VISIT STATE HEALTH COMPARE
Publication
Language Barriers and Health Equity: The Challenges Faced by Californians with Limited English Proficiency (CHCF Cross-Post)
The following is cross-posted from The California Health Care Foundation.
Author: Lacey Hartman, Senior Research Fellow, SHADAC
Key Takeaways
California is home to approximately 2.7 million adults with Limited English Proficiency (LEP), according to the California Health Interview Survey. They face significant health care challenges and disparities:
- Economic and insurance disparities. People with LEP are more likely to have lower incomes, be uninsured, or enrolled in public health insurance programs.
- Health status and discrimination. They often report fair or poor health status, experience discrimination within the health care system, and more likely identify as Latino/x.
- Communication barriers. People with LEP frequently have trouble understanding health care providers and are less likely to access telehealth services or have a usual place to go for care.
- Use of informal interpreters. Among people with LEP, 29% rely on family members or friends for help understanding their doctors, and 23% are unaware of their right to an interpreter.
California has a significant population with limited English proficiency (LEP), composing 25% of people with LEP in the U.S. age five and older. This group typically has less access to health coverage and care, leading to poorer health outcomes, and these challenges are often compounded by systemic racism and discrimination.
This brief uses pooled data from the 2021 and 2022 California Health Interview Survey to provide a comprehensive overview of adults with LEP in California. The data highlight their demographic characteristics, access to care, health outcomes, and communication challenges with health care providers. The brief concludes with policy implications and areas for future research to better support this vulnerable population.
The research showed that on some measures, people with LEP fare the same or better than English-proficient Californians. For example, they are no more likely to have missed a doctor visit in the past year or to have trouble finding a doctor. They are also less likely to delay or go without needed care. These findings suggest a need for further research to fully understand the experiences and barriers faced by those with LEP.
You can read the full brief here or by clicking the image to the right.
Blog & News
California Achieves Lowest Uninsured Rate Ever in 2022 (Cross-Post)
November 13, 2023:The following blog is cross-posted from The California Health Care Foundation.
Author: Lacey Hartman, Senior Research Fellow, SHADAC
Maintaining Gains Hinges on Transitioning People Who Lose Medi-Cal to Other Coverage in Coming Months
The share of Californians under age 65 (“nonelderly”) without health insurance reached a historic low in 2022. Based on the most recent California Health Interview Survey (CHIS), the percentage of nonelderly Californians without health insurance dropped to 6.2% in 2022, a statistically significant decline from 2021 (7.4%). The rate of nonelderly people without coverage for a year or more also reached a historic low in 2022. Commonly called the “long-term uninsured,” their rate dropped from 5.7% in 2021 to 4.5% in 2022, another statistically significant decline.
Disparities in Coverage by Race and Ethnicity Narrow, but Inequities Persist
California’s Latino/x population experienced the largest improvement in coverage between 2021 and 2022; the share who reported being uninsured at the time of the survey dropped from 11.4% in 2021 to 9.1% in 2022, a change that was statistically significant. The Latino/x rate in 2022 also represents a historic low for this group.
The uninsured rate for White Californians also declined by a statistically significant but smaller amount, from 3.6% to 2.8%. There were no other statistically significant changes between 2021 and 2022 by race/ethnicity. Although there have been important gains in narrowing disparities in coverage by race and ethnicity in the state, Latino/x Californians continue to be uninsured at rates triple that of their White counterparts. Black and Asian Californians are uninsured at twice the rate of White Californians. Due to small sample sizes for American Indians and Native Hawaiian / Pacific Islanders in the survey, it was not possible to produce reliable uninsured rates for those groups.
Discussion
The fact that fewer nonelderly Californians were without coverage in 2022 than ever before is clearly good news. However, in 2023, the federal continuous coverage requirement for Medicaid came to an end. It’s estimated that as many as 2–3 million Californians may leave Medi-Cal as a result. How many Californians ultimately lose their Medi-Cal coverage and whether those leaving the program get connected to other coverage will have a huge impact on the state’s uninsured rate going forward.
These issues — as well as other challenges, such as inflation — may make holding onto California’s coverage gains difficult in the coming years. It will be vital to continue monitoring data from 2023 and future years to fully understand the impact of the pandemic — and the end of associated coverage protections, as well as other policy changes — on California’s health coverage landscape.
Publication
Did Disparities in Access Worsen During the Pandemic? (CHCF Brief)
The following content is cross-posted from California Health Care Foundation
Author: Lacey Hartman, SHADAC
Previous research has shown that Medi-Cal enrollees fare worse in accessing health care than Californians with employer coverage. A key question is whether and how access to care shifted during the pandemic for the two groups. For example, did existing differences in access worsen or improve? Have new access challenges emerged for those with Medi-Cal, compared to those with employer coverage?
To answer these questions, authors of a new CHCF brief compared data from the 2017–18 and 2020–21 California Health Interview Survey (CHIS). Separate analyses were done for adults and children.
Key findings include:
- Data show that the pandemic did not widen differences in access to care for people with Medi-Cal coverage compared to those with employer coverage. This held true for both adults and children.
