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Big states see big Obamacare gains, still face challenges

California and Texas are different in many ways—including in their levels of enthusiasm about Obamacare—but the two huge states are seeing similar effects from the Affordable Care Act.

Two new studies show sharp declines in the number of people without health insurance in California and Texas after implementation of Obamacare.

But those separate studies are also underscoring the challenges that health-care reform advocates will face in getting the remaining uninsured people—who are disproportionately Hispanic in both states—health coverage in coming years.

Obamacare California
Allen J. Schaben | Los Angeles Times | Getty Images

The first study, from the Kaiser Family Foundation, looked at the experience of the uninsured in California, whose government wholeheartedly embraced the ACA when it was passed into law.

That research, which checked in with a pool of uninsured people over the past two years, found that 68 percent of previously uninsured adults in California obtained health coverage in the years since 2014, when Obamacare's full provisions took effect.

It also found marked decreases in the number of people having difficulty paying for health care and getting access to health care during that same time frame.

The biggest single driver of getting those people coverage, by far, was Medi-Cal, the Golden State's Medicaid program, where 34 percent of the previously uninsured obtained coverage.

California was among the earliest of what are now 30 states to have expanded eligibility of their Medicaid programs, which typically provide coverage at no charge to recipients, to include nearly all poor adults. Texas so far has refused to expand its Medicaid program to that population, despite the ACA's provision that the federal government will cover the lion's share of the costs from the newly eligible.

Another 14 percent of the previously uninsured reported getting covered by employer-based health insurance, Kaiser said. And 12 percent said they had gotten coverage though Covered California, the state-run Obamacare insurance marketplace, which has more than 1 million customers in plans sold by private insurers, according to the study.

Mollyann Brodie, who is in charge of Kaiser's public surveys, said the results of the study "certainly suggests that California has been incredibly successful at enrolling the uninsured."

Pointing to the large share of the gains realized by Medi-Cal enrollment, Brodie said, "you can immediately see why those states [that have not expanded their Medicaid programs] are a lot less successful" in reducing their uninsured rates.

Brodie also said that while California's reduction in the numbers of previously uninsured is "significant," she was more struck by the big drops in the number of people who have difficulty paying for and getting health care.

Two years ago, 86 percent of the then-uninsured people who since have obtained coverage said they had a very or somewhat difficult time paying for their or their family's health care. That dropped to 49 percent of those people by this past spring. The percentage of such people who had any problems paying medical bills in the previous 12 months was cut nearly in half, from 45 percent to 23 percent.

And, "when asked how well their health needs are being met, 86 percent of the recently insured now say that they are being somewhat or very well met—up from about half (51 percent) in 2013," the report found.

"I was surprised at the size of those changes," Brodie said,

In another key finding, the report showed that while eligible uninsured Hispanics signed up for Medi-Cal or Covered California plans at about the same rate as whites, they still account for a disproportionately large share of the remaining people without coverage.

Just 17 percent of the remaining uninsured are white. But 29 percent of the remaining uninsured are Hispanics who are eligible for Medi-Cal or exchange-sold plans, Kaiser found.

And another 41 percent of the uninsured are Hispanics whose undocumented immigration status makes them ineligible for either of those options, according to the Kaiser study.

California's Senate last month passed a bill that would allow undocumented children to enroll in Medi-Cal, and would have made undocumented adults eligible to buy Covered California plans, pending a federal waiver. But the bill failed to become law.

Despite the fact that Gov. Jerry Brown's budget includes plans for enrolling about 170,000 undocumented children into health coverage, the large remaining percentage of ineligible uninsured Hispanics represents a stumbling block for further large gains in overall coverage, as does the number of Hispanics who are eligible but have not gotten coverage.

"Future gains are going to be tough, if you look at the remaining uninsured," Brodie said. "A lot of of the easy-to-enroll people have now enrolled." Open enrollment in Obamacare insurance resumes in November; enrollment in Medicaid is year-round.

Barriers to signing up the remaining uninsured, particularly Hispanics, include concerns those people have about the cost of coverage, lack of awareness of their options for coverage and worry that if they obtain coverage their relationship to a family member who is undocumented will draw scrutiny from the government, Brodie said.

A similar situation is occurring in Texas, according to a new report from Rice University's Baker Institute for Public Policy, and the Episcopal Health Foundation. Texas' government has been hostile to Obamacare, choosing neither to expand Medicaid nor set up a state-run insurance marketplace, but more than 1.2 million people in the state selected plans during 2015's open enrollment season on the federal exchange HealthCare.gov.

The report found that since late 2013, the overall percentage of people without health insurance in Texas has fallen from 24.6 percent to 16.9 percent—or a decrease of almost one-third.

But there was stubbornly persistent relative high rates of lack of insurance among both the poor and Hispanics, according to the report.

Nearly 70 percent of the uninsured in Texas are people whose household incomes are less than 138 percent of the federal poverty level, or $27,724 for a family of three. The percentage of such low-income people who lack insurance in Texas actually increased by nearly 4 percentage points since Obamacare was implemented.

Elena Marks, president and CEO of the Episcopal Health Foundation, said the fact that low-income and poor people make up a big majority of the uninsured is not surprising, "because most of them were ineligible for coverage opportunities in the marketplace."

"The ACA offered coverage to this group through optional Medicaid expansion, but Texas has not expanded Medicaid," Marks noted.

People who earn less than 138 percent of the poverty level are eligible for Medicaid in states that have expanded Medicaid.

And people who earn less than 100 percent of the poverty level, or $20,090 for a family of three, are ineligible for federal subsidies that would allow them to enroll in private plans sold on Obamacare exchanges at no or very little direct cost to themselves.

The report noted that while Hispanics as a group saw the biggest drop in uninsured rates of any ethnic group—a nearly 38 percent decrease—they continue, by far, to comprise the majority of remaining uninsured people.

A total of 57.1 percent of Texas' uninsured are Hispanic, according to the report.

The report also found that the cost of health insurance was the most common reason cited by the uninsured when asked why they didn't have coverage A total of 57 percent gave that answer. Another 17.3 percent said, "I do not want health insurance" when asked why they were still uninsured.