facts and figures A California Perspective February 2006
Introduction Introduction California has the largest number of beneficiaries of any state over 4 million enrollees and as the population ages, the percentage of Californians with will continue to rise. California s entire elderly population, those 65 and over, will grow nearly 130 percent by 2030. The increase is especially striking among those 85 years and over. Across California s counties, the growth of this population has ranged from 33 percent to over 150 percent since 1990. The diversity of coming populations will also increase in the next decades and, accordingly, the number that speak non-english languages will likely continue to grow. Overall, spending continues to rise, with approximately 10 percent of all current expenditures occurring in California. California s spending per beneficiary is also higher than the national average about $700 more per beneficiary per year the eighth highest in the nation. This profile provides a factual framework to help consumer advocates, health care providers, and policymakers better understand California s population and inform their efforts to design programs and policies that meet beneficiaries needs. Data are drawn from the most recent national and statelevel sources available. Some of these charts rely on data from a sub-sample of the 2002 Current Beneficiary Survey (MCBS) in California. The MCBS is a stratified random sample of beneficiaries representing the entire population of aged and disabled beneficiaries and is not necessarily representative of each state. The MCBS sample for California includes 1,049 residents. Where possible, results were confirmed by comparison with Census records, the California Health Interview Survey, CMS, and Social Security statistics. There are more than 4 million beneficiaries in California and those numbers will continue to grow as the baby boomers age. 2006 California HealthCare Foundation 1
Population Growth Rates Elderly vs. Non-elderly California and the U.S., 2000 to 2030 Overview Projections of population growth in California show Non-elderly (< 65) 19% 26% U.S. California that the elderly population will grow much faster than the non-elderly population over the next 25 years due to the aging of the baby boomers. 104% Elderly (65+) 131% Note: The under-65 population in the nation is expected to grow by 45.7 million by 2030, including growth of 7.9 million in California. The national elderly population is expected to grow by 36.5 million over the same period, with 4.7 million of this growth occurring in California. Source: Table 4: Interim Projections: Change in Total Population and Population 65 and Older, by State: 2000 to 2030. U.S. Census Bureau, Population Division, Interim State Population Projections, 2005. 2006 California HealthCare Foundation 2
Enrollment in California and Selected States Overview There are 40.2 million Total Population Americans enrolled in 35,000,000 30,000,000 12% Enrollment as Share of Total Population Non- Population in the United States. California has the largest number of 25,000,000 beneficiaries in the nation 20,000,000 11% at 4.1 million, but ranks 14% much lower 46th in the 15,000,000 17% nation as a share of the 10,000,000 17% total population. 5,000,000 0 California Texas New York Florida Pennsylvania Note: Enrollment for California is 4,078,426; Texas 2,390,053; New York 2,763,299; Florida 2,920,971; and Pennsylvania, 2,110,470. Source: Centers for and Medicaid Services, Enrollment Data for July 2003 and Census Bureau State Population Estimates 2000 2005 (NST-EST2005-01). 2006 California HealthCare Foundation 3
Eligibility for California, 2002 ESRD Disabled 11% 2% Overview The majority of beneficiaries in the state are over 65. Eleven percent are eligible due to disability status, and a smaller percentage have end-stage renal disease (ESRD). Elderly 87% Note: One-third of enrollees with ESRD are disabled and another one-third are 65 or older. The remaining one-third is not otherwise eligible for. These enrollees are all included in the ESRD section above. Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 4
