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PublicPolicyInstitute ofCaliforniaHealth Insurance,Health Care Use,and Health Statusin Los AngelesCounty Marianne P. BitlerWeiyi Shi

Health Insurance,Health Care Use,and Health Status inLos Angeles County Marianne P. BitlerWeiyi Shi2006

Library of Congress Cataloging-in-Publication DataBitler, Marianne.Health insurance, health care usage, and health status in Los Angeles /Marianne P. Bitler and Weiyi Shi.p. ; cm.Includes bibliographical references.ISBN-13: 978-1-58213-117-7ISBN-10: 1-58213-117-11. Medical care—Utilization—California—Los Angeles. 2. Insurance, Health—California—Los Angeles. 3. Ethnic groups—Medical care—California—LosAngeles. I. Shi, Weiyi. II. Public Policy Institute of California. III. Title.[DNLM: 1. Health Services—utilization—Los Angeles. 2. Emigration andImmigration—Los Angeles—Statistics. 3. Ethnic Groups—Los Angeles—Statistics.4. Health Status—Los Angeles—Statistics. 5. Insurance, Health—utilization—LosAngeles. 6. Medically Uninsured—statistics & numerical data—Los Angeles.W 84 AC2 B624h 2006]RA410.54.C3B58 2006368.38'200979494—dc222006039035Copyright 2006 by Public Policy Institute of CaliforniaAll rights reservedSan Francisco, CAShort sections of text, not to exceed three paragraphs, may be quotedwithout written permission provided that full attribution is given tothe source and the above copyright notice is included.PPIC does not take or support positions on any ballot measure or onany local, state, or federal legislation, nor does it endorse, support, oroppose any political parties or candidates for public office.Research publications reflect the views of the authors and do notnecessarily reflect the views of the staff, officers, or Board of Directorsof the Public Policy Institute of California.

ForewordMany Americans are without health insurance. Others haveinsurance but are vulnerable to the cost of catastrophic events, some lackcoverage because they are unemployed, and still others are uncoveredeven though they hold full-time jobs—sometimes more than one. Thesesimple facts have challenged decisionmakers in Washington andSacramento for well over 30 years.With the nation now approaching 12 million illegal immigrants, theissue of un- or underinsured Americans has reached critical proportions.Meanwhile, Californians have an interest in health insurance not onlybecause so many regions of the state have low-wage workers but alsobecause the cost of providing care to the uninsured inevitably rests withthe county governments and taxpayers of the state.Marianne Bitler and Weiyi Shi have analyzed detailed data on healthinsurance coverage, individual health status, and the use of the healthcare system in Los Angeles County. They investigate three questions:Who has health insurance? How does health care use differ amongresidents in Los Angeles County? And how does health status differacross population groups in the county? Their findings will be ofimmediate benefit to decisionmakers wishing to address the rising cost ofcare in both the public and private sectors.The answer to the first question is not unexpected—Hispanic adultsare much more likely to be uninsured, after accounting for gender andage, than white, black, and Asian adults. Once immigration status istaken into account, however, the difference in coverage rates is greatlyreduced—suggesting that immigration is indeed a factor that will becentral to the resolution of this debate at the national level. In fact, bothdocumented and undocumented immigrants were much more likelythan U.S.-born residents to be uninsured.Perhaps the most surprising finding regarding the use of care is thathospital and emergency room (ER) visits did not differ much by race/iii

ethnicity or immigration status. Some immigrant groups and theirchildren may even have been less likely than other groups to have usedthe hospital or the emergency room. These findings suggest thatconcerns about immigrants and their children disproportionately usinghospitals and ERs may not be well-founded for Los Angeles County.Health status showed the least amount of variation by race/ethnicityand immigration group. However, according to some measures,Hispanic immigrants appeared healthier than U.S.-born residents—forexample, naturalized and undocumented immigrants were less likely thanthe U.S.-born to report high blood pressure, and the documented andundocumented were less likely to report asthma. Although the authorswarn of possible underreporting, these differences are significant enoughto provide useful insights into the health status of the Hispanicimmigrant population in Los Angeles County.As usual, when researchers take a close look at detailed personal andfamily data, simple generalizations melt away and the task of making newpolicy becomes even more challenging. Nevertheless, PPIC has beenproviding decisionmakers with findings like these for over 12 years, andnew policies at the federal, state, and local level have benefited greatlyfrom our efforts. With the coming session of the 110th Congress, theopportunity for improved policies in health insurance is with us again.These findings should help greatly to shape those improvements.David W. LyonPresident and CEOPublic Policy Institute of Californiaiv

