After Millions of Californians Gain Health Coverage under the Affordable Care Act, who will Remain Uninsured?

Press Coverage


The implementation of the Affordable Care Act (ACA) is predicted to expand coverage to millions of Californians by 2019. This increase in coverage will primarily result from the expansion of Medi-Cal and the availability of subsidized coverage in the California Health Benefit Exchange (Exchange). However, three to four million Californians could remain uninsured even after the law is fully implemented.

We use the California Simulation of Insurance Markets (CalSIM) model, version 1.8, to estimate the size and characteristics of the remaining uninsured under age 65 in California under two scenarios. In a base scenario we assume that take up of Medi-Cal follows current trends and that take up in the Exchange reflects typical individual behavior patterns from the health economics literature. In our enhanced scenario, we assume that eligibility determination will be simplified, outreach and enrollment efforts will be escalated in a culturally sensitive and language appropriate manner, and that the majority of individuals currently enrolled in existing categorical public programs that provide services but not full coverage will transition to Medi-Cal and the Exchange.

We predict that by 2019 when the ACA is fully implemented:

Health coverage will significantly expand in California

  • The number of uninsured Californians under age 65 will decrease by between 1.8 and 2.7 million.
  • Of the uninsured Californians who are predicted to gain coverage as a result of the ACA, between 640,000 and 1.0 million will newly enroll in Medi-Cal and between 790,000 and 1.2 million will enroll in subsidized coverage in the Exchange.

Many Californians will remain uninsured

  • 3.1 to 4 million Californians are predicted to remain uninsured in 2019.
  • Almost three-quarters of the remaining uninsured in California will be U.S. citizens or lawfully present immigrants.
  • Half of all remaining uninsured, or two million Californians, will be eligible for Medi-Cal or Exchange subsidies but remain unenrolled under the base scenario. Barriers to enrollment could include lack of awareness about the programs, challenges in the enrollment process, or inability to afford subsidized coverage. With stronger outreach and enrollment efforts, this group of uninsured would be reduced to 1.2 million or fewer.
  • 72 percent of remaining uninsured Californians will be exempt from paying tax penalties under the minimum coverage requirements of the ACA due to income, lack of an affordable offer of coverage or immigration status. Approximately three percent of all Californians will owe a tax penalty due to not obtaining minimum coverage.
  • Nearly 40 percent of the remaining uninsured will lack an offer of affordable coverage with premiums costing eight percent of household income or less. Some uninsured Californians will be ineligible for subsidized coverage due to income or immigration status, while others will be eligible for subsidized plans in the Exchange with premiums that exceed the affordability standard.
  • Some of the remaining uninsured will lack coverage for short time periods due to life transitions.

Some demographic groups will be more likely to remain uninsured

  • Two-thirds (66%) of Californians remaining uninsured will be Latino, compared to a projected 45 percent of the non-elderly population in 2020.
  • Nearly three out of five California adults who remain uninsured will be Limited English Proficient.
  • 62 percent of California’s remaining uninsured will be residents of Los Angeles and other Southern California counties.
  • 57 percent of Californians who remain uninsured will have household incomes at or below 200 percent of the Federal Poverty Level.


Outreach and enrollment efforts are needed to minimize the number of remaining uninsured

Outreach and enrollment efforts should be customized to reflect the groups of Californians with the highest rates of uninsurance: Latinos, Limited English Proficient adults, and residents of Southern California. We predict that nearly 800,000 more Californians would enroll in Medi-Cal or Exchange subsidies if there were robust outreach and enrollment efforts, based on the enhanced scenario. Outreach efforts are also needed to reduce the number of Californians who are uninsured for a short period of time when they lose a job or undergo another life transition, such as divorce or aging out of a parent’s coverage. In addition, Californians who already participate in categorical public programs that provide services but not full coverage should be pre-enrolled in Medi-Cal or the Exchange.

California will still have a great need for a strong safety net system post-ACA

A strong safety net of health care providers will still be needed to provide care for the predicted 2.3
million uninsured Californians with household incomes at or below 200 percent of the Federal Poverty Level.

Programs needed for Californians left with no affordable coverage option

In addition to securing the health care safety net, California should maintain and expand programs for individuals without an offer of affordable coverage. Existing programs for the uninsured, such as Family PACT for family planning services, should be sustained and new programs should be explored.