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The Uninsured at the Starting Line in California: California findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA

Executive Summary
  1. Kaiser Commission on Medicaid and the Uninsured, States Getting a Jump Start on Health Reform’s Medicaid Expansion (April 2012), http://kff.org/health-reform/issue-brief/states-getting-a-jump-start-on-health/.

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  2. Kaiser Commission on Medicaid and the Uninsured, California’s “Bridge to Reform” Medicaid Demonstration Waiver (Kaiser Family Foundation, October 2011), http://kff.org/health-reform/fact-sheet/californias-bridge-to-reform-medicaid-demonstration-waiver/.

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  3. Kaiser Family Foundation, How Will the Uninsured in California Fare Under the Affordable Care Act? (Washington, DC:  Kaiser Family Foundation, January 6, 2014), http://kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-california/.

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  4. Rachel Garfield, Rachel Licata, and Katherine Young, The Uninsured at the Starting line:  Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA (Washington, DC:  Kaiser Family Foundation, 2014), http://kff.org/uninsured/report/the-uninsured-at-the-starting-line-findings-from-the-2013-kaiser-survey-of-low-income-americans-and-the-aca/.

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  5. Kaiser Commission on Medicaid and the Uninsured, The Uninsured:  A Primer- Key Facts about Health Insurance on the Eve of Coverage Expansions (Washington, DC:  Kaiser Family Foundation), October 23, 2013, http://kff.org/uninsured/report/the-uninsured-a-primer-key-facts-about-health-insurance-on-the-eve-of-coverage-expansions/.

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  6. Helen Lee and Shannon McConville, Expanding Medi-Cal Profiles of Potential New Users (San Francisco, CA: Public Policy Institute of California, August 2011), http://www.ppic.org/main/publication.asp?i=868.

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  7. Ying-Ying Meng, Livier Cabezas, Dylan Roby, Nadereh Pourat, Gerald Kominski, Successful Strategies for Increasing Enrollment in California’s Low Income Health Program (LIHP) (UCLA Center for Health Policy Research, September 2012), http://healthpolicy.ucla.edu/publications/Documents/PDF/lihppolicynotesep2012.pdf.

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Introduction
  1. In addition, the waiver allows the state to enroll Medicaid-eligible seniors and persons with disabilities (excluding dual eligibles) into managed care plans and allows for the creation of the Delivery System Reform Incentive Pool (DSRIP) for University of California and county hospitals.

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  2. California Department of Health Care Services, LIHP September 2013 Monthly Enrollment (November 15, 2013), http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/September%20Enrollment.pdf.

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  3. California Department of Health Care Services, “California’s Low Income Health Program Transitions Hundreds of Thousands of New Members to Medi-Cal” (December 31, 2013), http://www.dhcs.ca.gov/formsandpubs/publications/opa/Documents/2013/13-07%20LIHP%20Medi-Cal%20Expansion%2012-31-13%20Final%20Version.pdf.

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  4. Kaiser Family Foundation, How Will the Uninsured in California Fare Under the Affordable Care Act?

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  5. Garfield, The Uninsured at the Starting Line.

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Background: The Challenge of Expanding Health Coverage in California
  1. Care without Coverage: Too Little, Too Late, Committee on the Consequences of Uninsurance, Board on Health Care Services, Institute of Medicine, National Academy Press, 2002

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  2. J. Hadley, J. Holahan, T. Coughlin, and D. Miller, 2008 “Covering The Uninsured In 2008: Current Costs, Sources Of Payment, And Incremental Costs” Health Affairs 27 (5) w399 (published online 25 August 2008).

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  3. G. Anderson, 2007, “From ‘Soak The Rich’ To ‘Soak The Poor’: Recent Trends In Hospital Pricing.” Health Affairs 26(4): 780-789.

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  4. D. Himmelstein et al., 2009. “Medical bankruptcy in the United States, 2007: results of a national study.” Am J Med. 122(8): 741-6. Available at: http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf.

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  5. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2011 and 2012 Current Population Survey (CPS: Annual Social and Economic Supplements), http://kff.org/other/state-indicator/total-population/?state=CA.