SummaryGovernment plays a large role in health care in the United States.More than 40 percent of health care is paid for by federal, state, and localgovernments. The eventual goal of government involvement is tosafeguard people’s health, with the hope of improving the health of allgroups, particularly the least well off. It is a government objective—explicitly articulated in the guidelines for the U.S. Department of Healthand Human Services’ Healthy People 2010 initiative—to eradicateexisting health disparities. Government involvement in health, however,is predominately through the provision of insurance and subsidized care.Research has shown that a considerable amount of variation in healthamong different population groups cannot be explained by differences ininsurance coverage or health care use. However, coverage and use of careare correlated with health for some groups.The government provides or subsidizes health care in two mainways. First, federal, state, and local governments provide public healthinsurance to a number of groups, including the aged, blind, and disabled;low-income women and children; parents of low-income children; andthe medically needy. Second, the government either provides free carethrough publicly owned facilities or subsidizes care via grants to clinicsand payments to hospitals that disproportionately serve the uninsuredand those covered by Medicaid (the public health insurance program forlow-income individuals and the blind or disabled). Given the large costsassociated with public insurance and the public provision andsubsidization of care, it is important for policymakers to have accurateinformation on the health insurance coverage, health care use, and healthstatus of various population groups to inform the development, funding,and targeting of these public expenditures.In this report, we provide information about differences in healthinsurance coverage, health care use and access to a usual source of care,and health status. We look at both children and adults in Los Angelesv

County, whose diverse population likely resembles the futuredemographics of the state and is a large share of California. We payparticular attention to Hispanics, who are a large, heterogeneous, andgrowing part of the state’s population. Because such a large fraction ofHispanics and Californians in general are immigrants, we analyzedifferences in insurance coverage, health care use, and general healthstatus by nativity (born in the United States or elsewhere), by citizenshipfor the foreign-born (naturalized), and by immigration status (amongnoncitizens, documented or undocumented).The ability to differentiate between the undocumented and thedocumented in looking at health outcomes is relatively novel. We canlook separately at adult outcomes for the U.S.-born, naturalized citizens,the documented, and the undocumented. Our data on children allow usto examine families with blended immigration status; that is, we are ableto show differences in health outcomes both for families in which oneparent is undocumented and the children are not U.S. citizens and thusare likely ineligible for public insurance, and for families in which anundocumented parent has children who are U.S. citizens and thus maybe eligible for public insurance if their income is low enough. As debatesover immigration and immigrant status continue, such distinctionsshould help to provide some factual ground for discussing anddetermining public health policies and choices.Key Facts and FindingsWe use a number of data sources and methods to conduct theanalysis for this report but rely primarily on the unique, high-quality,individual-level data available from the Los Angeles Family andNeighborhood Survey (LAFANS). In a series of interviews atrespondents’ homes, LAFANS asked about demographics, healthinsurance coverage, use of care, chronic conditions, and general healthstatus. In-person interviewing was completed during 2000–2001.Race, Ethnicity, and Insurance CoverageWe found extensive differences in insurance coverage betweenHispanics and other groups. Because there are big differences ininsurance coverage (and our other outcomes) by age and gender (e.g.,vi

