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Issue Brief

Continuing the Path Toward Universal Health Coverage in California

Sustaining Progress & Advancing Health Equity

October 2023 | By Adriana Ramos-Yamamoto and Monica Saucedo

A little girl of Asian decent, sit up on her Fathers lap during a routine check-up. She is dressed casually as the Father talks with the doctor about his daughters health.

key takeaway

California’s uninsured rate reached an all-time low in 2022, but the state must now work to maintain this progress. State leaders must ensure equitable access to health coverage as they process Medi-Cal renewals, which were temporarily suspended during the COVID-19 pandemic.

Consistent access to health care is necessary for everyone to be healthy and thrive. During the pandemic, millions of Californians with low incomes were able to stay continuously enrolled in Medi-Cal (California’s state Medicaid program) due to a federal pandemic-era policy.1A provision in the federal Families First Coronavirus Response Act passed in March 2020 required states to provide continuous coverage for Medicaid beneficiaries in exchange for enhanced federal funding during the federally declared Public Health Emergency (PHE). The Consolidated Appropriations Act of 2023, which federal policymakers passed in December 2022, delinked the continuous coverage provision from the PHE, thereby ending this provision on March 31, 2023. Partly as a result of this federal policy, Medi-Cal enrollment in California reached an all-time high — with over 15 million people enrolled — while the uninsured rate dropped to a historic low (6.5%).

Earlier this year, California began processing Medi-Cal renewals for the first time since the start of the pandemic. Recent data reveal an alarming trend: More than 500,000 Californians have lost Medi-Cal coverage during recent months. Although not everyone who loses Medi-Cal coverage becomes uninsured, the majority of people who lost coverage did so because of paperwork challenges. Certain groups, including immigrants, older adults, and people with disabilities, are at greater risk of losing Medi-Cal coverage during this continuous coverage “unwinding” period.

State leaders have implemented measures to reduce barriers to accessing and maintaining Medi-Cal coverage. Still, policymakers can take additional steps to prevent Californians who remain eligible for Medi-Cal from losing coverage. This includes pausing procedural terminations and investing in health navigators. By taking additional action, state leaders can strive to ensure that all Californians, regardless of race, age, disability, or immigration status, can access and maintain the critical health coverage they need to be healthy and thrive.

What is health equity?

When everyone has the opportunity to be as healthy as possible and no one is disadvantaged from achieving this because of their race, gender identity, sexual orientation, the neighborhood they live in, or any other socially defined circumstance.

California’s Health Coverage Landscape: Progress, Disparities, and the Path to Equitable Coverage

California has made significant strides in expanding access to health coverage. This progress is primarily due to the federal Affordable Care Act (ACA) and, more recently, the state’s efforts to expand comprehensive Medi-Cal coverage to income-eligible undocumented Californians. The percentage of Californians without health coverage decreased to 6.5% in 2022, down from the previous record low of 7% in 2021. These recent improvements in health coverage highlight the significant progress that California has made over the last decade when the uninsured rate was over 17%.

While access to health coverage has improved for all racial/ethnic groups in California over the last decade, racial disparities in coverage persist. Notably, gains in health coverage were significantly lower for Californians who identified as American Indian or Alaska Native (AI/AN), who had the highest uninsured rate. The uninsured rate of AI/AN Californians was nearly double that of the overall Californian population. Racial disparities were also evident for Latinx Californians, who had the second-highest uninsured rate. This is particularly concerning given that people identifying as Latinx account for over 40% of the state’s population.

The racial disparities in health coverage highlight the profound and enduring impact of racism, which blocks Californians of color from equal access to health care. For example, some people of color may hesitate to seek coverage because they distrust the government and health care systems that are responsible for past and ongoing mistreatment against them, their families, and their communities. Another instance of a racist policy is the exclusion of undocumented immigrants, driven by racial and xenophobic biases, from enrolling in federally funded Medicaid coverage or purchasing coverage through the ACA marketplaces.2Undocumented immigrants are not eligible to enroll in federally funded Medicaid coverage or purchase coverage through the ACA Marketplaces. In recent years, California has allocated state funding to expand eligibility for full-scope Medi-Cal to undocumented immigrants.

