The Affordable Care Act (ACA) provides a promise of expanding access to health coverage and minimizing gaps in coverage, and has made great strides in delivering on that promise in California. At the end of the second Open Enrollment in February 2015, 1.4 million Californians were enrolled through the state’s marketplace, Covered California, and several million Californians had newly enrolled in Medi-Cal.1
In addition to Open Enrollment periods, the ACA allows individuals and their families to sign up for coverage during Special Enrollment Periods, or SEPs, under certain conditions. These are narrow windows of time, typically 60 days, after a life transition that may affect health care coverage, such as employment changes, moving, graduating from college, and gaining citizenship or lawful presence in the U.S. In contrast to the strong enrollment numbers during Open Enrollment, there was less activity during SEPs in 2014 than had been anticipated.2
Between 2.7 and 3.4 million Californians are projected to be uninsured in 2019,3 some of whom will be recently and temporarily uninsured due to coverage loss during work or life transitions. In order to maximize health care enrollment in Covered California, it is essential that individuals who experience life or work transitions understand their coverage options and the SEP process.
Significant attention and specialized efforts are necessary to identify and enroll people who qualify for an SEP. As enrollment of the long-term uninsured levels off, Covered California outreach and enrollment strategies can shift from an emphasis on annual Open Enrollment periods towards Special Enrollment Periods. Many Californians interact with an institutional connection point at the time they undergo a life transition. Covered California has already begun leveraging government data sources to provide notifications to enrollees about coverage options, but those strategies could be strengthened and expanded. Gaining a fuller understanding of the nature of various life transitions that trigger SEPs can help Covered California in planning for ongoing enrollment, ensuring seamless health coverage transitions and continuity of care, and ultimately reducing uninsurance.
This policy brief is the third in a series discussing seamless health care coverage for individuals undergoing work or life transitions.4 The brief summarizes past research on the prevalence of loss of coverage due to life transitions and the importance of using existing institutions to inform and enroll people. It also describes California legislation and programs that have been adopted to connect people into coverage. Finally, the brief identifies remaining gaps in coverage for selected target groups and provides specific recommendations on how to maximize enrollment in Covered California for individuals undergoing work or life transitions.
Past Research Demonstrates a Link Between Life Transitions and Uninsurance
Research conducted prior to implementation of the ACA found that losing health coverage was more likely to happen during periods of work or life transition, including job loss, changing employers, or moving.5 These transitions oftentimes also result in income loss, which can change health coverage eligibility.
A significant percentage of the uninsured are transitionally uninsured for a short time period. The Urban Institute estimated that one in five uninsured Americans lacked coverage for five months or less in 2004,6 though this rate is likely to have changed under the ACA.7 Another pre-ACA study found that one out of three Americans had a lapse in coverage during a four-year period,8 demonstrating that the uninsured are not a static population. Regardless of whether one’s loss of coverage is temporary or more permanent, uninsurance can lead to negative health outcomes and put families at significant financial risk.
Special Enrollment Periods Offer Opportunities to Enroll Californians Experiencing Life Transitions, but Timing is Critical
The ACA provides Special Enrollment Periods (SEPs) that allow people who lose health coverage due to work or life transitions to enroll in health insurance through the Exchanges outside Open Enrollment periods. The ACA and state law determine the qualifying triggering events and the process and timing for enrolling during an SEP. Generally, individuals must report changes and select health plans within 60 days of the qualifying life event in order to purchase coverage in the Exchange during an SEP, which makes timely outreach and targeted enrollment efforts essential in getting people insured. Nationally, more than 8.4 million people are projected to qualify for SEPs as a result of qualifying life events each year; 5 million of these would qualify due to losing their employer-sponsored insurance coverage.9
Based on Covered California data, we estimate that approximately 300,000 Californians will enroll during an SEP in a given year if current trends are maintained.10 Through its eligibility and enrollment regulations, Covered California elected to allow individuals to self-attest to their experiencing a qualifying life event that provided for an SEP.11
Preliminary SEP data show that approximately half (49 percent) of the total SEP population were people who lost private or public health coverage, while another 6.6 percent moved to or within California, gained citizenship or lawful presence, had a baby, adopted a child, got married, returned from military service, or had an income change that changed subsidy eligibility. Approximately 2.3 percent of the total SEP enrollees were American Indian/Alaskan Natives, who qualify for SEPs at any time of the year. Another 42 percent were clas- sified as experiencing an “other qualifying life event,” a category that includes a number of possible reasons that are not separated in the data.12 Further analysis of SEP data could identify which, if any, SEP qualifying events are underutilized, helping to prioritize outreach efforts between Open Enrollment periods.
