SMALL AREA ESTIMATES OF HEALTH INSURANCE COVERAGE:

SMALL AREA ESTIMATES OF HEALTH INSURANCE COVERAGE: A LOCAL HEALTH DEPARTMENT PERSPECTIVE Sanaa Abedin, MPH sanaa.abedin@sdcounty.ca.gov Epidemiologist, Public Health Services Community Health Statistics Unit

Jun-2006 Jan-2007 Aug-2007 Mar-2008 Oct-2008 May-2009 Dec-2009 Jul-2010 Feb-2011 Sep-2011 Apr-2012 Nov-2012 Jun-2013 Jan-2014 Aug-2014 Mar-2015 Oct-2015 May-2016 Recipients WHAT WILL THIS PRESENTATION COVER OVERVIEW San Diego County Demographics Uninsured at Point in Time Insurance Coverage Distribution Sociodemographic Factors and the Uninsured 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Medi-Cal Recipients in San Diego County, 2006-2016 06/06, 256,255 ACA Enacted Medi-Cal Expansion 08/16, 742,077 Changes in the rate of health insurance coverage reflect^: Economic trends Demographic shifts Policy changes, such as the Affordable Care Act (ACA) ^http://www.shadac.org/sites/default/files/publications/shadac%20acs-cps-webinar_2016_final_sept21.pdf#overlaycontext=publications/new-data-acs-cps-annual-conversation-census-bureau-experts-webinar

THE VISION Building Better Health Living Safely Thriving 3

DATA SOURCES Regional and Subregional Trends American Community Survey 5-Year Data on Health Insurance Coverage San Diego County Trends American Community Survey 1-Year Data on Health Insurance Coverage San Diego County, California and US Trends U.S. Census Bureau, Small Area Health Insurance Estimates American Community Survey 1-Year Data on Health Insurance Coverage Health Access California Health Interview Survey Table S2701 ACS Table Contents/Data HEALTH INSURANCE COVERAGE STATUS: Age Group Sex Race/Ethnicity Nativity/Citizenship Educational Attainment Employment Status Work Experience Household Income Federal Poverty Level Health Coverage Type

San Diego County 2 nd most populous county in California and 5th most populous in the United States San Diego has: Close to 3.2 million residents. Majority minority population. Busiest land border crossing in the world 1 of every 13 people who enter US come through San Ysidro. 70 miles of Coastline. 16 naval and military installations. 18 federally recognized Indian reservations. A total area of 4,526 square miles, larger than Rhode Island and Delaware combined.

White Black Hispanic API Other 0-17 18-64 65+ Citizen Non-Citizen 0-99 100-199 200-299 300+ 5% 6% 4% 4% 10% 13% 14% 13% 11% 13% 23% 24% 17% 20% 11% 14% 19% 20% 47% 39% 33% 39% 52% 47% 63% 63% 89% 87% DEMOGRAPHICS SELECTED DEMOGRAPHIC CHARACTERISTICS OF THE SAN DIEGO COUNTY POPULATION, COMPARED TO CALIFORNIA OVERALL, 2015 San Diego County California Note: Data may not add to 100% due to rounding and data restrictions Asian & Pacific Islander Source: UCLA Center for Health Policy Research. California Health Interview Survey (CHIS), 2014. Prepared by: County of San Diego, Health & Human Services Agency, Public Health Services, Community Health Statistics Unit, 2016

