Working Californians Enrolled in Medi-Cal Share Their Stories OCTOBER 2020 AUTHORS Rebecca Catterson, MPH, and Lucy Rabinowitz, MPH, NORC at the University of Chicago Laurel Lucia, MPP, and Kevin Lee, MPH, UC Berkeley Contents About the Authors 3Executive Summary Laurel Lucia, MPP, is health care program director at the UC Berkeley Labor Center. 4Introduction Kevin Lee, MPH, is a Doctor of Public Health student at UC Berkeley School of Public 5California Workers Enrolled in Medi-Cal: Data Health. Lucia and Lee wrote the section enti- Analysis and Policy Context tled “California Workers Enrolled in Medi-Cal: How Many Working Californians Are Enrolled in Medi-Cal? Data Analysis and Policy Context.” Rebecca Where Are They Employed? Catterson, MPH, is a senior research director What Percentage of Nondisabled Adult Medi-Cal at NORC at the University of Chicago. Lucy Enrollees Work? Rabinowitz, MPH, is a principal research ana- Many Working Californians Enrolled in Medi-Cal Obtained lyst at NORC. Catterson and Rabinowitz were This Coverage Due to the Affordable Care Act responsible for “California Workers Enrolled in Medi-Cal Speak About Program” Why Workers May Turn to Medi-Cal Medi-Cal and Immigration Status About the Foundation Medi-Cal, Workers, and the COVID-19 Pandemic The California Health Care Foundation is dedicated to advancing meaningful, measur- 9California Workers Enrolled in Medi-Cal Speak able improvements in the way the health care About the Program delivery system provides care to the people of Key Findings from In-Depth Interviews California, particularly those with low incomes and those whose needs are not well served 18Conclusion by the status quo. We work to ensure that people have access to the care they need, 19Appendix. Methods when they need it, at a price they can afford. 21Endnotes CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. California Health Care Foundation www.chcf.org 2 Some of the key themes that emerged from the in- Executive Summary depth interviews, provided along with direct quotes Medi-Cal is California’s Medicaid program, which pro- from interviewees, include: vides health insurance to individuals and families who $ Employer-sponsored insurance was not an option earn low incomes, including 40% of the state’s chil- for the workers interviewed. The vast majority were dren, half of Californians with disabilities, and over a not offered coverage by their employer. The few million seniors. In total, the program covers more than that were could not afford it. 12 million people, or nearly one in three Californians. “I think it’d be important to understand that Medi-Cal also covers a large number of working Californians, although this may be one of the least you could be working two, three, or four recognized or understood populations served by the part-time jobs and still not have insurance program. In a 2018 poll, 42% of Californians said that they believed that most working-age adults without provided by your employer. So there’s no a disability enrolled in Medi-Cal are unemployed. way that your level of work is connected to Twenty percent said they didn’t know. This report com- bines key findings from survey data with insights from your insurance in American society.” 19 in-depth interviews with enrollees to paint a more $ Those interviewed said they would go without accurate and complete picture of working Californians health coverage or struggle financially if they had who rely on Medi-Cal, why they came to enroll in the to pay for coverage. program, and the role it plays in their lives. “I couldn’t have done it without Key findings include: [Medi-Cal]. . . . They covered all my $ 2.9 million workers — almost one in six (16%) of all California workers age 19 to 64 — were enrolled hospitalizations, my emergency room. in Medi-Cal, according to new analysis of the 2018 The cost would have been too much American Community Survey (ACS), the latest year for which data were available at the time of this for me to be able to pay for. I wouldn’t report. have been able to pay my bills if I had $ According to the ACS, the three industries with had to pay for my medical [bills].” the highest rate of enrollment in Medi-Cal were (1) agriculture, forestry, fishing, and mining (32% $ Workers consistently said that prevention was a pri- of workers); (2) restaurants, bars, and food services ority to them, and they put a premium on the ability (31%); and (3) “other services” (27%), a category to access care for chronic or urgent needs. that includes auto mechanics, hair salon workers, workers in private households, and other workers. “It provides a lot of security. Since I’ve $ 64% of working-age, nondisabled adults enrolled in had the Medi-Cal active, I’ve thought, Medi-Cal work either full- or part-time, according to ‘Hey, you know, this is really great a 2019 KFF analysis. because if I think I’ve been exposed to COVID-19, I will go get a test.’ Whereas in the past I would have just been like, ‘Well, now I’ll never know.’” Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 3 $ Medi-Cal provides peace of mind for workers who A 2019 health policy poll among Californians con- have it. ducted by the California Health Care Foundation found that, while there was strong overall support for “The advantage of [Medi-Cal] is that they Medi-Cal, 42% believed that most working-age adults without disabilities enrolled in Medi-Cal are unem- help with stress. . . . You know that if you ployed. Twenty percent said they didn’t know.3 have an accident or something, you know that you can go to the hospital. You’re The purpose of this report is to use data and inter- views with enrollees themselves to paint a more worried about your health, but you’re accurate and complete picture of working Californians not worried about the cost.” enrolled in Medi-Cal. The first section provides an analysis by the UC Berkeley Labor Center of the US $ Interview participants expressed a strong com- Census Bureau’s 2018 American Community Survey mitment to work and to improving their financial (ACS). (2018 was the latest year for which data were situation. available at the time of this report.) The analysis quan- tifies how many California workers rely on Medi-Cal “People need to realize just because we and provides these figures by industry. In addition, this section integrates key California-specific findings are on Medi-Cal doesn’t mean we are not from other studies on Medicaid enrollment and work working. We are hard workers, we just status from KFF and the Center for Budget Policy and cannot afford the health care system.” Priorities. It also provides some basic policy back- ground to understand the regulations and eligibility requirements around Medi-Cal coverage for working It is important to understand how, even before the adults, highlighting the role of the Affordable Care COVID-19 pandemic, Medi-Cal was already support- Act (ACA), which expanded eligibility for many adults ing a substantial percentage of working Californians with low incomes. The second section of the report is struggling to make ends meet in a high-cost state. a synthesis of findings, vignettes, and quotes from 19 Medi-Cal’s coverage for working Californians is even in-depth interviews (IDIs) conducted by the National more important during the COVID-19 pandemic, as Opinion Research Center (NORC) with working Medi- many are the “essential