Elderly Population Growth by County, 1990 to 2004 Age 65 to 84 Median and Below (21%) Above Median Age 85 and older Median and Below (87%) Above Median Overview Every county in California has experienced significant growth in the elderly population in the last 15 years. Even more dramatic is the growth among those 85 and older, with a median growth rate of 87 percent. Source: Calculated from both the 1990 and 2000 Census data. The 1990 data is available in archived population estimates (www.census.gov/popest/archives/1990s/co-99-13/cacamars.txt). The 2004 data is a projection from the 2000 Census in the file County estimates by demographic characteristics age, sex, race, and Hispanic Origin: Selected Age Groups and Sex (www.census.gov/popest/datasets.html). See appendix for more information on growth rates by county. 2006 California HealthCare Foundation 5
Beneficiaries with Disabilities California, 1999 to 2004 Overview The number of beneficiaries with 452,000 465,000 481,000 500,000 522,000 550,000 disabilities has grown steadily over the past five years. 1999 2000 2001 2002 2003 2004 Source: Table 83B, Hospital Insurance and/or Supplementary Medical Insurance: Number of disabled enrollees, by census division and state or other area, July 1, 1980 2004, selected years (in thousands), 2003 Annual Statistical Supplement, 2005 (www.ssa.gov/policy/docs/statcomps/supplement/2003/index.html, www.ssa.gov/policy/docs/statcomps/supplement/2005/index.html). 2006 California HealthCare Foundation 6
Beneficiary Income Distribution California, 2002 Under $5,000 3% $5,000 to 14,999 Disabled Elderly 29% Overview Most beneficiaries rely on relatively modest means. $15,000 to 24,999 23% $25,000 to 34,999 14% $35,000 to 44,999 11% $45,000 to 54,999 7% $55,000 to 64,999 $65,000 to 74,999 $75,000 to 99,999 $100,000 to 124,999 $125,000 and over 4% 3% 3% 2% 1% Note: ESRD beneficiaries are excluded unless also eligible by aged or disabled status. Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 7
Median Income of Beneficiaries by Age, California, 2002 Overview Disabled beneficiaries have the lowest median income. $28,000 Out-of-pocket costs for health care can consume a significant percentage $20,400 of that income. $18,000 $16,000 Under 65 (Disabled) 65 to 74 75 to 84 85 and Older Note: Excludes institutionalized beneficiaries and ESRD beneficiaries unless also eligible by aged or disabled status. Source: 2002 Current Beneficiary Survey 2006 California HealthCare Foundation 8
Overall Spending United States, 1967 2004 as Percent of GDP 3.5% 3.0% 2.5% in Billions $350 $300 $250 Utilization and Spending Over the last four decades, spending has risen sharply across the nation, both in total dollars and as a percentage of GDP. 2.0% $200 1.5% $150 1.0% $100 0.5% $50 0.0% 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004 $0 Source: Data from the Congressional Budget Office. Historical Budget Data. Appendix F of The Budget and Economic Outlook: Fiscal Years 2006 to 2015. Released January 25, 2005. Data from Tables 9 and 10: Outlays for Mandatory Spending. 2006 California HealthCare Foundation 9
Spending Per Beneficiary California and Selected States, 2001 Utilization and Spending Annual spending per beneficiary in California is $7,560 $6,680 $5,940 $4,960 the eighth highest in the nation, more than $700 higher than the national average. A great deal of variation exists in $4,020 spending across the nation. Contributing factors include demographic differences, medical practice, and price New Jersey California U.S. Average Colorado Hawaii variability. Note: Denominator excludes beneficiaries enrolled in managed care. Source: Centers for and Medicaid Services, CMS Health Care Financing Review and Medicaid Statistical Supplement, 2003, Table 15. Program Payments for Beneficiaries Residing in Urban and Rural Areas, by Area of Residence: Calendar Year 2001. 2006 California HealthCare Foundation 10
Hospital Utilization and Expenditures, California, 2000 to 2003 Utilization and Spending Both the unit cost and Average Expenditure per Day of Care $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 Number of Discharges 900,000 875,000 850,000 825,000 800,000 775,000 750,000 725,000 utilization of hospitals are rising for beneficiaries in California. Because inpatient care is typically the most expensive category of treatment, this trend has had a significant role in overall spending increases. $0 2000 2001 2002 2003 700,000 Source: Annual Statistical Supplement 2004:. Social Security Administration Table 8.B8a. 2006 California HealthCare Foundation 11
