Special Report: The Uninsured

Many Californians lack health insurance for long periods, say UCLA researchers

Often considered a bellwether state in health policy, California is demonstrating the extent of the problem of lack of health insurance, but it also will be seeing how one possible solution could work. A study of the health insurance situation in California by the University of California, Los Angeles (UCLA) Center for Health Policy Research, funded by the California Healthcare Foundation, found that 4.5 million Californians were uninsured for six months or longer in 2001, out of a total 6.3 million who lacked health insurance for all or part of the year.

A total of 3.3 million people were uninsured for longer than a year. Only 15% of the 6.3 million uninsured, less than 1 million people, were uninsured for three months or less. Study author Richard Brown says the lack of health insurance coverage "is a long-term condition for more than 5 million Californians. It has real consequences for their access to health services and for their health."

Pay or play’

Meanwhile, California is implementing the Health Insurance Act of 2003, a "pay-or-play" approach that requires California employers to pay a fee to the state to provide health insurance unless the employer provides coverage, in which case the fee is waived. The legislation was one of the last bills to be signed by Gov. Gray Davis before he had to leave office as a result of the recall election.

Because so-called pay-or-play provisions are one of many that analysts say could address the nation’s overall health insurance problems, attention will be focused on California’s experience with this bill for lessons that can be applied elsewhere.

Some coverage not stable

Mr. Brown’s survey found that some sources of coverage are less stable that others. Among adults and children who were uninsured at the time they were interviewed, 25% had had health insurance coverage during the year but lost it. Some 9.1% of children who were uninsured at the time of the interview had been covered by Medi-Cal, the state’s Medicaid program, but lost it, while 2.3% had been covered by the state’s Healthy Families program, and 10.8% had been covered by job-based insurance before becoming uninsured.

Among adults who were uninsured when interviewed, only 3.6% previously had Medi-Cal and lost it, 7.2% had privately purchased health insurance or some other coverage, and 13.3% had job-based coverage before becoming uninsured. Mr. Brown also found that the probability of retaining coverage throughout the year or lacking coverage for all or part of a year varied considerably depending on age group, income, ethnicity, citizenship status, level of English proficiency, and other social characteristics. The study found:

• Children younger than 12 were least likely to be uninsured all or part of the year, but nearly half were uninsured all year. Young adults ages 18 to 24 were most likely to be uninsured at least some of the year, and half of them were uninsured all year. Their rates of uninsurance decrease throughout adulthood, however.

• Among children in families with income below the federal poverty level, 24.8% were uninsured for all or part of the year, including 14.4% of all poor children who were uninsured all year. In contrast, only 4.5% of children in families with income above 300% of the poverty level were uninsured.

• Among adults with family income below the poverty level, 48.6% were without coverage for some portion of the year, including 33% who were uninsured all year. As with children, among adults with family incomes above 300% of the poverty level, 12% were uninsured for some portion of the year.

• Among children, nearly 25% of Latinos were uninsured at least part of the year, including 13.8% uninsured all year, the highest rate among all ethnic groups. However, only 4.3% of Asian Americans and Pacific Islander children, 6.8% of American Indian/Alaska Native children, and 2.5% of African-American children were uninsured all year.

• Among adults, 43.5% of Latinos were uninsured at least some of the year, including 28.5% who were uninsured the whole year, also the highest rate among all ethnic groups.

• Among noncitizen adults without a "green card," 61.5% were uninsured all or part of the year, including 44.4% who were uninsured all year. Some 40% of noncitizens with a green card were uninsured all or part of the year, including 27% uninsured all year. In contrast, 22.6% of naturalized citizens and 17.6% of U.S.-born citizens were uninsured some part of the year.

• Children whose parents were both born in the United States are least likely to be uninsured for all or part of the year (7.7%). However, 23.4% of children whose parents are noncitizens without a green card and 46.2% of noncitizen children were uninsured all or part of the year, including 34.1% of noncitizen children who were uninsured all year.

• While 19.7% of Californians up to age 64 who speak English very well experienced some period of uninsurance, 44.8% of those with limited English proficiency lacked coverage all or part of the year, including 32.2% who were uninsured all year.

Mr. Brown reports that most of California’s 13.6 million workers (78.6%) were insured continuously in 2001, but nearly 3 million (21.4%) were uninsured for some or all of 2001. More than 1.5 million workers (11%) were uninsured all year.

Disproportionate characteristics

Employees who experience at least some period of uninsurance were found to be disproportionately Latino, with limited English proficiency, single with no children, and have lower household incomes. Stability of coverage also varies significantly by labor market characteristics such as hourly wages, hours of work, size of firm, and industry type. Thus, employees who earn low hourly wages, work less than full time, are employed in smaller firms, and work in certain industries tend to account for a disproportionate share of employees who experience uninsurance all or part of the year.

Are the levels of intermittent coverage reflected in the health status of Californians? Absolutely, according to Mr. Brown. He says that nonelderly adults with all-year Medi-Cal coverage (including a small number in healthy families) reported the worst health status of any group, reflecting Medi-Cal’s role in serving the disabled. Among adult Medi-Cal beneficiaries, 39.6% reported being in fair or poor health, compared to 19.3% of those uninsured part of the year, 27.4% of those who were uninsured the entire year, and less than 11% of those with job-based or privately purchased coverage. Among children, he says, 18.3% of those who were uninsured the entire year were reported to be in fair or poor health, compared to 14% of those uninsured part of the year and those who had Medi-Cal or Healthy Families coverage all year, and less than 5% of those with job-based or privately purchased coverage.

Less likely to have medical home

Mr. Brown’s survey found that Californians who were uninsured all or part of the year were less likely to have a medical home, a usual source of care, were more likely to report experiencing delays in or not getting care, and were less likely to report taking medication for certain chronic conditions compared to those insured all year.

With respect to the relationship of insurance to delays in getting care or not receiving care at all, Mr. Brown reports that just more than 20% of those uninsured part of the year and just less than 20% of those uninsured all year reported delaying or not getting care, compared to less than 14% of those with continuous coverage. Health insurance coverage also was related to whether adults with chronic illnesses were taking prescription medications to help them control their condition. According to the UCLA report, lack of coverage results from not having access to affordable health insurance and has some real consequences for the health of Californians and their access to health services.

There are at least two sources from which relief may be forthcoming, the report says. One is a growing movement at the local level in a number of counties to expand health insurance. Mr. Brown says that such initiatives are targeted at maximizing enrollment of uninsured eligible children into Medi-Cal, Healthy Families, and other programs, and also at expanding coverage options for those who do not qualify for federal and state programs.

Another promising approach

A second promising approach is included in Senate Bill 2, which was signed in October 2003. Mr. Brown says that when it is fully implemented, the legislation will cover 698,000 workers and 372,000 spouses and children who were uninsured in 2001. Of the 4.52 million people who were uninsured at the time they were interviewed for the UCLA survey, 25% or 1.07 million would gain coverage. "The magnitude of the problem of uninsurance and the added burden it places on state and local public resources, as well as on the individuals and families who are directly affected, underscore the urgency of California adopting and implementing policies to provide coverage to all its residents," Mr. Brown says.

(To download the complete report, go to: www.healthpolicy.ucla.edu.)