The Kaiser Family Foundation’s report,聽based on a聽survey聽of 2,500 adult Californians before enrollment began in October, 聽provides a preliminary look at the roadblocks that could hinder the implementation of the law. (Kaiser Health News is an editorially聽independent program of the foundation.)

Among the challenges to uninsured and low-income residents are聽their poor聽connection to regular providers in the health care system, high costs, a limited understanding of the benefits the law provides, and technological聽problems聽going beyond initial computer glitches.聽(The聽survey was paid for by the , which聽helps fund KHN’s California coverage.)

“The [federal] startup problems I think gave everyone a sense that this was all just about making websites work and finding healthy people to balance the risk pool,” said Kaiser Family Foundation President and CEO Drew Altman.“This really is not just Travelocity or Kayak or Amazon.com, it’s a vastly more complicated, hands-on, community-based outreach challenge.”

Among the report’s key findings:

• Many uninsured people are largely disconnected from the health care system. Half of uninsured California adults have been uninsured for five or more years, and roughly 1 in 5 (22 percent) have never had insurance in their lives.

Some of these adults attempted to get insurance in the past but failed because of high cost or eligibility restrictions. According to the survey, only about a quarter of uninsured California adults say they have a regular doctor.

“These people are being asked to purchase or enroll in a new product to them,” said Rachel Garfield, the associate director of Kaiser Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. “There’s going to be a great need for education about what has changed under the law.”

Linking this population to the right providers and teaching them to use their new insurance policies may require targeted outreach — communicating with people through hospitals, social service programs, and community clinics.

“Insurance, which is incredibly valuable, is not health care. Insurance may or may not enable you to gain health care,” said Mitch Katz, the director of the Los Angeles County Department of Health Services. “And just because you get health care doesn’t mean you feel cared for.”

Health officials need to take into account聽the various stresses in people’s lives, including housing costs, mental health issues, food security聽— issues that traditionally have been considered outside the realm of health care delivery, Katz聽said.

• Choosing an insurance聽plan is hard.聽Consumers must compare costs, services and providers. Often the differences are subtle or masked by complicated language. The survey found almost four in 10 (38 percent)聽of insured聽聽California adults reported having聽some聽problems making聽out differences in costs, services and provider networks聽among plans.

With the implementation of Obamacare, up to 7 million uninsured聽Californians聽will聽be shopping for Medi-Cal or private insurance. While the federal and state exchanges, like Covered California, were supposed to bring an Amazon.com-like experience to health care, that hasn’t quite panned out. Making it easier for consumers to choose聽plans that best fit their needs is an important next step in making the health law work,聽advocates have said.

• Insurance status is not static. Almost 2 million people may lose or gain coverage within the course of a year because聽of changes聽in employment and eligibility for public programs or changes in plans. Californians who lost their insurance had a gap in coverage for an average of just over seven months, the survey found

• Health care costs can be astronomical. Roughly four in 10 low- and moderate-income adults reported having difficulty paying their premiums, according to the survey. With the health law in place, most single adults living at or below 138 percent of poverty聽— roughly $16,000 annually for an individual聽— are now eligible for Medi-Cal, and the government has subsidies to help people who earn up to 400 percent of the federal poverty line purchase insurance on the Covered California exchange.

While this will help, many will still earn too much to qualify for these benefits and health聽care will continue to be unaffordable.

“Health insurance is not cheap. It’s not easy,”聽said Anthony Wright, the executive聽director聽of Health Access CA, an advocacy group that calls for high-quality, affordable health care for Californians.聽“But聽it’s聽cheaper and聽easier聽[under Obamacare]. We are mindful of that.”

• Many uninsured people are largely unaware of the benefits the health law provides, according to the survey.

More recent data indicates that nearly half of all uninsured adults aren’t aware the聽health law聽offers financial assistance to low- and moderate-income people to help pay for insurance.

“When we look at national polls that tried to gauge knowledge, we actually don’t see much movement on these measures,”said the 麻豆女优’s聽Garfield.

• Many of the uninsured adults the health law was intended to help don’t have easy access to the Internet. That’s聽27 percent of those eligible for Medi-Cal and 13 percent of those eligible for private insurance subsidies. Moreover, some of those who report having聽Internet access may be surfing the Web through mobile devices, which advocates say isn’t optimal and may make the process more challenging than it needs to be.

Plus, the聽way the system is set up encourages digital payments, but for some consumers, that poses anotherchallenge聽because they lack bank accounts. Roughly 40 percent of Medi-Cal-eligible consumers are聽“unbanked,”according to the survey.

DanielaH@kff.org

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