Strategies to Enroll those Experiencing Life Transitions Should Build on Existing Institutional Connections
Existing public and private institutions can serve an essential role in informing and enrolling people into various health care coverage options. These institutions may include, but are not limited to: the insurance company terminating coverage, the unemployment insurance system or other public programs, the educational system, state and local courts in the case of divorce, and Departments of Motor Vehicles for those who move.13 The strategy revolves around using existing government data sources and relationships to inform enrollees about coverage eligibility and enrollment. Access to existing consumer data, website technology, and capacities to send out mass mailings are all factors that facilitate this approach.
In California, existing public and private institutions have created points of intervention in order to connect people to Medi-Cal and Covered California:
- Under a federal waiver, more than 200,000 Californians have enrolled in Medi-Cal since 2014 through the Express Lane Enrollment Project, which grants Medi-Cal eligibility to CalFresh (food stamps) enrollees without the need for a separate application or determination.14
- Many California counties are implementing health coverage enrollment initiatives for individuals on probation and for incarcerated individuals upon release from county jail.15
- A state law (Assembly Bill 792 – Bonilla, 2012) requires insurers and courts to provide notices of coverage options and how to obtain coverage when individuals dis-enroll from an individual or group plan, or file for divorce, separation, or adoption.
- Another state law (Assembly Bill 2706 – Hernandez, 2014) requires public schools to add information about health care coverage options and enrollment assistance services in its school enrollment forms.
Covered California has already initiated early public partnerships with state agencies that regularly contact and interact with target groups of Californians who tend to have high prevalence of uninsurance. In coordination with the Employment Development Department, Covered California sent more than 6 million direct mail pieces to unemployment insurance benefit recipients between November 2013 and March 2014. During the same time period, Covered California also mailed 300,000 educational pieces to child support program recipients and Healthy Families Program (now part of Medi-Cal) households.16 Furthermore, the Departments of Real Estate and Consumer Affairs circulated information about Covered California coverage options through their seasonal newsletters and bulletins, which were sent to thousands of licensed and certified professionals. Direct Covered California links have also been made available on the websites of the Board of Barbering and Cosmetology and CalVET, while other state agencies and departments are working to make the link readily visible and accessible on their websites.
Covered California should continue to build partnerships with existing institutions and create more systematic methods for reaching people at particular times of life transitions. This will require tremendous leadership buy-in and commitment from Covered California and state agency partners given staff and resource limitations.
Tying Notification to Availability of Hands-On Assistance can Increase Enrollment
While early and informative notifications are important, they are not sufficient for the consumer to substantively understand the entire process of applying and gaining insurance coverage. Sending mailings and newsletters to consumers and placing Covered California website links on other government websites are basic referral strategies. These approaches may not reach people during the narrow window in which they qualify for an SEP.
Past research has shown that individuals are more likely to successfully enroll in a program if they receive information combined with hands-on assistance during the enrollment process. In a controlled experiment, some individuals received assistance from tax assistants in filling out financial aid forms, and others received only personalized aid eligibility information and no personal assistance. The individuals who received hands-on assistance were substantially more likely to submit completed applications, enroll in programs, and receive coverage benefits.17 Another controlled experiment related to food stamps program enrollment had similar results.18 This type of help will be especially critical when a person is undergoing a stressful work or life transition that creates a gap in health coverage.
Beyond simple notification, more effective approaches could involve directly connecting consumers to Cov- ered California by phone or web at the end of an inter- action with another state entity. Alternately, consumers could opt in to being contacted directly by an insurance agent or certified enrollment counselor.
