California’s Steps to Expand Health Coverage and Improve Affordability: Who Gains and Who Will Be Uninsured?
Jointly produced with the UCLA Center for Health Policy Research
California’s success in implementing the Affordable Care Act resulted in the number of uninsured falling from 6.5 million in 2013 to 3.5 million in 2017. At the end of 2017, Congress voted to eliminate the individual mandate penalty starting with the 2019 tax year, a change projected to increase the uninsured by more than half a million Californians.
In 2019, state lawmakers took steps to protect California’s coverage gains and increase affordability of coverage by instituting a state individual mandate penalty, providing additional subsidies for Covered California’s individual market enrollees, and expanding Medi-Cal to low-income undocumented young adults. California is the first state to include undocumented adults in full Medicaid benefits and the first to provide subsidies to middle-class consumers not eligible under the ACA.
We model these policies using CalSIM, our micro-simulation model of insurance take up in California, and project that in the absence of these policies premiums in the individual market would be higher and the number of uninsured in California would climb to 4.3 million by 2022. On the other hand, with these policies in place, we project the number of uninsured will remain stable at 3.5 million. We estimate that by 2022, these policies will have prevented 770,000 Californians from becoming uninsured (Exhibit 1) and will have reduced premiums for 1.55 million Californians, benefitting a net total of 2.2 million Californians (Exhibit 2).
Nonetheless, 3.5 million Californians under age 65 will still be uninsured in 2022 (Exhibit 3). The largest group among the uninsured will remain undocumented Californians. Nearly 1 million citizens or lawfully present immigrants are projected to be eligible for Covered California but remain uninsured, most of whom (610,000) have family incomes that are under 400% of Federal Poverty Level (FPL). For this group of uninsured, affordability is the biggest barrier to enrollment.
Californians who are low-income, Latino, or adults under age 50 are projected to continue to be more likely to be uninsured.
These projections of how many and which Californians will remain uninsured can help inform state policymakers and the Healthy California for All Commission as they consider options to make health coverage more universal and affordable. Possible steps range from those that can be taken in the near-term without federal approval to a more fundamental overhaul of our state health care system, such as adopting a single-payer plan.
The Affordable Care Act covered millions of Californians and brought the number of uninsured to historic lows by increasing access to coverage and by providing financial assistance to cover the costs of insurance. However, health care costs in the United States continue to pose affordability challenges and remain significantly higher than in other countries. Since 2017, federal policy decisions that threaten to reverse the ACA coverage gains have led states to consider how to shore up the gains they have achieved, stabilize the individual market, and improve on the ACA. Many California policy makers have expressed a desire to get to universal coverage, and California’s 2019–2020 budget included a number of provisions focused on expanding health insurance coverage and improving affordability in the individual market beginning January 2020. This report details the projected effects of three key policies on coverage and affordability of individual market premiums, as well as the demographics of who will be helped by these policies. We also describe the 3.5 million Californians who are projected to be uninsured in 2022, highlighting the need for further state action to expand coverage and improve affordability.
We model the effect of these new health coverage policies using the California Simulation of Insurance Markets (CalSIM) version 2.7, a microsimulation model of health care coverage and decision making for the California population under age 65. CalSIM models the behavior of California employers (to offer or drop health insurance coverage) and individuals (to take up various health insurance offers for which they are eligible). The model accounts for population growth, minimum wage increases at the state and local levels, and premium growth in both the individual and employer markets. We calibrate the model to 2017 using California survey and administrative data on insurance coverage, and then project forward two different scenarios: (1) with recent California-specific policies, and (2) the counterfactual without those recent policies, keeping state and federal policies as they were at the beginning of 2019.
Using CalSIM, we model three policies passed by the California legislature and signed by the Governor in 2019, to begin in 2020:
(1) the expansion of Medi-Cal to undocumented young adults;
(2) state advance premium tax credit subsidies for individual market coverage for those 200–400% FPL and 400–600% FPL; and
(3) an individual mandate penalty.
Other state changes enacted in 2019 that are not modeled in CalSIM due to data limitations or limited evidence about the anticipated impact on enrollment include: state premium subsidies for those enrolled in Covered California with income at or below 138% FPL; additional funding for outreach and enrollment; automatic enrollment when transitioning from Medi-Cal to Covered California; and changes to Medi-Cal eligibility for adults age 65 and over. As we discuss below, the likely disenrollment due to changes to the federal “public charge” rule and other policies affecting immigrant families is also not included in our projections.
1. Medi-Cal for all young adults
California expanded Medi-Cal eligibility to include low-income adults ages 19 to 25 regardless of immigration status, starting in 2020. Children age 18 and under have already been eligible since 2016 under state policy. The governor has committed to working with the legislature in 2020 to expand eligibility to undocumented adults age 65 and over and has expressed support for eventually covering low-income Californians of all ages under Medi-Cal.
2. State Subsidies
California will provide premium subsidies for three groups of Californians enrolled in the individual market through Covered California (Exhibits 4 and 5).
- Income at or below 138% FPL: This group is already eligible for ACA subsidies; after implementation of state subsidies they will pay $1 monthly premiums, making costs more parallel with Medi-Cal enrollees at the same income level who pay no premiums. This group is not modeled in CalSIM. Approximately 24,000 subsidized Covered California enrollees fell into this income range as of March 2019.
- Income 200–400% FPL: This group is also already eligible for ACA subsidies, and will be eligible for state subsidies that will lower premium contributions by 0.1 to 0.88 percent of household income, depending on FPL.
- Income 400–600% FPL: This group has income above the ACA “cliff” beyond which there are no ACA subsidies; state subsidies will provide premium assistance to this group for the first time, limiting premium contributions to between 9.68 percent and 18 percent of income, depending on income level.
