Hartman, Lacey
Senior Research Fellow

p 612-625-0410
e hartm042@umn.edu

Telehealth Use and Experiences Among California Adults (CHCF Brief)

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.

Opportunities to Learn More About Serving Justice-Involved Individuals Through 1115 Demonstration Evaluations

May 2023:

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.

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)

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This work is supported by:

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

California Health Insurance Stable in 2021, but Many Will Need to Switch Coverage Once COVID-19 Pandemic Protections End (CHCF Cross Post)

The following content is cross-posted from California Health Care Foundation published on November 4, 2022.

Authors: Colin Planalp and Lacey Hartman, SHADAC

Employer-sponsored insurance declined significantly; Medi-Cal and individual market coverage held steady

During 2021, the second calendar year of the COVID-19 pandemic, California’s health insurance landscape remained relatively stable. This article focuses exclusively on Californians under age 65, which is the threshold for age-based Medicare coverage, and the coverage rates highlighted below include children except where otherwise specified (i.e., “nonelderly adults”). Based on the 2021 California Health Interview Survey (CHIS), the percentage of Californians under age 65 without health insurance, 7.4% in 2021, was not significantly different from the prior year. There also were no statistically significant changes across demographic groups, including income, age, geography, and race and ethnicity.

Also, the rate of Californians with individual market coverage, 5.9% in 2021, was statistically unchanged from 2020. While the rate of Californians with Medi-Cal coverage (California’s Medicaid program), 26.4% in 2021, appears higher than the 24.8% of 2020, the difference is not statistically significant. That finding contrasts with records from the California Department of Health Care Services, which reported that Medi-Cal enrollment increased by 7.3% (893,552 enrollees) in 2021 for people under age 65, growing from 12,244,085 in December 2020 to 13,137,637 in December 2021.¹

There are multiple potential explanations why survey data on Medi-Cal enrollment may differ from Medi-Cal’s records. Research shows that surveys tend to undercount people enrolled in state Medicaid programs, in part due to people’s confusion over program names and whether they are still enrolled in Medicaid. This second issue, of people being unaware they are still enrolled, may have been exacerbated during the pandemic. A temporary policy, termed “continuous coverage,” prevented enrollees from being disenrolled from Medicaid during the public health emergency, as health coverage has been vital to preserving access to health care. This policy may have resulted in some Californians retaining Medi-Cal coverage they assumed had expired.

Health Insurance in California by Coverage Type, 2013–21

At the same time, the rate of Californians with employer-sponsored insurance (ESI) declined significantly, from 60.1% in 2020 to 57.8% in 2021. The losses in ESI appear to have been offset by increases in Medi-Cal coverage for some key groups. For instance, while ESI rates declined significantly for nonelderly adults (age 18–64), people with moderate incomes (139%–400% of federal poverty level) and Latinx people experienced statistically significant increases in Medi-Cal coverage rates. ²

Although the percentage of Californians without health insurance at a given time was unchanged in 2021, the rate of Californians experiencing long-term uninsurance (for a year or more) rose from 4.8% in 2020 to 5.7% in 2021, a statistically significant increase.

Conclusions and Discussion

Overall, the stability of the state’s health insurance rate can be seen as positive, particularly during the upheaval of the COVID-19 pandemic. Despite massive job losses in 2020, California’s uninsurance rate declined to a historic low in the first year of the pandemic, almost certainly due to federal and state efforts to maintain or improve access to health insurance. The ability for California to hold that low rate of uninsurance into a second volatile year of the pandemic is notable.

There were other measures, however, that indicate California’s coverage landscape shifted slightly since 2020. For instance, the state’s rate of ESI coverage declined significantly in 2021, which would be concerning if it developed into a trend. However, it is important to recognize that in 2020 the portion of Californians with ESI was a high-water mark since full implementation of the Affordable Care Act in 2014, so it could be that the trend of increased ESI in recent years is only moderating.

