By Miranda Dietz Laurel Lucia, Dylan H. Roby, Ken Jacobs, Petra W. Rasmussen, Xiao Chen, Dave Graham-Squire, Greg Watson, Ian Perry, Gerald F. Kominski
UC Berkeley Labor Center and UCLA Center for Health Policy Research, November 2018
California’s successful implementation of the Affordable Care Act (ACA) resulted in historic increases in health insurance coverage. Over one million Californians have subsidized insurance through Covered California, the state’s ACA marketplace. The state’s Medicaid program (Medi-Cal) now covers approximately one out of three Californians, millions more than prior to the ACA.
Despite this success, 10.4 percent of non-elderly Californians (those under age 65) lacked insurance in 2016. Without state action to protect and build upon these coverage gains, we project that the uninsurance rate could grow to 11.7 percent in 2020, or approximately 4.02 million people, and to 12.9 percent in 2023, or 4.4 million people. These rates are based on a definition of insurance that excludes restricted-scope Medi-Cal for undocumented Californians.
The federal law zeroing out the ACA individual mandate penalty beginning in 2019 will result in lower individual market and Medi-Cal enrollment, but significant uncertainty exists about how much enrollment will decline in California. Using our California Simulation of Insurance Markets (CalSIM) microsimulation model and a range of assumptions about the extent to which the penalty influences enrollment decisions, we project that between 150,000 and 450,000 more Californians will be uninsured in 2020, growing to between 490,000 and 790,000 more uninsured in 2023, compared to the projected number if the ACA penalty had been maintained. The most substantial enrollment changes will occur in the individual market, where we project enrollment will decline by 10.1 percent in 2020 and 14.4 percent in 2023.
To protect the progress made under the ACA in expanding health coverage and to reduce the remaining coverage gaps, the state could expand Medi-Cal to all low-income residents regardless of immigration status, provide state subsidies to improve affordability of individual market premiums and out-of-pocket costs, implement a state individual mandate, and continue to support and strengthen outreach and enrollment efforts, among other strategies. As federal decisions threaten to reverse health coverage gains around the country, these policies would help to ensure that California continues to build on its successes and drive toward its goal of achieving universal health coverage.
By Don McCanne, M.D.
California has been a leader in implementing the Affordable Care Act. As such, it would be useful to estimate the impact of the law that is eliminating the penalty for not having health insurance. This meticulous study estimates that five years from now over half a million additional Californians will be uninsured when compared to estimates were the penalty to remain in place.
Many studies have demonstrated that being uninsured results in impaired physical and financial health for far too many individuals who lose their insurance. Obviously we need to pursue different policies that instead would improve access and affordability of health care.
The primary criticism of this otherwise excellent report is that the authors’ recommendations, though reducing the negative impact of eliminating the individual mandate penalty, would still fall far short of the goals of reform. Many would still be uninsured. Many would still face financial hardship due to underinsurance. Many would be deprived of their choices of health care professionals and institutions because of the perpetuation of restricted provider networks. We would all be paying more because of the costs of administrative excesses which would only increase under the authors’ recommendations, not to mention the burden placed on us by having to comply with these excesses.
So the primary defect in this 32-page report is that they left out any discussion of a proposal that would meet the crucial goals of reform: Single Payer Medicare for All. We can only speculate that the reason is that these distinguished policy experts still limit their recommendations based on their perceptions of political feasibility. It is true that President Trump and the Republican-controlled Senate would be barriers to such comprehensive reform, but with certainty only for the next two years. That is a very short time to mobilize the public into a frenzy that offers politicians no choice but to fulfill the wishes of the majority: enact Single Payer Medicare for All.
If we can show success in grassroots organizing, these authors would no doubt concur that Single Payer Medicare for All is the way to go. These policy wonks certainly understand the different impacts of a policy that financially penalizes a person for being uninsured versus a policy that automatically insures absolutely everybody for life. In fact, you don’t even have to be a policy wonk since that’s a no-brainer.
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