No additional state subsidies were given to households with incomes between 138–200% FPL. Massachusetts and Vermont also offer state subsidies to those with incomes below 300% FPL, but no other states currently offer subsidies to those over 400% FPL.
State subsidies are provided for plan years 2020, 2021, and 2022, with most of the funding allocated to those with income 400–600% FPL. Covered California may adjust the premium caps in future years as needed to meet budget targets.
3. State individual mandate penalty
The federal individual mandate penalty was zeroed out starting in 2019. Massachusetts, Vermont, New Jersey, DC, and Rhode Island will have penalties in 2020. California’s individual mandate penalty, assessed as part of state income tax, will be in effect starting January 2020 and will require residents to have minimum essential coverage for each month or pay a penalty when they file taxes in 2021. Both the penalty amount and exemptions generally mirror the ACA tax penalties that were in place prior to 2017.
CalSIM models the California penalty as being very similar in effect to the federal penalty. We do take into account the higher tax-filing threshold in California that will result in fewer households paying the penalty and slightly lower penalty amounts than would have been the case under the federal penalty. However, because we model most of the effect of the penalty as psychological (and unrelated to whether someone actually would have to pay it and the exact amount that it would be), the projected effect on insurance take-up is very similar under the state and federal penalties. We assume that awareness of the state penalty is similar to awareness of the federal penalty: some are unaware the federal penalty ever went away; for them the penalty effect remains constant, despite one year without one. Others may know that the federal penalty was zeroed out but will learn of the state penalty when they file taxes. In our projections we focus on 2022, assuming that in the absence of California’s new policies the effects of eliminating the federal penalty would have phased in over time, with the full effects evident by 2022.
The effect of an individual mandate penalty is that more and healthier people enroll in coverage. We assume that one of the ways the penalty works is as a “nudge” to encourage those losing insurance coverage to shop or apply for coverage. This especially affects enrollment among those eligible for Medi-Cal, despite the fact that they are often exempt from paying the penalty, because they may not know they are eligible for free coverage under Medi-Cal until they shop. The other way the penalty increases enrollment is by encouraging enrollment among healthier individuals, resulting in lower premiums for everyone. When premiums are lower, more people enroll.
Resulting individual market premiums
As a result of the state individual mandate penalty and state subsidies keeping more people in the individual market, we project that premiums in the individual market will be 8.5 percent lower in 2022 than they otherwise would have been due to a healthier risk mix in the individual market. With these policies, we assume baseline premium increases each year of 7 percent due to medical cost growth. Without these policies, we assume premiums by 2022 are an additional 8.5 percent higher than the baseline.
Estimates do not include anticipated disenrollment from Medi-Cal due to variety of policies affecting immigrant families including the public charge rule
The uninsured projections in this report do not include any decline in Medi-Cal enrollment among immigrant families due to the growing fears resulting from a range of immigration policies proposed federally. One policy expected to have a particularly large impact on health insurance enrollment is the recent Department of Homeland Security rule commonly referred to as the “public charge” rule. As of the date of publication of this report, implementation of the final rule has been halted by injunctions from multiple federal courts. Under the rule, when a person applies for lawful permanent residency (a “green card”) or for a visa to enter the country, U.S. immigration officials would conduct a public charge test to determine if that person may become primarily dependent on the government to meet their basic needs. Under the public charge test, the Department of Homeland Security could deny someone a green card or visa based on enrollment in certain health care, housing, or nutrition assistance benefits or having certain personal circumstances such as limited English proficiency, limited educational attainment, or low income.
It is anticipated that if this rule is implemented, immigrant families would face fear and confusion about the consequences of enrollment in public programs, resulting in a “chilling” effect on enrollment in programs such as Medi-Cal and CalFresh food assistance. Research by the UCLA Center for Health Policy Research, UC Berkeley Labor Center, and California Food Policy Advocates estimated that if 15 to 35 percent of Californians in immigrant families subject to this chilling effect disenroll from public programs, between 317,000 and 741,000 fewer Californians would have Medi-Cal coverage, most of whom would become uninsured.
While the research is clear that the public charge rule is likely to result in lower Medicaid enrollment in California and nationally, we have not yet incorporated the rule and its effects into the CalSIM model.
770,000 gain or retain coverage
These California policies are projected to result in 770,000 more Californians with health insurance coverage in 2022 than if these policies were not in place. Largely, the policies help Californians retain coverage, keeping the number of uninsured in California essentially constant at 3.5 million. The projected number of uninsured Californians would increase over the coming years if these policies were not in place.
Without the individual mandate penalty in place, we project the individual market would shrink and premiums would increase. Covered California estimated that premiums in 2019 were 3.5 percent higher than they would have been if the mandate penalty had not been zeroed out, and we project premiums would have increased even more in future years without state action. By 2022, the combination of the individual mandate, lower premiums, and additional state subsidies will result in 210,000 more individual market enrollees than if these policies were not adopted, an increase of 11 percent.
The individual mandate is also projected to affect Medi-Cal enrollment; without the extra nudge to shop for insurance, fewer people enroll in or discover they are eligible for Medi-Cal. In addition to the effect of the individual mandate, the expansion of Medi-Cal to undocumented young adults results in an increase of approximately 100,000 new full-scope Medi-Cal enrollees. The overall effect of 510,000 Californians who gain or retain Medi-Cal coverage by 2022 amounts to a 6 percent change in enrollment in Medi-Cal among those age 0 to 64.
The employer-sponsored insurance market—still the source of coverage for the majority of Californians under age 65—is largely unchanged by these policies. We project 60,000 Californians gain or retain coverage by 2022 as a result of the individual mandate, an increase of less than 1 percent.
