Previous reports show that Los Angeles County has the highest percentage of people without health insurance in California, yet little information is available describing who the uninsured are in Los Angeles, where they live and their access to health care services.1 This information is important because people without health coverage comprise a large proportion of patients in Los Angeles County Department of Health Services (DHS) facilities.2 Many private sector providers also serve large numbers of the uninsured including the county’s Public Private Partners, free and community clinics, some private physician groups, and private hospitals. Because of its role as provider of last resort, the County DHS, along with other safety net providers, must develop systems of care that respond to the health-related needs of the indigent population. Developing effective local policy initiatives requires information about users, as well as potential users of the broader safety net system of care. This report provides a profile of uninsured adults, ages 18 to 64, in Los Angeles County by age, race and ethnicity, family income relative to poverty, work status, and residential location within the county. Also provided is information about access to medical care for uninsured adults. Future reports will focus on insurance coverage for children and the elderly, access barriers, and health status and behaviors. These estimates are derived from a telephone survey of a random sample of 8,004 adults in Los Angeles County conducted in the Spring of 1997 by the Field Research Corporation for the Department of Health Services in conjunction with local universities.
Most Uninsured Are Working Poor And Their Dependents
‹ While the percentage of people uninsured is highest among the unemployed, 88% of the uninsured in Los Angeles are working adults and their dependents.
‹ There are 342,000 part-time workers without health insurance in Los Angeles County.
‹ One-third, or 475,000 adults who are not in the workforce are uninsured; this group is comprised of homemakers, students and others who are dependent on a primary wage earner for income and health insurance coverage.
‹ While the lowest percentage of uninsured is found among those employed full time (27%), these 906,000 workers comprise nearly half of the uninsured in Los Angeles County.
‹ Overall, one million adults in Los Angeles County are working poor—people employed full or part time or their dependents, and who have household incomes less than 200% of the federal poverty level.
‹ Overall, 2.5 million non-elderly adults had at least one episode of being uninsured in the past year.
‹ These data show that of the nearly 2 million uninsured adults, 20% had coverage some time in the past year; the other 80% had been uninsured for a year or more.
‹ An estimated 477,000 people who are currently insured, either privately or under a public program, were without coverage some time in the past year.
‹ Those who purchase insurance independently (20%) and those covered by Medi-Cal (19%) are most likely to have been uninsured in the past year, compared to Medicare beneficiaries and those who get their insurance through their jobs.
Uninsured Have Serious Problems Obtaining Access To Needed Care
‹ Fifty-eight percent of the uninsured, or 1.1 million persons, report that it is somewhat or very
difficult to obtain medical care, compared to 41% of those on Medi-Cal and 24% with
job-based coverage.
‹ Nearly one third of uninsured adults with self-reported diabetes are not under the care
of a physician, a rate almost three times greater than diabetics covered with job-based
insurance or Medi-Cal.
‹ One half of the uninsured have no regular doctor, compared to less than 20% of those
with job-based coverage.
‹ The uninsured are three times as likely as those with job-based coverage to be county
DHS users, although those on Medi-Cal had the highest DHS use rate. This suggests the
critical role DHS and other safety net providers play in assuring access to care for all low-income adults.
‹ Percentages of uninsured are lower among African Americans (26%) and Whites (24%).
‹ The percentage of uninsured adults is highest in the age group 18 to 34 years; young adults comprise over half of the uninsured in Los Angeles County.
‹ Uninsured rates are lower among older adults, although an estimated 288,000 adults 50 to 64 years of age are uninsured.
‹ Sixty percent of uninsured adults, nearly 1.2 million people in Los Angeles County, are medically indigent (they are uninsured and living in households with incomes below 200% of the federal poverty level).3
Uninsured Are Found Throughout Los Angeles County, But Low Income Communities Are More Affected Than Others
‹ Nearly half of adults living in the Metro and South Service Planning Areas (SPAs) are uninsured, one and one-half to two times the rate of other areas in the county.
‹ Large pockets of uninsured adults are also found within other SPAs. For example, there are 115,000 uninsured adults in the East Valley Health District (within the San Fernando Valley SPA); comprising 45% of the adult population in that health district.
‹ In other parts of the county, high uninsured rates are found in the Central (54%), Southeast (50%), Northeast (48%), Southwest (42%) and South (52%) health districts (see map on page 5).
Discussion
Nearly one third of adults under 65 years of age in Los Angeles County do not have health insurance. While lack of health insurance affects all groups, a higher concentration of uninsured adults is found among Latinos, low-income workers, younger adults and those living in the most impoverished communities of the county.
The high percentage of uninsured adults among ethnic groups suggests that many, particularly Latinos, are employed in industries without health coverage as an employee benefit. Therefore, many within these groups are not getting the care they need for themselves or their families.
Employee benefits are less common for part-time workers and low income workers who must either purchase plans on the open market, or go without coverage for themselves or their families. Many people lose health insurance when they change jobs, or when they are no longer enrolled in public assistance programs. The high percentage of uninsured among those who are not in the workforce reflects the lack of dependent coverage in many workplaces in Los Angeles County.