While California has made significant progress in increasing health coverage, there is much more work to be done to ensure equitable access to health coverage for all Californians. Addressing the racial disparities in health coverage requires targeted outreach and education efforts along with other antiracist policy actions to improve health and well-being for Californians of color.

Many Californians Are Losing Medi-Cal Coverage Due to Paperwork Challenges

On April 1, 2023, California began the process of redetermining eligibility for Medi-Cal enrollees for the first time since the onset of the COVID-19 pandemic. The California Department of Health Care Services (DHCS) publishes data showing the number of Californians who become disenrolled as a result of the redetermination process (i.e., undergo a procedural termination).3The California Department of Health Care Services (DHCS) publishes interactive Medi-Cal dashboards detailing statewide and county-level demographic data on Medi-Cal application processing, enrollments, redeterminations, and renewal outcomes. DHCS also provides valuable insight into the circumstances leading to the disenrollment of Medi-Cal beneficiaries, which are categorized as follows:

  • Procedural: an individual loses coverage due to issues with their renewal paperwork.4In this issue brief, the term "paperwork" is used in place of the term "procedural." This may be a result of a Medi-Cal enrollee not receiving or returning requested forms on time, or other issues with the application system.
  • Over Income: an individual's income exceeds the Medi-Cal eligibility threshold, potentially making them eligible for coverage through Covered California — the state’s health insurance marketplace. 
  • Other Reasons: an individual moves out of the state, voluntarily disenrolls, or passes away.

Nearly 9 in 10 Californians (89.2%) who lost Medi-Cal coverage in August 2023 did so because they did not complete the renewal paperwork or had incorrect or missing information in their forms. Although not everyone who loses Medi-Cal coverage becomes uninsured, the data reveal a troubling trend.5Medi-Cal members have 90 days after their disenrollment to provide the necessary outstanding information to their local Medi-Cal office to restore their coverage. After the 90 days, people can submit a new application. Historically, California has seen a reinstatement rate of about 4% over the 90-day period.

Completing the renewal process often involves complex paperwork and documentation requirements, which can be difficult to navigate. Additionally, some Californians have experienced extended call wait times when attempting to contact county Medi-Cal workers regarding their application.

Certain groups, including older adults and people with disabilities, are at greater risk of losing Medi-Cal coverage during the unwinding period.6Jennifer Tolbert and Meghana Ammula, 10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision (Kaiser Family Foundation, June 2023). Immigrants and their family members face unique obstacles to remaining covered, such as language barriers, privacy concerns, and fear of immigration consequences. As such, many Californians who are losing Medi-Cal coverage due to paperwork challenges may still meet the eligibility criteria.7Of the redeterminations that were received and processed in August 2023, about 20% were ineligible. See California Department of Health Care Services, Medi-Cal Continuous Coverage Unwinding Dashboard (August 2023), 14.

The high disenrollment rate due to paperwork challenges underscores the need to further streamline the renewal process and alleviate the paperwork burden on beneficiaries during the unwinding period and beyond. Addressing these challenges is essential to ensure that those who are eligible for Medi-Cal continue to receive vital health coverage.

Policy Recommendations to Support Equitable Access to Health Coverage Amidst the Unwinding Period

State leaders have taken steps to mitigate the impact of the continuous coverage unwinding period and better support access to health coverage. Earlier this year, the California Department of Health Care Services (DHCS) set forth a detailed plan with a guiding principle to maximize the continuity of coverage for Medi-Cal beneficiaries. These actions include: 

  • Providing one-time funding support to local county offices, which are responsible for determining the initial and continuing Medi-Cal eligibility for an individual or a family.
  • Authorizing Covered California to enroll individuals in a qualified health plan when they lose Medi-Cal coverage.
  • Engaging community partners to serve as “Coverage Ambassadors” to share information with Medi-Cal beneficiaries about how to maintain Medi-Cal coverage.

State leaders can build on previous policy changes by taking action on the following recommendations:

By taking these steps, state leaders can work towards ensuring that all eligible individuals, regardless of age, disability, or immigration status, can access and maintain the critical health coverage they need in order to be healthy and thrive.

