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Blog & News
Coverage During a Crisis: Insured Rate for Californians Hits Historic High in First Year of COVID-19 Pandemic (CHCF Cross Post)
September 13, 2023:The following content is cross-posted from California Health Care Foundation. It was first published on January 12, 2022.
Author: Lacey Hartman, Senior Research Fellow, SHADAC
Despite widespread concern that economic fallout from the pandemic could slow California’s progress toward covering the uninsured, more Californians had health insurance coverage than ever before in 2020, according to results from the latest California Health Interview Survey (CHIS). A combination of pre-pandemic state and federal policies that expanded health insurance coverage, along with quick action by policymakers in 2020 to bolster those policies with additional crisis stopgaps, helped protect coverage for many Californians during the pandemic.
In this brief prepared for the California Health Care Foundation (CHCF), SHADAC researcher Lacey Hartman, MPP, provides data from the CHIS about the coverage landscape in California in 2020, highlighting both encouraging trends and persistent disparities that warrant attention, particularly as federal policies that protect coverage connected to the pandemic end or wind down.
Key Findings
- The uninsured rate among the nonelderly California population declined significantly, from 8.4% in 2019 to 7.0% in 2020.
- Rates of uninsured dropped across several population subgroups from 2019 to 2020.
- Californians with incomes up to 138% of the federal poverty guidelines (FPG), dropping from 12.1% to 9.6%. (These are people whose income would make them eligible for Medi-Cal, many through the Affordable Care Act [ACA] expansion of the program.)
Californians who identify as Latinx, from 12.9% in 2019 to 10.5%.- Those residing in rural areas of the state, from 9.6% to 6.4%.
- Adults age 18 to 64, from 10.8% to 9.1%.
- Employer and individual coverage held steady statewide, and increased for some groups.
- The overall statewide rate of employer coverage among the nonelderly was statistically unchanged from 58.8% in 2019 to 60.1% in 2020.
- Employer coverage increased significantly from 59.2% to 60.9% among nonelderly adults, from 62.6% to 64.9% among citizens, and from 20.5% to 24.0% among those with incomes up to 138% FPG.
- Medi-Cal coverage held steady statewide, but declined significantly among Black Californians.
- Medi-Cal coverage held steady between 2019 and 2020, covering roughly one quarter of the nonelderly population.
- Changes by subpopulation were also limited, with the notable exception that the share of Black Californians with Medi-Cal declined from 34.5% in 2019 to 24.0% in 2020, a difference that was statistically significant, and is a continuation of recent trends.
- Despite measurable progress, critical disparities in coverage persist.
- The uninsured rate among Latinx Californians remains almost three times as high as that of their White counterparts (10.5% compared to 3.8%).
- Noncitizen adults are uninsured at more than three times the rate of their citizen counterparts (18.4% compared to 5.6%).
- Californians with lower incomes are more likely to be uninsured than those with incomes above 400% FPG.
Looking Ahead
The state’s robust implementation of the Affordable Care Act and additional state policies over the years, in combination with recent state and federal policies designed to protect against coverage losses during the pandemic, has enabled the rate of coverage among Californians to rise to historic levels, even during a massive public health and economic crisis. However, there is potential for coverage expansion to slow or even reverse as policies that provided robust protection during the pandemic unwind or scale back.
Blog & News
5 States and DC Led the Pack for Per-Capita State Public Health Funding over Past Decade: New Brief Explores Public Health Funding Estimates on State Health Compare
June 8, 2021:
New data collected by the Trust for America’s Health show that most states (43) and the District of Columbia maintained or increased total public health funding levels in FY 2020 amid the COVID-19 public health emergency. However, seven states decreased their total public health funding during this time, and TFAH points out that increases due to state-supported COVID-19 response funding are unlikely to lead to sustained funding growth. It will be important to continue monitoring state funding for public health activities throughout and after the COVID-19 emergency, as these activities have been persistently underfunded over time.1
A new SHADAC brief provides an overview of TFAH’s FY 2020 data on state public health funding--which we standardize to the estimated population of each state to create per-capita estimates--looking at state variation in 2020 and trends over the last decade. SHADAC’s State Health Compare web tool provides access to these per-capita estimates, which are available for data years 2005 through 2020.2
Highlights from the brief are below.
