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Volume 1
Issue 2 July 1998 |
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One-Fourth of Los Angeles County
Children Are Uninsured And Nearly
One-Third Are Covered By Medi-Cal
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Children without
health insurance face significant barriers to receiving primary health care services.1
This report, based on data from the Los Angeles County Health Survey, provides a profile
of the health insurance status of Los Angeles County children by age, race-ethnicity,
income and area of residence.2 In addition, this report describes the use of health services by children
in Los Angeles County who have no insurance coverage, and the implications for
children’s health status. Because there are limited population-based data on
uninsured children in different areas of Los Angeles County, this information is important
to effectively plan children’s health services under California’s Healthy
Families Program.
Future reports will describe the
health status of children and the financial and non-financial barriers that families in
Los Angeles County face in obtaining health care for their children. |
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1998-Year Of Healthy Children
The Los Angeles County Board of Supervisors
proclaimed 1998 as the Year of Healthy Children and requested the Department of Health
Services (DHS) take the lead in implementing this initiative. As part of its public health
assessment and planning functions, DHS has initiated a series of child health assessment
reports. The first report, Toward Improving the Health and Futures of Los Angeles
Children, released on April 1, 1998, focused on developing a better understanding of
child health. This issue and issue 3 of LA Health, on access barriers to health care
services in the county, represent the second round of child health assessment reports. DHS
plans to publish a final report on all accomplishments and issues regarding the status of
children’s health in the county. Toward Improving the Health and Futures of Los Angeles
Children, released on April 1, 1998, focused on developing a better understanding of
child health. This issue and issue 3 of LA Health, on access barriers to health care
services in the county, represent the second round of child health assessment reports. DHS
plans to publish a final report on all accomplishments and issues regarding the status of
children’s health in the county.
Jonathan Fielding, MD, MPH
Director of Public Health and Health Officer
Los Angeles County Department of Health Services
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Uninsured Children Are Concentrated Among Low Income Families, Latinos And Asians.
Previous reports have shown that Los
Angeles County has the highest percentage of people without health insurance in
California.3 There are an estimated 696,000 uninsured children in the county,
or one-fourth of children under 18.4 Nearly one-third (31%) of children are
covered by Medi-Cal, and 44% have private health insurance through their own employer,
their parents’ employers, or through independently purchased plans (see Figure 1). 1.P. Newcheck, J. Stoddard, D. Hughes and M. Pearl, Health insurance
and access to primary care for children, NEJM, 338(8): 1998.
2.Two geographic areas of the county are used: Service Planning Areas (SPAs) and Health
Districts. SPAs are eight regions of the county each with a total population of
approximately 1.2 million people. They were established by the Children’s Planning
Council and approved by the Board of Supervisors as geographic areas for purposes of
planning in 1993. There are 26 health districts.
3.H. Schauffler, UC Berkeley and E. R. Brown, UCLA, The State of Health Insurance in
California, 1997
4.The estimated percentage of uninsured children is subject to sampling error and could be
as low as 23% and as high as 26%. |
| Note: For easier printing of this whole
article, click here. |
 | p.1 2 3 4 5 6 7 8
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| Percentages
in this report were based on respondent answers and weighted to the most recent data
available for the Los Angeles County population. When possible, data were weighted to the
1996 Current Population Survey data for Los Angeles County. Weighted percentages were
applied to population estimates from the 1996 Current Population Survey. Job based coverage includes insurance that
people receive through employment(or past employment) regardless of who pays for part or
all of the premium. People are also classified as job-based if theyare covered as a
dependent on an employer-based plan. Independent coverage is health insurance purchased
directly from an insurance company or managed care organization. |
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Results of the survey reveal the
following about uninsured children in Los Angeles County:
- There are over 210,000 uninsured children less than 5 years of
age, 295,000 between 5 and 12 and close to 190,000 uninsured adolescents (ages 13-17).
- Eighty-one percent of uninsured children in Los Angeles County
(560,000) are
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FIGURE
1. Current Health Insurance
Status Of Children In Los
Angeles County, 1997 |
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In any survey some degree of error is introduced by the sampling process. This is because
the survey results are not based on a complete census of all potential respondents within
the population. According to statistical theory, 95% of the time, results from the overall
sample would have a sampling error of +/-1.2 percentage points. Because the sample sizes
of subgroups are smaller |
living in families with incomes at or below 200% of federal
poverty level.5
This percentage rises to 90% in some areas of
the county.