Health & Safety Net
  • 1
    A provision in the federal Families First Coronavirus Response Act passed in March 2020 required states to provide continuous coverage for Medicaid beneficiaries in exchange for enhanced federal funding during the federally declared Public Health Emergency (PHE). The Consolidated Appropriations Act of 2023, which federal policymakers passed in December 2022, delinked the continuous coverage provision from the PHE, thereby ending this provision on March 31, 2023.
  • 2
    Undocumented immigrants are not eligible to enroll in federally funded Medicaid coverage or purchase coverage through the ACA Marketplaces. In recent years, California has allocated state funding to expand eligibility for full-scope Medi-Cal to undocumented immigrants.
  • 3
    The California Department of Health Care Services (DHCS) publishes interactive Medi-Cal dashboards detailing statewide and county-level demographic data on Medi-Cal application processing, enrollments, redeterminations, and renewal outcomes.
  • 4
    In this issue brief, the term "paperwork" is used in place of the term "procedural."
  • 5
    Medi-Cal members have 90 days after their disenrollment to provide the necessary outstanding information to their local Medi-Cal office to restore their coverage. After the 90 days, people can submit a new application. Historically, California has seen a reinstatement rate of about 4% over the 90-day period.
  • 6
    Jennifer Tolbert and Meghana Ammula, 10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision (Kaiser Family Foundation, June 2023).
  • 7
    Of the redeterminations that were received and processed in August 2023, about 20% were ineligible. See California Department of Health Care Services, Medi-Cal Continuous Coverage Unwinding Dashboard (August 2023), 14.

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Read this publication in English.

El cuidado infantil asequible y enriquecedor es esencial para apoyar a las familias de California. Aunque la ayuda del gobierno federal proporcionó fondos para apoyar el sistema de cuidado infantil de California durante el COVID-19, estos fondos son temporales y muchas familias pronto enfrentarán la realidad de costos más altos para el cuidado infantil. Esto es particularmente importante para las mujeres de color que tenían muchas más probabilidades de sufrir los efectos económicos de la recesión del COVID-19.

Según datos recolectados en el año 2020, las mujeres latinas, afroamericanas y la mayoría de las demás mujeres de color tenían muchas más probabilidades de vivir en hogares atrasados ​​con el pago de la renta o la hipoteca y en hogares con dificultad para poner suficientes alimentos en sus mesas. Durante este periodo de tiempo, el estado de California suspendió el requisito de que las familias que participan en el programa estatal de subsidios para el cuidado infantil paguen tarifas asociadas con el cuidado infantil, también conocidas como “tarifas familiares”. Esta suspensión vence el 30 de septiembre de 2023.

Sin embargo, con el liderazgo de Voces de Padres en movilización y defesa (como se detalla más abajo), a partir del 1 de octubre de 2023, las familias tendrán un programa de tarifas más equitativo que minimiza la necesidad de tener que escoger entre pagar por cuidado de niños y pagar otras necesidades básicas. Los líderes estatales ahora tienen la oportunidad de adoptar un programa de tarifas que realmente minimice los desafíos económicos que ya enfrentan muchas familias de California.

Acerca de esta publicación

Esta publicación fue escrita en colaboración con Voces de Padres. A través de la organización de base y el desarrollo de liderazgo, Voces de Padres activa y centra la sabiduría de los padres para transformar el cuidado infantil y garantizar que todos los sistemas que impactan a nuestras familias sean justos, equitativos e inclusivos.

Un agradecimiento especial a Marisol Rosales, una madre líder de Voces de Padres, por traducir este informe al español.

Acerca de las tarifas familiares para el cuidado infantil

Las tarifas familiares varían según los ingresos de la familia. Una familia que gana hasta el 85% del ingreso medio estatal califica para el programa de cuidado infantil subsidiado por el estado.1Las familias con ingresos hasta el 100% del ingreso medio estatal califican para el Programa Preescolar del Estado de California. El monto de una tarifa para el cuidado infantil de tiempo completo y de tiempo parcial está asociado con niveles de ingresos de hasta el 85 % del ingreso medio estatal. Estas familias deben pagar una tarifa basada en sus ingresos para acceder al cuidado infantil de tiempo completo o tiempo parcial subsidiado por el estado.