young adults are less likely than older adults to be insured), we adjustedall of our comparisons to take these differences into account. Havingdone so, we found that Hispanics were much more likely than othergroups to be uninsured. In addition, we found that coverage differencesbetween Hispanics and others were larger when we looked at gaps ininsurance coverage over time. That is, more Hispanics than members ofother groups had been uninsured at some point in the two years beforethe LAFANS interview, and this number was even larger than thenumber of those who were uninsured at the time of the interview. Thisfinding calls attention to the fact that looking at coverage at a singlepoint in time may not reveal the extent to which individuals areuninsured.To further refine our findings on race/ethnicity and insurancecoverage, we explored the effects of a number of individual andneighborhood characteristics. We know that Hispanics differ fromwhites, blacks, and Asians in terms of immigrant status, family income,home ownership, net worth, completed education, and where they live.Thus, some of the differences we see in comparisons that adjust only forage and gender may be related to differences in these or othercharacteristics. As it turns out, immigration status is an important factorin explaining insurance coverage differences between whites andHispanics, for both adults and children. Controlling for immigrationstatus made the Hispanic-white differences disappear for adults andshrink considerably for children.Table S.1 presents how much more or less likely Hispanic, black,and Asian children were to lack insurance, compared to non-Hispanicwhite children. The first column takes into account age and gender, andthe next four columns take into account a number of othercharacteristics. Note that in Table S.1, differences that are statisticallysignificant at the 5 percent level or below are marked with an asterisk.As we can see, Table S.1 shows that Hispanic children were 20percentage points more likely than whites to lack insurance coverage,after controlling for age and gender. They were 15 percentage pointsmore likely than whites to lack insurance after also controlling forparent’s education and 13 percentage points more likely aftervii

Table S.1Percentage by Which Hispanic, Black, and Asian Children in Los AngelesCounty Are More or Less Likely Than Non-Hispanic White Childrento Be Uninsured or to Have Had a Gap in CoverageAdjustment CharacteristicAge, Gender,Parent’s Age, Gender, Age, Gender,Parent’sParent’sEducation,Age, Gender, and Parent’s Education, Education,Age and and Parent’s Immigration and Family and ntage difference between Hispanic children and white childrenUninsured20*15*9*13*14*Gap in coverage28*23*16*20*21*Percentage difference between black children and white childrenUninsured–2–3–4–4–7Gap in coverage–2–2–2–4–7Percentage difference between Asian children and white childrenUninsured–1–1–4–1–4Gap in coverage695117SOURCE: Authors’ calculations from LAFANS.NOTES: Uninsured status is as of the time of the LAFANS interview. Gaps ininsurance coverage include any uninsured periods occurring during the two years beforethe LAFANS interview. Data are weighted. All groups but Hispanics are non-Hispanics.*Significantly different from the value for whites at the 5 percent level ofsignificance or below.controlling for family income along with a parent’s education. Together,a parent’s immigration status and education level had a marked effect onthe insurance coverage differences between white and Hispanic children,dropping that difference to 9 percentage points.The table also shows that a larger share of children had experienced agap in coverage some time over the two years before the LAFANSinterview than were uninsured at the time of the interview. Hispanicchildren were 16 percentage points more likely than white children tohave had a gap in coverage after controlling for immigration status andthe education of a parent (compared to a difference of 9 percentagepoints in the share uninsured with the same controls). In contrast to theviii

findings for Hispanic children, black children were about as likely aswhite children to be uninsured or have a gap in coverage as were Asianchildren.Race, Ethnicity, and the Use of Ambulatory Health CareWe also found some significant differences between Hispanic andwhite adults, both in the use of ambulatory health care (for example,doctor and dentist visits) and in having a usual source of care. Even aftercontrolling for education, we found that Hispanic adults were less likelythan white adults to have seen a doctor or dentist during the year beforethe LAFANS interview. To the extent that the dental visits were forpreventive care, this finding suggests that Hispanic adults have beenmissing recommended care. In addition, there is some evidence thatHispanic adults may also have been less likely than white adults to have ausual source of health care.We also found noteworthy patterns of health care use among blackadults. On average, in Los Angeles County, black and Hispanic adultshave lower socioeconomic status than white adults. But in contrast toHispanic adults, black adults were more likely than whites both to haveseen a doctor in the year before the interview and, in some cases, to havea usual source of care, after adjusting for education and immigrationstatus, income, and other characteristics. These findings were similarwhen comparing blacks and Hispanics, with black adults being morelikely to have used these forms of health care.We found some significant, perhaps surprising, differences betweenHispanic children and others in the use of ambulatory care. Forexample, despite the fact that Hispanic children were less likely thanwhite children to have insurance coverage, they were not significantly lesslikely than white children to have seen a doctor or to have had a checkupin the year before the interview or to have a usual source of care.Hispanic children were less likely than white children to have seen adentist after adjusting for gender and age only. However, this differencegoes away after we adjust for parent’s education alone or for a parent’simmigration status, family income, or family housing assets andnonhousing net worth.ix