workers” that California is now Cal enrollees, giving voice to their experiences in the heavily relying on. program and the role Medi-Cal plays in their lives. This report was originally conceived before the Introduction outbreak of the COVID-19 pandemic. As much as possible, however, it attempts to capture relevant Medi-Cal is California’s Medicaid program, which pro- information from the current crisis. Even though the vides health insurance to individuals and families who latest ACS data is from 2018, the IDIs were conducted earn low incomes, including over 40% of the state’s in the summer of 2020, allowing for insights about the children, half of Californians with disabilities, and role of Medi-Cal in the lives of workers both before over a million seniors.1 In total, the program covers and during the pandemic. more than 12 million people,2 or nearly one in three Californians. Among these diverse groups of Californians covered by Medi-Cal, perhaps one of the least recognized or understood is the many working adults in the program. California Health Care Foundation www.chcf.org 4 Figure 1. C alifornia Workers Age 19 to 64 Enrolled in California Workers Medi-Cal, by Industry, 2018 Enrolled in Medi-Cal: All Industries Data Analysis and 16% Policy Context Agriculture, Forestry, Fishing, and Mining 32% How Many Working Californians Are Restaurants, Bars, and Food Services 31% Enrolled in Medi-Cal? Where Are They Employed? Other Services 27% According to the 2018 ACS, about 2.9 million Administrative and Building Services California workers — or about one in six (16%) of all California workers age 19 to 64 — were enrolled in 26% Medi-Cal in 2018 (see Figure 1 and Table 1 [page 6]).4 Retail The three industries with the highest rates of enroll- 22% ment in Medi-Cal were: Transportation and Warehousing $ Agriculture, forestry, fishing, and mining 21% (32% of workers) Construction 19% $ Restaurants, bars, and food services (31%) Arts, Entertainment, Recreation, and Accommodation $ Other services (27%), including auto mechanics, 17% workers in hair salons or private households, Health Care and Social Assistance and other workers 16% Wholesale Other industries with a higher-than-average rate of Medi-Cal enrollment in 2018 included: 14% Educational Services $ Administrative and building services (26%) 11% $ Retail (22%) Manufacturing $ Transportation and warehousing (21%) 11% Finance, Insurance, and Real Estate $ Construction (19%) 8% $ Arts, entertainment, recreation, and Information and Communication accommodation (17%) 8% Professional, Scientific, and Management Workers in certain industries have a higher-than-aver- 6% age rate of Medi-Cal enrollment as a result of being Public Administration, Utilities, and Military less likely to be offered or eligible for employer- sponsored insurance5 and more likely to earn low 6% household incomes. Notes: Workers include self-employed; other services includes auto mechanics, workers in hair salons, private households, and others. Source: UC Berkeley Labor Center analysis of American Community Survey 2018; Medi-Cal estimates adjusted to match enrollment total from California Department of Health Care Services in June 2018. See the Appendix for details. Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 5 Table 1. California Workers Age 19 to 64 Enrolled in Medi-Cal, by Industry, 2018 ENROLLED IN MEDI-CAL WORKFORCE TOTAL NUMBER PERCENTAGE All Industries 17,780,000 2,910,000 16% Retail 1,833,000 405,000 22% Restaurants, Bars, and Food Services 1,126,000 350,000 31% Health Care and Social Assistance 2,202,000 349,000 16% Other Services 913,000 249,000 27% Construction 1,187,000 223,000 19% Administrative and Building Services 849,000 217,000 26% Manufacturing 1,602,000 183,000 11% Transportation and Warehousing 872,000 180,000 21% Educational Services 1,473,000 156,000 11% Agriculture, Forestry, Fishing, and Mining 392,000 126,000 32% Arts, Entertainment, Recreation, and Accommodation 654,000 110,000 17% Professional, Scientific, and Management 1,588,000 101,000 6% Finance, Insurance, and Real Estate 1,030,000 83,000 8% Wholesale 493,000 70,000 14% Public Administration, Utilities, and Military 1,043,000 67,000 6% Information and Communication 525,000 42,000 8% Notes: Workers include self-employed; other services includes auto mechanics, workers in hair salons, private households, and others. Source: UC Berkeley Labor Center analysis of American Community Survey 2018; Medi-Cal estimates adjusted to match enrollment total from California Department of Health Care Services in June 2018. See the Appendix for details. California Health Care Foundation www.chcf.org 6 What Percentage of Nondisabled be suffering from a shorter-term disability). Of survey respondents who were not employed: Adult Medi-Cal Enrollees Work? In 2019 KFF published an analysis of what percentage $ 8% were ill or disabled of adults age 19 to 64 enrolled in Medicaid worked.6 $ 14% were caretakers The analysis excluded those who: (1) qualified for federal disability through the Supplemental Security $ 8% were going to school Income (SSI) program or (2) were dually eligible for Medicaid and Medicare.7 Many Working Californians Enrolled The analysis found that 64% of working-age nondis- in Medi-Cal Obtained This Coverage abled, nondual Californians enrolled in Medi-Cal were Due to the Affordable Care Act employed (45% full-time and 19% part-time). See Before the ACA, Medi-Cal primarily served children Figure 2. Eighty-six percent were living in a household and parents with low incomes, seniors, and people with at least one employed person (72% with a full- with disabilities. California’s decision to adopt the time worker, 14% with a part-time worker). ACA’s Medicaid expansion extended eligibility to “childless adults” age 19 to 64 without minor children Those who were not employed reported various living at home and to a broader group of parents with reasons for being out of the workforce. The reasons low incomes than were previously eligible. As a result, included disability although, in this instance, the most California adults are now eligible for Medi-Cal if enrollee’s condition may not meet the strict eligibility they have household income at or below 138% of the requirements for federal SSI disability benefits, which federal poverty level (FPL), or approximately $17,610 require that a disability exist for at least a year or be for an individual and $29,970 for a family of three. (See likely to result in death (for example, someone may “Medi-Cal and Immigration Status” for more details.) Figure 2. E mployment Status of Medi-Cal Enrollees, Age 19 to 64, Non-SSI, Non-Dual-Eligible, 2017 INDIVIDUAL WITHIN FAMILY • Ill or Disabled (8%) No • Caretaker (14%) Worker 14% Not Working Part-time Working • Student (8%) (by reason) Worker Full-time 36% 14% 45% Full-time • Other (6%) Worker Working 72% Part-time 19% Source: Understanding the Intersection of Medicaid and Work: What Does the Data Say?, KFF, (August 2019). Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 7 Why Workers May Turn to Medi-Cal Medi-Cal, Workers, and the Low-wage workers are less likely to be offered job- COVID-19 Pandemic based coverage than their higher-income counterparts The Medi-Cal program has and will continue to play a or may not be able to afford the coverage they are particularly important role in ensuring access to health offered by an employer,8 and as a result many enroll care during the COVID-19 pandemic. Approximately in Medi-Cal. Medi-Cal also provides an important one-quarter of Californians working in industries at option for people to maintain coverage when they are high risk of job losses were estimated to have had between jobs and temporarily have low income and Medi-Cal coverage in 2018 before the crisis began, lack an offer of job-based coverage. and those workers can continue to rely on that cover- age without interruption in spite of job loss or other The Medi-Cal program, like job-based coverage, is employment changes.9 The Center on Budget Policies required to cover 10 categories of essential health and Priorities, also using the 2018 ACS data, estimates care services under the ACA. Medi-Cal benefits are that 950,000 essential/frontline workers are enrolled in more expansive than the typical job-based plan Medi-Cal.10 because Medi-Cal also covers nursing home care and home and community-based services for those who Millions of Californians are projected to lose job-based meet the eligibility criteria. Medi-Cal coverage also coverage due to the job loss associated with the pan- includes some dental benefits, while not all employers demic, and many of those workers and their family who offer health coverage also offer dental coverage. members may newly enroll in Medi-Cal.11 Additionally, California created a new Medi-Cal program that Most Medi-Cal enrollees pay no premiums or cost covers COVID-19-related testing and treatment for sharing. In contrast, most Californians with job-based uninsured people regardless of income level or immi- coverage make monthly premium contributions from gration status.12 their paychecks and pay for a portion of the costs when they access care, through copayments, co-insur- ance, or deductibles. The background on Medi-Cal eligibility and benefits provided is meant as a summary of key points only. For more details, see Medi-Cal and Immigration Status The Medi-Cal Program: An Overview, Citizens, lawful permanent residents who have had part of CHCF’s Medi-Cal Explained series. a green card for five years, and certain other quali- fied immigrants are eligible for full Medi-Cal benefits under federal policy, but California provides Medi-Cal to a broader group of immigrants using state funds. In California, children and young adults in households with low incomes are eligible for full Medi-Cal benefits regardless of immigration status until they turn 26, along with lawful permanent residents who have had a green card for less than five years and Californians with Deferred Action for Childhood Arrivals status. Medi-Cal covers emergency and pregnancy-related services only (called restricted-scope Medi-Cal) for undocumented Californians with low incomes who are 26 or older. California Health Care Foundation www.chcf.org 8 The majority were female and ranged in age from 20 California Workers to 65, with an average age of 43. Half of the partici- Enrolled in Medi-Cal pants were Latinx, and nearly a third were non-Latinx white or other. Most lived in family households, while Speak About the four were single. (See the appendix for more detail, as well as for details on methods, including screen- Program ing and recruitment, and the interview and analysis Among California workers enrolled in Medi-Cal, what process.) is the value of the program in their lives? What role does Medi-Cal coverage play in their physical and mental health, ability to work, finances, and welfare Key Findings from In-Depth of their families? How has the COVID-19 pandemic Interviews affected their experiences with, or feelings about, the The workers who agreed to be interviewed had impor- program? tant and diverse stories to share about the interaction between their Medi-Cal coverage, employment, and In the summer of 2020, NORC conducted 19 qualita- health. Key findings are detailed and illustrated with tive in-depth interviews (14 in English and 5 in Spanish) quotes below. with workers who are Medi-Cal enrollees to answer these and other critical questions about the program’s Participants came from a diverse array impact on their lives. By design, interview participants of professions. came from all over the state and represented a mix of Though there were some jobs that more than one par- urban and rural geographies (Figure 3). ticipant cited as their main source of employment (i.e., warehouse worker, and in-home support services), there were almost as many professions as there were Figure 3. Geographic Location of Interview Participants participants. They included a pastor, a violin teacher, office assistant, and coffeeshop owner, to name a few. Though most participants described “falling into” cer- • Rural tain jobs or industries and sticking with a job because • Urban it was generally a dependable source of income, a minority described long years of training (e.g., the violin teacher), advanced degrees (e.g., the pastor), and deliberate plans (e.g., the coffee shop owner) that led them to their current employment situation. Most participants reported feeling secure with their jobs. Some, especially seasonal workers in agriculture, construction, or school work, rely on multiple jobs or working odd jobs to make ends meet. In particular, the majority of the participants whose interviews were conducted in Spanish reported working seasonal jobs. A majority of respondents described looking for more hours with their primary job, whether to cover the off- season or throughout the year, and prevent them from Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 9 constantly looking for additional sources of income I think it’d be important to understand that to make ends meet. COVID-19, in particular, caused some interview participants to lose one of their jobs, you could be working two, three, or four have hours cut back, or find different second jobs to part-time jobs and still not have insurance make ends meet. provided by your employer. So there’s no way that your level of work is connected to your insurance in American society. — 43-year-old white and Native American / Alaska Native13 woman In-Home Supportive Services employee, Chico George, 30, teacher’s aide, Tulare County George is a 30-year-old resident of a suburb of Tulare. Despite his not needing care or prescription medica- He is primarily employed as a teacher’s aide for his tions for any ongoing or chronic health conditions, local school district, working with students with special Medi-Cal coverage provides peace of mind for George. needs for about 20 hours per week during the school He talked about not having to worry about affording year. He finds his job fulfilling and would like to work a doctor or medication and stated, “I can really be at more hours to increase his financial security, negate ease and know that I can get things done.” And when the need to work a second job, and qualify for the asked about the most important health services he has school district’s health insurance program, which is only received through Medi-Cal, George responded, “My available to full-time employees. During the summer, health screening, because it’s to check how I’m doing George works a second job as a camp counselor, but or what can I do better about my health.” this year the camp is closed due to the COVID-19 George had received employer-sponsored coverage