Skip Ribbon Commands
Skip to main content
External PublicationKathryn O'Neill

Summary: This report describes characteristics of LGBT adults in California, a population of nearly 1.7 million, in relation to their vulnerability to illness and other health consequences stemming from the COVID-19 pandemic. A separate report examines the vulnerability to economic disruption experienced by LGBT Californians due to efforts to contain COVID-19 (see related link below). Because the data were extracted from the 2015-2018 California Health Interview Survey, the information reported in this report does not reflect recent changes in health related to the COVID-19 pandemic. 

Findings include: 

  • In the four years covered by the survey, 361,000 LGBT adults in California had fair or poor health.
  • 134,000 did not have health insurance.
  • 231,000 had problems paying for their own or a family member’s medical bill.
  • 150,000 had delayed or forgone needed medical care because of cost, lack of insurance, or another insurance-related reason.
  • Many LGBT adult Californians had health conditions which elevate their risk for serious illness from COVID-19.3 
  • Over 500,000 had a history of suicidal ideation.

Report: Health Vulnerabilities to COVID-19 Among LGBT Adults in CaliforniaRelated Report: Economic Vulnerabilities to COVID-19 Among LGBT Adults in CaliforniaCalifornia Health Interview Survey (CHIS)The Williams InstituteN1690
External PublicationKathryn O'Neill

Summary: This report describes characteristics of LGBT adults in California, a population of nearly 1.7 million, in relation to their vulnerability to economic harm from the COVID-19 pandemic. A separate report examines COVID-19 related health vulnerabilities (see related link below). Because the data were pulled from the 2015-2018 California Health Interview Survey (CHIS), the information reported in the report was collected prior to the COVID-19 pandemic and does not reflect recent changes related to COVID-19.

Findings include: 

  • About 612,000 LGBT adults in California were living below 200% of the federal poverty level.
  • Poverty among this group is concentrated among young people and people of color.
  • An estimated 814,000 LGBT Californians were employed in industries that have been heavily impacted by the pandemic. These include health care and social assistance, retail, leisure and hospitality, professional and business services, and construction.
  • An estimated 251,000 were working in highly impacted industries and earned below 200% of the federal poverty line prior to COVID-19.

Report: Economic Vulnerabilities to COVID-19 Among LGBT Adults in CaliforniaRelated Report: Health Vulnerabilities to COVID-19 Among LGBT Adults in CaliforniaCalifornia Health Interview Survey (CHIS)The Williams InstituteN1690
Policy BriefPeggy Toy, MA

Study focus: The proportion of Californians reporting exposure to secondhand smoke (SHS) from tobacco and marijuana and electronic cigarette (e-cigarette) vapor has grown over time, despite an increasing number of smoke-free local laws in the last 10 years. Residents of market-rate, privately owned multi-unit housing (MUH) — e.g., apartments — are particularly at risk of drifting SHS.

Participants: Authors conducted a study of 4,800 tenants and 176 MUH owners in the city of Los Angeles in 2019.

Outcomes studied: Exposure to secondhand smoke in privately owned multi-unit housing, aggregating by race/ethnicity and by whether tenants have children or family members with chronic disease in the household; MUH tenant and owner attitudes toward smoke-free housing policies.

Findings: Forty-nine percent of tenants reported exposure to drifting SHS, including SHS from tobacco (39%), marijuana (36%), and e-cigarettes (9%). Tenants who lived with children and those who had lived or were living with someone who had a chronic health condition were significantly more likely to report exposure to drifting SHS. The vast majority of tenants and owners supported policies that restricted smoking in MUH, with most supporting tobacco and marijuana policies. Yet support for smoke-free policies was mixed with strong concerns about enforcement of such policies.

Findings reveal the high level of SHS in MUH, gaps in existing voluntary smoke-free policies, and the need for a consistent implementation and enforcement plan to prevent exposure to SHS for all Los Angeles residents. 

Policy Brief: Health at Risk: Policies Are Needed to End Cigarette, Marijuana, and E-Cigarette Secondhand Smoke in Multi-Unit Housing in Los AngelesSlides: Social Media Slides for Health at Risk Policy BriefSmokefree Multi-Unit Housing Profile - City of Los AngelesCouncil District 1Council District 2Council District 3Y90YCatherine Yount, MPHYing-Ying Meng, DrPHY507William ZouUCLA study finds overwhelming support for smoke-free policies among L.A. tenants, landlords331UCLA study finds overwhelming support for smoke-free policies among L.A. tenants, landlords
Research ReportLaurel Lucia, MPP

Study focus: Many California workers are at risk of losing their employer-sponsored health coverage when they lose their jobs due to the COVID-19 pandemic. In this data brief, authors from UC Berkeley Center for Labor Research and Education and UCLA Center for Health Policy Research examine which types of health insurance, if any, the workers most at risk of job loss had prior to this crisis. 

Outcomes measured/Methodology: Using data from the 2018 American Community Survey, the authors analyze workers in industries at highest risk of job losses due to the economic fallout related to the coronavirus pandemic and, within those industries, front-line occupations that are likely to be the first to experience job loss. 