Average Medical Spending Among Beneficiaries, by Source and Age, California, 2002 $14,877 $828 $1,571 $2,741 $2,568 $8,666 $596 $1,745 $13,258 $436 $1,544 $1,868 $764 $8,646 Other Out of Pocket Private Insurance Medicaid Utilization and Spending The disabled population and the very old have the highest overall medical expenditures and account for the most spending. $7,169 $1,306 $546 $4,473 Disabled (Under 65) 65 to 74 75 and Older Note: Data excludes beneficiaries enrolled in managed care and all beneficiaries in nursing homes. Source: 2002 Current Beneficiary Survey 2006 California HealthCare Foundation 12
Average Annual Out-of-Pocket Spending for Prescriptions by Age, California, 2002 Utilization and Spending Annual out-of-pocket spending for prescription drugs $454 $431 averages just under $400, with higher spending among the disabled and older elderly. These averages may $305 change as a result of the implementation of the new drug benefit. Under 65 (Disabled) 65 to 74 75 and Over Note: Data excludes nursing home residents and ESRD beneficiaries unless also eligible by aged or disabled status. Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 13
Elderly* Enrollee Health Coverage California, 2002 Coverage Few of California s enrollees age 65 and older and Medigap 17% and Medi-Cal 22% Only 8% HMO Only 27% and Employer- Sponsored 26% rely exclusively only on traditional for health insurance. More than half rely on Medi-Cal, Medigap, or employersponsored insurance to help cover health care costs. *Age 65 and older. Note: This graph represents primary coverage sources; in some cases, enrollees may have an additional source of coverage. Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 14
Under 65 Enrollee Health Coverage California, 2002 and Medigap <1% HMO Only 14% Coverage enrollees under 65 with disabilities have less private coverage than do the elderly. Nearly half of these disabled beneficiaries rely on Medi-Cal and and Employer-Sponsored 17% and Medi-Cal 47%. Only 22% Note: This graph represents primary coverage sources; in some cases, enrollees may have an additional source of coverage. For adults age 18 to 64, eligibility for is tied to qualification for Social Security Disability Insurance. Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 15
HMO Enrollment California vs. the U.S., 1989 to 2004 Beneficiaries in an HMO 40% 35% 30% 25% 20% 15% California Coverage California has much higher rates of managed care enrollment than the nation. As of June 2004, California had the fourth highest enrollment in HMOs in the nation (not shown). 10% U.S. 5% 0% 1990 1992 1994 1996 1998 2000 2002 2004 Source: Data for Nation and for California 1989 through 1996 taken from Kaiser Family Foundation California Healthcare Chartbook (www.kff.org/statepolicy/7086/sec5.cfm); 1997 to 2005 California data gathered from CMS Managed Care Contract (MMCC) Plans Monthly Summary Reports from the relevant years. Taken from the March quarter report in each year except for 1997 (June). Available online at www.cms.hhs.gov/healthplans/statistics/mpsct/. Source: Centers for and Medicaid Services: Market Penetration Quarterly State/County Data File, June 2004. Cited in: Health Care Financing Review: and Medi-Cal Statistical Supplement, 2003. Centers for and Medi-Cal. 2006 California HealthCare Foundation 16
Elderly and Advantage Plans Density and Number by County Coverage The majority of Senior Population Per Square Mile 0 5 6 19 20+ Advantage Plans 2 4 5 14 15 24 25 38 Advantage plans are in densely populated areas. Since the implementation of the Modernization Act, which introduced new plan types, at least two plans are available in every county. Sources: Density of elderly in the state from the 2000 Census. Number of Advantage Plans by County from CMS, 2005. 2006 California HealthCare Foundation 17