pandemic. Subsequently, he secured a job working through a previous job as an aide at a facility caring for for UPS loading trucks and trailers. He is concerned adults with developmental disabilities. He noted that about his primary employment with the school district the combination of biweekly premium payments of because as of the date of our interview, the district had more than $200 and $50 copays made a big differ- not yet announced its plan for the 2020–21 school year. ence in his take-home pay, ultimately discouraging him George is unsure how a fully or partially virtual school from seeking care. George described seeking care for year would impact his employment status and hours. keloids on his face, scars that were uncomfortable and George considers himself generally able to afford what impacted his confidence. He initially started treatment he considers the essentials, but he has to put off buying for them while he was covered by his employer, but new clothes. Sometimes, he has to go without gas for stopped because of the high out-of-pocket cost. He his car and depends on others to drive him to work. He is relieved that Medi-Cal is covering the continued is currently in a debt management program that helps treatment. him pay off student loans and credit card debt. George George is thankful for the coverage provided thorough reported that, prior to the COVID-19 pandemic, he Medi-Cal and is surprised by the breadth of coverage. sometimes needed to use community resources such as When he needed an appendectomy, he was “shocked food pantries to ensure he had enough food. Since the that [Medi-Cal] paid for it” since it was an expensive start of the COVID-19 pandemic, he has depended on procedure. When he need care for a leg injury, CalFresh to ensure he has enough to eat. Medi-Cal covered his physical therapy expenses without impacting his already tight finances. In dis- cussing this care episode, George said that without Medi-Cal, “I would have been in bad shape.” California Health Care Foundation www.chcf.org 10 Most interview participants noted being Employer-sponsored insurance was not able to meet their monthly expenses. an option for the workers interviewed. The However, they live on the financial edge vast majority were not offered coverage and cannot afford to miss paychecks or by their employer. The few that were incur unexpected expenses. could not afford it. Most participants cited the work they put into creating Interview participants’ jobs do not often provide the and sticking to a household budget as a main rea- option for health insurance and only a handful of son they are able to make ends meet from month to participants described having a job that offered sick month. However, when unexpected costs arise or work leave. For those whose jobs do offer health insurance hours change, they often have to rely on other sources benefits, most interviewees reported that they do not for additional financial support. Half of the interview work enough hours to qualify for these benefits or that participants described a portion of their monthly the insurance options are too expensive for them to expenses going to pay off student loans or credit card enroll and pay the monthly premium. debts. Many describe seeking support from family or friends in times of need. During COVID-19, those who lost their jobs or had reduced work hours described contacting organizations to seek relief from paying bills, relying on credit cards, depending on community I couldn’t have done it without [Medi-Cal]. . . . organizations such as local food pantries, or asking They covered all my hospitalizations, my friends and family for financial help. emergency room. The cost would have been Making financial sacrifices is a part of life for too much for me to be able to pay for. I the people interviewed. Most interviewees described prioritizing payment of wouldn’t have been able to pay my bills if I rent and utilities and forgoing expenses related to had had to pay for my medical [bills]. eating out, entertainment, and clothing. Some par- ticipants with children noted prioritizing expenses — 62-year-old white woman janitorial service employee, near Chico for them, such as clothing, food, and supplies, over expenses for themselves when faced with tough finan- cial decisions. Though most participants report usually having enough food on the table, some noted they also rely on churches and pantries for food in times There are so many people who don’t make of need or minimize their food budgets by eating mostly at home and buying low-cost foods like rice enough to pay for insurance, and so I think and beans. A minority of participants discussed relying Californians are very lucky to have it. on government programs like CalFresh and Special Supplemental Nutrition Program for Women, Infants, — 61-year-old white woman and Children for additional support. Many of the church office assistant, near San Diego participants said the financial pressure causes them anxiety and stress. They cited coping mechanisms like exercise, prayer and meditation, and talking to friends and family to manage the stress. Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 11 Workers interviewed would go without coverage or struggle financially if they had If I didn’t have any insurance at all, I would to pay for coverage. probably take my kids only if there was As noted previously, interview participants described extreme pain in their body or in their teeth. tight financial situations and little room in their bud- gets for anything except what they describe as the And with Medi-Cal, I’m able to take them to essentials. Most participants discussed the “financial regular well visits. relief” of having Medi-Cal cover most health care costs — 38-year-old Latinx woman and that paying for coverage is out of financial reach. legal secretary, Fullerton Ana, 31, field worker, Kern County Ana is a 31-year-old single mother of two daughters. Medi-Cal has helped Ana manage her ongoing vertigo She has lived in Arvin her entire life. She is primarily and her daughter’s sleep issues. She has been able to employed as a field worker, picking different fruits and feel confident that her health care needs would be met vegetables throughout the year and has done this work by Medi-Cal and is thankful for the coverage. “Without since completing high school. When there is less field Medi-Cal . . . I believe I would be doing really badly, work, she works in a packaging plant, which provides to be honest. . . .” Over the past two years, Ana has her more work hours. She also finds creative ways to received treatments to help with her vertigo. These earn additional income by preparing and selling des- treatments have helped her to keep her job, feel better serts to extended family members. She continues to while working, and to work more productively. look for extra work to supplement her income. Ana’s work offers health insurance, but her Medi-Cal Ana says she is generally able to afford the necessities coverage allows her to keep more of her paycheck for herself and her daughters. Sometimes, she has to for monthly expenses. About the $120 per month she delay purchases; for example, she mentioned waiting would have to pay to enroll in her employer’s health to save up to buy her children new clothes for school. insurance, she noted, “those $120 that they take from She frequently has to