Reducing Access Disparities in California by Insuring Low-Income

Health Policy Brief

February 2019

Reducing Access Disparities in

California by Insuring Low-Income

Undocumented Adults

Nadereh Pourat and Ana E. Martinez

SUMMARY: While the Patient Protection and

Affordable Care Act (ACA), signed into law in

2010, expanded health insurance coverage to

millions of Californians, it did not extend eligibility

for coverage to undocumented U.S. residents.

Federal policy prohibits the use of federal funds to

provide Medicaid to undocumented individuals.

In 2015, the state of California extended Medi-Cal

(California’s Medicaid program) to undocumented

children using state funds, and policies to extend

eligibility to undocumented adults have been

proposed. This policy brief includes the latest data

from the California Health Interview Survey (CHIS)

on the health insurance, demographics, health

status, and access to care of undocumented low-

income Californians ages 19-64. The data indicate

that the great majority of these undocumented

adults are working, live in families with children,

and report being relatively healthy. However,

signiﬁcant disparities exist in access to health

care between this group and their documented

counterparts. This overview of undocumented

low-income adult residents of California provides

insights into the implications of extending full-

scope Medi-Cal eligibility to this population, who

currently have very limited options for affordable

health insurance coverage and experience access

disparities.

nder the Patient Protection and

Affordable Care Act (ACA),

California’s uninsured rate has reached a

historic low, driven in large part by the

expansion of Medi-Cal (California’s Medicaid

program) to include low-income adults with

earnings at or below 138 percent of the

federal poverty level (FPL). But federal policy

prohibits the use of federal Medicaid funds to

provide full-scope coverage to undocumented

residents, a restriction unchanged by the

Affordable Care Act.* However, in 2016,

California extended full-scope Medi-Cal

eligibility to undocumented low-income

children up to age 19, using state funds.

Most undocumented low-income California

adults have remained uninsured due to

ineligibility for full-scope Medi-Cal, the

inability to purchase policies under Covered

California (California’s ACA exchange

marketplace),

†

and limited affordable private

options for coverage. Undocumented low-

income adults are projected to comprise an

estimated 37 percent of California’s remaining

uninsured in 2020.

As of January 2019,

the California legislature was considering

proposals to expand Medi-Cal to low-income

undocumented adults. Governor Gavin

Newsom has also proposed state funding to

‘‘

The Affordable

Care Act...

did not extend

eligibility for

coverage to

undocumented

U.S. residents.

’’

This policy brief was funded by a

generous grant from the

California Health Care Foundation.

* Undocumented low-income residents of the United States

are eligible for restricted-scope Medicaid, which covers

emergency and pregnancy-related services rather than providing

comprehensive coverage. Throughout this brief, we use

Medicaid/Medi-Cal to refer to full-scope Medicaid/Medi-Cal,

which covers the full set of beneﬁts described here.

† Under the ACA, undocumented immigrants are prohibited

from purchasing insurance through the ACA marketplaces.

UCLA CENTER FOR HEALTH POLICY RESEARCH

extend Medi-Cal to low-income undocumented

young adults ages 19-25.

We analyzed the most recent data from the

California Health Interview Survey (CHIS)

to provide information on the characteristics

of California’s low-income undocumented

adults, including sources of health insurance

coverage, demographics, health status, and

access to health care. We included English

proﬁciency to assess the ability of individuals

to communicate effectively with medical

professionals in English and to navigate the

health care system. To understand access

to care, we examined rates of utilization of

services and, as an indicator of continuity and

ease of getting care when needed, whether

survey respondents had a usual source of care

other than the emergency department.

In this policy brief, we focus on

undocumented adults ages 19-64 with

incomes at or below 138 percent of the

federal poverty level (FPL), which is the

Medi-Cal income eligibility threshold

for low-income adults with satisfactory

immigration status. We excluded the

undocumented elderly in the analyses due to

their very small sample size. We compared

the characteristics of low-income nonelderly

undocumented adults to those of their

documented counterparts, including U.S.-

born citizens, naturalized citizens, and legal

permanent residents (see the “Methodology”

section for further detail).