Covered California has various enrollment service channels that offer consumers multiple connection points. Covered California data show that at least 70% of those who enrolled in coverage during the second Open Enrollment period received hands-on and in-person assistance from licensed insurance agents, certified enrollment counselors, service center representatives, county workers, and plan-based enrollers.19 The remainder used the self-service method, though they may have also interacted with other service channels and outreach organizations to get help prior to their application submission. This demonstrates that consumers value hands-on and in-person assistance, and it promotes successful enrollment. Providing notices is not enough; the more Covered California proactively contacts people during work and life transitions, the more successful they will be in getting people signed up for coverage.
Target Groups: Individuals Experiencing Work or Life Transitions
In this report, we identify groups of Californians experiencing work or life transitions that could be targeted for outreach. We recommend these particular life transitions for special outreach efforts because (1) they affect a high number of Californians each year, (2) they are associated either with losing coverage or with an already high rate of uninsurance, and (3) they are common among individuals who are likely to be eligible for Covered California subsidies. This list of target groups should not be considered exhaustive.
Target groups include:
- Unemployed individuals applying for Unemploy- ment Insurance benefits
- Job switchers
- Workers applying for or renewing an occupational license/certification from the state
- New Legal Permanent Residents (LPRs) y Movers
- Entering and graduating college students
Unemployment Insurance Applicants
Approximately 2.9 million Californians file an initial claim for Unemployment Insurance (UI) each year.20 We estimate that, prior to the ACA, 38% of unemployed individuals were likely to lack insurance.21 This percentage may have declined under the ACA, but data is not yet available. A significant share of UI claimants may have annual household income in the Covered California income range if another member of their household is working.22 Unemployed individuals who have lost job-based coverage are eligible for an SEP, but job loss itself is not a triggering event.
Covered California’s existing partnership with EDD emphasizes a central institutional connection point for the distribution of coverage information to people applying for unemployment insurance. Covered Califor- nia should explore further expanding their partnership with EDD. Unemployed Californians call EDD and use EDD’s online web portals to make claims for unemployment benefits. The unemployed will also turn to the state EDD and local “One-Stop-Career-Centers,” “One Stop Shops,” and job training program sites.
EDD callers on hold could hear Covered California advertisements. Additionally, EDD call centers should have the functionality of connecting and transferring calls to Covered California Service Center representatives if a UI claimant/applicant indicates an interest in finding out more about health coverage when asked. Similarly, the online UI application could end with a prompt asking applicants if they would like to be directed to the Covered California website for more information. Moreover, Covered California should consider arranging the presence of certified insurance agents or certified enrollment counselors at local “One-Stop-Career Centers” and “One Stop Shops.”
Switching jobs often creates short and temporary gaps in coverage. Prior to the ACA, people who were switching jobs essentially had just one option to fill the coverage gap: COBRA. Under this federal law, employers must offer employees and their families limited-time continuing access to health insurance benefits when23 the benefits are lost due to certain qualifying events. Employers with 20 or more employees are subject to COBRA requirements; Cal-COBRA provides the same protection as COBRA for small employers with 2 to 19 employees. Many individuals switching jobs have found COBRA and Cal-COBRA to be too expensive to utilize because they themselves become responsible for the full premium cost under the program. The ACA greatly expands options for job switchers because of SEPs, subsidies in the Exchange, and the requirement that insurers can no longer refuse to cover, or have higher premiums for, those with pre-existing medical conditions.
We estimate that nearly 900,000 Californians change jobs and lose previous job-based coverage annually.24 Some of these Californians will have a temporary gap in coverage even if they switch to a job that offers coverage due to waiting periods most employers require before benefits begin. The ACA and state law have limited waiting periods of employer-provided health benefits to 90 days. Prior to passage of the ACA, approximately three-quarters of California employers had waiting periods of at least 30 days, but only a small percentage of these were for waiting periods of more than 90 days (6% of all employers).25 Other workers will experience a gap in coverage by switching to a job that does not offer insurance, potentially leading to longer-term uninsurance. For both categories of job switchers, the main institutional connection points are their employers who provide COBRA or Cal-COBRA notices, and insurers who provide coverage option notices when job-based coverage ends upon employment termination, as mandated under recent state law (Assembly Bill 792 – Bonilla, 2012). The Department of Labor also provides model COBRA notices that include information about health coverage availability offered through the Exchanges and during SEPs.26
Federally-guided COBRA notices should be thought of as “sample” or “model” notices; they can be adapted to reflect and include state law as long as they continue to include the federally-required information. Covered California should make such changes to current COBRA notices and then share the revised notices with employers, as well as make them available on the Covered California website. Small employers who purchase coverage through the Small Business Health Options Program (SHOP), called Covered California for Small Business, can elect to have Covered California administer federal COBRA and Cal-COBRA notices on their behalf, giving Covered California an already-established conduit for distributing modified COBRA notices to small employers.27 Covered California should also examine how it can work with the human resources departments at large employers to facilitate the dissemination of information about coverage options to those who have lost or changed their jobs.
