Number of Uninsured in Question

The most extensive study ever on the health insurance status of Californians shows that the number of uninsured is significantly lower than what many have long believed based on federal surveys.

The finding that about 4.5 million non-elderly Californians are uninsured--instead of the 6.3 million estimated by the Census Bureau--was heartening to policy analysts and health professionals, some of whom have viewed the widespread lack of health insurance as one of society’s most costly and intractable problems.

But they noted that the number of uninsured still represents a hefty 15% of Californians. The research suggests that the Census Bureau’s national estimate of 14% uninsured may be overstated, but the study’s authors cautioned against extrapolating from a survey of one state that used a different methodology.

The study, portions of which are being released today by the UCLA Center for Health Policy Research, is expected to influence the debate over public and private efforts to aid the uninsured. The $12-million California Health Interview Survey, funded with government and foundation money, has been reviewed by two outside experts.

The immediate effect could come from the way the report is used by budget-strapped policymakers. Advocates for universal health care worry that California’s progress in covering low-income families through government programs such as Medi-Cal will slow if the problem of the uninsured is seen as less urgent.

UCLA’s study shows significant gains in enrolling Californians in Medi-Cal and in Healthy Families, which is geared more toward covering children. These programs were a major factor in the lower-than-expected numbers of uninsured. The study also makes clear that enrollees received more frequent and critical care than uninsured people.

But Gov. Gray Davis’ new budget already has done away with outreach money for these programs and made other changes that are likely to slow, if not reverse, the growth in Medi-Cal and Healthy Families. A spokeswoman at the governor’s office, which was briefed on the study this week, said the state was pleased to have had a role in UCLA’s study but did not comment further. California’s Department of Health Services provided about $3.8 million for the two-year project.

Dr. Robert Ross, chief executive of the California Endowment, a health foundation that helped fund the UCLA research, said this was not the time to be pulling back on efforts that have been working. Though he said it was comforting to learn that “we have less of a road to travel” to solve the uninsured problem, Ross expressed concern that government budget cuts, combined with the sluggish economy and soaring health insurance costs, will lead to a sharp increase in the uninsured.

“We could see these numbers radically shift in the other direction,” he said.

UCLA researchers said that the number of uninsured today probably is higher than 4.5 million, because their survey was conducted last year when the unemployment rate was lower than it is now.

The state’s impending cutbacks will be felt particularly in Los Angeles County, which is proposing deep cuts in its public health system. UCLA’s research confirmed that the county is the epicenter of the uninsured, with about 1.7 million without coverage, reflecting its higher share of people with less income and education and without citizenship or permanent resident status. Statewide, nearly 900,000 people who are uninsured said they did not have green cards.

Researchers interviewed adults and adolescents in more than 55,400 randomly selected homes, about 10 times the sample size of the Census Bureau’s annual survey. Interviews were conducted in six languages and included people who had no telephones in their homes.

Analysts have suspected that the census health insurance data undercounted certain groups, but the magnitude of the difference from the UCLA study was surprising, even when taking into account variations in time frame and methodology.

One key difference is that UCLA’s survey asked people whether they were currently insured, whereas the census asks respondents in March about their insurance coverage in the previous year. Census surveys consistently have reported uninsured rates in the 20% range for California, with the most recent estimate, for the year 2000, at exactly 20%.

The UCLA research also found higher rates of job-based coverage and private insurance in California than did the census report. Census Bureau officials said they could not comment on a study they have not yet reviewed.

National policy experts said that what may be more important than a snapshot of the uninsured population is the trend. Families USA, a consumer group in Washington, has estimated that the number of uninsured nationally rose by 2.2 million last year, to 41 million, as unemployment and insurance costs rose.

In addition to the 4.5 million identified as the core group of uninsured, researchers found that nearly 2 million others in California had temporary lapses in their medical coverage. Separate data on this group suggests that many of them occurred when the workers were between jobs.

UCLA’s study also made a finer distinction, noting that 80% of the core group were chronically uninsured and deserved special attention.

The survey also dispelled what analysts called a myth about the uninsured: that they largely are unemployed or young people who think they don’t need insurance. In fact, only about 10% of the uninsured statewide said they did not believe in health insurance; most said they could not afford to buy insurance or were unable to obtain coverage through their employer.

About 1 in 6 California workers, excluding those self-employed, said their employers do not offer health insurance. The survey shows that the larger the firm, the more likely it is to provide health benefits. But whether workers are offered insurance by their employer is probably more closely linked to their wages, industry and level of unionization.

Griselda Martinez, a 28-year-old mother of two in Pacoima, said her husband has worked full-time for the same construction firm for three years. Yet his employer does not offer coverage, so Martinez and her family don’t have health insurance.

When someone gets sick, the Martinezes go to community clinics or pay cash for doctor visits. In the past, Martinez said, she has gotten some exams and medications when visiting Mexico, where they are cheaper. But sometimes she simply delays care. A couple of years ago, when she was burning up with fever and suffering abdominal pains, she waited three days before her anxious husband finally pushed her to see a doctor.

“I’m trying to stay healthy because I don’t have insurance,” Martinez said.

Latinos in California have the highest uninsured rate, at 28% of the population, contrasted with less than 10% for whites and blacks and 13% for Asian Americans.

Researchers at UCLA said their study underscores the travails of uninsured residents such as the Martinez family.

“One of the things that some policymakers and the public think is that people who have no insurance nevertheless get care,” said E. Richard Brown, director of the UCLA Center for Health Policy Research. “Our data show that’s not true.”

The study found that 26% of uninsured children and adolescents had no usual source of care, but that figure dropped to 6% for those covered by Medi-Cal or Healthy Families.

UCLA researchers said that enrollment in Medi-Cal and Healthy Families grew by more than 500,000 over the 10-month period of their survey last year. But there are an additional 1.1 million uninsured children and adults eligible for these programs who are not enrolled, many because they did not believe they qualified or had never heard of Healthy Families.