Cada año fiscal, el Departamento de Servicios Sociales de California establece los montos de tarifas para cada nivel de ingresos en un “programa de tarifas familiares”. Estas tarifas han sido inasequibles para las familias de California con ingresos bajos a moderados, lo que las ha obligado a muchas familias a decidir entre pagar el cuidado de niños y otras necesidades básicas, como alimentos y vivienda.

Sin embargo, la ley de presupuesto estatal de 2023-24 modificó permanentemente el programa de tarifas para que estos pagos sean más asequibles. Específicamente, a partir del 1 de octubre de 2023, las familias con ingresos por debajo del 75% del ingreso medio estatal ya no pagarán una tarifa, y las tarifas tendrán un límite del 1% de sus ingresos para aquellas familias al 75% o más del ingreso medio estatal. La siguiente tabla muestra los ingresos anuales de una familia al 75% del ingreso medio estatal.2Las estimaciones de ingreso medio estatal se basan en la encuesta American Community Survey del año 2021.

Ingresos al 75% del ingreso medio estatal

Número de miembros en la familiaIngresos anuales
1-2$64,884
3$73,382
4$84,969

Además, familias no tendrán que pagar tarifas pendientes de antes del 1 de octubre de 2023. La ley de presupuesto estatal de 2023-24 refleja los principales puntos de reforma de las tarifas familiares de Voces de Padres (como se detalla a continuación), pero el programa específico de tarifas que refleja estos puntos aún no se ha confirmado.

Hacia un programa de tarifas más equitativo

Desde 2019, padres líderes de Voces de Padres han expresado sus frustraciones y preocupaciones sobre el alto costo de las tarifas familiares. Señalaron el confuso formato del programa y cómo las altas tarifas limitan las posibilidades para sus familias. Los padres líderes se enteraron de que otros estados tienen programas de tarifas más asequibles y fáciles de entender.

Concretamente, los padres líderes se inspiraron en el programa de tarifas de Dakota del Sur, el cual limita los pagos al 1% de los ingresos de una familia, y también en el programa del estado de Washington que tiene un formato fácil de entender. Lo que surgió de esta investigación y conversaciones fue una visión clara para mejorar el programa de tarifas familiares en California, que incluye:

  • Eliminación de tarifas para todas las familias con ingresos hasta el 75% del ingreso medio estatal.
  • Tarifas en una escala móvil de pago equitativa con un límite del 1% de ingresos para familias al 75% o más del ingreso medio estatal. 
  • Simplificar el programa de tarifas para que los principales niveles de ingresos se agrupen.
  • Suspender el cobro de tarifas atrasadas.3Muchas familias tenían planes de pago antes de la pandemia. Esos planes de pago han estado suspendidos, y sin medidas por parte de lideres estatales, los pagos reiniciarían el 1 de octubre de 2023.

Voces de Padres, con el apoyo del Child Care Resource Center y Every Child California, creó este sueño en un programa de tarifas familiares concreto que permitiría a las familias minimizar la necesidad de tener que escoger entre pagar por el cuidado infantil y pagar otras necesidades básicas. El programa de tarifas propuesto por Voces de Padres cuenta con el respaldo de sus padres líderes y refleja ahorros sustanciales comparado con el programa de tarifas original del Departamento de Servicios Sociales de California de 2023-24.

Expandiendo oportunidades con un nuevo programa de tarifas

La siguiente tabla muestra que porcentaje de los ingresos de una familia compuesta por una madre y su hijo debe gastarse en tarifas según el programa del Departamento de Servicios Sociales de California de 2023-24 comparado con el programa propuesto por Voces de Padres.

Porcentaje de ingresos pagados en tarifas para una familia de dos

Ingreso medio estatalIngresos anualesPorcentaje de ingresos pagados en tarifas: programa del Departamento de Servicios Sociales 23-24Porcentaje de ingresos pagados en tarifas: Programa de Voces de Padres
40% a 74%$34,606 – $64,0202.5% – 9.9%0%
75%$64,8849.9%0.2%
76%$65,7519.9%0.2%
78%$67,4819.9%0.2%
80%$69,2119.9%0.2%
82%$70,9419.9%0.4%
83%$71,8079.9%0.4%
84%$72,6729.9%0.4%
85%$73,5379.9%0.4%

Con el programa de tarifas familiares de Voces de Padres, en algunos casos, las familias recuperarían casi el 10% de sus ingresos anuales. La siguiente gráfica muestra la cantidad de dinero que las familias de California de dos personas ahorrarían al usar el programa de tarifas de Voces de Padres. La tabla (después de la gráfica) muestra la cantidad de las tarifas para familias al 75% del ingreso medio estatal para varios tamaños de familias.