Workers in Certain Occupations that are Licensed or Certified by the State
Each year, more than 2.8 million California workers in over 200 occupations are issued licenses, certificates, and work and business approvals by the various boards and bureaus under the Department of Consumer Affairs (DCA). The DCA and its registering, licensing, and certifying entities are in regular communication with these workers, especially regarding renewals, re-certifications, and fees.
It’s quite possible that many uninsured Californians work in occupations licensed by DCA, establishing a natural connection point for providing information about health coverage. Exhibit 1 (page 6) lists industries regulated by DCA with large numbers of Californians who were uninsured or had a high rate of being uninsured prior to implementation of the ACA. The insurance rates among these groups may have improved as a result of the Medi-Cal eligibility expansion, the availability of premium subsidies through Covered California, and the ACA’s requirements regarding pre-existing conditions, but data is not yet available to analyze this.
Currently, DCA aims to establish a closer and more active partnership with Covered California in order to contact its many licensees and stakeholders. Joint action between Covered California and DCA will help ensure coverage information is appropriately developed for each specific type of licensee, depending on education level and other demographic factors. DCA will connect Covered California to professional associations and trade groups that have licensees as active members, leveraging DCA’s existing relationships with these organizations. DCA’s health coverage communication plan involves tactics ranging from website information, social media blasts, listserve messages, board and bureau newsletters, call center on-hold messaging, field office signage, and collateral materials available at licensing and certifying offices. DCA further plans to work with the Bureau for Private Post-Secondary Education, the agency that regulates the private schools and training centers designed for individuals seeking to obtain the education and additional training they need to begin or transition into a new career.
DCA should be sure to devise and implement some practices that target outreach to individuals who are likely to be eligible for an SEP. For example, first-time licensees in certain occupations may have a high likelihood of being eligible for an SEP around the time they apply for their license because they may have moved or lost health coverage from a previous job around the same time they are starting a new occupation. DCA and Covered California should work together to determine which licensees are mostly likely to be eligible for SEPs at which times of year and the best ways to reach them.
Some of the individuals licensed by DCA are employees, such as auto mechanics, and some are owners or independent contractors, such as gas station owners and hairdressers who rent space. Notification language should vary based on status as an employee or owner/ independent contractor. Owners also have a role in providing insurance coverage information to their employees. In addition, some DCA-licensed professionals who interact and communicate directly with the public may also be in a good position to disseminate information about health coverage options. For example, realtors can provide homeowners moving into new Covered California pricing regions with information about coverage options. In these cases, coverage information should be specific to the 60-day SEP.
While it makes strategic sense to begin an outreach partnership with DCA because of its wide reach, other state departments that license other occupations should also be considered for targeted outreach. For example, California has approximately 33,000 family child care home licensees.28 Many of these self-employed family child care providers are uninsured and have household income that would make them eligible for Covered California. These providers renew their licenses annually through the Department of Social Services Community Care Licensing, and a licensing analyst visits each provider’s home every two to three years. Both processes present an opportunity to provide coverage information. Additionally, there are close to 45,000 home-health aides and 97,000 certified nursing assistants,29 which are occupations licensed by the Department of Public Health (DPH). A majority work in licensed homecare agencies, private homes, and hospices owned and operated by individual business owners that may not offer insurance coverage.
New Legal Permanent Residents (LPRs)
Under the ACA, Legal Permanent Residents (LPRs) are eligible for subsidized coverage through the Exchanges, depending on income.30 According to the UCLA Center for Health Policy Research, legal non-citizen immigrants, a category which includes LPRs along with refugees, asylum seekers, and people with temporary work permits, have a significantly higher rate of uninsurance (35%) than U.S.-born citizens (16%) or naturalized citizens (19%).31 Uninsurance may be especially high among new arrivals to the U.S., who make up ap- proximately half of those who recently became LPRs.32 New arrivals to the country may be uninsured while they apply for employment or otherwise seek information about their eligibility for public health coverage programs.
