1. COVERAGE AND ACCESS
Julie Sonier, Deputy Director
State Health Access Data Assistance Center
(SHADAC) at University of Minnesota
Catherine Dower, JD
Center for Health Professions at UCSF
Let’s Get Healthy California Task Force

2. FRAMEWORK FOR TRACKING THE
IMPACTS OF THE ACA IN
CALIFORNIA
Julie J. Sonier, MPA
State Health Access Data Assistance Center
University of Minnesota
August 14, 2012
Let’s Get Healthy California Task Force

3. Project Background
• Funded by a grant from the
California HealthCare Foundation
• Goal was to recommend how
California can measure and monitor
the impacts of the Affordable Care
Act (ACA) in three areas:
• Health insurance coverage
• Access to health care services
• Affordability and
comprehensiveness of coverage
• Many components of the
framework we developed are
relevant to monitoring coverage
and access more generally
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4. Our Process
• What is most important to monitor?
Identify priority measures
• What do we know now?
Identify and compare existing data
sources
• Where are the gaps?
Identify priorities for new/modified data
collection
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5. Today’s Presentation
• Considerations for selecting indicators and data sources
• Overview of recommended indicators for monitoring
health insurance coverage and access to care
• Current availability of recommended indicators
• Baseline and trends for selected indicators
• Note: we did not establish benchmarks or goals
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6. CONSIDERATIONS FOR
SELECTING MEASURES
AND DATA SOURCES
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7. Considerations for Selecting Measures
• Measures that reflect major
goals and provisions of the
law
• Outcomes rather than
implementation process
• Relevant/meaningful to
policymakers
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8. Considerations for Recommending Data
Sources
• Comparability over time
• Ability to do in-depth analysis
(e.g., by
geography, age, income, race/ethnic
ity)
• Population coverage – complete
population of interest
• Availability of benchmarks/national
comparisons
• Timeliness of estimates
• Accessibility of data
• Flexibility to adapt to changing
needs – for example, to change
survey content, sample size, or
oversample certain populations
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9. HEALTH INSURANCE
COVERAGE MEASURES
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10. Priority Measures: Coverage
• Overview: % with each type of Coverage Type Data Source1
Availability
coverage
Employer-sponsored CHIS
• In-depth topical measures:
• Uninsurance Nongroup CHIS
• Public coverage
• ESI Public CHIS
Uninsured CHIS
1 Source: California Health Interview Survey
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11. Priority Measures: Coverage
Uninsurance Measures Data Source
Availability
• In-depth topical Point in time CHIS1
measures:
• Uninsurance Uninsured at some point in
CHIS
the past year
• Public coverage
Uninsured for a year or
• ESI CHIS
more
Reasons for uninsurance CHIS
Beginning in 2014:
# exempt from coverage
Exchange
mandate
# paying tax penalty Tax records
1 Source: California Health Interview Survey
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12. Priority Measures: Coverage
• In-depth topical
measures: Public Coverage Measures Data Source
• Uninsurance Availability
• Public coverage Enrollment trend in state DHCS1,
• ESI programs MRMIB2
Participation rate (% eligible
CHIS3
who are enrolled)
Churning/coverage
DHCS,
transitions (% leaving who
MRMIB
re-enroll within 3 months)
1 Source: Department of Health Care Services
2 Source: Managed Risk Medical Insurance Board
3 Source: California Health Interview Survey
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13. Priority Measures: Coverage
ESI Measures Data Source
Availability
• In-depth topical Percent of employers offering
CEHBS2
measures: coverage
Percent of workforce in firms that CEHBS
• Uninsurance offer coverage
• Public coverage
At employers offering coverage, CEHBS
• ESI1 % of employees eligible
% of eligible employees who CEHBS
enroll (take-up rate)
Percent of families with any ESI
NHIS3
offer
Percent of families offered ESI
NHIS
with all family members enrolled
Number of employers paying
CEHBS
penalty for not offering coverage
1 Employer Sponsored Insurance
2 Source: California Employer Health Benefits Survey
3 Source: National Health Interview Survey
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14. Priority Measures: Coverage
• Health insurance exchange related measures: These
measures relate to the small group insurance market,
the nongroup market, and the health insurance
exchange.
Health Insurance Exchange Data Source
Availability
Number of people purchasing nongroup coverage
Exchange
through exchange (with and without subsidies)
Percent of nongroup market purchasing through Exchange, insuranc
exchange e regulators
Number of employers and people with group
CEHBS1, Exchange
coverage through exchange
Percent of small group market purchasing through
CEHBS
exchange
1 Source: California Employer Health Benefits Survey
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15. Priority Measures: Coverage
Distribution of insurance coverage
Source: California Health Interview Survey (CHIS), 2001-2009
60% 54.9%
52.3% 53.7%
51.8%
49.6%
50%
40%
30%
21.1% 21.6% 22.5%
20.4%
18.7%
20%
14.0% 13.5% 13.2% 14.5%
14.6%
10% 5.0% 6.0% 6.0% 5.0% 6.0%
0%
2001 2003 2005 2007 2009
Employer Public Individual Uninsured
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16. Priority Measures: Coverage
Uninsurance rate by county, 2009
Source: California Health Interview Survey (CHIS), 2009
25%
21.7%
20%
14.5%
15%
10%
7.2%
5%
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17. Priority Measures: Coverage
Measures of uninsurance
Source: California Health Interview Survey (CHIS), 2001-2009
30%
25%
21.9% 21.1% 21.2%
20.2% 19.4%
20%
15%
11.8% 11.3%
10.6% 10.2% 10.3%
10%
5%
0%
2001 2003 2005 2007 2009
Uninsured all year Uninsured at some point in past year Point in time uninsured
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18. Priority Measures: Coverage
Percent of employers offering health insurance coverage
Sources: California Employer Health Benefits Survey, 2000-2011;
Kaiser Family Foundation Employer Health Benefits Survey, 2000-2011.
90%
80%
73%
70% 71% 70% 71% 71% 70%
69% 69%
70% 67% 67%
63%
69% 68%
66% 66% 69%
60% 63% 63%
60% 61% 60%
59% 59%
50%
40%
30%
20%
10%
California United States
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
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19. Priority Measures: Coverage
At employers that offer coverage: % of employees eligible, and %
eligible who enroll
Source: California Employer Health Benefits Survey, 2000-2011
100%
88% 87% 87% 86% 86%
84% 84% 83% 83% 84% 84% 85%
80% 83%
79% 79% 79% 79% 77% 80% 79% 78% 79%
75% 76%
60%
40%
20%
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
% of employees eligible % eligible who enroll
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20. Priority Measures: Coverage
Med-Cal program enrollment
Source: California Department of Health Care Services
8,000,000 7,505,841
7,000,000 6,534,983
6,000,000
5,000,000
5,073,522
4,000,000
3,000,000
2,000,000
1,000,000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
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21. Priority Measures: Access
Use of Services Data Source
• Individual Availability
perspective Percent of people with a
CHIS1
• Use of services usual source of care
Type of place for usual
• Barriers to care CHIS
source of care
Percent of people with a
• System perspective doctor visit in the past CHIS
year
• Provider-based Percent of people with a MEPS-
measures preventive care visit in the HC2,
• Safety net past year CHIS
1 Source: California Health Interview Survey
2 Source: Medical Expenditure Panel Survey –Household Component
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22. Priority Measures: Access
Barriers to Care Data Source
Availability
• Individual Percent of people who forgo MEPS-
perspective needed care HC1
MEPS-
• Use of services Reasons for forgone care
HC
• Barriers to care Percent of people not able to MEPS-
get an appointment with a HC,
doctor in a timely way CHIS*2
• System perspective Percent of people who had
• Provider-based difficulty finding a provider that
NHIS3,
measures would accept new patients
CHIS*
• Primary care
• Safety net • Specialty care
Percent of people who had
difficulty finding a provider that
CHIS*,
would accept their insurance
NHIS**
• Primary care
*Requires new data collection • Specialty care
**Not able to distinguish between primary and specialty care
1 Source: Medical Expenditure Panel Survey –Household Component
2 Source: California Health Interview Survey
3 Source: National Health Interview Survey
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23. Priority Measures: Access
Provider-Based Measures Data Source
Availability
• Individual perspective Percent of physicians accepting Medical
new patients, by payer
• Use of services Board of
• Primary care
CA*
• Barriers to care • Specialty care
Percent of physicians
Medical
participating in public programs
Board of
• System perspective • Primary care
CA*
• Specialty care
• Provider-based
measures Emergency room visit rates OSHPD1
• Safety net Ambulatory care sensitive
OSHPD
hospital admissions
Preventable/avoidable
OSHPD
emergency room visits
*Requires new data collection
1 Source: Office of Statewide Health Planning and Development
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24. Priority Measures: Access
• Individual
perspective
Safety Net Data Source
• Use of services Availability
• Barriers to care
Volume and type of services OSHPD1,
provided by safety net clinics counties*
• System perspective
• Provider-based Uncompensated care OSHPD*
measures
• Safety net County indigent care volume
Counties*
and cost
*Requires new data collection
1 Source: Office of Statewide Health Planning and Development
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25. Priority Measures: Access
Percent of people with a usual source of care
Source: California Health Interview Survey, 2001-2009
90% 87.6% 87.5% 87.8% 85.8%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2001 2003 2005 2009
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26. Priority Measures: Access
Percent of people without a usual source of care
Source: California Health Interview Survey, 2009
30%
22%
20%
14%
10% 9%
0%
Let’s Get Healthy California Task Force