HEALTH INSURANCE IN SAN DIEGO COUNTY

Percent Uninsured (%) Percent Uninsured US, STATE & COUNTY TRENDS IN THE UNINSURED Since 2010: San Diego County: - 8.8 percentage points California: - 9.9 percentage points US: - 6.1 percentage points 30 25 20 Uninsured Among Civilian Noninstitutionalized Population by Age, 2009-2015 24.4 25.3 24.9 24.7 23.9 22.1 22.9 23 22 21.5 20.1 20.7 20.2 20 19.4 18.8 19.1 19 15 18.4 17.9 16 12.1 10.8 14.1 9.6 8.6 8.9 8.3 11.6 10 13.4 6.6 9.7 10 9.5 8.6 9.5 5 8.4 7.9 3.6 5.8 0 3.6 2009 2010 2011 2012 2013 2014 2015 18 to 64 years - California 18 to 64 years - San Diego County, CA Under 19 years - California Under 19 years - San Diego County, CA Under 65 years - California Under 65 years - San Diego County, CA 17.3 Uninsured Among Civilian Noninstitutionalized Population, 2009-15 35% 30% 25% 20% 15% 10% 5% 0% 2009 2010 2011 2012 2013 2014 2015 United States 15.1% 15.5% 15.1% 14.8% 14.5% 11.7% 9.4% California 18.0% 18.5% 18.1% 17.9% 17.2% 12.4% 8.6% San Diego County 17.0% 17.6% 17.4% 17.0% 16.3% 12.3% 8.8% Since 2010: Generally, all age groups experienced a decline in the percent uninsured for both the county and state. The 18-64 year age group experienced the greatest decline in number of people uninsured under the ACA.

** Please Note: 2012 and 2015 San Diego County percentage of uninsured come from ACS 1-Year estimates; whereas, 2012 and 2015 San Diego County HHSA Region and Subregional estimates come from ACS 5-Year estimates. The sub-county estimates are underestimates of the actual percentage of uninsured for 2015. UNINSURED IN SAN DIEGO COUNTY 100% 80% 60% 40% 20% 0% Comparison of ACS 1-Year and 5-Year Estimates of San Diego County's Uninsured Population, 2012-2015 17.1% 16.8% 15.9% 14.1% 17.0% 16.3% 12.3% 8.8% County of San Diego 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 2008-12 (ACS 5-Year) 2009-13 (ACS 5-Year) 2008-14 (ACS 5-Year) 2011-15 (ACS 5-Year) 2012 (ACS 1-Year) 2013 (ACS 1-Year) 2014 (ACS 1-Year) 2015 (ACS 1-Year) 0.0% Uninsured San Diego County Residents by Health & Human Services Agency Region, 2012-2015 (5-Year Est.) 2008-12 2009-13 2010-14 2011-15 25.1% 20.6% 15.8% 12.9% 11.1% 9.5% 16.2% 15.5% 12.7% 13.4% 20.7% 16.9% 2012 SDC % Uninsured 2015 SDC % Uninsured Central East North Central North Coastal North Inland South

Percentage (%) SOCIODEMOGRAPHICS BY HHSA REGION Poverty Among San Diego County Residents by HHSA Region, 2014 & 2015 (Pooled) 0-99% FPL 100-199% FPL 200-299% FPL 300% FPL and above 57.2 64.2 41.7 35.2 42.4 51.7 49.6 7.4 9.9 15 27.2 25.9 19.4 15.3 13.5 15.5 12.3 13.5 14.8 7.6 23.8 29 22.2 16.3 19.9 16 16.7 17.1 North Coastal North Central Central South East North Inland San Diego County

SOCIODEMOGRAPHICS BY HHSA REGION 1 1 1 1 66.0% Type of Usual Source of Care by HHSA Region in San Diego County, 2014-15 (Pooled) 63.9% Doctor's office/hmo/kaiser Community clinic/government clinic/community hospital Emergency room/urgent care, Some other place/no one place No usual source of care 70.6% 50.3% 50.6% 61.4% 60.7% 0 0 0 0 0 19.9% 20.2% North Coastal 12.9% 11.9% North Central 28.2% 20.4% 29.6% 18.1% 17.4% 9.6% 25.0% Central South East North Inland 11.5% 23.3% 2.1% 13.9% San Diego County

Percentage (%) SOCIODEMOGRAPHICS BY HHSA REGION Delay in Care Experienced by San Diego County Residents by HHSA Region, 2013-15 (Pooled) Healthcare system/provider issues and barriers or Personal reasons Cost, lack of insurance, or other insurance-related reasons 47.1 50.1 37.5 37.8 47.7 42.3 52.9 49.9 62.5 62.2 52.3 57.7 North Coastal North Central Central South East North Inland San Diego County

** Please Note: 2012 and 2015 US, CA and San Diego County percentage of uninsured come from ACS 1-Year estimates; whereas, 2012 and 2015 San Diego County HHSA Region and Subregional estimates come from ACS 5-Year estimates. The sub-county estimates are underestimates of the actual percentage of uninsured for 2015. UNINSURED IN SAN DIEGO COUNTY US: 9.4% CA: 8.6% 2015: SAN DIEGO COUNTY: 8.8%

