Health Insurance

People with health insurance tend to have better access to care and preventative services than those who do not.[1] Those who are uninsured are likely to receive less medical care and less timely care, which can lead to being diagnosed at a later stage of an illness or getting less treatment for an illness.[2] In 2021, working age adults (ages 18-64) without health insurance were almost twice as likely to have problems paying their medical bills as those with health insurance.[3]

Because of the high cost of health insurance, low-income workers are more likely to be uninsured. Low-income workers are also less likely to have access to employer-based coverage, due in part to job characteristics like working in smaller firms, working part-time, and working in certain industries like retail or personal services.[4] For those who are insured, unemployment can mean losing access to health coverage. Uncertain access can impact health outcomes: if patients believe they are at risk of losing their insurance, they may choose shorter-term treatment options, postpone, or avoid medical care to reduce future bills.[5] Additionally, race independent of income also plays a big role in whether people are insured.[6] Even though disparities in the uninsured rate between White people and peoples of other racial groups nationwide decreased after the Affordable Care Act (ACA) was implemented in 2014, uninsured rates are not yet equal.[7] These and other healthcare inequities lead Hispanic, Black or African American, and American Indian or Alaska Native people to have lower life expectancy or higher rates of specific health problems when compared to other groups.[8] Among disabled adults in the U.S., health insurance improves healthcare access, reduces the cost burden of healthcare, and reduces disparities in healthcare access and use by race, ethnicity, and socio-economic status.[9]
The percentage of uninsured in San Diego County (7.6%) was lower than the percentage of uninsured nationally (8.8%) in 2021.[10] Figures 1-4 illustrate the disparities for health insurance coverage by race/ethnicity, sex, disability status, and immigrant status. Higher percentages of American Indian or Alaska Native and Hispanic or Latino people were uninsured than people in the county overall, at 20% and 13%, respectively (Figure 1). Hispanic or Latino people were more than three times as likely, Black or African American people nearly twice as likely, and American Indian or Alaska Native people five times as likely to be uninsured than White people. More males had no health insurance than females (Figure 2). Immigrants face additional barriers to acquiring health insurance, including financial constraints and potential ineligibility for free statewide programs; immigrants were more than twice as likely as non-immigrants to have no health insurance (Figure 3).  These disparities persist (and even worsen in some cases) looking only at those employed in San Diego County.
Those with a reported disability in San Diego County in 2021 were more likely to have health insurance than those without a reported disability (Figure 4). This may be in part because some people with disabilities are qualified for government programs that provide insurance. It is also worth considering that some people with disabilities may be acutely aware of their need for health insurance, causing them to prioritize health insurance when they select an employer over other important factors, like pay. 
Figure 5 shows the differences by geography for Public Use Microdata Areas (PUMAs).
According to the 2021 National Health Interview Survey, the greatest barrier to obtaining health insurance in the U.S. was reported to be unaffordable coverage, with 69.5% of nonelderly adults citing that as a reason for being uninsured. Other reasons included not being eligible, 26.2%; not needing or wanting insurance, 23.5%; difficulty with or confusion about signing up, 19.9%; and not finding a plan that meets their needs, 18.3%.[11] The Family Health Centers of San Diego‘s Insurance Enrollment Assistance program[12] and the Community Transition Center[13] are helping fill these gaps and increase health insurance enrollment by helping residents sign up.
Figure 6 outlines the types of health insurance coverage among San Diego County residents in 2021. Most people, 1,757,818 (53.3%) had private insurance through their employer or union. Among public insurance types, most people were enrolled in Medicaid, with about 657,663 (20.0%) people enrolled in 2021 according to the ACS. According to California’s Department of Health Care Services, the number of people in the county enrolled in Medi-Cal, the State’s version of Medicaid, was 953,824 (28.9%) as of Jul. 1, 2021.[14] The difference can be attributed to differences in the data sources, where ACS is a survey that a portion of the population completes (respondents may not know what type of insurance they have or leave it blank), while the California’s Department of Health Care Services data are based on the program enrollment system.
During the COVID-19 pandemic, the federal government expanded affordable care options through the American Rescue Plan. As these temporary programs expire, people are likely to struggle once again to obtain and maintain access to health insurance.

