Getting Uninsured Into Health Care System a National Challenge

By Gary Feuerberg
Gary Feuerberg
Gary Feuerberg
February 21, 2014 Updated: February 21, 2014

WASHINGTON—A new report by the Kaiser Family Foundation presents a sobering picture of the challenges facing health care providers and state government health officials in implementing the Affordable Care Act (ACA). The report, “The Uninsured at the Starting Line in California,” found more significant barriers to signing up people for health care than the website glitches that we hear so much about. 

The report finds that it’s going to be a challenge to get the uninsured integrated into the health care system for reasons that aren’t typically discussed on your evening news. For example, engaging people who have never had insurance coverage in their lifetime, or have not had a place to go when they get sick apart from the emergency room, or know nothing at all about the health care exchanges or Medicaid.

To discuss this report and the latest developments about the ACA implementation in California, the Kaiser Foundation on Feb. 19 at its Washington, D.C., office held a panel discussion made up of California government officials and experts. 

Drew Altman, President and CEO, Kaiser Family Foundation, said that a “social mission” lies behind the ACA. The challenge is not creating a website like some business, for example,, but “It’s really a more complicated hands-on, community-based outreach challenge.” 

One of the aims of the Affordable Care Act (ACA) was to expand health care coverage to the uninsured, potentially 47 million Americans. The expansion of Medicaid in the ACA enabled nearly all adults with incomes at or below 138 percent of the federal poverty level (FPL) ($16,105 for an individual or $27,210 for family of three in 2014) to qualify for Medicaid, but the Supreme Court allowed states to opt out of the Medicaid expansion program, and about half of the states did. 

The ACA was also designed, as its name implies, to make health care more affordable. Low and moderate income families with incomes at 139—400 percent FPL) can receive tax credits to purchase coverage.

People mistakenly believe that once the law was passed, “that’s it; it’s done,” said Peter Long, president and CEO of Blue Shield of California Foundation. 

Long likes to remind people, “This law is not self-implemented.”

Nearly all of the uninsured are eligible for some kind of coverage under the ACA. However, getting the eligible uninsured signed up and continuing coverage into the future is difficult. Assisting people who have gaps in their coverage and have been outside the health care system will also be challenging. The Kaiser report will help policymakers understand where the needs of the uninsured are greatest for attention. 

The report bases its conclusions on the 2013 Kaiser Survey of Low-Income Americans. That survey is intended to serve as a baseline for pre-ACA conditions for the uninsured. It surveyed low-income Americans in California, Missouri, and Texas.

The survey included a representative sample of 2,558 nonelderly (age 19-64) adults in California. Virtually all of the uninsured people in California belong to this age group of the nonelderly adult population. Medicare generally takes care of persons over 65, and low-income children are covered through California’s version of Medicaid, called Medi-Cal.

Uninsured Typically Poor

About half (52 percent) of the uninsured nonelderly adults in California have incomes below the FPL, which “mirrors what we see nationwide,” said Rachel Garfield, senior researcher and associate director at the Kaiser Commission on Medicaid and the Uninsured. The majority is at or near the poverty level compared to 10 percent of adults who have employer coverage. 

Most of the eligible uninsured can get coverage through Medi-Cal or CHIP—43 percent of the total uninsured. Another 20 percent of the uninsured can get coverage by tax credits. 

Eight in ten (82 percent) uninsured nonelderly adults do not have access to employer coverage. The majority of uninsured, who did have access to employer coverage reported that the coverage offered to them was not affordable. 

The ACA does not cover undocumented immigrants, and so 21 percent of the uninsured in California are ineligible.

Gaps in Coverage

“For most uninsured adults, lack of coverage is a chronic issue,” states the report. The report found that about half (47 percent) have not been insured for at least 5 years, and 18 percent report that they never had coverage in their lifetime. Implementing the ACA is not a one shot process but “will require continuous effort to enroll and keep people in coverage,” states the report.

Nearly a quarter (24 percent) tried to sign up for Medi-Cal in the past 5 years, while one in six (17 percent) tried to purchase nongroup policy.

“The vast majority of these cases failed because of eligibility or the cost,” said Garfield. These people will need to be told what has changed in the law, she said. Eligibility rules have changed and financial assistance is now available. For example, single adults without children can now apply for Medi-Cal, which the uninsured may not know.

“A large share of uninsured adults has been outside the insurance system for quite some time, and the long-term uninsured may require targeted outreach and education efforts to link them to the health care system and help them navigate their new health insurance,” states the report.

Anticipating Service Needs

A major conclusion of the report is that “a large segment of the uninsured has little or no connection to the health care system.” Half (51 percent) do not have a regular place they go when they get sick, compared to 16 percent of those with employer coverage. 

Only 23 percent have a regular physician, compared to 76 percent of employer insured, states the report. Two-thirds had no preventive care visits in the past year, compared to 25 percent insured by employer coverage.

The report anticipates some “pent-up demand” for health care services of the newly covered. Only 30 percent of the uninsured have identified an already diagnosed illness compared to 
44 percent of the insured adults through employer coverage, said Garfield. 

The report signals, “outreach may be needed to link the newly-insured to a regular provider and help them establish a pattern of regular preventive care.” Some individuals who have relied on emergency rooms as their usual source of care may need assistance in changing their approach and navigating the primary care system, according to the report. 

As the enrollment process has been underway since October, California and presumably other states, have a major challenge in educating uninsured adults who are income eligible for coverage under the Medicaid or marketplace programs. Seven in ten uninsured adults who qualify for Medi-Cal by income know “nothing at all” about it. Eight in ten uninsured adults with incomes at 139-400 percent FLP, which qualifies for marketplace subsidies, know nothing at all about Covered California (the name of California’s private health insurance marketplace or exchange).

Twenty percent of the uninsured have no Internet access. Fewer Hispanics, who make up more than half the uninsured, have access (29 percent). 

Surveying California’s Low-Income

“Prior to implementation of the ACA, nearly 7 million Californians—21 percent of the state’s nonelderly adult population—were without health insurance coverage,” says the report.

The report focused on implementation of the ACA in California, which has embraced the ACA to a degree unlike most states. California was selected in part because it’s the largest state in population, it has many uninsured, it has heavily invested in outreach, and its population is highly diverse. 

Altman said that California has been a relative ACA success story, a state that other states will likely want to emulate. As of Feb. 4th, 22 percent of the potential enrollees—about 1.6 million Californians out of 7 million—have signed up for Covered California, or Medi-Cal, Altman said. Only three other states—Vermont, Connecticut, and Rhode Island—have done better.