The Uninsured at the Starting Line in California: California findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA
II. What to Look for in Enrolling in New Coverage
How Low-and Moderate-Income Adults in California Sign Up For and View Their Coverage
While many currently uninsured adults in California have limited experience in signing up for and using health coverage, past successes and challenges of insured low- and moderate-income adults can inform the experiences of those seeking coverage under the ACA. A majority of insured Californians do not experience problems choosing, enrolling in, and using their coverage, and this pattern holds true for both those in Medi-Cal and private insurance. Still, based on the experience of their insured counterparts, the uninsured population in California that is being targeted by the ACA coverage expansions is likely to encounter some barriers in the process of choosing and enrolling in coverage. While the ACA aims to make the process smoother, it is likely that some challenges inherent in the complexity of health coverage will require concerted efforts to address.
While many adults in California reported facing no difficulty in applying for Medi-Cal coverage prior to the ACA, some encountered difficulties in the process of applying for public coverage in the past.
In comparison to the process for gaining coverage through an employer—which is typically facilitated by the firm or a representative and may require limited action on the part of the insured—applying for publicly-financed coverage typically requires proactive steps to gain coverage. Adults in California who currently have Medi-Cal or who have attempted to enroll in the past five years reported little difficulty in enrolling in Medi-Cal. Almost half of adults (48%) who applied to Medi-Cal said the entire process was very or somewhat easy. However, the rest found at least one aspect of the process – finding out how to apply, filling out the application, assembling the required paperwork, or submitting the application – to be somewhat or very difficult. The most commonly reported difficulty was assembling the required paperwork, which over a third (34%) of Californians who enrolled or applied said was somewhat or very difficult (Figure 6 and Appendix Table A3).
In recent years, California, along with many other states, has made strides towards providing individuals multiple avenues to enroll in coverage, including through online applications to facilitate access to coverage and ease administrative burdens.1 However, more than four in ten California adults (42%) who have applied to Medi-Cal in the past five years reported that they did so through traditional routes—that is, in person at a state or county government office—and only 7% reported using an online application (Figure 7).
The ACA includes provisions to further simplify the application, enrollment, and renewal process for coverage in all states. These requirements include the adoption of a single streamlined application that is available online, by phone, and on paper and that screens for all health coverage options; electronic transfers of accounts between agencies to facilitate transitions across health coverage programs; and reliance on trusted sources of electronic data, rather than requesting paper documentation, to verify eligibility criteria.2As of late 2013, California and other states were still in the process of implementing many of these changes and coordinating enrollment processes with Covered California.3 Ongoing efforts in the state are also trying to make the process of enrolling in Medi-Cal coverage a more positive and welcoming experience, which calls for a culture shift to reorient Medicaid management, systems, and caseworker training away from welfare-style “gatekeeping” and toward encouraging participation.4
In addition, state and county investments are being made to train professionals and dedicate resources to assist with enrollment into new Medi-Cal and Covered California coverage options. Through federal grant funds, private investments, and dedicated local efforts, California has developed a robust outreach network that relies heavily on community organizations, such as community health centers. In-Person Assisters, referred to in California as certified enrollment counselors, and Navigators are being trained by Covered California to help individuals and families enroll in both public and private coverage. However, backlogs in certifying enrollment counselors have delayed the rollout of assistance available at the local level.5 It is possible that uninsured Californians applying for coverage after these new processes are implemented and the full range of assistance is in place will encounter fewer challenges in navigating the enrollment process than applicants have in the past.
When adults with Medi-Cal or private insurance plan have a choice of plan, they do not always prioritize costs over other plan features in making that choice, and many find some aspect of the plan choice process to be a challenge.
As Californians gain coverage, many will have the option to select an insurance plan. People may chose a particular plan for a variety of reasons, including low cost, choice of providers, recommendations from friends and family, or coverage of a particular benefit. Among the 58% of insured adults in California who had a choice of plans,6 roughly three in ten (27%) reported that they chose their plan because their costs would be low, 29% because it covered a wide range of benefits or a specific benefit that they need, and 27% because of its provider network (Figure 8 and Appendix Table A4).
In choosing a plan, Californians may face challenges in comparing costs, services, and provider networks across plans, as these factors typically varied greatly across plans in the past. In general, insured adults in California reported that they did not have difficulty in comparing their plan choices, but 38% found some aspect of plan choice—comparing services, comparing costs, and comparing providers— to be difficult (Figure 9 and Appendix Table A4). Insured adults in California were least likely to report difficulty comparing costs (versus providers or services) across plans (17%).
