California's Uninsured on the Eve of ACA Open Enrollment

This report presents the findings of a baseline survey of California’s uninsured adult population just before the start of the first open enrollment period under the Affordable Care Act (ACA). It will be followed by three other surveys over the course of the next two years that will capture the changing experiences and attitudes of this same group of 2,000 people over time, whether they obtain coverage or remain 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 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 population we are terming the ‘eligible uninsured’.

Eight in ten uninsured Californians feel the need for health insurance

• According to the survey, a large majority of California’s eligible uninsured¹ – eight in ten – do feel they need health insurance coverage. Even seven in ten (72 percent) of the youngest uninsured Californians – those ages 19 to 25 – say they need health insurance.
• Many have not had coverage for some time, though. About two-thirds have been without health insurance for at least two years. One in five say they’ve never had health insurance. Cost remains the primary reason for not having health insurance, followed by job loss.
• A majority of the uninsured (57 percent) do believe that health insurance is worth the money it costs, while just over a third disagree. These views are obviously based on perceptions of the cost of coverage before the opening of exchange enrollment in October.

California’s uninsured and the ACA: A steep learning curve ahead, but cautious optimism

• California’s eligible uninsured tilt more optimistic than pessimistic on the ACA’s expected impact in their own lives: Four in ten believe the law will enhance their ability to get health care and health insurance, compared to about two in ten who expect the law to make this more difficult. About a third don’t expect it to make any difference.
• Yet at the same time, the large majority of California’s eligible uninsured –seven in ten (70 percent) –say that as of late August, before the start of the most intensive phase of outreach, they don’t yet have enough information about the ACA to understand how it will impact them in concrete terms.
• At this early stage, then, among those whose incomes put them in the Medi-Cal target group, three-quarters (77 percent) say they have heard little or nothing about the program’s upcoming expansion.  And among those in the exchange subsidy target group, more than eight in ten say they have heard little or nothing about the state’s newly minted health insurance marketplace.

As of late August, many doubt they are eligible, but large shares say if they qualified for Medi-Cal they would join

• As of late August, there is widespread confusion among the state’s uninsured as to whether they are eligible for any of the newly expanded benefits: three-quarters in the income group targeted to get subsidies in the marketplace are either not sure or presume they will not be eligible for such financial assistance. Only half of those in the Medi-Cal income group presume they will be qualified for the program.
• But there is a good deal of interest in signing up for Medi-Cal if those eligibility uncertainties could be put to rest. Nine in ten (89 percent) in the Medi-Cal eligible income group say that if told they qualified for the state health insurance program, they would want to enroll.
• Medi-Cal is viewed quite positively by the uninsured (62 percent favorable), a group that has widespread ties to the program: over four in ten of those with incomes 138 percent of the poverty level or less say they have been on Medi-Cal at some point, and another three in ten know someone who has participated in the program.
• The survey suggests that, as of late August, when told of the existence of the individual mandate, the preliminary impression of about half the population is that they would plan to get health coverage, with the other half either thinking they won’t get coverage (32 percent) or not sure what they will do (15 percent).

California’s uninsured: financially stressed, medically underserved

• The survey suggests that the new coverage options will be presented to a population that is in real need of help on this front, with many skipping care they need because of cost and most feeling anxiety over their inability to pay for a major health crisis. At the same time, the rollout will meet a population already quite financially overstretched, both leery of new costs and anxious for financial relief.
• A majority of California’s eligible uninsured population (57 percent) describe themselves as financially insecure, with over eight in ten (84 percent) reporting their family finds it difficult to pay for health care.
• As a result, more than six in ten (64 percent) say that they’ve gone without needed health care because of the cost during the time they’ve been uninsured. Four in ten say they have had trouble paying the medical bills they did incur.
• There is widespread worry about what would happen if a family member was struck by a serious illness or involved in an accident. Three in four say they are “very worried” about not being able to pay the resulting medical bills.
• This group also stands out for more attenuated links to the financial system. More than half report they do not have a credit card, three in ten do not have a bank savings or checking account, and one in four does not have Internet access at home.  Over half say they ‘rarely’ or ‘never’ shop online.

Uninsured and undocumented

• The survey suggests that about a fifth of the state’s uninsured are undocumented immigrants², a group that is not eligible to buy coverage through Covered California or to join Medi-Cal.
• This group may have misplaced expectations of getting help that in actuality will not be forthcoming: about half (49 percent) say they think they may be eligible to get insurance through Medi-Cal as a result of the ACA. Forty-three percent expect they will be eligible to shop for health insurance on the exchange.
• As is true for the rest of the state’s uninsured population, currently eight in ten undocumented uninsured report finding it difficult to pay for health care, and 46 percent say they have gone without needed health care because they couldn’t afford it.
• This group stands out as particularly concerned about being able to find a doctor that would treat them if they needed one: 68 percent say they are “very worried”, nearly 30 percentage points higher than among other uninsured Californians.