Uninsured Now?

Where are California's Uninsured Now? Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey

By Bianca DiJulio and Jamie Firth and Larry Levitt and Gary Claxton and Rachel Garfield and Mollyann Brodie

Last summer, just before the first open enrollment period under the Affordable Care Act (ACA), the Kaiser Family Foundation (KFF) conducted a baseline survey of California’s uninsured nonelderly adult population. After the open enrollment period came to a close, we conducted a second survey with the same group of individuals who participated in the baseline (a longitudinal-panel survey) to find out whether they obtained coverage or remained uninsured and to explore the coverage choices people made, their experiences with open enrollment and their new insurance. Additional waves of the panel survey over the next two years will continue to track this same group of individuals to capture their changing attitudes and experiences. The surveys are designed and analyzed by researchers at KFF and the fieldwork costs associated with Wave 2 of the survey were paid for by The California Endowment.

California was an early adopter of the ACA and has been a leader in enrolling eligible residents in coverage through the two main avenues for expanding coverage under the law – Medi-Cal, the state Medicaid program, and Covered California, the new state marketplace where people can shop for insurance and access government subsidies to help pay for coverage.

This longitudinal panel study allows us to follow a large group of randomly selected uninsured Californians and assess how their insurance status changes over time to learn more about why or why not those changes occurred, and what gaining health insurance means for their daily lives without having to rely on respondents ability to report and recall details from months or years ago. By tracking a scientifically representative panel, we can quantify how widespread or limited certain problems or changes that may have been reported anecdotally actually were. Statistically representative narratives and stories from individual’s actual experiences can then be drawn from the sample to illuminate more accurately how the uninsured fare as the law is implemented in California.

Key Findings

Of those Californians who were uninsured prior to open enrollment, 58 percent now report having health insurance, which translates to about 3.4 million previously uninsured adult Californians who have gained coverage, and 42 percent say they remain uninsured.¹ The most common source of coverage was Medi-Cal with 25 percent of previously uninsured Californians reporting they are now covered by Medi-Cal. An additional 9 percent of California’s previously uninsured say they enrolled in a plan through Covered California, resulting in about a third reporting new coverage from the two sources most directly tied to the ACA. Twelve percent say they obtained coverage through an employer and 5 percent report enrolling in non-group plans outside of the Covered California Marketplace; some enrollment in these types of coverage may have been motivated by the ACA’s requirement to purchase insurance and some may be the result of normal movement within the marketplace.

Fifty-two percent of Hispanics who were previously uninsured report enrolling in coverage, a share that rises to 61 percent of Hispanics after excluding those who are likely to be ineligible for financial assistance through Covered California or Medi-Cal due to their immigration status.² And, over half of young adults age 19 to 34 (58 percent), those earning 138% of the federal poverty level (FPL) or less (54 percent), those earning greater than 138% and up to 400% FPL (61 percent),³ and those reporting fair or poor health (53 percent) report getting coverage since last summer. Outreach played a role in getting people covered — 69 percent of California’s previously uninsured who said they were contacted about signing up for health insurance since October 1st say they obtained coverage, compared to 52 percent of those that say they weren’t contacted.

Overall, after controlling for a number of demographic factors, the remaining uninsured are more likely to be male, undocumented immigrants, or people who have never had insurance, while those who are newly insured are more likely to be married, have been uninsured for less than two years, have a debilitating chronic condition or report being contacted about signing up for coverage.

California’s Newly Insured

• A majority of the newly insured say their plan is a good value for the amount they pay (73 percent) and report feeling well protected by their plan (64 percent). More newly insured report that gaining coverage has made them feel more financially secure than less (37 percent vs. 16 percent), but nearly half (46 percent) of those newly insured in plans other than through Medi-Cal say that paying for coverage is difficult.

• Getting coverage went smoothly for many newly insured, the majority of whom said it was easy to find the information they needed about enrolling (80 percent) and to sign up for coverage (76 percent). Six in 10 (60 percent) of those with coverage through Medi-Cal or Covered California say they had someone help them enroll.

• Among the newly insured, just over 4 in 10 (43 percent) say they visited the website during the open enrollment period, and the majority of them found their visit at least somewhat helpful. And, for those who ultimately enrolled in a Covered California plan, 72 percent say they visited the website, including just over half who say they found it helpful (55 percent).

• But some enrolling in Medi-Cal or Covered California report experiencing problems in confirming enrollment (29 percent and 42 percent, respectively) or determining if their income qualified them for Medi-Cal (19 percent) or financial assistance through Covered California (26 percent). Once enrolled, most newly insured report positive experiences with their plan so far (75 percent) and 43 percent say they have already visited a doctor or health provider.

• The newly insured are split on whether they attribute their new coverage to the ACA or not – 45 percent say they got insurance because of the law and 52 percent aren’t directly attributing their new coverage to the ACA and say it’s something they would have done anyway. But, looking at the two types of coverage that are most directly related to coverage expansions under the ACA, 60 percent of the newly insured (or 34 percent of previously uninsured Californians overall) say they enrolled in Medi-Cal or through Covered California.

• Most newly insured Hispanics say shopping was relatively easy. For those newly insured Hispanics who prefer to communicate in Spanish, nearly 9 in 10 (87 percent) say it was easy to find information in Spanish, including about two thirds (65 percent) who said it was very easy.

California’s Remaining Uninsured

• Many characteristics of the remaining uninsured indicate that they are a difficult to reach group with limited ties to health insurance. Nearly 4 in 10 (37 percent) say they have never had health insurance (compared to 20 percent who became insured) and an additional 45 percent say they have been uninsured for two or more years. Six in 10 (62 percent) are Hispanic, including 29 percent who are unable to take advantage of coverage expansions under the ACA due to their immigration status, and 70 percent of whom prefer to communicate in Spanish. In addition to those who are not eligible due to their immigration status, about 4 in 10 (39 percent) have incomes that put them in the group likely eligible for Medi-Cal and another quarter (24 percent) are likely eligible for financial assistance through Covered California.

• Roughly 7 in 10 (71 percent) of those who remain uninsured after the first open enrollment period say health insurance is something they need, but a third (34 percent) say cost remains a barrier to getting coverage.

• Just over a third (36 percent) of those who remain uninsured say they tried to get coverage but most say they did not enroll either due to the cost of coverage or difficulty completing the process.

• Nearly 6 in 10 (57 percent) of those still uninsured think they will get coverage later this year, though most (57 percent) of them are unsure where they might get it.

• Almost half of Hispanics who remain uninsured may not be eligible for coverage through Covered California or Medi-Cal under the ACA due to their immigration status, and just over half of remaining uninsured Hispanics (54 percent) are worried that enrolling in coverage would bring attention to their family’s immigration status. At the same time, Hispanics who remain uninsured largely feel that insurance is something they need (78 percent).

Newly Insured vs. Remaining Uninsured

Finally, in many areas examined in the survey differences exist between those who got insurance and those who remain uninsured. The majority of remaining uninsured don’t feel like they have enough information to understand how the ACA will impact them and their families (61 percent) whereas the majority of newly insured say they do (58 percent). The newly insured, including those who report ultimately getting coverage from a different source, were slightly more likely than the remaining uninsured to visit the Covered California website (43 percent vs. 30 percent) but while most of the newly insured report finding it helpful, most of those that remained uninsured said it was not helpful. More generally, the newly insured largely report positive experiences shopping for coverage and comparing plans, while the 36 percent of the remaining uninsured who tried said they had a hard time examining their options.

How Many Previously Uninsured Californians Got Covered?

Nearly 6 in 10 (58 percent), or approximately 3.4 million, previously uninsured adult Californians report obtaining health insurance since the start of open enrollment including 10 percent who say they have signed up but are waiting for coverage to start, while the remainder continued to go without health insurance (Figure 1). Fully a quarter of those uninsured prior to open enrollment report signing up for Medi-Cal while smaller shares report getting coverage through an employer (12 percent), a plan through Covered California (9 percent) and other non-group coverage (5 percent).

Under the Affordable Care Act, access to coverage in California was expanded primarily in two ways. Medi-Cal eligibility was broadened to include parents and adults without dependent children earning 138% FPL or less, two groups that had limited access to Medi-Cal coverage prior to the ACA. In addition, the Covered California Marketplace was developed as a place where people could shop and compare health insurance plans and access federal subsidies for health insurance. Outreach efforts and media coverage about the ACA may have encouraged some people who were previously eligible for coverage through Medi-Cal to obtain coverage, sometimes referred to as the “woodwork” effect. It is difficult to distinguish those who may already have been eligible for Medi-Cal from those who are newly eligible due to expanded eligibility under the ACA in this survey, but the combined enrollment of the newly insured in Medi-Cal and in plans through Covered California indicate that about a third (34 percent) of California’s previously uninsured got coverage through these ACA-related coverage options. In contrast, it is more typical for access to job-based insurance to shift frequently as people change jobs or become eligible after a waiting period, so some people may now have coverage through an employer because of normal movement in the insurance market, but others may have been motivated to enroll in an offer of coverage through an employer due to the ACA’s requirement to have insurance.

Figure 1

Which Previously Uninsured Californians Got Covered?

