Low-Income Californians and Health Care Selected Findings from the Kaiser Family Foundation/California Health Care Foundation California Health Policy Survey Prepared by: Liz Hamel, Lunna Lopes, Bryan Wu, and Mollyann Brodie Kaiser Family Foundation and Lisa Aliferis, Kristof Stremikis, and Eric Antebi California Health Care Foundation June 2019 Low-Income Californians and Health Care 1 Introduction Despite its large economy, California is also the state with the highest poverty rate (19 percent) according to the U.S. Census Bureau. 1 As Governor Gavin Newsom begins his tenure in office, Californians across income groups see health care as a key issue for the new governor and legislature to address. In late 2018, the Kaiser Family Foundation and the California Health Care Foundation conducted a representative survey of the state’s residents to gauge their views on health policy priorities and their experiences in California’s health care system. This summary examines key findings from the survey among “low-income” Californians, defined here as those whose self-reported incomes are below 200 percent of the federal poverty level (approximately $49,000 for a family of four). Where relevant, they are compared to higher-income Californians — those with self-reported incomes at or above 200 percent of the federal poverty level. Overall, the survey finds that while Californians at all income levels see health care as an important priority for the governor and legislative leaders to work on, health care affordability and access emerge as particularly prominent concerns among low-income residents of the state. Key findings include: Affordability of health care has affected treatment decisions for many low-income Californians, with over half saying that in the past year, they or someone in their family has delayed or forgone some type of medical or dental treatment due to costs. Californians with low incomes are almost twice as likely as higher-income residents to say they have had problems paying medical bills. As a result, many of those who experienced difficulty paying medical bills say they have had to cut back spending in other areas, use savings, or borrow money. Low-income Californians are also more likely than other residents to report nonfinancial barriers to accessing health care, such as long wait times to get an appointment. A majority of Californians with low incomes say their community does not have enough mental health providers, and about four in ten say their community lacks enough primary care doctors and specialists to meet the needs of residents. The distinctive health care experience of low-income Californians is also evident in their attitudes toward Medi-Cal. While overwhelming majorities of Californians across income levels say Medi- Cal is important to the state, low-income Californians are twice as likely as those with higher incomes to say the program is important to them and their families. Low-Income Californians and Health Care 2 Health Care Priorities When asked about a number of health care issues facing the state and its residents, Californians with low incomes say most are important priorities for state political leaders to address. About half of low-income Californians say that it is “extremely important” for the governor and the legislature to work on making sure people with mental health problems can get treatment (51 percent) and to work on making sure all Californians have access to health insurance (49 percent). Nearly half say it is “extremely important” that the governor and legislature work on lowering the amount people pay for health care (46 percent) and on making sure there are enough health care providers across the state (46 percent). Sixteen percent of Californians with low incomes think it is “extremely important” for state leaders to work on decreasing state spending on health care (Figure 1). While ratings of health care priorities are similar across income levels, Californians with low self-reported incomes are more likely than those with higher incomes to say making sure there are enough health care providers across the state should be an “extremely important” priority for state leaders (46 percent versus 33 percent [not shown]). Ranking Of Health Care Priorities Among Low-Income Californians NOTE: Among those with self-reported household incomes below 200% of the Federal Poverty Level. SOURCE: KFF/CHCF California Heath Policy Survey (Nov. 12-Dec. 27, 2018). See topline for full question wording and response options. Figure 1 Percent who say it is extremely importantfor the new California governor and legislature to work on each of these areas within health care in 2019: 51% 49% 46% 46% 41% 39% 33% 16% Making sure people with mental health problems can get treatment Making sure all Californians have access to health insurance Lowering the amount people pay for health care Making sure there are enough health care providers across CA Making information about prices more available to patients Lowering the price of prescription drugs Making sure people with substance use problems can get treatment Decreasing state government spending on health care Low-Income Californians and Health Care 3 Experiences with Health Care Affordability Californians with low incomes are nearly twice as likely as those with higher incomes to say they or a household member had problems paying medical bills in the past 12 months (29 percent versus 15 percent) (Figure 2). Many Californians with low incomes who had problems paying medical bills report having to cut back in other areas, dip into savings, or borrow money to help address their medical costs. Among the 29 percent of low-income Californians who report problems paying medical bills, nearly three-quarters (73 percent) say they have cut spending on household items to pay medical bills. Two-thirds (67 percent) say they used up all or most of their savings and about six in ten say they put off a vacation or major purchase (63 percent) or borrowed money from friends or family (60 percent) (Figure 3). Low-Income Californians More Likely To Report Problems Paying Medical Bills SOURCE: KFF/CHCF California Heath Policy Survey (Nov. 12-Dec. 27, 2018). See topline for full question wording and response options. Figure 2 Percent who say they or a household member had problems paying or an inability to pay any medical billsin the past 12 months: 20% 29% 15% Total Income <200% FPL Income 200%+ FPL Low-Income Californians and Health Care 4 More than half of Californians with low incomes (55 percent) say that they or a family member living in their household delayed or went without some type of medical or dental care in the past year because they had difficulty affording the cost. This compares to 36 percent of those with higher incomes (not shown). Four in ten low-income Californians say someone