would see them 5.4% 4.7% better than adults with IM Hard time understanding doctor: visit in past 2 years 4.0% 2.7% plans on both measures. Sometimes/never able to get appt. within 2 days: sought 36.8% 36.8% Adults with IM plans were Gaps in Receipt of Care more likely to report delaying No doctor visits in past year 18.8% 19.1% getting a prescription in Two or more emergency room visits in past year 11.0% 7.5% the past year and delaying Delayed getting prescription in past year 9.7% 14.7% * medical care due to cost or Did not receive needed medical care in past year 9.5% 11.3% insurance. Gaps in Affordability of Care Delayed medical care due to cost/insurance 6.0% 10.1% * Did not get help for mental health due to cost 3.6% 4.7% *Significantly different from Medi-Cal at the .05 level, two-tailed test. A two-tailed test checks for the possibility of a relationship in both directions - that is, the number being compared can be greater than or less than the reference number. Note: This table shows regression-adjusted differences controlling for health care needs and socioeconomic status. Source: California Health Interview Survey, 2017–18 combined file, weighted to 2018 population. CALIFORNIA HEALTH CARE FOUNDATION 8 Access to Care for Children with Medi-Cal vs. Employer- Sponsored Insurance (Unadjusted Analysis) Table 6. Access to Care Under Medi-Cal Compared to ESI, Children Age 0-18, California, 2018 There was no statistically significant difference in MEDI-CAL ESI access to care between Gaps in Connections to Health Care System children with Medi-Cal and No usual source of care (USOC) other than ER 16.0% 7.6% * children with ESI, with one USOC is emergency room 2.2% 1.2% exception: Children with Hard time understanding doctor: visit in past 2 years 1.8% 1.1% Medi-Cal were more likely to Sometimes/never able to get appt. within 2 days: sought 28.2% 20.5% have no usual source of care Gaps in Receipt of Care other than the ER compared No doctor visits in past year 15.2% 11.4% to children with ESI. One or more emergency room visit in past year 19.3% 18.5% Delayed getting prescription in past year 4.3% 3.1% Did not receive needed medical care in past year 1.7% 1.6% Did not visit dentist in past year (among children with teeth) 14.6% 14.1% *Significantly different from Medi-Cal at the .05 level, two-tailed test. A two-tailed test checks for the possibility of a relationship in both directions - that is, the number being compared can be greater than or less than the reference number. Note: Access indicators are not adjusted for differences in health and socioeconomic status. Source: California Health Interview Survey, 2017–18 combined file, weighted to 2018 population. CALIFORNIA HEALTH CARE FOUNDATION 9 Access to Care for Children with Medi-Cal vs. Employer- Sponsored Insurance (Adjusted Analysis) Table 7. Adjusted Indicators of Access to Care Under Medi-Cal Compared to ESI, Children Age 0–18, After adjusting for health California, 2018 and socioeconomic status, MEDI-CAL ESI children enrolled in Medi-Cal continued to be less likely Gaps in Connections to Health Care System No usual source of care (USOC) other than emergency room 14.6% 8.4% * than those with ESI to have USOC is emergency room 1.6% 1.7% a usual source of care other than the ER, although the Gaps in Receipt of Care No doctor visits in past year 13.8% 11.8% disparity between the two One or more emergency room visits in past year 18.1% 19.5% groups narrowed. There Delayed getting prescription in past year 4.0% 3.5% remained no statistically Did not receive needed medical care in past year 1.7% 1.7% significant differences on any Did not visit dentist in past year (among children with teeth) 13.0% 14.8% of the other measures. * Significantly different from Medi-Cal at the .05 level, two-tailed test. A two-tailed test checks for the possibility of a relationship in both directions - that is, the number being compared can be greater than or less than the reference number. Note: This table shows regression-adjusted differences controlling for health care needs and socioeconomic status. Source: California Health Interview Survey, 2017–18 combined file, weighted to 2018 population. CALIFORNIA HEALTH CARE FOUNDATION 10 Conclusions ➤ Medi-Cal enrollees differ considerably from Californians with ESI or IM plans in terms of socioeconomic factors and health status. Yet even after adjusting for these factors, adults in Medi-Cal were still more likely than those with ESI to report no usual source of care, being told a doctor wouldn't accept their health insurance, having trouble finding a specialist that would see them, having had no doctor visit in the last year, and having had more than one ER visits in the last year. ➤ Children in Medi-Cal generally experience comparable access to care as children with ESI, with one exception: They are more likely to report no usual source of care other than the ER, even after adjusting for health and socioeconomic factors. ➤ Although at first glance Medi-Cal access appears worse than IM, deficiencies disappear when the differences in the populations' health and socioeconomic status are taken into consideration. The only two measures that showed a difference between the two groups after adjusting for health and socioeconomic