- Of the 560,000 uninsured children in indigent families,
314,000 live at or below the federal poverty level, and 246,000 between 100% and 200% of
poverty.
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| than
the overall sample, results based on subgroups have larger sampling errors. For all
estimates reported, standard errors are available. There are many other possible sources
of error in any survey other than sampling variability. Other differences could occur
because of question wording and sequencing, or through errors in sampling, interviewing or
data processing. The survey research professionals working on this study made every effort
to minimize such errors. L.
A. County Board of Supervisors
Gloria Molina
Yvonne Braithwaite Burke
Zev Yaroslavsky
Don Knabe
Michael Antonovich
L. A. County Department of Health Services
Mark Finucane, Director
Nancy Rubin,Chief of Staff
Jonathan Fielding, MD, MPH Director of Public Health and,
Health Officer
Donald C. Thomas, III MD
Associate Director of Health Services,
Clinical and Medical Affairs
313 North Figueroa Street, Room
1014
Los Angeles, CA 90012
Phone: 213/240-7702
Website: www.dhs.co.la.ca.us |
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Within racial and ethnic groups,
percentages of uninsured are highest among Latino (33%) and Asian children (20%). Lower
rates are found among African-American (14%) and white children (10%). See Table 1. The
estimated 556,000 uninsured Latino children account for 8 of every 10 children who have no
health coverage in Los Angeles County. Nearly Half Of
The Uninsured Children In Los Angeles County Are Eligible For But Not Enrolled In
Medi-Cal.
While nearly one-third of all children (851,000) in Los Angeles
County under 18 years of age are covered by Medi-Cal,
5For a family of four, the 1997 federal
proverty level was an annual family income of $16,050; 200% of poverty was $32,100.
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another 314,000 uninsured children may be eligible
for Medi-Cal benefits
based on their income, but are not enrolled.
- Only 57% of children in families with incomes below the federal
poverty
level are covered by Medi-Cal.
- Medi-Cal coverage is highest among African-American (38%) and
Latino children (37%), somewhat lower for Asian children (23%), and lowest among white
children (13%).
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Concentrations Of Uninsured Children And Those
Enrolled In Medi-Cal Are Highest In The South And Metro Service Planning Areas (SPAs) And
The South and Central Health Districts.6
- An estimated one-third of children living in the South (33%) and
Metro (32%) SPAs are uninsured.
- The South (45%) and Metro (46%) SPAs also have the highest
percentage of children covered by Medi-Cal.
- The South health district has the highest estimated percentage of
uninsured children (46%), almost twice the percent in the county as a whole. In contrast,
Pomona (15%), Bellflower (14%), and Whittier (13%) health districts have the lowest
uninsured rates.
- Of the twenty-six health districts in Los Angeles County, those
with the highest percentage of children covered by Medi-Cal include the Southeast (56%)
and Northeast (51%) health districts. The West (16%), Pomona (15%), Torrance (15%), and
Whittier (13%) health districts have the lowest percentage of children covered by Medi-Cal
(see Table 2).
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| Low-Income And Latino Children Are
Least Likely To Have Job-Based Coverage. Children are
less likely than adults to have private coverage, which contributes to the high uninsured
rate for children in Los Angeles County. Overall, only 44% of children in Los Angeles
County are insured privately: 1.16 million are covered through employment (their own, in
the case of some older adolescents, or more commonly, as a dependent on their parents' or
guardians' health. |
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TABLE 1.
Health Insurance Status Of Children (under 18)
By Race And Ethnicity, 1997. |
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White |
African
American |
Latino |
Asian |
Other |
All Children |
| Private |
77% |
48% |
31% |
57% |
77% |
44% |
| Medi-Cal |
13% |
38% |
37% |
23% |
9% |
31% |
| Uninsured |
10% |
14% |
33% |
20% |
13% |
25% |
| Total |
100% |
100% |
100% |
100% |
100% |
100% |
| Note: Percentages may not add to 100% due
to rounding. |
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| 6. While the confidence intervals for these
estimates are wide, they represent the best available data at the SPA and health district
level. |
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TABLE 2.