Industries studied include restaurants and bars; select retail industries; hotels and other lodging; amusement, gambling, and recreation; performing arts, sports, and museums; landscaping and building services; select other services; employment services; air transportation; and select private passenger transportation. The analysis excludes independent contractors because they are not offered health coverage through their own jobs. The industries studies in this brief accounted for approximately 16 percent of the California workforce in 2018.

Findings: Authors estimate that for every 100,000 California workers losing their jobs due to the pandemic, up to 67,000 workers, spouses, and children are at risk of losing job-based coverage.

Data Brief: Health Coverage of California Workers Most at Risk of Job Loss Due to COVID-19Y944NKevin LeeKen JacobsY132Gerald F. Kominski, PhD
External PublicationNadereh Pourat, PhD

In April 2020, authors asked Whole Person Care (WPC) pilots previously evaluated in “Integrating Health and Human Services In California’s Whole Person Care Medicaid 1115 Waiver Demonstration” to describe whether and how they used WPC partnerships and infrastructure to respond to COVID-19 and whether the COVID-19 pandemic affected WPC implementation. A rating of 1 meant that a pilot did not rely at all on a WPC resource in their COVID-19 response; 5 meant that they relied on that resource to a great extent. Twenty-one of the 26 WPC counties, representing 20 WPC Pilots, responded to our questionnaire between April 7 and April 20, 2020. Their collective responses are summarized in the blog post.

External Blog: How California Counties’ COVID-19 Response Benefited From The “Whole Person Care” ProgramRelated Journal Article: Integrating Health and Human Services in California’s Whole Person Care Medicaid 1115 Waiver DemonstrationY94NEmmeline Chuang, PhDLeigh Ann Haley, MPPY1418
Research ReportGerald F. Kominski, PhD

Study focus: The primary goals of this report are: (1) to update information on the impacts of the Patient Protection and Affordable Care Act (ACA) on rates of uninsurance using the latest data available (from 2018), and (2) to examine disparities from a broad perspective, including some measures that have not received attention in previous studies.

Participants: For most analyses, authors focused on respondents ages 0 to 64, with exceptions depending on nine population characteristics (shown below). Authors used 2008 through 2018 data from the American Community Survey (ACS), a federal annual survey of about 3 million respondents conducted by the U.S. Census Bureau.

Outcomes studied: Each report chapter provides analyses of trends in insurance coverage according to the following population characteristics: (1) State Medicaid expansion status; (2) Education; (3) Housing; (4) Employment; (5) Citizenship; (6) English proficiency; (7) Race/ethnicity; (8) Age; (9) Type of insurance.

Findings: Highlights are detailed at the beginning of each chapter heading and include:

  • Medicaid expansion states had similar improvements in coverage, regardless of when expansion occurred
  • Higher education is associated with substantially lower rates of uninsurance at every income level
  • Individuals whose homes lacked a basic necessity always had higher rates of uninsurance than those with complete housing, regardless of income level or state expansion status
  • Coverage has improved regardless of citizenship status, but 1 in 3 non-citizens remain uninsured
  • Uninsured rates decreased for all racial/ethnic groups, but Hispanics/Latinos and American Indians/Alaska Natives still have the highest uninsured rates 
  • All age groups have lower rates of uninsurance under the ACA, but 19- to 25-year-olds have had the largest gains in coverage
Report: Ten Years of the Affordable Care Act: Major Gains and Ongoing DisparitiesSlides: ACA report chapter slidesClaremont Graduate UniversityHealth Economics and Evaluation Program (HEER)Y144YPetra Rasmussen, MPHChengcheng ZhangN1672Safia HassanNew report highlights lesser known factors that impact insurance rates after ACA330New report highlights lesser known factors that impact insurance rates after ACA
Journal ArticleEmmeline Chuang, PhD

Study focus: This study provides an overview of early progress in and strategies used to implement California’s Whole Person Care (WPC) Pilot Program, a $3 billion Medicaid Section 1115(a) waiver demonstration project focused on improving the integrated delivery of health, behavioral health, and social services for Medicaid beneficiaries who use acute and costly services in multiple service sectors. 

Findings: WPC pilots reported significant progress in developing partnerships, data-sharing infrastructure, and services needed to coordinate care for identified patient populations. The authors also identified major barriers to WPC implementation, such as difficulty identifying and engaging eligible beneficiaries and the lack of affordable housing. Early results from WPC suggest that given adequate financial incentives, systemwide changes needed to facilitate cross-sector integration of care are possible and can be initiated under Medicaid. 

Journal Article: Integrating Health and Human Services in California’s Whole Person Care Medicaid 1115 Waiver DemonstrationRelated Blog Post: How California Counties’ COVID-19 Response Benefited From The “Whole Person Care” ProgramN1615YNadereh Pourat, PhDLeigh Ann Haley, MPPY1418Brenna O'Masta, MPH
External PublicationSarah Alnahari

Study focus: As of March 26, California ranks third in the nation for confirmed COVID-19 cases following Washington and New York. Of the confirmed 4,943 cases and 81 deaths in California, 282 have been diagnosed across the 11 counties in the Central Valley and the Foothills. There is emerging evidence that smokers, former smokers, and children and adults exposed to chronic secondhand smoke are also vulnerable to COVID-19. This report briefly summarizes the emerging literature on COVID-19 and tobacco use and secondhand smoke exposure.