The majority of undocumented residents

are low-income and nonelderly adults.

An estimated 2.2 million California residents

are undocumented.

Of these, 61 percent are

low income, deﬁned here as having an income

of 0–138 percent FPL (data not shown). The

great majority of low-income undocumented

residents are nonelderly adults, including 56

percent who are ages 26-44 (Exhibit 1). Young

adults between 19 and 25 years of age comprise

7 percent of the low-income undocumented

population. The age distribution of

documented and undocumented low-income

populations is signiﬁcantly different, with more

undocumented than documented adults being

between 26 and 44 years of age (56 percent vs.

19 percent).

Most undocumented low-income adults

are working and have children.

Examining selected demographic characteristics

of low-income undocumented and documented

adults revealed statistically signiﬁcant

differences between the two groups in

education level, English proﬁciency (spoken

English), family status, and employment

status. For example, fewer undocumented

than documented low-income adults have

12 or more years of education (35 percent vs.

69 percent), and more are limited English

proﬁcient, reported as speaking English less

Undocumented

Documented

0-18 19-25

26-44 45-64 65 and older

12% 7% 56% 23%

36% 11% 19% 22% 12%

Exhibit 1

Age Distribution of Low-Income Documented and Undocumented Populations, California,

2016-2017

Source: UCLA Center for Health Policy analysis of the combined

2016 and 2017 California Health Interview Survey

(CHIS).

‘‘

Sixty-one

percent [of

undocumented

Californians]

are low-income.

’’

Notes: “Low-income” is deﬁned as having income of 0-138

percent FPL.

Estimates do not sum to 100 percent due to rounding.

UCLA CENTER FOR HEALTH POLICY RESEARCH

than very well (96 percent vs. 38 percent;

Exhibit 2). Similarly, compared to low-

income documented adults, more low-

income undocumented adults live in families

with children (63 percent vs. 37 percent),

and more are employed (67 percent vs.

60 percent). The two groups do not differ

signiﬁcantly in the proportion who are female

(52 percent vs. 56 percent, respectively).

Most low-income undocumented adults

are uninsured.

The great majority (89 percent) of low-

income undocumented adults in California

are uninsured, and 7 percent have private

insurance, most often through employers

(Exhibit 3).* In contrast, only 11 percent

Selected Demographic Characteristics of Documented and Undocumented Low-Income

Adults Ages 19-64, California, 2016-2017

Exhibit 2

Source: UCLA Center for Health Policy analysis of the combined

2016 and 2017 California Health Interview Survey

(CHIS).

Note: “Low-income” is deﬁned as having income of 0-138% FPL.

‘‘

Eighty-nine

percent of

low-income

undocumented

adults in

California are

uninsured.

’’

Employed

Families with children

Limited English proficient

12 or more years of education

67%

60%

63%

37%

96%

38%

35%

69%

Undocumented Documented

Insurance Status of Documented and Undocumented Low-Income Adults Ages 19-64,

California, 2016-2017

Exhibit 3

Undocumented

Documented

Uninsured Private Public

89% 7% 3%

11% 21% 69%

Source: UCLA Center for Health Policy analysis of the combined

2016 and 2017 California Health Interview Survey

(CHIS).

Notes: “Low-income” is deﬁned as having income of 0-138

percent FPL.

Undocumented low-income adults who reported

Medi-Cal are identiﬁed as uninsured.

Private

insurance includes employer-sponsored insurance and

privately purchased insurance. Public insurance for the

documented population includes Medi-Cal, Medicare,

and other public programs.

Estimates do not sum to 100 percent due to rounding.

* Uninsured undocumented low-income adults include 52

percent who report having Medi-Cal. We considered these

individuals to have restricted-scope emergency beneﬁts, as they

are ineligible for full-scope Medi-Cal.

UCLA CENTER FOR HEALTH POLICY RESEARCH

of low-income documented adults report

being uninsured, and 21 percent have private

insurance. The latter includes 16 percent with

employer-sponsored coverage and 5 percent

with privately purchased insurance. Insurance

among undocumented individuals reporting

public coverage was primarily through county

programs. The majority (69 percent) of low-

income documented adults have coverage

through public sources, including 66 percent

with Medi-Cal.