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  6. For state uninsured population: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements); for LA County uninsured population: U.S. Census Bureau, 2008-2012 American Community Survey results for Los Angeles County.

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  7. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements).

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  8. Hans Johnson and Marisol Mejia. Just the Facts: Immigrants in California (Public Policy Institute of California, May 2013), http://www.ppic.org/content/pubs/jtf/JTF_ImmigrantsJTF.pdf.

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  9. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements).

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  10. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements).

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  11. California figure from the Table 3, Regional and State Employment and Unemployment: October 2013, and Unemployment rates by State, seasonally adjusted: October 2012 and 2013, Bureau of Labor Statistics, http://www.bls.gov/news.release/laus.t03.htm; U.S. figures from Bureau of Labor Statistics, http://data.bls.gov/cgi-bin/surveymost?bls.

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  12. California Health Care Almanac, California’s Uninsured: By the Numbers (California HealthCare Foundation, December 2013), http://www.chcf.org/publications/2013/12/californias-uninsured/.

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  13. California Health Care Almanac, California Employer Health Benefits Survey: Workers Feel the Pinch (California HealthCare Foundation, January 2014), http://www.chcf.org/publications/2014/01/employer-health-benefits.

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  14. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements).

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  15. The five insurers were Kaiser Permanente (34%), Anthem Blue Cross (15%), Health Net (10%), Blue Shield (9%), and United Health Care (8%). California HealthCare Foundation. California Health Care Almanac: California Health Plans and Insurers (March 2013), http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20CAHealthPlansInsurersAlmanac2013.pdf.

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  16. Ibid.

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  17. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements).

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  18. In the past, children were eligible for coverage through either Medi-Cal (Medicaid) or Healthy Families, the state’s Children’s Health Insurance Program. In 2013, the state began transitioning children covered through Healthy Families to Medi-Cal.

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  19. Martha Heberlein, Tricia Brooks, Jocelyn Guyer, Samantha Artiga, and Jessica Stephens, Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2011-2012 (Kaiser Family Foundation, January 2012), http://kff.org/medicaid/report/performing-under-pressure-annual-findings-of-a/.

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  20. Stephen Zuckerman and Dana Goin. How Much Will Medicaid Physician Fees for Primary Care Rise in 2013? Evidence from a 2012 Survey of Medicaid Physician Fees (Urban Institute and Kaiser Commission on Medicaid and the Uninsured), December 2012, http://www.kff.org/medicaid/issue-brief/how-much-will-medicaid-physician-fees-for/.

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  21. This payment cut was implemented in 2011 and upheld by the 9th Circuit Court of Appeals in May 2013. See: United States Court of Appeals for the 9th Circuit. Managed Pharmacy Care v. Sebelius (May 24, 2013), http://www.dhcs.ca.gov/Documents/AB97OpinionDocument.pdf.

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  22. California Department of Health Care Services, Implementation of Assembly Bill 97 Reductions (August 15, 2013), http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_21682_1.asp.

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  23. California Department of Health Care Services, ACA Increased Medicaid Payment for Primary Care Physicians, http://files.medi-cal.ca.gov/pubsdoco/aca/aca_form_landing.asp.

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  24. For more information about the primary care rate increase, see: Lucian Wulsin, Primary Care Rate Increases: Why are they Important and What’s the Reason for the Delay in Implementation in California (Insure the Uninsured Project, August 2013), http://itup.org/wp-content/uploads/downloads/2013/10/Primary-Care-Rate-Increases.pdf.

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  25. California HealthCare Foundation, County Programs for the Medically Indigent in California (October 2009), http://www.chcf.org/publications/2009/10/county-programs-for-the-medically-indigent-in-california.

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  26. Public Policy Institute of California, California’s Health Care Safety Net (October 2013), http://www.ppic.org/main/publication_show.asp?i=1074.