The demographics of this group of 770,000 individuals reflects the fact that the majority are enrolled in Medi-Cal coverage, with a disproportionate share being in low-income households (see Appendix Exhibit A1).
800,000 Californians get state subsidies
State subsidies will lower the contribution cap for those with incomes 200-400% FPL and will provide a contribution cap for the first time for Californians with incomes 400-600% FPL.
Comparison to Estimates from Covered CA
Our estimates for how many will receive subsidies are largely in line with Covered California’s estimate of 235,000 having income 400–600% FPL in 2020 and being eligible for subsidies by virtue of having insurance through the individual market. We project 260,000 Californians in this group in 2022 (Exhibit 7). Of these 260,000, we project that 120,000 will have premium costs that exceed the contribution cap for their FPL and therefore get a positive dollar subsidy (and count among the 800,000 receiving state subsidies). Another 140,000 Californians have incomes 400–600% FPL and will purchase coverage on the individual market but are not projected to receive a subsidy in 2022 because their unsubsidized premiums already cost less than the cap (9.68 to 18 percent of household income). They will, however, count among the 750,000 who benefit from lower premiums in the individual market, as discussed below.
We project that in 2022, 680,000 Californians with incomes 200–400% FPL will get state subsidies that average $15 per person per month, in addition to their federal subsidies. These state subsidies lower premiums for these enrollees by an average of 8 percent.
Another 120,000 Californians with income above the federal “cliff” of 400% FPL but below 600% FPL will get state subsidies that average $310 per person per month. This amounts to a 43 percent lower premium, on average, than if people had enrolled in the same plan without subsidies. Many of these enrollees would have had individual market coverage even in the absence of state policies, but the state subsidies provide substantial financial help. Because premiums increase with age, most of those who hit the premium contribution cap and receive these subsidies (65 percent) are ages 50–64 (Exhibit 7). Most are either self-employed (52 percent) or the spouse or child of someone who is self-employed (another 16 percent). The remainder are either not working or working part-time; very few full-time workers in households with income 400–600% FPL lack an affordable offer of employer based insurance (a requirement for subsidy eligibility).
Taken together, this group of 800,000 individual market enrollees newly receiving state subsidies is projected to be somewhat more likely to be white and age 50 or older than the overall individual market universe, defined as those either enrolled in the individual market or uninsured and eligible (see Exhibit 8).
While the majority of the people getting state subsidies will be under 400% FPL (680,000), most of the money will be spent on the 120,000 with incomes 400–600% FPL, as budgeted.
750,000 benefit from lower premiums in the individual market
As a result of the individual mandate penalty and state subsidies, we project that the risk mix in the individual market under these policies will be somewhat healthier than without the policies. As a result, premiums in the individual market in 2022 are projected to be 8.5 percent lower than they would have been without state action. Passage of the additional subsidies and state mandate penalty has already played a key role in driving down premium growth in 2020 according to Covered California.
Individual market enrollees who receive subsidies are shielded from the increase in premiums by design—their contribution is a function of their income. However, individual market enrollees who do not get subsidies face the full cost of coverage and thus benefit from lower prices. Californians are ineligible for subsidies if they meet any of these criteria:
- Have income above 600% FPL;
- Have premiums low enough that they do not exceed the contribution cap (which extends up to 18 percent of family income for those at 600% FPL);
- Have an “affordable” offer of employer-sponsored coverage;
- Are eligible for public coverage such as Medi-Cal, Medicare, or VA health benefits; or
- Are undocumented.
750,000 Californians are projected to be enrolled in the individual market without subsidies in 2022 and therefore will benefit from these lower prices. Unsubsidized individual market enrollees are concentrated in higher income groups and, similar to the individual market universe as a whole, are more likely to be white than the overall California population age 0–64 (Exhibit 8).
The overall effect
As a result of these policies, California will see 770,000 more insured in 2022 than if these policies were not in place, and 1.55 million Californians will benefit from lower premiums, either as a result of subsidies or lower prices. There is overlap between these groups, however, as illustrated in Exhibit 9. On net in 2022 we project that 2.2 million Californians will benefit from coverage and/or affordability help as a result of California’s policies.
Of the 800,000 Californians getting subsidies, we project that the majority (720,000) would have been insured even in the absence of these policies, while 80,000 would have been uninsured. These 80,000 gained or retained coverage as a result of the individual mandate penalty and/or additional subsidies.
Similarly, of the 750,000 individual market unsubsidized enrollees, most (670,000) would have had insurance even in the absence of these policies, despite premiums being 8.5 percent higher. However, 80,000 would be uninsured in the absence of these policies; they gain or retain coverage as a result of either the individual mandate or the lower premiums in the individual market.
Who Is Uninsured?
Even with these policies in place, 3.5 million Californians are projected to be uninsured in 2022, and disparities by race and ethnicity, income, and age persist among this group. Below we identify and enumerate the different groups of those who are uninsured on the basis of their eligibility for various existing programs.
Health Insurance Matters
Health insurance coverage plays a significant role in facilitating access to needed health care. Recent evidence suggests that health insurance protects individuals from financial distress and excessive out-of-pocket spending, encourages earlier diagnosis of chronic conditions, improves use of preventive services, and reduces preventable mortality. The short-term gains resulting from insurance coverage expansions in the ACA include improved coverage and reduced disparities in access to care, improved use of preventive services, improved affordability of health care, improved health status, increased prescription drug use and adherence, improved access to mental health treatment, and improved health status and mental health among the chronically ill. Insurance coverage is linked to obtaining a usual source of care, which reduces preventable mortality and out-of-pocket spending on health care by individuals.]