27. Priority Measures: Access
Type of place for usual source of care
Source: California Health Interview Survey, 2001-2009
80%
70%
70% 67%
64%
61%
60%
50%
40%
30%
23% 23%
18%
20% 16%
10% 14%
12% 13% 12%
0%
2001 2003 2005 2009
Doctor's office Community/Government clinic No usual source
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28. Priority Measures: Access
Percent of people with a doctor visit in the past year
Source: California Health Interview Survey, 2001-2009
90% 83.0%
83.2% 83.5% 82.7%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2003 2005 2007 2009
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29. Priority Measures: Access
Ambulatory care sensitive hospital
admissions based on AHRQ prevention
quality indicators (PQIs)
Example:
Short-term Complications of Diabetes (PQI 1) &
Uncontrolled Diabetes (PQI 14)
Source: California Office of Statewide Health Planning and
Development , 2009
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30. Stakeholder Feedback
• CHCF solicited stakeholder feedback on the framework
through a series of 6 stakeholder meetings in Feb. 2012
• Response to the framework was largely positive
• Key coverage and access issues identified by
stakeholders:
• “Drill-down” is very important (e.g., by
geography, race/ethnicity, large vs small employers)
• Understanding who remains uninsured and why is a top priority
• Need for better measures of access:
• Providers accepting Medi-Cal
• Consider broadening the definition of provider beyond physicians
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