A Crisis for Caregivers:
Health Insurance Out of Reach for
Los Angeles Home Care Workers

Findings from a Survey of Los Angeles County
In-Home Supportive Services Providers
By
Michael R. Cousineau, Dr.PH,
University of Southern California
Carol Regan, MPH, Service Employees International Union
Alicia Kokkinis, MA, University of Southern California

February 2000

This study was supported by a grant from the California HealthCare Foundation. The California HealthCare Foundation, based in Oakland, California, is a non-profit philanthropic organization whose mission is to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental improvements in the health status of the people of California.

EXECUTIVE SUMMARY

Home care is the fastest growing sector of the health care industry, assisting the elderly and disabled to avoid costly institutionalization and remain in their homes. In the county of Los Angeles, over 90,000 indigent clients depend on IHSS providers for their care, yet many of the home care aides providing this care are themselves poor or near-poor, have no insurance, and are in poor health.

WORKING BUT UNINSURED

There are approximately 32,000 uninsured home care workers in Los Angeles County, representing nearly half (45%) of the IHSS provider workforce. Most home care workers depend on their IHSS provider job as their primary or sole source of income. These workers only have access to insurance if they are a dependent on a spouse's plan, or are linked to the Medi-Cal system. Few can afford to purchase a plan in the private market.

COVERAGE IS UNAFFORDABLE

Since 90% of uninsured home care workers are poor or near poor, few could afford the monthly premiums for even the lowest cost health plan. Sixty-one percent of those who are uninsured reported difficulty paying for health care in the previous year (compared to 25% of privately insured home care workers), and over forty percent delayed or did not receive needed medical care because they couldn't afford it.

CHRONIC CONDITIONS GO UNTREATED

Not surprisingly, there are striking differences between home care workers with and without health insurance with respect to health status and access to health care services. Compared to those with private coverage, uninsured home care workers:
· have poorer health status (33% of uninsured workers with diabetes are not under care for their condition compared to 13% of diabetic workers with private insurance)
· use fewer health care services (uninsured workers are four times more likely not to have a regular provider than their privately insured counterparts -- 42% vs. 12%)
· are more likely to delay or forgo needed health care (nearly one-quarter of uninsured home care workers - 23% - had not filled or postponed filling a needed prescription in the past year compared to 6% of privately insured home care workers)
· are less likely to have received clinical preventive services (35% of uninsured female workers aged 50 and older have not received a mammogram in the previous two years, nearly 4 times greater than those with private health insurance [9%]).

RELIANCE ON PUBLIC SUBSIDIES FOR CARE

Thirteen percent of home care workers are enrolled in Medi-Cal, 8% in Medicare, and a high number of the uninsured home care workers (24%) rely on LA County's Department of Health Services facilities for their health care. While the percentage of home care workers with uninsured children is similar to the general county population, the proportion of home care workers' children with Medi-Cal or Healthy Families coverage is substantially higher. Half of providers with children have one or more children covered by either Medi-Cal or Healthy Families (51%). One-fourth of home care workers with children have at least one child age 18 or younger, who is uninsured (24%).

Since the IHSS program is supported entirely with public funds, public policy can and should ensure adequate subsidies and/or payment rates to ensure the provision of health insurance coverage for IHSS workers. California enjoys a $6 billion surplus and will be receiving $25 billion over the next 25 years from the tobacco settlement, funds more than adequate to cover home care workers and other uninsured working families in CA.

Insurance coverage will help stabilize the workforce and improve the health status of thousands of low-income women who spend their days helping keep others out of the more expensive hospital or nursing home care. They deserve no less.

INTRODUCTION

The California In-Home Supportive Services (IHSS) program provides non-medical assistance to 230,000 individuals who are Medi-Cal eligible aged, blind or disabled and who are unable to remain in their home without assistance. There are 200,000 IHSS providers in California and over one-third (72,000) work in Los Angeles County alone . These Los Angeles County independent providers care for over 90,000 IHSS recipients. The program is supported with federal, state, and local funds, with a State general fund contribution of $667 million last year. The California Department of Social Services administers the IHSS program while counties are responsible for its day-to-day administration.

In September 1997, the Los Angeles County Board of Supervisors established a public authority, the Personal Assistance Services Council (PASC), which is the employer of record and with whom IHSS providers can collectively bargain for better wages and benefits. LA County is one of six counties in CA that have established public authorities for IHSS.

Under the independent provider mode, the state offers minimal benefits: unemployment insurance, state disability insurance, and workers' compensation. Health benefits, along with improved wages, are tied directly to state reimbursement policy, and the current rate does not include adequate funds for insurance coverage. Only one county -- San Francisco -- currently offers health care benefits for IHSS providers.

The Los Angeles County In-Home Supportive Services Provider Health Insurance Project was undertaken in order to gain a better understanding of IHSS providers' health coverage in order to investigate options for insurance. Neither the state nor local agencies collect any such data on health insurance coverage or costs for IHSS providers. With over one-third of the entire IHSS workforce employed in LA, data collected in this project will assist in shaping coverage options for other counties.

In 1999, the California HealthCare Foundation awarded a grant to University of Southern California researcher Michael Cousineau, Dr.PH, working in collaboration with the Service Employees International Union (Washington, D.C.) to conduct a six-month strategic planning study, one component of which was gathering data (focus groups and telephone survey). This report discusses the results of the telephone survey of IHSS providers conducted to better understand workforce characteristics, assist in an actuarial analysis, describe home care workers' insurance coverage and avenues for coverage, and describe health needs and access to care for this population.

KEY FINDINGS

Nearly half -- 45% -- of Los Angeles home care workers are uninsured.