ask her mother for help with me, I can use that for my food, or for a bill payment, bills and depends on her mother to watch her children [like] gas or water.” She is able to receive the health ser- when she is working. Ana also has to limit her budget vices she needs, but has had trouble getting specialty for food and focus on eating less expensive meals like care for her daughter’s sleep issues. After her daughter rice and beans. She is stressed by her financial situa- had been seen at a children’s hospital, there was a time tion sometimes, but she uses prayer and exercise with when the hospital said a treatment wasn’t covered, and her daughters to relieve that stress. Based on previous Ana was going to have to pay over $400. Ana noted experience, Ana is generally nervous about taking time that, after some back and forth, “Medi-Cal replied and off when sick. She fears it will cause her to get laid off, thank God, yes, the girl did qualify.” When asked what and she’ll have to find another job. words come to mind when she thinks about Medi-Cal, she said, “Help — they help you.” California Health Care Foundation www.chcf.org 12 Because of coverage through Medi-Cal, Most interview participants had previous experience working enrollees who were interviewed can with coverage from an employer or with periods where access care and manage their health. they went without insurance. People who experienced Interview participants described how fears of medical either of those situations discussed how the costs bills would make them less likely to seek both preven- associated with care led them to avoid the health sys- tive services and screenings, as well as care when they tem. Several examples of participants who were once are sick or injured, if they did not have Medi-Cal cover- covered by employer-sponsored plans included an age. They feel comfortable seeking care only because African American man who stopped care for treatment they are covered by Medi-Cal and do not need to pay of facial keloids (scars that were painful and impacting for most care. his mental health) due to copays, a white woman who Lydia, 40, warehouse worker, Fresno County Lydia is a 40-year-old resident of Fresno, a city she has Though Lydia and her husband report not needing a lot lived in for almost 20 years and which she describes of health care services, Lydia noted Medi-Cal coverage as having extreme weather patterns and lots of smog. has been helpful for her family, particularly for her kids Lydia lives with her husband, an 18-year-old son, a and her parents. She recounted that when her son was 10-year-old daughter, and her parents. Both Lydia and born, he had a heart murmur and needed open-heart her husband work in dry fruit packing, a seasonal job surgery. Lydia noted that without Medi-Cal, “I don’t she has been doing for almost four years. Lydia works know what we would’ve done. We would’ve gone eight hours a day on average but notes that, because crazy because the child needed the operation, and we the job is seasonal, there are periods where there are didn’t have the money.” Medi-Cal helps cover her chil- more or fewer hours available depending on need. dren’s regular checkups as well as inhalers and allergy Though Lydia originally felt secure at her job, layoffs medicine for her daughter, who has asthma. Lydia also there due to COVID-19 have made her more fearful says Medi-Cal has helped her parents have access to about losing her job. She noted she tries not to ask for services that they wouldn’t otherwise due to cost. For time off for fear that they’ll respond, “Well, it’s best that example, her father needed eyeglasses but was unable you don’t come back.” to afford them without coverage through Medi-Cal. Lydia is generally able to afford the essentials, and Medi-Cal provides Lydia with peace of mind; she notes her family tries to budget but notes having periods of that having Medi-Cal helps with stress and improves hardship. When making considerations around costs or her family’s health: “The advantage is that they help expenses, food is often one of the expenses that she with stress. Your health is better because of going for looks to cut back. Lydia notes, “I don’t know why, but checkups. Not having to worry about someone getting the food is what we look at. Because, well, you can’t sick and you not having the money to take them to change the rent. The bills, maybe a little more electric- the doctor. . . . Like my daughter, who has her inhalers ity, but you try to watch it. At any rate, it ends up being for asthma. She has them on hand. She always brings the same price. . . . It’s about the food, the foods you them with her. You know that if you have an accident or buy.” She limits her food budget by making less expen- something, you know that you can go to the hospi- sive meals for her family like rice, soup, and lentils. tal. You’re worried about your health, but you’re not To make ends meet, she relies on loans from friends, worried about the cost.” Despite this assurance, Lydia and she and her husband look for other temporary job does note there are still instances her family must forgo opportunities such as construction jobs. Lydia noted medical services due to cost. Though the dentist noted that the economic pressure makes her stressed and her daughter needed braces, because they weren’t depressed, stating “with depression . . . you feel over- covered by Medi-Cal, Lydia decided to not get braces whelmed. You feel that the time to pay rent goes very for her daughter since she cannot afford them. fast every month, and you’re afraid you won’t be able to pay the whole amount.” Lydia manages the stress by participating in Zumba classes or going for a walk. Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 13 avoided the system after a large medical bill for her I would say that without Medi-Cal I wouldn’t husband’s MRI, and a Latinx woman who described the premium contribution coming out of each pay- even go to the doctor when I was sick. I check as “taking our food money.” would only go to the hospital when it was an Interview participants who experienced periods with- emergency. . . . The people who don’t go to out insurance described seeking care only when it doctor’s visits when they’re sick end up in the was an emergency or when they were in “extreme pain,” and several expressed the belief that the emer- emergency room eventually. . . . That’s going gency room was their only option for care. Individual to cost everybody more in the long run. respondents describe either skipping annual screen- ings and wellness visits to avoid paying cash out of It provides a lot of security. Since I’ve had pocket or reported trying “home remedies” to deal with what they considered more minor maladies (e.g., the Medi-Cal active, I’ve thought, ‘Hey, you an ear infection). Each of the participants described know, this is really great because if I think I’ve in the examples above confirmed that they were able to resume treatment or seek both primary care and been exposed to COVID, I will go get a test.’ treatment for more urgent matters without fear or hes- Whereas in the past I would have just been itation now that they are covered by Medi-Cal. like, ‘Well, now I’ll never know.’ Interviewed workers consistently said that — 43-year-old white and Native American / prevention was a priority to them, and they Alaska Native woman put a premium on the ability to access care In-Home Supportive Services employee, Chico for chronic or urgent needs. Interview participants repeatedly discussed the impor- tance of preventive and primary care and expressed gratitude that they were able to access these services through Medi-Cal for both themselves and their chil- The advantage of [Medi-Cal] is that they dren. Participants cited screenings, annual checkups, help with stress. Your health is better and for children, prenatal care and regular well-child visits as services that they access through Medi-Cal. because of going for checkups. Not having Similarly, a number of workers who take prescription to worry about someone getting sick and medication for chronic conditions conveyed an under- standing of how much their medications would cost you not having the money to take them to out of pocket, or even with copays. They discussed the doctor. . . . You know that if you have an how they may not be able to feel as well as they do without their access to prescription medications accident or something, you know that you can through Medi-Cal. People interviewed expressed their go to the hospital. You’re worried about your pleasant surprise in the generous coverage offered health, but you’re not worried about the cost. by Medi-Cal, especially for things they believed are expensive, including emergency room care, emer- — 40-year-old Latinx woman gency surgery, and prescription medications. packing house worker, Fresno California Health Care Foundation www.chcf.org 14 Medi-Cal provides peace of mind to the Knowing [you can get] the checkups with workers in this study population. the doctor, knowing that everything is doing Most interview participants expressed appreciation that they do not have to worry about the cost of health good . . . that means that your lifestyle and care while enrolled in Medi-Cal. Interview participants the way that you’re eating, that exercise and felt “protected,” “really at ease,” and “secure” know- everything is okay. And it’s just if you don’t ing that their Medi-Cal will cover the costs associated with their and their family’s health care. Participants have this kind of checkup, you might be doing conveyed how concern and worry associated with something wrong or might have some issues, health care expenses at times impacted their mental health and sense of well-being, and a majority of par- and you don’t know until they get very bad. ticipants identified that having Medi-Cal significantly reduced their stress and anxiety about getting sick — 30-year-old Black man, Tulare and not being able to afford needed care. While some participants described a few health care I know I would be a lot sicker because costs that Medi-Cal didn’t cover, most stated that hav- I wouldn’t have been able to get the ing health insurance through Medi-Cal allowed them to see the doctor and get the basic care they need medical care that I need, or if for whatever when they need it, without worrying about costs. The reason I got the care, I would be much more most commonly reported health care expenses that stressed because of the financial burden. Medi-Cal didn’t cover were certain types of prescrip- tion medications, followed by higher levels of vision and dental care. In the few cases where Medi-Cal did If I didn’t receive the services [from not cover all health care expenses, interview partici- Medi-Cal], I think I’d feel a lot sicker. . . . pants described working with providers or with the program directly to get services covered or to find out Given the limitations that I have had more about what their out-of-pocket expenses would financially and physically, [Medi-Cal] be and how they could pay them. has made a huge difference. A few participants described how having Med-Cal — 63-year-old white woman provides a new sense of security given the ongo- retail sales employee, East Bay ing COVID-19 pandemic. One participant noted, “Knowing that I have Medi-Cal, that I’m covered in anything, that if I get sick, if I get the coronavirus, if I need some assistance, I know it’s going to be there [Medi-Cal] is a relief, peace of mind, that for me.” In some cases, this sense of security allowed last thing that I don’t have to carry on my participants to continue to work, including in jobs out- side the home. shoulders. It’s not extra stress. — 38-year-old Latinx woman childcare provider, Sacramento Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 15 Susan, 63, retail sales, East Bay Susan is 63 years old and lives in the East Bay, in what After Susan lost her previous job in education, she she considers “a rural suburban area.” She lives with received a letter from the state outlining her health care her older brother, who is a carpenter working for the coverage options, and she applied for Covered Cali- University of California. She grew up in California but fornia. Covered California enrolled her in Medi-Cal due moved away for many years and then came back sev- to her income at the time. While it took a few months eral years ago for a job in mental health and education. for her application to process, Medi-Cal extended her Unfortunately, shortly after she started this new job, eligibility back to the date when she applied, so all the she was diagnosed with a pre-invasive form of breast services she needed were covered. After gaining her cancer, ductal carcinoma in situ. The job she had at Medi-Cal coverage, she started her cancer treatment. the time would not allow her to take the six weeks off Her doctors monitored her closely, gave her medica- recommended by her doctors to receive treatment and tions and physical therapy, and she continues to see recover. She was let go shortly after her diagnosis. Her an oncologist every six months. She feels that she treatment and recovery ended up taking six months, “wouldn’t have been able to afford any of the treatment and she noted that she “was totally not able to do any- that I have had” for her diagnosis without Medi-Cal. thing for six months after the surgery.” In the past nine Additionally, she emphasized that “if I didn’t receive the months she has been able to start working again. She services, I think I’d feel a lot sicker.” Currently, she feels currently works two part-time jobs; one fulfilling orders her health is good and she is in the “healing phase.” at Macy’s and one in financial services. Medi-Cal has paid for all of Susan’s care. “My prescrip- Susan finds her work at Macy’s enjoyable because she tions are covered, my doctor visits are covered, and any gets to be physically active during the day, which has medical exams I have had to take have been covered been a struggle in the past year both during her cancer so far.” She is very grateful to Medi-Cal for providing treatment, which left her partially disabled for a few her with the care she needed at the time she needed it: months, and her recovery. The financial services industry “I think, given the limitations that I have had financially is new to her, but she is appreciative of her organization and physically, it’s made a huge difference.” She also and her role as an educator helping people find better believes that Medi-Cal is attentive to people and even vehicles for saving and growing their money. Neither mentioned that they send her information related to of her jobs offers paid sick leave, and while one of her age and specific health