As President Barack Obama struggles to implement — and defend — the health care reform he signed last year, he is finding that the public does not understand how the program is supposed to work, and based on what they do know, many voters doubt the overhaul will help them in the end.
It turns out this is true not only for middle class voters who already have insurance but, at least in California, also for low-income, uninsured people for whom the new law holds the most promise. Many of them are confused about the law’s details and fear it could make their ability to access care, often portrayed as desperate, even worse.
And the centerpiece of the law — the so-called “individual mandate” requiring everyone to obtain insurance coverage, seems to be no less controversial among the poor than it is among middle-income and affluent people.
Those findings and more emerge from a recent study by sociologist Helen Lee, who has said that the new law seeks to create a “culture of coverage,” in which insurance is expected, maintained, and ultimately valued.
Lee is a fellow at the Public Policy Institute of California. She and a colleague, Shannon McConville, recently researched the group of Californians who will become newly eligible for Medi-Cal, the state health insurance for people at or near poverty, when the federal law is fully in place in 2014.
In addition to describing the demographics—age, ethnicity, health status, etc.—of the newly-eligible pool, Lee and McConville also asked participants to share their understandings of current and future scenarios of state health insurance. Lee and McConville drew from two broad groups: 1) parents whose children are enrolled in state health insurance, and 2) uninsured childless adults.
Medicaid, the nation’s subsidized health insurance for the indigent, in California is known as Medi-Cal. With the Affordable Care Act’s state health insurance expansion, 1.7 million to 3 million additional Californians will become eligible for Medi-Cal, beginning in 2014. That would add around 17 million more people to the nationwide Medicaid roster.
According to Lee and McConville’s study, “roughly half of the reduction in the uninsured is projected to come from increased Medicaid participation.”
With the expansion authorized in the Affordable Care Act, Medicaid could cover people whose annual income is less than or equal to 139 percent of federal poverty level. Previously, Medicaid was unavailable to people making more than 133 percent of federal poverty level.
In California, families of three with incomes less than $18,530 are considered poor under federal poverty guidelines.
Using statistics on obesity, smoking, and chronic health conditions, Lee and McConville showed that poor uninsured adults are no less healthy than current non-disabled Medi-Cal subscribers. Marginalized people of color comprise a significant portion of California’s uninsured: Latinos and African-Americans together account for 55 percent of uninsured adults in California.
Through focus group interviews of potential new users of expanded Medi-Cal, Lee and McConville observed people’s thoughts and feelings regarding changes to public insurance, as well as their understanding and opinion about the individual mandate—widely regarded as the hallmark of the plan.
The researchers witnessed great concern from the participants who had experienced current Medi-Cal through their children. Participants highlighted a few key difficulties with current coverage: long, over-busy providers and insufficient provider-patient interaction. Focus group participants worried that Medi-Cal expansion would burden providers and agency staff, further distancing low-income patients from adequate care.
Uninsured participants reported strategies of self-care that they employ in order to avoid health care costs beyond their reach. A diabetic, Krista continually finds her treatment prohibitively expensive:
“I…choose what’s more important, my insulin or testing my blood sugar,” she said. “I’m taking half care of myself because I can’t afford it. It’s dangerous.”
Part of the challenge of promoting a culture of coverage is for providers and health administrators to reorient newly-insured people to preventative medicine, while maintaining respect for their individual judgment and self-determination.
Participants—mostly childless—who had not experienced Medi-Cal worried that their new eligibility may not be reliable. For example, even a moderate income fluctuation could disrupt enrollment. In general, participants were unsure about whether and how the reforms would affect them.
Kelly, a single and childless non-disabled adult from the Bay Area, tended to assume that government health programs would not apply to her.
“First of all, right now, if you are poor and have kids, you have a better chance of getting some medical attention,” she said. “With being single, no kids, like myself, the hell that I go through basically any time I want to go anywhere to get help, it’s got to be an emergency, like going to County [hospital] or some sort. They don’t have different programs for me.”
Vigorous outreach may be necessary to reach currently ineligible people not privy to the reform. Indeed, many of the study’s participants felt confused about the particulars of present and future coverage.
Some participants were unhappy with the individual mandate—the ACA’s provision requiring most citizens purchase health insurance or be fined a tax penalty.
Opposition seems to spring from two types of reservations: some respondents found the requirement financially untenable, and others were ideologically opposed to the role of the government
In some cases, though, the participants likened the individual mandate to the law requiring drivers to have auto insurance. Already there exists a widely accepted cultural norm of auto insurance. The analogy may be useful for messaging the value of health insurance.