Gaining lawful presence in the U.S. is a qualifying life event that triggers an SEP.33 In California, as many as 200,000 individuals become LPRs each year.34 A California-specific analysis by the UCLA Center for Health Policy Research suggests that the majority of Legal Permanent Residents are likely to be in the Covered California–eligible income range, with a substantial fraction likely to be income-eligible for subsidies.35 However, new LPRs may have lower income than LPRs overall. Based on Covered California data, we estimate that approximately 1,700 Californians in a given year will enroll in Covered California after qualifying for an SEP based on newly gaining citizenship or lawful presence if current trends are maintained.36 This number may grow with targeted outreach and enrollment efforts.
Since many new LPRs may have never had insurance, special consideration must be given to outreach and education strategies for reaching new LPRs who are new arrivals to the country.37 These individuals may also be eligible for SEPs due to their moving residences, which is a qualifying life event. New LPRs may not be familiar with the ACA and may not know whether they or their family members are eligible for various health coverage options. Many may not realize that the indi- vidual mandate will apply and that therefore they need to get health insurance or pay penalties.
Covered California has already worked with partner organizations to target outreach to immigrants.38 Outreach strategies that specifically target new LPRs in the 60 days after they adjust their immigration status should be developed to ensure these residents do not miss their SEP. Some legal aid organizations and community-based organizations that work with immigrant communities are also Covered California grantees and Certified Enrollment Entities (CEEs), and have helped people enroll into coverage. Covered California should meet with this group of grantees and CEEs to develop strategies and recommendations specific to reaching LPRs during their SEP. To further support these trusted organizations, foundations should consider funding efforts by CEEs for enrolling new LPRs during the time they are eligible for an SEP.
While there currently is no state government entity that connects with California residents as they become LPRs, the California Legislature is considering establishing a California Office of New Americans (Senate Bill 10 – Lara, 2015). The new state agency would coordinate efforts to help immigrants better integrate into the state and provide immigration assistance and citizenship services to those who need them. Other states such as New York, Illinois, and Maryland have an Office of New Americans. If established, this state entity could serve as the first institutional connection point for new LPRs to access a range of services and critical information, including health coverage information.
Moving is frequently associated with losing health insurance because it often occurs at the same time as leaving a job, leaving the service area of an insurance company, getting married or divorced, or undergoing some other life or work transition. In and of itself, moving does not trigger an SEP unless the individual moves into a new Covered California pricing region that offers at least one different Qualified Health Plan (QHP). The SEP applies regardless of whether or not an individual is already enrolled in a QHP through Covered California.
Research by Enroll America found that uninsured people are more likely to move than the general adult population: 20% of uninsured adults reported that they lived at their current residence for less than one year compared to 15% of all adults.39 Enroll America estimated that approximately 180,000 individuals move to a new California county each year.40 This is an upper bound estimate of the number eligible for an SEP because 10 out of 19 Covered California pricing regions span multiple counties, and some Covered California pricing regions offer the same set of QHPs as other regions. Additionally, it is not known how many of the individuals who have moved are uninsured and eligible for subsidized coverage through Covered California. If current enrollment trends continue, we estimate that roughly 10,600 movers will enroll in Covered California through an SEP in 2015,41 but this number may grow if targeted outreach and enrollment efforts are adopted.
When people move to new residences, the initial institutional touch point will likely be the local Department of Motor Vehicles, the Post Office, and utility companies. Covered California has already begun mailing out postcards to those who move within and into the state. They are able to do so because the Post Office sells new resident lists. With this resource, Covered California can target areas with moderate-income zip codes where many eligible enrollees reside.
Covered California should consider creating an ongoing partnership with the DMV and utility companies to capture people at a time when they are open to and seeking information. The state DMV’s website should include a visible and accessible Covered California website link. Additionally, the DMV should consider including a check box on its online change of address application for consumers to indicate if they want to receive information on health coverage options. A link to Covered California’s website on the last page of a consumer’s online change of address application would also be useful. These tactics should also be considered in partnership with utility companies. Such strategies help to ensure online referrals lead to some type of connection with Covered California information, a service center representative, or in-person assistance.