needs. She articulated that them does have an option for health insurance, it is too having Medi-Cal helped improve her mental health, as expensive for her to afford at this time. She noted that well as her physical health, and when discussing what “since I began working, I work part-time, and I make so her life would be like without Medi-Cal, she said, “I little that I am still within the eligibility for Medi-Cal.” know I would be a lot sicker because I wouldn’t have Susan has been struggling financially recently and finds been able to get the medical care that I need, or if for that she can barely afford to pay monthly expenses. She whatever reason I got the care, I would be much more has delayed payments on many expenses due to the stressed because of the financial burden.” Today, Susan fact that Macy’s has provided her with fewer working feels blessed for having been able to afford the treat- hours since the start of the COVID-19 pandemic. She ment she needed and for her ability to recover and feel was able to cover other costs based on accommoda- healthy enough to move and work again: “Being able tions from lenders and financial help from her brother. to move and physically get some exercise every day These financial troubles make her feel “stressed all the is actually building and making me stronger, so while time” and often she prays, “Please don’t let anything anything could happen at any point, there is also the go wrong this month.” To cope with financial stress, she part of me that feels like I am healthy, doing all the right prays a lot and talks with friends. things to stay healthy. . . . Feeling blessed.” California Health Care Foundation www.chcf.org 16 Interview participants detailed their People need to realize just because we are on commitment to work and improving their Medi-Cal doesn’t mean we are not working. financial situation. Across all of the interview participants, there were We are hard workers; we just cannot afford deep expressions of pride in hard work. In response the health care system. to hearing the misperception that Medi-Cal enrollees were not working or didn’t want to work, respondents — 61-year-old white woman conveyed that anyone who said this is judgmental church office assistant, near San Diego and relying on inaccurate assumptions. A number of respondents asserted that “just because we are on Medi-Cal doesn’t mean we are not working.” One participant pushed back on this depiction of Medi-Cal I would want people to think that just enrollees by detailing her struggle to find a job and because I’m on Medi-Cal, don’t assume that stating that “what I would want people to understand, if they were judgmental about Medi-Cal and people I’m not working. Maybe it’s just because I’m just not working or being too lazy to work, is that it’s working, but I can’t afford the other medical darn hard. It is darn hard to find a job.” Another par- ticipant described the contradiction inherent in the coverages. So just for you to assume that judgment of those covered by Medi-Cal as lazy or not I’m not working ’cause I’m receiving it? interested in working by listing their multiple jobs and noting that none offer health insurance. That’s not right. — 29-year-old Black woman Many interview participants explained that Medi-Cal In-Home Supportive Services employee, outside L.A. is a government-sponsored benefit for working-class families with low income, and that while some people who use the program might not be able to work, the “vast majority” are committed to finding and main- For us, I mean, even though we work, it taining stable employment. Participants described themselves as “hard workers” who “cannot afford the wasn’t enough for us to make it. We weren’t health care system.” Many participants have never making enough money to also have another had the option to get health insurance through their employers and, while they do work, they generally insurance that has as much as Medi-Cal was don’t make enough to “afford regular insurance.” providing to us. So, again, I think for us it Further, one participant characterized the dilemma of individuals enrolled in Medi-Cal as they are “lower- was very beneficial for our family. It’s not that class people who don’t earn as much money or can’t we don’t try. I mean, we’re working but we afford to pay the higher cost of insurance through weren’t making enough that it would cover their employer, which takes a lot out of their check.” As described earlier in this brief, interview participants our medical bills or insurance. So this helped were living close to the financial edge and generally a lot for us. had enough money to cover basic needs, but not to cover unexpected or additional expenses. This means — 51-year-old Asian man that Medi-Cal is often the only option low-wage work- pastor, L.A. ers have for affordable health insurance coverage. Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 17 Despite overall satisfaction with The interviews with working Medi-Cal enrollees reveal Medi-Cal, interviewees noted challenges a population that takes pride in working hard yet lives with the program. on the financial edge, struggling to make ends meet Interview participants described how basic health care in a high-cost state. Private health coverage remains is generally covered, but that additional or more com- out of their reach, either because their employer plex health needs related to vision and dental care can doesn’t offer it, or they can’t afford what is offered to come with a cost to the enrollee. Additionally, some them. Medi-Cal provides peace of mind, especially participants expressed the belief that they would during the COVID-19 pandemic, and allows enrollees get higher-quality care if they were enrolled in pri- to access important preventive services and care for vate insurance. A few participants mentioned feeling chronic conditions. that Medi-Cal limits their options for selecting certain providers, medications, or treatments. Some others For a program as important to California as Medi-Cal, described challenges with accessing the Medi-Cal it’s critical that the public, policymakers, and other key system, including long wait times for getting appoint- audiences understand the role that Medi-Cal plays in ments and burdensome documentation requirements covering working Californians and the impact the pro- for enrollment and eligibility. Overall, interview partici- gram has on the lives of working enrollees. pants are satisfied with their Medi-Cal coverage. This safety net is more important than ever during the pandemic, not just for the state’s “essential work- Conclusion ers” already enrolled in Medi-Cal but for the many California workers likely to turn to the program in the In 2018 42% of Californians said that they believed coming months as they lose their job-based coverage that most nondisabled adults enrolled in Medi-Cal are and income. unemployed, while another 20% said they didn’t know. The idea that nondisabled adults in the program are unemployed can undermine support for the program by the public or policymakers. It also perpetuates an unhelpful stigma, which might discourage enrollment among some. The data paint a different picture: The vast major- ity (64%) of nondisabled adults enrolled in Medi-Cal work, and the program covers close to three million working Californians, which constitutes a substantial percentage (16%) of