Population focus: Smokers, former smokers, and people exposed to chronic secondhand smoke, with additional attention to the health status of residents in California's Central Valley.

Outcomes studied: Authors discuss the potential effects COVID-19 may have on people with primary and secondary tobacco exposure, especially those with chronic diseases, such as diabetes, asthma and other respiratory problems. Among sources cited in the brief is 2018 California Health Interview Survey (CHIS) smoking rates for Central California counties (Calaveras, Fresno, Kern, King, Madera, Mariposa, Merced, San Joaquin Stanislaus, Tulare, Tuolumne). Also referenced is 2013-14 CHIS data from a Center study, Prediabetes in California: Nearly Half of California Adults on Path to Diabetes.

Findings: Even without a chronic disease diagnosis, it is reasonable to conclude that three distinct mechanisms  suppressing the immune system, increasing susceptibility, and increasing the likelihood that the illness will progress to the most extreme stages  place current and former smokers at greater risk of contracting COVID-19 and experiencing severe outcomes.

Tobacco Control is a Critical Component to COVID-19 ManagementCalifornia Health Interview Survey (CHIS)Prediabetes in California: Nearly Half of California Adults on Path to Diabetes.N1683Net al
Research ReportNadereh Pourat, PhD

California is in the midst of promoting value-based care in its public hospitals under a Section 1115 Medicaid Waiver called Public Hospital Redesign and Incentives in Medi-Cal (PRIME)a waiver overseen by California’s Department of Health Care Services (DHCS). PRIME requires public hospitals to significantly transform their outpatient care delivery, intensify efforts to manage high-risk or high-cost populations, and promote efficient use of resources in outpatient and inpatient settings with the ultimate goals of better care, better health, and lower costs for Medi-Cal and statewide. A total of 54 public hospitals across California have participated in PRIME and have collectively implemented as many as 18 projects and reported on a total of 103  performance metrics.

The interim evaluation of PRIME led by Center’s Associate Director Nadereh Pourat has examined how PRIME projects were implemented by participating hospitals, the challenges they encountered and strategies they used to overcome them, and early outcomes of their efforts. Overall, the results indicated establishment of needed infrastructures such as health information technology and protocols, delivery of care according to evidence-based guidelines, and regular monitoring of efforts to ensure these efforts led to the desired results. Examples of better care outcomes included increased screening for depression and follow up, tobacco assessment and counseling, colorectal cancer screening, and high blood pressure screening and follow up. Examples of improvements in better health included increased number of patients with hypertension control, reduced number of patients whose diabetes was not under control.  

Interim Evaluation of California’s Public Hospital Redesign and Incentives in Medi-Cal (PRIME) ProgramCalifornia Department of Health Care ServicesY94YXiao Chen, PhD Ana E. Martinez, MPHY123Lina Tieu
Policy BriefSteven P. Wallace, PhD

Study focus: Concern has been raised that immigrant populations — particularly Latino — may be less willing than others to participate in the 2020 U.S. census due to federal-level anti-immigrant rhetoric and practices. This brief estimates the dollar amount of health services funding Los Angeles County risks losing from an undercount of immigrants and how many children, students, older adults and families in the county would be affected by the funding loss.

Participants: Authors surveyed 100 county key stakeholders and service providers most likely to be impacted by an undercount.

Outcomes studied: Examines the effect that a 2%, 5%, and 10% undercount of Latino immigrants and U.S.-born Latinos would have on federal funding for Los Angeles County for health care and health promotion services that are provided for everyone in the county. These services include:

  • Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps)
  • Early Head Start home visitation programs for children 0-3
  • Home-delivered meals for seniors
  • Section 8 Housing choice vouchers for low income households
  • Free and reduced-price meals in schools
  • Federally-Qualified Community Health Centers (FQHC)

Findings: Authors estimate from $117 million to $586 million dollars in federal funding could be lost across all programs in the county if Latinos are undercounted by 2% to 10% (up to nearly half a million individuals) in the upcoming census. Estimated effects of such funding loss include cuts of up to 30,000 meals to older adults and the disabled, up to almost 55,000 reduced-price meals to students, and health services for up to nearly 79,000 patients. 

This study is funded in part by the National Center for Advancing Translational Sciences through UCLA CTSI Grant UL1TR001881 and the UCLA Resource Center for Minority Aging Research/Center for Health Improvement of Minority Elderly (RCMAR/CHIME) Grant AG021684.

Policy Brief: Health and Social Service Implications of a Census Undercount in Los AngelesAppendixRelated seminar: “Census Undercount of Latino Immigrants: Impact on Health and Socials Programs in Los Angeles”UCLA Clinical and Translational Science InstituteNational Center for Advancing Translational SciencesY163NAngubeen KhanHomero E. del PinoN1513Census undercount of Latinos could cost L.A. dearly in funds for critical health and social services329Census undercount of Latinos could cost L.A. dearly in funds for critical health and social services
External PublicationTracey Gronniger

Study focus: More than 4 million women in the United States ages 65 and older live in poverty. They are 80% more likely to live in poverty than men. Older women of color are twice as likely as white women to experience poverty. Women who have worked all their lives, both in the workforce and/or as family caregivers, find themselves struggling to meet even their most basic needs as they become older. This report uses a variety of sources, and references the California Elder Index, to analyze the challenges to economic security among older women.