Wide State Variation in Per Capita Public Health Funding Persisted in 2020
As in 2019, there was a wide gap between state public health funding levels among states in 2020, with state-provided funding ranging from $7 per capita in Missouri to $365 per capita in the District of Columbia. While Missouri’s spending held steady at $7 per capita between 2019 and 2020, the District of Columbia increased its funding by $2 per capita and stayed far ahead of the next-highest funding rate of $215 per capita seen in Alaska. Kentucky held the median spot for 2020, spending $36 per person on public health.
Figure 1. Per Person Public Health Funding, 2020
A Handful of States Consistently Near the Top for Public Health Spending
Five states (Alaska, Hawaii, Idaho, New York, and California) and the District of Columbia were consistently among the top 10 for public health funding over the course of the last 10 years (2011 through 2020). Alaska, the District of Columbia, and Hawaii were among the top five for public health spending during each of the last ten years as well, with Alaska and Hawaii each having been the top spending state four times.
A Few States Consistently among Lowest-Ranked for Public Health Spending
There was more movement among the ranks of the states with the lowest public health spending than among the highest-ranking states from 2011 to 2020. Just three states were consistently among the bottom 10 for public health spending during this time: Missouri, Nevada, and Mississippi. Missouri and Nevada were among the bottom five for public health spending during each of the last ten years as well, and each of the two states was the lowest spending state overall five times.
Explore Additional Public Health Data at State Health Compare
Visit State Health Compare to explore national and state-level estimates for the following public health indicators:
- Weight Assessment in Schools
- School Nutrition Standards Stronger than USDA
- School Required to Provide Physical Activity
- Smoke Free Campuses
- Cigarette Tax Rates
State Health Compare also features a number of other indicator categories, including health insurance coverage, cost of care, access to and utilization of care, care quality, health behaviors, health outcomes, and social determinants of health.
1 McKillop, M., & Lieberman, D.A. (May 2021). “The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2021.” Trust for America’s Health Issue Report. Available at https://www.tfah.org/wp-content/uploads/2021/05/2021_PHFunding_Fnl.pdf
2 With the exception of data year 2006, for which no estimates are available.
Publication
50-State Analysis of Drug Overdose Trends: The Evolving Opioid Crisis Across the States (Infographics)
This set of two-page infographics uses estimates from SHADAC’s State Health Compare online data tool to explore the evolving opioid overdose epidemic across all 50 states and the District of Columbia, examining state variation in both the prevalence of opioid deaths and the types of opioids associated with these deaths. Additionally, due to growing concern and evidence that the opioid crisis may be expanding to other non-opioid illicit drugs, we have included data on drug overdose deaths from two types of drugs that are commonly involved in opioid overdoses: cocaine and psychostimulants, such as methamphetamine.
The infographics highlight key findings for trends in drug overdose deaths from 2000-2018, show how each state's overdose rates compare to the national average, and provide a high-level comparison of all 50 states' overdose death rates broken down by each of the five drug types.
Click on a state below to see its two-page infographic or download all state's infographics here.
Explore the drug overdose death data further on State Health Compare.
