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

Executive Summary

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.

Key Findings

Introduction

The California Longitudinal Panel Survey is a series of surveys that tracks the experiences and perceptions of a representative, random sample of 2,001 nonelderly Californian adults who were uninsured prior to the initial open enrollment period created by the Affordable Care Act (ACA). The first survey in the series was conducted prior to the open enrollment period¹ and the second, presented here, took place at its conclusion. This longitudinal panel is a unique opportunity to follow the same group of Californians to find out whether they gained coverage or remained uninsured, how they feel about and interact with the new coverage options and what barriers to getting insurance remain. Additional surveys in this series will continue to track these individuals to keep the pulse on how their experience with and views towards coverage are evolving, how coverage impacts their feelings of financial security, and will illuminate how key groups of previously uninsured Californians are faring, such as Hispanics, new Medi-Cal or Covered California enrollees, or people reporting poor health.

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 is estimated to have enrolled about 1.6 million people and Covered California, the new state marketplace where people can shop for insurance and access government subsidies to help pay for coverage, is estimated to have enrolled about 1.4 million people.² Because of California’s size and early embrace of the ACA, the experiences of those who were uninsured prior to the coverage expansions within the state can help inform future enrollment efforts both locally and across the country.

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.

And, while the ACA makes it easier for some people to get and keep coverage, there will inevitably continue to be people who move in and out of coverage as their job status changes, as shifts in their income change their eligibility for public assistance, or as they miss deadlines for enrollment. And, just as people have moved from being uninsured to having insurance since last summer (reported on in this study), others likely moved in the opposite direction and were covered then, but are uninsured now.³ This survey does not capture those experiences, and hence, does not estimate the overall change in the number of uninsured Californians since the start of open enrollment, but instead estimates the share of previously uninsured who got coverage.

Section 1: Who Got Covered?

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.

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 (Figure 2). 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.

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).² 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).

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 (Figure 5). 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) (Figure 6).

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.³

 

Section 2: The Newly Insured

Section 3: The Remaining Uninsured

Who Remained Uninsured?

As many previously uninsured Californians gained coverage, 42 percent remained uninsured. Many of the remaining uninsured have tenuous links to health insurance posing challenges for future enrollment efforts. Forty-five percent of the remaining uninsured reported in the baseline survey that they had been without health insurance for two or more years (Figure 25) and an additional 37 percent said they have never had insurance. Hispanics make up 62 percent of the remaining uninsured and nearly half of them (29 percent) are undocumented Hispanics who are not eligible for Medi-Cal or assistance through Covered California. About 4 in 10 (39 percent) report family income 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.¹ These shares reflect the demographics of people who were uninsured prior to the first ACA open enrollment period and did not get coverage during the open enrollment period. Others may have been covered prior to open enrollment but now uninsured – a group not captured by this survey.

Why Did They Remain Uninsured?

Why did 42 percent of California’s uninsured prior to open enrollment remain without coverage? Most of the remaining uninsured seem to value insurance, with majorities saying it is something they need (71 percent) and that it is worth the costs (59 percent) (Figure 26). Still roughly 3 in 10 of the remaining uninsured say they can get by without insurance (28 percent) or don’t feel coverage is worth the price (33 percent), including 4 in 10 (40 percent) of those who are likely eligible for coverage through Covered California or Medi-Cal due to their self-reported income level and immigration status.

The cost of insurance (whether perceived or actual) remains a barrier. When asked in their own words why they didn’t get coverage, one-third (34 percent) point to costs as the reason. Fifteen percent say they don’t qualify or don’t think they do, including 9 percent who say they can’t enroll or are worried about signing up because of their immigration status. Other reasons the remaining uninsured give for not signing up for coverage include not having yet tried or being too busy (9 percent), not having enough information about enrolling (9 percent), having tried but not being successful (8 percent), and not wanting or needing coverage (7 percent) (Figure 27). A few (6 percent) say they didn’t get insurance because of issues associated with the application process, including three percent who say they are still awaiting contact or approval – a finding that is perhaps related to the large backlog of about 900,000 Medi-Cal applicants waiting for counties across the state to process their applications.²

Do They Think They Will Get It Later?

Although they missed the ACA’s first open enrollment period, almost 6 in 10 (57 percent) of the remaining uninsured think they will enroll in a plan later this year, while 3 in 10 (31 percent) think they will continue to go without health insurance (Figure 28). More than 7 in 10 (73 percent) of the remaining uninsured who are likely eligible for Medi-Cal say they plan to enroll later this year, compared to about half of those in the exchange target group (51 percent). Of those who see coverage in their future, 57 percent are uncertain where they will get insurance, and small shares say they expect to get it from Medi-Cal (15 percent), an employer (13 percent), or through Covered California (11 percent).

Some may in fact be able to enroll in coverage before the next Covered California open enrollment period. People eligible for Medi-Cal may sign up any time of the year, and others with qualifying events such as marriage may be able to enroll though Covered California outside of the specified enrollment periods. About half of the remaining uninsured say they are aware that people can still sign up for Medi-Cal (51 percent) or Covered California (54 percent); however it is unclear if they know that enrollment through Covered California is only a possibility if they have had a qualifying life event.

Did They Try To Get Coverage? Why Didn’t They Get It?

Over a third (36 percent) of the remaining uninsured say they have tried to get insurance since the open enrollment period began (Figure 29). Most of those that report trying pursued more than one avenue in their attempt to get coverage. Nearly a quarter (23 percent) of the remaining uninsured say they tried to get coverage through Covered California and 19 percent say they tried to get coverage from Medi-Cal. Smaller shares of the remaining uninsured say they looked directly to private health insurance companies (10 percent), to health insurance agents or brokers (7 percent), and to their employer (5 percent). But they ran into barriers – some remaining uninsured report trying to sign up for non-group insurance and found it too expensive (15 percent) and others were not able to complete the application process (6 percent). Eight percent of the remaining uninsured say they tried to sign up for Medi-Cal and were not eligible for coverage and another 7 percent said they tried to get Medi-Cal but were not able to complete the application process.

In contrast to those who got insurance, the majority of people who tried to get coverage but remain uninsured say that shopping for coverage was difficult. Those that report trying to get Medi-Cal or non-group coverage say it was hard to find a plan that met their needs (76 percent, or 25 percent of the remaining uninsured overall). Weighing the trade-offs between coverage and costs also proved difficult for most who report attempting to get non-group coverage; roughly 7 in 10 say it was difficult to compare the services the plans covered (71 percent, or 18 percent of remaining uninsured overall), the out-of-pocket costs required to use services (69 percent, or 18 percent of remaining uninsured overall), and the monthly premium payment (67 percent, or 17 percent of remaining uninsured overall). Nearly 6 in 10 (58 percent, or 20 percent of remaining uninsured overall) of those who say they tried to get insurance say it was difficult to find the information they needed about signing up for coverage (Figure 30).

Some of the remaining uninsured report visiting the Covered California website (30 percent) or calling the 1-800 number (15 percent), but unlike those who got insurance, most say they found them unhelpful (65 percent of those who visited website and 66 percent of those who called the 1-800 number).

Are The Remaining Uninsured Aware Of Coverage Options?

Eight in ten (81 percent) of the remaining uninsured are aware of the requirement to buy health insurance under the ACA, and most (65 percent) think the mandate applies to them (Figure 31). The remaining uninsured are divided on whether or not they’ll have to pay a fine this year with 44 percent saying they think they will be penalized and 43 percent saying they won’t. Many, in fact, may be exempt due to financial hardship or other exceptions under the law.

Other provisions are less widely recognized, including the parts of the law that may benefit the remaining uninsured most. For example, 6 in 10 remaining uninsured say they are aware of the Medi-Cal expansion (58 percent), and a similar share say they are aware the law provides financial assistance to help low and moderate income Americans (60 percent), leaving roughly 4 in 10 unaware of these aspects of the law that may open doors for them to access coverage (Figure 31).

On a more personal level, 6 in 10 (61 percent) of the remaining uninsured say they are lacking information on how the law will impact them (Figure 32). Confusion about what assistance they may be eligible for is also widespread. Less than half (43 percent) of those likely eligible for Medi-Cal think they would qualify for the program. Of those in the group potentially eligible for subsidies through Covered California, about 3 in 10 (29 percent) think they are eligible for assistance.