Cantidad anual en tarifas familiares para una familia al 75% del ingreso medio estatal

Número de miembros en la familiaPrograma del Departamento de Servicios Sociales 23-24Programa de Voces de Padres
1-2$6,418$133
3$6,418$151
4$6,418$174

Los padres líderes compartieron lo que estos ahorros podrían hacer posible para sus familias:

De acuerdo con los números de inscripción del año anterior y con el actual programa de tarifas del Departamento de Servicios Sociales de California, las familias pagarían colectivamente más de $100 millones de dólares en tarifas durante el transcurso del año. La ley de presupuesto estatal de 2023-24 reducirá significativamente el monto de las tarifas familiares, y en los próximos meses, líderes estatales consolidarán una escala actualizada de tarifas para confirmar exactamente cuánto será esta reducción.

A medida que los líderes estatales deciden sobre el nuevo programa de tarifas para 2023-24, el programa de tarifas familiares propuesto por Voces de Padres proporciona un modelo para garantizar que las familias, en particular aquellas encabezadas por mujeres de color como Elizabeth, Stevie y Karina, tengan los ingresos necesarios para pagar las necesidades básicas como la renta, servicios públicos y comida, para abrir posibilidades y lograr sus metas profesionales y educativas y también brindar una vida enriquecedora para sus hijos.

Health & Safety Net
  • 1
    Las familias con ingresos hasta el 100% del ingreso medio estatal califican para el Programa Preescolar del Estado de California.
  • 2
    Las estimaciones de ingreso medio estatal se basan en la encuesta American Community Survey del año 2021.
  • 3
    Muchas familias tenían planes de pago antes de la pandemia. Esos planes de pago han estado suspendidos, y sin medidas por parte de lideres estatales, los pagos reiniciarían el 1 de octubre de 2023.

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key takeaway

With the leadership of Parent Voices’ efforts, families will have a more equitable family fee schedule that minimizes tradeoffs between paying for child care and other essentials. Starting October 1, 2023, families below 75% of the state median income (SMI) will no longer pay a family fee, and fees will be capped at 1% for families at 75% or over the SMI.

Lea esta publicación en español.

Affordable and nurturing child care is essential for supporting California’s families. While federal relief dollars provided one-time funding to support California’s child care system during COVID-19, this funding is not ongoing, and many families will soon face the reality of higher costs for child care. This is particularly consequential for women of color who were far more likely to experience the economic effects of the COVID-19 recession.

According to data collected in 2020, Latinx, Black, and most other women of color were far more likely to live in households that were behind on their rent or mortgage payment and in households struggling to afford enough food. During this time, the state suspended the requirement for families participating in the state child care subsidy program to pay any fees associated with child care, otherwise known as “family fees.” This suspension expires on September 30, 2023.

However, with the leadership of Parent Voices’ organizing and advocacy efforts (as further detailed below), starting October 1, 2023, families will have a more equitable family fee schedule that minimizes tradeoffs between paying for child care and other basic needs. State leaders now have the opportunity to adopt a family fee schedule that truly minimizes economic challenges already faced by many California families.

About This Report

This Issue Brief was co-authored with Parent Voices. Through grassroots organizing and leadership development, Parent Voices activates and centers the wisdom of parents to transform child care and ensure all systems that impact California families are just, fair, and inclusive.

Special thank you to Marisol Rosales, a parent leader with Parent Voices, for translating this piece into Spanish.

About Family Fees

Family fees vary depending on a family’s income. A family earning up to 85% of the state median income (SMI) qualifies for the state subsidized child care program.1Families earning up to 100% of the state median income qualify for the California State Preschool Program. A family fee amount for both full-day and part-day care is associated with income levels up to 85% SMI. These families must pay an income-based family fee to access subsidized full-day or part-day care.