Further Reading and Resources
The Opioid Epidemic in the United States
SHADAC Resource, March 2020 (Updated)
The Evolving Opioid Epidemic: Observing the Changes in the Opioid Crisis through State-level Data
SHADAC Webinar, September 2019
The Opioid Epidemic: National and State Trends in Opioid-Related Overdose Deaths from 2000 to 2017
SHADAC Briefs, June 2019
Archive: 2000-2017 Evolving Opioid Crisis Infographics
SHADAC Infographics, February 2019
Blog & News
An Updated Brief Examines State Health Compare Estimates on State Funding for Public Health
May 13, 2020:
As states have urgently strategized responses to the sudden arrival of the initial wave of the coronavirus pandemic and begun to prepare for the possibility of a second wave in the fall, states’ per-capita public health funding is a metric that has garnered new attention. Estimates for this measure not only reveal a state’s prioritization of investment in public health infrastructure, but also levels of preparedness for health emergencies such as COVID-19. With this understanding, a number of media outlets have used the public health spending rankings chart provided by SHADAC’s State Health Compare to publish articles which highlight the challenges that states on the lower end of the public health spending spectrum now face in attempting to respond to the COVID-19 crisis.
In light of this information, and with the release of the latest estimates for public health spending for 2019, SHADAC has just recently updated our brief on estimates of state-provided funding for the State Health Compare measure, “Public Health Funding.” Though this updated brief highlights state public health funding data from 2015–2019, data is available on the State Health Compare website for every year, starting in 2005 (with the exception of data year 2006 for which no estimates are available).
The Big Picture: Wide Variation between States
There is a wide gap between state public health funding among states, with 2019 state-provided funding ranging from $7 per capita in Missouri to $363 per capita in the District of Columbia (D.C.). In 2019, the median state, Kentucky spent $35 per capita in public health funding.
Per Person Public Health Funding, 2019
Top States for State Public Health Funding
Eight states occupied the top five funding spots over the course of five years, from 2015 through 2019 (the most recent five years for which data are available): Alaska, D.C., Hawaii, Idaho, New Mexico, New York, North Dakota, and West Virginia. Alaska, D.C., and Hawaii were among the top five states for each of the five years. In 2019, the top five states for per-capita state public health funding were Alaska, D.C., Hawaii, Idaho, and New Mexico.
Bottom States for Public Health Funding
Eight states also occupied the bottom five funding spots at various times over the five-year period (2015 through 2019). Arizona, Indiana, Kansas, Mississippi, Missouri, Nevada, North Carolina, and Ohio moved among the bottom five positions for state-provided public health funding during this time period. Both Missouri and Nevada consistently ranked among the bottom five states for each year of this period. In 2019, the bottom five states with regard to public health spending were: Kansas, Missouri, Nevada, North Carolina, and Ohio.
About the Estimates
Estimates of state funding for public health come from data collected by Trust for America's Health (TFAH), which obtains its calculations using budget documents that are publicly available through state government websites. Depending on which information is available, TFAH uses executive budget documents listing actual expenditures, estimated expenditures, or final appropriates; appropriations bills enacted by the state's legislature; and documents from legislative analysis offices to calculate public health spending. TFAH defines "public health" broadly to include most state-level health funding with the exception of Medicaid, CHIP, or comparable health coverage programs. SHADAC standardizes these estimates of state public health funding to the estimated population of each state to create per-capita estimates.
Why the Variation among States on this Measure?
According to Trust for America's Health, comparisons of public health funding levels across states are difficult because every state allocates and reports its budget in different ways, and states vary widely in the budget details they provide. Non-methodological sources of inter-state variation in state public health funding may also include the relative performance of individual state economies (since state public health funding is often cut during economic downturns) as well as the relative tax bases of individual states along with state population counts.
Explore Additional Public Health Data at State Health Compare
Visit State Health Compare to explore national and state-level estimates for the following public health indicators:
- Weight Assessment in Schools
- School Nutrition Standards Stronger than USDA
- School Required to Provide Physical Activity
- Smoke Free Campuses
- Cigarette Tax Rates
State Health Compare also features a number of other indicator categories, including: health insurance coverage, cost of care, access to and utilization of care, care quality, health behaviors, health outcomes, and social determinants of health.
