Data Note: California’s Young Uninsured – A Look at 19- to 34-Year Olds Pre-ACA Rollout

A Data Note based on the Kaiser Family Foundation California Uninsured Baseline Survey

In California, as across the United States, the young uninsured are a key piece of the new Affordable Care Act (ACA) marketplace puzzle. Having a good-sized component of young people, with their generally more robust health and less frequent need for medical care and prescription drugs, in the newly created insurance pools would provide an important counterbalance to the incoming group of Americans who had previously been locked out of coverage because of preexisting health conditions.

In this data note, we take a closer look at a broadly defined ‘young invincible’ population using a recently released baseline survey of California’s uninsured population by the Kaiser Family Foundation (KFF). The representative, probability-based sample survey is the first of 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.¹ For the purposes of this analysis, we are defining the young uninsured as those Californians aged 19 to 34 that have not had insurance for at least two months and by their income and status as citizens or permanent residents should be eligible to participate in the ongoing insurance expansion under the 2010 health law. Overall, these young uninsured Californians make up nearly half (47 percent) of the state’s adult, eligible uninsured population.²   

Who are California’s young uninsured?

The majority of the Golden State’s young uninsured are men – 59 percent are male, 41 percent are female – a distribution not significantly different than California’s eligible uninsured as a group, which tends to be disproportionately male due to Medi-Cal’s previous rules regarding eligibility. Roughly half are Latino, much like the state’s uninsured population as a whole. Compared to the state’s older uninsured population, the young uninsured are more likely to report being American born citizens: 78 percent say so, compared to about six in ten of those age 35 and over. Like the rest of the eligible uninsured, a large share live in very low-income households, with roughly half (48 percent) saying their household’s annual income is 138% or less of the Federal Poverty Level (FPL) Medi-Cal eligibility ceiling.³

The 19 to 34 year olds are also different in predictable ways in terms of their stage of life: more than six in ten (63 percent) have yet to marry, compared to fewer than two in ten among older uninsured; roughly one in four (28 percent) have a dependent child at home, compared to more than half (55 percent) of those in the middle age group; and roughly one in eight (12 percent) are students.

Young, but not new to lack of coverage; Health insurance history differs from older groups

Though these Californians are relatively young, most of those aged 19 to 34 report that they have been uninsured for a significant length of time. Overall, six in ten among the young uninsured say they have been uninsured for at least two years. Four in ten have lost insurance within the past two years, compared to roughly three in ten among the older groups. As is true for the rest of the state’s uninsured, the main reason this group remains uninsured is cost-related: half (48 percent) say the main reason they don’t have health insurance is that it’s too expensive.

This group does stand out as having a different past relationship with health insurance coverage compared to those 35 and older. While a majority of those aged 50 to 64, and nearly half of the middle-aged group, say that their previous source of health coverage was through an employer, only 22 percent of those under age 35 say the same. Newer to the workforce, their experience with employer-sponsored coverage is obviously more limited. Instead, one in four say that before they were uninsured they were on their parents’ health plan, and nearly as many (22 percent) say they were covered by Medi-Cal or another state’s Medicaid program (programs that have been required to cover low-income youth until they turn 19). Four in ten among this group have been on Medi-Cal at some point in the past. Note they are also the group least likely to have shopped for health insurance in the individual market: 20 percent have done so, roughly half as many as among older uninsured Californians. In this respect, the exchange experience will be even newer for this group than for other uninsured Californians.

The ‘benefits of youth’ are real, but limited: Half financially insecure and nearly as many say health needs not being met

This group of uninsured report experiencing at least two of the benefits of youth: They are less likely to report feeling financial stress than their older peers, and they are more likely to say they are in good health.

Across several fronts, the young uninsured report feeling less financial insecurity than those in the thick of child-rearing or in the pre-retirement years. Overall, half say they feel secure when it comes to their financial position, compared to roughly a third of those aged 35 and over. They report less worry about their income keeping up with rising prices and about having enough money for what must seem a far-distant retirement horizon.

Despite this comparatively optimistic picture, it’s important to keep in mind that this still leaves half among this group saying they do not feel financially secure at this point, an important consideration when it comes to evaluating any costs that might come with new insurance coverage.

Those under age 35 are also more likely than older Californians without coverage to say they are in good health, with three in four saying so. They are also less likely to report having a disability, handicap or chronic disease. But while just over half in this group – 54 percent – say that their health needs are basically being adequately met at this point, the rest – 45 percent – say they are not getting the care they need.

California’s young uninsured report plenty of trouble getting and paying for the health care they need

Their overall good health, however, does not protect this group from incurring medical bills on occasion and then having trouble paying them.

Young people are just as likely as any other uninsured state resident to say they have had trouble paying medical bills over the past year. Overall, four in ten (39 percent) say so – and they report just as much worry about paying for health care going forward. Just over seven in ten of those aged 19 to 34 years say they are “very worried” about how they would pay for health care in the case of a serious accident or illness, putting their concern about a catastrophic medical event well within range of uninsured Californians of any age. They are somewhat less worried about not being able to cover the cost of routine health care services: 44 percent are very worried about this, compared to about 55 percent of older uninsured.

One way this generation deals with the problem of hard to pay medical bills is, like the rest of the uninsured population, by skipping health care, even when they feel they need it. Roughly six in ten (59 percent) in this population say that they’ve gone without needed health care since they’ve been uninsured because of the cost. This is somewhat lower than their older compatriots, but still a majority among a supposedly “invincible” population.

