Rising Number of Uninsured in Sonoma County

October 20, 2008

Prepared for Indigent Health Group
Marion Deeds, Director of Economic Assistance, Human Services Department
Lynn Scuri, Manager of Planning and Population Health, Department of Health Services
Kim Seamans, Section Manager of Medi-Cal Eligibility, Human Services Department

Prepared by Division of Planning, Research and Evaluation
Marla Stuart, Director
Tara Smith, Planner Analyst

Graphics Assistance provided by the Division of Administration
Lee Lewis, Systems and Program Analyst

Page

Summary ......................................................................................................................................... 1

Description of CMSP ...................................................................................................................... 2

Purpose of Study ............................................................................................................................. 2

Methodology ................................................................................................................................... 3

Description of CMSP Recipients .................................................................................................... 4

Tables and Graphs

1. Number of Enrollees by Month........................................................................................... 4

2. Aid Codes by Month ........................................................................................................... 5

3. CMSP Patterns of Enrollments ........................................................................................... 6

4. CMSP Recipient Demographics ....................................................................................... 10

5. Months on CMSP by Demographic .................................................................................. 11

Conclusions ................................................................................................................................... 12

Recommendations ......................................................................................................................... 12

Endnotes ........................................................................................................................................ 13

The number of Sonoma County CMSP enrollees is increasing (page 4)
11,977 different Sonoma County residents received CMSP in the 20 months
beginning December 2006 and continuing through July, 2008. This represents 4% of the adult
population age 19-65. On average, 4,228 residents received CMSP each month January through
July, 2008. Comparatively, approximately 54,000 Sonoma County residents received Medi-Cal
in July, 2008.
The number of residents receiving CMSP each month increased from 3,431 in December 2006 to
4,440 in July 2008 (a 29% increase). From 1999-2006, the Sonoma County population age 19-59
increased 4.33%.
In 2008 (January through July), an average of 468 individuals each month are new CMSP
enrollees (11% of all enrollees in the month). These individuals did not receive CMSP in the
previous 12 months.
NATIONAL COMPARISON: This growth in the Sonoma County CMSP caseload reflects the
national trend of increasing numbers of individuals without health insurance. 18% of the US
population does not have health insurance (46.5 million people). 12.9% of the US population did
not have health insurance in 1987.

37% of Sonoma County CMSP recipients are “churning” (page 7)
60% of CMSP recipients have predictable acute enrollment patterns
3% of CMSP recipients receive CMSP continually.
37% of CMSP recipients move on and off CMSP. This represents over 1,600 Sonoma County
residents each month who do not have reliable and consistent medical coverage.
NATIONAL COMPARISON: Senior citizens, Latino’s, and low-income individuals are most
likely to lack medical insurance for extended periods of time.2

The most common Sonoma County CMSP recipient is a white male younger than 60 (page 11)
However, when compared to the Sonoma County population, Sonoma County CMSP recipients
are disproportionately Hispanic males under age 29.
NATIONAL COMPARISON: People of color are less likely to have health insurance.1 80% of
uninsured people in the United States live in families with one or more full-time workers. 9

Impact
HEALTH IMPACT: Uninsured Americans have higher rates of mortality, poor health outcomes, are less
likely to receive preventive care, and are more likely to require inpatient care.3 The number of excess
deaths in 2000 among uninsured adults was estimated at 18,000.9
ECONOMIC IMPACT: People without health insurance are often unable to pay for their medical care.
The cost of uncompensated medical care was $41 billion in 2004. Federal, state and local governments
reimburse health care providers for 85% of these costs.9

Recommendations (page 13)
CMSP regulations should promote continued medical coverage for eligible individuals to improve the
health of Sonoma County and to reduce uncompensated medical care costs.
Report on Sonoma County CMSP, M. Stuart, HSD PRE, October 20, 2008, page 1

In California, Medi-Cal (Medicaid) provides a array of programs to meet the health care of most low-income
individuals. Medi-Cal coverage is available for all children through age 20 and for those 65 and older. In some
cases, the parents of a child are also eligible for Medi-Cal. Other Medi-Cal programs provide coverage for adults
in short-term nursing facilities, as well as those with specific medical needs such as dialysis, tuberculosis
treatment, total intravenous nutrition, or breast or cervical cancer treatments.

