New Census Figures Provide More Evidence That Health Care Reform Is Working in California

The number of Californians without health care coverage plunged in 2014 because of our state’s decision to fully implement federal health care reform, including strengthening Medi-Cal so that it reaches more residents who otherwise couldn’t afford health insurance.

The US Census Bureau today released new data on health care coverage from the American Community Survey. These new figures show that the number of Californians without coverage fell by more than one-quarter (26.7 percent) last year, declining from 6.5 million in 2013 to less than 4.8 million in 2014.* As more Californians gained health care coverage, the uninsured rate also declined: The share of Californians without coverage dropped from 17.2 percent in 2013 to 12.4 percent in 2014. (The Census Bureau tomorrow will release detailed state-level data on health care coverage in 2014.)

Health Coverage Gains in 2014 Reflect California’s Comprehensive Implementation of Federal Health Care Reform

The coverage gains shown in the new Census data reflect the efforts of California policymakers and advocates to fully implement the reforms and coverage expansions included in the federal Patient Protection and Affordable Care Act (ACA) of 2010. Key policy changes that California put in place in early 2014 include:

  • Expanding eligibility for Medi-Cal — our state’s Medicaid program — to parents and childless adults who were previously excluded from the program. More than 2 million California adults who are under age 65, have low incomes, and were previously excluded from coverage are now enrolled in Medi-Cal as a result of this expansion, according to the California Department of Health Care Services (DHCS). The federal government is currently paying the full cost of this expansion. Starting in 2017, California will pay 5 percent of these costs, and the state’s share will gradually increase to a maximum of just 10 percent in 2020 and beyond. California is one of 30 states — plus the District of Columbia — that have opted to expand Medicaid eligibility.
  • Simplifying Medi-Cal’s eligibility and enrollment rules. These ACA-related changes made it easier for eligible Californians to sign up for Medi-Cal and stay enrolled. Simpler rules, along with the ACA’s requirement that individuals have health care coverage or pay a penalty, have encouraged more Californians who were eligible for — but not enrolled in — Medi-Cal prior to health care reform to sign up. In fact, more than 1 million Californians who were already eligible for Medi-Cal are now enrolled as a result of the changes associated with the ACA, according to the DHCS.
  • Launching subsidized coverage through Covered California, the state’s health insurance marketplace. Californians who earn too much to qualify for Medi-Cal and yet lack access to affordable job-based health insurance can shop for individual or family coverage through this new marketplace. People with low or moderate incomes receive federal subsidies that reduce their premiums and related expenses, such as co-pays. More than 1.3 million Californians were enrolled in health plans offered through Covered California as of March 2015, with nearly 9 in 10 receiving federal subsidies, according to Covered California.

California Can Take Steps to Further Reduce the Number of Residents Without Health Care Coverage

Despite its success in implementing health care reform to date, California can — and should — do more to reduce the number of Californians who face the health and financial consequences of not having health care coverage. Even with the full implementation of health care reform, 1 in 8 Californians — nearly 4.8 million — lacked health care coverage in 2014, according to the new Census data.

Californians continue to go without coverage for several reasons, including “confusion about eligibility” and “lack of awareness of new coverage options and financial assistance,” according to a 2014 survey of uninsured Californians conducted by the Kaiser Family Foundation. Based on these findings, Kaiser suggests that “one-on-one assistance” may be needed to enroll larger shares of young adults, people with limited English proficiency, and other members of “hard-to-reach” groups.

In addition, federal restrictions on coverage for undocumented immigrants lock many hard-working Californians out of the health insurance market and contribute to the state’s still-too-high uninsured rate. States cannot use federal dollars to enroll undocumented immigrants in comprehensive — or “full-scope” — Medicaid coverage (although they are allowed to use state dollars for this purpose). In addition, federal law prohibits undocumented immigrants from purchasing coverage through a health insurance marketplace set up under the ACA, such as Covered California. While some of California’s more than 2 million undocumented residents get coverage through an employer, most do not. Those who remain uninsured — because they’re unable to sign up for Medi-Cal or purchase private coverage through Covered California — may have no regular source of health care and could face huge out-of-pocket costs for any care they do receive.

Absent a wholesale change in federal law, it’s up to California policymakers to take the lead in boosting coverage options for undocumented immigrants — people who work, pay taxes, and contribute to the state’s economic prosperity. California has already taken significant steps down this road. For example, a longstanding state policy allows undocumented immigrants who qualify for “deferred action” under federal immigration rules to sign up for full-scope Medi-Cal, so long as they meet the program’s income eligibility guidelines, as we explained earlier this year. In addition, undocumented immigrant children and youth (age 18 and under) in families with low incomes — an estimated 170,000 young people in all — will be able to sign up for comprehensive Medi-Cal coverage starting in May 2016 under a change included in the 2015-16 state budget. In contrast, efforts to expand coverage to undocumented adults in California have not yet succeeded, although deliberations on doing so are expected to resume in 2016.


Boosting coverage options for undocumented immigrants is key to further reducing the share of Californians without health insurance. Barring significant changes in state and/or federal laws, up to half of Californians who remain uninsured by 2019 are expected to be “undocumented immigrants who are not eligible under the ACA,” according to recent projections. Expanding coverage to all undocumented immigrants — a cost-effective investment in public health — would reduce the state’s uninsured rate and move California further down the road to a health care system that works for all residents.

— Scott Graves

*American Community Survey estimates are based on respondents’ coverage status at the time of the interview and “reflect an annual average of current health insurance coverage status,” according to the Census Bureau. The differences between the 2013 and 2014 estimates cited in this blog post are statistically significant from zero at the 90 percent confidence level.