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  27. Laurel Lucia, Ken Jacobs, Greg Watson, Miranda Dietz, and Dylan H. Roby. Medi-Cal Expansion under the Affordable Care Act: Significant Increase in Coverage with Minimal Cost to the State (UC Berkeley Center for Labor Research and Education and UCLA Center for Health Policy Research, January 2013), http://laborcenter.berkeley.edu/healthcare/medi-cal_expansion13.pdf.

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  28. Department of Health & Human Services, California Bridge to Reform Waiver Approval Letter, November 2, 2010, http://www.dhcs.ca.gov/provgovpart/Documents/Waiver%20Renewal/CA%20Waiver%20Approval%20Letter.pdf.

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  29. Kaiser Commission on Medicaid and the Uninsured. Key Facts on California’s “Bridge to Reform” Medicaid Demonstration Waiver (Kaiser Family Foundation, October 2011), http://www.kff.org/medicaid/8197.cfm.

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  30. California Department of Health Care Services, Delivery System Reform Incentive Payments (DSRIP), http://www.dhcs.ca.gov/provgovpart/Pages/DSRIP1.aspx.

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  31. For more information on the SPD transition to Medi-Cal managed care, see: Carrie Graham, et al., Transitioning Beneficiaries with Complex Care Needs to Medicaid Managed Care: Insights from California (July 2013), http://kff.org/medicaid/issue-brief/transitioning-beneficiaries-with-complex-care-needs-to-medicaid-managed-care-insights-from-california/.

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  32. The LIHP program is an extension of the HCCI program in California’s 2005 Medicaid Waiver. For more information about the 2005-2010 HCCI program and a comparison of the two waivers, see: Peter Harbage and Meredith Ledford King. A Bridget to Reform: California’s Medicaid Section 1115 Waiver (California HealthCare Foundation, October 2012), http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/B/PDF%20BridgeToReform1115Waiver.pdf.

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  33. California Department of Health Care Services. LIHP September2013 Monthly Enrollment (November 15, 2013).

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  34. California Department of Health Care Services. Consumer Information – Local Low Income Health Program (LIHP) Contracts (November 2013).

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  35. California Department of Health Care Services, LIHP September 2013 Monthly Enrollment (November 15, 2013), http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/September%20Enrollment.pdf.

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  36. California Department of Health Care Services, “California’s Low Income Health Program Transitions Hundreds of Thousands of New Members to Medi-Cal” (December 31, 2013).

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  37. The Center for Consumer Information & Insurance Oversight (CCIIO), California Health Insurance Marketplace Grants Awards List (CMS), updated January 22, 2014, http://www.cms.gov/CCIIO/Resources/Marketplace-Grants/ca.html.

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  38. Covered California. Health Plans & Rates for 2014: Making the Individual Market in California Affordable (May 23, 2013), http://coveredca.com/news/PDFs/CC_Health_Plans_Booklet.pdf?elq=012957b360434a93b4502bfb84654239&elqCampaignId=2141.

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  39. Kaiser Family Foundation analysis of the March 2012 and 2013 CPS, http://kff.org/report-section/state-by-state-estimates-of-the-number-of-people-eligible-for-premium-tax-credits-under-the-affordable-care-act-table-1/.

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  40. UCLA Center for Health Policy Research, Low-Income Health Program Performance Dashboard: Alameda July 1, 2011 – September 30, 2013, http://healthpolicy.ucla.edu/programs/health-economics/projects/coverage-initiative/Documents/Dashboard_Alameda.pdf.

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  41. Community Health Councils. On the Path to Enrollment: Getting Californians Covered Under the ACA. California Healthcare Foundation. October 2013. Available at: http://www.chcf.org/publications/2013/10/path-enrollment-aca.

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  42. California Department of Health Care Services, “Outreach and Enrollment Workgroup,” (November 1, 2013), Accessed February 10, 2014, http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/OEworkgroup.aspx

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  43. The California Endowment, “The Department of Health Care Services and The California Endowment Announce $23 Million in Grants to Boost County-Based Medi-Cal Enrollment Efforts” (January 28, 2014), http://tcenews.calendow.org/releases/department-of-health-care-services-and-the-california-endowment-announce-23-million-in-grants-to-boost-county-based-medi-cal-enrollment-efforts.