The largest group of the projected uninsured are 1.34 million undocumented Californians. Low-income undocumented Californians over age 25 continue to be ineligible for full-scope Medi-Cal coverage unless they have DACA. Many of these individuals have restricted scope Medi-Cal, which we do not count as insurance because doctor visits, hospital care, prescription drugs, and other basic health services are not covered unless they are necessary for the treatment of an emergency medical condition or the enrollee is pregnant. (Covered services do not include, for example, most of the care needed by someone with cancer, diabetes, or many other conditions.) Categorizing restricted scope Medi-Cal as uninsurance makes an important difference in our estimates. Survey-based estimates of uninsurance generally rely on self-reported insurance status without adjusting for scope of coverage. Since some undocumented adults report having Medicaid coverage, survey-based estimates generally report fewer uninsured than our CalSIM estimates.
Most Californians who are both undocumented and uninsured have incomes below the Medi-Cal threshold; those with incomes above the threshold are not eligible for federal or state premium subsidies to help afford private coverage. While some undocumented Californians enroll in coverage through their employers, undocumented adults are among the least likely to have job-based coverage in spite of their high rate of employment.
We project that 660,000 Californians who are eligible for Medi-Cal will nevertheless be uninsured in 2022. While more than 90 percent of those eligible for Medi-Cal are projected to enroll, the remainder may not realize they are eligible or may not try to enroll for other reasons. Those eligible for Medi-Cal can enroll at any time of year, unlike those eligible for individual market coverage who can only enroll during the annual open enrollment period or if they experience a qualifying life event (e.g. divorce, job loss, etc.). Our projection does not take into account the chilling effect on enrollment that is likely to occur if the Trump administration’s change to the public charge rule, currently halted by the courts, is implemented. On the other hand, in 2019 California made a budget investment to support community-based outreach by health enrollment navigators to provide enrollment, retention, and utilization assistance to Medi-Cal eligible individuals; our projection does not take these potential impacts into account either.
Another 970,000 Californians are projected to be uninsured and eligible for Covered California and without an employer offer of coverage—most (780,000) with incomes in the subsidy eligible range at or below 600% FPL. These 780,000 may be able to receive financial assistance with premiums and/or cost-sharing in the individual market if they were to enroll, but may not be aware that they qualify for financial assistance. Others may find the cost of coverage unaffordable, despite the increased financial assistance available from the state. Californians’ struggles with affordability on the individual market in the absence of state subsidies have been well documented. Among those who enrolled in coverage on the individual market in 2017, 40 percent reported difficulty paying their monthly premiums and 31 percent reported trouble paying out-of-pocket costs. While the addition of state subsidies helps improve affordability, potential enrollees may still face daunting affordability challenges. A single minimum wage worker earning $24,000 per year in 2020 (just over 190% FPL) would still be asked to pay 6.1 percent of income, or $122 per month, in premiums for an enhanced silver plan with a deductible of $1400. For those in the 400–600% FPL range, expected contribution caps of 9.86 percent to 18 percent of income may still feel unaffordable. For example, a single worker at 500% FPL ($62,500 per year) in 2020 could pay up to 16 percent of income—$10,000 per year or $833 per month—for a silver plan with a $4,000 deductible.
Another 550,000 Californians are projected to be eligible for an “affordable” offer of employer sponsored coverage but nevertheless remain uninsured. Under the ACA, an offer of employer-sponsored insurance is considered “affordable” if the worker’s contribution to premiums for the lowest cost self-only plan offered by the employer is less than 9.78 percent of family income in 2020. If this condition is met, family coverage is also considered “affordable,” even if it requires a premium contribution of more than 9.78 percent of family income. Despite eligibility for an offer, workers and their family members may find coverage unaffordable: nationally 90 percent of uninsured workers who turned down an offer of employer coverage cited cost as the primary reason. Even among those who take up employer-sponsored insurance, affording premiums and out-of-pocket costs can remain a challenge. While deductibles are still much less common in employer plans than on the individual market, their prevalence is increasing: of California workers with single coverage from an employer, the share who have a large deductible has grown from 10 percent in 2007 to 25 percent in 2017.
Demographics of the uninsured
The uninsured in 2022 are projected to continue to be disproportionately Latino, low-income, and adults under age 50 compared to California as a whole (Appendix Exhibit A1). The uninsured are concentrated in Los Angeles County mainly as a result of the large undocumented uninsured population there (Appendix Exhibit A2).
While California has cut its uninsured rate dramatically under the ACA and recent state actions are projected to protect those coverage gains, 3.5 million will to continue to lack insurance in 2022 and many insured Californians will continue to struggle to afford coverage and care.
In support of the goal of providing all Californians with timely access to high-quality, affordable health care, state policymakers have established the Healthy California for All Commission to explore options for establishing a unified financing system in the state, such as a single-payer system. Establishment of this commission is concurrent with national policy debates that increasingly focus on ways to achieve more universal and affordable coverage. Proposals to this end range from building on the current multi-payer system to adopting Medicare for All, with many variations in between. Other countries have taken a variety of approaches to get to universal coverage. Our CalSIM estimates of how many and which Californians are projected to remain uninsured provide important context to the discussion on national proposals to reform our healthcare system, as well as to the Healthy California for All Commission as it analyzes gaps in the current system and develops options for coverage expansions and a state-level unified financing system.
To address the largest group of uninsured in the state, California could expand Medi-Cal to all low-income California adults regardless of immigration status and age, as the state has already done for children and young adults under age 26. As with the expansion to children and young adults, many of the uninsured are already enrolled in restricted-scope Medi-Cal, which covers emergency and pregnancy-related services using federal and state funding and state-funded long-term care when needed. These adults could be automatically transitioned to full-scope Medi-Cal upon enactment of such a policy, ensuring a substantial reduction in the uninsured. The majority, though not all, of uninsured undocumented Californians would qualify for Medi-Cal based on their income, making this an important first step in expanding eligibility and coverage to all regardless of immigration status.