- Rather, among adults, there was some narrowing of differences on select measures. However, this is not a positive development, as it appears to have been caused by worsening access to care for adults with employer-sponsored insurance coverage during the pandemic rather than improvements for adults with Medi-Cal.
Authors note that a key issue going forward is how the end of the federal Medicaid continuous coverage requirement will impact access to care among Californians.
Blog & News
Telehealth Use and Experiences Among California Adults (CHCF Brief)
September 12, 2023:The following content is cross-posted from the California Health Care Foundation (CHCF).
Author: Lacey Hartman, Senior Research Fellow, State Health Access Data Assistance Center
California’s Medi-Cal program is leveraging telehealth to meet patient needs. Many of the telehealth coverage and reimbursement flexibilities enacted during the pandemic were made permanent in 2022, including payment parity for services provided in person or by telehealth. With the end of the public health emergency, there are important questions about how telehealth is being used to meet patients’ needs and which flexibilities should remain in place over the long term.
This CHCF issue brief authored by SHADAC's Senior Research Fellow Lacey Hartman, uses data from the 2021 California Health Interview Survey (CHIS) to explore how telehealth use varies across subpopulations of adults in the state and reports how people rate their telehealth experience compared to in-person care. The brief concludes with a discussion of potential policy implications of the findings, and areas for future data collection and research.
Key findings:
- Telehealth use varies by coverage type, race/ethnicity, and language
- People on Medi-Cal use less telehealth
- Less English proficiency is associated with less telehealth use
- Black Californians are more likely to use telehealth
- Most Californians who use telehealth like it as much as or better than in-person care
Our findings suggest that telehealth use follows the variation in the use of doctor visits overall. People who report more doctor visits also tend to use more telehealth, and people less likely to go to the doctor also tend to use less telehealth, with some important exceptions, including by coverage type, race/ethnicity, and language. Often, telehealth does not exacerbate overall disparities in health care access. However, while many people report that telehealth improves access to care, more telehealth use did not eliminate access to care disparities at the population level during the pandemic. The likely cause is the persistence of structural barriers, such as limited provider availability, even as telehealth use has grown.
Publication
Opportunities to Learn More About Serving Justice-Involved Individuals Through 1115 Demonstration Evaluations
Medicaid is a vital source of coverage for the almost four million justice-involved individuals living in the community – individuals who are disproportionately poor and people of color. Upon release from prison or jail, many of these individuals face significant obstacles navigating and accessing medical and behavioral health care services. Therefore, many state Medicaid programs, as well as the federal government, are looking at ways to improve continuity of coverage, provide seamless transitions back to the community, and reduce disparities in health care access. A major obstacle states face in trying to improve access to care for justice-involved individuals is the Medicaid inmate exclusion policy – a provision in the Social Security Act Amendments of 1965 that prohibits use of federal Medicaid funds for most health care services during incarceration. One way a growing number of states are trying to support reentry for justice-involved individuals is by providing Medicaid services prior to release from prison or jail through a Section 1115 demonstration waiver. Under Section 1115 of the Social Security Act, states can apply for a waiver to test new policies in their Medicaid program that federal rules typically do not allow.
In April 2023, the Centers for Medicare & Medicaid Services (CMS) issued new guidance outlining opportunities for states to design 1115 demonstration projects to improve care transitions for incarcerated individuals. Before the CMS guidance was released in January 2023, California became the first state to receive 1115 demonstration authority approval to waive the inmate exclusion and provide some Medicaid services in the 90 days pre-release. As of February 2023, an additional fourteen states have pending reentry demonstration proposals before CMS.
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This new issue brief from SHADAC researchers, funded by the California Health Care Foundation (CHCF), identifies the unique opportunities states should consider when designing evaluation plans specific to their justice-involved populations, provides an overview of justice-involved 1115 demonstration initiatives, and summarizes what is known from existing evaluations of these activities. The brief also identifies a set of opportunities to design robust and equity-focused 1115 demonstration evaluation plans specific to justice-involved populations. Given the complex dynamics, unique obstacles, and varied experiences justice-involved individuals face, a new, more equity-focused evaluation approach is needed. |
Key recommendations for designing a robust and accountable evaluation of justice-involved initiatives.
1. Center the voices of people with lived experience in the evaluation approach
2. Collect robust monitoring data in order to build evidence for a topic where existing knowledge is limited
3. Consider additional meaningful outcome measures outside typical health outcomes
4. Seek to understand the unique experiences of different populations in the data analysis plan in order to address equity
5. Prioritize cross-sector data linkage activities and start planning early
To complete this work, SHADAC researchers reviewed states’ 1115 waiver applications, related CMS guidance and public waiver documentation, relevant grey and peer-reviewed literature, and conducted interviews with 11 key informants with expertise in state Medicaid, federal policy, justice-involved health care, evaluation, and lived experience.
Related Reading:
Targeting Justice-Involved Populations through 1115 Medicaid Waiver Initiatives: State Implementation Experiences (SHADAC)
From Corrections to Community: Reentry Health Care (CHCF Project)
This work is supported by:
