Coverage Expansions and the Remaining Uninsured: A Look at California During Year One of ACA Implementation

In January 2014, the major coverage provisions of the 2010 Affordable Care Act (ACA) went into full effect in California and across the country. These provisions include the creation of a new Health Insurance Marketplace, known in the state as Covered California, where middle income families (between around $27,000 and $79,000 for a family of three in 2014) can receive premium tax credits to purchase coverage and, in states like California that opted to expand their Medicaid program, the expansion of Medi-Cal eligibility to low-income adults (about $27,000 or less for a family of three in 2014). With these provisions, millions have gained coverage and access to needed health care services.

While much attention has been paid to enrollment in new coverage options and changes in the uninsured over the past year, less is known about how this coverage has affected people’s lives. To help fill this gap, the Kaiser Family Foundation is conducting a series of comprehensive surveys of the low and moderate-income population. These projects include both national surveys and a specific focus on California.

California is a bellwether state for understanding the impact of the ACA. Through a Medicaid waiver, the state was an early adopter of the Medicaid expansion, covering over 650,000 people by 2013 through its Low-Income Health Program (LIHP). The state was also the first to create a state-based Marketplace, and California engaged in an aggressive, multi-faceted outreach and enrollment campaign to reach and enroll individuals eligible for Medi-Cal or Covered California. The state’s efforts have led to substantial gains in coverage: Medi-Cal enrollment grew by 30% (2.8 million people) between the pre-open enrollment period in the fall of 2013 and the end of 2014,¹ and roughly 1.7 million people applied and were determined eligible for Covered California health plans between October 2013 and October 2014.² In addition, California’s sheer size means that the state’s experience in implementing the ACA has implications for national goals of reducing the total number of uninsured.

Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA, fielded prior to the start of open enrollment for 2014 ACA coverage, provided a baseline snapshot of health insurance coverage, health care use and barriers to care, and financial security among insured and uninsured adults at the starting line of ACA implementation and discussed how those findings could inform early implementation.³ The 2013 survey included both a national sample and a California sample, funded by the Blue Shield of California Foundation. In fall 2014, we conducted a second wave of the Kaiser Survey of Low-Income Americans and the ACA nationally and in California (again with support from the Blue Shield of California Foundation) to understand how these factors have changed under the first year of the law’s main coverage provisions. The survey, which included a state-representative sample of 4,555 nonelderly (age 19-64) California adults, was conducted between September 2 and December 15, 2014, with the majority of interviews (67%) conducted prior to November 15, 2014 (the start of open enrollment for 2015 Marketplace coverage; Medicaid enrollment is open throughout the year). In addition to the survey, qualitative interviews were conducted with key stakeholders throughout the state to provide policy context and insight into survey findings. Additional detail on the survey methods is available online.

This report, based on the California sample of the 2014 Kaiser Survey of Low-Income Americans and the ACA, examines the populations that gained coverage and remained uninsured in 2014. It describes the characteristics of these groups in California, comparing them to those who had coverage before 2014. It also provides information on how the newly insured view their coverage and any problems they have encountered in using their coverage; examines how the remaining uninsured and newly insured fare with respect to access to medical care and financial burden; and analyzes why people in California continue to lack coverage and their plans for obtaining coverage in 2015. Where relevant, the report also includes trended data from 2013.