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  44. Health Resources and Services Administration, California: Health Center Outreach & Enrollment Assistance, http://www.hrsa.gov/about/news/2013tables/outreachandenrollment/ca.html.

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  45. California Health Benefit Exchange. Outreach and Education Grant Webinar (September 27, 2012), http://www.healthexchange.ca.gov/StakeHolders/Pages/2012StakeholderArchive.aspx.

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  46. California Health Benefit Exchange. Outreach and Education Grant Webinar (September 27, 2012), http://www.healthexchange.ca.gov/StakeHolders/Pages/2012StakeholderArchive.aspx.

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  47. Covered California. Covered California to Award Community Organizations $37 Million in Grants for Outreach and Education (May 2013), http://www.healthexchange.ca.gov/Documents/COVERED%20CA-Grantee%20Announcement%20Press%20Release%205-14-13.pdf.

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  48. Kaiser Family Foundation, State Marketplace Profiles: California (November 26, 2013), http://kff.org/health-reform/state-profile/state-exchange-profiles-california/.

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  49. CCIIO, California Health Insurance Marketplace Grants Awards List, January 22, 2014.

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I. Patterns of Coverage and the Need for Assistance
  1. PBS NewsHour, “Language Barrier, Immigration Status Keep Some Latinos From Health Care Enrollment” (February 5, 2014), http://www.pbs.org/newshour/bb/language-immigration-keep-some-latinos-health-care-enrollment/.

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  2.   See: Kaiser Commission on Medicaid and the Uninsured, Medicaid Eligibility for Adults as of January 1, 2014 (October 1, 2014), http://www.kff.org/medicaid/fact-sheet/medicaid-eligibility-for-adults-as-of-january-1-2014/ for more detail on pre- and post-ACA Medicaid eligibility for adults.

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  3. Martha Heberlein, Tricia Brooks, and Joan Alker, Georgetown Center for Children and Families, Samantha Artiga and Jessica Stephens, Kaiser Commission on Medicaid and the Uninsured, Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013, (Washington, DC:  Kaiser Family Foundation), January 2013.  Available at: http://www.kff.org/medicaid/report/getting-into-gear-for-2014-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-2012-2013/

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  4. Between July 2012 and July 2013, nearly 150,000 individuals enrolled in LIHP. California Department of Health Care Services, LIHP July 2012 Monthly Enrollment (September 2012), http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/DY8-M01_Enrl_Rpt.pdf and LIHP July 2013 Monthly Enrollment (September 2013), http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/LIHP%20July%202013%20Monthly%20Enrollment.pdf.

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  5. See “Protections in individual insurance markets” at http://kff.org/state-category/health-insurance-managed-care/.

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  6. On February 10, 2014, the Obama Administration delayed penalties associated with this Employer Responsibility Provision until 2015. U.S. Department of the Treasury, Treasury and IRS Issue Final Regulations Implementing Employer Shared Responsibility Under the Affordable Care Act for 2015 (February 10, 2014), http://www.treasury.gov/press-center/press-releases/Pages/jl2290.aspx.

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  7. 2013 Kaiser Survey of Low-Income Americans and the ACA.

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  8. Collins S, et al. 2012. “Gaps in Health Insurance: Why So Many Americans Experience Breaks in Coverage and How the Affordable Care Act Will Help.” The Commonwealth Fund. http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Apr/1594_collins_gaps_in_hlt_ins_tracking_
    brief_v2.pdf
    ;  Cassedy A, Fairbrother G, and Newacheck PW. 2008. “The Impact of Insurance Instability on Children’s Access, Utilization, and Satisfaction with Health Care. Ambulatory Pediatrics. 8(5):321-8.

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  9. Martha Heberlein, et al., Getting into Gear for 2014:  Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 (Kaiser Family Foundation), January 2013.