Established by California law in January 1983, the County Medical Services Program (CMSP) provides medical
and dental care for medically indigent adults between the ages of 21 through 64 who are not eligible for Medi-
Cal, who have an income at or below 200% of the federal poverty level of $10,4004 and who have less than
$2,000 in liquid assets. Applicants are approved for one of five aid categories. Most applicants are eligible for
standard CMSP coverage which is approved for six months and which covers all approved procedures or
medications. Some applicants, based on their income, must pay a share of cost and are only approved for three
months. “Share of cost” is the amount that these applicants must pay or obligate before CMSP coverage will pay
the medical provider. This is similar to a co-pay in private insurance. Other applicants are approved for restricted
benefits. These are emergency services only and are approved for two months. Restricted benefits are provided
to residents who lack documentation of satisfactory immigration status or citizenship. Finally, CMSP can also be
approved for an individual claiming disability while they complete the Medi-Cal disability application and for
individuals receiving Long Term Care to supplement the Medi-Cal coverage.
CMSP is administered by the CMSP Governing Board comprised of county supervisors, administrators, health
officials, and welfare directors. Benefits are administered by Anthem Blue Cross for medical, dental and vision
and by Med-Impact for prescriptions. Thirty-four (34) small, rural counties currently participate in CMSP
including Sonoma which is the second largest county with CMSP. These counties have a combined monthly
caseload of 40,000 people and an annual budget of approximately $238 million derived from motor vehicle
license fees, sales tax and county general revenue.5

In September 2007, the Sonoma County Human Services Department (HSD) and the Sonoma County Health
Services Department (DHS) convened the Indigent Health Group. The overall purpose of the group is to gain
better knowledge of the medically indigent in Sonoma County and to develop recommendations to reduce their
obstacles to care. This study was designed to assist the Indigent Health Group’s activities by providing a better
understanding of the Sonoma County CMSP population. Specifically, this study explored the following
questions.
1. What are the characteristics of Sonoma County CMSP recipients?
2. What is the pattern of enrollment for Sonoma County CMSP recipients?

It is anticipated that this study will be useful to the following groups:
HSD and DHS managers and executives for policy making.
HSD and DHS staff for practice guidance.
Sonoma County Administrator’s Office for information and policy development.
CMSP Governing Board for policy development.

Report on Sonoma County CMSP, M. Stuart, HSD PRE, May 30, 2008, page 2

Information about CMSP recipients was extracted from the California State Business Objects MEDS Database. A
query was run for each of 20 months (December, 2006 through July, 2008). The following information was
extracted for each recipient.

Name Primary language
Case number Month of eligibility
Date of birth Aid code
Gender Amount of share of cost (if any)
Ethnicity

Other information was of interest and attempts were made to include this information. However, this information
was not, ultimately, available in a format that was reliable.

Date and source all applications General Assistance (GA) status
Date of all approvals Zip code
Date of all denials Share of cost met
Date of all discontinuations Earned and unearned income

All information was compiled in Excel, imported into the Statistical Package for the Social Sciences (SPSS), and
restructured to maximize analysis options. The following analyses were employed:

Descriptive statistics describe information with numbers. Frequency, percent and mean are reported here.
Inferential statistics quantify the level of uncertainty when using sample information to describe a whole
population. This report uses independent sample t-test (t) to examine the difference between two means and
chi-square (X2) to examine the difference between two percents. With both statistics, a p-value of less than
.03 indicates that the difference identified in the sample is most likely evident in the whole population.
A cohort of CMSP recipients was selected to examine CMSP enrollment patterns over time. To conduct
this longitudinal analysis, a subset of one month of CMSP recipients was selected. 563 individuals received
CMSP benefits in January, 2007 but not in December, 2006. These individuals were selected as the January
2007 Cohort because they appeared to be starting a new enrollment period and because information for 19
consecutive months was available for them. Observing these individuals for 19 consecutive months
(January, 2007 through July, 2008) provides information about trends in CMSP enrollment and differences
between demographic groups.

