Tag: health insurance

The Uninsured and the Safety Net

Open enrollment in California has ended, and preliminary tallies indicate that more than 3 million Californians will be enrolled in health plans through Covered California or will become new members of the Medi-Cal program. While it is still too soon to tell how many uninsured people have gained coverage, projections suggest about 4 million Californians will still lack health insurance. About 30 percent of these uninsured residents are estimated to be eligible for Medi-Cal and can enroll at any time during the year.

Uninsured residents who are not eligible for ACA coverage because they are undocumented immigrants—and those who did not purchase coverage through Covered California during the open enrollment period—will continue to rely on county programs and safety net providers, such as health clinics and emergency departments (EDs).

Access to these resources varies considerably across the state. Eligibility for indigent programs differs across counties, as there are no state standards for services provided or populations served. For example, most county indigent programs do not cover undocumented immigrants; these residents rely on clinics and EDs, particularly in counties that do not operate public hospital systems. Also, many counties set relatively low income thresholds for their indigent programs, limiting the number of uninsured residents who qualify for services.

Because the Medi-Cal expansion will cover many of the people currently served by county indigent care programs, the state is shifting funds previously allocated to county health programs. This fiscal year, state funding for county health programs was reduced by $300 million (under AB 85); there will be deeper cuts in subsequent years, as more Californians gain insurance coverage. The state will determine future funding reductions in consultation with the counties. In most cases, counties have selected a formula-based approach that accounts for the actual costs and revenues associated with indigent care programs to determine how much funding will be shifted back to the state.

Over the next several years, it will be important to monitor how these and other changes affect both safety net providers—including counties and public hospital systems—and the communities that continue to rely on them for health care.

How Does Access to Care Affect Health?

Enrolling eligible, low-income Californians—including the 1.7 million uninsured projected to be eligible for Medi-Cal—is the focus of Affordable Care Act implementation right now. But in the longer term, there is a bigger question: How will the expansion of Medi-Cal under the Affordable Care Act impact the medical care and health of those who gain coverage?

It may come as a surprise, but the effect of insurance on health care use and outcomes is not well understood. The best recent evidence we have comes from the Oregon Health Insurance Experiment, a collaborative effort among academic researchers and state health department officials to evaluate how access to public insurance affects the health of low-income residents.

Early results from this rigorous study, which began in 2008, indicate that people who gain Medicaid coverage use more health care services—both inpatient and outpatient. The study found improvements in primary care access and significant increases in the use of preventive care such as mammograms and cholesterol screening. Medicaid coverage also reduced observed rates of depression and greatly reduced financial hardships and medical debt. But these positive results were not accompanied by signs of improved physical health outcomes, such as changes in blood pressure or cholesterol levels, and the study found evidence of increased use of emergency rooms among those who gained Medicaid coverage.

Of course, these results are from a short period of time: the first one to two years of coverage. If people are able to maintain coverage and consistent contact with providers, we could see improvements in health outcomes and decreased use of high-cost care settings such as ERs over time.

The good news is that these improvements may have gotten a head start in California.Before this year’s Medi-Cal expansion under the Affordable Care Act, the state expanded access to more services and better coordinated care through county-based programs under a federal waiver designed to prepare California for health care reform. This means that more than 600,000 uninsured residents, who will comprise a large share of new Medi-Cal enrollees this year, were brought into systems of care and already had the opportunity to receive needed services. This could mean that utilization in California will not increase as much as it did in the Oregon experiment. Evaluations of these county-based programs suggest that hospitalizations and ER visits could be reduced, but this will probably take longer than one or two years.

So while there is promising evidence of the benefits expanded Medicaid coverage can offer, including financial protection and increased use of preventive and primary care, it will probably take some time to bring about other desired changes.

Health Care and California’s Undocumented Immigrants

Despite California’s embrace of federal health care reform, millions of Californians are expected to remain uninsured even five years from now. Undocumented immigrants are likely to be a large share of this uninsured group because they are excluded from coverage under the Affordable Care Act. At the state level, legislation has been introduced (SB 1005) to provide subsidized insurance options for all low-income Californians, regardless of immigration status.

California is home to an estimated 2.5 million undocumented immigrants. This population is distributed unevenly around the state, but undocumented immigrants reside in nearly every county. Los Angeles and other Southern California counties have the largest number of undocumented immigrants—nearly a million are estimated to reside in Los Angeles County alone—and this region is projected to have more than 60 percent of uninsured Californians in 2019.

What do we know about how undocumented immigrants use health care today? The limited body of research on health care use among undocumented immigrants finds lower levels of utilization and spending relative to the native born. Despite their limited access to other health care settings, noncitizens are less likely to have recently visited the emergency room than citizens, even when demographic and health factors are taken into account. In part, this is because undocumented immigrants are relatively young and likely to be working, which suggests that they may be healthier than the general population. However, some of these immigrants—particularly farm workers—face heightened health risks.

Without changes in state or federal law, we can expect that undocumented immigrants will continue to rely on the health care safety net—particularly health clinics and hospital emergency departments. Some counties provide services to undocumented immigrants under their indigent care programs—particularly counties that operate public hospital systems— but the majority do not and are not required to do so. Recent PPIC research suggests that California’s network of clinics is well positioned to serve low-income communities, including those with large numbers of undocumented immigrants. About 75 percent of California’s undocumented immigrants live within two miles of a health clinic, although proximity and access varies across counties.

Comprehensive immigration reform at the federal level could improve insurance coverage and access to care in the long-run, but recent proposals have specifically excluded undocumented immigrants on a path to citizenship from federally subsidized coverage. It’s hard to imagine that changing anytime soon. That leaves it up to the state to grapple with health care access for this sizeable group of residents.

Will Uninsured Californians Get Health Care? Most Say Yes

California’s health insurance exchange, Covered California, has enrolled more than 625,000 people under the Affordable Care Act. However, many eligible enrollees have yet to sign up, including a disproportionate share of Latinos. But if residents follow through on the intentions they express in PPIC Statewide Surveys, enrollment should continue to grow for all groups. This is significant because Covered California will need to enroll a broad group of eligible Californians—particularly the young and healthy—to keep premiums low in the future.

In PPIC’s January survey, 72 percent of the uninsured say they will obtain insurance in accordance with the law, up slightly from our December survey (66%). We then combined the two surveys and found that solid majorities of the uninsured in all demographic groups say they plan to sign up, with particularly high numbers in the following groups:

  • Young people: 76 percent of residents ages 18 to 34 plan to enroll in health insurance. Of all the uninsured who say they will do this, 52 percent are in this age group.
  • Latinos: 72 percent say they will enroll. Latinos comprise just 20 percent of current enrollments, but in our survey 61 percent of all those who say they plan to sign up are Latino.
  • Spanish-preferring residents: 70 percent of those who took the survey in Spanish say they will sign up.
  • Lower-income residents: 75 percent of those with annual household incomes under $20,000 say they will obtain insurance. Of those with annual incomes of $20,000 to $40,000, 65 percent plan to enroll.
  • Women: 75 percent plan to enroll.

Chart Sources: PPIC Statewide Surveys, December 2013 and January 2014.