Uninsured adults with lower incomes are likely to have the greatest difficulty obtaining primary or preventive care, are more likely to delay or forgo care, utilize hospital emergency rooms for primary care, and are most likely to use the health care safety net. This may actually increase costs to the county and other providers in the long run. For example, for diabetics, easily accessible primary care can help prevent complications and unnecessary hospitalizations.
While uninsured adults are found in all age groups, younger adults, who are generally healthier, may not perceive the importance of health insurance. Health insurance is particularly important for adults with chronic conditions such as hypertension and diabetes. These conditions are more prevalent among older adults, and insurance reduces barriers to ongoing primary care, specialty and ancillary services, medical devices and pharmaceuticals important for disease management and the prevention of hospitalization.
While large numbers of uninsured adults are found throughout Los Angeles County, the lack of health coverage and other access problems are likely to vary among communities within the county. These data show that rates do vary across Service Planning Areas (SPAs) as well as health districts.
Uninsured adults in Los Angeles County have a greater problem obtaining medical services compared to those with insurance, including Medi-Cal. Without health insurance, many adults do not have access to a range of preventive services that are important for people of all age, ethnic and socio-economic groups. Health insurance is also important for protecting people against the economic consequences of catastrophic illnesses and unintentional injuries.
Several initiatives and programs promise to reduce the number of uninsured people or expand access to health care services. California’s Healthy Families program may cover up to half of the nearly 700,000 uninsured children in the county. The County’s Medicaid Demonstration project (1115 Waiver), provides several opportunities to expand access to care for the medically indigent. The Public Private Partnership program and DHS’ effort to expand its own outpatient capacity will provide the framework for improving access to community based primary care for the medically indigent in Los Angeles County.
These findings suggest the need for additional countywide approaches to reducing the number of uninsured people in Los Angeles County, and improving access to needed primary health care services for this population. This includes strategies for maintaining health insurance for people who lose coverage because they change or lose their jobs, and for expanding coverage among businesses with low wage employees. Also, new and innovative programs could be developed to assist indigent people who have, or who are at risk for, health problems based on their age, ethnicity, health status and area of residence.
Authors
This report was written by Michael R. Cousineau, Dr. PH, University of Southern California and Alicia Kokkinis, MA, Los Angeles County Department of Health Services. Also contributing to this brief were Daniel Gera, Julie Park, Brian Shimabukuro, Mark Wildeman and Jim Wilson.
Acknowledgement is given to Doug Bagley, Connie Diaz, Jonathan Fielding, Janice Gilden, Lucy Johns, Beth Osthimer, Marc Strassburg, Gary Wells, and Toni Yaffe who reviewed earlier versions of this report.
With this issue we inaugurate our L.A. Health series data analysis from DHS sponsored surveys and other sources that provide perspectives on the health of the population of Los Angeles. It is part of our responsibility to assess the changing health of the public, and to present these reports to concerned organizations and citizens. In support of our mission to safeguard and improve the health of all Angelenos, these analyses identify opportunities for our Department, along with community partners and other public agencies, to enhance health through action at the local, state and federal levels.
The information in L.A. Health is derived from the Los Angeles County Health Survey (LAHS), a population-based telephone questionnaire. Data were collected on health status, health risks, attitudes, access to and use of the health services by adults and children. Under the direction of our new Director of Public Health, Jonathan Fielding, MD, MPH, we plan to conduct population health surveys at regular intervals, with the next iteration slated for 1999.
We would like to thank the Los Angeles County residents who voluntarily participated in this survey. Their willingness to confidentially share personal information made LAHS possible.
To request additional copies of this issue, or to be added to our mailing list, please write to:
L.A. County Department of Health Services
L.A. Health Survey, Room 1014
313 North Figueroa Street
Los Angeles, California 90012
We welcome your comments.
Mark Finucane
Director
Los Angeles County Department of Health Services
Over 40% Of Non-elderly Adults In Los Angeles County Have Experienced Uninsured Periods During The Past Year
Uninsured Are Found In All Racial, Income And Age Groups
‹ Los Angeles County is home to over 2.7 million uninsured individuals representing 32% of the county’s population.
‹ Latinos (46%) and Asians (35%) have the highest percentages of uninsured, non-elderly adults.
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‹ A study of the Los Angeles County population conducted in 1997 shows that there are 2.7 million uninsured people in Los Angeles County including 2 million adults 18-64 years of age; 60% are medically indigent (have incomes below 200% of poverty).
‹ There are 477,000 currently insured adults who experienced uninsured periods during the last year. Thus 2.5 million adults were either uninsured at the time of the survey, or uninsured at least once in the past year.
‹ Eighty-eight percent of uninsured adults are working people or are dependents of workers.
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‹ Over half of adults living at or below poverty are uninsured.
‹ One million adults are working poor. This means they are uninsured, full or part-time workers and have incomes at or below 200% of the federal poverty level.
‹ 46% of Latino adults are uninsured.
‹ Over 44% of adults living in the Metro and South Service Planning Areas are uninsured.
‹ Over half of the uninsured report difficulty in obtaining medical care. This is over two times the rate of adults with job-based coverage.
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