Remaining Uninsured Hispanics

Forty-eight percent of Hispanics who were uninsured prior to open enrollment report remaining uninsured, and almost half of these remaining uninsured Hispanics (46 percent) may not be eligible for coverage under the ACA due to their immigration status (22 percent of previously uninsured Hispanics overall) (Figure 33). As a result, many worry about the potential link between health insurance and immigration authorities. Over half (54 percent) of Hispanics who remain uninsured, particularly those who prefer to communicate in Spanish or are undocumented themselves (69 percent or 73 percent, respectively), say they are worried that getting coverage will draw attention to their families immigration status (Figure 34), and despite the Administration’s assurance otherwise³ many worry it could result in deportation. Seven in 10 remaining uninsured Hispanics who say they were born outside the U.S. (72 percent, or 52 percent of remaining uninsured Hispanics overall) say they are worried that signing up for health insurance could hurt their ability to become a U.S. citizen, including half (51 percent) who say they are very worried.

In addition to immigration concerns, language may also present a barrier for some Hispanics who remain uninsured. Fully 70 percent of remaining uninsured Hispanics took the survey in Spanish (34 percent of Hispanics overall) and they are divided as to the amount of information about signing up for health insurance that is available in Spanish. About half (52 percent) say that, in their experience, there is at least some information in Spanish available (Figure 35) and about 4 in 10 say there is only a little or no information in Spanish. Personal assistance in Spanish may be more visible – about 6 in 10 (58 percent) remaining uninsured Hispanics who took the survey in Spanish say they are aware of people in their community trained to help them sign up for coverage in Spanish.

Figure 35: Remaining Uninsured By Race/Ethnicity
Percent remaining uninsured Spanish-speaking Hispanics (70 percent of remaining uninsured Hispanics) reporting that…
…there are at least some information about signing up for coverage available in Spanish	52%
…there are people in their community trained to help them sign up for health insurance in Spanish	58%
Percent remaining uninsured reporting that, in their view,…	HISPANIC	WHITE, NOT HISPANIC
…Health insurance is something I need	78%	60%
…Health insurance is worth the money	72%	38%

In spite of these potential barriers there is widespread overall support for the role of health insurance among Hispanics who remain uninsured – roughly three quarters (78 percent) say health insurance is something they need and is worth the cost (72 percent), shares that are higher than their white peers (Figure 35).

California’s Undocumented Uninsured

In California, undocumented immigrants make up about a fifth of those who were uninsured before the ACA expansions kicked in, and under the law, they are not eligible for Medi-Cal or subsidies through the exchange. As a group they are largely aware of these restrictions – 63 percent say they are not eligible for Medi-Cal and 70 percent say they don’t qualify for financial assistance through Covered California. Half say the mandate doesn’t apply to them and most (60 percent) correctly respond that they won’t have to pay a fine for not having coverage.

While the ACA restricts access to health benefits for undocumented immigrants under the law, there is still keen interest in coverage among this group. Since last summer about a third (35 percent) of California’s undocumented uninsured say they obtained coverage and of those who remain uninsured, half say they intend to get coverage later this year. In fact, the remaining undocumented uninsured are more apt to say they place a high value on insurance than other remaining uninsured Californians; nearly three quarters (73 percent) of the undocumented uninsured say health insurance is worth the cost and 85 percent say it is something they need, each 20 percentage points higher than the share for other remaining uninsured Californians.

Conclusion

About The Terms Used In This Report

Methodology

This is the second in a series of surveys by the Kaiser Family Foundation (KFF) tracking the views and experiences of a group of Californians who were uninsured in the summer of 2013, prior to implementation of the ACA’s insurance market reforms and coverage expansions through Covered California and Medi-Cal. Future surveys will continue to track this group’s experiences over the course of the next year and a half. The first survey (Wave 1) was conducted from July 11-August 29, 2013, with a randomly selected group of individuals who were uninsured at the time of the interview and was paid for entirely by KFF. The current survey (Wave 2) was conducted from April 1-June 15, 2014, with the same longitudinal panel of respondents, whether they obtained coverage or remained uninsured. Both surveys were designed and analyzed by researchers at KFF. Social Science Research Solutions collaborated with KFF researchers on sample design, weighting, and supervised fieldwork. Fieldwork costs associated with Wave 2 of the survey were paid for by The California Endowment.