Elderly Prescription Drug Coverage by County, 2003 60 to 69% 70 to 79% 80 to 89% 90 to 100% Coverage Rates of self-reported prescription drug coverage tend to be higher in Southern California and lower in the more rural areas of Northern California. Note: In response to the question asked of all insured, 65 and older, Are you covered for your prescription drugs? That is, does some plan pay any part of the cost? Source: 2003 California Health Interview Survey. 2006 California HealthCare Foundation 18
Prescription Coverage Source by Beneficiary s Income, California, 2001 Coverage Historically, lower-income 16% 28% 21% 54% 17% 82% None Private Medi-Cal beneficiaries have relied largely on Medi-Cal for prescription coverage; other beneficiaries have received coverage from employer- 56% sponsored coverage, Medigap plans, HMOs, and other private sources. The implementation of the new 24% drug benefit on 1% January 1, 2006, will cause Up to 100% FPL 101 to 200% FPL Over 200% FPL this to change. Note: The 2001 Federal Poverty Level (FPL) for an individual was $8,590 with $3,020 added for each additional person in the household. Federal Register, Vol. 66, No. 33, February 16, 2001: 10695 10697. Does not include disabled beneficiaries or those with end-stage renal disease only. Source: Kaiser/Commonwealth/Tufts-New England Medical Center 2001 Survey of Seniors in Eight States. Cited in California Seniors and Prescription Drugs. Kaiser Family Foundation and Tufts-New England Medical Center. November 2002. 2006 California HealthCare Foundation 19
Race/Ethnicity of Elderly Beneficiaries California vs. the U.S., 2000 Demographics California s elderly Caucasian (non-latino) Latino Asian African American (non-latino) Other population is more diverse than that of the nation. 10% 5% California 2% 2% 7% 10% U.S. 1% Latino, Asian, and African American beneficiaries make up almost a third of the state s population. 13% 70% 80% Note: Other includes Pacific Islanders, American Indians, and multiracial. Source: Census 2000 Summary File 1 (SF 1) 100-Percent Data. 2006 California HealthCare Foundation 20
Diversity of Elderly Population, California, 2000 and 2020 Demographics The diversity of the elderly Caucasian (non-latino) Latino Asian African American (non-latino) Other population in California in 2020 will be 5% 2000 2020 2% 3% 6% even greater than in the current population. The Latino population is 10% expected to have the 15% most significant increase 13% 70% 22% 54% over the next 14 years. Note: Other includes Pacific Islanders, American Indians, and multiracial. Sources: 2000 data from Census 2000 Summary File 1 (SF1) 100-Percent Data and 2020 data from RAND analysis of Department of Finance projections. 2006 California HealthCare Foundation 21
Language Spoken in the Home by Age, California, 2003 Demographics Future 35% Asian* Spanish beneficiaries are more likely to speak a non-english language in the home. This suggests a need for 21% resources in multiple languages. 16% 12% 9% 8% 8% 6% 5% 8% Under 44 45 to 64 65 to 74 75 to 84 85 and Older *Predominantly Chinese, Vietnamese, Korean. Note: Estimates for both languages may be low because the category other in the survey may include combinations of languages. Data include the non- population. Insurance status not included in data. Source: 2003 California Health Interview Survey. 2006 California HealthCare Foundation 22
Age and Gender of Beneficiaries California, 2002 Demographics Except among those Male Female beneficiaries with disabilities, 56% enrollees in California 44% 59% are overwhelmingly female due to general population trends and 41% longer life expectancy. 71% 58% 42% 29% Under 65 (Disabled) 65 to 74 75 to 84 85 and Older Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 23
Number of Chronic Conditions among Beneficiaries, California, 2002 Health Status Almost two-thirds of elderly Elderly Disabled and disabled beneficiaries have two or more chronic health conditions. None 12% One 25% None 25% One 14% Three or more 36% Two 27% Two 27% Three or more 34% Note: The definition of chronic condition used here is reported hypertension, cancer, diabetes, heart disease, lung disease, stroke, arthritis or Alzheimer s disease. An individual qualifies for disabled status based on health status in addition to the ability to work in one s profession and many other factors. Beneficiaries do not include those with end-stage renal disease only. Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 24