The state can continue efforts to maximize enrollment among those eligible for Medi-Cal by taking steps such as:
- Investing in and strengthening culturally- and linguistically- appropriate outreach and enrollment assistance;
- Supporting education for families as well as service and health care providers to address fears and misinformation caused by increased anti-immigrant policies and practices at the federal level;
- Adopting express lane eligibility efforts to automatically enroll individuals in Medi-Cal if their enrollment in another public program deems them eligible for Medi-Cal;
- Continuing to improve and provide assistance with transitions between Covered California and Medi-Cal upon changes in eligibility;
- Aligning Medi-Cal program rules across populations; and
- Reducing administrative barriers to consumers renewing Medi-Cal.
California’s strong investment in marketing and enrollment assistance in the individual market will continue to be needed to inform Californians about their obligations under the state penalty, as well as the ACA and new state assistance for which they may qualify. As Californians continue to churn into eligibility for different types of coverage as their circumstances change, they will continue to need help accessing trusted information and staying aware of their options.
Close to 1 million Californians are projected to be eligible for Covered California but uninsured, and many who purchase individual market coverage will still struggle to afford it. To address these concerns and continue to strengthen the individual market, California could provide state subsidies for those 138–200% FPL, improve state subsidies for those 200–600% FPL, and help with cost sharing. Cost-sharing assistance—reductions to out-of-pocket costs and deductibles based on income— has been available to Covered California enrollees with incomes at or below 250% FPL since 2014, but that assistance was not expanded as part of the state subsidy program. Expanding eligibility for cost-sharing assistance up to 400% FPL and improving cost-sharing assistance levels for those who need more assistance could encourage enrollment and improve the affordability of and financial security provided by existing coverage.
As we projected in our April 2019 brief, robust state policies providing additional help for individual market enrollees and expanding Medi-Cal to the undocumented of all ages could have a substantial impact on the uninsured rate, allowing the state to further reduce the number of uninsured below the 3.5 million projected under the already-enacted state policies.
The federal government has the broadest set of options available for improving affordability of employer-sponsored insurance—for example, setting further limits on workers’ contributions to premium and out-of-pocket costs, such as capping out-of-pocket spending at 2 percent of income as Germany does. (States are pre-empted from regulating self-insured employer-sponsored insurance plans under the Employee Retirement Income Security Act of 1974, or ERISA.) At the state level, one option for addressing affordability for a subset of the uninsured who are offered employer-sponsored insurance may be to fix the family glitch by using state funds to provide ACA-equivalent premium and cost-sharing subsidies to spouses and children who are eligible for family coverage that costs more than 9.78 percent of household income. State policies designed to slow the rate of healthcare cost growth or reduce healthcare costs while also improving quality would likewise help to ensure stable enrollment among Californians eligible for employer coverage or insurance through Covered California.
California has taken important steps toward expanding coverage by successfully implementing the ACA, expanding Medi-Cal eligibility to certain immigrants not eligible under federal policy, and taking steps to stabilize the individual market in the face of federal health policy changes that threatened to weaken it. The policies adopted by the governor and legislature in 2019 will build upon these earlier efforts to prevent an increase in the uninsured and further stabilize the individual market. But with 3.5 million Californians projected to be uninsured in 2022, the state must take additional steps to fully achieve the vision of access to affordable health care for all Californians.
We are grateful to the California Health Care Foundation and The California Wellness Foundation for their support of this report. We thank Covered California and The California Endowment for their support of the development and maintenance of the CalSIM model. We would like to thank Amy Adams, Beth Capell, and Jen Flory for their review of this report. We appreciate Nadereh Pourat’s contribution to the analysis of the undocumented population, which is critical to the CalSIM model and this report. Thanks to Jenifer MacGillvary for her help in preparation of the report.
About the Authors
Miranda Dietz, MPP, is the CalSIM Project Director at the University of California, Berkeley, Center for Labor Research and Education. Laurel Lucia, MPP, is Director of the Health Care Program at the UC Berkeley Center for Labor Research and Education. Xiao Chen, PhD, is Associate Director of the Health Economics and Evaluation Program at the UCLA Center for Health Policy Research. Dave Graham-Squire, PhD, is a Statistician at the UC Berkeley Center for Labor Research and Education. Hanqing Yao is a Programmer and Analyst at the UCLA Center for Health Policy Research. Petra W. Rasmussen, MPH, is a Graduate Student Researcher at the UCLA Center for Health Policy Research. Greg Watson, MS, is a Statistical Programmer at the UCLA Center for Health Policy Research. Dylan H. Roby, PhD, is an Associate Professor at the University of Maryland School of Public Health, and a Faculty Associate at the UCLA Center for Health Policy Research. Ken Jacobs is Chair of the UC Berkeley Center for Labor Research and Education. Srikanth Kadiyala, PhD, is a Senior Economist at the UCLA Center for Health Policy Research. Gerald F. Kominski, PhD, is Professor of Health Policy and Management, UCLA Fielding School of Public Health, and Senior Fellow, UCLA Center for Health Policy Research.
 Miranda Dietz et al., “California’s Health Coverage Gains to Erode Without Further State Action” (UC Berkeley Center for Labor Research and Education and UCLA Center for Health Policy Research, November 27, 2018), http://laborcenter.berkeley.edu/ca-coverage-gains-to-erode-without-further-state-action/.
 Irene Papanicolas, Liana R. Woskie, and Ashish Jha, “Health Care Spending in the United States and Other High-Income Countries,” The Commonwealth Fund, March 13, 2018, https://www.commonwealthfund.org/publications/journal-article/2018/mar/health-care-spending-united-states-and-other-high-income.