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  10. Veronica Guerra and Shannon McManon, Minimizing Care Gaps for Individuals Churning Between the Marketplace and Medicaid: Key State Considerations (Center for Health Care Strategies, Inc., January 2014), http://www.statecoverage.org/files/CHCS_Minimizing_Churn.pdf.

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II. What to Look for in Enrolling in New Coverage
  1. Martha Heberlein, et al., Getting into Gear for 2014:  Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 (Kaiser Family Foundation), January 2013.

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  2. For more information, see: Martha Heberlein, Tricia Brooks, Samantha Artiga, and Jessica Stephens, Getting into Gear for 2014: Shifting New Medicaid Eligibility and Enrollment Policies into Drive (Kaiser Family Foundation), November 2013, http://www.kff.org/medicaid/report/getting-into-gear-for-2014-shifting-new-medicaid-eligibility-and-enrollment-policies-into-drive/.

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  3. Martha Heberlein, et al., Getting into Gear for 2014: Shifting New Medicaid Eligibility and Enrollment Policies into Drive (Kaiser Family Foundation), November 2013.

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  4. Helen Lee, Expanding Medi-Cal Profiles of Potential New Users (Public Policy Institute of California).

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  5. Adrian Florido, “Delays Persist in Certifying Covered California Enrollment Counselors” (KPCC Southern California Public Radio, December 13, 2013), http://www.scpr.org/news/2013/12/13/40891/delays-persist-in-certifying-covered-california-en/.

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  6. Includes people who had a choice of plans and reported that they made the choice themselves.

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  7. California Department of Health Care Services, “Medi-Cal Managed Care Health Plan Directory,” (2014), Accessed February 10, 2014, http://www.dhcs.ca.gov/individuals/Pages/MMCDHealthPlanDir.aspx.

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  8. Zhou, C. and Zhang, Y. (2012). The vast majority of Medicare Part D beneficiaries still don’t choose the cheapest plans that meet their medication needs.  Health Affairs, 31: 2259-2264; McLaughlin, C.G., Chernew, M., & Taylor, E.F. (2002).  Medigap premiums and Medicare HMO enrollment.  Health Services Research 37: 1445-1468.

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  9. Kaiser Commission on Medicaid and the Uninsured. Oral Health and Low-Income Nonelderly Adults:  A Review of Coverage and Access (Washington, DC:  Kaiser Family Foundation), June 2012.  Available at: http://www.kff.org/medicaid/issue-brief/access-to-affordable-dental-care-gaps-for/.

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  10. Vernon Smith, Kathleen Gifford, Eileen Ellis, Robin Rudowitz, and Laura Snyder, Hoping for Economic Recovery, Preparing for Health Reform: A Look at Medicaid Spending, Coverage and Policy Trends. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2010 and 2011 (Kaiser Family Foundation), September 2010, http://kff.org/medicaid/report/hoping-for-economic-recovery-preparing-for-health-reform-a-look-at-medicaid-spending-coverage-and-policy-trends-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2010-and-201/.

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  11. Vernon Smith, Kathleen Gifford, Eileen Ellis, Robin Rudowitz, and Laura Snyder, Medicaid in a Historic Time of Transformation: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014 (Kaiser Family Foundation), October 2013, http://kff.org/medicaid/report/medicaid-in-a-historic-time-of-transformation-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2013-and-2014/, (see page 96).

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III. Gaining Coverage, Getting Care
  1. Institute of Medicine, Committee on the Consequences of Uninsurance, Board on Health Care Services, Care without Coverage: Too Little, Too Late (Washington, DC: National Academy Press: Institute of Medicine), May 2002, http://www.iom.edu/~/media/Files/Report%20Files/2003/Care-Without-Coverage-Too-Little-Too-Late/Uninsured2FINAL.pdf.

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  2. Institute of Medicine, Committee on the Consequences of Uninsurance, Board on Health Care Services Coverage Matters: Insurance and Health Care (Washington, DC: National Academy Press: Institute of Medicine), 2001.