Data Information
Data Source: 2021 American Community Survey 5-year Estimates from IPUMS USA.
Figure 1 Footnote:
  • Persons of Hispanic or Latino ethnicity may belong to any race group. All categories except Hispanic or Latino include persons for whom race is known but ethnicity is non-Hispanic or unknown.
Figure 6 Footnotes:
  • The percent of people with health insurance coverage is out of all county residents, N=3,296,897.
  • According to California’s Department of Health Care Services, the number of people in the county enrolled in Medi-Cal, the State’s version of Medicaid, was 953,824 (28.9%) as of Jul. 1, 2021.   
  • Health insurance policies though Indian Health Services are not always comprehensive, so the Census Bureau does not consider people with only IHS coverage to be insured.[15]
References
  1. AHIP. (2018). The Value of Medicaid: Providing Access to Care and Preventive Health Services. Retrieved from https://www.ahip.org/resources/the-value-of-medicaid-providing-access-to-care-and-preventive-health-services   
  2. Buchmueller, T. C., Grumbach, K., Kronick, R., & Kahn, J. G. (2005). The effect of health insurance on medical care utilization and implications for insurance expansion: A review of the literature. Med Care Res Rev, 62(1), 3–30. https://doi.org/10.1177/1077558704271718
  3. Cohen, R., & Cha, A. (2023). Problems Paying Medical Bills: United States, 2021. National Center for Health Statistics (U.S.). https://doi.org/10.15620/cdc:122191
  4. Lee, K., Lucia, L., Graham-Squire, D., & Dietz, M. (2019, November 22). Job-based coverage is less common among workers who are Black or Latino, low-wage, immigrants, and young adults. Rising Health Care Costs in California: A Worker Issue. UC Berkeley Labor Center. https://laborcenter.berkeley.edu/job-based-coverage-is-less-common-among-workers-who-are-black-or-latino-low-wage-immigrants-and-young-adults/
  5. Bittker, B. M. (2020). Racial and Ethnic Disparities in Employer-Sponsored Health Coverage. Human Rights Magazine, 45(4). Retrieved from https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/health-matters-in-elections/racial-and-ethnic-disparities-in-employer-sponsored-health-coverage/
  6. Lee, D.-C., Liang, H., & Shi, L. (2021). The convergence of racial and income disparities in health insurance coverage in the United States. International Journal for Equity in Health, 20(96). https://doi.org/https://doi.org/10.1186/s12939-021-01436-z
  7. Artiga, S., Hill, L., Orgera, K., & Damico, A. (2021). Health Coverage by Race and Ethnicity, 2010-2019. Kaiser Family Foundation.
  8. USAFACTS. (2022). Does access to healthcare differ by race and ethnicity? USAFACTS. https://usafacts.org/articles/does-access-to-healthcare-differ-by-race-and-ethnicity/
  9. Miller, N. A., Kirk, A., Kaiser, M. J., & Glos, L. (2014). The relation between health insurance and health care disparities among adults with disabilities. American Journal of Public Health, 104(3), e85–e93. https://doi.org/10.2105/AJPH.2013.301478
  10. Selected Characteristics of Health Insurance Coverage in the United States. (2021). United States Census Bureau. S2701: S2701: SELECTED CHARACTERISTICS OF ... - Census Bureau Table
  11. Tolbert, J., Drake, P., & Damico, A. (2022). Key Facts about the Uninsured Population. Kaiser Family Foundation. Retrieved from https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/
  12. Family Health Centers of San Diego. (n.d.). Insurance Enrollment Assistance. https://www.fhcsd.org/insurance-enrollment/
  13. Liebler, D. (2016, April 25). San Diego County Partnership Focuses on Health of Probationers. The County Voice, California State Association of Counties. https://www.counties.org/county-voice/san-diego-county-partnership-focuses-health-probationers
  14. Medi-Cal Managed Care Operations Division/Research & Analytics Unit. Medi-Cal Managed Care Enrollment Report January 2007-present. California Department of Health Care Services. https://data.chhs.ca.gov/dataset/medi-cal-managed-care-enrollment-report
  15. Branch, B., & Conway, D. (2021). Health Insurance Coverage by Race and Hispanic Origin: 2021.
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Updated February 7, 2024