As enrollment numbers for particular plans are released and policymakers in California begin to assess plan choice among new enrollees, these findings can inform evaluations of plan choice under the ACA. While California has a concentrated private health insurance market, with six insurance carriers accounting for three-quarters of business, each offers a variety of plans to choose from. In Medi-Cal, not all enrollees have a choice of plans,7 and those that do have a choice face a limited number of standardized options. Still, people may face challenges in choosing among even limited options. While the ACA requires health plans in Covered California to provide a standard set of benefits and provide detailed information about what services are covered, which could make it easier for individuals to select a plan, it is important to bear in mind that, even before the ACA, insured adults faced some challenges in comparing and selecting insurance coverage. While provisions in the ACA could address these challenges, some are inherent to the complexity of insurance coverage. In particular, low-income adults who receive Medi-Cal may require assistance in navigating plan choices if they live in counties that have more than one plan, as provisions requiring comparable information on plans do not apply to Medi-Cal.
Further, contrary to expectations that people may opt for the lowest cost plan,8 survey findings indicate that Californians place value on a range of factors related to insurance, including scope of services and provider networks. Thus, assessments of whether people are choosing the optimal plan for themselves and their families will need to consider the multiple priorities that people balance in plan selection.
Overall, insured adults in California reported satisfaction with their current coverage but also reported gaps in covered services and problems when using their coverage.
Most insured adults in California reported high levels of satisfaction with their current coverage, but they also reported gaps in services that are covered by their current insurance. Eighty-five percent of insured adults in California rate their coverage as excellent or good (Figure 10). Adults with employer coverage gave plans high ratings, with 89% grading their plans as excellent or good. Adults with Medi-Cal or nongroup coverage were less likely to give their plans high ratings, but nearly three-quarters in each coverage group (74% and 73%, respectively) rated their plans as excellent or good.
Despite the high ratings, notable shares of insured adults in California reported a problem with their plan. Specifically, one in five (20%) insured adults reported needing a service that is not covered by their current plan (Figure 11 and Appendix Table A5). People with Medi-Cal coverage (34%) or nongroup coverage (35%) are more likely to report that their plan does not cover certain services compared to those with employer coverage (14%). The most frequently reported services people say they need but lack coverage for are ancillary services, such as dental, vision care, and chiropractor services. In private health coverage, these ancillary services are often covered under stand-alone private insurance policies that must be purchased separately from health coverage, and in Medicaid, most are not federally-required benefits, but rather are covered at state option. Lack of coverage for adult dental services in Medicaid—the most frequently reported service needed but excluded from coverage—has been a longstanding issue facing beneficiaries and providers, despite a particularly high need among the low-income population.9 In SFY2010, California had eliminated most adult dental services in Medi-Cal due to budget restrictions,10 though the state plans to restore this benefit as of May 2014.11
Insured adults in California also reported experiencing other problems with their insurance plans. Many insured adults reported facing a problem with their current insurance plan covering a specific benefit, either because they were denied coverage for a service they thought was covered (24%) or their out-of-pocket costs for a service were higher than they expected (35%). Some of these services may be over-the-counter products, which are excluded from the majority of insurance plans but which people may believe their plans should cover. Reports of these difficulties varied by insurance coverage. California adults with Medi-Cal or with nongroup coverage (both 36%) were more likely than those with employer coverage (20%) to report they were surprised that their plan would not cover a service they believed was covered. Pre-ACA, adults with Medi-Cal coverage had particularly high health needs, which could explain why they reported relatively high rates of problems. In contrast, the results for nongroup could reflect limits on coverage. Adults with Medi-Cal (25%) were less likely to report facing higher costs than expected than privately insured adults (35% among those employer coverage and 61% among those with nongroup). This pattern most likely reflects the nominal out of pocket costs Medi-Cal beneficiaries are required to pay compared to the high cost-sharing of many private plans.
Among the goals of the ACA was ensuring that the coverage people gained provided at least a basic level of coverage and that the Marketplaces helped people navigate their insurance coverage. Thus, new coverage must include a set of essential health benefits (EHB), and participating plans in Covered California must report information on claims payment policies, cost-sharing requirements, out-of-network policies, and enrollee rights in plain language. These provisions may address some of the problems that insured adults in California have experienced with their coverage in the past. However, many of the services that people report needing coverage for—such as dental services—are not included in the EHB. Many newly-insured Californians may be surprised to learn that some ancillary services are not included in their plan, and education efforts will be needed to make sure people understand their coverage. In addition, some uninsured people who gain coverage may need help with plan selection, having not navigated the process before. Despite these possible challenges, most insured people—even those who reported difficulties—are overall satisfied with their coverage.