The Wave 1 survey was conducted among a representative random sample of 2,001 adults ages 19-64 living in California who reported having been without health insurance for at least two months at the time of the interview¹ (note: persons without a telephone could not be included in the random selection process). Computer-assisted telephone interviews conducted by landline (990) and cell phone (1,011, including 660 who had no landline telephone) were carried out in English and Spanish by SSRS. To increase efficiency in reaching this low-incidence, hard-to-reach group, both the landline and cell phone sampling frames oversampled areas with a lower-income population (since being uninsured is negatively correlated with income). The landline sample frame also oversampled households whose phone numbers were matched with directory listings indicating the presence of at least one person age 19-64 and a household income of less than $25,000. Additionally, 230 interviews (130 landline, 100 cell phone) were conducted with respondents who previously completed recent national SSRS omnibus surveys of the general public and indicated they were ages 19-64 and uninsured. These previous surveys were conducted with nationally representative, random-digit-dial landline and cell phone samples.

The current survey, Wave 2, also consisted of computer-assisted telephone interviews conducted by landline (623) and cell phone (545, including 327 who had no landline phone) in English and Spanish. Screening for Wave 2 involved verifying that the respondent had participated in Wave 1. Multiple attempts were made to reach every respondent from Wave 1 and encourage participation in Wave 2. Efforts included multiple dialing at various times of day and throughout the week, mailings and emails to those who provided such contact information, repeated dialing of non-working numbers, and attempts to find alternative phone numbers for non-working numbers.

In order to re-connect with respondents who may be more willing to complete the survey online, an abbreviated web version was introduced on May 14. The online questionnaire was offered in English and Spanish and was limited to key questions about insurance status, type of coverage, and reasons for obtaining coverage or remaining uninsured. A total of 51 respondents completed the online version of the survey.

A multi-stage weighting design was applied to ensure accurate representation of California’s nonelderly adult uninsured population prior to the ACA’s coverage expansions. The weighting process for Wave 2 involved corrections for sample design, as well as sample weighting to match the weighted Wave 2 sample to Wave 1 responses along demographic characteristics. As it did for Wave 1, the Wave 2 base weight accounted for the oversamples used in the sample design, as well as the likelihood of non-response for the sample from earlier omnibus surveys, number of eligible household members for the landline sample, and a correction to account for the fact that respondents with both a landline and cell phone have a higher probability of selection. Demographic weighting parameters for Wave 2 were based on Wave 1 weighted demographics, which were adjusted for age, education, race/ethnicity, nativity (for Hispanics only), Hispanics by gender, presence of own child in household, marital status, California region, poverty level, and phone usage. For more information on weighting and data sources, see the Wave 1 methodology. All differences referred to in the report are statistically significant. Statistical tests of significance account for the effect of weighting, and, for trend analysis, testing takes into account the survey’s panel design.

A unique consideration for surveys with a longitudinal panel design is whether those who participate in subsequent waves of the survey differ from those who refuse to participate again or are unable to be recontacted. Sixty-one percent of Wave 1 respondents completed the Wave 2 survey, and while there are some differences in the unweighted demographics of those who completed Wave 2 and the full Wave 1 sample, these differences are corrected for by weighting. As shown in the table below the total weighted distributions are similar for Wave 1 and Wave 2 for age, gender, race/ethnicity, self-reported health status, disability status, party identification, education and income. See the Wave 2 Attrition Appendix for more information on attrition.

	Unweighted			Weighted
	Wave 1	Wave 2	Percentage Point	Wave 1	Wave 2	Percentage Point
			Difference (W1 – W2)			Difference (W1 – W2)
Gender
Male	48%	44%	4	54%	53%	1
Female	52	56	-4	46	47	-1
Race/ethnicity
White	27	32	-5	26	27	-1
Black	7	8	-1	5	6	-1
Hispanic	58	52	6	56	55	1
Other Race	8	7	1	12	12	0
Age
18 to 29	23	18	5	33	32	1
30 to 39	21	21	0	24	24	0
40 to 49	22	22	0	21	21	0
50 to 64	35	39	-4	22	24	-2
Education
HS or less	57	53	4	58	57	1
Some college	28	31	-3	29	30	-1
College Grad+	15	16	-1	12	13	-1
Phone status
Landline	49	54	-5	42	44	-2
Cell	51	46	5	58	56	2
Marital status
Married	33	32	1	37	37	0
Not Married	67	68	-1	62	63	-1
Family income
<138% FPL	60	59	1	52	53	-1
138%-400% FPL	30	32	-2	36	35	1
400%+	5	5	0	7	7	0
Language of interview
English	63	68	-5	65	67	-2
Spanish	37	32	5	35	33	2
Resident status
Citizen/legal immigrant	79	82	-3	78	79	-1
Undocumented immigrant	20	16	4	21	19	2
Party identification
Republican	11	12	-1	11	12	-1
Democrat	35	36	-1	32	31	1
Independent	35	34	1	37	38	-1
Other	9	8	1	9	9	0