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  3. Julia Paradise and Rachel Garfield, What is Medicaid’s Impact on Access to Care, Health Outcomes, and Quality of Care? Setting the Record Straight on Evidence (Washington, DC:  Kaiser Commission on Medicaid and the Uninsured), August 2, 2013, http://kff.org/medicaid/issue-brief/what-is-medicaids-impact-on-access-to-care-health-outcomes-and-quality-of-care-setting-the-record-straight-on-the-evidence

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  4. Wilper AP, Woolhandler S, Lasser KE, McComick D, Bor DH, Himmelstein DU. Hypertension, diabetes, and elevated cholesterol among insured and uninsured US adults. Health Affairs. 2009;28(6):w1151-9.

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  5. Stephen Zuckerman and Dana Goin, The Urban Institute, How Much Will Medicaid Physician Fees for Primary Care Rise in 2013?  Evidence from a 2012 Survey of Medicaid Physician Fees, (Washington, DC:  Kaiser Commission on Medicaid and the Uninsured, December 2012), http://kff.org/medicaid/issue-brief/how-much-will-medicaid-physician-fees-for/.

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  6. Sandra L. Decker, “Two-thirds of Primary Care Physicians Accepted New Medicaid Patients in 2011-12: A Baseline to Measure Future Acceptance Rates,” Health Affairs 32, no. 7 (Jul. 2013): 1183-7, http://content.healthaffairs.org/content/32/7/1183.abstract.

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  7. Garfield, The Uninsured at the Starting Line.

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  8. Kaiser Commission on Medicaid and the Uninsured, Community Health Centers in an Era of Health Reform: An Overview and Key Challenges to Health Center Growth (Washington, DC:  Kaiser Family Foundation), March 1, 2013, http://kff.org/health-reform/issue-brief/community-health-centers-in-an-era-of-health-reform-overview/.

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  9. Gerald Kominski, et al., Final Evaluation of the Health Care Coverage Initiative in California (UCLA Center for Health Policy Research, January 2014), http://healthpolicy.ucla.edu/publications/search/pages/detail.aspx?PubID=1266.

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V. Poised at the Starting Line
  1. Kaiser Commission on Medicaid and the Uninsured, Key Lessons from Medicaid and CHIP Outreach and Enrollment Under the Affordable Care Act (Washington, DC:  Kaiser Family Foundation), June 2013, http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8445-key-lessons-from-medicaid-and-chip.pdf.

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  2. In this section, we exclude uninsured adults who are undocumented immigrants, as this group is ineligible for coverage under the law. See Methods for more detail on determining immigration status based on survey responses.

     

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  3. Kaiser Family Foundation, Kaiser Health Tracking Poll: January 2014 (conducted January 14-21, 2014), http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-january-2014/.

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  4. [45 CFR] § 156.124o, http://www.ofr.gov/OFRUpload/OFRData/2013-21338_PI.pdf.

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  5. Community Health Councils. On the Path to Enrollment: Getting Californians Covered Under the ACA. California Healthcare Foundation. October 2013. Available at: http://www.chcf.org/publications/2013/10/path-enrollment-aca.

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  6. Kaiser Commission on Medicaid and the Uninsured. Fast Track to Coverage: Facilitating Enrollment of Eligible People into the Medicaid Expansion (Washington, DC:  Kaiser Family Foundation), November 19, 2013, http://www.kff.org/medicaid/issue-brief/fast-track-to-coverage-facilitating-enrollment-of-eligible-people-into-the-medicaid-expansion/.

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  7. Ibid.

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  8. Medicaid.gov, Targeted Enrollment Strategies, October 1, 2013, http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Targeted-Enrollment-Strategies/targeted-enrollment-strategies.html.

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  9. Ying-Ying Meng, Livier Cabezas, Dylan Roby, Nadereh Pourat, Gerald Kominski, Successful Strategies for Increasing Enrollment in California’s Low Income Health Program (LIHP) (UCLA Center for Health Policy Research, September 2012), http://healthpolicy.ucla.edu/publications/Documents/PDF/lihppolicynotesep2012.pdf.

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  10. Health Resources and Services Administration, California: Health Center Outreach & Enrollment Assistance, http://www.hrsa.gov/about/news/2013tables/outreachandenrollment/ca.html.