Most undocumented low-income adults

report being relatively healthy.

We examined differences in several indicators

of health status between undocumented and

documented low-income adults. Compared

with their documented counterparts,

undocumented low-income adults report

statistically signiﬁcant lower rates of asthma,

high blood pressure, heart disease, high

levels of psychological distress, two or

more chronic conditions, or being current

smokers (Exhibit 4). Undocumented low-

income adults reported statistically similar

rates of fair or poor health (34 percent vs. 38

percent), diabetes (13 percent vs. 10 percent),

and being overweight or obese (69 percent vs.

71 percent) compared to documented low-

income adults (data not shown).*

Undocumented low-income adults have

limited access to care.

Data reveal disparities in access to health care

between documented and undocumented low-

income adults. Low-income undocumented

adults have statistically signiﬁcant lower rates

of having a usual source of care and higher rates

High psychological distress

2 or more chronic conditions

Heart disease

High blood pressure

Asthma

Current smoker

15%

26%

42%

18%

29%

Undocumented Documented

17%

12%

19%

Health Status of Documented and Undocumented Low-Income Adults Ages 19-64,

California, 2016-2017

Exhibit 4

Source: UCLA Center for Health Policy analysis of the combined

2016 and 2017 California Health Interview Survey

(CHIS).

Notes: “Low-income” is deﬁned as having income of 0-138

percent FPL.

Multiple chronic conditions include asthma, diabetes,

heart disease, and high blood pressure.

‘‘

Most

undocumented

low-income

adults report

being relatively

healthy.

’’

* The age-adjusted estimates of health status of documented

and undocumented low-income adults showed results similar

to those of the unadjusted estimates presented in this brief for

being a current smoker, having asthma, high blood pressure,

heart disease, two or more chronic conditions, and high

psychological distress. The age-adjusted results showed a

higher likelihood of being in poor health and a lower likelihood

of having diabetes and being overweight or obese, but these

relationships were not signiﬁcant.

UCLA CENTER FOR HEALTH POLICY RESEARCH

of no doctor visits in the past year compared

with their documented counterparts. In

addition, undocumented adults report lower

rates of ﬁve or more doctor visits, any mental

health visits, and any emergency department

(ED) visits in the past year compared to low-

income undocumented adults. In contrast,

undocumented adults report statistically similar

rates of delays in getting medical care due to

cost (13 percent vs. 14 percent) and delays in

getting needed medications (14 percent vs. 10

percent) as documented adults (data not shown).

Opportunities to reduce disparities in

access to care among the remaining

uninsured

This policy brief provides data on

demographics, insurance coverage, health

status, and access to care for undocumented

low-income nonelderly adults in California.

The great majority are not highly proﬁcient

in English and are uninsured, and many

experience access limitations, including lacking

a usual source of care and going without a

doctor visit in the past year. These results are

consistent with research showing that uninsured

individuals face greater access barriers to health

care than documented adults.

Research shows that individuals without

access often postpone seeking needed care

and may have higher rates of undiagnosed

conditions.

Thus, the lower prevalence

of chronic conditions among low-income

undocumented adults compared to their

documented counterparts may be partly due

to lower rates of health insurance and fewer

visits to health care providers to diagnose

conditions.

7-9

Linguistic, education level, and

cultural differences can contribute to variations

in how individuals report on their health and

their need for care.

These variations might

contribute to the contradictory ﬁndings that

low-income undocumented adults report being

in fair or poor health or delaying needed care

at similar rates as low-income documented

Access to Care of Documented and Undocumented Low-Income Adults Ages 19-64 in the

Past Year, California, 2016-2017

Exhibit 5

‘‘

Low-income

undocumented

adults have …

lower rates of

having a usual

source of care.

’’

Source: UCLA Center for Health Policy analysis of the combined

2016 and 2017 California Health Interview Survey

(CHIS).

Note: “Low-income” is deﬁned as having income of 0-138

percent FPL.