Both black and Asian children tended to be more likely than whitechildren to have used any of several forms of health care. Black andAsian children were both about as likely as white children to have seen adentist. Black children were about as likely and Asian children morelikely than white children to have seen a doctor. Both black and Asianchildren were more likely than white children to have gotten a checkupin the year before the interview. These differences were mostlyunchanged after controlling for the immigration status of a parent,family income, net worth, or neighborhood characteristics.Race, Ethnicity, and Health StatusWe examined the prevalence of various doctor-diagnosed chronicconditions in adults and children, in part because health status bearssome relation both to insurance coverage and to health care use.1 Wealso looked at levels of self-rated health for adults and parent-rated healthfor children. We found that differences in prevalence across conditionsfor adults differed among racial and ethnic groups. We also found thatthese differences were often sensitive to our adjustments for individualcharacteristics. For example, we found racial and ethnic differences inasthma prevalence for adults, with Hispanic adults reporting lower levelsof asthma diagnoses. However, these differences go away once weaccount for education and immigration status, family income, assets/networth, or neighborhood characteristics. In addition, we found fewdifferences in self-rated health among adults across race/ethnicity oncewe account for age, gender, education, and the language in which theinterview was conducted.We found fewer differences across racial and ethnic groups indoctor-diagnosed conditions for children. However, we did find racialand ethnic differences in parent-rated general health for children.Parents of black and Hispanic children were considerably less likely thanparents of white children to report that their children were in excellent orvery good health, and these differences remained even after accounting1There is some dispute in the literature about the strength of the ties between healthinsurance, health care use, and health status (e.g., Levy and Meltzer, 2004; McGinnis,Williams-Russo, and Knickman, 2002).x

for parent’s education alone or along with parent’s immigration, familyincome, or comparisons within neighborhoods.Immigration Status, Insurance Coverage, and Health CareUseImmigration status is a strong predictor of insurance coverage andhealth care use. Undocumented adults were by far the most likely to lackinsurance. This finding suggests that expanded outreach related topublic insurance eligibility is unlikely to fully address current Hispanicwhite differences in insurance coverage.Our measures of health care use are also closely tied todocumentation status, with the undocumented much less likely to haveseen a dentist in the year before the interview or to have a usual source ofcare. Figure S.1 presents a comparison of foreign-born and U.S.-bornadults for these two measures, controlling for age, gender, education, andrace/ethnicity. As we can see, documented immigrants were 11percentage points less likely than the U.S.-born to have a usual source ofcare. For the undocumented, the differences were even greater—theywere 20 percentage points less likely than the U.S.-born to have a usualsource of care. Undocumented immigrants were also 15 percentagepoints less likely than the U.S.-born to have seen a dentist during the lastyear.Immigration status comes into play somewhat differently forchildren. Most children in our data were born in the United States.Therefore, we examine children according to the immigration status oftheir primary caregiver (almost always a parent). Among children of theundocumented, we also looked at whether the child was a citizen. Thedistinction between citizen children and noncitizen children isparticularly important when it comes to insurance coverage. Many lowincome citizen children are likely eligible for public health insurance, butmany low-income noncitizen children are not.We found that noncitizen children of an undocumented parent weremuch less likely than children of a U.S.-born parent to have insurancecoverage, both after adjusting for age and gender and after adjustingadditionally for race/ethnicity and a parent’s education. Even afterxi

