Resource Page: Expanding Coverage to All Californians

Under California’s implementation and improvement of the Affordable Care Act (ACA), the percentage of insured Californians has risen to 93%. The goal of covering every Californian is within reach. California is currently in the midst of a critical discussion about how to expand coverage to the three million Californians who remain without health insurance.

Through this page, CHCF will curate key California-specific resources and analyses that can inform the discussion around policy options designed to help expand coverage to all Californians. Many of the resources are presentations from the hearings of the California Assembly’s Select Committee on Health Care Delivery Systems and Universal Coverage (Assembly Select Committee), held between October 2017 and February 2018. A full list of presentations is available. All the linked Assembly Select Committee presentations are also available for download under Related Materials below.

Resources are organized reverse-chronologically and cover the following topics:

This page will be updated regularly. If you have suggested additions, please email Anne Sunderland.

Current Sources of Health Coverage in California

The following presentations were all given before the Assembly Select Committee in October 2017 and provide a broad overview of how Californians are currently covered and how the state’s health insurance markets function.

Overview of Coverage and Care in California (Insure the Uninsured Project [ITUP], October 23, 2017)

Public Programs: Medicare, Medicaid, and CHIP (Center on Budget and Policy Priorities, October 23, 2017)

Individual Health Insurance Market (ITUP, October 23, 2017)

Employer-Sponsored Insurance in California (UC Berkeley Center for Labor Research and Education, October 23, 2017)

Safety Net Programs, Populations, and Providers (ITUP, October 23, 2017)

Who Remains Uninsured in California?

The resources below provide in-depth analyses of the approximately three million Californians who continue to live without coverage.

Fact Sheet: Remaining Uninsured in California (ITUP, April 25, 2018)

California’s Uninsured: As Coverage Grows, Millions Go Without
Relies on the March 2016 supplement to the Current Population Survey as well as 2015 California Health Interview Survey data to describe California’s uninsured, put the declining uninsured rate in the context of other trends in California’s health insurance market, and describe the experience of the uninsured accessing care. (California Health Care Foundation, November 14, 2017)

Health Coverage Gaps in California
This presentation to the Assembly Select Committee uses a variety of data sources to describe California’s remaining uninsured, as well as the main factors behind lacking insurance — namely, immigration status and affordability. (UC Berkeley Center for Labor Research and Education, October 23, 2017)

Preliminary Regional Remaining Uninsured 2017 Data Book, California Simulation of Insurance Markets (CalSIM) version 2.0
This publication models the number of uninsured per large county (such as Fresno, Los Angeles, and others), and breaks that number out by those (1) not eligible due to immigration status, (2) eligible for Medi-Cal but not enrolled, (3) eligible for subsidies through Covered California, and (4) non-subsidy-eligible citizens and lawfully present immigrants. In areas where individual county populations were too small to obtain an adequate sample size, the analysis is done by Covered California rating region, which group together multiple counties. (UC Berkeley Center for Labor Research and Education, August 11, 2016). See this CHCF page for a summary of the data.

Immigration Status as a Barrier to Health Coverage

Undocumented adults remain ineligible for both Medi-Cal and coverage through Covered California. For this reason, immigration status is the most prevalent reason for lacking coverage among California’s uninsured. These resources provide a deeper overview of undocumented Californians and describe the challenges they experience accessing health care. As undocumented Californians have continued to be excluded from traditional forms of coverage, some counties have stepped up to provide them with safety-net health services.

Six Facts About Undocumented Californians (Nadereh Pourat, PhD, UCLA Center for Health Policy Research, June 2018)

Immigrant Communities in California Under the Cloud of Immigration Enforcement (PDF) (ITUP, January 2018)

Access to Care for Undocumented Californians by County (2015) (Health Access)

Health Coverage and Care for Undocumented Immigrants
Due to its publication in 2015, some of the data and analysis of the political environment in this paper are now slightly outdated. (Public Policy Institute of California, November 2015)

Affordability on the Individual Market as a Barrier to Coverage

While the ACA made coverage for many in the individual market much more affordable, challenges remain. The lack of affordability in the individual market is second only to immigration status as the biggest driver of the state’s uninsured rate. The following reports dive deeper into these affordability challenges, which are exacerbated by California’s high cost of living.

Towards Universal Health Coverage: California Policy Options for Improving Individual Market Affordability and Enrollment
This paper provides an overview of the affordability challenges for those already enrolled in the individual market to maintain coverage, as well as the over one million Californians who are eligible for Covered California but remain uninsured. (UC Berkeley Center for Labor Research and Education, March 5, 2018)

Balancing the Books: How Affordable Is Health Insurance Through Covered California When Local Cost of Living Is Taken Into Account?
California’s high cost of living can make it even more difficult for families to afford health insurance. This analysis identifies the minimum amount a typical household would need to earn to cover its basic needs (housing, food, etc.) and Covered California premiums and out-of-pocket costs after federal subsidies. An interactive map shows how this amount varies widely by California county, mostly due to the cost of living. In every California county, there are families and individuals who fall into an affordability gap: They earn too much for Medi-Cal but not enough to afford health insurance through Covered California, even with subsidies. (California Health Care Foundation, June 8, 2016)

Policy Options to Expand Coverage

The resources below highlight bills currently active in the 2017–18 session of the California legislature in addition to broader policy proposals articulated by groups such as advocates and unions.

2017–18 Legislative Session Bills in California
On this page, ITUP will track and update numerous bills related to health care coverage in the California legislature. These bills are grouped into categories including “expanding coverage, improving affordability, and containing costs,” “preserving ACA advances,” and more. (ITUP, updated regularly)

Care4All California Policy Agenda
In March 2017 a coalition was launched consisting of consumer, community, labor, progressive, and health care organizations. Their policy proposals includes expanding Medi-Cal to the undocumented, making ACA coverage more affordable, and addressing the biggest drivers of health care costs.

It’s Imperative. We Need Guaranteed Healthcare: SB 562. (PDF) A presentation to the Assembly Select Committee. (California Nurses Association, February 7, 2018)

Protecting & Advancing California’s Progress on Health Care & Coverage in Turbulent Times (PDF)
A presentation to the Assembly Select Committee. (Health Access, February 7, 2018)

Analysis of Proposals Designed to Expand Coverage

As various policy options designed to expand coverage have been unveiled, different analyses have assessed key implementation considerations.

California Strategies for Covering California’s Remaining Uninsured and Improving Affordability  This issue brief analyzes policy proposals advanced in early 2018 to move the state closer to universal coverage by focusing on the challenges many Californians face. (Insure the Uninsured Project, June 2018)

Exploring Public Options in California (Insure the Uninsured Project, March 20, 2018)

Implementation Considerations for Universal Coverage: Federal Law Considerations and Medicare (PDF)
A presentation to the Assembly Select Committee. (Kaiser Family Foundation, February 5, 2018)

Implementation Considerations for Universal Coverage: ERISA (PDF)
A presentation to the Assembly Select Committee. (University of Missouri, Kansas City, School of Law, February 5, 2018)

Understanding the Rules: Federal Legal Considerations for State-Based Approaches to Expand Coverage in California
Also available is the February 2018 testimony of Chiquita Brooks-LaSure (PDF), managing director, Manatt Health, to the Assembly Select Committee based on this paper. (California Health Care Foundation, February 2, 2018)

Asking the Important Questions About Single Payer in California
Also, Susan Philip’s February 2018 testimony to the Assembly Select Committee (PDF) based on this paper. (California Health Care Foundation, November 13, 2017)