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  11. Rafael A. Gomez and Bobbie Wunsch. Ready, Set, Enroll: Community Health Center Strategies to Facilitate Enrollment of Uninsured Patients into Coverage Under the Affordable Care Act. Pacific Health Consulting Group/Blue Shield of California Foundation. 2013. Available at: www.blueshieldcafoundation.org/sites/default/files/publications/downloadable/Ready_Set_Enroll_9_26_2013.pdf.

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  12. Centers for Medicare & Medicaid Services, Final Rule for Strengthening Medicaid, The Children’s Health Insurance Program and The New Health Insurance Marketplace (July 5, 2013), http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-07-05.html. Final Rule included in July 15, 2013 Federal Register, https://www.federalregister.gov/articles/2013/07/15/2013-16271/medicaid-and-childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit#h-34.

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  13. California Department of Health Care Services, Hospital Presumptive Eligibility (PE) Program, http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/HospitalPE.aspx.

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  14. California Department of Health Care Services, ACA Hospital Presumptive Eligibility (PE) Program, http://files.medi-cal.ca.gov/pubsdoco/aca/aca_HPE_landing.asp.

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  15. Cindy Mann, Implementation of Hospital Presumptive Eligibility (Center for Medicaid & CHIP Services, Centers for Medicare & Medicaid Services, January 2014), http://www.naph.org/Links/POL/CMS-Presumptive-Eligibility-Bulletin-14214.aspx.

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  16. Varney, Sarah. “Emergency Rooms Are Front Line For Enrolling New Obamacare Customers.” Kaiser Health News/NPR, January 14, 2014; available at: http://www.kaiserhealthnews.org/stories/2014/january/14/signing-up-for-obamacare-in-the-er.aspx.

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  17.   California Department of Health Care Services, “Medi-Cal Eligibility and Covered California – Frequently Asked Questions,” (2014), Accessed February 10, 2014, http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/Medi-CalFAQs2014b.aspx.

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Conclusion & Policy Implications
  1. Community Health Councils, On the Path to Enrollment: Getting Californians Covered Under the ACA. (California Healthcare Foundation, October 2013), Available at: http://www.chcf.org/publications/2013/10/path-enrollment-aca.

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  2. California Department of Health Care Services, Express Lane, http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/ExpressLane.aspx.

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  3. Elizabeth Lytle, et al., Smooth Transitions into Medi-Cal: Ensuring Continuity of Coverage for Low Income Health Program Enrollees (UC Berkeley Labor Center and UCLA Center for Health Policy Research, April 2013), http://laborcenter.berkeley.edu/healthcare/lihp_medi_cal13.pdf.

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  4. Cynthia Cox, Gary Claxton, Larry Levitt, Hana Khosla. An Early Look at Premiums and Insurer Participation in

    Health Insurance Marketplaces, 2014. Kaiser Family Foundation, Updated Table, as of October 22, 2013; available at: http://kff.org/health-reform/issue-brief/an-early-look-at-premiums-and-insurer-participation-in-health-insurance-marketplaces-2014/.

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  5. Center for Studying Health System Change. Ready or Not: Are Health Care Safety-Net Systems Prepared for Reform? June 2013. Available at: http://www.chcf.org/publications/2013/06/regional-safety-net-systems.

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  6. Rafael A. Gomez and Bobbie Wunsch. Ready, Set, Enroll: Community Health Center Strategies to Facilitate Enrollment of Uninsured Patients into Coverage Under the Affordable Care Act. Pacific Health Consulting Group/Blue Shield of California Foundation. 2013. Available at: www.blueshieldcafoundation.org/sites/default/files/publications/downloadable/Ready_Set_Enroll_9_26_2013.pdf

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Methods
  1. In capturing family size, we include all members of the respondents’ immediate family, including themselves, spouse (if married), and any dependents, as well as parents if the respondent is a dependent. These groupings mimic “health insurance units” that are used to determine eligibility for Medi-Cal and Marketplace coverage.

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