Another potentially concerning indicator was the increase in California’s rate of long-term uninsurance from 2020 to 2021. But in this case, trend data show that the 2020 long-term uninsurance rate of 4.8% may simply have been an outlier — possibly to due to the pandemic — with the 2021 rate of 5.7% falling back in line with the narrow range of rates between 5.3% and 5.8% for other years since 2016.

Altogether, data from the 2021 CHIS illustrate a surprisingly stable landscape of health insurance coverage. The COVID-19 pandemic — which began in 2020 and continued into 2021 and beyond — had the potential to cause massive losses of health insurance coverage, primarily through declining ESI caused by sharp job losses. But uninsurance rates did not spike, and ESI coverage has not shown dramatic erosion compared to the prepandemic trend.

Even as the pandemic persisted into 2022, many of the government supports that helped people maintain coverage during the crisis have already ended or are expected to sunset soon. For example, the growth of Medi-Cal coverage for key subpopulations during the pandemic is due in large part to the continuous coverage provision associated with the public health emergency, expected to end sometime in 2023. While researchers project that most Californians losing Medi-Cal will be eligible for other types of coverage, as CHCF has written elsewhere, it will be critical to take action to keep enrolled those who continue to be eligible for Medi-Cal, and to connect those who become ineligible to alternative sources of coverage. This — as well as other challenges, such as inflation — may make holding onto California’s coverage gains difficult. To fully understand whether and what kinds of impacts the pandemic triggered in California’s health coverage landscape, it will be vital to continue monitoring data from 2022 and future years.

Notes
¹ Wilson Analytics analysis of “Month of Eligibility, Race/Ethnicity, and Age group, by County, Medi-Cal Certified Eligibility” (Jan. 2010–March 2022), California Health and Human Services Open Data portal.

² Groups typically eligible for Medi-Cal above 138% FPL include children, pregnant women, and some disabled people. However, due to the continuous coverage provision under the federal COVID-19 public health emergency, some whose incomes rose above the 138% threshold may have temporarily retained Medi-Cal coverage, even though they would have lost eligibility under normal circumstances.

Hartman, Lacey
Senior Research Fellow

p 612-625-0410
e hartm042@umn.edu

Coverage During a Crisis: Insured Rate for Californians Hits Historic High in First Year of COVID-19 Pandemic (CHCF Cross Post)

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.

Anticipating COVID-19 Vaccination Challenges through Flu Vaccination Patterns

January 2021:

A new issue brief from SHADAC researchers, funded by the California Health Care Foundation (CHCF), examines flu vaccination rates as the closest possible analog to understanding how the implementation of a widespread coronavirus vaccination campaign will unfold.

Using data from the U.S. Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS) survey, the brief analyzes flu vaccination rates among United States and California adults (age 18 and older). The analysis also includes a breakdown of findings across several demographic categories and by indicators of health and health care access for both California and the U.S. across multiple data years (2017-2019). Estimates for these three years were pooled in order to achieve greater accuracy in measuring data for smaller subgroups.

Key findings from the brief indicate that current flu vaccination rates fall short of the needed targets to reach COVID-19 herd immunity goals not only among the overall population, but also across all subgroups, even those with the highest reported vaccinations (adults age 65 and older), for both California and the U.S. However, understanding the wide variation in reported vaccine rates among subpopulations provides states (such as California) with the ability to identify which groups may be hardest to reach with a COVID-19 vaccine as well as craft strategies and guide outreach to ensure the greatest equity and effectiveness in vaccination efforts.

Click on the image to the right to download the brief, or head to the SHADAC blog to learn more about the key findings of this brief.

SHADAC researchers also developed a set of two-page infographics that explore state-level estimates on flu vaccination rates for adults (age 18+) using data for all 50 states and the District of Columbia (D.C.) from the Behavioral Risk Factor Surveillance System (BRFSS) survey.

This work is supported by the California Health Care Foundation.