Health & Medicine

2.7 million Californians don’t have health insurance. Can that number go lower?

After a streak of steady declines, California’s uninsured rate bottomed out last year with some 2.7 million people still without health coverage.

The latest estimates from the U.S. Census offer a fragmented portrait of the remaining people who are uninsured while posing an even bigger question for the state: How much lower can the uninsured rate go?

According to the Census Bureau, 7.2 percent of Californians were without health insurance in 2017. That’s lower than the national average of 8.7 percent.

As open enrollment begins this week, health care experts say it will be difficult for the state to move forward, largely because of California’s population of immigrants who don’t qualify for Affordable Care Act plans.

Shana Alex-Charles, a health policy professor at California State University, Fullerton, said about 60 percent of Califfornia’s uninsured are hampered by their immigration status.

“The other half is people that still say they’re caught in the middle, and you get this a lot in San Francisco and Los Angeles,” Alex-Charles said.

Last year, the insurance rate fell a modest one-tenth of a point, from 7.3% in 2016. While it’s still vastly better than the 16% uninsured rate in 2013 — the year before the Affordable Care Act provided insurance plans to all Americans — there are still millions without insurance.

The slowed progress and challenges from the federal government have led to conversations about universal health coverage.

California offers insurance to all children regardless of their immigration status, and Medicaid also covers adults. A sizable number of people still remain uninsured, including immigrants and many young working-age adults between the ages 26 and 44. More than 400,000 residents who were surveyed in 2016 said cost remains a challenge in spite of generous subsidies, and another 550,000 were not eligible for financial help at all.

“There are always some people on the margins who are harder sells for insurance but they aren’t the same ones each year,” said Peter Lee, executive director for Covered California. “It is absolutely the case that on the margins it is lower-income people and younger people who are less apt to sign up for coverage.”

Shannon McConville, a health care researcher at the Public Policy Institute of California, said even Massachusetts found the goal of providing every resident with health coverage elusive. In a law that went into effect in 2006, the state mandated that residents carry health insurance.

The Affordable Care Act was modeled after Massachusetts’ program, and as of 2017, there were still 190,000 people uninsured — almost 3 percent of the state’s population. “Massachusetts is a good example. They implemented a reform in 2006. They sit right now at the lowest uninsured rate across all the states,” McConville said. “But they still do have uninsured residents.

“To get to 100 percent insurance coverage under current policy seems unlikely, which is why I think at the state level the legislature is trying to explore different options to try and get to universal coverage, but that would require different policies than we currently have,” McConville said.

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This question was actually contemplated and debated before the ACA was passed.

“The Congressional Budget Office concluded that it will be great and saves the country $1 trillion in about 10 years but it will not cover everybody,” said Alex-Charles. “Even when the Affordable Care Act was as good as it could be, we would have 30 million uninsured.”

In California, there is bipartisan consensus on getting people into whatever coverage they’re eligible for, but many barriers to improvement remain, Alex-Charles said.

Perhaps the biggest unforeseen challenge in recent years has come from the federal government, where a new presidential administration has shown little interest in maintaining the benefits of the health law.

“The problem is now in 2017 there was a real shift with the new administration coming in, changing focus from how can we improve and enroll more people to how can we make it more business-friendly,” Alex-Charles said, “and if we lose people that’s fine.”

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