The California Department of Social Services (CDSS) sets the fee amounts for each income level in a “family fee schedule” each fiscal year. These fees have been unaffordable for low to moderate income California families, forcing them to make hard choices between paying for child care and other basic needs such as food and housing.

However, the 2023-24 Budget Act permanently revised the family fee schedule to make these payments more affordable. Specifically, starting October 1, 2023, families below 75% of the SMI will no longer pay a family fee, and fees will be capped at 1% for families at 75% or over the SMI. The table below shows a family’s annual income at 75% of the SMI.2SMI estimates are based off of the 2021 American Community Survey.

Annual Income at 75% of the SMI

Family SizeAnnual Income
1-2$64,884
3$73,382
4$84,969
5$98,564

Moreover, outstanding fees prior to October 1, 2023 will be waived. While the 2023-24 Budget Act reflects Parent Voices’ main family fee reform points (as detailed below), the specific family fee schedule reflecting these points has yet to be confirmed.

Toward a More Equitable Family Fee Schedule

Since 2019, Parent Voices’ parent leaders have voiced their frustrations and concerns about the high price of family fees. They pointed to the schedule’s confusing formatting and how high family fees limited what was possible for their families. Parent leaders learned that other states have more affordable family fee schedules that are easier to understand.

Namely, parent leaders drew inspiration from South Dakota’s family fee schedule which capped payments at 1% of a family’s income, as well as Washington state’s schedule which had an easy-to-understand format. What emerged from this research and conversations was a clear vision for improvements to California’s family fee schedule, including:

  • Removing family fees for all families up to 75% of the SMI. 
  • For families at 75% of the SMI or higher, paying fees on an equitable sliding scale capped at 1% of their income. 
  • Simplifying the family fee schedule so that key income levels are grouped together.
  • Stopping the collection of delinquent family fees.

Parent Voices, with the support of the Child Care Resource Center and Every Child California, translated this dream into a concrete family fee schedule that would allow families to minimize the tradeoffs they often make between child care and basic needs. The family fee schedule proposed by Parent Voices is endorsed by their parent leaders and reflects substantial savings from the original CDSS 2023-24 family fee schedule.

Expanding Opportunities with a New Family Fee Schedule

The table below shows how much of a family’s income must be spent on family fees under the CDSS 2023-24 fee schedule and under Parent Voices’ proposed schedule for a single parent with one child.

Percent of Income Spent on Family Fees for a Family of Two

State Median IncomeAnnual IncomePercent of Income Paid in Family Fees:
CDSS FY 23-24 Schedule		Percent of Income Paid in Family Fees: Parent Voices Schedule
40% to 74%$34,606 – $64,0202.5% – 9.9%0%
75%$64,8849.9%0.2%
76%$65,7519.9%0.2%
78%$67,4819.9%0.2%
80%$69,2119.9%0.2%
82%$70,9419.9%0.4%
83%$71,8079.9%0.4%
84%$72,6729.9%0.4%
85%$73,5379.9%0.4%

With the Parent Voices family fee schedule, in some cases, families would recoup over nearly 10% of their annual income. The chart below shows the amount of money California families of two would save from using the Parent Voices family fee schedule. The table that follows shows the amount owed in family fees at 75% of the SMI for various-sized households.

A line chart showing the annual fees for a family of two by the percent of state median income where a more equitable family fee schedule would help many families save thousands of dollars in child care fees.

Amount Owed Annually on Family Fees for a Family at 75% of the SMI

Family Size23-24 CDSS ScheduleParent Voices Schedule
1-2$6,418$133
3$6,418$151
4$6,418$174
5$6,418$202

Parent leaders shared what this reclaimed income could make possible for their families:

Based on prior year enrollment numbers, using the current CDSS family fee schedule, families would collectively pay over $100 million in families fees over the course of the year. The 2023-24 Budget Act will create a significant reduction in the amount of family fees, and state leaders will act in the coming months to solidify a revised family fee scale to determine exactly how much this reduction will be.