Publication
Targeting Justice-Involved Populations through 1115 Medicaid Waiver Initiatives: Implementation experiences of three states
New SHADAC Report on States Serving Justice-Involved Populations through Section 1115 Waivers
Under a Research in Transforming Health and Health Care Systems grant from the Robert Wood Johnson Foundation, SHADAC recently conducted a study of the ways in which states are using Section 1115 transformation waivers to test new approaches to serving individuals with criminal justice involvement.1
While each of the three states included in SHADAC’s study (Illinois, Texas, and Washington), faced unique financial, political, and economic dynamics when designing their respective 1115 waivers, states reported several similar factors that drove decisions to include justice-involved initiatives:
1) finding innovative ways to address the opioid crisis; 2) recognition of the justice-involved as a high-need, vulnerable population on which smaller scale initiatives could be piloted; and 3) recognition of justice-involved individuals as an important target for efforts to better integrate primary care and behavioral health.
About the Study
Ten states currently have initiatives targeting individuals with criminal justice involvement in their 1115 waivers, and another five states and Washington, D.C. have pending waivers with justice-involved provisions. States have been successful in using 1115 waivers to provide presumptive eligibility for the justice-involved, to target Medicaid eligibility and services to justice-involved individuals, and to provide transitional care for individuals at re-entry from an institution back into the community.
SHADAC’s study sought to understand how three diverse states—Illinois, Texas, and Washington— approached the development, launch, and ongoing management of their justice-involved programs under Section 1115 waivers. To address these questions, SHADAC reviewed states’ Section 1115 waiver applications, related waiver documentation, relevant grey and peer reviewed literature, and conducted interviews with both state agency and local programmatic staff involved in the implementation of waiver programs across the study states.
Key Report Themes
Interview responses across the three states revealed several key themes as they related to common facilitators and challenges during the waiver implementation process, as well as pros and cons of the waiver itself as a mechanism for transformation.
Successful implementation of justice-involved initiatives in all three study states involved:
- Significant coordination among multiple stakeholders, especially law enforcements
- Drawing on stakeholders’ previous experience with justice-involved grants
- Leveraging existing infrastructure
Stakeholders also reported many similar barriers and challenges in carrying out their work, including:
- Aligning goals of the multiple sectors that interact with justice-involved populations
- Placing culturally competent program staff in criminal justice settings
- Addressing privacy and security concerns related to sharing data among various sectors, and also capabilities of partners to perform data analysis that could prove the value of the work
Some individuals were especially hopeful that investing waiver resources in new infrastructure would help identify and reduce health disparities that have long existed in this population. Stakeholders also felt that 1115 waiver forced their partners to be more collaborative,
The small size of the target population meant that specific justice-involved issues were not necessarily at the forefront of waiver discussions and community partners felt that required waiver reporting was administratively complex and burdensome. Stakeholders also expressed concerns that waiver reimbursement methods and corresponding evaluation metrics wouldn’t adequately reflect the success of a justice-involved initiative.
However, they ultimately felt that efforts to undertake such programs were worthwhile because the waiver expanded access to services that would not otherwise be available to a high-need population.
Looking to the Future
Ensuring the sustainability of any justice-involved initiative implemented under a state’s 1115 waiver was a major focus of all the stakeholders. Stakeholders advocated bringing together multiple parties early and often to discuss sustainability of the project after the waiver ends—including structuring a supportive staffing model, collecting needed data to conduct return-on-investment analyses, securing the participation of other payers, and setting up an adequate reimbursement structure and value-based payment bundles reflective of population needs.
The experiences of stakeholders in Illinois, Texas, and Washington can be helpful to other states as they consider whether to implement programs aimed at individuals involved in the criminal justice system via Section 1115 Medicaid waivers.
[1] Criminal justice-involved individuals include individuals who have recently served sentences in prisons or jails, who are awaiting trial or sentencing, and those under community supervision, such as parole or probation.
