A Final Look: California's Previously Uninsured after the ACA's Third Open Enrollment Period

About The Terms Used In This Report

This report primarily uses the following definitions for key groups examined in the survey:

The overall group of Californians who were uninsured prior to the ACA’s first open enrollment period, most often referred to as “California’s previously uninsured.”

1. The subgroup of previously uninsured Californians who currently report that they are uninsured, referred to as “California’s remaining uninsured.” This group includes some who reported having coverage in 2014 or 2015, some who reported not having coverage in 2014 or 2015, and some whose 2014 coverage status or 2015 coverage status is unknown because they were unable to be contacted during those years.
2. The subgroup of previously uninsured Californians who now report that they have health insurance, referred to as “California’s recently insured.” Two subgroups within California’s recently insured are:
   1. Those who reported that they were uninsured in the summer of 2013 and either said in spring 2014 or spring 2015 that they did not have coverage or were unable to be contacted, but now report having health insurance, referred to as “California’s newly insured,” and
   2. Those who reported that they were uninsured in the summer of 2013, reported gaining insurance sometime in the past two years and say they still have coverage in spring 2016, referred to as “California’s still insured.”

And, as noted in the Survey Methodology Section, only those uninsured for at least two months were included in the baseline survey. Other terms used occasionally throughout the report are defined below.

• Eligible Previously Uninsured Californians: Because the coverage expansions under the ACA do not extend to undocumented immigrants, some of the analyses focuses on those who reported being U.S. citizens or permanent residents in the baseline survey, described in shorthand as those who are ‘eligible’ for the ACA’s coverage expansions.
• Undocumented Previously Uninsured Californians: For the purposes of this report, undocumented immigrants are defined as those who reported in the baseline survey that a) they were not born in the United States or Puerto Rico, b) they came to this country without a green card, and c) they have not received a green card or become a permanent resident since arriving. There are several ways that this definition, while workable for the purposes of a broad analysis of this sort, falls short of the complexity of real life. First, it relies on self-reporting, and since respondents have an incentive not to reveal unlawful immigration status, it is undoubtedly a somewhat imperfect measure. Second, those that did not answer all three in the series of immigration status items in the baseline survey were not able to be categorized. Third, by necessity of time and efficiency, the survey did not allow for a full exploration of the many nuances inherent in the U.S. immigration system. For example, this category may actually include a small number of individuals in California as refugees, asylees or other humanitarian immigrants who might better be placed among the ‘eligible uninsured’. The survey, unfortunately, does not allow this level of detailed sorting. Since estimated immigration status is based on individuals’ responses to the baseline survey, it is possible that some small share of those thought to be undocumented immigrants have now become permanent residents or received a green card.
• Income categories: Because eligibility for two of the law’s main components – the Medi-Cal expansion and the tax credits being made available to purchase insurance on the new exchanges – is based on an individual’s family income relative to the federal poverty level (FPL), in some cases we report survey results by FPL categories. Eligible previously uninsured Californians with incomes 138% FPL or less (roughly $33,000 a year for a family of 4 in 2015) are eligible for Medi-Cal coverage, while those with incomes greater than 138% and up to 400% FPL (roughly $33,000-$97,000 for a family of 4 in 2015), are eligible for subsidies to purchase insurance through Covered California Marketplace. Those with incomes above 400% FPL are allowed to buy insurance through Covered California but are not eligible for subsidy assistance. For convenience, we sometimes refer to the eligible group with incomes 138% FPL or less as the “Medi-Cal target group”, and those greater than 138% and up to 400% FPL as the “exchange subsidy target group”. These obviously are approximations that do not allow for every real world exception to be taken into account. For example, lawfully present immigrants may remain subject to a five year wait before they may enroll in Medi-Cal, but for the purposes of this analysis they are included in the Medi-Cal target group if they meet the income criteria. Similarly, some of those in the exchange subsidy target group may not be eligible for marketplace subsidies if they have access to affordable employer coverage, a situation difficult to ascertain in a phone survey.