Estimating the potential and likely number and cost of the uninsured post-Affordable Care Act enactment from a local health department perspective

Background: In 2014, under the provisions of the Patient Protection Affordable Care Act (ACA), an individual mandate for health insurance went into effect, along with the enactment of the Medicaid Expansion. However, even after Medicaid Expansion efforts, there remains an uninsured population. These uninsured individuals will continue to use the County’s safety net system, since the County is the payer of last resort, as mandated by section 17000 of California’s Welfare and Institutions Code.

Objectives: The purpose of this analysis is to estimate the number and cost of the remaining uninsured, or "residually uninsured," population in San Diego County, after the ACA Medicaid Expansion in 2014.

Methods: This analysis utilized County level population data from the 2011 American Community Survey (ACS) to estimate the number of individuals in San Diego County who met certain demographic and socioeconomic parameters. Insurance take-up rates among the uninsured were referenced from UC Berkeley Center for Labor Research and the UCLA Health Policy Research Center, California Simulation of Insurance Market’s (CAL-SIM) report on “Health Insurance Coverage under the Affordable Care Act.” Additionally, estimates for the percentage of the unauthorized immigrant population in San Diego County were referenced from the Public Policy Institute of California’s “Unauthorized Immigrants in California: Estimates for Counties” July 2011 report.

Historical healthcare utilization data were derived from the San Diego County Medical Services (CMS) Fiscal Year (FY) 2011-2012 data and used to estimate the potential and likely utilizers, and their costs to CMS, post-ACA enactment.

Results: Assuming the health profile of potential CMS utilizers, in 2014, matches the health profile of CMS FY11-12 utilizers between 139-350% FPL. Every individual who is eligible seeks necessary medical services through CMS. The annual estimate of liability to CMS would be between $330,114,009 and $457,530,154 (or 90,275 to 125,119 potential utilizers), under the "Enhanced" and "Base" scenarios, respectively. When taking the historical usage rate into consideration, the estimates reduce further. After applying the FY11-12 CMS usage rate of 1.88% to the "Residual Population," the likely estimate of individuals who would utilize CMS is between 1,697 and 2,352 under the "Enhanced" and "Base" scenarios, respectively, yielding a financial annual liability to CMS between $6,205,522 and $8,600,700.

Conclusions: Due to the unprecedented number of changes in the insurance marketplace and public program eligibility criteria under the ACA, it is important to identify, forecast, and plan for financial solvency of local indigent care programs.