Entering & Graduating College Students
College students have several options for obtaining health insurance. They can be covered through their parents’ insurance plans until they are 26 years old, or through plans offered by their university. Some college students also qualify for Medi-Cal or subsidized cover- age through Covered California. Young adult uninsurance rates have fallen significantly under the ACA—from 31.5% in 2010 to 18.9% in 2014.42
Nonetheless, entering and graduating students at community colleges and four-year universities are facing times of transition. Students may lose health coverage because they move outside their plan’s service area, change employment, or lose their student health plans. Some may age off of a parent’s health plan, or their parents may choose to no longer pay their premium costs once they finish high school or college. All of these changes may trigger an SEP. The various UC, CSU, and community college campuses will be students’ primary institutional connection points for receiving information about health coverage. Each year approximately 233,000 students enter the UC system,43 67,000 enter the CSU system,44 and 263,000 enter community colleges throughout the state.45 Each year roughly 66,000 UC46 and 101,000 CSU students47 graduate, and 168,000 students receive their associates degrees and certificates from California community colleges.48
The UC system requires that all registered students have health insurance. It also offers and automatically enrolls students into student health insurance plans, unless students waive their enrollments. UC also offers short-term “continuation plans” for gap coverage to graduating students who meet eligibility requirements.49 The continuation plan, which lasts one term after graduation, provides a significant opportunity for continuing health coverage, but some students may not be able to afford it. Premiums are twice those paid by current UC students50 and must be paid in full prior to receiving coverage. CSU and community college students do not have a comparable health plan available to them. Therefore, graduation may be less of a significant point of transition for community college and CSU students than for UC students.
During the first Open Enrollment, Covered California partnered with the CSU system on an outreach, education, and enrollment program called the CSU Health Insurance Education Project. Through peer-to-peer education, presentations, enrollment events, and email notifications, the percentage of uninsured CSU students fell from 25 to30% prior to the first Open Enrollment Period in 2014 to 10% after Open Enrollment.51 At least 60,000 CSU students are estimated to have enrolled in Covered California in the First Open Enrollment Period.52
The Covered California-CSU partnership provides important lessons about best practices for reaching this target group. Covered California should consider expanding and launching similar projects within the community college system. In addition to helping students obtain health coverage in the first place, the projects should also provide information and resources to assist students in maintaining that coverage when they graduate or transition into other educational institutions. Moreover, universities should consider sending out notices of coverage options to all entering and graduating students since they have data and already send out orientation and exit-information to students.
Developing systems and strategies to minimize gaps in health coverage is challenging. People in the midst of work or life transitions can be especially vulnerable to loss of coverage—but these times of transition also provide unique opportunities for Covered California and other agencies to connect with residents. Covered California can target its outreach, education, and enrollment activities to individuals undergoing life transitions, such as those receiving unemployment insurance, those changing jobs, workers in occupations that require state licensure, new Legal Permanent Residents, those who have moved into or within the state, and entering and graduating college students. All of these life transitions lead to institutional connection points that can be channels of information about Covered California and other health care options. By capitalizing on these opportunities, Covered California will further chip away at the number of Californians who remain uninsured.
1 Covered California, Executive Director’s Report, March 5, 2015. DHCS and Covered California, California Eligibility and Enrollment Report: Insurance Affordability Programs, for the Reporting Period October 2013 through September 2014.
2 Covered California, Executive Director’s Report, March 5, 2015.
3 Lucia L, Dietz M, Jacobs K, Chen X, and Kominksi GF, Which Californians will Lack Health Insurance under the Affordable Care Act? UC Berkeley Center for Labor Research and Education and UCLA Center for Health Policy Research, January 2015.
4 Jacobs K, Lucia L, O’Leary A, and Marciarille AM, Maximizing Health Care Enrollment Through Seamless Coverage for Families in Transition: Current Trends & Policy Implications, UC Berkeley Center for Labor Research and Education and UC Berkeley Center on Health, Economic & Family Security, March 2011.
