The Uninsured at the Starting Line in California: California findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA

Conclusion & Policy Implications

The survey findings related to: i) patterns of insurance coverage, ii) the process of enrolling in and choosing health coverage, iii) interactions with the health care system, iv) financial security, and v) readiness for ACA coverage expansions have implications for early implementation of the ACA in California. Uninsured adults in California are generally in low-income, working families and have lacked insurance coverage for quite some time. Many have substantial health care needs but have only loose ties to the health system. Uninsured adults in California are also disproportionately Hispanic, and many may be ineligible for ACA assistance due to their immigration status. Below, we summarize how this pre-ACA baseline data can inform outreach and enrollment, plan selection and scope of coverage, and providers and health systems.

Reaching Eligible Uninsured Adults

Outreach and enrollment will be an ongoing process. While there is much focus on the initial push to enroll people in coverage under the ACA, enrollment is not a “one shot” effort that will be completed in the first few months of implementation. The survey findings reveal that millions of Californians lose and gain coverage throughout the year because of job changes, income fluctuations, or problems at renewal. Thus, implementing the ACA will require ongoing efforts to enroll and keep people in coverage, and efforts to promote coverage stability are important. There have already been substantial investments in outreach and education in California, including statewide marketing campaigns, community mobilization to reach people at the local level, provider training, outreach to transition people from LIHP coverage to Medi-Cal, and targeted efforts to reach vulnerable populations who may be newly-eligible for Medi-Cal.1 Many of these initiatives include funding through 2014 and beyond, and it will be important to sustain efforts throughout 2014 and in future years to reach people who have a need for ACA coverage in the future. As more people are enrolled in coverage under the ACA, the focus of these efforts may also shift from initial enrollment to ensuring continuous, stable coverage.

Some eligible uninsured adults in California have little or no connection to pre-ACA health or social services systems and may be hard to reach. Many people targeted for coverage expansions are not currently connected to the health care system, have been outside the health insurance system for quite some time, or are not linked to social services programs. The survey shows that nearly half of uninsured adults have lacked coverage for five years or longer, most do not have a regular source of care, and many have no health care visits over the course of a year. Further, while many low-income (≤138% FPL) uninsured California adults have a family connection to a social services program, the majority of moderate-income (139-400% FPL) uninsured adults do not. Efforts in California to reach individuals through community mobilization, fast-track enrollment, and provider outreach are a promising approach to reach the notable shares of uninsured adults who have ties to health systems, social services, or community groups. However, marketing campaigns are also important avenues for reaching the “unconnected” uninsured, and it will be important to focus them on both people who may be eligible for Covered California and those eligible for Medi-Cal.

Many eligible uninsured adults in California have experience with pre-ACA health care, health insurance, or social services systems, but there is great need for continued education about new coverage options. Some people targeted for coverage expansions have experience with the health care system and health insurance but may be unaware that eligibility and costs have changed under the ACA. Despite some early outreach and enrollment efforts in the state, notable shares reported in the survey that they were unaware of new coverage options at the start of open enrollment. Further, many reported pre-ACA experiences of trying to get coverage and encountering cost or eligibility barriers. It will be important for outreach messages to emphasize how coverage options have changed in order to reach out to people who have tried to apply for coverage in the past. The state’s plan to reach people through “fast track” enrollment2 may be particularly fruitful for reaching low-income uninsured Californians, as these approaches require limited paperwork and reach people with known eligibility.

Connecting People to Suitable Coverage

In addition to technical issues with the Covered California website, it will be important to monitor whether other challenges in enrolling in health coverage that existed prior to the ACA are addressed by ACA simplification provisions. Policymakers have made strides in addressing many of the website glitches that plagued early enrollment efforts under the ACA, and they continue to focus attention on addressing these technical issues. However, there are other challenges to enrolling in coverage and picking a plan that policymakers may still need to address. Survey results indicate that, before the ACA, some insured Californians reported challenges in compiling required paperwork to apply for Medi-Cal. Adults also reported challenges with the next stage of enrollment: comparing plan information to choose a plan. While Medi-Cal enrollees have more limited choices and face standardized plans, they were more likely than adults with other types of coverage to report challenges in selecting a plan. The ACA includes provisions to simplify the application process for Medi-Cal and to ease the plan selection process for people purchasing coverage through Covered California. The ACA also provides for enrollment assistance for people applying to both Covered California and Medi-Cal, and the state is using a wide range of entities—including community groups, schools, health care providers, insurance brokers, unions, and other organizations—to provide one-on-one assistance to applicants. Further, LIHP enrollees across the state are being automatically transitioned to new coverage under the ACA, primarily Medi-Cal. Additional technical support may be needed to assist with transferring data from the county to state level, and additional education and training may be needed to help beneficiaries and providers understand changes to coverage as a result of the transition.3 While it is still early to evaluate the success or challenges of these efforts, it will be important to track implementation of these simplifications to ensure that challenges that some people faced in the past do not carry over to ACA enrollment.

