California Healthline, October 1, 2012
As many as four million Californians could remain uninsured after all national health reforms are in place, and about half of them will be eligible for subsidized coverage but not enrolled, according to a new report.
National reform will bring health coverage to millions of previously uninsured Californians through the expansion of Medi-Cal and creation of subsidized insurance through the new Health Benefit Exchange. However, millions still will fall through the cracks, say authors of a joint report from the UC-Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research. According to the authors, 3.1 million to four million Californians still will be uninsured after health reform fully takes effect.
"The number of remaining uninsured doesn't surprise us, but I suspect it will surprise others," said Ken Jacobs, chair of the UC-Berkeley Labor Center and one of the report's authors.
"Both the overall number and the mix of who those people are...important data and should serve as a wake-up call for the need to maintain the safety net system in California," Jacobs said.
Among the findings and predictions in the report, "Who Will Remain Uninsured?":
- Half of all remaining uninsured, or two million Californians, will be eligible for Medi-Cal or exchange subsidies but will remain unenrolled due to lack of awareness about the programs, challenges in the enrollment process or an inability to afford subsidized coverage;
- Nearly 40% of the remaining uninsured will not be able to afford coverage;
- More than 70% of the remaining uninsured will be exempt from the federal tax penalty; approximately 3% of all Californians will owe a tax penalty in 2019 due to not obtaining minimum coverage;
- Latinos will make up two-thirds of the remaining uninsured; and
- Californians with limited English proficiency will account for about 60% of the uninsured.
Report Recommends Extra Effort in Latino Community
Authors of the report recommend that state officials make an extra effort to connect with the Latino community.
Chad Silva, policy director for Latino Coalition for a Healthy California, agreed.
"The California Departments of Health Care Services and Managed Health Care and the Health Benefit Exchange need to engage community-based stakeholder groups who are already working with this population," Silva said. "Groups such as ours, who have ties with many of these groups, can help to facilitate the dialogue and linkages," he said.
Silva said there is some doubt in the Latino community about whether outreach efforts by the state's new insurance exchange will be adequate.
"It is our understanding that the exchange plans to allocate $250,000 for a statewide outreach effort. This would not be sufficient to engage a population the size of Fresno," Silva said.
"It is concerning that they underestimate how hard it will be to engage the Latino community, especially those residing in rural communities in isolated areas. The report highlights some of the issues: language, age, class, etc., that would make engagement difficult if the right people are not treated as partners in this process," Silva said.
"All of this is exacerbated by their compressed timeline," Silva added. "People and things can get missed when done very quickly. We need to be diligent, and help the exchange help themselves."
The Health Benefit Exchange this week begins a nomination process to identify and select stakeholders to participate in advisory groups.
'Safety Net Will Still Be Needed'
Report authors recommend that California officials take steps to ensure a strong post-ACA safety net.
"The most important take-away from this report I think," UC-Berkeley's Jacobs said, "is to urge governments at every level -- federal, state and county -- to maintain whatever they're doing after ACA arrives. It's fair to assume most programs won't need as much money or attention because a lot of the people who use those programs now will be insured, but it won't be everyone -- not by a long shot."
Jacobs added, "Programs like Family PACT and LIHP and others will still serve an important role -- maybe not as big a role, but still important."
Family PACT provides family planning services to low-income Californians, and LIHP -- the Low Income Health Program -- is part of the state's 1115 Medicaid waiver known as the "Bridge to Reform." Both programs are administered by the state Department of Health Care Services.
The report also suggests state officials might consider creating new safety-net programs once the ACA is in place and the state's needs change.
"We don't really have anything I mind at this point," Jacobs said. "That is more a long-range recommendation that California be thinking of new possibilities."
Undocumented Immigrants Part of the Mix
The report predicts that after health care reforms are in place almost three-quarters of California's uninsured will be U.S. citizens or documented immigrants. That means as many as one million undocumented immigrants may be among the uninsured.
That meshes with estimates by Latino Coalition for a Healthy California, Silva said, adding that it's a difficult group to count.
"This is not a population that tends to want to be counted due to fear [of] reprisals," Silva said.
"We agree with the conclusions made in the report that point to strengthening the safety net, in particular the clinics, which can be federally qualified, FQHC look-alikes. The state needs to avail itself of every federal opportunity to fund the clinics and increase funding to assure that health care is provided to all," Silva said.
Silva said the report's findings support a broader approach to health care that goes beyond insurance.
"I think the conclusions and recommendations in this report would tend to support investments into wellness and health at the community level," Siva said. "Clearly, insurance coverage is not going to do enough to address health disparities and health equity. It is clear that millions will be left out for one reason or another. The best way to address this is to not focus on insurance coverage but to focus on preventing disease."
Silva said investing in clinics and taking advantage of federal programs that support creating healthier communities, such as safe routes to schools and community transformation grants, would help.
"If the environment in which we live is healthier as the result of smarter planning, more open spaces, greater access to healthier foods, the community as a whole benefits. This report supports the idea that we need to be thinking about this differently. Insurance coverage only deals with one side of the equation. The greater impact can be realized by investing in health and wellness," Silva said.