Another consideration for panel surveys is the potential for “sensitization effects,” that is, what effect returning to the same people about the same topics has on their experiences or views. For example, after taking the baseline survey that covered many aspects of the coverage expansions under the ACA, were people more likely to seek out information about health insurance and enroll than they would have been otherwise? While there is no direct way to measure this effect on this survey, other analyses have found that these effects are minimal and short-lived² and we do not believe they would have had a substantial impact on results presented here, particularly given all the other media coverage, advertising, and outreach targeted at this population during the fall and winter of 2013 and 2014.

The margin of sampling error including the design effect for the full sample is plus or minus 4 percentage points. For the newly insured, it is plus or minus 5 percentage points and for the remaining uninsured it is plus or minus 7 percentage points. Numbers of respondents and margin of sampling error for key subgroups are shown in the table below.

Group	N	MOSE
Total Wave 2	1,219	+/- 4 percentage points
Newly insured	740	+/- 5 percentage points
Newly insured by non-group plan	160	+/- 11 percentage points
Newly insured through Covered California	116	+/- 13 percentage points
Newly insured by Medi-Cal	368	+/- 8 percentage points
Newly insured through an employer	129	+/- 12 percentage points
Newly insured Hispanics	347	+/- 8 percentage points
Remaining uninsured	478	+/- 7 percentage points
Remaining uninsured Hispanics	284	+/- 8 percentage points
Remaining uninsured undocumented immigrants	131	+/- 12 percentage points

For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margin of sampling errors for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

Some demographic measures referred to in the report were only asked during the baseline survey, such as questions about educational attainment, debilitating chronic condition, length of time uninsured, resident status, and race/ethnicity. For more information on the first wave of the Kaiser Family Foundation California Longitudinal Panel Survey visit, https://www.kff.org/health-reform/report/californias-uninsured-on-the-eve-of-aca-open-enrollment/.

Endnotes

Executive Summary

1. The baseline survey included only those adult Californians ages 19-64 who reported being without coverage for at least two months.  Because this panel survey focuses on a specific group who were uninsured prior to open enrollment, it does not estimate the overall change in the number of uninsured Californians.  The approximate number of newly insured adult Californians is calculated with the estimate of 5.9 million uninsured nonelderly adults based on a Kaiser Family Foundation analysis of 2013 ASEC Supplement to the Current Population Survey, available at https://www.kff.org/other/state-indicator/adults-19-64/.

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2. For the purposes of this report, undocumented immigrants are defined as those that reported in the baseline survey that a) they were not born in the United States, and b) they came to this country without a green card, and c) they have not received a green card or become permanent residents since arriving. See the “About The Terms In This Report” Section for more details.

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3. Among ‘eligible’ previously uninsured Californians earning 138% FPL or less, 61 percent report gaining coverage and 39 percent say they remain uninsured. For those ‘eligible’ between 139% and 400% FPL, 66 percent report now being covered and 34 percent say they remain uninsured. For the purposes of this report, the previously uninsured who are ‘eligible’ are defined as California residents ages 19-64 who have been uninsured for at least two months and would be eligible for participation in the ACA coverage expansion based on their self-reported status as a citizen, permanent resident, or lawfully present immigrant.

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Key Findings

Introduction

1. For more information on Wave 1, see “California’s Uninsured on the Eve of ACA Open Enrollment: The Kaiser Family Foundation Baseline Survey,” Kaiser Family Foundation, September 2013, https://www.kff.org/health-reform/report/californias-uninsured-on-the-eve-of-aca-open-enrollment/.

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2. DHHS Centers for Medicare & Medicaid Services, “Medicaid & CHIP: May 2014 Monthly Applications, Eligibility Determinations and Enrollment Report,” July 11, 2014 http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/May-2014-Enrollment-Report.pdf. DHHS Office of the Assistant Secretary for Planning and Evaluation Issue Brief, “Health Insurance Marketplace: Summary Enrollment Report For The Initial Annual Open Enrollment Period,” May 1, 2014 http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf. The California Department of Health Care Services estimates 1.9 million people have enrolled in Medi-Cal since open enrollment started, http://news.coveredca.com/2014/04/covered-californias-historic-first-open.html.