Participants: Women in the United States, ages 65 and older.

Outcomes studied: 

  • Drivers of economic insecurity, including inequitable income, racial and ethnic inequity, long-term unemployment, unpaid caregiving, financial exploitation
  • Lower sources of retirement stability, including debt and lower Social Security benefits, pensions, and homeownership levels  
  • Erosion of wealth and income due to financial shocks such as health care expenses and debt
Findings: These risks can be mitigated through targeted action to help older women build and maintain wealth, plus access available income, as well as through policies and systems changes to prevent older women from falling into poverty when they cannot build sufficient income as they age.

Report: From Surviving to Thriving: Ensuring the Golden Years Remain Golden for Older WomenElder IndexInsight CenterJustice for AgingN1678NAmber Christ
Fact SheetDeborah Freund, PhD

Study focus:  Whether having housing is related to the likelihood of having health insurance coverage.

Participants: Authors use pre-ACA and post-ACA data for people ages 0-64 from the 2013 and 2018 American Community Survey, which contains responses from almost 3 million individuals.

Outcomes studied: Authors compared people ages 0-64 who had complete housing amenities with those who lacked one basic housing necessity. Basic necessities are defined as having a bathtub or shower, a sink with a faucet, a stove or range, and a refrigerator. Data are stratified based on these federal poverty level  (FPL) income categories: <100% FPL; 100-399%; 400 or more FPL.

Findings: Despite declines in uninsurance for all income levels between 2013 and 2018, uninsurance rates for those who had all basic housing necessities were lower and had larger percentage declines compared to those who lacked at least one basic housing necessity, particularly among the two lowest income groups. The findings suggest that having housing that lacks at least one basic necessity is associated with being uninsured.

Fact Sheet: Despite Gains From ACA, Lower Rates of Health Insurance Coverage Persist Among Those Lacking Housing BasicsPress Release: New study shows a link between housing lacking in basic amenities and health insuranceClaremont Graduate UniversityN1671NChengcheng ZhangPetra Rasmussen, MPHY1427Safia Hassan
External PublicationEsi Hutchful

Study focus: The author explores why SSI/SSP is such an important resource for Californians with low incomes -- particularly for older women and people of color -- and why state policymakers should reinvest in the program that helps people pay for their basic needs.

Participants: Disabled and older adult Californians with low incomes. Data from the California Department of Social Services, Social Security Administration data and other sources are used. The Elder IndexTM, a tool refined and disseminated by the UCLA Center for Health Policy Research and the Insight Center for Community Economic Development, is referenced.

Outcomes studied: Labor market inequalities that create challenges to saving for retirement among women and people of color; California's deep reductions to SSI/SSP grants (post- Great Recession), which largely remain in place a decade later.

Findings: SSI/SSP grants are an important source of income. As California’s population ages, it will become even more important for state leaders to promote policies reflecting the needs of an older and more racially diverse state.


External Publication: The SSI/SSP Grant: A Critical Support for Older Women and People of Color in California Left Behind by the Labor Market and State PolicyThe Elder IndexCalifornia Budget & Policy CenterN1677
CHIS Journal ArticleAlexandra C. Adia

​Study focus: Determine the impact of data disaggregation on the ability to identify health disparities and needs for future research of Filipino, Vietnamese, Chinese, Japanese, and Korean adults in California.

Participants: Using available data for the above groups from the 2011-2017 California Health Interview Survey.

Outcomes studied: Authors conducted bivariate and multivariable analyses to assess disparities in health conditions, outcomes, and service access compared with non-Hispanic Whites for Asians as an overall group and for each individual subgroup.

Findings: As an aggregate category, Asians appeared healthier than did non-Hispanic Whites on most indicators. However, every Asian subgroup had at least one disparity disguised by aggregation, with Filipinos having the most disparities. Authors conclude that failure to disaggregate health data for individual Asian subgroups disguises disparities and leads to inaccurate conclusions about needs for interventions and research.

Journal Article: Health Conditions, Outcomes, and Service Access Among Filipino, Vietnamese, Chinese, Japanese, and Korean Adults in California, 2011-2017California Health Interview Survey (CHIS)N1676YNinez A. Ponce, PhD, MPPet alN151
Journal ArticleHiroshi Gotanda

​Study focus: The association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17).

Participants: 37,819 low income adults (family income below 138% of the federal poverty level), ages 19 to 64, after Medicaid expansions using the 2010-17 Medical Expenditure Panel Survey.

Outcomes studied: Out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income).

Findings: Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change −28.0%; adjusted absolute change −$122); lower out-of-pocket plus premium spending (adjusted percentage change −29.0%; adjusted absolute change −$442); and lower probability of experiencing a catastrophic financial burden in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions.

Journal Article: Out-of-Pocket Spending and Financial Burden Among Low Income Adults After Medicaid Expansions in the United States: Quasi-Experimental Difference-in-Difference StudyN1666NAshish K. JhaKT LiN1675Gerald F. Kominski, PhD
Fact SheetGerald F. Kominski, PhD

Since 2013, the Affordable Care Act (ACA) has produced significant reductions in the number of uninsured individuals. Nevertheless, important disparities persist among the remaining uninsured. Such disparities are based on a number of factors, including Medicaid expansion status, race and ethnicity, occupation, and employment status. 