The following pages describe Sonoma County CMSP recipients.


The number of Sonoma County CMSP enrollees is increasing ______________________________
TABLE 1: Number of Enrollees by Month
Year # CMSP # New % New # with % with
Month Enrollees Enrollees* Enrollees SOC+ SOC
2006 Dec 3,431 508 15%
2007 January 3,517 526 15%
February 3,449 489 14%
March 3,541 515 15%
April 3,591 528 15%
May 3,687 564 15%
June 3,722 564 15%
July 3,767 549 15%
August 3,881 576 15%
September 3,807 551 14%
October 3,877 550 14%
November 3,885 532 14%
December 3,862 549 14%
2007 Average 3,716 541 15%
2008 January 3,961 552 14% 505 13%
February 4,066 433 11% 482 12%
March 4,173 415 10% 511 12%
April 4,206 548 13% 544 13%
May 4,300 425 10% 576 13%
June 4,449 474 11% 602 14%
July 4,440 426 10% 609 14%
2008 YTD Average 4,228 468 11% 547 13%
*
New enrollees are those in the month who were not enrolled in CMSP in the previous 12 months.
+
Share of Cost (SOC) is an amount that must be obligated by the enrollee to the healthcare provider before
CMSP coverage will pay the provider. This is similar to a co-pay in private insurance.
Sonoma County Human Services Department
Number of CMSP Enrollees

5,000
4,440

4,000
3,431
Number of CMSP Enrollees

3,000

2,000

1,000

0
May 07

Nov 07

May 08
Dec 06

Jan 07

Feb 07

Mar 07

Apr 07

Jun 07

Jul 07

Aug 07

Sep 07

Oct 07

Dec 07

Jan 08

Feb 08

Mar 08

Apr 08

Jun 08

Jul 08


TABLE 2: Aid Codes by Month (see definition for each aid code on following page)
88 89 8F
50 50 Disability Disability CMSP
84 85 Restricted Restricted Pending Pending Companion
No Share of Cost Share of Cost (SOC) (no SOC) (no SOC)6 (SOC)6 (LTC)
Month # % # % # % # % # % # % # %
Dec 06 2,821 82.2 447 13.0 84 2.4 60 1.7 14 0.4 0 0.0 5 0.1
Jan 07 2,888 82.1 462 13.1 87 2.5 62 1.8 12 0.3 0 0.0 6 0.2
Feb 07 2,852 82.7 437 12.7 94 2.7 49 1.4 10 0.3 0 0.0 7 0.2
Mar 07 2,922 82.5 458 12.9 91 2.6 54 1.5 9 0.3 1 0.0 6 0.2
Apr 07 2,954 82.3 465 13.0 98 2.7 60 1.7 7 0.2 2 0.1 5 0.1
May 07 3,009 81.6 493 13.4 101 2.7 67 1.8 8 0.2 2 0.1 7 0.2
Jun 07 3,043 81.8 502 13.5 101 2.7 57 1.5 8 0.2 4 0.1 7 0.2
Jul 07 3,089 82.0 486 12.9 99 2.6 55 1.5 25 0.7 6 0.2 7 0.2
Aug 07 3,124 80.5 499 12.9 101 2.6 62 1.6 75 1.9 13 0.3 7 0.2
Sep 07 3,040 79.9 472 12.4 94 2.5 61 1.6 117 3.1 18 0.5 5 0.1
Oct 07 3,074 79.3 478 12.3 96 2.5 51 1.3 154 4.0 21 0.5 3 0.1
Nov 07 3,070 79.0 459 11.8 92 2.4 44 1.1 189 4.9 29 0.8 2 0.1
Dec 07 3,014 78.0 469 12.1 52 1.4 72 1.9 224 5.8 28 0.7 3 0.1
07 Average 3,007 81.0 473 12.8 92 2.5 58 1.6 70 1.8 10 0.3 5 0.2
Jan 08 3,146 79.4 413 10.4 66 1.8 78 3.8 227 5.7 26 0.3 8 0.1
Feb 08 3,259 80.2 400 9.8 62 1.5 81 2.0 239 5.8 22 0.1 3 0.0
Mar 08 3,329 79.8 435 10.4 56 1.3 65 1.6 264 6.3 22 0.5 2 0.0
Apr 08 3,351 79.7 471 11.2 66 1.6 52 1.2 244 5.8 21 0.5 1 0.0
May 08 3,405 79.2 503 11.7 61 1.4 54 1.3 258 6.0 19 0.4 0 0.0
Jun 08 3,510 78.9 518 11.6 73 1.6 64 1.4 264 5.9 20 0.4 0 0.0
Jul 08 3,449 77.7 503 11.3 85 1.5 77 1.7 296 6.7 29 0.7 1 0.0
08 YTD Average 3,350 79.3 463 10.9 67 1.5 67 1.9 256 6.0 23 0.4 2 0.0