HEALTH CARE COVERAGE TYPE

UNINSURED UNINSURED BY CITIZENSHIP/NATIVITY

Percent Uninsured Percent Uninsured Percent Uninsured Percent Uninsured UNINSURED AMONG NATIVE BORN AND FOREIGN BORN Uninsured Among Native Born, 2009-15 Uninsured Among Foreign Born, 2009-15 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2009 2010 2011 2012 2013 2014 2015 United States 12.5% 12.7% 12.4% 12.1% 11.9% 9.4% 7.4% California 12.8% 13.1% 12.9% 12.9% 12.4% 8.6% 5.5% San Diego County 13.0% 13.4% 12.9% 12.9% 12.2% 9.0% 5.9% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2009 2010 2011 2012 2013 2014 2015 United States 33.6% 34.3% 33.6% 32.8% 32.1% 26.5% 22.2% California 32.0% 32.9% 32.0% 31.3% 30.1% 22.6% 16.7% San Diego County 30.4% 31.0% 31.8% 30.3% 29.0% 22.9% 17.5% Uninsured Among Foreign Born Naturalized Citizens, 2009-15 Uninsured Among Foreign Born Non-citizens, 2009-15 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2009 2010 2011 2012 2013 2014 2015 United States 15.7% 16.4% 16.6% 16.2% 16.1% 11.4% 8.4% California 16.1% 16.9% 16.5% 16.2% 15.5% 9.6% 5.8% San Diego County 14.4% 16.4% 15.3% 14.9% 14.4% 10.3% 6.7% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2009 2010 2011 2012 2013 2014 2015 United States 47.4% 48.3% 47.4% 46.7% 46.0% 40.0% 34.9% California 45.4% 46.4% 45.7% 45.1% 43.9% 35.2% 27.4% San Diego County 44.2% 43.1% 46.3% 44.6% 42.4% 35.2% 29.0%

UNINSURED BY CITIZENSHIP/NATIVITY

UNINSURED BY CITIZENSHIP/NATIVITY

SUMMARY OF ADDITIONAL SOCIODEMOGRAPHIC FACTORS Uninsured status was highest among adults (25 years and older) with less than high school education; however, this group saw the largest drop in uninsured status overall between 2012-2015 (- 16.5% points) Particularly high among communities in Northern San Diego (Anza-Borrego Springs and San Marcos; 55.1% and 54.0% respectively) in 2011-15 Adults working part-time had a higher percentage of uninsured, when compared to full-time or adults who did not work, at 15.2% in 2015. Highest in Palomar-Julian (46.0%) and National City (43.8%) in 2011-15 Unemployed adults(18+ years) had the largest percentage of uninsured adults at 21.3% in 2015 compared to employed adults and those not in the labor force. Valley Center and National City had the highest percentage (54.4% and 54.8% respectively) in 2011-2015 Households with incomes between $25,000 and under $50,000 had the largest percentage of uninsured at 14.0% in 2015. Especially high in National City and Central San Diego; 33.3% and 31.0%, respectively in 2011-15

SUMMARY: IMPACTS OF THE ACA IN SAN DIEGO COUNTY Who Were More Likely to Remain Uninsured in San Diego County? Foreign born non-citizens (29%) Adults < HS Graduation (23.6%) Unemployed (21.3%) Groups with the largest decreases in the uninsured in 2015 were: Unemployed (- 24.8%) Adults with less than high school graduation (- 16.5%) Hispanics (- 14.7%) Foreign born non-citizens (- 14.1%) Households making <$25K (-12.9%) Adults ages 18-64 years (- 11.3%) Individuals below 138% of FPL(16%) Adults 25-34 year olds (15.4%) American Indian/Alaska Native (21.7%) and Hispanics (15.3%) Part-time workers (15.2%) Household making $25K-$49.9k (14%)

QUESTIONS? Soon to be Released Report from Community Health Statistics Unit: Sanaa Abedin, MPH Epidemiologist sanaa.abedin@sdcounty.ca.gov County of San Diego, Health & Human Services Agency, Public Health Services For more information, including data, resources and reports, from Public Health Services: www.sdhealthstatistics.com