Had an emergency department visit

Had a mental health visit

5 or more doctor visits last year

No doctor visits last year

No usual source of care

22%

29%

15%

12%

28%

38%

21%

Undocumented Documented

44%

24%

UCLA CENTER FOR HEALTH POLICY RESEARCH

adults, while other health indicators have

signiﬁcant differences. Research also shows

that immigrants often arrive with better health

proﬁles, but that this advantage declines

over time.

11, 12

Thus, the healthier proﬁle of

undocumented low-income adults compared

to the documented group might vary with the

number of years of having lived in the U.S.

Undocumented low-income adults are eligible

only for restricted-scope Medi-Cal, which is

limited to episodic access to pregnancy-related

services and emergency care for speciﬁc urgent

conditions and is not designed for receipt of

comprehensive preventive, primary, or specialty

care.

Previous research indicates that obtaining

comprehensive and affordable insurance is likely

to reduce access disparities.

8, 14

In particular,

Medicaid expansion has been associated with

reduced mortality and improved health status,

as well as better access to care.

Extending full-

scope Medi-Cal eligibility to undocumented

low-income adults provides new opportunities

to reduce the remaining disparities in health

and access statewide.

Data Source and Methods

We pooled the 2016 and 2017 CHIS data for these

analyses. Undocumented individuals were identiﬁed

using a predictive model described elsewhere.

Documented individuals include U.S.-born citizens,

naturalized citizens, and permanent residents.

Undocumented low-income adults who reported

having Medi-Cal are identiﬁed as uninsured. English

proﬁciency is based on self-reported data on how well

the individual speaks English. We combined data on

chronic conditions to identify those with multiple (two

or more) chronic conditions. These included asthma,

diabetes, high blood pressure, and heart disease. High

psychological distress is based on having a Kessler 6

score of 13 or higher in the past year. Those without a

usual source of care included individuals who reported

using the emergency department as their usual source

of care. We considered differences between estimates

as statistically signiﬁcant when probabilities were less

than 0.05.

Author Information

Nadereh Pourat, PhD, is associate director of the

UCLA Center for Health Policy Research and

director of the Center’s Health Economics and

Evaluation Research program, professor of health

policy and management at the UCLA Fielding

School of Public Health, and professor at the UCLA

School of Dentistry. Ana E. Martinez, MPH, is a

project director at the UCLA Center for Health

Policy Research.

Funder Information

This policy brief was funded by a generous grant from

the California Health Care Foundation.

‘‘

Medicaid

expansion has

been associated

with reduced

mortality and

improved health

status.

’’

This publication contains

data from the California

Health Interview Survey

(CHIS), the nation’s largest

state health survey.

Conducted by the UCLA

Center for Health Policy

Research, CHIS data give

a detailed picture of the

health and health care

needs of California’s large

and diverse population.

CHIS is a collaboration

of the UCLA Center for

Health Policy Research,

California Department of

Public Health, California

Department of Health

Care Services, and the

Public Health Institute.

Learn more at:

www.chis.ucla.edu

UCLA CENTER FOR HEALTH POLICY RESEARCH

Acknowledgments

Sincere thanks to Steven Wallace of the UCLA

Center for Health Policy Research, Laurel Lucia of

the UC Berkeley Labor Center, and Amy Adams

of the California Health Care Foundation for their

careful review of and insightful comments on this

publication. Thanks also to Pan Wang, PhD, for her

statistical assistance, and to Venetia Lai and Celeste

Maglan Peralta for their contributions to production

and public communication of this brief.

Suggested Citation

Pourat N, Martinez AE. 2019. Reducing Access

Disparities in California by Insuring Low-Income

Undocumented Adults. Los Angeles, CA: UCLA

Center for Health Policy Research.

Endnotes

1 Dietz M, Lucia L, Roby DH, Jacobs K, Rasmussen PW,

Chen X, et al. 2018. California’s Health Coverage Gains

to Erode Without Further State Action –Projections from

California Simulation of Insurance Markets (CalSIM) Model.

