Affordability on California’s Individual Market Under the ACA

The Affordable Care Act (ACA) created new, more-affordable health coverage options for low- and moderate-income consumers by expanding Medicaid (called Medi-Cal in California) and providing subsidies to those purchasing their own coverage on the individual market. Five years into the full implementation of the ACA, close to five million Californians benefit from these new options. However, costs remain high for some, particularly for many purchasing coverage in the individual market.

This issue brief explores trends in key data on the affordability of health coverage in California, to highlight both progress and remaining challenges to affordability on the state’s individual market under the ACA. The authors examine trends from 2013, the last year before full implementation of the ACA, to 2017, the most recent year for which key data are available. To put individual market affordability challenges in context, the authors compare the spending and cost burden experienced by those relying on the individual market to Californians with employer-sponsored coverage.

Key Findings

Under the ACA, spending on health care dropped dramatically for Californians relying on the individual market, but still remained higher than for those with employer-sponsored coverage.

Individual-market consumers saw the greatest decline in high-burden spending (defined as spending more than 10% of family income on health care) after ACA implementation, but still fared worse than those with employer-sponsored coverage.

Individual-market consumers were far more likely to report cost as the reason for delaying or forgoing care than those with employer-sponsored coverage.

Looking Ahead

California’s robust implementation of the Affordable Care Act has improved affordability on the individual market. Yet affordability challenges remain greater for those in the individual market compared to those with employer-sponsored coverage, and many individual market consumers report difficulty paying for coverage and care.

In recognition of these problems, California policymakers are considering a range of proposals to improve affordability on the individual market. If they are enacted, it will be important to continue to monitor the data discussed above and other key indicators of affordability to assess the impact of new policies.

Methods

Estimates of median out-of-pocket and high-burden spending were based on State Health Access Data Assistance Center (SHADAC) analysis of the Current Population Survey’s Annual Social and Economic Supplements public use microdata files. Family is defined as the health insurance unit, which includes one or more individuals in a household who would likely be considered a family unit in determining eligibility for private or public coverage.

Estimates of delayed and forgone care were based on UCLA Center for Health Policy Research analysis of California Health Interview Survey data. Statistical significance for all estimates was calculated at the 95% confidence level.