California's Uninsured on the Eve of ACA Open Enrollment

Introduction

The nearly six million people that make up California’s adult uninsured population are, as a group, financially stressed, medically underserved, and on the brink of what could well be a once-in-a-lifetime policy shift that will put health insurance within many of their grasps. The large majority report they do feel the need for health insurance, but based on past experience in an increasingly high-priced insurance market, some wonder whether coverage is worth the cost. They also, as a group, feel woefully under-informed about the practical mechanics of this upcoming change, and as of late August most report having heard little about the coverage expansion opportunities ahead. Though many are cautiously optimistic, they remain divided in their expectations of whether the Affordable Care Act (ACA) will, in their own lives, represent a change for the good, the bad, or no change at all. The survey suggests this may in part be due to confusion, and perhaps even misplaced pessimism, about their potential eligibility for the widespread benefits.

These are the results of a baseline survey of California’s uninsured population by the Kaiser Family Foundation (KFF), the first in what is expected to be a series of four surveys that will track the views and experiences of the same group of people over the next two years and will be complemented by a series of profiles and stories intended to put a face on these numbers. The project hopes to provide a unique contribution by beginning with a representative, random sample survey of 2,000 uninsured Californians that mirror and represent the state’s large uninsured population, and then returning to those same 2,000 residents at three future points in time – including at the end of the first enrollment period next spring – to learn how they are, or are not, interacting with the nascent coverage expansion.

With its ‘largest in the nation’ status that includes having the largest number of uninsured, its racial and ethnic diversity, and the state government’s full and early commitment to a smooth rollout of the ACA, California stands out as a laboratory of how the three year old law – up until now a remote political football for many Americans – will translate into real world, person-to-person changes. In all, 15 percent of the nation’s uninsured reside there, and will see the ACA through the window of the Golden State.¹

This first report seeks to sum up the opinions, concerns and experiences of the state’s uninsured population as they are poised on the brink of this change. The first section assesses what California’s uninsured population knows and thinks about the ACA changes that are on the horizon, and examines their past experiences and current attitudes about health insurance in general.  The second section presents a snapshot of the primary characteristics of this group of residents, along with the numerous challenges they currently face in getting, and paying for, the health care they need. And the third section examines the group of uninsured that will not be eligible to participate in the expansion of coverage: the undocumented uninsured.

The report analyzes the uninsured population in terms of four basic groups: those whose incomes would put them in the ‘Medi-Cal target group’ (138 percent of the federal poverty level (FPL) or less), possibly qualifying them to be covered by California’s Medicaid program; those whose incomes would put them in the ‘exchange subsidy target group’ (greater than 138 percent and up to 400 percent FPL), giving them access to subsidies to purchase insurance through the state’s new health insurance exchange marketplace, Covered California; those who will be able to shop on the exchange but will not be eligible for tax credits based on their relatively higher incomes (greater than 400 percent FPL); and finally those uninsured who will not be able to access health insurance via either option due to their immigration status. The first three groups together comprise a group we are terming the ‘eligible uninsured’. This survey of the adult population ages 19-64 somewhat underrepresents the full “eligible insured” group that also includes children.

Putting survey results in context: Numbers of uninsured in California

Nearly 7 million people in California were without health insurance in 2012, including just under 6 million adults ages 19-64.² Estimates of the exact number who will be eligible for new coverage under the ACA vary, but according to data from the Centers for Medicare & Medicaid Services (CMS), roughly 5.5 million uninsured Californians (including roughly 4.8 million adults ages 19-64) may be eligible to participate in some way based on their income and immigration status. This includes about 3 million in the Medi-Cal eligible income range (138 percent FPL or less), about 2 million who may be eligible for subsidies to purchase insurance through Covered California (incomes greater than 138 percent and up to 400 percent FPL), and just under 500,000 who will be eligible to purchase unsubsidized coverage through the new marketplace (incomes greater than 400 percent FPL).³ According to estimates by researchers at the University of California, roughly one million uninsured Californians will be ineligible for new coverage under the ACA due to their immigration status.⁴