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A Final Look: California's Previously Uninsured after the ACA's Third Open Enrollment Period

The Kaiser Family Foundation California Longitudinal Panel Survey is a series of surveys that, over time, tracked the experiences and views of a representative, randomly selected sample of Californians who were uninsured prior to the major coverage expansions under the Affordable Care Act (ACA). The initial baseline survey was conducted with a representative sample of 2,001 nonelderly uninsured Californian adults in summer 2013, prior to the ACA’s initial open enrollment period.

After each enrollment period concluded, a survey was conducted of the same group of previously uninsured Californians who participated in the baseline (a longitudinal panel survey). The fourth and final survey in the series, and the focus of this report, followed up with them after the third open enrollment period in spring 2016 to find out whether more have gained coverage, lost coverage, or remained uninsured, what barriers to coverage remain, how those who now have insurance view their coverage, and to assess the impacts that gaining health insurance may have had on financial security and access to care. The surveys were designed and analyzed by researchers at KFF and the fieldwork costs associated with the spring 2014, spring 2015, and spring 2016 surveys were paid for by The California Endowment.

This longitudinal panel study allows us to follow a large group of randomly selected uninsured Californians and assess how their insurance status changed over time to learn more about why those changes did or did not occur, and what gaining health insurance means for their daily lives without having to rely on respondents’ ability to report and recall details from months or years ago. By tracking a scientifically representative panel, we can quantify how widespread or limited certain problems or changes that may have been reported anecdotally actually were. Statistically representative narratives and stories from individuals’ actual experiences can then be drawn from the sample to illuminate more accurately how the uninsured fare as the law is implemented in California.

Key Findings

Coverage Among Key Groups

After three rounds of open enrollment under the Affordable Care Act, 72 percent of Californians who were uninsured prior to the first open enrollment period now report that they have health insurance (including 78 percent of all eligible individuals). This is similar to the share who reported having insurance last year, after the second open enrollment period (68 percent). The largest share of California’s previously uninsured, one-third, say they have coverage through the state’s Medicaid program, Medi-Cal, while 21 percent say they have insurance through an employer, about one in ten (11 percent) say they have a plan through Covered California — the state’s health insurance marketplace where people can shop for and compare health insurance plans and access federal subsidies for coverage — and another 8 percent say they have non-group coverage or insurance through some other source.

By tracking the insurance status of these individuals over a period of four years, it is clear that the majority of individuals who get health insurance coverage keep some form of coverage. Sixty-three percent of habitual survey respondents report having had health insurance for a period of at least one year, including 48 percent who have had coverage for at least two years. In fact, 14 percent of the habitual respondents have unstable health insurance status, meaning that they have gained health insurance in the past two years and have subsequently lost their coverage. Of the individuals with unstable health insurance status, 5 percent gained coverage again but 9 percent remain without health insurance coverage.

Gains In Financial Security and Health Needs Being Met For Recently Insured

Overall, Californians who recently obtained health insurance are more likely to report that their health needs are being met today than they were in 2013. About three-fourths (77 percent) of those who report now having coverage after the third open enrollment period say their health needs are being met either “very” or “somewhat” well today, while half of them (49 percent) said the same thing when they were uninsured in summer 2013, prior to the first open enrollment period. This is compared to the remaining uninsured, among whom a similar share say their health needs are being met well today as did in 2013 (62 percent compared to 59 percent). In addition, 60 percent of insured Californians currently say it is difficult for them to afford health care. While this is still more than half, it is considerably smaller than the 85 percent of these individuals who reported the same in 2013. And while half (53 percent) of California’s recently insured are still “very worried” that they would not be able to pay medical bills in the event of a serious illness or accident, this is a smaller share than the percent of these who reported being “very worried” in 2013 (80 percent) and smaller than the share of the remaining uninsured who now report being “very worried” (72 percent).

Most Rate Plan Favorably, But Some Report Access Challenges

The majority of the recently insured say their experiences with their current health insurance plan have been positive. About one-third (31 percent) say their experiences have been very positive with an additional 48 percent saying their experiences have been somewhat positive. Only 15 percent say their experiences have been negative. Despite this, one-fifth of the recently insured report forgoing needed medical care in the past year due to cost. But this share is smaller than the share of those remaining without insurance (32 percent) who report not getting medical care due to costs. The share of those with insurance who have foregone medical care due to costs is similar across insurance type, with about one in five of those with Medi-Cal, Covered California, and employer-sponsored insurance saying they have not gotten care due to costs. In addition, some of the recently insured report problems accessing medical care. One-fourth of the recently insured say they have had to wait longer than a reasonable time to get an appointment for medical care and about one in ten (12 percent) say they have been told by a doctor’s office or clinic in the past 12 months that they would not be accepted as a new patient.

Remaining Uninsured Are Largely Long-Term Uninsured, Cite Costs As Reason For Not Getting Insurance

Although many previously uninsured Californians gained coverage since the health care law went into effect, 27 percent report that they do not currently have health insurance. Many of these remaining uninsured had little interaction with the health insurance system in the years prior to the ACA implementation. Nearly four in ten of the remaining uninsured reported in the baseline survey that they had been without health insurance for two or more years. When asked to say in their own words the main reason why they do not currently have health insurance, 47 percent of California’s remaining uninsured say it is because health insurance is too expensive and they can’t afford it. This is in spite of the fact that many of the remaining uninsured report a family income that makes them likely eligible for Medi-Cal (27 percent) or for financial assistance through Covered California (30 percent).

Hispanics Lag in Coverage

One-third of the Hispanic individuals included in the panel still do not have insurance. A significant portion of these uninsured Hispanics may not have insurance due to the fact that they are not eligible for coverage because of their immigration status. Of all eligible Hispanics in this survey, three-fourths (76 percent) report having health insurance, which is similar to the share of non-Hispanic whites who report having health insurance (80 percent).

Most Know About Health Care Law Fines, Fewer Know About Provisions

A large share (83 percent) of the remaining uninsured in California are aware of the health care law’s requirement that most Americans have health insurance or pay a fine, and most (54 percent) think that the requirement applies to them. Smaller shares of the remaining uninsured are aware of provisions of the health care law, beyond the requirement to have coverage, intended to expand coverage to the uninsured and those with lower-incomes. Just over half know that the law allowed for the expansion of the Medi-Cal program to cover more low-income Californians (54 percent), and half (49 percent) know that the law provides financial help to low- and moderate-income people to help them purchase health insurance coverage.

Introduction

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.