More entedLess likely–15–20–25Have a usual source of careSaw a dentist last yearSOURCE: Authors’ calculations from LAFANS.NOTES: Usual source of care is as of the time of the LAFANS interview. A dentist visitis any visit occurring during the year before the LAFANS interview. Data have beenadjusted for gender, age, race/ethnicity, and education and are weighted.*Significantly different from the value for U.S.-born adults at the 5 percent level ofsignificance or below.Figure S.1—Percentage by Which Foreign-Born Adults in Los Angeles CountyAre More or Less Likely Than U.S.-Born Adults to Have Had aUsual Source of Care or to Have Had Any Dentist Visitadjusting for all of these factors, the noncitizen children of anundocumented parent were 44 percentage points more likely thanchildren of a U.S.-born parent to be uninsured at the time of theLAFANS interview. Citizen children of an undocumented parent werealso more likely than children of a U.S.-born parent to be uninsured,adjusting only for age and gender. However, they were much morelikely than noncitizen children of an undocumented parent to becovered. After adjusting additionally for a parent’s education andchildren’s race/ethnicity, citizen children of the undocumented were only8 percentage points more likely than children of the U.S.-born to beuninsured. (This finding is significant only at the 10 percent level.)Differences according to immigration status in the use of care weresomewhat less stark. Children with a parent of any immigration statuswere about equally likely to have seen a doctor or to have had a checkupin the year before the interview, adjusting for race/ethnicity and parent’sxii

education. Noncitizen children of an undocumented parent were muchless likely than children of a U.S.-born parent and children of adocumented parent were less likely to have visited a dentist in the yearbefore the interview.Use of Hospitals and Emergency RoomsThere is considerable public policy discussion about immigrant groupsusing emergency rooms (ERs) and hospitals unnecessarily or excessively.There is also concern about the relationship of that use to uncompensatedcare. In fact, a section of the 2003 Medicare Modernization Act (MMA)devotes federal funds to reimbursing states for uncompensated emergencycare given to undocumented aliens.2 The LAFANS data allow us to lookat the overnight use of a hospital at any time in the two years before thesurvey (for adults) and at any visits to an emergency room during the yearbefore the interview (for children). However, we do not know if thesevisits were a form of uncompensated care.Additionally, we cannot assess the cause of these visits. For example,we do not know whether they were for treatment for flare-ups of chronicconditions, such as hypertension or asthma, or for other problems thatwould have been preventable if timely and adequate ambulatory care hadbeen provided. We also do not know whether the visits were for causesthat could have been attended to by ambulatory care providers. Inaddition, it is important to note that different population groups mayhave different levels of general health, suggesting they would havedifferent rates of use of care.That said, we found that the use of hospitals overnight (for adults)and emergency rooms (for children) did not vary much by race/ethnicityor immigration status. If anything, some of the results suggest that somegroups of immigrants and their children were less likely than othergroups to have stayed overnight in the hospital (adults) or have visitedthe emergency room (children). This is true both when we adjust for age2The MMA funds are to reimburse hospitals, physicians, and ambulance services foremergency care required under the Emergency Treatment and Labor Act (EMTALA).EMTALA requires that Medicare-participating hospitals with emergency departmentsscreen any person requesting examination or treatment for the presence of an emergencymedical condition, and stabilize persons with such conditions.xiii