Estimated Number and Percent of Children, Under 18,
Who Are Uninsured And Covered By Medi-Cal, 1997. |
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Uninsured |
Medi-Cal |
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(+-95% |
Estimated |
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(+-95% |
Estimated |
| Geographic Area |
Percent |
confidence interval)1 |
Number |
Percent |
confidence interval)1 |
Number |
| Los Angeles County |
25% |
(+- 2%) |
696,000 |
31% |
(+- 2%) |
851,000 |
| Antelope Valley2 |
19% |
(+- 12%) |
20,000 |
23% |
(+- 13%) |
24,000 |
| San Fernando Valley |
26% |
(+- 5%) |
122,000 |
25% |
(+- 5%) |
117,000 |
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25% |
(+- 10%) |
28,000 |
29% |
(+- 11%) |
33,000 |
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17% |
(+- 12%) |
11,000 |
23% |
(+- 13%) |
14,000 |
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28% |
(+- 11%) |
32,000 |
18% |
(+- 9%) |
20,000 |
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28% |
(+- 8%) |
52,000 |
27% |
(+- 8%) |
51,000 |
| San Gabriel Valley |
21% |
(+- 5%) |
121,000 |
23% |
(+- 5%) |
132,000 |
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18% |
(+- 9%) |
20,000 |
19% |
(+- 9%) |
21,000 |
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28% |
(+- 10%) |
55,000 |
31% |
(+- 10%) |
61,000 |
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23% |
(+- 11%) |
17,000 |
24% |
(+- 12%) |
19,000 |
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23% |
(+- 16%) |
6,000 |
29% |
(+- 18%) |
7,000 |
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15% |
(+- 7%) |
24,000 |
15% |
(+-7%) |
24,000 |
| Metro |
32% |
(+- 7%) |
100,000 |
46% |
(+- 8%) |
145,000 |
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34% |
(+- 14%) |
31,000 |
46% |
(+- 15%) |
42,000 |
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37% |
(+- 12%) |
34,000 |
39% |
(+- 13%) |
35,000 |
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26% |
(+- 11%) |
35,000 |
51% |
(+- 13%) |
68,000 |
| West2 |
31% |
(+- 12%) |
26,000 |
16% |
(+- 9%) |
13,000 |
| South |
33% |
(+- 7%) |
131,000 |
45% |
(+- 8%) |
180,000 |
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25% |
(+- 14%) |
28,000 |
43% |
(+- 16%) |
47,000 |
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46% |
(+- 14%) |
36,000 |
45% |
(+- 14%) |
35,000 |
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34% |
(+- 18%) |
32,000 |
56% |
(+- 19%) |
52,000 |
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30% |
(+- 11%) |
35,000 |
38% |
(+- 12%) |
45,000 |
| East |
20% |
(+- 5%) |
91,000 |
31% |
(+- 6%) |
137,000 |
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14% |
(+- 7%) |
17,000 |
28% |
(+- 9%) |
34,000 |
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27% |
(+- 15%) |
17,000 |
44% |
(+- 17%) |
28,000 |
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29% |
(+- 10%) |
42,000 |
41% |
(+- 11%) |
60,000 |
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13% |
(+- 9%) |
15,000 |
13% |
(+- 9%) |
16,000 |
| South Bay |
22% |
(+- 5%) |
84,000 |
27% |
(+- 6%) |
102,000 |
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30% |
(+- 14%) |
21,000 |
30% |
(+- 15%) |
21,000 |
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22% |
(+- 10%) |
27,000 |
25% |
(+- 11%) |
31,000 |
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20% |
(+- 9%) |
20,000 |
37% |
(+- 11%) |
38,000 |
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19% |
(+- 9%) |
16,000 |
15% |
(+- 8%) |
12,000 |
| 1. The percentages and
numbers reported reflect the best estimates of uninsured children and those on Medi-Cal in
each SPA and health district. These estimates should not be considered exact population
numbers but, should be used as trend data for planning purposes. The actual percentages
and numbers may be lower or higher based on the confidence interval reported for each
area. We are 95% confident that the actual percentage of uninsured children or children
covered by Medi-Cal in each area is within the range of the confidence interval presented
for that area. 2. The
Antelope Valley and West SPAs each contain only one health district.