Rates of coverage among previously uninsured adult Californians are similar across age groups, income groups, and self-reported health status. For example, 58 percent of previously uninsured younger adults age 19 to 34 report getting insurance, similar to the share of middle-aged adults age 35 to 49 (55 percent) and the same as the share of near-elderly age 50 to 64 (58 percent). Reports of new coverage are also similar for those at different income levels. And, those reporting their health as fair or poor were just as likely to say they got insurance as Californians reporting being in at least good health (53 percent and 60 percent).

Prior to the coverage expansions under the ACA, Hispanics made up over half of the uninsured adult population in California and now over half of Hispanics (52 percent) who were previously uninsured report getting coverage (Figure 3), a share that is statistically similar to whites (61 percent). Still, concern over lagging enrollment among Hispanics in plans through Covered California warrants a closer look at new coverage rates among previously uninsured Hispanics. As many as a third of previously uninsured Hispanics may be ineligible for coverage through Medi-Cal or Covered California due to their immigration status.¹ Therefore, focusing only on previously uninsured Hispanics whose immigration status permits them to enroll in Medi-Cal or participate in Covered California, 61 percent are newly insured, the same share as newly insured whites.

Figure 3

But for other characteristics, rates of coverage vary widely. For example, college graduates are more likely to have gained coverage than those with less education. In addition, those who report having a debilitating chronic disease, disability, or handicap are more likely than those without to say they now have coverage, with almost 8 in 10 reporting they obtained health insurance since last summer (Figure 4).

Meanwhile, less than half of those who have spent their lifetime without insurance say they obtained coverage, a share that is 20 percentage points lower than those who say they have been insured at some point. Many in this group – 40 percent of those who say they have never had insurance – are undocumented immigrants who are ineligible for coverage through Medi-Cal or Covered California under the ACA. Still, it is notable that about 4 in 10 (43 percent) of previously uninsured Californians who report never having coverage before now report being insured. In addition, men were slightly less likely to report getting insurance than women (52 percent vs. 63 percent).

Figure 4

How much California’s uninsured knew about the law and what their view of it was before open enrollment are also factors that may contribute to some obtaining coverage. Those who were aware before open enrollment started of the requirement to obtain insurance, the Medi-Cal expansion, or the subsidies available to help people purchase insurance are somewhat more likely to say they now have insurance than those who were unaware of these key provisions. But, a similar share of those with favorable views of the law last summer report getting coverage as those who had unfavorable views (59 percent vs. 57 percent).

Outreach played a role in getting some people covered – 69 percent of California’s previously uninsured who said they were contacted about signing up for health insurance since October 1^st say they obtained coverage, compared to 52 percent of those that say they weren’t contacted. On the other hand, those that say they were encouraged by a family or friend to sign up for coverage are no more likely to report being newly insured than those who didn’t report the same encouragement (58 percent and 55 percent)

Many of these factors tend to overlap so to attempt to isolate the personal elements that best predict who was more likely to get insurance during this first open enrollment period, we conducted a regression analysis with demographic factors, relevant perceptions of the law, and outreach indicators. This analysis showed Californians who say they obtained insurance are more likely to report being married, having a debilitating chronic condition, having been uninsured for less than two years, and being contacted about getting coverage after controlling for a variety of demographic factors such as age, education, and income. On the other hand, the regression analysis also showed that Californians who reported remaining uninsured are more likely to be male, have never had insurance, or be undocumented immigrants. And, there are no differences by race/ethnicity after controlling for these demographics, particularly after controlling for immigration status and never having had coverage. Knowledge of key provisions or attitudes of the law going into open enrollment did not significantly predict enrollment after controlling for other characteristics.

As the open enrollment period came to a close in the spring, nearly 6 in 10 of California’s previously uninsured report gaining coverage, with the largest share (25 percent) reporting they got coverage through Medi-Cal. All told, about a third of California’s previously uninsured say they enrolled in the two types of coverage most directly tied to the ACA – Medi-Cal and plans through Covered California. Forty-two percent say they remain uninsured including 13 percent who are ineligible for Medi-Cal or Covered California due to their immigration status.

Future waves of the Kaiser Family Foundation California Longitudinal Panel Survey will continue to track this same, representative group of individuals who were uninsured before the major provisions of the ACA took effect to learn more about how people are using their coverage, their experiences finding health care providers and paying for care, and whether they shop for coverage during the next open enrollment period, remain in the same plan or become uninsured again. At the same time, future surveys will determine if some of the remaining uninsured from this wave of the survey gain coverage and what eventually brought them into the fold. They also will measure the extent to which perceived or actual barriers such as cost and immigration status keep others from getting health insurance and how those remaining uninsured fare. Returning to the same previously uninsured Californians at multiple points in time allows for a unique look at the views and experiences of this key group as they navigate new coverage options under the ACA and the changing health care system.