Early assessments of plan choice under the ACA may account for the fact that cost is only one factor in Californians’ preferences for health coverage. Much focus in early coverage of ACA enrollment has been on the premiums and deductibles that people will face under their new coverage. These features provide concrete measures that people can examine, and certainly costs are a key concern for new enrollees. However, the survey shows that Californians also value other aspects of their coverage, such as benefits and networks, sometimes even more than low out-of-pocket costs. Future evaluations of coverage, therefore, may consider how well new plans are meeting the full range of priorities and preferences for health coverage, and future changes to plan offerings under the law may consider the broad range of people’s priorities for their coverage.

Even once Californians have insurance, they may face issues with their plans covering the range and scope of services they need. Survey findings reveal that the vast majority of enrollees in various types of coverage reported being satisfied with their plan, but notable shares reported a problem with their scope of coverage. Many adults on Medi-Cal reported needing coverage for dental services that are not included in their plan, and Californians with private coverage also reported gaps in ancillary services. New Medi-Cal enrollees in California will receive the same benefits as currently-enrolled adults, and while the state plans to reinstate coverage of dental services, it will be important to monitor access to this and other ancillary services.  In addition, while people gaining coverage under Medi-Cal and Covered California will receive coverage for essential health benefits, it will be important to assess whether the scope of coverage Californians have under the law meets their needs and work to educate people about both what is and what is not included in their coverage.

While the ACA could ameliorate the financial burden of health care for many, affordability of health services may remain a challenge. In addition to the goal of facilitating access to health care services, a goal of coverage expansions is to provide financial protection from medical expenses. As survey findings show, even among Californians who have insurance, health care costs can be a challenge. Though less likely than their uninsured counterparts to have difficulties with medical costs, low-income insured adults in California reported challenges in paying premiums, copayments, out-of-pocket costs for uncovered services, and other health care expenses. In addition, all low-income families, regardless of insurance coverage, face financial hardship in making ends meet. While affordability provisions in the ACA may address some of the challenges that low-income insured individuals face in affording medical care, it will be important to track ongoing financial barriers and financial instability even among those who have coverage. Early evaluation of premiums for plans in Covered California indicates that, for a 40-year old at 250% FPL, subsidized premiums in California for the second-lowest cost silver plan ($193/month) and the lowest-cost bronze plan ($125/month) are at the median of plans analyzed across states.4 Ongoing efforts may assess people’s other out-of-pocket costs and affordability of these expenses.

Adapting the Health System and Patterns of Care to Meet New Needs

Based on demonstrated need and barriers to care among the uninsured in California prior to the ACA, health care providers may see increases in California adults seeking care. Ultimately, the goal of coverage expansions under the ACA is to help people access needed health care services. Thus, once people gain coverage, providers and health systems will need to be prepared to serve newly insured people. Survey findings reinforce conclusions from prior research that gaining health coverage is likely to alter the way that people interact with the health system. Compared to their insured counterparts, uninsured California adults face barriers to care, despite many having a demonstrated need. Some uninsured California adults have ongoing health conditions yet still are not receiving regular care, and others have postponed preventive or other services, primarily due to cost. These findings indicate that there is likely to be some pent-up demand for health care services among California’s newly-covered. However, survey findings indicate that barriers to seeking care, such as difficulty traveling to a provider’s office, may continue to persist among insured adults, particularly Medi-Cal beneficiaries. Outreach and education may be needed to link the newly-insured to a regular provider and help them establish a pattern of regular preventive care. In addition, efforts to ensure access to care for low-income adults with coverage, such as Medi-Cal, will be important to continue.

Changes in insurance coverage may lead people to use new or different providers, but clinics and health centers will continue to serve many of California’s vulnerable populations. Many are concerned about shifting patterns of care under the ACA, as changes where people receive care may alter revenue streams for providers. The effect of changing revenue streams for different types of providers is unclear at this point. Based on the survey findings, uninsured Californians are likely to have more options for where to receive their care once they obtain coverage under the ACA. Compared to their insured counterparts, prior to the ACA, they were more likely to seek care in clinics and to report that finances drove their decisions about where to seek care. As people gain Medi-Cal or Covered California coverage, they may shift their service locations to more closely resemble that of people who had Medi-Cal or private coverage prior to the ACA, respectively. Clinics and health centers are likely to continue to see a substantial share of the low-income population, and these providers also may continue to see high levels of the uninsured. As markets evolve in the wake of ACA coverage changes, these providers may be strained to meet demand in the face of shrinking resources.5

As implementation unfolds, California providers may continue to be on the front lines of not only service delivery but also outreach and enrollment. Providers are one avenue that policymakers are using to reach out to uninsured adults who may be eligible for coverage expansions under the ACA. Survey findings indicate that emergency rooms and hospitals may be promising avenues for reaching eligible individuals who have episodic interactions with the health system, and community health centers can reach a share of the uninsured who use them for ongoing care. California is already acting on these opportunities: clinics and health centers are taking an active role enrollment, including in “inreach” to their patient populations,6 and the state’s hospital presumptive eligibility program may reach many people who find themselves in need of hospital services.

Moving Forward in ACA Implementation

As enrollment in new coverage options grows and people begin to use their coverage, survey findings point to several issues that can inform ongoing efforts to implement the ACA. Future reports using the 2013 Kaiser Survey of Low-Income Americans and the ACA will continue to delve into these issues and provide state-specific findings, and future surveys can assess whether and how coverage, access, and family finances change under the law.

V. Poised at the Starting Line Methods

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