Though robust Affordable Care Act (ACA) implementation efforts in California have resulted in larger numbers of residents with health care coverage, Californians are now facing coverage-related issues regarding rising costs of care and increasing financial burdens as a result of lack of affordable health care.

In this brief prepared for the California Health Care Foundation (CHCF), SHADAC researchers Colin Planalp, MPA, and Lacey Hartman, MPP, use a multitude of measures from the California Health Insurance Study (CHIS) to measure affordability of health care coverage in California in 2018.

Foundations of Analysis
As found in previous surveys, a number of Californians have reported spending large portions of income on medical bills, with corresponding ramifications such as trouble paying off medical bills, credit card debts, and affording basic necessities such as food and housing. Other consequences, such as skipping or delaying care have also been reported by recent surveys.¹

In order to better understand these affordability issues, SHADAC used 2018 data from the California Health Insurance Study (CHIS), the latest year of available data, to perform an analysis of the following cost-of-care measures:

• Health insurance deductibles
• Trouble paying medical bills - Difficulty paying for basic necessities among those reporting trouble paying medical bills
• Medical bill-related credit card debt

SHADAC examined statistically significant changes over time—between 2013, the last year before ACA implementation in 2014, as well as between 2017 and 2018—and between certain demographic groups and the overall state population.

Key Findings
Deductibles
In 2018, 31% of individuals in California reported a deductible of more than $2,000, which was roughly double the rate of 16% in 2013—a statistically significant difference.² Significant increases in the proportion of California residents with a $2,000 deductible also occurred in key subgroups, including all income levels (up to 138% of FPG, 139% to 249% of FPG, 250% to 399% of FPG, and more than 400% of FPG); Asian, Latin(x), and White Californians; individuals living in both urban and rural areas of the state; and Californians with employer-sponsored insurance (ESI).

Trouble Paying Medical Bills
In 2018, 10% of Californians reported having trouble paying medical bills. Compared to this state average, subgroups reporting a higher percentage of trouble paying medical bills included: individuals with an income level at 139%-249% of Federal Poverty Guidelines (FPG); individuals reporting as multiracial; and uninsured individuals and those with Medicare coverage

Medical Bill-related Burdens
Of those reporting trouble paying medical bills in 2018, 44% said they used credit card debt in order to pay their medical bills. Of that population using credit cards, 35% of people incurring debt of $4,000 or more. Across key subpopulations, those reporting using credit card debt to pay medicals bills at a significantly higher percentage than the statewide average included: individuals with an income level 250% to 399% FPG; White Californians; and those with individual-market coverage. Additionally, the report found a statewide average of 32% of individuals who reported trouble paying medical bills also said those bills caused difficulties affording basic necessities, such as housing and food.

Looking ahead
Though this brief was written before both the arrival of the COVID-19 pandemic and the release of 2019 employer-sponsored insurance (ESI) measures, it is important to note that trends of increasing costs of care and medical bill-related trouble and financial burden found in 2018 are being echoed in data for 2019.

For instance, SHADAC’s recently released annual employer-sponsored insurance report found that Californians experienced significant increases in premiums from 2018 to 2019. Single-coverage premiums rose by $397 from $6,229 to $6,939, and family-coverage premiums rose by $1,221 from $19,567 to $20,788—both of which mark continued concerns around health care affordability for Californians even before the arrival of COVID-19 and our understanding of how that public health crisis will affect these same issues.