 Miranda Dietz et al., “3.6 Million Californians Would Benefit If California Takes Bold Action to Expand Coverage and Improve Affordability” (UC Berkeley Center for Labor Research and Education UCLA Center for Health Policy Research, April 2019), http://laborcenter.berkeley.edu/3-6-million-californians-would-benefit/.
 As in previous work we exclude restricted scope Medi-Cal coverage from our definition of insurance. Because some undocumented Californians with restricted scope coverage report having Medi-Cal coverage on surveys, our CalSIM estimates for the current number of uninsured are higher than survey-based estimates. For more, see “Why Uninsurance Estimates Vary” in Dietz et al., “California’s Health Coverage Gains to Erode Without Further State Action.”
 For more on the CalSIM methodology, see: UC Berkeley Labor Center and UCLA Center for Health Policy Research, “The California Simulation of Insurance Markets, Version 2: Methodology and Data Sources” (UC Berkeley Center for Labor Research and Education and UCLA Center for Health Policy Research, July 2019), http://laborcenter.berkeley.edu/pdf/2019/CalSIM-2-Methods-Sources.pdf.
 See California Senate Bill 260.
 The potential enrollment changes as a result of the public charge rule are the largest in magnitude—an estimated 317,000 to 741,000 fewer Californians with Medi-Cal coverage; see Ninez Ponze, Laurel Lucia, and Tia Shimada, “How Proposed Changes to the ‘Public Charge’ Rule Will Affect Health, Hunger and the Economy in California” (November 7, 2018), http://healthpolicy.ucla.edu/newsroom/Documents/2018/public-charge-seminar-slides-nov2018.pdf. The other policies not considered in this analysis are likely to have much smaller impacts on enrollment totals.
 Some undocumented young adults with Deferred Action for Childhood Arrivals (DACA) were already eligible for and enrolled in full-scope Medi-Cal. We are unable to model the DACA population separately from undocumented Californians in CalSIM.
 “Senator Durazo Announces Agreement with Governor Newsom to Work on Providing Medi-Cal Coverage to Undocumented Seniors,” Senator Maria Elena Durazo, September 17, 2019, https://sd24.senate.ca.gov/news/2019-09-14-senator-durazo-announces-agreement-governor-newsom-work-providing-medi-cal-coverage.
 For 2020, California premium contribution caps by FPL are
FPL Premium contribution cap (% of income) 200% 6.24% 250% 7.80% 300% 8.90% 400% 9.68% 450% 14% 500% 16% 600% 18%
See Katie Ravel, “Covered California Policy and Action Items,” (June 26, 2019), https://board.coveredca.com/meetings/2019/06-26/PPT.Policy%20and%20Action.June%202019.pdf and “California Senate Bill 106,” Pub. L. No. SB 106 (2019), http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB106.
 Jennifer Tolbert et al., “State Actions to Improve the Affordability of Health Insurance in the Individual Market,” Issue Brief, Health Reform (Kaiser Family Foundation, July 17, 2019), https://www.kff.org/health-reform/issue-brief/state-actions-to-improve-the-affordability-of-health-insurance-in-the-individual-market/.
 For modeling purposes, we inflate state premium caps at the same rate as federal premium caps. By 2022 the premium cap for those 600% FPL increases to 18.22% of income.
 Tolbert et al., “State Actions to Improve the Affordability of Health Insurance in the Individual Market.”
 Exemptions exist for people who are undocumented, lack an affordable offer of coverage, are members of an Indian tribe, are granted an exemption for hardship or religious conscience, are members of health care sharing ministries, are incarcerated, are residents of another state for that month, or do not have to file taxes. The tax-filing threshold is significantly higher for California than it is federally–$17,693 in gross income for a single person under age 65 in California in 2018, compared to the federal threshold of $12,000. “California Senate Bill 78,” Pub. L. No. SB 78 (2019), https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB78.
 See Appendix D of Dietz et al. Nov 2018 for more details on modeling the individual mandate in CalSIM
 For more on the individual mandate penalty acting as an incentive to seek coverage, see page 7 of Dietz et al. November 2018.
 Samantha Artiga and Olivia Pham, “Addressing Health and Social Needs of Immigrant Families: Lessons from Local Communities” (Kaiser Family Foundation, October 2019), http://files.kff.org/attachment/Issue-Brief-Addressing-Health-and-Social-Needs-of-Immigrant-Families-Lessons-from-Local-Communities.
 U.S. Department of Homeland Security, “Final Rule on Public Charge Ground of Inadmissibility” (2019), https://www.uscis.gov/legal-resources/final-rule-public-charge-ground-inadmissibility.
 Laurel Wamsley, Pam Fessler, and Richard Gonzales, “Federal Judges In 3 States Block Trump’s ‘Public Charge’ Rule For Green Cards,” NPR.org, October 11, 2019, https://www.npr.org/2019/10/11/769376154/n-y-judge-blocks-trump-administrations-public-charge-rule.
 Ponze, Lucia, and Shimada, “How Proposed Changes to the ‘Public Charge’ Rule Will Affect Health, Hunger and the Economy in California.”