The large majority of young people – about eight in ten – say it is difficult for their family to afford health care, though they don’t express quite as much intensity on the issue as older uninsured Californians. For example, 42 percent of those aged 19 to 34 say their family finds it “very difficult” to afford health care, compared to 63 percent of those aged 50 to 64.

Majority of young uninsured say they feel the need for health coverage

Perhaps because of these worries and negative financial experiences involving medical bills, about three in four of California’s young uninsured say they feel the need to have health insurance. On the other hand, one in four say they feel healthy enough that they don’t really need coverage.

And the majority of young people – six in ten – say that health insurance is worth the cost.

More positive views of the ACA, but low information

The uninsured 19 to 34 year olds look roughly the same as the rest of the state’s eligible uninsured population when it comes to general views of the health law: somewhat more positive toward the law than the American public nationwide,⁴ but even more likely to feel they don’t have enough information to understand how it will impact them personally. Overall, half of those under 35 have a favorable view of the ACA, 27 percent an unfavorable view and 21 percent don’t have any opinion. Though many have a sense of whether or not they like the law as a whole, at least at the end of the summer far fewer felt confident they understood how the law’s changes would affect their own lives. Overall, seven in ten (69 percent) said they don’t know what to expect in terms of personal impact. And as of the end of August, most had heard little or nothing about the Medi-Cal expansion (77 percent) or the creation of the Covered California insurance marketplace (88 percent), similar to their older peers.

Young people not immune to confusion regarding eligibility

Because of this limited exposure to recent information about the rollout of the insurance coverage expansions under the ACA, it is perhaps not surprising that as of late August, many young people in California were not aware of their potential eligibility for either subsidy assistance on the exchanges or inclusion in the expanded Medi-Cal program. Awareness of the availability of tax credit help when purchasing through Covered California was particularly limited at this early point. Overall, roughly seven in ten young people identified as in the appropriate income group either thought they would not be eligible for financial assistance (43 percent) or weren’t sure (26 percent).

Uninsured Californians of all ages, including younger folks, were more likely to recognize their potential eligibility for the Medi-Cal program, a program they may be more familiar through previous exposure or family and friend networks. Still, roughly four in ten of the 19 to 34 year olds expected to be eligible for Medi-Cal were not aware of this eligibility as of August (25 percent in the target group thought they would not be eligible, and another 17 percent had no idea either way).

What to expect in 2014

When told or reminded that “nearly all Americans [will be required] to have health insurance by 2014 or else pay a fine,” a clear majority of the youngest group of uninsured Californians – 58 percent – said they planned to get coverage next year. At least as of late summer, roughly a third thought they would remain uninsured.

As is true in other age groups, a large majority of young people said that if they were told they were eligible for Medi-Cal, they would sign up.

A note on process issues: Compared to older uninsured, the young are more involved in internet economy

Though there are many avenues for Californians to learn about the new insurance options, including in-person and phone opportunities, much of the shopping and learning is structured around the web. This is an advantage for younger state residents, as compared to the older uninsured population, the 19 to 34 year olds are more likely to have access to the internet overall, more likely to have internet access in their own home, and more likely to have at least occasionally bought things online. Still, it’s worth noting that just under half (44 percent) have rarely or never made an online purchase.

What Next

Most of California’s youngest uninsured residents report that they are healthy, but like the rest of the uninsured, most say they have skipped needed medical care because of cost during their period of uninsurance and they report a high degree of worry about what would happen if they were to become severely ill or be injured. Many have struggled to pay the health bills they have incurred. And perhaps because of all these reasons, most say that they feel the need for health insurance.

At the same time, in the months before open enrollment in California, this generation of the uninsured was just as likely as any other to feel they didn’t understand the health reform changes coming down the pike and to have heard little about the state marketplace or Medi-Cal expansions. And as a consequence, there likely remains a fair bit of eligibility confusion to sort out. Add to this the fact that half of this younger group feel financially insecure and only one in five have shopped for insurance before on their own, and it becomes clear that the open enrollment period will be a learning experience on all sides.

Over the next several months many of these young Californians will be learning more about the health coverage available to them via various ACA channels, and many will take steps to understand the costs and benefits such coverage will offer them. Beginning next spring, KFF will be back in the field revisiting these young people and asking them to reflect on their experiences – or lack of experience – with Medi-Cal and the exchanges.

Methodology

The survey of California’s uninsured population was designed and analyzed by public opinion researchers at the Kaiser Family Foundation. Fieldwork was conducted in English and Spanish via telephone by SSRS, an independent research company, from July 11 through August 29, 2013, among a representative sample of 2,001 adults ages 19 to 64 living in California, who reported having been without health insurance for at least two months at the time of the interview. Of the 2,001 respondents, 990 were interviewed via landline, and 1,011 via cell phone. The current data note is based on the 515 respondents that were between the ages of 19 and 34 at the time of the interview, and that qualified as being part of the ‘eligible uninsured’ (those who reported being U.S. citizens or permanent residents, and thus eligible for the health insurance expansion under the Affordable Care Act). The margin of sampling error including the design effect for the sample of eligible uninsured 19 to 34 year olds, on which most findings in this Data Note are based, is plus or minus 6 percentage points. Numbers of respondents and margin of sampling error for other age groups are show in the table below. To access a more detailed methodology, please see the online report.