Aid Code Definitions
84 No share of cost (No SOC) – Individual does not incur any portion of the medical expense, as long as it is an approved procedure or medication.
85 Share of Cost (SOC) - Individual must first pay or be obligated to pay a monthly amount before CMSP begins. The share of cost amount is based
on a person’s net nonexempt income minus their maintenance need.
50 Restricted – Individual is entitled to emergency services only. Restricted benefits are provided to residents who lack documentation of satisfactory
immigration status or citizenship.
88 or 89 Disability Pending – An individual claiming disability is entitled to CMSP while they complete the Medi-Cal disability application, if
otherwise eligible.
8F CMSP Companion (LTC) -Individual typically has both CMSP and Medi-Cal. The CMSP pays for any expense not related to Long Term Care;
Medi-Cal covers the Long Term Care expense. (Long-Term Care is inpatient medical care which lasts for more than the month of admission and is
expected to last for at least one full calendar month after the month of admission.)


37% of Sonoma County CMSP recipients are “churning”__________________________________
CMSP eligibility is approved for two months (restricted), three months (share of cost) or six months (no share of
cost). Patterns of enrollment were examined for the 563 individuals in the January 2007 cohort (recipients who
received CMSP benefits in January 2007 but not in December 2006). Enrollment activity was tracked for 19
months for these recipients (January 2007 through July 2008). This cohort represents a sample of all CMSP
recipients.
The most common CMSP enrollment longevity is six months (see pattern 1 in Table 3.1). Approximately
25% of CMSP recipients experience this single enrollment episode.
Approximately 60% of CMSP recipients appear to receive benefits for an acute episode of care (see patterns
1-8 in Table 3.1).
Approximately 3% of CMSP recipients appear to receive benefits continuously (see pattern 9 in Table 3.1).
The remaining 37% of CMSP recipients appear to be “churning.” They move on and off CMSP in
unpredictable patterns of enrollment. These enrollment patterns are illustrated in the Table 3.2.

TABLE 3.1: CMSP Patterns of Enrollment (cohort) = enrolled = not enrolled
2007 2008
Cum # of
# % % J F M A M J J A S O N D J F M A M J J Months
1 142 25.22 25.22 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 6
2 62 11.01 36.23 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3
3 50 8.88 45.12 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
4 26 4.62 49.73 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 12
5 21 3.73 53.46 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
6 12 2.13 55.60 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4
7 12 2.13 57.73 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5
8 8 1.42 59.15 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 9

9 19 3.37 62.52 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 19

TABLE 3.2: CMSP Patterns of Enrollment (cohort) = enrolled = not enrolled
Cum 2007 2008 # of
10 19 3.37 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 18
11 7 1.24 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 18
12 5 0.89 68.03 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 18