5 Unpublished research by Lara Shore-Sheppard, reported in O’Leary A, Capell B, Jacobs K and Lucia L, The Promise of the Affordable Care Act, the Practical Realities of Implementation: Maintaining Health Coverage During Life Transitions, UC Berkeley Center for Labor Research and Education and UC Berkeley Chief Justice Earl Warren Institute on Law and Social Policy, October 2011.<
6 Zuckerman S. and Haley JM, Variation and Trends in the Duration of Uninsurance, Urban Institute, November 2004.
7 The ACA provisions banning exclusion from health insurance due to pre-existing conditions, providing subsidies through the Exchanges, and expanding Medicaid will reduce the overall number of long-term and short-term uninsured individuals, but it is not yet known whether the percentage of uninsured who are short-term uninsured will grow or decline, or how the average duration of uninsurance will change.
8 Short PF and Graefe DR, Battery-Powered Health Insurance? Stability in Coverage of the Uninsured, Health Affairs 22(6), pages 244-255, November 2003.
9 Hartman L, Espinoza GA, Fried B, and Sonier J, Millions of Americans May Be Eligible for Martketplace Coverage Outside Open Enrollment as a Result of Qualifying Life Events, Health Affairs, April 2015.
10 Covered California, Executive Director’s Report, April 16, 2015. Using available Covered California SEP data, we estimated that 300,000 people would gain coverage through SEPs annually. Covered California offered a limited-term (February 16 through April 30, 2015) Special Enrollment Period for individuals who were informed of the tax penalty risk of being uninsured; this estimate excludes individuals who qualified for that SEP.
11 Covered California, Board Background Brief: Special Enrollment Period Verification, June 2014.
12 Covered California, Executive Director’s Report, April 16, 2015. Covered California offered a limited-term (February 16 through April 30, 2015) Special Enrollment Period for individuals who were informed of the tax penalty risk of being uninsured; this estimate excludes individuals who qualified for that SEP.
14 California Department of Health Care Services, Express Lane Enrollment Project, February 2015.
15 Californians for Safety and Justice and Local Safety Solutions Project, Health Coverage Enrollment of California’s Local Criminal Justice Population, September 2014.
16 Covered California, Covered California Open Enrollment 2013-2014: Lessons Learned, October 2014.
17 Bettinger EP, Long BT, Oreopoulos P, and Sanbonmatsu L, The Role Of Simplification And Information In College Decisions: Results From The H&R Block FAFSA Experiment, National Bureau of Economic Research, September 2009.
18 Schanzenbach D, Experiment Estimates of the Barriers to Food Stamp Enrollment, Institute for Research on Poverty, University of Wisconsin-Madison, September 2009.
19 Covered California, Executive Director’s Report, March 5, 2015.
20 California Employment Development Department, Quick Statistics, December 2014.
21 This estimate includes an estimated 18% who lose insurance upon becoming unemployed (Gruber) plus an estimated 20% of working non-elderly adults who are uninsured and would presumably remain uninsured upon losing their jobs (CHIS). Gruber J, Transitional Subsidies for Health Insurance Coverage, Inquiry 38: pages 225-231, Summer 2001. California Health Interview Survey (CHIS) 2011-2012.
22 Households with income between 139% and 400% of the Federal Poverty Level are potentially eligible for subsidies through Covered California. This is equivalent to between $27,510 and $79,160 for a family of 3 for households applying for coverage in 2015.
23 California Department of Managed Health Care. Keep Your Health Coverage (COBRA).
24 This estimate reflects UC Berkeley Labor Center analysis assuming 17.3 million employed workers in California (EDD) and a 42% annual separations rate (BLS), then subtracting out those who are estimated to become unemployed. The estimate assumes that 46.4% of all California workers had job-based coverage through their own employer in 2012 (SHIC) and 74% of California covered workers had a waiting period of at least 30 days for coverage in 2010 (Gabel et al.). California Employment Development Department, Quick Statistics, September 2014. BLS, News Release: Job Openings and Labor Turnover – August 2014. Charles SA, Jacobs K, Roby DH, Pourat N, Snyder S, and Kominski GF, The State of Health Insurance in California: Findings from the 2011/2012 California Health Interview Survey (CHIS), December 2014.
