Under California’s implementation and improvement of the Affordable Care Act (ACA), the percentage of Californians who are insured has risen to an all-time high. The goal of covering every Californian is within reach. The state is in the midst of a critical discussion about how to expand coverage to the approximately three million Californians who remain without health insurance, as well as how to preserve current sources of coverage for insured Californians.
Starting in the spring of 2018, CHCF began to curate, through this page, key California-specific resources and analyses to 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.
This page will continue to be updated in 2019 as the discussion in California around preserving and expanding coverage evolves. If you have suggested additions, please email Anne Sunderland.
Resources are organized reverse-chronologically and cover the following topics:
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.
The resources below provide in-depth analyses of the approximately three million Californians who continue to live without coverage.
Snapshot: Remaining Uninsured in California (Updated)
Uses California Health Interview Survey data to examine California’s uninsured in 2017 — by region, income, and ethnicity. It also summarizes projections from the California Simulation of Insurance Markets (CalSIM) model (see next entry) that the number of uninsured in California will rise in future years. (ITUP, February 1, 2019)
California’s Health Coverage Gains to Erode Without Further State Action
Starting in 2019, the ACA’s individual mandate penalty for not having health insurance is no longer in effect. This report, based on the CalSIM microsimulation model, projects how many Californians will be uninsured in 2020 and 2023 in the wake of this federal policy change. It details which populations are projected to remain uninsured, such as undocumented Californians, who make up the largest group, and others who struggle to afford insurance. It also provides an overview of the trend in the uninsured rate in California from 2012 to 2017. (UC Berkeley Center for Labor Research and Education, November 2018)
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)
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.
Reducing Access Disparities in California by Insuring Low-Income Undocumented Adults
Using the latest California Health Interview Survey (CHIS) data, researchers draw a basic demographic profile of undocumented low-income Californians age 19–64, including health insurance status, health status, and access to care. A higher percentage of undocumented adults are working, live in families with children, and report being relatively healthy compared to low-income documented California adults. However, over 90% of undocumented adults are uninsured, and they report significantly higher disparities in access to health care. (UCLA Center for Health Policy Research, February 19, 2019)
Affordability on the Individual Market as a Barrier to Coverage
Although 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.
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 2016)
Policy Options Designed to Expand Coverage
The resources below highlight state bills and broader policy proposals that have been articulated by groups such as advocates and unions since 2017.
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 include expanding Medi-Cal to the undocumented, making ACA coverage more affordable, and addressing the biggest drivers of health care costs.
Analysis of the Medi-Cal Budget
In the section “Expands Coverage for Income‑Eligible Young Adults, Regardless of Immigration Status,” the LAO estimates net general fund costs for 2019–20 of $134 million to allow low-income undocumented adults, age 19–25, to enroll in Medi-Cal. The LAO also projects out-year costs and estimates that this Medi-Cal expansion would reduce the state’s overall uninsured rate by about 4%. (LAO, February 13, 2019)
The 2019-20 Budget: The Governor’s Individual Health Insurance Market Affordability Proposals
Provides the LAO’s official assessment of the governor’s proposals to (1) create a state requirement that most Californians purchase health insurance coverage (“individual mandate”) or pay a financial penalty and (2) use the revenues from this penalty to fund additional health insurance subsidies for households purchasing coverage through Covered California. (LAO, February 7, 2019)
Towards Universal Health Coverage: Expanding Medi-Cal to Low-Income Undocumented Adults
Under a scenario in which all restricted-scope enrollees are automatically transitioned to full-scope Medi-Cal coverage and additional eligible individuals newly enroll, approximately 1.05 million undocumented adults would be predicted to enroll, of which 104,000 are estimated to be young adults age 19–25 and 25,000 are estimated to be seniors age 65 and over. (UC Berkeley Labor Center for Labor Research and Education, February 5, 2019)
Options to Improve Affordability in California’s Individual Health Insurance Market (PDF)
Prepared pursuant to AB 1810, which required Covered California to develop options to improve affordability for low- and middle-income consumers, this report presents a range of policy options for enhancing the financial support provided by the ACA and estimates the enrollment increases and consumer cost reductions that could be gained by Californians if such policies were enacted. (Covered California, February 1, 2019)