13 5 0.89 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 17
14 3 0.53 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 17
15 2 0.36 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17
16 2 0.36 1 1 1 1 1 1 0 1 1 1 1 1 1 0 1 1 1 1 1 17
17 1 0.18 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 17
18 1 0.18 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 17
19 1 0.18 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 0 17
20 1 0.18 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 17
21 1 0.18 71.05 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 17


TABLE 3.2 (continued): CMSP Patterns of Enrollment (cohort) = enrolled = not enrolled
Cum 2007 2008 # of
22 3 0.53 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 16
23 3 0.53 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 1 1 1 1 16
24 3 0.53 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 16
25 2 0.36 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 1 16
26 1 0.18 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 16
27 1 0.18 73.36 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 16

28 4 0.71 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 1 15
29 3 0.53 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 1 1 1 15
30 2 0.36 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 15
31 1 0.18 1 1 1 0 0 0 1 1 1 0 1 1 1 1 1 1 1 1 1 15
32 1 0.18 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 1 1 1 1 15
33 1 0.18 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 0 15
34 1 0.18 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 1 0 15
35 1 0.18 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 1 1 1 15
36 1 0.18 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 0 15
37 1 0.18 76.20 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 0 0 15

38 3 0.53 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 1 1 14
39 2 0.36 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 0 1 1 14
40 1 0.18 1 1 1 0 0 1 1 1 0 0 0 1 1 1 1 1 1 1 1 14
41 1 0.18 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 0 0 14
42 1 0.18 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 1 1 14
43 1 0.18 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 0 0 1 1 14
44 1 0.18 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 14
45 1 0.18 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 14
46 1 0.18 78.33 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 14

47 3 0.53 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 1 1 1 13
48 2 0.36 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 13
49 1 0.18 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 1 13
50 1 0.18 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 0 0 13
51 1 0.18 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 13
52 1 0.18 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 1 13
53 1 0.18 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 1 13
54 1 0.18 80.28 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 13

55 5 0.89 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 12
56 5 0.89 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 1 1 0 12
57 3 0.53 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 0 0 0 0 12
58 2 0.36 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 0 0 12
59 2 0.36 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 0 12
60 2 0.36 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 0 0 12
61 1 0.18 1 0 0 0 0 0 0 1 1 1 1 1 1 1 0 1 1 1 1 12
62 1 0.18 1 1 1 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 12
63 1 0.18 84.19 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 0 0 0 12


Cum 2007 2008 # of
64 5 0.89 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 11
65 3 0.53 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 11
66 2 0.36 1 1 1 1 1 1 0 1 1 1 1 1 0 0 0 0 0 0 0 11
67 2 0.36 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 11
68 1 0.18 1 1 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 11
69 1 0.18 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 11
70 1 0.18 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 0 1 1 11
71 1 0.18 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 11
72 1 0.18 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 0 11
73 1 0.18 1 1 1 1 1 1 0 0 0 0 1 1 1 0 0 0 0 1 1 11
74 1 0.18 87.57 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 0 0 0 0 11

75 2 0.36 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 10
76 2 0.36 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 10
77 1 0.18 1 1 1 1 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 10
78 1 0.18 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 0 0 0 0 10
79 1 0.18 88.81 1 1 1 1 1 1 0 1 1 1 1 0 0 0 0 0 0 0 0 10

80 4 0.71 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 9
81 2 0.36 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 9
82 2 0.36 1 1 1 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 9
83 1 0.18 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 9
84 1 0.18 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 9
85 1 0.18 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 9
86 1 0.18 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 9
87 1 0.18 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 9
88 1 0.18 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 0 0 0 0 9
89 1 0.18 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 9
90 1 0.18 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 9
91 1 0.18 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 9
92 1 0.18 92.01 1 1 1 1 1 1 1 1 0 0 0 1 0 0 0 0 0 0 0 9