25 Gabel J, Lore R, McDevitt R, and Pickreign J, Health Insurance Reforms: How Will They Affect Employment-Based Coverage in California? UC Berkeley Center for Labor Research and Education, April 2012.
26 United States Department of Labor, COBRA Continuation Coverage.
27 Covered California, Small Business Health Options Program (SHOP) Employer Guide, March 2014.
28 California Child Care Resource & Referral Network, 2013 California Child Care Portfolio.
30 Under federal law, new immigrants are barred from receiving coverage through Medicaid for the first five years they live in the United States, but under state policy these new Legal Permanent Residents are eligible for Medi-Cal immediately.
31 Wallace SP, Torres J, Sadegh-Nobari T, Pourat N, and Brown ER, Undocumented Immigrants and Health Care Reform, UCLA Center for Health Policy Research, August 2012.
32 Monger R and Yankay J, Annual Flow Report: U.S. Lawful Permanent Residents: 2013, Unites States Department of Homeland Security, May 2014.
34 Gonzales R, State Estimates of the Number of Uninsured Adults Eligible for a Special Enrollment Period in 2014, Enroll America, August 2014.
35 According to the 2009 California Health Interview Survey, among legal non-citizen immigrants in California, which includes Legal Permanent Residents and other immigrants, 32% had household income below 100% of the Federal Poverty Level (FPL), 31% had household income between 100% and 200% FPL, 11% had income between 200% and 299% FPL, and 26% had income above 300% FPL. Wallace SP, Torres J, Sadegh-Nobari T, Pourat N, and Brown ER, Undocumented Immigrants and Health Care Reform, UCLA Center for Health Policy Research, August 2012. Findings from a national analysis by the Urban Institute also found that the majority of LPRs have income that exceeds the Medicaid eligibility threshold. According to an analysis of Current Population Survey data from 2000 to 2008, 34% of Legal Permanent Residents had income less than 133% FPL, while 42% had income between 133% and 399% FPL, and the remainder had higher income. Zuckerman S, Waidmann, TA, and Lawton E, Undocumented Immigrants Left Out of Health Reform, Likely to Continue to Grow as Share of Uninsured, Health Affairs 30(10), pages 1997-2004, October 2011.
36 Covered California, Executive Director’s Report, April 16, 2015. Using available Covered California SEP data, we estimate that 1,672 new LPRs gain coverage during the nine months of the year that is not during Open Enrollment.
37 Most of the people who will use an SEP to obtain coverage will likely be individuals who are obtaining lawfully present status for the first time, as opposed to individuals who are already US citizens and LPRs.
38 With several well-known and trusted national and state immigrant rights organizations, Covered California developed an FAQ fact sheet assuring that information provided in a health coverage application is secure and confidential. Covered California, Getting the Health Care You Deserve, December 16, 2014.
39 Gonzales R, State Estimates of the Number of Uninsured Adults Eligible for a Special Enrollment Period in 2014, Enroll America, August 2014.
41 Covered California, Executive Director’s Report, April 16, 2015. Using available Covered California SEP data, we estimated that 10,635 movers gain coverage during the nine months of the year that is not during Open Enrollment.
42 Commonwealth Fund, Uninsured Rates Continue to Drop Among Young Adults, July 2014.
43 Office of the President of the University of California, Statistical Summary of Student and Staff University of California, Fall 2013, page 7.
44 California State University, 2012-2013 CSU Undergraduate and Graduate Degrees Granted, Table 15.0, November 2013.
45 California Community Colleges Chancellor’s Office, Management Information Systems Data Mart, Enrollment Status Report – Data & Format Area, Fall 2012.
46 Office of the President of the University of California, Statistical Summary of Student and Staff University of California, Fall 2013, page 29.
47 California State University, 2012-2013 CSU Undergraduate and Graduate Degrees Granted, Table 1, November 2013.
48 California Community Colleges Chancellor’s Office, Student Success Score Card: 2013 State of the System Report, page 3, 2013.
49 UC Student Health Insurance Plan, Health Insurance Options after UC SHIP, University of California Office of the President, Risk Services, May 2014. University Health Services Tang Center at Berkeley, Health Insurance After Graduation.
51 Zelman W, Enrolling College Students in Health Insurance: Lessons from California (Part 2), Health Affairs Blog, October 21, 2014.