Chronic Conditions of Beneficiaries by Eligibility Category, California, 2003 Health Status Many beneficiaries have Elderly Disabled an array of chronic 55% 60% illnesses; the prevalence of conditions varies by beneficiary category. 36% 32% 27% 27% 18% 15% 17% 14% 19% 18% 9% 11% 5% 0% Alzheimer s Disease Cancer Diabetes Heart Disease High Blood Pressure Lung Disease Obesity Stroke Note: Excludes ESRD-only beneficiaries. ESRD beneficiaries who also qualify as disabled or aged are included in that category. Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 25
Chronic Conditions of All Beneficiaries by Race/Ethnicity, California, 2002 75% 70% 65% 60% 55% 50% Caucasian (non-latino) Latino Asian African American (non-latino) Other Health Status The prevalence of chronic conditions varies by race and ethnicity. Heart disease and high blood pressure are the most prominent across all groups. 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Alzheimer s Disease Cancer Diabetes Heart Disease High Blood Pressure Lung Disease Obesity Stroke Notes: Other includes Pacific Islanders, American Indian/Alaskan Native and persons of multiple races/ethnicities. Sources: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 26
Beneficiaries in Nursing Homes California, 2002 Health Status Disabled beneficiaries and the very old are the most likely to be living in a 14% nursing facility. 11% 5% 4% All Beneficiaries Disabled (Under 65) 65 and Older 85 and Older Source: 2002 Current Beneficiary Survey. 2006 California HealthCare Foundation 27
Quality of Care by Spending California vs. Other States, 2001 Overall Quality Ranking 51 46 41 36 31 26 21 16 11 6 Best Higher Quality Lower Spending 1 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 Spending per Beneficiary CA Worst Lower Quality Higher Spending Quality The quality of care for California s beneficiaries is among the worst in the nation, despite the fact that spending in California is $700 more per beneficiary than the national average. Of all 50 states, California is among the worst for high spending and low quality of care. Notes: Quality ranking is created through use of twenty-two Quality Improvement Organization quality indicators abstracted from state-wide random samples of medical records for inpatient fee-for-service care and from beneficiary surveys or claims for outpatient care (Jencks 2003). The spending per beneficiary data presented here diverges from the data shown in earlier information in this presentation because the data used by Baicker and Chandra is limited to FFS beneficiaries and is also three years older. Source: 1999 claims data and S.F. Jencks et al, Change in the Quality of Care Delivered to Beneficiaries, 1998 1999 and 2000 2001. Journal of the American Medical Association. 2003. Vol. 239, No. 3: 305 312. Cited in Baicker, Katherine and Amitabh Chandra. Spending, The Physician Workforce, And Beneficiaries Quality of Care. Health Affairs Data Watch. Web Exclusive. April 7, 2004. 2006 California HealthCare Foundation 28
Beneficiaries Who Received Recommended Care Orange County, California, 2001 All Chronic Conditions 52% Quality Beneficiaries in California receive recommended care for chronic conditions about half the time. Quality of Diabetes Pulmonary Disease 41% 45% care varies across chronic illnesses, from 41 percent for diabetes to 63 percent Heart Disease 52% for high blood pressure. Depression 56% Hypertension (High Blood Pressure) 63% Note: This data is limited to Orange County, California. Data in geographic areas tend to be very similar however, and so this is likely reflective of California, and particularly of the Southern California region. Recommended care is defined through 439 quality indicators developed by RAND staff and validated by four multi-specialty expert panels, using the RAND/UCLA modified Delphi method. Source: Community Tracking Survey and Telephone Surveys. Eve A. Kerr, Elizabeth A. McGlynn, John Adams, Joan Keesey and Steven M. Asch. Profiling The Quality Of Care In Twelve Communities: Results From The CQI Study Used with Permission from the authors. Health Affairs, Vol. 23, No. 3: 247 256. 2006 California HealthCare Foundation 29
