Listening to Californians with Low Incomes: How They Experience the Health Care System and What It Means for the Future

To better understand how the COVID-19 pandemic impacted the health and health care experiences of Californians with low incomes, the California Health Care Foundation and NORC at the University of Chicago, a national research organization, conducted a statewide survey of California residents who had received care since March 2019,¹ with an oversampling of residents with low incomes (defined as below 200% of the federal poverty level).²

The survey was conducted in the summer of 2020 and was supplemented with qualitative findings from interviews conducted with 37 survey respondents with low incomes and with 10 health care experts.

Key Findings: Understanding the Impact of the COVID-19 Pandemic

The study found that the pandemic exposed and exacerbated inequities in health, mental health, and health care access for Californians with low incomes, particularly for Californians of color. In addition, the pandemic heightened and increased economic and employment inequalities, placing additional stress on people most likely to experience inequities. Specific findings include these:

Deteriorating Mental Health for Many

The pandemic exerted a significant impact on the mental and emotional health of many Californians with low incomes, especially those who already considered their mental health to be “fair or poor.” More than half of respondents with low incomes (53%) who rated their prepandemic mental health as “fair or poor” reported worse mental health since the start of the pandemic.

“It’s not just regular stress; it starts to deviate into mental health stress. It’s physical on the body. . . . For the portion of the population that I am included in that does have mental health issues already, it’s a double whammy. And to be separated and have loneliness and have that feed into the mental health disease that’s already there just waiting to be fed.”

—24-year-old Latinx resident, Central Coast

Strong Interest in Care for Mental Health Problems

More than two-thirds of respondents with low incomes (68%) who wanted to see a provider during the pandemic wanted care for a mental health problem. This finding reveals both the extent of the pandemic’s negative impact on people’s mental health and indicates that the long-entrenched stigma associated with acknowledging and seeking care for mental health problems may be decreasing.

Pent-Up Demand for Health Care

Many Californians with low incomes have not received needed care or have delayed care since the start of the pandemic. This survey was limited to Californians who had received care since March 2019. However, only 24% reported a problem that they wanted to see a provider for since the start of the pandemic, suggesting many may have been delaying care. Furthermore, among those who wanted to see a provider, many did not receive care for their health problem.

Telehealth a Critical Source of Care

Two-thirds of respondents with low incomes (65%) and three-quarters of respondents of color (76%) who received care during the pandemic received care via telehealth (either phone or video). Among those who received care via telehealth, satisfaction was high, with 70% of respondents with low incomes and 82% of respondents of color with low incomes saying they would likely choose a phone or video visit over an in-person visit in the future.

Experience of Stress Prevalent and Debilitating

Californians with low incomes were more likely to experience pandemic-related stressors than those with higher incomes.³ Ninety-six percent of respondents with low incomes experienced at least one pandemic-related stress. Stress was associated with worsening mental health during the pandemic.

“Inequality is growing. We know that as a result of the pandemic, economic, health, and inequality otherwise, the gap has only widened. The pandemic served as this great magnifier of what was already there. I talk about it as a crisis within a crisis. . . . We should have known it was going to happen because it’s building upon decades, generations of inequities and injustices.”

—Kiran Savage-Sangwan, California Pan-Ethnic Health Network

Looking Forward: Implications for the Future

Interviews with leading health care experts revealed six key themes for how California’s health care system should respond to the lessons learned during the pandemic.

Restructuring payment systems to address health care inequities. Addressing inequities in health and health care access will require changes to policy and to health care payment models. One expert stressed the importance of moving away from fee-for-service payment models toward value-based and place-based contracting to incentivize health care systems to proactively engage high-risk patients in their communities, and to coordinate care and services that address their physical, behavioral, and social needs.

“Equity has to be at the center, not just the way we talk about health care, but the way we deliver health care, the way we pay for health care, and the way in which we hold health systems and payers accountable to deliver care, to make sure that outcomes are delivered well.”

—Dr. Rishi Manchanda, HealthBegins

Expanding access to mental health care and promoting emotional well-being. There is an urgent need to increase access to care for mental health issues. Experts emphasized that mental health services should be integrated into primary care settings and be redesigned to reach people where they are (instead of waiting for them to engage with the system) and to promote mental well-being and prevention. In addition, the mental health workforce needs to be expanded and diversified to better meet the needs of people from different cultural backgrounds. This includes leveraging a community-based workforce to provide outreach to people experiencing mental health issues and expanding the use of nontraditional mental health services such as technology-based supports.

Redefining access to health care. Californians with low incomes need to be brought back into the health care system as soon as possible. Experts recommended leveraging primary care providers, the mass COVID-19 vaccination effort, and community health workers and promotores de salud to reengage patients not only to address existing health issues but also for critical preventive health services, such as screenings and vaccinations for children. These measures should serve as a starting point for reconsidering how California’s health care system ensures convenient and comprehensive access to care in the long term, especially for those with low incomes and for people of color.

Ensuring equitable access to telehealth. The pandemic connected many more Californians to telehealth, and telehealth will continue to play a critical role in the health care system moving forward. However,  investment is needed to ensure that Californians with low incomes have sufficient technology, connectivity, and privacy for effective telehealth visits. While telehealth offers significant benefits, such as requiring less time and hassle to get care and expanding access to linguistically and racially/ethnically diverse providers, all patients should be able to choose whether they receive care in person or via telehealth.

Breaking down data silos in health and social services. Many Californians with low incomes need health care, mental health care, social services, and economic support. Patient needs can be more easily and safely addressed by establishing data systems and structures that enable health care providers to share health information about patients, both between health care delivery systems and between health systems and other types of providers such as jails and prisons or homeless service providers.

Addressing social determinants of health. The study emphasized the importance of social determinants of health, and their impact on the stress and deteriorating health experienced by many Californians with low incomes during the pandemic. Experts universally agreed that addressing these social determinants of health, including housing, food security, and employment, will be critical to reducing inequities in health but cautioned that there are no easy solutions.

1. The survey was limited to Californian residents age 18 to 64 who had received health care between March 2019 and the time of the survey, which was conducted June 24 to August 21, 2020. ↩︎
2. Sixty-eight percent of the sample were residents with low incomes. In 2020 the FPL was $12,760 for a single person and $26,200 for a family of four. ↩︎
3. Respondents were asked if they experienced any of the following COVID-related stresses: concern about the health or well-being of a loved one; affording based needs, such as food, rent, and utilities; children out of school or childcare unavailable; stress in your relationship or marriage; death of a loved one; other stress. ↩︎