and gender and once we adjust for education or a number of othercharacteristics. These findings suggest that perhaps concerns aboutparticular groups disproportionately using these sources of care may notbe well-founded for Los Angeles County.Figure S.2 shows the percentage by which foreign-born adults wereless likely than U.S. born adults to have had an overnight hospital stay.It also shows the percentage by which children with a foreign-bornparent were less likely than children with a U.S.-born parent to have hadNaturalizedDocumentedUndocumented0Parent naturalizedParent documentedParent undocumented, citizen childParent undocumented, noncitizen child**–1–2Less likely–3–4–5–6–7–8–9Hospital stay, adultsER visit, childrenSOURCE: Authors’ calculations from LAFANS.NOTES: Hospital stays are any stay occurring during the two years before the LAFANSinterview. ER visits are any visit occurring during the year before the LAFANS interview.Data have been adjusted for gender, age, race/ethnicity, and parent’s or adult’s educationand are weighted. Statistics for ER visits are reported according to the Hispanic ethnicityof the child and the immigration status of the parent who is the child’s primary caregiverand for children of an undocumented parent, by whether the child is a citizen.*Significantly different from the value for U.S.-born adults or children with a U.S.-bornparent at the 5 percent level of significance or below.Figure S.2—Percentage by Which Foreign-Born Adults in Los Angeles CountyAre Less Likely Than U.S.-Born Adults to Have Had Any OvernightHospital Stays and by Which Children with a Foreign-BornParent Are Less Likely Than Children with a U.S.-BornParent to Have Had Any ER Visitsxiv

an emergency room visit. For children with an undocumented parent,we show results for both citizen and noncitizen children.We see from the figure that no group of foreign-born adults wassignificantly more likely than U.S.-born adults to have stayed in thehospital overnight. Documented adults were a statistically significant9 percentage points less likely than the U.S.-born to have had anovernight stay. Similarly, no group of children with a foreign-bornparent was more likely—and children of a naturalized parent wereactually less likely—than children with a U.S.-born parent to have hadan ER visit.ConclusionThis report presents an overview of insurance coverage, use of care,and general health status of the population in Los Angeles County. Asour key findings indicate, large racial and ethnic differences exist inhealth insurance coverage and the use of some forms of medical care.Immigration status plays an important part in these differences as well.That said, controlling for other individual characteristics makes many ofthe significant race/ethnicity or immigrant status differences shrink. Inaddition, we found that racial, ethnic, and, in some cases, immigrantstatus differences in our health status measures were smaller than thosefound in our other measures. Because government plays an importantrole in the public provision and subsidization of care in California, aclear need exists for specific information about the populations that mayuse these public services. The large cost of these services, and theirimportance to the public’s overall health, makes this need more pressing.Our findings offer some insight into how particular population groupswere faring in 2000–2001 with regard to several health-related measures.These findings may be of use to policymakers and others interested inpublic health insurance and the public health safety net in Los AngelesCounty.xv

ContentsForeword. iiiSummary.vFigures . xixTables . xxiAcknowledgments. xxiiiAcronyms . xxv1. INTRODUCTION .12. LOS ANGELES COUNTY: CONTEXT AND DATA .53. HEALTH INSURANCE COVERAGE IN LOS ANGELESCOUNTY .Public and Private Health Insurance .Health Insurance and Health Status .Overview of Insurance Coverage.Racial and Ethnic Differences in Insurance Coverage .Hispanics, Immigration Status, and Insurance Coverage .Accounting for Individual and NeighborhoodCharacteristics.Individual Characteristics .Neighborhood Characteristics .Gaps in Insurance Coverage and Other Coverage Spells .Summing Up .4. HEALTH CARE USE AND ACCESS TO A USUALSOURCE OF CARE .Racial and Ethnic Differences in Doctor and Dentist Visitsand Having a Usual Source of Care .Individual and Neighborhood Characteristics .Location, Access, and Use of Care .Use of Hospitals and Emergency Rooms .Summing Up .xvii1314171819212729343742434854606268

5. HEALTH STATUS .Differences in Health Status, by Race and Ethnicity .Differences in Heath Status, by Immigration Status .Accounting for Individual and NeighborhoodCharacteristics.Immigration Status and Other Influential Factors .The Hispanic Health Paradox and Immigrant Selection .Summing Up .7175776. CONCLUSION .8981848587AppendixA. Notes on Data and Methods . 95B. Public Programs Related to Health Care in Los AngelesCounty

Public Policy Institute of California. Health Insurance, . Library of Congress Cataloging-in-Publication Data Bitler, Marianne. Health insurance, health care usage, and health status in Los Angeles / Marianne P. Bitler and