Preventive Care for Beneficiaries by Income, California, 2003 Quality The poorest Had a colonoscopy in the last five years? 47% 51% 65% 0 99% FPL 100 199% FPL 200%+ FPL beneficiaries receive fewer recommended preventive care services. Ever had a Pneumonia shot? 47% 60% 66% This income disparity is least apparent in the Flu shot in last 12 months? 68% 72% 74% number of beneficiaries who received a flu shot Had mammogram in past two years? 75% 74% 82% in the previous year. 70% Ever had a PSA test? 77% 90% Note: The 2003 Federal Poverty Level (FPL) for an individual was $8,980 with $3,140 added for each additional person in the household. Federal Register, Vol. 68, No. 26, February 7, 2003: 6456 6458. PSA is a screening test for prostrate cancer. Source: 2003 California Health Interview Survey. 2006 California HealthCare Foundation 30
Elderly Population Growth by County, 1990 to 2004 Total 65 85 County Population and Older and Older Alameda 12% 11% 58% Alpine 7% 70% 140% Amador 26% 28% 96% Butte 17% 2% 91% Calaveras 44% 45% 151% Colusa 25% 14% 88% Contra Costa 26% 31% 105% Del Norte 21% 18% 134% El Dorado 37% 37% 148% Fresno 30% 22% 71% Glenn 11% 0% 48% Humboldt 8% 10% 78% Imperial 39% 43% 110% Inyo 0% 0% 35% Kern 35% 26% 96% Kings 40% 33% 99% Lake 27% 6% 86% Lassen 26% 9% 74% Los Angeles 12% 16% 56% Madera 58% 38% 91% Marin 7% 25% 90% Mariposa 26% 25% 124% Mendocino 10% 11% 84% Merced 33% 29% 91% Modoc 1% 7% 33% Mono 28% 71% 94% Monterey 17% 18% 69% Napa 19% 4% 48% Nevada 24% 17% 107% Total 65 85 County Population and Older and Older Orange 24% 41% 79% Placer 78% 106% 182% Plumas 8% 17% 105% Riverside 60% 42% 137% Sacramento 27% 32% 102% San Benito 53% 29% 74% San Bernardino 35% 27% 74% San Diego 17% 20% 85% San Francisco 3% 4% 39% San Joaquin 35% 19% 76% San Luis Obispo 17% 19% 95% San Mateo 8% 13% 77% Santa Barbara 9% 13% 59% Santa Clara 13% 34% 74% Santa Cruz 9% 3% 37% Shasta 21% 29% 121% Sierra 5% 1% 94% Siskiyou 3% 15% 86% Solano 22% 51% 146% Sonoma 21% 13% 87% Stanislaus 35% 24% 78% Sutter 35% 41% 116% Tehama 21% 11% 66% Trinity 5% 25% 97% Tulare 29% 11% 65% Tuolumne 18% 31% 135% Ventura 19% 35% 103% Yolo 31% 29% 75% Yuba 11% 6% 67% Appendix Almost all of California s counties experienced significant growth in their elderly population; growth was most pronounced in the 85 and older population. Source: Calculated from both the 1990 and 2000 Census data. The 1990 data is available in archived population estimates (www.census.gov/popest/archives/1990s/co-99-13/cacamars.txt). The 2004 data is a projection from the 2000 Census in the file County estimates by demographic characteristics age, sex, race, and Hispanic Origin: Selected Age Groups and Sex. 2006 California HealthCare Foundation 31
Resources Annual Statistical Supplement, Office of Data Policy, Social Security Administration www.ssa.gov/policy/docs/statcomps/supplement/2004/index.html California Health Care Chartbook, Kaiser Family Foundation, June 2004 www.kff.org/statepolicy/7086/index.cfm California Health Interview Survey www.chis.ucla.edu Centers for and Medicaid Services, Enrollment Data www.cms.hhs.gov/enrpts Congressional Budget Office, Historical Budget Data www.cbo.gov/budget/historical.pdf Health Care Financing Review www.cms.hhs.gov/healthcarefinancingreview Current Beneficiary Survey www.cms.hhs.gov/mcbs Web site provides information on how the program functions in California www.calmedicare.org Authors Cynthia R. Schuster, M.P.P. Dana P. Goldman, Ph.D. Mary Vaiana, Ph.D. RAND Corporation Appendix GIVE US YOUR FEEDBACK Was the information provided in this report of value? Are there additional kinds of information or data you would like to see included in future reports of this type? Is there other research in this subject area you would like to see? We would like to know. Click to complete our survey at www.chcf.org/feedback and enter Report Code #1040. Thank you. FOR MORE INFORMATION California HealthCare Foundation 476 9th Street Oakland, CA 94607 510.238.1040 www.chcf.org RAND Corporation 1776 Main Street Santa Monica, CA 90401 310.393.0411 www.rand.org 2006 California HealthCare Foundation 32