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California’s Previously Uninsured After The ACA’s Second Open Enrollment Period

The Kaiser Family Foundation California Longitudinal Panel Survey is a series of surveys that, over time, tracks 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 the first open enrollment period concluded in spring 2014, the second survey in the series followed up with the same group of previously uninsured Californians who participated in the baseline (a longitudinal panel survey). The third in the series, and the focus of this report, followed up with them again after the second open enrollment period in spring 2015 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. A fourth survey in the series will keep tracking these individuals as the expansions and changes in California continue under the ACA. The surveys are designed and analyzed by researchers at KFF and the fieldwork costs associated with the spring 2014 and spring 2015 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 changes over time to learn more about why those changes did or did not occurr, 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 individual’s 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

After two rounds of open enrollment under the Affordable Care Act, 68 percent of Californians who were uninsured prior to the first open enrollment period now report that they have health insurance, referred to in this report as the “recently insured.” This share is up from 58 percent after the first open enrollment period in the spring of 2014. The largest share of California’s previously uninsured, a third (34 percent), say they have coverage thought the state’s Medicaid program, Medi-Cal, up from 25 percent after the first open enrollment period. In addition, 14 percent say they are insured through an employer, 12 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 7 percent say they have other non-group coverage or insurance through some other source. About a third (32 percent) report being currently uninsured, referred to in this report as the “remaining uninsured.” Because the same group of previously uninsured people has been followed over time, the survey is also able to explore the dynamics of health insurance and track how many people have moved in to or back out of coverage since the baseline survey in 2013.

Coverage Among Key Groups

Enrollment rates for whites and Hispanics are similar (79 percent for whites and 74 percent for eligible Hispanics) when excluding those Hispanics who are likely to be ineligible for financial assistance through Covered California or Medi-Cal due to their immigration status. In addition, just over half (53 percent) of those who say they’ve spent their lifetime without insurance now report having coverage, significantly lower than the more than 7 in 10 who said they had insurance at some point in the past who report gaining coverage since the health care law was implemented. Still, the gains in coverage among those who report never having coverage are notable.

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

The survey finds significant improvements in perceptions of health care affordability and access to care for the recently insured, but that affordability and access issues remain even for those who gained coverage. Those who have gained insurance are much less likely than they were in the baseline survey to report problems paying for medical bills in the past 12 months (23 percent now, compared to 45 percent in 2013) or difficulty affording health care (49 percent now, compared to 86 percent in 2013). They also are more likely to now report that their health needs are being met (86 percent now, compared to 51 percent in 2013) and that they now have a usual source of care to go to when they are sick or need medical advice (76 percent now, compared to 60 percent in 2013). For those who have remained uninsured, they report having difficulty affording care, problems paying for medical bills, their health needs being met, or having a usual source of care at similar rates as they did in the baseline survey.

Most Rate Plan Favorably, But Some Report Access Challenges

While most of California’s recently insured (76 percent) report positive experiences with their current plan and say they are satisfied with their plan’s choice of primary care doctors (79 percent), hospitals (75 percent), and specialists (67 percent), some say they have experienced problems accessing care in the past year. For example, 16 percent of the recently insured say they have been told by a doctor’s office in the past year that they would not accept them as a new patient and 28 percent say that within the past year they have had to wait longer than they thought was reasonable for a medical appointment.

Remaining Uninsured Are Largely Long-Term Uninsured Or Ineligible For ACA Coverage

Many of California’s remaining uninsured have had little interaction with the health insurance system in the years prior to the ACA implementation. Four in 10 (41 percent) of the remaining uninsured are undocumented immigrants who are not eligible for Medi-Cal or assistance through Covered California and 43 percent are likely eligible for coverage but had been without coverage for two years or more or never had insurance as of the baseline survey. In addition, 70 percent of the remaining uninsured are Hispanic, including 41 percent who are Hispanic undocumented immigrants and 29 percent who are Hispanics likely eligible for coverage under the ACA. Immigration concerns may be a barrier for some Hispanics to enroll in coverage; half of remaining uninsured Hispanics report being worried that if they sign up for health insurance they will draw attention to their immigration status or that of a family member.

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.