One overlooked disparity in coverage is the association between educational attainment and lack of insurance. Although the impact of education on earnings is well documented, the authors' findings suggest that education continues to have an important impact on the likelihood of being uninsured, regardless of income level. Using data from the 2013 and 2018 American Community Survey, researchers found substantial differences by educational level within each category of income. Specifically, lower levels of educational attainment are associated with higher rates of uninsurance in both the pre- and post-ACA periods, even among those in the 400%+ federal poverty level (FPL) income level. 

Furthermore, differences in rates of uninsurance by educational level have increased in the post-ACA period, indicating greater disparities based on educational attainment.

Fact Sheet: Education Matters: Despite Improvements Under the ACA, Disparities in Coverage Based on Educational Level PersistClaremont Graduate UniversityY144YPetra Rasmussen, MPHet alN151
Policy Research ReportNadereh Pourat, PhD

​The California Department of Health Care Services (DHCS) implemented a Section 1115 Medicaid Waiver called “Medi-Cal 2020,” which started on January 1, 2016, and is scheduled to end on December 31, 2020. Under this Waiver, DHCS implemented Whole Person Care (WPC) for high-risk, high-utilizing enrollees who have a complex profile and are high need. A total of 25 Pilots (27 Lead Entities), representing the majority of counties in California, implemented WPC starting in January 2017. WPC requires participating Pilots to identify and enroll eligible Medi-Cal beneficiaries; coordinate care across health, behavioral health, and social services; involve relevant stakeholders; and share data in real-time with the goals of improved care delivery, better health, and lower costs. 

The interim evaluation of WPC, led by UCLA Center for Health Policy Research Associate Director Nadereh Pourat, used qualitative data sources to examine the infrastructure developed, implementation processes, and services delivered by Pilots in WPC, as well as challenges encountered and promising strategies used to overcome them. UCLA used Pilot-reported metrics and Medi-Cal data to determine whether WPC led to better care and better health within the first three years of WPC. 

Overall, the results indicated significant progress in the establishment of needed infrastructure and processes to support effective care coordination, including the development health information technology and the establishment of partnerships for managing care. Examples of better care outcomes included improved rates of follow-up after hospitalization for mental illness, initiation and engagement in alcohol and other drug dependence treatment, and timely provision of comprehensive care plans. Examples of better health outcomes included improved beneficiary self-reported overall and emotional health, controlled blood pressure, and diabetes control.

Report: Interim Evaluation of California's Whole Person Care (WPC) ProgramPolicy Brief: Whole Person Care Improves Care Coordination for Many CaliforniansCalifornia Department of Health Care ServicesWhole Person CareWhole Person Care PilotsReport: Trends in Whole Person Care (WPC) Pilot Program Challenges, Lessons Learned, and Successes: January 2017-June 2019Y94NEmmeline Chuang, PhDXiao Chen, PhD Y689Brenna O'Masta, MPH
CHIS Journal ArticleLinda Diem Tran, MPP

This dissertation advances the small but growing literature on the relationship between gentrification and adult mental health. Using multiple data sources, the author identified Southern California neighborhoods that gentrified between 2010 and 2015 and investigated the impact of living in a gentrified neighborhood on mental health distress. Econometric techniques such as instrumental variables estimation and propensity score analyses were applied to reduce bias arising from residential selection and reverse causality.

The first study compared three quantitative approaches for identifying gentrified neighborhoods and demonstrated that each approach generated a different set of results. Findings highlighted the importance of the strategy used for identifying gentrified neighborhoods, especially when assessing gentrification’s effects on health outcomes. The second study used five years of pooled data from the California Health Interview Survey to examine the causal relationship between gentrification and adult mental health. Relative to living in a low-income and not gentrified neighborhood, living in a gentrified neighborhood was associated with increased likelihood of serious psychological distress among longtime residents, renters, and people with low incomes. In the third study, the author evaluated reasons for moving between residents who moved within gentrified and not gentrified neighborhoods and found evidence that people in gentrified neighborhoods were more likely to experience within-neighborhood displacement. Residents who experienced within-neighborhood displacement had greater likelihoods of having serious psychological distress.

Taken together, findings suggest that gentrification imposes a mental health cost on longtime residents and the most financially vulnerable residents, which has important implications for population health. By elevating levels of mental health distress of population groups who are already disproportionately exposed to stressors, gentrification can exacerbate mental health inequities.

Journal Article: Impact of Gentrification on Adult Mental HealthCalifornia Health Interview Survey (CHIS)Y1310
Journal ArticleChristopher Cai

The United States is the only high-income nation without universal, government-funded or -mandated health insurance employing a unified payment system. The U.S. multi-payer system leaves residents uninsured or underinsured, despite overall health care costs far above other nations. Single-payer (often referred to as Medicare for All), a proposed policy solution since 1990, is receiving renewed press attention and popular support. This review seeks to assess the projected cost impact of a single-payer approach.