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3. For more information on the experiences of insured and uninsured Californians prior to open enrollment, see, “The Uninsured At The Starting Line In California,” Kaiser Family Foundation, February 2014, https://www.kff.org/uninsured/report/the-uninsured-at-the-starting-line-in-california-california-findings-from-the-2013-kaiser-survey-of-low-income-americans-and-the-aca/

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Section 1: Who Got Covered?

1. For the purposes of this report, undocumented immigrants are defined as those that reported in the baseline survey that a) they were not born in the United States, and b) they came to this country without a green card, and c) they have not received a green card or become permanent residents since arriving. See the “About The Terms In This Report” Section for more details.

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2. In the baseline survey, 13 percent of California’s uninsured population reported having a disability, handicap or chronic disease that keeps them from participating fully in work, school, housework, or other activities. Most of those reporting such an ailment also report being in fair or poor health, but the measure of health status is more general with about a third reporting being in fair or poor health (32 percent for Wave 2 and 38 percent for Wave 1). The fact that the group reporting a debilitating chronic condition is a small but specific group may help explain why 77 percent of them report getting health insurance compared to 53 percent of those reporting being in fair or poor health.

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3. Regression results are available on request.

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Section 2: The Newly Insured

1. This share is lower than what has been reported by Covered California. According to Covered California, 88 percent of those covered through the Marketplace (including those who were previously insured and those who were not) have subsidized coverage. This may indicate that some of the newly insured are unaware of the assistance they’re receiving and may not know the real cost of their plan. Multiple factors may be contributing to this apparent under-reporting on the survey, but it is likely that at least some individuals receiving government financial help may be unaware that the government is paying a portion of their premium. Insurance concepts are complicated and many people have trouble reporting detailed information about their plans. During the enrollment process, some people may have been focused on the bottom line question of “What do I pay?” and less focused on whether that amount was subsidized or not. For the numbers from Covered California, see http://news.coveredca.com/2014/04/covered-californias-historic-first-open.html

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2. Los Angeles Times, “Website glitch slows Obamacare enrollment in California,” March 11, 2014. http://articles.latimes.com/2014/mar/11/business/la-fi-mo-covered-california-obamacare-enrollment-20140311

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3. The Covered California Marketplace reports the distribution of enrollment across metal types for all Covered California enrollees, not just the previously uninsured, as follows: 26% bronze, 62% silver, 6% gold, 5% platinum, 1% catastrophic.  For more information, see http://news.coveredca.com/search?updated-max=2014-05-07T08:46:00-07:00&max-results=7&start=7&by-date=false  This survey only includes those who were previously uninsured prior to the open enrollment period, but after excluding the 24 percent who said they didn’t know the metal level of their plan, the distribution is similar to what Covered California reported for all of its enrollees: 23% Bronze, 65% Silver, 2% Gold, 5% Platinum, 0% catastrophic.

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Section 3: The Remaining Uninsured

1. For the purposes of this report, the ‘eligible remaining uninsured’ are California residents who said they had been uninsured for at least two months in the baseline survey and would be eligible for participation in the ACA coverage expansion based on their self-reported status as a citizen, permanent resident, or lawfully present immigrant. See the “About The Terms In This Report” Section for more details.

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2. Kaiser Health News, “Mountainous Backlog Stalls Medi-Cal Expansion in California,” July 02, 2014. http://www.kffhealthnews.org/stories/2014/july/02/mountainous-backlog-stalls-medical-expansion-in-california.aspx

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3. U.S. Immigration and Customs Enforcement. Clarification of Existing Practices Related to Certain Health Care Information, October 25, 2013. http://www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdf

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Methodology

1. Those who had been uninsured for less than two months were excluded from the survey since they may be experiencing a short period of uninsurance (i.e. someone who is between jobs), and the goal of the survey was to capture the experiences and views of those who have been without insurance for a longer period of time and are poised to experience the new coverage provisions of the ACA.

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2. M. Brodie, “Sensitization Effects in a Study of the Impact of a Nationally Broadcast Special on Health Care Reform,” in Doctoral Thesis: Political Institutions, Participation, and Media Evaluations— Influences on Health Care Policy (Boston, Mass.: Harvard University, 1995).

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