As state leaders decide on the new 2023-24 family fee schedule, Parent Voices’ proposed family fee schedule provides a model to ensure that families – particularly those headed by women of color like Elizabeth, Stevie, and Karina – have the income needed to pay for basic needs such as rent, utilities, and groceries, to open up possibilities for achieving their professional and educational goals and provide an enriching life for their children. 

Health & Safety Net
  • 1
    Families earning up to 100% of the state median income qualify for the California State Preschool Program.
  • 2
    SMI estimates are based off of the 2021 American Community Survey.

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key takeaway

In February 2022, there were 437 unhoused Californians per 100,000 Californians statewide — the Los Angeles and South Coast region and the San Francisco Bay Area having the highest shares of unhoused individuals in California.

Having a place to call home is the most basic foundation for health and well-being no matter one’s gender, race, or zip code. But thousands of Californians in all areas of the state fall into homelessness and experience its devastating health, economic, and intrapersonal effects daily.

“Homelessness is a statewide challenge that affects Californians in every region and county.”

Homelessness in California is a statewide challenge that affects individuals in every region and county — rural, suburban, and urban alike. In February 2022, the Los Angeles and South Coast region (49.9%) and the San Francisco Bay Area (22.2%) had the highest shares of unhoused individuals, based on point-in-time data, followed by the Sacramento Region (7.2%) and the Central Valley (7.1%). Smaller but notable shares of unhoused Californians reside in the Central Coast (4.7%), Inland Empire (4.5%), Far North (4.0%), and the Sierra Nevadas (0.5%).

Higher concentrations of unhoused Californians typically reflect the denser overall populations in their respective regions. For example, Los Angeles County alone is home to more than 40% of unhoused Californians in part due to its dense population, high living costs, and insufficient affordable housing — which is the primary driver of homelessness regardless of geographical region. Regions with denser, urban populations also tend to have more robust homelessness support and delivery systems which can better track the number of unhoused residents living in sheltered and unsheltered spaces.

A map showing the share of unhoused population by state region in February 2022 where most unhoused Californians reside in Los Angles, south coast region, and the San Francisco Bay Area.

Another way to understand the magnitude of homelessness across the state is per capita — or per 100,000 Californians — by region. Homelessness per capita shows the prevalence of being unhoused at a point in time across regions with varing population sizes. For instance, per capita measures provide better insight into the magnitude of rural homelessness which can appear less notable through point-in-time counts. It also puts into perspective the number of unhoused residents in more densely populated regions where homelessness is typically more visible.

In February 2022, California had 437 unhoused people per 100,000 residents. The Far North had the highest per capita unhoused population with 647 unhoused residents per 100,000 residents in the region, followed by the Central Coast (540 per 100,000), despite these regions having among the lowest statewide shares of unhoused Californians. In contrast, the San Francisco Bay Area (503 per 100,000) and Los Angeles and the South Coast (477 per 100,000) regions rank closer to the statewide average in prevalence, despite ranking the highest by share. Homelessness was less prevalent in the Sierra Nevada, Central Valley, and the Inland Empire regions which aligned with their lower shares of unhoused Californians.

A bar chart showing unhoused Californians per 100,000 residents by region in February 2022 where California's far north region has the highest number of people experiencing homelessness per capita.

Comprehending the prevalence of homelessness, both in terms of regional share and per capita rates, is crucial to understanding how homelessness is affecting communities statewide. However, regardless of geographical region, effectively addressing homelessness requires us to continue building the capacity and resources required to meet the housing needs of Californians experiencing or at risk of homelessness.

Fundamentally this begins with deeply affordable housing, supportive services, rental assistance, and eviction prevention, all of which are evidence-based interventions the pandemic showed us state policymakers can rapidly mobilize to help people exit homelessness and stay in their housing.

Statewide planning and policy interventions need to also address the inequities among populations that disproportionately experience homelessness — within all regions of the state. These include Black, American Indian or Alaska Native, Pacific Islander, and increasingly Latinx Californians alongside adults without children, older adults, and LGBTQ+ individuals.

Above all, ending homelessness statewide is possible with persistence and sustained commitments by policymakers that represent all regions of California. By funding at-scale and permanent solutions, state leaders can ensure every Californian has a place to call home.

Health & Safety Net

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