December 17, 1999
UC NEWS SERVICE
Berkeley -- More than 7 million Californians who lack health insurance are low-income workers and their families — 85% of all residents who lack health insurance — according to a new University of California report. The state's 700,000 hired farmworkers, their families, and most of the communities in which they live have the least access to health care.
The authors of "Expansion of Health Care to the Working Poor," a four-part report published by the California Policy Research Center, examine why increasing numbers of low-income workers are uninsured and suggest solutions for California that have broad applicability to the national debate about increasing health coverage.
Driving the increased number of uninsured residents are the decline in job-based health insurance over the past two decades, the high cost of coverage, and the lack of public subsidies to make health insurance affordable for low-income workers. In addition, many people who are eligible for public insurance do not apply because of the stigma and demeaning application process associated with public coverage. Thus, 50 percent of California's adult workers in low-income families are uninsured, as are 60 percent of low-income workers in small businesses.
In a foreword, state senator Martha Escutia said that because both managed care and public insurance programs negotiate below-cost reimbursements, the uninsured "not only lose the price discount enjoyed by insured members, but also have to pay inflated rates that make up for the savings realized by the insured." She added, "The uninsured . . . pay more than 18% of all health expenditures annually, or approximately $25 billion."
The inconsistency between the lack of any health insurance subsidy for low-income workers and the significant subsidy the government provides to insured workers by not taxing employer contributions to their health coverage is noted by two of the report's authors, UC San Diego professor Richard Kronick and research associate Todd Gilmer. This subsidy amounts to approximately $111 billion nationwide.
Kronick and Gilmer examined model programs developed by other states to subsidize coverage for uninsured workers, and found that "When states make subsidized insurance available, substantial numbers of people purchase coverage." They think California "should actively evaluate options to expand health insurance subsidies to low-income workers," and say "there are many opportunities for using federal funds to support such expansions."
Lucien Wulsin Jr., project director of Insure the Uninsured Project in Santa Monica, reviews state, county, employer, health plan, and private provider efforts to cover California's uninsured working poor before concluding: "To cover the uninsured working poor will require solving problems of both affordability and structure. There are no feasible `silver bullet' solutions. Multiple strategies and the concerted efforts of both public and private sectors are required."
In a third paper, Don Villarejo, executive director of the California Institute of Rural Studies at the time of writing, reports that "hired farmworker communities are disproportionately represented at the bottom of the health access ladder compared with other rural communities." Large numbers of hired farmworkers are doing without the health care services they need because they lack medical insurance, access to a primary care physician, and a usual (non-emergency) source of health care.
Among the issues Villarejo discusses in a wide-ranging survey of the health problems of hired farmworkers are the second-highest occupational mortality and injury rate (following construction) as well as lack of labor standards enforcement, and the loss of employer-provided housing. Since living costs are so high in California, this has led to farmworkers residing "in toolsheds, garages, informal shacks constructed of plywood or sheet metal, abandoned automobiles, and even the spaces underneath porches." In one community, researchers found that these "back houses" were inhabited by 28% of the residents — virtually none of whom are enumerated in the census.
In the final paper, Professor E. Richard Brown, director of UCLA's Center for Health Policy Research, articulates a vision for a new Healthy Californians Program that would provide a universal system of affordable coverage for uninsured children and adults, take health care out of welfare, and integrate all public coverage programs to form a seamless system. The strategy he describes involves implementing incremental structural reforms, which may have a chance of overcoming the political barriers to comprehensive reforms.
The report's proposals were supported in a foreword by Assembly member Gilbert Cedillo, who said, "Today we are at a historic juncture when the convergence of funding, political will, and policy ideas have provided a window of opportunity to make affordable coverage a reality. By adopting a multistage strategy to fix the problems with existing programs and consolidate both funding and program administration, California has the opportunity to insure a greater number of children, add coverage for their low-income working parents, and integrate its public health systems to form a seamless system of subsidized coverage."
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