by Kathleen Scalise
Not only are Californians less likely than the rest of the nation to have health insurance, but a substantial portion of those who do have coverage report serious problems trying to use it over the last year, say researchers at Berkeley and UCLA, who on Jan. 22 released a new comprehensive report on "The State of Health Insurance in California, 1997".
"California's continuing failure to provide accessible and affordable health care coverage to large percentages of the state's residents, and its growing problems with the quality of care provided through managed care have very real and troubling implications for the health of Californians," said Helen Schauffler, associate professor of health policy, director of the Berkeley Health Insurance Policy Program and one of the report's principal authors.
Funded by a grant from the California Wellness Foundation as part of its Work and Health Initiative, the report looks at many aspects of health coverage for Californians under age 65. It found that despite recent reforms, California continues to trail the nation, with 22 percent of the population under the age of 65 lacking insurance as compared to only 18 percent nationally.
At the same time, 42 percent of insured Californians reported problems with their coverage over the last year. These problems included difficulty in getting referrals to specialists, problems with billing or payment, finding their plan does not cover needed care and not receiving care in a timely manner.
"This continuing lack of health insurance, combined with growing concerns over the quality of insurance coverage, not only underscores problems with our health care system but is creating strong public support for fundamental change," said report co-author Professor E. Richard Brown of the UCLA Center for Health Policy Research at the UCLA School of Public Health.
Some regions of the state had dramatically more uninsured people than others. The worst rates were reported in Los Angeles, where more than a third of the city's population had no medical insurance. The report also found those least likely to have health insurance continue to be men aged 19 to 24. Nearly half lack insurance, as do a third of women in the same age group. In both populations, insurance rates climbed significantly with age, reaching a high of 84 percent insured for men in their mid-40s to mid-50s, and subsequently dropping slightly until age 65. Rates for women stabilized near 82 percent from age 35 to 64.
Minorities fared badly, with Latinos the most disadvantaged group. Thirty-five percent are uninsured. Asians and African- Americans had similar health insurance profiles, both seeing a drop in coverage from 1994 to 1996 and winding up with about one-fourth of their population uninsured.
More than eight of 10 of the uninsured (84 percent) are in working families, including 49 percent in families headed by at least one full-time, full-year employee. "These are low- and moderate-income working families and individuals who do not get any coverage through employment, as more affluent workers have come to expect," Brown said.
As for those with insurance, 76 percent of the state reported satisfaction with their coverage, but nearly half had experienced problems in the last 12 months, based on data from the California Managed Health Care Improvement Task Force Survey released this month. Fifty-four percent of Californians agreed with the statement that fundamental or major changes are needed to make the system work better.
For instance, 1.6 million insured Californians reported difficulty obtaining referrals to specialists. This problem was more prevalent in network HMOs without salaried physicians such as Health Net or PacifiCare than in HMOs under the group model, such as Kaiser, or discounted fee-for-service preferred provider organizations such as Blue Cross. Without sufficient access to specialists, Californians reported increased pain and suffering; many said lack of medical attention resulted in permanent disability. The report recommends changing how referrals to specialists are handled in some situations and regulating some of the most problematic insurance strategies, including a payment method called capitation in which financial risk is passed to the doctor.
"While there is much new information in this report, the real news unfortunately is how much things remain the same," said Gary Yates, president and CEO of the California Wellness Foundation. "California continues to trail the nation in providing health coverage to its residents, at great cost to their health and to the health of our communities. California policy makers should act now to address this issue. This report provides critical information that can help to develop effective solutions to meet this challenge and serve as a benchmark from which to measure progress."
One potential bright spot concerns children. Recent federal and state initiatives could improve access to health care for young people in California, of whom 1.7 million now have no insurance. California's new Healthy Families legislation could potentially extend health coverage to 562,000 of these children, while 678,000 uninsured children could be covered by Medi-Cal.
California continues to trail the nation in providing health coverage to its residents, at great cost to their health and to the health of our communities.
"The expansion of health coverage for children through Healthy Families is an important policy achievement and a step in the right direction," said Brown. "But these 1.2 million uninsured children will get coverage from Healthy Families or Medi-Cal only if we really simplify the eligibility process, effectively educate parents and enroll their children."
Other state health care reform this year remained minimal. "All the state did was bring itself into compliance, and not even full compliance, with federal law," added Schauffler. The researchers found the State Legislature introduced nearly 100 separate bills that regulated or provided consumer protection in the managed care industry. According to the report, Governor Wilson signed only one, concerning length of hospital stay following childbirth.
"Recent policy and program changes have failed to address the issue of affordability of insurance or the continued use of health conditions in determining eligibility, thus failing to increase access to insurance coverage for those who need it most-those least able to pay for health services and those in greatest need of health care," said Schauffler.
This report "makes clear there is very little to cheer about in regards to health insurance in California," said Brown. "More than one-fifth of the state's residents, the majority of them full-time workers or members of working families, lack any type of health insurance that provides access to important health services."
"Given the high rate at which Californians are experiencing problems with the health care system and the strong support for fundamental changes evidenced in our research, now is an opportune time for policy makers and health experts to come together to find ways to provide affordable, quality health insurance for Californians," concludes Schauffler.
The report offers several recommendations for improving the accessibility and quality of health insurance-including expanding the Healthy Families program so all Californians to 200 percent of the federal poverty level can purchase insurance-the development of a standard benefit package across all plans for price comparison and the designation of a state-level agency whose sole purpose is to monitor and assess quality of plans.
Other suggestions include giving counties more control over selecting the model of Medi-Cal managed care most appropriate to their situation and strengthening the public health system to ensure that basic health care is available to the remaining uninsured Californians.