factors revealed that those with Medi-Cal fared better. Adults with Medi-Cal were less likely to report delaying getting a prescription in the past year or delaying medical care due to cost or insurance. The latter may reflect higher out-of-pocket costs and copayments in the IM. ➤ Overall, this research points to the need for improvement in several areas for Medi-Cal enrollees: ensuring a usual source of care, increasing the supply of providers that will take Medi-Cal patients, and facilitating access to specialists who will see Medi-Cal patients. Addressing these critical areas would help close the gaps in access to care for many California adults and children. CALIFORNIA HEALTH CARE FOUNDATION 11 Appendix 1. Population Characteristics of Adults with Medi- Cal Compared to ESI and IM Health and Socioeconomic Status Differences Across Insurance Types, Adults Age 19–64, California, 2018 There are important Individual Market ESI Medi-Cal health and socioeconomic Fair/Poor Health differences between adults 32.6% in Medi-Cal and those 12.6% with ESI and IM plans. 17.6% Because of income eligibility Family Income Below Poverty requirements, adult Medi-Cal 40.9% enrollees are more likely to 5.9% have family incomes below 6.9% the poverty level. Also, in Not White part because people with 78.4% disabilities are eligible for 56.2% Medi-Cal coverage, the 51.8% Medi-Cal adult population Less Than High School has poorer health status than 32.7% those with ESI or IM coverage. 7.0% 7.1% Not Employed 39.8% 15.5% 26.0% Noncitizen 26.8% 9.6% 11.1% Note: In general, people who are lawfully present in the US are eligible for full-scope Medi-Cal. They are either considered "qualified" immigrants or individuals who are permanently residing under the color of law. "Qualified" immigrants include lawful permanent residents (or "green card holders"), refugees, asylees, and more. Source: California Health Interview Survey, 2017–18 combined file, weighted to 2018 population. CALIFORNIA HEALTH CARE FOUNDATION 12 Appendix 2. Population Characteristics of Children with Medi-Cal Compared to ESI Health and Socioeconomic Status Differences Across Insurance Types, Children, 0–18, California, 2018 There are important health and socioeconomic differences Medi-Cal ESI between children in Medi-Cal and those with ESI. Fair/Poor Health Because of income eligibility 10.3% requirements, children with 2.8% Medi-Cal were more likely to have family income below the Height and Weight Imply Obesity poverty level. Children with 20.6% Medi-Cal also experienced fair or poor health at higher 10.4% rates than those with ESI Family Income Below Poverty and were more likely to have heights and weights that 42.2% imply obesity. More children 6.0% with Medi-Cal were a race other than White compared to Not White children with ESI. 87.8% As with adults, differences 65.0% in socioeconomic status and health can influence children's Noncitizen access to care and contribute 6.0% to a greater need for care. (The small number of children 2.5% with IM plans in the CHIS sample does not allow for a comparison with children with Medi-Cal.) Source: California Health Interview Survey, 2017–18 combined file, weighted to 2018 population. CALIFORNIA HEALTH CARE FOUNDATION 13 Appendix 3. More Information on Adjustment To account for differences in health status and socioeconomic status between those with Medi-Cal and those with ESI or IM plans, estimates are adjusted for both health care need and socioeconomic status. The predicted percentages are computed from regression models designed to make the individuals in the different insurance groups comparable in terms of their observed health care needs and socioeconomic factors. The models incorporate factors that have been shown to affect an individual's need for health care, including age, gender, health status, presence of chronic conditions, disability status, mental health status, current smoking status for adults, and obesity as well as socioeconomic factors such as family income, race/ethnicity, education, citizenship status, employment status, and household composition. Adjustments used in the regression analysis are limited to measures that are available in the survey and thus may not control for all of the differences between Medi-Cal, ESI, and individual market enrollees. CALIFORNIA HEALTH CARE FOUNDATION 14 About the Authors Ninez Ponce, PhD, MPP, is the director of the UCLA Center for Health Policy Research. Susan Babey, PhD, is a senior research scientist and director of the Chronic Disease Program at the center; Tara Becker, PhD, and A. J. Scheitler, EdD, are senior public administration analysts at the center. Petra W. Rasmussen, PhD, MPH, is an associate policy researcher at the RAND Corporation. Design team at Dennis Johnson Design: Joan Black, Katy Costantinidis, Al B. Goldin, and Dennis Johnson. About the UCLA Center for Health Policy Research The UCLA Center for Health Policy Research is one of the nation's leading health policy research centers. It is the home of the California Health Interview Survey and is affiliated with the UCLA Fielding School of Public Health and Luskin School of Public Affairs. About CHCF 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. CALIFORNIA HEALTH CARE FOUNDATION 15