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