 Similar disenrollment rate scenarios were used by other researchers in their analyses of the public charge rule. Recent research by the Urban Institute indicates that a chilling effect has already occurred, despite the final rule not yet going into effect: one out of seven adults in immigrant families (13.7%) reported not participating in a noncash government benefit program in 2018 because of fear that participation would risk future green card status for themselves or a family member. For more see Samantha Artiga and Rachel Garfield, “Estimated Impacts of Final Public Charge Inadmissibility Rule on Immigrants and Medicaid Coverage” (Kaiser Family Foundation, September 18, 2019), https://www.kff.org/disparities-policy/issue-brief/estimated-impacts-of-final-public-charge-inadmissibility-rule-on-immigrants-and-medicaid-coverage/; Fiscal Policy Institute, “FPI Estimates Human & Economic Impacts of Public Charge Rule: 24 Million Would Experience Chilling Effects,” October 10, 2018, http://fiscalpolicy.org/public-charge; Hamutal Bernstein et al., “One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018” (Urban Institute, May 2019), https://www.urban.org/sites/default/files/publication/100270/one_in_seven_adults_in_immigrant_families_reported_avoiding_publi_7.pdf; Leah Zallman and Karen Finnegan, “Changing Public Charge Immigration Rules: The Potential Impact on Children Who Need Care” (California Health Care Foundation, October 2018), https://www.chcf.org/wp-content/uploads/2018/10/ChangingPublicChargeImmigrationRules.pdf.
 Covered California, “Covered California Releases 2019 Individual Market Rates: Average Rate Change Will Be 8.7 Percent, With Federal Policies Raising Costs,” July 19, 2018, https://www.coveredca.com/newsroom/news-releases/2018/07/19/Covered-California-Releases-2019-Individual-Market-Rates-Average-Rate-Change-Will-Be-8-7-Percent-With-Federal-Policies-Raising-Costs/.
 Ravel, “Covered California Policy and Action Items.”
 Seventeen percent of the budgeted state funds are allocated to those 200-400% FPL, and the remaining 83 percent to those <138% FPL and 400-600% FPL, with subsidies to those <138% FPL costing approximately $5 million per year (just over 1%). See Ravel.
 Covered California, “Covered California Releases Regional Data Behind Record-Low 0.8 Percent Rate Change for the Individual Market in 2020,” July 19, 2019, https://www.coveredca.com/newsroom/news-releases/2019/07/19/covered-california-releases-regional-data-behind-record-low-0-8-percent-rate-change-for-the-individual-market-in-2020/.
 Jack Hadley, “Sicker and Poorer—the Consequences of Being Uninsured: A Review of the Research on the Relationship between Health Insurance, Medical Care Use, Health, Work, and Income,” Medical Care Research and Review: MCRR 60, no. 2 Suppl (June 2003): 3S–75S; discussion 76S–112S, https://doi.org/10.1177/1077558703254101; Michael McWilliams, “Health Consequences ofUninsuranceamong Adults in the United States: Recent Evidence and Implications,” The Milbank Quarterly 87, no. 2 (June 2009): 443–94, https://doi.org/10.1111/j.1468-0009.2009.00564.x; Benjamin D. Sommers, Atul A. Gawande, and Katherine Baicker, “Health Insurance Coverage and Health—what the Recent Evidence Tells Us,” New England Journal of Medicine 377 (August 10, 2917): 586–93.
 Bhashkar Mazumder and Sarah Miller, “The Effects of the Massachusetts Health Reform on Household Financial Distress,” American Economic Journal: Economic Policy 8, no. 3 (August 2016): 284–313, https://doi.org/10.1257/pol.20150045; Kao-Ping Chua and Benjamin D. Sommers, “Changes in Health and Medical Spending among Young Adults under Health Reform,” JAMA 311, no. 23 (June 18, 2014): 2437–39, https://doi.org/10.1001/jama.2014.2202; Amy Finkelstein et al., “The Oregon Health Insurance Experiment: Evidence from the First Year*,” The Quarterly Journal of Economics 127, no. 3 (August 1, 2012): 1057–1106, https://doi.org/10.1093/qje/qjs020; Katherine Baicker et al., “The Oregon Experiment—Effects of Medicaid on Clinical Outcomes,” New England Journal of Medicine 368, no. 18 (May 2, 2013): 1713–22, https://doi.org/10.1056/NEJMsa1212321; Benjamin D. Sommers, Katherine Baicker, and Arnold M. Epstein, “Mortality and Access to Care among Adults after State Medicaid Expansions,” New England Journal of Medicine 367, no. 11 (September 13, 2012): 1025–34, https://doi.org/10.1056/NEJMsa1202099.
 Héctor E. Alcalá et al., “Impact of the Affordable Care Act on Health Care Access and Utilization Among Latinos,” Journal of the American Board of Family Medicine: JABFM 30, no. 1 (02 2017): 52–62, https://doi.org/10.3122/jabfm.2017.01.160208; Adele Shartzer, Sharon K. Long, and Nathaniel Anderson, “Access To Care And Affordability Have Improved Following Affordable Care Act Implementation; Problems Remain,” Health Affairs 35, no. 1 (January 1, 2016): 161–68, https://doi.org/10.1377/hlthaff.2015.0755; Ausmita Ghosh, Kosali Simon, and Benjamin D Sommers, “The Effect of State Medicaid Expansions on Prescription Drug Use: Evidence from the Affordable Care Act,” Working Paper (National Bureau of Economic Research, January 2017), https://doi.org/10.3386/w23044; Hefei Wen, Benjamin G. Druss, and Janet R. Cummings, “Effect of Medicaid Expansions on Health Insurance Coverage and Access to Care among Low-Income Adults with Behavioral Health Conditions,” Health Services Research 50, no. 6 (December 2015): 1787–1809, https://doi.org/10.1111/1475-6773.12411; Tyler N. A. Winkelman and Virginia W. Chang, “Medicaid Expansion, Mental Health, and Access to Care among Childless Adults with and without Chronic Conditions,” Journal of General Internal Medicine 33, no. 3 (March 2018): 376–83, https://doi.org/10.1007/s11606-017-4217-5; Benjamin D. Sommers et al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” JAMA Internal Medicine 176, no. 10 (October 1, 2016): 1501–9, https://doi.org/10.1001/jamainternmed.2016.4419.