University of California, Berkeley, Center for Labor

Research and Education and University of California,

Los Angeles, Center for Health Policy Research. http://

laborcenter.berkeley.edu/pdf/2018/CA-Coverage-Gains-To-

Erode-Without-Further-State-Action.pdf

2 Pourat N. 2018. Six Facts About Undocumented

Californians: Analysis of 2015–2016 California Health

Interview Survey. California Health Care Foundation.

https://www.chcf.org/wp-content/uploads/2018/06/

SnapshotSixFactsUndocumentedCalifornians.pdf

3 Passel JS, Cohn DV. 2018. U.S. Unauthorized Immigrant

Total Dips to Lowest Level in a Decade. Pew Research

Center. http://www.pewhispanic.org/2018/11/27/u-s-

unauthorized-immigrant-total-dips-to-lowest-level-in-a-decade/

4 Sommers BD, Baicker K, Epstein AM. 2012. Mortality

and Access to Care Among Adults After State Medicaid

Expansions. New England Journal of Medicine 367(11):

1025-1034.

5 Sommers BD, Gawande AA, Baicker K. 2017. Health

Insurance Coverage and Health — What the Recent

Evidence Tells Us. New England Journal of Medicine

377(6): 586-593. https://www.nejm.org/doi/full/10.1056/

NEJMsb1706645

6 Pourat N, Wallace SP, Hadler MW, Ponce N. 2014.

Assessing Health Care Services Used by California’s

Undocumented Immigrant Population in 2010. Health

Affairs (Millwood) 33(5): 840-847.

7 Decker SL, Kostova D, Kenney GM, Long SK. 2013.

Health Status, Risk Factors, and Medical Conditions

Among Persons Enrolled in Medicaid vs.Uninsured Low-

Income Adults Potentially Eligible for Medicaid Under

the Affordable Care Act. Journal of the American Medical

Association 309(24): 2579-2586. http://dx.doi.org/10.1001/

jama.2013.7106

8 Baicker K, Taubman SL, Allen HL, Bernstein M,

Gruber JH, Newhouse JP, et al. 2013. The Oregon

Experiment—Effects of Medicaid on Clinical Outcomes.

New England Journal of Medicine 368(18): 1713-1722.

9 Barcellos SH, Goldman DP, Smith JP. 2012.

Undiagnosed Disease, Especially Diabetes, Casts Doubt

on Some of Reported Health ‘Advantage’ of Recent

Mexican Immigrants. Health Affairs 31(12): 2727-

2737. https://www.healthaffairs.org/doi/abs/10.1377/

hlthaff.2011.0973

10 Kandula NR, Lauderdale DS, Baker DW. 2007.

Differences in Self-Reported Health Among Asians,

Latinos, and Non-Hispanic Whites: The Role of Language

and Nativity. Annals of Epidemiology 17(3): 191-198.

11 Markides KS, Rote S. 2018. The Healthy Immigrant

Effect and Aging in the United States and Other Western

Countries. https://dx.doi.org/10.1093/geront/gny136

12 Antecol H, Bedard K. 2006. Unhealthy Assimilation:

Why Do Immigrants Converge to American Health

Status Levels? Demography 43(2): 337-360.

13 Lucia L. 2019. Towards Universal Coverage: Expanding

Medi-Cal to Low-Income Undocumented Adults. UC

Berkeley Center for Labor Research and Education. http://

laborcenter.berkeley.edu/medi-cal-undocumented-adults/

14 Derose KP, Escarce JJ, Lurie N. 2007. Immigrants and

Health Care: Sources of Vulnerability. Health Affairs

(Millwood) 26(5): 1258-1268.

UCLA CENTER FOR HEALTH POLICY RESEARCH

10960 Wilshire Blvd., Suite 1550

Los Angeles, California 90024

The UCLA Center

for Health Policy Research

is part of the

UCLA Fielding School of Public Health.

The analyses, interpretations, conclusions,

and views expressed in this policy brief are

those of the authors and do not necessarily

represent the UCLA Center for Health Policy

Research, the Regents of the University

of California, or collaborating

organizations or funders.

PB2019-2

Editor-in-Chief: Ninez Ponce, PhD

Phone: 310-794-0909

Fax: 310-794-2686

Email: [email protected]

healthpolicy.ucla.edu

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