in their household skipped dental care or checkups, 28 percent say they or a household member put off or postponed getting health care, and about a quarter say someone in their household skipped a recommended test or treatment (24 percent) or did not fill a prescription (24 percent) because of cost (Figure 4). Many Low-Income Californians With Problems Paying Bills Report Cutting Back In Other Areas To Pay Medical Bills SOURCE: KFF/CHCF California Heath Policy Survey (Nov. 12-Dec. 27, 2018). See topline for full question wording and response options. Figure 3 AMONG THE 29% OF LOWER-INCOME CALIFORNIANS WHO REPORTED PROBLEMS PAYING MEDICAL BILLS DURING THE PAST 12 MONTHS:Percent who say they or someone else in their household did each of the following in order to pay medical bills: 73% 67% 63% 60% 54% 46% 37% 31% 28% 25% 20% 4% Cut spending on household items Used up all or most of savings Put off vacation or major household purchases Borrowed money from friends or family Took an extra job or worked more hours Increased credit card debt Changed living situation Sought the aid of a charity or non-profit organization Took money out of long-term savings accounts Borrowed money from a payday lender Took out another type of loan Took out another mortgage on home Low-Income Californians and Health Care 5 Three in four low-income Californians (75 percent) say they are very or somewhat worried about being able to afford unexpected medical bills, outranking other financial worries asked about in the survey, including paying for housing. Nearly seven in ten (68 percent) say they are worried about affording out-of- pocket costs for health care services (Figure 5). Over Half Of Low-Income Californians Report Delaying Care Due To The Cost NOTE: Among those with self-reported household incomes below 200% of the Federal Poverty Level. SOURCE: KFF/CHCF California Heath Policy Survey (Nov. 12-Dec. 27, 2018). See topline for full question wording and response options. Figure 4 Percent who say they or a family member living in their household have done each of the following in the past twelve months because of the cost: 40% 28% 24% 24% 18% 16% 55% Skipped dental care or checkups Put off or postponed getting health care Skipped a recommended medical test or treatment Not filled a prescription for a medicine Cut pills in half or skipped doses of medicine Put off or postponed getting mental health care Experienced any of the above problems Three-Quarters Of Low-Income Californians Worry About Affording Unexpected Medical Bills NOTE: *Item asked of those who have insurance. Among those with self-reported household incomes below 200% of the Federal Poverty Level. SOURCE: KFF/CHCF California Heath Policy Survey (Nov. 12-Dec. 27, 2018). See topline for full question wording and response options. Figure 5 How worriedare you about being able to afford each of the following for you and your family? 51% 41% 48% 44% 36% 33% 26% 24% 29% 22% 24% 29% 24% 26% 12% 15% 10% 14% 17% 19% 18% 13% 14% 19% 17% 16% 23% 26% Unexpected medical bills Gasoline or other transportation costs Rent or mortgage Out-of-pocket costs for health care services Monthly utilities like electricity or heat Prescription drug costs Your monthly health insurance premium* Very worriedSomewhat worriedNot too worriedNot at all worried Low-Income Californians and Health Care 6 Cost concerns are also evident among low-income adults who are uninsured. Among uninsured Californians age 18–64 with low incomes, about half (49 percent) say they have been without health insurance for two years or more, and cost and affordability (28 percent) is the top reason cited for why they lack insurance (Figure 6). Cost Is The Biggest Barrier To Getting Insurance For Low- Income Uninsured Californians NOTE: Among uninsured adults ages 18-64 with self-reported household incomes below 200% of the Federal Poverty Level. SOURCE: KFF/CHCF California Heath Policy Survey (Nov. 12-Dec. 27, 2018). See topline for full question wording and response options. Figure 6 Less than 3 months 10% 3 months to less than a year 15% Don't know/refused 6% 1 year to less than 2 years 20% 2 years or more 49% How long have you been uninsured? What’s the main reason you do not currently have heath insurance? (open-end) 28% 11% 8% 6% 6% 6% Too expensive/can't afford Employment-related reasons Haven't gotten to it/too busy Don’t need it/Don’t want it Can't get it/refused coverage Citizenship/residency issues Low-Income Californians and Health Care 7 Access to Providers A majority of low-income Californians (56 percent) say their community does not have enough mental health care providers to serve the needs of local residents. Those with low incomes are more likely than Californians with higher incomes to say their community does not have enough primary care doctors (41 percent versus 31 percent), specialists (42 percent versus 24 percent), and hospitals (34 percent versus 22 percent) (Figure 7). About half of Californians with low incomes (52 percent) say most people in the state with mental health conditions are not able to get the services they need. A similar share (47 percent) say those with alcohol or drug use problems in California are not able to get needed services (Figure 8). Those With Lower Incomes More Likely To Feel Their Community Lacks Adequate Numbers Of Various Types Of Providers NOTE: *Denotes statistically significant difference between lower-and higher-income California residents. SOURCE: KFF/CHCF California Heath Policy Survey (Nov. 12-Dec. 27, 2018). See topline for full question wording and response options. Figure 7 56% 41% 42% 34% 51% 31% 24% 22% Mental health care providers Primary care doctors* Specialists* Hospitals* Income <200% FPL Income 200%+ FPL Percent who say their community does not have enough …to serve the needs of local residents: Low-Income Californians and Health Care 8 Similar shares of Californians across income levels say they or a family member have sought counseling or treatment for alcohol or drug use (Figure 9). Californians with low incomes are slightly more likely than those with higher incomes to say they or a family member sought counseling or treatment for a mental health condition, such as anxiety or depression, in the past twelve months (29 percent versus 23 percent) (Figure 9). Half Of Low-Income Californians Say State Residents Are Not Able To Access Needed Mental Health, Substance Use Services NOTE: Among those with self-reported household incomes below 200% of the Federal Poverty Level. SOURCE: KFF/CHCF California Heath Policy Survey (Nov. 12-Dec. 27, 2018). See topline for full question wording and response options. Figure 8 Do you think that most people with … in California are able to get the services they need? 42% 43% 52% 47% 6% 10% Mental health conditions Alcohol or drug use problems YesNoDon’t knowNext >