Authors conducted a literature search between June 1, 2018, and December 31, 2018, without start date restriction for included studies. They surveyed an expert panel and searched PubMed, Google, Google Scholar, and preexisting lists for formal economic studies of the projected costs of single-payer plans for the U.S. or for individual states. Their search yielded economic analyses of the cost of 22 single-payer plans over the past 30 years. Exclusions were due to inadequate technical data or assuming a substantial ongoing role for private insurers. Nineteen (86%) of the analyses predicted net savings (median net result was a savings of 3.46% of total costs) in the first year of program operation and 20 (91%) predicted savings over several years; anticipated growth rates would result in long-term net savings for all plans. The largest source of savings was simplified payment administration (median 8.8%), and the best predictors of net savings were the magnitude of utilization increase, and savings on administration and drug costs. Only drug cost savings remained significant in multivariate analysis. Included studies were heterogeneous in methods, which precluded the authors from conducting a formal meta-analysis.


Journal Article: Projected Costs of Single-Payer Healthcare Financing in the United States: A Systematic Review of Economic AnalysesN1669NJackson RunteNinez A. Ponce, PhD, MPPY243Michael A. Rodriguez, MD, MPH
Journal ArticleDahai Yue, MD, MS

​Diabetes is one of the most common and expensive diseases in the nation. Although the positive impact of the Affordable Care Act’s (ACA) Medicaid expansions on insurance coverage, access, and health have been extensively studied in the general population, the extent to which the ACA Medicaid expansions affect people with diabetes is unclear. 

In this study, authors use data from 2011 to 2017 Behavioral Risk Factor Surveillance System (BRFSS) and compare residents in 24 Medicaid expansion states with those in 20 non-expansion states using a difference-in-differences (DD) approach. The analytic sample includes low-income nonelderly BRFSS respondents (income less than or equal to 138% Federal Poverty Level, ages 19–64) who reported having ever been told that they have diabetes in the 2011 to 2017 BRFSS. To reveal possible changes in policy effects across the years, authors fit two sets of models: The first set considers 2015 and 2016 as the early post-expansion period (year 2 and 3 effect), while the second set uses data from 2017 as the later post-expansion period (year 4 effect). All models control for the following variables: age, gender, educational attainment, language of interview, employment status, marital status, race/ethnicity, self-reported health, income level, number of children in the household, number of adults in the household, state and year-quarter fixed effects, and state annual unemployment rates. 

In the results, the final sample includes 16,666 respondents from expansion states and 19,176 respondents from non-expansion states. Characteristics of individuals between the two groups are similar. The year 2 and 3 effect of the expansions on health insurance coverage is 7.0 percentage points (pp), and is 6.2 pp on having no financial barriers to care. However, the effects decreased and became insignificant in 2017. The year 4 effect (3.2 pp) of receiving a routine annual checkup is larger than the year 2 and 3 effect (2.7 pp), but still insignificant. 

While non-Hispanic whites saw continued gains in health insurance coverage (9.5 pp in year 2 and 3, and 7.0 pp in year 4) and significant increases in routine checkups in year 4 (7.9 pp), blacks and Hispanics did not.

Journal Article: Coverage, Affordability, and Care for Low-Income People with Diabetes: 4 Years after the Affordable Care Act’s Medicaid ExpansionsY1523NYuhui ZhuPetra Rasmussen, MPHY1427James Godwin
Fact SheetUCLA Center for Health Policy Research
The California Health Interview Survey (CHIS) is the largest state health survey and one of the largest health surveys in the nation. Conducted by the UCLA Center for Health Policy Research (Center), CHIS interviews more than 20,000 households each year and collects health data on adults, teenagers and children to construct a detailed picture of California's diverse population. CHIS data is used by state and local legislators and policymakers, academic researchers, advocacy groups, educational institutions, hospital groups, media, and others who value working with credible data.
Highlights of CHIS in 2019 include the survey redesign/methodology update, informing legislation on multiple health areas such as older adult health and health insurance costs, projects for county health agencies, and other uses in research and advocacy work.


Fact Sheet: CHIS Making an Impact - 2019California Health Interview Survey (CHIS)CHIS Making an ImpactN28
Policy BriefTara Becker, PhD

This policy brief examines gender differences in health insurance coverage and access to care using data from the 2012-2016 waves of the California Health Interview Survey (CHIS). By the end of 2016, following three years of full health insurance expansion due to the Patient Protection and Affordable Care Act (which went into effect on January 1, 2014), just over 10% of both men and women had gained coverage, leaving the gender gap in uninsured rates intact. 


These gains in coverage were predominantly the result of increased ennrollment in Medi-Cal. Women remained more likely to be enrolled in public health insurance coverage, while men were more likely to have coverage through an employer. The gains in coverage changed the composition of the uninsured and Medi-Cal populations. 


The socioeconomic status of Medi-Cal enrollees and of men who remained uninsured increased. Men were less likely than women to have contact with the health care system, but they were also less likely to report experiencing delays in care. 


Though part of this difference could be due to the greater difficulty Medi-Cal enrollees face in accessing care, these gender disparities are also present by health insurance coverage type, suggesting that they cannot be eliminated solely by expanding health insurance coverage.