Source: Los Angeles County Health
Survey, 1997 |
plans),
and 67,000 are covered under independently purchased plans.
- Twelve percent of children in households with incomes
below the poverty level and 43% of children with incomes between 100% and 200% of poverty
have private coverage.
- Private coverage is highest for white children
(77%) compared to other racial and ethnic groups. Only 31% of Latino children have private
coverage.
Uninsured Children Live In Households Where Working
Parents Do Not Have Dependent Coverage.
- Many children in Los Angeles County are uninsured
because their parents' employers do not offer dependent coverage or they cannot afford to
pay the premium. There are 127,000 children who are uninsured though they live in
households where one or both parents have job-based coverage.
- Over three quarters of these children (98,000) live
in families with incomes below 200% of the federal poverty level (see Figure 2). These
98,000 uninsured children represent close to 20% of all children living in low-income
families where at least one parent has job-based coverage.
Uninsured Children In Los Angeles County Are Not
Receiving Needed Primary And Preventive Care.
- Lack of health insurance creates financial barriers
to health care services. Eighteen percent of uninsured children in Los Angeles County did
not get needed medical care in the past three months. This is nearly twice the percentage
among children covered by Medi-Cal, and six times the percentage among children who are
privately insured.
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"Less
than
half the
children in
Los Angeles
County
have private
health
insurance7" |
- One in five uninsured children has not
had a physician visit in the past year: this is nearly twice the proportion among
privately insured children and three times greater than the proportion among children
covered by Medi-Cal (see Figure 3).
Discussion
Expanding health insurance coverage for
children in Los Angeles County could significantly improve access to preventive services,
including immunizations, child screening, and developmental testing. For children with
health problems, health insurance can assist families in obtaining care in appropriate
primary care settings and reduce reliance on emergency rooms for routine care. Insurance
coverage is also important for assisting families in managing care for children with
chronic illness such as asthma and diabetes. Greater access to health insurance could
improve the overall health status of children and their
families in Los Angeles County. |
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| FIGURE
2. Uninsured Children in Los Angeles County, By Poverty Level, 1997 |
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| 7. Private coverage
includes job-based insurance and plans that families purchase independently. |
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FIGURE 3. Access to Care for
Children
In Los Angeles County, By Insurance Status, 1997 |
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There are several ways to expand insurance coverage. One approach is to
expand Medi-Cal enrollment among children. Over half of uninsured children are living in
households with family incomes below the federal poverty level. While the survey provides
us with no information about the immigration status of these children, many are probably
eligible for Medi-Cal.8 Federal matching funds are now available for outreach
efforts to identify and enroll uninsured children in Medi-Cal and Healthy Families
programs. These outreach efforts could have a significant effect on reducing the number of
uninsured children in the county, particularly in communities with large numbers of
indigent families. The recently enacted
Healthy Families program is another approach to expand |
| coverage for children. Many of the 246,000 uninsured children, whose
family incomes are between 100% and 200% of poverty, are eligible for California’s
Healthy Families program (see sidebar on page 7).9 While eligible children for
Medi-Cal or Healthy Families are found throughout Los Angeles County, outreach efforts are
particularly important in those health districts with large concentrations of medically
indigent children. Schools, day care centers, churches and other community-based
organizations are likely sites for identifying and enrolling eligible children. |
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State and federal
policies are needed to expand job-based coverage for families, particularly dependent
coverage. Public policies might include incentives or requirements for businesses to offer
health insurance for their employees and their families, or to expand existing employee
coverage to dependents. Expanding dependent coverage alone could reduce the number of
uninsured children in Los Angeles County by up to 18%.
In conclusion, expanding health coverage for uninsured children
will reduce financial barriers to health care services, promote appropriate use of
preventive and primary care, and contribute significantly to the improvement in the health
of children and their families in Los Angeles County.
