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


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 moderate income families 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. With these coverage provisions, the ACA has the potential to reach many of the 7 million uninsured Californians. The ACA also makes improvements to coverage for people who already have insurance by setting new requirements for health plans.

To help the state prepare for the 2014 ACA coverage expansions, the federal government approved California’s five-year “Bridge to Reform” §1115 Medicaid Demonstration Waiver in 2010. In addition to other provisions,1 the waiver allows for federal matching funds for the creation of a county-based coverage expansion program for low-income adults not otherwise eligible for Medi-Cal, known as the Low Income Health Program (LIHP). This waiver coverage was intended to seamlessly transition to the ACA coverage expansions when they took effect. The majority of counties in the state participated in the LIHP program, and as of 2014 these enrollees were transitioned to Medi-Cal or Covered California coverage.2,3

LIHP reached many uninsured adults, and millions more are eligible for coverage through the Medi-Cal expansion or through Covered California.4 Though the ACA implementation is underway and people are already enrolling in coverage, policymakers in California continue to need information to inform the early stages of these coverage expansions. Reports of difficulties in enrolling in coverage and continued confusion and lack of information about the law point to some early challenges with implementation. Detailed data on the population targeted for coverage expansions and their past experiences with health coverage, current patterns of care, and family situation, can help policymakers target early efforts and provide insight into some of the challenges that are arising in the first months of new coverage.

Based on findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA, this report provides a snapshot of health insurance coverage, health care use and barriers to care, and financial security among insured and uninsured adults in California at the starting line of ACA implementation and discusses how these findings can inform early implementation. The survey, conducted between July and September 2013, is a nationally representative survey that also includes a state-representative sample of over 2,500 nonelderly (age 19-64) adults in California. It was designed to focus on people targeted for financial assistance under the ACA and includes nonelderly adults with low incomes (≤138% FPL, or about $27,000 for a family of three in 2014) or moderate incomes (139-400% FPL, between approximately $27,000 and $79,000 for a family of three), as well as a comparison group with incomes over 400% FPL. The survey includes adults with employer coverage, nongroup, Medi-Cal, and other sources of coverage, as well as those with no health insurance. The California component of the survey and report on its findings complements a report on similar findings for the nation.5 This survey and report provides new data to help policymakers further understand early challenges in implementing health reform and assist outreach and enrollment workers, health plans, and providers and health systems. The survey also provides a baseline for future assessment of the impact of the ACA on health coverage, access, and the financial security of low- and moderate-income individuals in California. A detailed explanation of the methods underlying the survey and analysis is available in the Methods section of the report.

Executive Summary Background: The Challenge of Expanding Health Coverage in California

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