Policy Brief: Persistent Gap: Gender Disparities in Health Insurance and Access to Care in CaliforniaAppendixCalifornia Health Interview Survey (CHIS)Y1099YSusan H. Babey, PhD
Journal ArticleHiroshi Gotanda

The objective of the study is to examine the association between the Medicaid expansions and changes in the utilization of primary care physicians (PCPs) and emergency departments (EDs) at the national level during the first 3 years (2014–2016) of ACA implementation. A difference-in-differences analysis was used to compare outcomes between 17,803 individuals in 32 states that expanded Medicaid versus individuals in 19 non-expansion states. A nationally representative sample was used of US-born individuals 26–64 years old with family incomes lower than 138% of the federal poverty level from the 2010–2016 Medical Expenditure Panel Survey. Main measures authors examined were PCP-related outcomes [(i) whether a participant had any PCP visit during a year and (ii) the annual number of PCP visits per person) and ED-related outcomes ((i) whether a participant had any ED visit during a year and (ii) the annual number of ED visits per person].

The proportion of individuals with any PCP visit during a year marginally increased following the Medicaid expansions, without any change in the annual number of PCP visits per person. Authors found no evidence that ED utilization (both the proportion of individuals with any ED visit during a year and the annual number of ED visits per person) changed meaningfully after the Medicaid expansions.
Journal Article: Association Between the ACA Medicaid Expansions and Primary Care and Emergency Department Use During the First 3 YearsN1666YGerald F. Kominski, PhDYusuke Tsugawa, M.D., Ph.D., M.P.H.Y1593
Journal ArticleNadereh Pourat, PhD

Authors examined differences in rates of unmet need between low-income uninsured and Medicaid patients of Health Resources and Services Administration–funded health centers (HRSA HCs) and safety-net clinics in general or private physicians. Logistic regression models were used to compare the predicted probabilities of unmet need for uninsured and Medicaid individuals whose usual source of care is HRSA HCs versus clinics in general or private physicians. The sample was a nationally representative survey of low-income, adult patients who identified HRSA HCs as their usual source of care. We used the National Health Interview Survey to independently identify low-income individuals whose usual source of care was clinics (National Health Interview Survey clinics) or physicians (National Health Interview Survey physicians) in the general population.

Dependent variables measured were unmet need and delay in medical care, and unmet need for prescription medications, mental health, and dental care. The primary independent variable of interest was the usual source of care. Authors controlled for potential confounders. Findings: The probability of unmet need for medical and dental care was lower among HRSA HC patients than individuals whose usual source of care were not HRSA HCs. Authors concluded HRSA HC patients have lower probabilities of unmet need for medical and dental care. This is likely because HRSA HCs provide accessible, affordable, and comprehensive primary care services. Expanding capacity of these organizations will help reduce unmet need and its consequences.

Journal Article: HRSA-funded Health Centers Are an Important Source of Care and Reduce Unmet Needs in Primary Care ServicesY94YXiao Chen, PhD Christopher Lee, MPHN1258Weihao Zhou, MS
Policy Research ReportShana Charles, Ph.D., M.P.P.

California led the way in implementing ACA reforms, and national data comparisons of all 50 states clearly show the state has been one of the most successful states in enrolling eligible people in new coverage from the ACA’s full launch in 2014 until today. But California still must contend with and operate under federal rules and guidelines, and when the federal administration changed in 2017 to a president hostile to the ACA, even California felt the pinch and saw uninsured rates begin to creep up again.

This report, which presents 2015-2016 California Health Interview Survey data, is a snapshot in time. The data are from just before the current administration took power, just before the mantra of a Republican-led Congress was that it was going to “repeal and replace Obamacare” in 2017. That did not happen, and the House became controlled by ACA supporters in the next election. This report shows the peak of the ACA, before federal regulators began to backpedal on expansions.
Additionally, a new focus on Medicare data is added to this year’s report. With the ACA under attack since 2017, much of the policy conversation around expanding health insurance coverage has turned to building instead on the one widely admired public program, Medicare. While proposals can differ on just how to expand Medicare, they all should be based on solid initial data on what Medicare does for its current enrollees and on how the program compares with other public and private coverage. Authors note that while the ACA’s impact is now slowly declining, even at its height in 2016, millions of Californians still did not have any health insurance coverage.
Report: The State of Health Insurance in California: Findings from the 2015-2016 California Health Interview SurveyRelated Report - The State of Health Insurance in California: Findings from the 2014 California Health Interview SurveyCalifornia Health Interview Survey (CHIS)The California EndowmentY81YTara Becker, PhDIan PerryN1568Ken JacobsUCLA report shows California's unique position to enact health care reform325UCLA report shows California's unique position to enact health care reform
Policy Research ReportMiranda Dietz

California’s success in implementing the ACA resulted in the number of uninsured falling from 6.5 million in 2013 to 3.5 million in 2017. At the end of 2017, Congress voted to eliminate the individual mandate penalty starting with the 2019 tax year, a change projected to increase the uninsured by more than half a million Californians.

In 2019, California lawmakers took steps to protect California’s coverage gains and increase affordability of coverage by instituting a state individual mandate penalty, providing additional subsidies for individual market enrollees, and expanding Medi-Cal to low-income undocumented young adults. California is the first state to include undocumented adults in full Medicaid benefits and the first to provide subsidies to middle-class consumers not eligible under the ACA.

