Racial and ethnic disparities in coverage after the Affordable Care Act

Background: While the Affordable Care Act (ACA) will greatly expand access to affordable coverage, an estimated 3 to 4 million Californians are predicted to remain uninsured in 2019. State specific outreach and enrollment strategies will have a significant impact on program enrollment and the success of the ACA in reducing health disparities.

Objectives: Provide a demographic profile of the population predicted to be left out of coverage under the ACA and identify major barriers to enrollment.

Study Design: We use the California Simulation of Insurance Markets (CalSIM) model to characterize the remaining uninsured population in 2019. CalSIM is a state-specific micro-simulation model designed to predict shifts in health insurance coverage based on firm and individual responses to policy changes. The CalSIM model uses individual and firm data to predict eligibility for coverge and estimate probabilities of taking up insurance through each of the available sources.

Results: Almost three-quarters of the remaining uninsured in California will be U.S. citizens or lawfully present immigrants. Nearly 40 percent of the remaining uninsured will lack an offer of affordable coverage with premiums costing more than eight percent of household income. 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. 66% of Californians remaining uninsured will be Latino, even though Latinos make up only 45% of the non-elderly population. 11% of the remaining uninsured will be Asian, while 18% will be White. Nearly three out of five California adults who remain uninsured will be limited English proficient (LEP), while 57% of Californians who remain uninsured will have household incomes at or below 200 percent of the Federal Poverty Level.

Conclusions: Half of the remaining uninsured, or two million Californians, will be eligible for Medi-Cal or Exchange subsidies but remain unenrolled. 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.

The findings underscore the need for culturally competent and language-appropriate outreach to make people aware of available programs. Affordability will continue to be a significant problem for those who remain uninsured. California will still need a strong safety net system and programs for the uninsured after ACA implementation.