 P. Franks and K. Fiscella, “Primary Care Physicians and Specialists as Personal Physicians. Health Care Expenditures and Mortality Experience,” The Journal of Family Practice 47, no. 2 (August 1998): 105–9; Barbara Starfield, Leiyu Shi, and James Macinko, “Contribution of Primary Care to Health Systems and Health,” The Milbank Quarterly 83, no. 3 (2005): 457–502, https://doi.org/10.1111/j.1468-0009.2005.00409.x.
 DACA recipients are eligible for full-scope coverage, but we are not able to model DACA in CalSIM. Any undocumented children and young adults who are uninsured but eligible for Medi-Cal are counted among the “uninsured Medi-Cal eligible” group.
 For more on our definition of insurance, see Dietz et al. 2018.
 Ken Jacobs, “Employment-Based Coverage and the Individual Market,” in The State of Health Insurance in California: Findings from the 2014 California Health Interview Survey (UCLA Center for Health Policy Research, 2017), 23–38, http://healthpolicy.ucla.edu/publications/Documents/PDF/2017/shicreport-jan2017.pdf.
 Laurel Lucia, “More than 500,000 Californians Estimated to Be Eligible for Medi-Cal but Uninsured in 2016-2017,” Center for Labor Research and Education (blog), March 19, 2019, http://laborcenter.berkeley.edu/500000-californians-estimated-eligible-medi-cal-uninsured-2016-2017/.
 Insure the Uninsured Project, “2019-20 Final State Budget Health Care Highlights,” Legislative Update (Insure the Uninsured Project, June 27, 2019), http://www.itup.org/wp-content/uploads/2019/07/2019-20-Final-State-Budget_Legislative-Update-7.15.19.pdf.
 Covered California, “Covered California Sentiment Research Wave 2” (Covered California, October 5, 2017), https://www.coveredca.com/PDFs/October_2017_Covered_California_Sentiment_Survey_FINAL.pdf.
 Laurel Lucia and Ken Jacobs, “Towards Universal Health Coverage: California Policy Options for Improving Individual Market Affordability and Enrollment” (University of California Berkeley: Center for Labor Research and Education, March 5, 2018), http://laborcenter.berkeley.edu/ca-policy-options-individual-market-affordability/.
 California Health Care Foundation, “Affordability on California’s Individual Market: What Policymakers Need to Know” (California Health Care Foundation, April 2019), https://www.chcf.org/wp-content/uploads/2019/04/AffordabilityCAIndividualMarket.pdf.
 Covered California, “2020 Patient-Centered Benefit Designs and Medical Cost Shares,” 2019, https://www.coveredca.com/PDFs/2020-Health-Benefits-table.pdf.
 Kaiser Family Foundation, “Key Facts about the Uninsured Population,” Uninsured (Kaiser Family Foundation, December 7, 2018), https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/.
 Heidi Whitmore and Jon Gabel, “2018 Edition — California Employer Health Benefits,” California Health Care Foundation (blog), June 26, 2018, https://www.chcf.org/publication/2018-edition-california-employer-health-benefits-workers-shoulder-more-costs/.
 Liz Hamel et al., “The Health Care Priorities and Experiences of California Residents: Findings from the Kaiser Family Foundation/California Health Care Foundation California Health Policy Survey” (Kaiser Family Foundation, California Health Care Foundation, January 2019), https://www.chcf.org/wp-content/uploads/2019/02/HealthCarePrioritiesExperiencesCaliforniaResidents.pdf.
 Others may be enrolled in county programs that provide access to non-emergency health services to low-income residents regardless of immigration status—through programs like My Health LA and Healthy San Francisco. These programs only cover care provided in a designated network within the county and are not considered to be insurance. For more see Denisse Rojas and Miranda Dietz, “Providing Health Care to Undocumented Residents” (UC Berkeley Center for Labor Research and Education, October 4, 2016), http://laborcenter.berkeley.edu/pdf/2016/Providing-Health-Care-to-Undocumented-Residents.pdf. Research and Analytic Studies Division, “Medi-Cal Monthly Enrollment Fast Facts” (California Department of Health Care Services, May 2018), https://web.archive.org/web/20181202080606/https://www.dhcs.ca.gov/dataandstats/statistics/Documents/Fast_Facts_May_2018_ADA.pdf.
 Peter Lee et al., “Marketing Matters: Lessons From California to Promote Stability and Lower Costs in National and State Individual Insurance Markets” (Covered California, September 2017), https://hbex.coveredca.com/data-research/library/coveredca_marketing_matters_9-17.pdf.
 Dietz et al., “3.6 Million Californians Would Benefit If California Takes Bold Action to Expand Coverage and Improve Affordability.”
 Miriam Bluemel and Reinhard Busse, “Germany : International Health Care System Profiles,” The Commonwealth Fund, accessed October 30, 2019, https://international.commonwealthfund.org/countries/germany/.
 Lucia and Jacobs, “Towards Universal Health Coverage.”
Miranda Dietz, Laurel Lucia, et al. “California’s Steps to Expand Health Coverage and Improve Affordability: Who Gains and Who Will Be Uninsured?” (University of California Berkeley Center for Labor Research and Education and UCLA Center for Health Policy Research), November 2019,
The analyses, interpretations, conclusions, and views expressed in this report are those of the authors and do not necessarily represent the UC Berkeley Institute for Research on Labor and Employment, the UC Berkeley Center for Labor Research and Education, the UCLA Center for Health Policy Research, the Regents of the University of California, or collaborating organizations or funders.
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