Authors model these policies using CalSIM, the UCLA CHPR/UC Berkeley Labor Center micro-simulation model of insurance take up in California, which uses California Health Interview Survey (CHIS) data from 2011-2012, 2014 data on Medi-Cal, other public coverage, and insurance coverage by citizenship. Authors project that in the absence of these policies prices in the individual market would be higher and that the number of uninsured in California would climb to 4.3 million by 2022. However, with these policies in place, authors project the number of uninsured would remain stable at 3.5 million. They estimate that by 2022, these policies will have prevented 770,000 Californians from becoming uninsured  and reduced premiums for 1.55 million Californians, benefitting a total of 2.2 million Californians.


California’s Steps to Expand Health Coverage and Improve Affordability: Who Gains and Who Will Be Uninsured?Related Report: Preliminary CalSIM v 2.0 Regional Remaining Uninsured ProjectionsLearn more about California Simulation of Insurance Markets (CalSIM)California Health Interview Survey (CHIS)N945YLaurel Lucia, MPPXiao Chen, PhD Y689Dave Graham-SquireNew UC Berkeley/UCLA Report: California’s Health Care Policies Keep Uninsured from Growing, Improve Affordability for 1.55 Million 324New UC Berkeley/UCLA Report: California’s Health Care Policies Keep Uninsured from Growing, Improve Affordability for 1.55 Million
External PublicationKidsdata

Oral health is essential for healthy development and affects overall health. However, not all California children are receiving dental care at recommended intervals. According to 2015-2016 county-by-county California Health Interview Survey data, 78% of children ages 2-11 received dental care within six months in 2015-2016. Timely dental care varied greatly across California, ranging from 61% in Imperial County to 90% in Marin County.

External Publication: Timely Dental Care Remains a Challenge for Some California ChildrenCalifornia Health Interview Survey (CHIS)Kidsdata.orgN1320
CHIS Journal ArticleEn-Jung Shon

​Authors’ objective was to investigate predictors (including ethnicity) of never having a mammogram in middle-aged and older Chinese, Vietnamese, and Korean immigrant women (main effects). The second objective was to explore whether relationships between predictors and never having a mammogram varied across the three groups (moderation effects of ethnicity).

Merged (2005-2007-2009-2011) California Health Interview Survey data were used. Unweighted sample was 3,710 Asian women ages 40 years and older (Chinese = 1,389; Vietnamese = 1,094; Korean = 1,227). Replicate weighted total sample size was 1,710,233 (Chinese = 940,000; Vietnamese = 410,000; Korean = 360,000). Replicate-weighted multivariate logistic regression was applied. Interaction effects (moderator role of ethnicity) were also examined, using multivariate logistic regression, for the second objective.

Authors found that for the first objective, odds of never having a mammogram were higher for women who were Korean (Ref = Vietnamese), unmarried, or a non-U.S. citizen. Odds were lower in women ages 50-59 or 60-69 (Ref = 70-85). Regarding the second objective, only for Chinese women, odds of never having a mammogram were lower as the number of physician visits got higher.

Journal Article: Predictors of Never Having a Mammogram Among Chinese, Vietnamese, and Korean Immigrant Women in the U.S.California Health Interview Survey (CHIS)N1659Net al
CHIS Journal ArticleChristina M. Ramirez

​Survey responses in public health surveys are heterogeneous. The quality of a respondent's answers depends on many factors, including cognitive abilities, interview context, and whether the interview is in person or self-administered. A largely unexplored issue is how the language used for public health survey interviews is associated with the survey response. Authors introduce a machine learning approach, Fuzzy Forests, which they use for model selection. They use the 2013 California Health Interview Survey (CHIS) as the training sample and the 2014 CHIS as the test sample. 

Authors find that non-English language survey responses differ substantially from English responses in reported health outcomes. 

Heterogeneity among the Asian languages suggest that caution should be used when interpreting results that compare across these languages. The 2013 Fuzzy Forests model also correctly predicted 86% of good health outcomes using 2014 data as the test set. 

Journal Article: Using Machine Learning to Uncover Hidden Heterogeneities in Survey DataCalifornia Health Interview Survey (CHIS)N1658Net al
Journal ArticlePetra Rasmussen, MPH

The individual health insurance market has grown significantly since the 2014 implementation of the Affordable Care Act’s state-based and federally facilitated Marketplaces. During annual open enrollment periods, Marketplace enrollees can switch plans for the upcoming year. The percentage of re-enrollees in California’s state-based Marketplace, Covered California, who made changes to their coverage steadily increased between the 2014–15 and 2017–18 open enrollment periods. Following the implementation of “silver loading”— in which insurers raised 2018 silver-tier plan premiums to compensate for their loss of federal payments for cost-sharing reductions — the proportion of consumers who moved into gold plans during the 2017–18 open enrollment period dramatically increased, compared to previous years. Among bronze or silver plan enrollees who switched metal tiers during open enrollment, those who could enroll in gold plans that were no more than $49 per month more expensive than their initial bronze or silver plan had a significantly higher probability of switching to gold coverage than those who faced larger premium differences.

Journal Article: California’s New Gold Rush: Marketplace Enrollees Switch To Gold-Tier Plans In Response To Insurance Premium Changes (Health Affairs)Y1427YThomas Rice, Ph.D.Gerald F. Kominski, PhDY144
1 - 30Next