• There are 32,000 uninsured IHSS workers, 45% of the nearly 72,000 home care workers in Los Angeles County.
• Thirty-three percent of home care workers have private health insurance, two-thirds of whom receive their benefits through a spouse's or family member's plan and one-third through their other job or purchased in the individual market.
• Public programs cover the remaining 21%.

(Health Insurance Status of IHSS Providers, Los Angeles County, 1999)

A large number of IHSS workers live below the poverty level.

• Nearly half (48%) of home care workers live in households with income below poverty, and 80% of all IHSS providers are poor or near poor.
• Uninsured workers are worse off: 90% are living below or near the poverty threshold. This percentage contrasts sharply to the 54% of uninsured working-age adults (18-64) in the County who are poor or near poor. Home care workers face significant financial barriers to health care.
• Over 40% of uninsured home care workers delayed or did not receive needed medical care because they couldn't afford it, five times greater than those with private coverage.
• An estimated 61% of those who are uninsured have some difficulty paying for health care costs compared to 25% of privately insured home care workers.
• Nearly one-quarter of uninsured home care workers (23%) had not filled or postponed filling a needed prescription in the past year compared to 6% of privately insured home care workers.
• Uninsured IHSS providers are four times more likely not to have a regular provider then their privately insured counterparts (42% vs.12%).

(Difficulty Paying Health Care Costs by Insurance Status, IHSS Providers, Los Angeles County, 1999)

 

Many uninsured IHSS workers and their children may be eligible for public health care programs, including Medi-Cal.

• Thirteen percent of all home care workers are currently covered by Medi-Cal and 8% have Medicare coverage. Those with Medicare coverage include nearly all providers age 65 or older as well as 1% of those under age 65.
• The percentage of IHSS providers who are uninsured increases to 48% when limiting the analysis to only those between the ages of 16 and 64 - considerably higher than the 34% estimated to be uninsured among the county's working age adult population.
• With so many workers living in poor and near-poor households, many of the uninsured are potentially eligible for Medi-Cal.
• A third of uninsured home care workers are poor or near poor and have children which should make them eligible for Medi-Cal or other publicly-financed health care programs

(Uninsured Providers by Poverty and Whether Respondent has Dependent Children)

 

IHSS workers are more likely to utilize County health care facilities.

• Fifteen percent of home care workers have used DHS facilities in the past year compared to 11% of the general adult population.
• Uninsured IHSS providers use DHS facilities at a noticeably higher rate than the general adult population (24% vs. 15%).
• Of the home care workers who used DHS in the past year, 72% consider a county or community clinic as their regular provider or the last place they went for care.
• Seven percent of home care workers were hospitalized in the past year; of these hospital stays, 14% occurred at a DHS hospital.

(Department of Health Services (DHS) Use in Previous Year, by Insurance Status, IHSS Providers & Adult Population (ages 18 and older), Los Angeles County, 1997 & 1999)

 

Many uninsured home care workers delay care and have chronic medical conditions that go untreated.

• Many home care workers are suffering from chronic medical conditions including diabetes, hypertension and high blood cholesterol.
• Compared to those with private coverage, 33% of uninsured home care workers with diabetes are not under care for their condition compared to 13% of privately insured diabetic home care.
• Five percent of uninsured home care workers have delayed or forgone needed surgery.

(Prevalence of Chronic Conditions Among IHSS Providers Compared to Adults, Ages 18 and older, 1997 & 1999)

 

Home care workers lack access to preventive care.
Preventive services can significantly impact the health status of the individual through screening, early detection, diagnosis and treatment of disease:

• Over one-third (35%) of uninsured female home care workers aged 50 and older have not received a mammogram in the previous two years, nearly 4 times greater than those with private health insurance (9%).
• One in three uninsured female IHSS providers (aged 18-64) has not had a pap test in the past two years compared to 87% of privately insured home care workers who have had such tests.

(Female IHSS Providers, Who Have Not Had Received Recommended Preventive Services* in the Past Two Years, by Insurance Status, Los Angeles County, 1999)

 

CONCLUSION

These data underline the critical need for providing health coverage to IHSS caregivers. Without health care, existing health conditions will worsen, requiring more costly and expensive treatment and case management. Insurance will help prevent unnecessary hospitalization and reduce costs. Lack of prevention and early detection of new conditions will lead to a reduced quality of life as well as adding to personal and public financial costs.

There are several possible solutions and approaches to insure this workforce. Since the IHSS program is supported entirely with public funds, public policy can and should ensure adequate subsidies and/or payment rates to ensure the provision of health insurance coverage for IHSS workers. California enjoys a $6 billion surplus and will receive $25 billion over the next 25 years from the tobacco settlement, funds more than adequate to cover home care workers and other uninsured working families in California. New York passed legislation in December 1999 using tobacco settlement funds to expand coverage a million uninsured workers and provide seamless coverage to 45,000 home care workers in New York City. In San Francisco County, a partnership between the city/county, public authority, and union resulted in health insurance coverage for IHSS workers there.

Insurance coverage will help stabilize the workforce and improve the health status of thousands of low-income women and men who spend their days helping keep others out of more expensive hospital or nursing home care. They deserve no less.

METHODOLOGY

Data for the Los Angeles County IHSS Provider Health Survey was collected through a telephone interview of 1,244 IHSS workers in November and December of 1999. Field Research Corporation, an independent survey research firm, conducted the study. A random sample was drawn from payroll records that contained providers' names and telephone numbers. The interviews lasted about 15 minutes and were conducted in either English (81%) or Spanish (19%). The adjusted completion rate after removing wrong numbers, those who didn't answer, and those ineligible to participate was 59% and the cooperation rate was 81.0%. The responding sample was similar to the larger IHSS provider workforce based on age and gender, and where people live within Los Angeles County. The survey results reported here have an error rate of +/- 3%.

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