93 5 0.89 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 8
94 5 0.89 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 8
95 1 0.18 93.96 1 1 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 8

96 7 1.24 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 7
97 2 0.36 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 7
98 1 0.18 1 1 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 7
99 1 0.18 1 1 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 7
100 1 0.18 96.09 1 1 1 1 1 1 0 0 0 0 1 0 0 0 0 0 0 0 0 7

101 4 0.71 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 6
102 2 0.36 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 6
103 2 0.36 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 6
104 1 0.18 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 6
105 1 0.18 97.87 1 1 0 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 6


Cum 2007 2008 # of
106 1 0.18 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 5
107 1 0.18 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 5
108 1 0.18 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 5
109 1 0.18 1 1 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 5
110 1 0.18 98.76 1 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 5

111 2 0.36 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4
112 1 0.18 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 4
113 1 0.18 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 4
114 1 0.18 99.64 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 4

115 1 0.18 99.82 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3

116 1 0.18 100.00 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2


The most common Sonoma County CMSP recipient is a white male younger than 60 ___________
TABLE 4: CMSP Recipients Demographics (Compared to Sonoma County)
CMSP Recipients 2006 Sonoma County
Dec 06 – Mar 08 2006
Ages 21-65 Ages 21-65
n=11,977 n=286,1907 Statistic p
Number Percent Number Percent
Gender Female 4,879 40.8% 141,730 50% X2=404 .00
n=11,958 Male 7,079 59.2% 144,460 50%
Ethnicity White 7,708 66.1% 205,249 77.5% X2=2,000 .00
n=11,654 Hispanic or Latino 2,615 22.4% 42,865 16.2%
African American 551 4.7% 3,860 1.5%
Asian 340 2.9% 8,892 3.4%
Native American 307 2.6% 3,258 1.2%
Pacific Islander 133 1.1% 566 0.2%
Other or No Data 323 21,500
Age 21-29 140 24.9% 56,132 19.6% X2=35.57 .00
n=563 30-39 105 18.7% 73,692 25.7%
(cohort only) 40-49 146 25.9% 80,113 28.0%
50-59 115 20.4% 59,554 20.8%
60-65 57 10.1% 16,699 5.8%

CMSP Recipients Compared to Sonoma County Population
(All enrollees Jan 2007-Jul 2008: n=11,977. Cohort: n=563.)
80%

The most common
CMSP recipient is a 70%
Gender
White male under (n=11,958) CMSP Recipients
Sonoma County
age 60. 60%

However, CMSP
Percent of Population

50%
recipients are more
likely than the 40%
Sonoma County Age
n=(563)
population to be 30%
Hispanic, or male, Ethnicity
or under age 29. 20%
(n=11,654)

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an

e
ni

ci
iv
pa

Pa
ric

at
is

N
Af
H


TABLE 5: Months on CMSP by Demographic (cohort, n=563, from January 2007 through July 2008)
Average Number of Months
in 19 months
(Jan 07 – Jul 08)
Demographic Sub-Groups with CMSP Enrollment Statistic p
Age 21-29 (n=140) 4.42 F=10.92 .00
30-39 (n=105) 7.61
40-49 (n=146) 8.77
50-59 (n=115) 10.43
60-65 (n=57) 7.49
Ethnicity White (n=339) 8.79 F=10.55 .00
Hispanic or Latino (n=140) 5.69
African American (n=27) 9.48
Asian (n=20) 8.80
Native American (n=14) 12.21
Pacific Islander (n=11) 10.73
Primary Spanish (n=106) 5.13 F=25.15 .00
Language English (n=447) 8.83
Other (n=10) 11.50
Gender Female (n=238) 8.45 t=1.01 .31
Male (n=325) 7.98

Average Number of Months with CMSP Enrollment
January 2007 through July 2008
Cohort n = 563
14