all working Californians. California Health Care Foundation www.chcf.org 18 Appendix. Methods UC Labor Center Analysis of 2018 ACS Data Table A1. P articipant Demographics for In-Depth The industry-specific Medi-Cal enrollment estimates Interviews by NORC are based on analysis of American Community Survey PARTICIPANTS NUMBER (PERCENTAGE) data adjusted upward by 16% to reflect the percent- age by which the Medi-Cal enrollment total from Medi-Cal Enrollees 19 (100%) the California Department of Health Care Services Employed (full- or part-time) 19 (100%) in June  2018 (12.2 million) exceeded the estimated Preferred Language Medi-Cal enrollment total reflected in the American Community Survey 2018 (10.5 million). The 12.2 mil- $ English 14 (74%) lion administrative enrollment total excludes nearly $ Spanish 5 (26%) 1 million Californians enrolled in restricted-scope Gender Medi-Cal who are only eligible for emergency and pregnancy-related services. Survey data typically show $ Female 13 (68%) lower Medicaid enrollment than administrative data $ Male 6 (32%) for a variety of methodological reasons. Race $ Non-Latinx Black 2 (11%) In-Depth Interviews by NORC $ Non-Latinx Asian 2 (11%) Demographics $ Non-Latinx White/Other 6 (32%) Table A1 provides a demographic breakdown of inter- $ Latinx 9 (47%) view participants. Geographic Area Survey respondents were asked whether they iden- $ Urban 13 (68%) tified as Hispanic or Latino, and then asked about their racial identity and offered the option to select $ Rural 6 (32%) any response options that applied. For the purpose Region of this report, all Hispanic and Latino respondents $ Bay Area 2 (11%) will be referred to as Latinx. All respondents were then categorized broadly based on their responses $ Central Coast 2 (11%) to the questions as Non-Latinx White, Black, Asian, $ Inland Empire 1 (5%) Multiracial, and Other. All of the respondents who did $ Los Angeles 3 (16%) not identify as Hispanic are referred to in this report with simplified labels (Black, Asian, White, etc). $ Northern and Sierra 2 (11%) $ Sacramento 1 (5%) $ San Joaquin 5 (26%) $ Other Southern California 3 (16%) Household Mix $ Single 4 (21%) $ Family 15 (79%) Note: Source used the terms Hispanic or Latino. Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 19 Outreach and Screening a California-based market research firm for support in To identify potential respondents for in-depth inter- recruiting and scheduling additional one-hour inter- views, NORC leveraged a separate California Health views with Spanish-speaking participants who met Care Foundation grant for which NORC was fielding the above criteria. NORC’s goal was to represent the a survey of Californians with low incomes. The pur- diversity of California’s geography and population, to pose of that survey was to understand the health care the extent possible, in the study population of 15–20 wants, needs, and values of the study population, spe- participants. NORC was able to accomplish this goal cifically related to the COVID-19 pandemic. Potential by tracking the characteristics of completed cases and participants were recruited by sending invitations to targeting outreach and recruitment of those who met members of NORC’s AmeriSpeak Panel and partner certain gender, race, ethnicity, geography, and house- Dynata’s panel. People qualified to take the survey hold size criteria toward the end of the data-collection who: effort. $ Lived in California Interview and Analysis Process $ Were between 18 and 64 years old Interviewers followed a semi-structured discussion guide developed by NORC and CHCF to facilitate the $ Had seen a doctor or health care provider interviews. With the permission of the participants, in the past 18 months interviewers recorded the audio to allow for appropri- $ Spoke English, Spanish, Cantonese, or ate translation and transcription of the conversation. Vietnamese The interviews lasted between 45 and 60 minutes, and interviewees received a $50 gift card to thank them for For this study on working Californians also enrolled their participation. Audio recordings were transcribed, in Medi-Cal, survey respondents were identified who and transcripts were thematically coded using NVIVIO agreed to participate in an interview and who: software. $ Were enrolled into Medi-Cal $ Were employed either full-time or part-time $ Lived in households at or under 200% of FPL $ Spoke English or Spanish $ Agreed to be contacted for additional research At the time this study commenced, NORC identified 85 cases from the survey data who met the inclusion criteria to participate in an interview. NORC sent invi- tations to 66 of the 85 via phone and/or email to ask whether they were interested in participating, and to rescreen invitees to ensure each qualified for the in- depth interviews. Twenty-seven of the 66 responded, and after excluding those who did not meet the eligibility criteria above, NORC scheduled and con- ducted 14 interviews in English and 1 in Spanish. After exhausting the sample of Spanish speakers from the survey, and to ensure representativeness from Spanish speakers in this study, NORC contracted with California Health Care Foundation www.chcf.org 20 Endnotes 2019 Edition — Medi-Cal Facts and Figures: Crucial 1. Coverage for Californians with Low Incomes, California Health Care Foundation (CHCF), February 2019. Medi-Cal at a Glance, Most Reported Recent Month (PDF) 2. (March 2020), California Dept. of Health Care Services (DHCS), June 2020. The Health Care Priorities and Experiences of California 3. Residents (PDF), CHCF, January 2019. 4.This estimate is based on analysis of American Community Survey data adjusted up by 16% to reflect the percentage by which administrative Medi-Cal enrollment data from the California Department of Health Care Services in June 2018 exceeded the estimated Medi-Cal enrollment reflected in the American Community Survey 2018. The estimate excludes nearly one million Californians enrolled in restricted-scope Medi-Cal who are only eligible for emergency and pregnancy- related services. See the appendix for further details. 5.Kevin Lee et al., “Job-Based Coverage Is Less Common Among Workers Who Are Black or Latino, Low-Wage, Immigrants, and Young Adults,” UC Berkeley Labor Center Blog, November 22, 2019. 6.Rachel Garfield et al., “Understanding the Intersection of Medicaid and Work: What Does the Data Say?,” KFF, August 8, 2019. 7.Federal guidance issued at the time exempted both groups from state Medicaid waiver proposals that would impose work requirements in Medicaid as a condition of eligibility. California has not pursued work requirements. 8.Kevin Lee et al., “Job-Based Coverage.” 9.Laurel Lucia et al., “Health Coverage of California Workers Most at Risk of Job Loss Due to COVID-19,” UC Berkeley Labor Center and UCLA Center for Health Policy Research, May 8, 2020. 10.Matt Broaddus, “5 Million Essential and Front-Line Workers Get Health Coverage Through Medicaid,” Center on Budget and Policy Priorities, August 4, 2020. 11.See, for example, Laurel Lucia et al., “Health Coverage”; and Rachel Garfield et al., “Eligibility for ACA Health Coverage Following Job Loss,” KFF, May 13, 2020. 12.“COVID-19 Uninsured Group Program,” DHCS, accessed July 17, 2020. 13.Data source uses American Indian / Alaska Native. Working Californians Enrolled in Medi-Cal Share Their Stories www.chcf.org 21