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8. Undocumented immigrants are not
eligible for standard Medi-Cal coverage. The Survey, however, did not ask respondents
about documentation status in reference to immigration so as not to discourage
participation.
9. Children whose parents are covered by job-based insurance may not be eligible for
Healthy Families. |
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Authors
This report was written by Michael R. Cousineau and
Alicia Kokkinis, Los Angeles County Department of Health Services. Also contributing to
this report were Daniel Gera, Janice Gilden, Miya Iwataki, Julie Park, Magda Shaheen,
Brian Shimabukuro and Mark Wildeman. Acknowledgement
is given to Douglas Bagley, Carolyn Clark, Nancy Delgado,Vicki Edwards, Jonathan Fielding,
Leticia Gonzalez, Lucy Johns, Andy Martinez, Arthur Ragazzi, Paul Simon, Marc
Strassburg,Sharon Watson,Gary Wells and Toni Saenz Yaffe who reviewed earlier versions of
this report. |
Healthy Families
President Clinton enacted the State Children’s Health
Insurance Program (SCHIP) in August 1997. This program allocates $20.3 billion over the
next five years to states to provide expanded health coverage for uninsured children
between 100-200% of the federal poverty level (FPL) who are not eligible for Medicaid;
plus $4 billion for expansion of the Medicaid program.
The program requires each state to either expand Medicaid or to
develop a new health insurance program for children. California’s SCHIP program,
Healthy Families, is a health insurance model with a benefit plan equivalent to the
California Public Employees Retirement System (CALPERS) coverage including dental and
vision coverage, with some modifications to make it more child-appropriate. The Healthy
Families Program utilizes a total of $478.7 million to provide services to an estimated
580,000 eligible children, less than half of California’s federal share. |
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California has
also instituted a cost-sharing requirement with monthly premiums of $7 per child, maximum
$14/month for families at 100-149% FPL and $9 per child, maximum $27/month for families at
150-200% FPL. Co-payments are $5 for most outpatient services excluding preventive
services. Los Angeles County DHS’ Community Health Plan (CHP) has been designated as
the Community Provider Plan. Families enrolling in the County’s plan will have
reduced premiums. The success of Healthy Families is
contingent upon outreach and enrollment. Twelve million dollars have been designated for
community-based outreach. A $25 application assistance fee will be paid to organizations
that assist families with enrollment. In order to allow more children to be eligible for
Medi-Cal, the Healthy Families legislation also includes the following changes to
Medi-Cal:
- Increases the income threshold to 100% FPL for children 14-18
years old.
- Waives the asset test for children.
- Allows one month of continuous eligibility for families who no
longer qualify for no-share-of-cost Medi-Cal during their transition into Healthy
Families.
- Directs the California State Department of Health Services to
design a simplified, mail-in Medi-Cal application for children.
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| The
Los Angeles County Health Survey is a population-based telephone survey of 8,004
households in Los Angeles County, examining health and health-related issues of children
and adults. The survey was conducted in the Spring of 1997 by Field Research Corporation
for Los Angeles County Department of Health Services in conjunction with local
universities. The children’s data reported here are derived from interviews with
2,363 parents in households with children. The survey was sponsored by California
Department of Health Services and The California Endowment. |
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- An estimated 25% of all children under 18 years of age (696,000)
in Los Angeles County have no health insurance.
- Nearly one-third of all children (851,000) in Los Angeles County
are covered by Medi-Cal. There are 314,000 uninsured children who may be eligible for some
type of Medi-Cal benefits based on their income.
- Latinos have the highest percentage of children (33%) without
health insurance.
- Of all children living in families with incomes at or below the
poverty level, 31% are uninsured.
- Over two-thirds of uninsured children (560,000) in Los Angeles
County are medically indigent (they live in families with incomes at or below 200% of
poverty).
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- In the South and Metro Service Planning Areas, over three-quarters
of children are either uninsured or covered by Medi-Cal.
- Eighteen percent of uninsured children in Los Angeles County did
not get needed medical care in the past three months: this is nearly twice the percentage
among children covered by Medi-Cal, and six times the percentage among children who are
privately insured.
- Expanding dependent coverage in households where parents have
job-based coverage could reduce the number of uninsured children in Los Angeles County by
up to 18%.
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