12 Average = 8.18
months
Ethnicity

10 Age Language
Average Months on CMSP

Gender

8

6

4

2

0
er

e
9

9

9

9

5

n

sh
n

ish

e
o

an

er
te

al
-2

-3

-4

-5

-6

ia

ica

al
tin

th
hi

nd

i
ic

an

gl

M
m
As
21

30

40

50

60

La
W

O
er
er

la

En

Fe
Sp
Am
Am

Is
or

ic
c

e
an

cif
ni

iv
pa

Pa
r ic

at
is

N
Af
H


1. With certification periods of two months (restricted), three months (share of cost), and six months (no share
of cost) it appears difficult for recipients to maintain health coverage (based on patterns of enrollment), and
presumably, to access preventive and chronic health care. CMSP appears to be utilized primarily by
recipients as coverage for acute or emergency health needs.

2. A very small percent of Sonoma County CMSP enrollees (12%) have a share of cost. The three-month
certification period for recipients with a share of cost is not justified for such a small group. Increasing the
share of cost certification period to six months would ease the burden for recipients, reduce workload (each
CMSP re-application requires 59 minutes10), and presumably improve health outcomes.

3. Within the Sonoma County medically indigent population, Hispanic, Spanish-speaking individuals have
lower rates of coverage and coverage for shorter amounts of time. This may reflect the use of CMSP by
undocumented residents of Sonoma County who are eligible for restricted CMSP.

1. Collect and report this information on an ongoing, monthly basis (from MEDS) for use in policy development
and practice management by the Human Services Department and the Department of Health Services.

2. Add information about utilization of medical care to more fully understand the types of health care received
by CMSP recipients and the impact of intermittent health coverage on health outcomes.

3. Conduct additional study to determine the impact of CMSP enrollment patterns on health outcomes in
Sonoma County.

4. Continue to explore, and promote (as appropriate), a longer CMSP certification period to promote improved
health. This may include testing, and if successful advocating for, self-recertification at six months and full
recertification at 12 months.

5. Explore methods to reduce churning (recipients going on and off CMSP). For instance, explore the feasibility
of sending each recipient a reminder notice that their certification period will be ending in 15 (or 30) days and
include instructions about how to renew the certification. Or, develop innovative strategies for utilizing the
Certified Application Assisters (CAA) to assist with re-certification.


1
DeNaval-Walt, C., Proctor, B., and Smith, J. (2007). Income, Poverty and Health Insurance Coveragein the
United States: 2006 (U.S. Census Bureau, Current Population Reports). Washington, DC, U.S. Government
Printing Office, 60-233.
2
Rhoades, J., Cohen, S. (2007, August). The Long-Term Uninsured in America, 2002-2005: Estimates for the
U.S. Population Under Age 65. Rockville, MD, Agency for Healthcare Research and Quality.
3
Lucey, P. (2001, January). An Access Program for Medially Indigent Individuals. Nursing Economics, 19.1,
12.
4
2008 HHS Poverty Guidelines (2008, January 23). Federal Register, 783:15, 3971-3972.
5
History of CMSP (2005). www.cmspcounties.org.
6
According to Clo Hair, Economic Assistance Program Specialist, an effort has been made to more correctly
use the “Disability Pending” aid code. First, a clerical worker was assigned to specifically work on referrals
from the CMSP Governing Board. Second, reminders were made to staff at monthly technical meetings.
And, third, programming was corrected in CalWIN to facilitate the use of the “Disability Pending” aid code.
7
American Fact Finder (2006). US. Census Bureau. www.factfinder.census.gov.
8
The disposition of the 21 individuals with only 1 month of CMSP eligibility is as follows:

Disposition # of Recipients % of Recipients

Converted to Medi-Cal 14 56%

Over Income 5 20%

Administrative Error 4 16%

Client Request 2 8%

9
The Uninsured: A Primer (2007, October). The Henry J. Kaiser Family Foundation.
10
Himes, D. et al (2007, June). County Medical Services Program Work Measurement Study Initiative. Robert
E. Nolan Company, Inc.


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